Professional Misconduct Finding for GP Inappropriately Prescribing Drugs

Health Care Complaints Commission v Sriskanda [2021] NSWCATOD 42

Introduction

In March 2021, the Health Care Complaints Commission (HCCC) (the Applicant) prosecuted a complaint in the NSW Civil and Administrative Tribunal against Dr Urmila Sriskanda, a general practitioner (the Respondent). The Tribunal found that the conduct of the Respondent satisfied the definition of both unsatisfactory professional conduct and professional misconduct as alleged in the Complaints.

Facts

The Respondent began working as a General Practitioner registrar in January 2011 and was awarded Fellowship of The Royal Australian College of General Practitioners in 2013. In February 2012, the Respondent commenced working as a General Practitioner Registrar for Reliance Medical Centre (the Practice) in Wyoming, New South Wales. In July 2013, the Practice moved to West Gosford under the name Reliance Health. The Respondent was registered from 2005 until 31 January 2019 when she was suspended following an inquiry under s 150(1)(a) of the Health Practitioner Regulation National Law 2009 (NSW) (National Law).

Issues

The Director of Proceedings of the HCCC determined to prosecute the Respondent pursuant to section 90B(1) of the Health Care Complaints Act 1993 (NSW)  alleging that the Respondent was guilty of unsatisfactory professional conduct within the meaning of section 139B(1)(a),(b) and/or (l) and professional misconduct within the meaning of section 139E of the National Law.

Relevant Legislation

Unsatisfactory professional conduct is defined under section 139B of the National Law as meaning:

(1) Unsatisfactory professional conduct of a registered health practitioner includes each of the following–

(a) Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner’s profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

(b) A contravention by the practitioner (whether by act or omission) of a provision of this Law, or the regulations under this Law or under the NSW regulations, whether or not the practitioner has been prosecuted for or convicted of an offence in respect of the contravention.

(l) Any other improper or unethical conduct relating to the practice or purported practice of the practitioner’s profession.

Professional misconduct is defined under section 139E of the National Law as meaning:

(a) unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner’s registration; or

(b) more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner’s registration.

Complaints

The HCCC alleged:

  1. From 2017 to 2019 when the Respondent was working at the practice in West Gosford, she inappropriately prescribed Schedule 8 drugs of addictionand/or Schedule 4D drugs to 9 patients in circumstances where:
  • She knew, or ought to have known, the patients were drug dependent (including some on an opioid treatment program);
  • She did not have an authority to prescribe Schedule 8 drugs;
  • The prescriptions were issued without proper clinical assessment or referral for specialist support, and in a manner not therapeutically indicated;
  • The Schedule 4D drugs were issued concurrently with oxycodone.
  1. The Respondent failed to record in her medical notes any information or advice given to the abovementioned patients regarding the purpose, importance, benefits, or risks of the drugs prescribed.
  2. In October 2018, the Respondent breached patient confidentiality by disclosing to Patient K that Patient J engaged in an extramarital affair and during that same consultation, failed to conduct an adequate examination, arrange appropriate specialist support or prepare an appropriate management plan after the patient made disclosures of self-harm and threats to others.

Evidence

Standard of Proof

The Applicant was required to establish to a high standard that the conduct had occurred. Whilst there is no burden of proof in a tribunal hearing where the rules of evidence do not prevail, the standard on the balance of probabilities is the usually accepted standard. The Applicant commissioned an expert report by Dr. Gary Deed (the expert), an Adjunct Senior Research Fellow of Monash University.

Findings

  1. TheTribunal concurred with the opinion of the expert regarding the clinical assessment, management and the gross, dangerous and reckless overprescribing of Schedule 8 and Schedule 4D drugs to 9 patients. On every occasion, there was a lack of the required due diligence to ascertain if the patient was drug-dependent, a lack of clinical assessment and a lack of a comprehensive management plan. The Respondent prescribed Schedule 8 drugs to patients who had a history of drug dependence or abuse, such as oxycodone, alprazolam, fentanyl patches and flunitrazepam. The Respondent should not have provided any opioid scripts unless authorised by the appropriate regulatory and clinical framework under the Poisons and Therapeutic Goods Act 1996 (NSW) which establishes the therapeutic standard, dosage frequency or duration. In certain instances, the prescription quantities were so high as to evoke serious concern that the prescribed drugs could have put the patient at risk of significant harm and/or that these drugs were being illegally diverted to other persons.
  2. The Tribunal concurred with the expert that the Respondent’s medical records did not meet the‘safe and quality use of medicines’ criterion of The Royal Australian College of General Practitioners Standards (the Standard) for ‘prescribing records,’ in which her records failed to include any indication that the patients are informed about the purpose, benefits and risks of their medications. In respect to each patient, there was poor documentation in the medical records of the required history of the presenting complaint, examination findings, clinical assessment and the clinical indication for prescribing the various medications and a lack of documentation of a management plan including follow-up, which makes it difficult for any other practitioner to continue the care of the patient. The Tribunal concluded that the medical records were significantly below the expected standard.
  3. The Tribunal concurred with the expert findings regarding the confidentiality breach. The Respondent disclosed to Patient K that Patient J had engaged in an extramarital affair without Patient J’s prior knowledge or consent, without proper therapeutic or clinical reason and in the absence of a legal or public interest requirement, which constituted a breach of the Good Medical Practice: A Code of Conduct for Doctors in Australia (the Code).

Clause 3.4 of the Code outlines:

‘Patients have a right to expect that doctors and their staff will hold information about them in confidence unless release of information is required by law or public interest considerations. Good medical practice involves:

         3.4.1 Treating information outpatients as confidential…’

The Respondent’s responses during the section 150 hearing held on 31 January 2019 demonstrated that she did not foresee any conflict of interest between the consultation with Patient J and with Patient K she was ‘not even thinking about confidentiality during this consult.’ The Respondent detailed that she was more concerned about Patient K either self-harming or harming her husband or the third-party. The Respondent said she thought she would reduce such risk by telling her that her husband was unsure whether he wished to return to the relationship. It was found that the Respondent showed a total lack of understanding by thinking it would be acceptable to inform a spouse that she had seen the partner, without having obtained any consent to do so. She considered that as long as she didn’t show a file or ‘tell them anything on their file’ it was appropriate. The Respondent admitted with hindsight, she realised revealing such information could have escalated the potential conflict between the 2 patients. The expert observed that it was alarming that the patient mentioned she was self-harming and that she wanted to ‘kill the other partner’ of her estranged husband. The psychological needs of Patient K were acute, yet no plan was devised. The Respondent failed to conduct an adequate examination of Patient K and failed to refer her for appropriate specialist allied health and psychiatric support and to construct an appropriate ongoing management plan for her. This conduct fell significantly below the standard reasonably expected of a practitioner.

Outcome

On 14 April 2021, the Tribunal found that the conduct of the Respondent satisfied the definition of both unsatisfactory professional conduct and professional misconduct as alleged in the Complaints. The proceedings are currently adjourned to determine the appropriate disciplinary sanction to be imposed.

Compliance Impact

Organisations should be aware of the Respondent’s poor conduct as a reminder that health practitioners must not breach patient confidentiality, inappropriately prescribe drugs of addiction without authority, prescribe drugs in excessive quantities for no apparent therapeutic reason and improperly keep medical records to prevent falling significantly below the standard reasonably expected.

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