VICTORIAN CIVIL AND ADMINISTRATIVE TRIBUNAL
administrative DIVISION
REVIEW AND REGULATION LIST	
vcat reference NoS. Z200/2020 & Z543/2021	
CATCHWORDS	
Review and Regulation List – Health Practitioner Regulation National Law (Victoria), s 196 – Eight allegations of professional misconduct or unprofessional conduct concerning respondent’s treatment of family members – Agreed Statement as to findings, characterisation and proposed determinations other than length of suspension – Tribunal comfortably satisfied allegations proven – Consideration as to impact of family violence on appropriate period of suspension – Respondent reprimanded, suspended for 6 months and conditions imposed on registration on return to practice.	

APPLICANT	Medical Board of Australia	
RESPONDENT	AEB	
WHERE HELD	Melbourne	
BEFORE	R. Tang AM, Senior Member
Dr A. Sungaila, Member
Dr L. Warfe OAM, Member	
HEARING TYPE	Videoconference Hearing	
DATE OF HEARING	6 April 2023	
date of further family violence submissions	Respondent (2 May 2023)
Applicant (18 May 2023)	
DATE OF ORDER and reasons	16 June 2023	
date of correction	6 September 2023	
CITATION	Medical Board of Australia v AEB (Review and Regulation) (Corrected) [2023] VCAT 674	

findings
1	In respect of each of Allegations 1, 2, 3, 4 and 8, AEB engaged in professional misconduct within the meaning of paragraphs (a) and (b) of the definition in section 5 of the Health Practitioner Regulation National Law (Victoria) Act 2009 (National Law), in that:
(a)	from on or about 19 December 2016 to on or about 24 August 2018, AEB prescribed pethidine, a Schedule 8 poison, to a patient who is not a drug dependent person, for a continuous period greater than 8 weeks without having applied for or obtained a permit as required by the Drugs, Poisons and Controlled Substances Act 1981 (Vic) (DPCS Act);
(b)	from on or about September 2004 to in or about April 2019, AEB provided ongoing medical care as the treating medical practitioner to her father, Patient A, in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners;
(c)	between 19 December 2016 and 24 August 2018, AEB inappropriately prescribed pethidine, a Schedule 8 poison, to patient, namely Patient A, without having regard to the appropriateness and possible risks of this treatment; 
(d)	from in or around September 2004 to on or around 13 April 2020, AEB provided ongoing medical care as the treating medical practitioner to her mother, Patient B, in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners; and
(e)	between in or around September 2004 and on or about 3 December 2011, AEB provided medical care as the treating medical practitioner to her grandfather, Patient F in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.
2	In respect of each of Allegations 5, 6 and 7, AEB engaged in unprofessional conduct within the meaning of the definition in section 5 of the National Law, in that:
(a)	on or around 11 January 2019, AEB provided medical care as the treating medical practitioner to her son, Patient C, in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners;
(b)	on or around 23 June 2017 and on or around 21 December 2017, AEB provided medical care as the treating medical practitioner to her son, Patient D, in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners; and 
(c)	on or around 9 November 2014, AEB provided medical care as the treating medical practitioner to her husband, Patient E in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners. 
Orders
1	Under section 196(2)(a) of the National Law, AEB is reprimanded.
2	Under section 196(2)(d) of the National Law, AEB’s registration as a medical practitioner is suspended, with effect from 30 June 2023, for a period of 6 months, expiring on 30 December 2023.
3	Under section 196(2)(b) of the National Law, the conditions set out in the attachment to these orders are imposed on AEB’s registration on her return to practice, with the review period for the conditions set at 12 months from the date of AEB’s return to practice under section 196(3) of the National Law.

R. Tang, AM
Senior Member and Presiding Member	Dr A. Sungaila
Health Practitioner Member	Dr L. Warfe, OAM
Health Practitioner Member	

APPEARANCES:		
For Applicant 	Ms M. Isobel of Counsel	
For Respondent	Ms R. Ellyard of Counsel	
Orders are in place under the open courts act 2013 (ViC)
On 6 April 2023, the Tribunal made the following orders under s 17 of the Open Courts Act 2013 (Vic):

1.	The respondent in these proceedings must be referred to as ‘AEB’.
2.	Any report of the whole or part of these proceedings or information derived from these proceedings that might enable the patients the subject of these proceedings to be identified, including but not limited to by identifying the respondent, must not be published or otherwise disclosed.
3.	This order applies throughout Australia on the basis that VCAT’s reasons for decision for final orders are published on AustLII and that website may be accessed throughout Australia. The privacy of the people referred to in order 2 would be breached if persons living outside Victoria know or come to know their identity.
4.	This order operates until the later of the death of all of the people referred to in order 2.

Attachment to orders
Conditions on registration
Attend treating practitioner(s)
1.	The Practitioner must undertake treatment with a registered psychologist (the treating practitioner(s)) and attend at a frequency determined by the treating practitioner(s).
2.	Within 21 days of the notice of the imposition of these conditions, the Practitioner must provide the following to Ahpra:
a.	The contact details, on the approved form (HPF3), of all treating practitioners.
b.	Acknowledgement, on the approved form (HPF3), from the Practitioner that Ahpra may seek reports from the treating practitioner(s) every three months.
c.	Confirmation, on the approved form (HPNA3), from the treating practitioner(s) that they have seen a copy of the conditions on the Practitioner’s registration and are aware Ahpra may contact them to seek reports.
Attend for mentoring
3.	The Practitioner must be mentored by another registered medical practitioner in relation to managing conflicts of interests and professional boundaries; prescribing schedule 8 medications; and chronic pain management.
For the purposes of this condition, 'mentoring' is defined as a relationship in which a skilled registered practitioner (the mentor) helps to guide the professional development of another practitioner.
4.	The mentoring must comprise a minimum of 12 sessions with each session being of one hour duration occurring over a 12-month period.
5.	Within 21 days of the notice of the imposition of these conditions, the Practitioner must, on the approved form (HPN16), nominate a person(s) to be approved by the Board to act as mentor. The Practitioner must ensure that the nomination is accompanied by acknowledgement, on the approved form (HPNA16), from the nominated person.
6.	Within 21 days of the notice of the imposition of these conditions the Practitioner must provide to Ahpra, on the approved form (HP16), acknowledgement that Ahpra may seek reports from the approved mentor on any or all of the following occasions:
a.	every month
b.	at the conclusion of the mentoring relationship in order to confirm the outcomes of the mentoring
c.	whenever the mentor has a concern or becomes aware of a concern regarding the Practitioner’s conduct or professional performance, and
d.	when otherwise requested by Ahpra.
7.	In the event an approved mentor is no longer willing or able to provide the mentoring required the Practitioner is to provide a new nomination in the same terms as previous nominations. Such nomination must be made by the Practitioner within 21 days of becoming aware of the termination of the mentoring relationship.
8.	Within 60 days of the conclusion of the mentoring the Practitioner must provide a report demonstrating, to the satisfaction of the Board, that the Practitioner has reflected on the issues that gave rise to the condition requiring they attend for mentoring and outlining how the Practitioner has incorporated the lessons learnt in the mentoring into their practice.
Other
9.	Within 21 days of the notice of the imposition of these conditions the Practitioner must provide to Ahpra, on the approved form (HPC), the contact details of a senior person, such as the Director of Medical Services, Director of Nursing, Senior Practice Manager, Senior Manager, Senior Partner, Proprietor, Owner, or equivalent (the senior person) at each current place of practice. In providing this form, the Practitioner acknowledges that Ahpra will contact the senior person and provide them with a copy of the conditions on the Practitioner’s registration or confirm that the senior person has received a copy of the conditions from the Practitioner. The Practitioner will be required to provide the same form:
a.	within seven days of the commencement of practice at each subsequent place of practice, and
b.	within seven days of each and every notice of any subsequent alteration of these conditions.
10.	All costs associated with compliance with the conditions on their registration are at the Practitioner’s own expense.

Reasons
1	This proceeding relates to eight allegations of professional misconduct or unprofessional conduct, referred by the Medical Board of Australia (Board) to the Tribunal under section 193 of the Health Practitioner Regulation National Law (Victoria) (National Law), concerning the medical treatment provided by AEB, a general practitioner, to her father (Patient A), mother (Patient B), sons (Patients C and D), ex-husband (Patient E) and grandfather (Patient F).  
2	In each case, the provision of medical treatment by AEB to her family members is alleged (and accepted by AEB) to have been contrary to applicable standards and codes of conduct for registered medical practitioners which have been in place since September 2004.  Further, the medical treatment provided by AEB to her father included the regular prescription of pethidine (a Schedule 8 (S8) drug or poison) over an extended period, without a permit, which is alleged (and accepted by AEB) to have been: 
•	contrary to the Drugs, Poisons and Controlled Substances Act 1981 (Vic) (DPCS Act); and 
•	otherwise inappropriate in that the prescribing occurred without regard to the appropriateness and possible risks of that treatment.
3	For the reasons set out below, we are comfortably satisfied that she engaged in the conduct as particularised and that:
(a)	in the case of each of the allegations relating to her father, mother and grandfather, the conduct amounts to ‘professional misconduct’ as defined in paragraphs (a) and (b) of the definition of that term in section 5 of the National Law; and
(b)	in the case of each of the allegations relating to her sons and ex-husband, the conduct amounts to ‘unprofessional conduct’ as defined in section 5 of the National Law.
4	The parties have jointly proposed that AEB be reprimanded, suspended for a period of time and have conditions as to mentoring and psychological treatment imposed on her registration when she returns to practice.  The only area of disagreement between the parties is the appropriate length of suspension.  The Board seeks that AEB be suspended for a period of nine months, while AEB contends that a shorter period of three months is appropriate in all the circumstances, particularly having regard to the family dynamics discussed in these reasons.
5	For the reasons set out below, we have determined that AEB should be reprimanded, suspended for a period of 6 months and have conditions as to mentoring and psychological treatment imposed on her registration when she returns to practice.
6	The risks of doctors treating their family members has long been recognised as problematic.  As the Board’s expert witness (Associate Professor Morton Rawlin) observes: 
[the] risk of adverse outcomes and power imbalance within family relationships can be particularly difficult to resolve and can cause significant stress as well as potential for poor medical outcomes due to bias in treatment and investigation and being influenced by factors other than medical fact.
7	AEB’s extended prescription of pethidine to her father, without a permit and without proper consideration of the appropriateness and risks of such treatment, is an illustration of the problems which can arise.
Findings as to conduct and its characterisation
8	The Amended Notice of Allegations filed on 29 September 2022 (Amended Notice) sets out eight allegations relating to AEB’s treatment of her family members, which are set out in full in the Annexure to these Reasons.
Allegation 1: Prescribing of pethidine to father without a permit
9	The first allegation relates to AEB’s prescribing of pethidine to her father between December 2016 and August 2018 without a permit as required under the DPCS Act.  
10	The conduct came to light as a result of a notification made by the (then) Victorian Department of Health and Human Services (DHHS) to the Australian Health Practitioner Regulation Agency (Ahpra) in September 2018.  This followed an investigation by the Drug and Poisons Regulation unit of DHHS of ‘[a]n unusually large quantity of pethidine injections’ being supplied to a chemist in suburban Melbourne.  That investigation revealed that AEB had prescribed pethidine to Patient A on some 72 occasions between 6 February 2009 and 24 August 2018. 
11	Section 34 of the DPCS Act provides that a doctor must apply for a permit from the Secretary of the Department of Health (Secretary) if the doctor considers it necessary to prescribe a S8 poison (which includes pethidine) to a person (who is not drug dependent) for a continuous period greater than 8 weeks.  It is an offence to continue to prescribe without such a permit.  
12	While the records demonstrate that AEB had been prescribing pethidine to her father from at least February 2009, the frequency of prescription increased from late 2016, and the quantity of the dosage increased from mid 2017.  In response to a question from the Tribunal, Ms Ellyard (Counsel for AEB) confirmed that AEB accepted that her prescribing of pethidine for her father had been undertaken for a continuous period greater than 8 weeks by 19 December 2016.  
13	A certificate issued by a delegate of the Secretary of DHHS confirms that AEB has never held a permit to treat her father with pethidine.  While there is some evidence that AEB did apply for a permit in September 2018, this was after she had become aware of the DHHS investigation and beyond the date range for the allegation.
14	The parties jointly submit that the conduct the subject of allegation 1 is ‘professional misconduct’ as defined in sub-paragraphs (a) and/or (b) of the definition of that term in section 5 of the National Law, i.e.:
(a)	unprofessional conduct by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and
(b)	more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; 
15	The Tribunal Book includes an opinion from Dr Benny Monheit, a doctor with specialist qualifications in public health and addiction medicine, who states that the pattern of prescribing without a permit, particularly from 2017 onwards, was ‘below the standard reasonably expected of a registered medical practitioner’.  We think this downplays the seriousness of the conduct.  In this regard, we note Associate Professor Rawlins observes that the breach of the ‘S[chedule] 8 legislative requirements over a long time … is a serious offence’.
16	As already noted, the conduct the subject of this allegation gives rise to an offence against the DPCS Act and is demonstrably serious.  As observed by Hope JA in Spicer v NSW Medical Council: 
it is clear beyond argument that the proper handling and prescribing of drugs by medical practitioners are of the greatest importance to the community. If a medical practitioner handles or carries out that very great responsibility in a way that is reckless and which shows a disregard for the law, it cannot be said that he is fitted at such a time to be a medical practitioner ...
17	While that quote suggests it might be open to make a finding under paragraph (c) of the definition of ‘professional misconduct’ (ie. that the conduct is inconsistent with AEB being a fit and proper person to hold registration), we are mindful that the parties have advanced a joint position that the conduct falls within paragraphs (a) and/or (b) of the definition.  This clearly involved some level of negotiation and compromise by the parties.  For instance, AEB did not seek to cavil with the date which the Board had chosen as the starting point for the relevant conduct.
18	In all the circumstances, we are comfortably satisfied and find that:
AEB engaged in professional misconduct within the meaning of paragraphs (a) and (b) of the definition in section 5 of the Health Practitioner Regulation National Law (Victoria) Act 2009 (National Law), in that from on or about 19 December 2016 to on or about 24 August 2018, AEB prescribed pethidine, a Schedule 8 poison, to a patient who is not a drug dependent person, for a continuous period greater than 8 weeks without having applied for or obtained a permit as required by the Drugs, Poisons and Controlled Substances Act 1981 (Vic) (DPCS Act).
Allegation 2 – Treatment of father where avoidable and contrary to standards
19	The second allegation relates to AEB’s general treatment of her father between September 2004 and April 2019 contrary to applicable standards and codes of conduct.
20	In an early response to Ahpra, AEB confirmed that she had been Patient A’s treating doctor since 1995.  
21	It has long been recognised that doctors ought not treat their family members.  In this regard, Associate Professor Rawlins refers to ‘professional distance’ between doctor and patient as forming part of medical school training in ethical practice ‘from at least the 1970’s’.  
22	The allegation relates to AEB’s continuing treatment of her father following the publication, in September 2004, of a Bulletin by the (then) Medical Practitioners Board of Victoria (MPBV) which included a ‘Statement on Doctors Treating Members of their Family’.  While the statement recognised that doctors can ‘play a valuable role in the health care of family members’ in an advisory capacity, it was recommended that they ‘encourage family members to have an independent and trusted general practitioner to coordinate their care’ and ‘avoid being the primary treating doctor of a family member’, except in cases of emergency or where other medical care is not accessible.
23	Associate Professor Rawlins describes AEB’s roles as general practitioner for her father for more than 25 years as ‘very inappropriate’.  Noting that Patient A is ‘a complex individual with multiple intersecting chronic illnesses’, he goes on to state that the ‘treatment of chronic illness in family members should be avoided wherever possible’ and that the treatment which AEB provided was of ‘a very long term nature and is clearly outside and against the stated intent of the [standards and guidelines]’.
24	The particulars of the allegation include that AEB’s clinical records demonstrate a failure to:
have proper regard to the appropriateness and possible risks of the specific treatment of pethidine provided to the patient ([Patient A]);
have proper regard to the appropriateness and possible risks of prescribing, and continuing to prescribe, pethidine to the patient ([Patient A]);
conduct an appropriate pain specialist review in respect of the patient ([Patient A]); and
to maintain accurate, up-to-date and legible records in respect of her treatment of the patient ([Patient A]).
25	Further, it is suggested that AEB’s records do not:
identify on what day each injection was given to the patient ([Patient A]), or who administered the injections;
contain all of the information or diagnoses subsequently relied on by [AEB] to justify her prescribing conduct in respect of the patient ([Patient A]); or
provide sufficient detail to allow for continuity of care of the patient ([Patient A]).
26	These particulars are supported by the opinion of Dr Monheit, who (in response to a question of whether each pethidine prescription was justified) observes:
a. 	The clinical notes for the dates corresponding to the script date are inadequate for me to make a judgement on its clinical appropriateness on each of the 69 occasions a separate Pethidine script was written during the nine years.
b. 	The clinical notes do not specify on what day the injection was given, what the pain level was before and after the injection.
c. 	I am also unclear whether [AEB] administered the injections to her father herself and therefore able to assess the ongoing need for it each time, or whether the injection was given by someone else who was just following [AEB’s] order for an injection to be give once or twice a day.
27	For example, in relation to the pethidine prescription of 6 July 2018, Dr Monheit observes that:
In spite of 4 Pethidine scripts in July the 2 clinical notes during that [month] do not explain the increasing need for Pethidine. There is no justification given for 40 ampoules of Pethidine prescribed during this time. This amount of Pethidine I believe exposed [Patient A] to harm from increased risk of fits, poor pain control and this in turn contributing to his mental health problems. The intermittent use of benzodiazepine increases the risk of lethargy and accidental overdose.
28	Dr Monheit also suggests that ‘[a]s the pain treatment was not working (perhaps due to greater tolerance to the Pethidine) a referral for advice or specialist treatment should … have been sought’.
29	Again, the parties jointly submit that the conduct the subject of allegation 1 is ‘professional misconduct’ as defined in sub-paragraphs (a) and/or (b) of the definition of that term in section 5 of the National Law.
30	Associate Professor Rawlins opines that AEB ‘transgressed the Good Medical Practice code in a significant and sustained way’ that ‘was inappropriate and should not have occurred’.  
31	Individually and collectively, the consultations that AEB had with her father fell substantially below the standard which is reasonably expected of a practitioner.  We are comfortably satisfied and find that:
AEB engaged in professional misconduct within the meaning of paragraphs (a) and (b) of the definition in section 5 of the National Law, in that from on or about September 2004 to in or about April 2019, AEB provided ongoing medical care as the treating medical practitioner to her father, Patient A, in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.
Allegation 3 – Prescribing of pethidine without regard to appropriateness and risks
32	The third allegation is a further allegation relating to AEB’s prescribing of pethidine to her father, namely that she did so without regard to the appropriateness and risks of doing so.
33	This allegation overlaps somewhat with the particulars of Allegation 2 that are discussed in the preceding section.  In addition, the particulars include reference to guidance, from at least 2015, which indicated that the prescribing of pethidine was inappropriate for chronic non-malignant pain.  In this regard, in January 2015, the Victorian Department of Health issued its Policy for issuing S8 permits, which included a reference to advice from the Australian Pain Society that:
There is agreement internationally and within Australia that intra-muscular opioids [i.e. opioids given by injection] should play no part in the treatment of chronic nonmalignant pain. In particular intra-muscular pethidine should be avoided.
34	Similarly, in 2017, in its publication  on ‘Prescribing drugs of dependence in general practice, Part C2’, the Royal Australian College of General Practitioner provided the following guidance on pethidine:
Pethidine is a synthetic opioid active at the mu receptor. [Intra-muscular] pethidine has been widely used in Australia for a range of pain problems. Its use is decreasing because of multiple disadvantages compared to other opioids. Repeated dosing or renal failure leads to accumulation of its active metabolite (norpethidine), which is associated with neuroexcitatory effects that range from nervousness to tremors, twitches, multifocal myoclonus and seizures.
When used parenterally [i.e. administered outside the intestines], pethidine does not provide better analgesia than morphine, but does induce more nausea and vomiting than morphine.
In practice
Use of pethidine is discouraged in favour of other opioids.
It has high addiction potential and is not recommended for the treatment of persistent pain.
35	In his opinion, Associate Professor Rawlins observes that:
as a general rule pethidine is rarely used over the last 5 -10 years due to its short acting nature, its euphoric reaction ability and high addiction possibility. Using increasing levels of this medication raises grave concerns albeit that it is clear [Patient A] does have significant chronic pain that does require treatment.
36	This material supports the proposition (as set out in particular [24]) that pethidine ‘was not an appropriate prolonged treatment for the medical conditions of [Patient A] in the period between 19 December 2016 and 21 August 2018’.
37	Dr Monheit concludes that AEB’s ‘prescribing of long term short acting opioids such as Pethidine to her patient during this time falls below the standard reasonably expected of a registered medical practitioner’.
38	Again, we consider this downplays the risks involved.  While there is no evidence that Patient A actually became addicted to pethidine or suffered any long-term adverse effects, there was clearly a significant risk – which a reasonably competent general practitioner ought to have been aware of – that addiction or harm may have resulted from the long-term use of pethidine for the management of Patient A’s chronic pain. 
39	In the circumstances, we are comfortably satisfied and find that:
AEB engaged in professional misconduct within the meaning of paragraphs (a) and (b) of the definition in section 5 of the National Law in that, between 19 December 2016 and 24 August 2018, AEB inappropriately prescribed pethidine, a Schedule 8 poison, to patient, namely Patient A, without having regard to the appropriateness and possible risks of this treatment.
Allegations 4 and 8 - Treatment of mother and grandfather where avoidable and contrary to standards
40	The fourth and eighth allegations concern AEB’s treatment of her mother between September 2004 and April 2020, and AEB’s treatment of her grandfather between September 2004 and his death in December 2011.
41	In particular [28], it is stated that AEB:
regularly provided medical care services to [her mother] as her treating medical practitioner. The medical care services included, among other things, consulting and treating [her mother], as [AEB's] patient, for long-term chronic medical conditions, referrals to specialists, and prescribing various medications to treat various medical conditions.
42	Similarly, particular [40] states that AEB provided medical services to her grandfather ‘for long-term chronic medical conditions, referrals to specialists, and prescribing various medications to treat various medical conditions’.
43	That AEB was her mother’s treating medical practitioner between 2004 and 2020, and her grandfather’s treating medical practitioner between 2004 and 2011, is evident from the medical records included in the Tribunal Book.
44	AEB’s conduct, in continuing to act as the treating medical practitioner for both her mother and grandfather after September 2004, despite the guidance to the contrary, in each case fell substantially below the standard which is reasonably expected of a practitioner for the reasons already discussed in relation to Allegation 2.  We are comfortably satisfied and find that:
AEB engaged in professional misconduct within the meaning of paragraphs (a) and (b) of the definition in section 5 of the National Law, in that from in or around September 2004 to on or around 13 April 2020, she provided ongoing medical care as the treating medical practitioner to her mother, Patient B, in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners; and
AEB engaged in professional misconduct within the meaning of paragraphs (a) and (b) of the definition in section 5 of the National Law, in that between in or around September 2004 and on or about 3 December 2011, AEB provided medical care as the treating medical practitioner to her grandfather, Patient F in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.
Allegation 5 to 7: Treatment of ex-husband and two sons where avoidable and contrary to standards
45	Each of the fifth to seventh allegations relate to the provision of medical treatment to a family member (her ex-husband and two sons) on one or two occasions.  The medical records in the Tribunal Book evidence that treatment was provided as particularised.
46	While the provision of that treatment might have been convenient, it does not appear that in any of those cases, the treatment was provided in an emergency or where alternative medical care was not accessible.  Accordingly, it was still contrary to the applicable standards at the time and therefore below the standard reasonably expected of a practitioner like AEB. 
47	However, unlike allegations two, four and eight, it does not appear that AEB was the usual treating practitioner for those family members and, as each allegation only relates to one or two instances of treatment, we do not consider that it fell substantially below the standard expected.
48	For these reasons, we are comfortably satisfied and find that:
AEB engaged in unprofessional conduct within the definition in section 5 of the National Law, in that on or around 11 January 2019, AEB provided medical care as the treating medical practitioner to her son, Patient C, in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners;
 AEB engaged in unprofessional conduct within the definition in section 5 of the National Law, in that on or around 23 June 2017 and on or around 21 December 2017, AEB provided medical care as the treating medical practitioner to her son, Patient D, in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners; and 
AEB engaged in unprofessional conduct within the definition in section 5 of the National Law, in that on or around 9 November 2014, AEB provided medical care as the treating medical practitioner to her husband, Patient E in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.

Determinations
49	The law relating to the making of determinations has been considered in many cases and is not in dispute.  Essentially, the purpose of determinations is protective, rather than punitive.  The need for specific and/or general deterrence and the protection of the public will be relevant, as will be the remorse and insight of the practitioner and any steps they have taken to rehabilitate themselves or in that direction.
50	Delay can be relevant, as can be character evidence and ‘other potentially mitigating factors such as medical or psychological evidence, personal or family circumstances’.
Board’s submissions
51	The Board contends that this is an appropriate case to make global determinations and that the Board should reprimand AEB and impose conditions on her registration relating to mentoring and psychological treatment on the basis that has been agreed between the parties.
52	The Board contends that, in addition, AEB should be suspended from practice for a period of 9 months.  Ms Isobel (Counsel for the Board) suggested that the Board had determined this period on the basis that the appropriate period of suspension in respect of: 
•	Allegations 1 to 3 is 3 months; and
•	Allegations 4 to 8 is 6 months.
53	Ms Isobel contended that the proposed period of suspension is appropriate when regard is paid to:
•	the nature and gravity of AEB’s excessive prescribing of pethidine to her father over an ‘extraordinary period’;
•	the ‘repeated breaches’ of guidelines and legislation;
•	the conduct relates to ‘so many members of her family’; and
•	the conduct continued for some time after AEB was notified by Ahpra of the investigation.
54	It was submitted that, while this might ‘ordinarily raise questions as to a practitioner’s suitability to continue in practice’, the Board accepted that there were ‘special circumstances’ and, as such, was not seeking cancellation of AEB’s registration. In particular, the Board accepts that the need for specific deterrence is somewhat ‘tempered’ given the work that AEB has done (and continues to do) to understand her conduct and drivers.
55	Nevertheless, the Board contends that there is still a need for a ‘severe sanction’ and that the proposed period of suspension is the ‘absolute minimum’ necessary to reflect the gravity of the offending and for the purposes of general deterrence.
56	The Board highlighted the following cases as providing some assistance:
Case	Conduct	Special Circumstances	Determinations (and comparability)	
Medical Board of Australia v Fox (Fox)	Inappropriate prescriptions, deficiencies in medical management and patient records	Doctor practised in rural area, with focus on aboriginal health and had a high patient load, provided strong references, suffered from health problems and had ageing parents and witnesses a colleague’s suicide	Reprimand, 12 month suspension and conditions (case involved the prescription of more drugs to more patients and was more serious, but did not involve treatment of family members)	
Medical Board of Australia v Sutton	10 allegations, including prescription of S8 drugs without a permit and prescription of S4 drugs to close family 		Disqualification for 4 years (prior offending)	
Medical Board of Australia v Sevdalis (Sevdalis)	Treatment of 2 family members, including prescribing S8 drugs, also prescribing intravenous antibiotics to other patients		Reprimand, suspension for 6 months (higher than agreed between parties) and conditions on registration (previously sanctioned)	
Medical Board of Australia v PXI (PXI)	Treatment of 1 patient (with whom doctor in close relationship), including prescribing S8 drugs without permit	Remorse and insight shown by doctor	Reprimand and disqualification for 3 months (aggravating factor that relationship was with former patient)	

57	The Board submits that AEB’s conduct is more serious than that of the respondents in Sevdalis and PXI, given the length of time over which it occurred, the number of family members involved and the repetition of the conduct.  
AEB’s submissions
58	While AEB accepts that she ought to be suspended, she contends that a period of no longer than 3 months is appropriate, having regard to:
•	the context for her conduct, particularly the family dynamics which Ms Ellyard suggested operated to ‘reduce her personal culpability’ and the ‘gravity’ of the offending having regard to the Court of Appeal decisions in Quinn v Law Institute of Victoria and Legal Services Commissioner v Stirling.
•	the effect that the suspension will have on AEB’s patient cohort; and
•	the absence of any need for specific deterrence.
59	Ms Ellyard submitted that, when it came to considering other cases, it was necessary to separate cases involving inappropriate prescribing from cases involving the treatment of family members.  In relation to: 
•	inappropriate prescribing cases, reference was made to three cases where the period of suspension ranged from 3 to 6 months; and
•	treatment of family members, reference was made to Sevdalis (6 months) and to Medical Board of Australia v Koniuszko (reprimand and conditions on registration for treatment of family and friends, which continued despite an undertaking to stop). 
60	In terms of the relevance of the impact of any period of suspension on patients, Ms Ellyard made reference to Fox and Medical Board of Australia v Ballekere.
61	Ms Ellyard said AEB accepts that she engaged in ‘objectively serious conduct, involving decades of acting as a general practitioner’ for close family members, and that the ‘starting point might be [to ask] how can AEB be relied upon to be a competent general practitioner’.  However, Ms Ellyard observed that, setting aside AEB’s prescribing of pethidine to her father, the quality of care provided was ‘sound’ and that she maintained ‘good records’.
62	Ms Ellyard said that while the prescribing of pethidine by AEB to her father was ‘contrary to law’ and was ‘not the right treatment’, her reasons for doing so was ‘inextricably linked to her relationship with her father’ (noting that there was no evidence of AEB prescribing pethidine to any other family member).
63	In that regard, Ms Ellyard suggested that AEV was ‘profoundly affected’ by the ‘toxic’ environment in respect with her parents and grandparents in terms of:
•	how they behaved with each other;
•	how they behaved with AEB (in terms of lack of respect); and
•	the expectations that they placed on AEB,
which she ‘tried to manage despite the criticisms and demands’, and feeling obliged to provide medical care to them ‘despite, or because of, how they treated her’.
64	Ms Ellyard referred to AEB’s initial response to Ahpra, where AEB referred to looking after her parents as her ‘duty and privilege’ because in her mind and in practice, doing so was unavoidable (referencing an ‘ethical debt to be repaid to [her] parents, who disrupted their lives to bring [her from Ukraine] to Australia so that [she could] have a future’).  Similarly, she treated her grandfather out of loyalty, despite his verbal abuse directed to her grandmother.
65	Ms Ellyard submitted that the three reports prepared by Ms Kaye Frankcom, a clinical and counselling psychologist, demonstrated the ‘trajectory of AEB’s insight’, namely that she was angry at first, was developing her insight in the next session and, by March 2022, had come to appreciate that she was suffering the effects of ‘intergenerational coercive control’.
Submissions regarding the impact of domestic violence on moral culpability
66	Noting AEB’s submissions at [58] (first dot point), which seemed to us to be novel, we gave the parties leave to file submissions identifying any relevant decisions which had addressed the impact of domestic violence on moral culpability in a criminal law context and/or in the context of disciplinary matters.
67	AEB’s solicitors wrote to the Tribunal on 2 May 2023 identifying a number of criminal cases and disciplinary cases where family violence was in issue, although conceding that none ‘deals specifically, in the disciplinary context, with the principles from R v Verdins (Verdins principles) relating to the family violence’.  However, it is suggested that the criminal law cases ‘all support the significance of family violence as a mitigating factor’ and that if a ‘mental condition [is] caused by family violence … [it] may make a practitioner an inappropriate vehicle for general deterrence’.  Based on the opinion of Ms Frankcom, it was submitted to be ‘clear that experience of family violence and abuse played a key role in why [AEB] engaged in the conduct’ and, as there was a causal link between the family violence, AEB’s psychological condition and the misconduct, it ‘ought to mitigate, the significance of general deterrence’.
68	In submissions prepared by the Board’s solicitors dated 18 May 2023, it is suggested that the Verdins principles are a ‘set of nuanced principles that require careful consideration’, which in this case: 
would require an assessment of factors such as the nature and severity of [AEB]’s symptoms, the effect on the condition on [AEB]’s mental capacity, and whether she acted with knowledge of what she was doing and … the gravity of her actions.
69	The Board submits that AEB has ‘not provided sufficient evidence to engage Verdins or to allow the Tribunal to directly apply any of [its] principles’.  The Board suggests that, in any event, it has taken account of the evidence as to family violence in seeking a 9 month period of suspension and that, absent that, ‘the Board would almost certainly be seeking a far more significant sanction’.
Reprimand
70	It is necessary and appropriate for the Tribunal to reprimand AEB in order to express its condemnation of her misconduct given its nature and extent (in terms of the number of family members she treated, the period of time over which it took place and the nature of the medications (i.e. S8 drugs) prescribed to her father). 
Suspension
71	While it can be accepted that ‘personal or family circumstances’ can be a mitigating factor in disciplinary proceedings, including (if relevant) cultural factors impacting on the place of a women in the family unit, we agree with the Board’s submission that something more is required if it is sought to be contended that, because of such circumstances, the person does not represent an appropriate vehicle for general deterrence.  Even if it were accepted that the coercive control exercised by her grandfather (and perhaps also by her husband) impacted on her level of moral culpability, it would not explain sufficiently why she also felt it necessary to treat her mother, grandmother and sons.
72	We accept that the Board has taken account of the family violence in contending for a suspension of 9 months.  For comparison, in Medical Board of Australia v RRB, a doctor found to have prescribed Schedule 4 drugs (in large quantities) to a family member over a period of 4 years, was disqualified for an agreed period of 18 months (on top of a period of around 3½ years that the doctor has been out of practice, following retirement).
73	In all the circumstances, we do not accept that the issues of coercive control identified in Ms Frankcom’s report is such as to warrant a relatively nominal period of suspension of 3 months.
74	We accept the Board’s submissions that AEB’s conduct is more serious than in PXI given the number of family members involved and the extended period over which it occurred, warranting a period of suspension greater than 3 months.
75	However, we do consider that when regard is paid to all circumstances, with the issue of family violence countervailing the larger number of family members to which the conduct relates, Sevdalis is the closest analogy and suggests that a 9 month period of suspension is too long. 
76	Ultimately, we have determined that the appropriate period of suspension is 6 months.  We will delay the commencement of the suspension for 14 days to allow arrangements to be made by AEB and her practice for any consequential rescheduling of patient appointments.  
Conditions on registration
77	The proposed conditions as to counselling and mentoring will enable AEB to return to practice, successfully and safely, after she completes the period of suspension.
78	Given the family dynamics which gave rise to the misconduct, we consider that these conditions are both necessary and appropriate.

R. Tang, AM
Senior Member and
Presiding Member	Dr A. Sungaila
Health Practitioner Member	Dr L. Warfe, OAM
Health Practitioner Member	

Annexure – Amended Notice of Allegations

ALLEGATION ONE

1. 	That [AEB], a registered medical practitioner, engaged in:

1.1	professional misconduct within the meaning of paragraphs (a), (b) and/or (c) of the definition in section 5 of the Health Practitioner Regulation National Law (Victoria) Act 2009 (the National Law); and/or

1.2 	unprofessional conduct within the meaning of the definition in section 5 of the National Law.

in that from on or about 19 December 2016 to on or about 24 August 2018, [AEB] prescribed pethidine, a Schedule 8 poison, to a patient who is not a drug dependent person, for a continuous period greater than 8 weeks without having applied for or obtained a permit as required by the Drugs, Poisons and Controlled Substances Act 1981 (Vic) (DPCS Act).

Particulars

2. 	The DPCS Act regulates the prescribing of various drugs, poisons and controlled substances in the State of Victoria.

3. 	Pethidine is and was at all material times a Schedule 8 poison under the DPCS Act.

4. 	The Victorian Department of (DoH), formerly the Department of Health and Human Services (DHHS), is responsible for the administration of the permit system for Schedule 8 poisons under the DPCS.

5. 	Section 34 of the DPCS Act provides that a registered medical practitioner who considers it is necessary to administer, supply or prescribe a Schedule 8 poison for a continuous period greater than 8 weeks to or for a patient who is not a drug dependent person must apply to the Secretary for a Schedule 8 permit.

6. 	Section 34C of the DPCS Act provides that it is an offence to administer, supply or prescribe a Schedule 8 poison to or for a person who is not a drug dependent person for a continuous period greater than 8 weeks unless the practitioner holds a Schedule 8 permit for that administration, supply or prescription for that person or is otherwise authorised under the Act.

7. 	DHHS's review of pharmacy dispensing records at Chemist Warehouse, The Links Shopping Centre, Oakleigh South identified that, between 12 May 2017 and 21 August 2018, that 325 pethidine 100mg injections were supplied to the patient ([Patient A]) upon prescriptions issued by [AEB].

8. 	DHHS has no record that [AEB] applied for or had been granted a permit to administer, supply or prescribe a Schedule 8 poison to the patient ([Patient A]) under the DPCS Act.

9. 	In response to a DHHS request for information, [AEB] provided a Past
Prescription Report for the patient ([Patient A]) showing that [AEB] had on multiple occasions between 6 February 2009 and 24 August 2018 prescribed pethidine to the patient ([Patient A]) (see Schedule 1 to this Notice). [AEB]’s clinical records in respect of the patient ([Patient A]) confirm this.

ALLEGATION TWO

10. 	That [AEB], a registered medical practitioner, engaged in:

10.1 	professional misconduct within the meaning of paragraphs (a), (b) and/or (c) of the definition in section 5 of the National Law; and/or

10.2 	unprofessional conduct within the meaning of the definition in section 5 of the National Law.

in that from on or about September 2004 to on or about 27 Mayin or about April 2019 she provided ongoing medical care as the treating medical practitioner to a close family member, namely [Patient A], in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.

Particulars

11. 	[Patient A] is the father of [AEB].

12. 	[AEB]’s clinical records demonstrate a failure to:

12.1 	have proper regard to the appropriateness and possible risks of the specific treatment of pethidine provided to the patient ([Patient A]);

12.2 	have proper regard to the appropriateness and possible risks of prescribing, and continuing to prescribe, pethidine to the patient ([Patient A]);

12.3 	conduct an appropriate pain specialist review in respect of the patient ([Patient A]); and

12.4 	to maintain accurate, up-to-date and legible records in respect of her treatment of the patient ([Patient A]).

13. 	In September 2004 the Medical Practitioners Board of Victoria produced a Bulletin for all registered medical practitioners in Victoria, which included a finalised ‘Statement on Doctors Treating Their Family’. The statement provided that the ‘Medical Practitioners Board of Victoria "believes that it is advisable for family members of medical practitioners to have an independent treating doctor."

14. 	In December 2006 Medical Practitioners Board of Victoria produced a "Good Medical Practice, Guidelines on professional conduct". The Guidelines describe the principles of good medical practice and standards of care expected of medical practitioners in all aspects of their professional work. Guideline 2 stated that medical practitioners must observe professional and ethical obligations in the practice of medicine and this includes: avoid treating members of your own family.

15. 	From 1 July 2010 the Medical Board of Australia published the "Good Medical Practice: A Code of Conduct for Doctors in Australia" (Code of Conduct). In the Code of Conduct at paragraph 3.14, it states that "Whenever possible, avoid providing medical care to anyone with whom you have a close personal relationship. In most cases, providing care to close friends, those you work with and family members is inappropriate because of the lack of objectivity, possible discontinuity of care and risks to the doctor and patient."

16. 	The Code of Conduct also states at paragraph 8.4.1 that medical practitioners must "keep accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners".

17. 	On 17 March 2014 the Medical Board of Australia published the an updated version of "Good Medical Practice: A Code of Conduct for Doctors in Australia". Paragraph 3.14 of the Code repeats the statements set out in paragraphs 15 and 16 above. This Code of Conduct has been in force since 17 March 2014 and remains in force.

18. 	Between 1995 and 27 May 2019 [AEB] regularly provided medical care services to [Patient A] as his treating medical practitioner. The medical care services included, amongst other things, consulting and treating [Patient A], as [AEB]’s patient, regarding various medical conditions, referrals to other medical practitioners (such as specialists) and prescribing various medications to treat various medical conditions.

19. 	These medical care services are documented in medical records maintained by [AEB], correspondence with other medical practitioners, prescriptions and Medicare records. However, [AEB]'s records do not:

19.1 	identify on what day each injection was given to the patient ([Patient A]), or who administered the injections;

19.2 	contain all of the information or diagnoses subsequently relied on by [AEB] to justify her prescribing conduct in respect of the patient ([Patient A]); or

19.3 	provide sufficient detail to allow for continuity of care of the patient ([Patient A]).

ALLEGATION THREE

20. 	That [AEB], a registered medical practitioner, engaged in:

20.1 	professional misconduct within the meaning of paragraphs (a), (b) and/or (c) of the definition in section 5 of the National Law; and/or

20.2 	unprofessional conduct within the meaning of the definition in section 5 of the National Law

in that, between 19 December 2016 and 21 24 August 2018, [AEB] inappropriately prescribed pethidine, a Schedule 8 poison, to patient, namely [Patient A], without having regard to the appropriateness and possible risks of this treatment.

Particulars
21. 	Between 19 December 2016 and 21 August 2018 (the Period) [AEB] prescribed pethidine to the patient ([Patient A]) during the Period as set out in items 32-71 in Schedule 1 to this Notice.

22. 	Prior to and throughout the Period, relevant health authorities published guidance to practitioners that the prescribing of pethidine for the treatment of chronic non-malignant pain was inappropriate, for reasons including its effectiveness and its high possibility of addiction:

22.1 	In April 2006, pethidine was deleted from the list of drugs supplied through the Pharmaceutical Benefits Scheme (PBS) Emergency (Doctor’s Bag) Supply.

22.2 	In April 2007, pethidine was removed from the PBS due to lack of evidence of its safety and effectiveness.

22.3 	In January 2015, the DoH published a ‘Policy for issuing Schedule 8 permits’, which, inter alia, referred to advice from the Australian Pain Society that “there is agreement internationally and within Australia that intra-muscular opioids should play no part in the treatment of chronic non-malignant pain. In particular intra-muscular pethidine should be avoided”.

22.4 	In 2017, the RACPG issued guidelines to all GPs which stated that [intramuscular pethidine]: "has high addiction potential and is not recommended for the treatment of persistent pain."

23. 	In 2010, this Tribunal, in consideration of treatment provided by a medical practitioner to a patient during the period 1996 to 2001 evidently accepted evidence about Pethidine’s addictive qualities and that it would be "extremely unusual that any doctor will advise these addictive medications as appropriate management of recurrent or persistent painful conditions" [Omitted]

24. 	Pethidine was not an appropriate prolonged treatment for the medical conditions of the patient ([Patient A]) in the period between 19 December 2016 and 21 August 2018.

ALLEGATION FOUR

25. 	That [AEB], a registered medical practitioner, engaged in:

(c)	professional misconduct within the meaning of paragraphs (a) and/or (b) and/or (c) of the definition in section 5 of the National Law; and/or

(d)	unprofessional conduct within the meaning of the definition in section 5 of the National Law;

in that, from at least on or around 25 June 2003in or around September 2004 to on or around 13 April 2020, she provided ongoing medical care as the treating medical practitioner to her mother, [Patient B], in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.

Particulars

26. 	[Patient B] was the mother of [AEB].

27. 	The particulars at paragraphs 13 to 15 and 17 above are repeated.

28. 	From at least on or around 25 June 2003 to on or around 13 April 2020, [AEB] regularly provided medical care services to [Patient B] as her treating medical practitioner. The medical care services included, among other things, consulting and treating [Patient B], as [AEB]'s patient, for long-term chronic medical conditions, referrals to specialists, and prescribing various medications to treat various medical conditions.

ALLEGATION FIVE

29. 	That [AEB], a registered medical practitioner, engaged in:

(a) 	professional misconduct within the meaning of paragraph (a) of the	definition in section 5 of the National Law; and/or

(e)	unprofessional conduct within the meaning of the definition in section 5 of the National Law;

in that, on or around 11 January 2019, [AEB] provided medical care as the
treating medical practitioner to her son, [Patient C], in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.

Particulars

30. 	The particulars at paragraphs 13 to 15 and 17 above are repeated.

31. 	On or around 11 January 2019, [AEB] prescribed temazepam to her son, [Patient C], as his treating medical practitioner.

ALLEGATION SIX

32. 	That [AEB], a registered medical practitioner, engaged in:

(a) 	professional misconduct within the meaning of paragraphs (a) and/or (b) of the definition in section 5 of the National Law; and/or

(b) 	unprofessional conduct within the meaning of the definition of in section 5 of the National Law;

in that, on or around 23 June 2017 and on or around 21 December 2017, [AEB] provided medical care as the treating medical practitioner to her son, [Patient D], in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.

Particulars

33. 	The particulars at paragraphs 13 to 15 and 17 above are repeated.

34. 	On or around 23 June 2017, [AEB] prescribed oxazepam to her son, [Patient D], as his treating medical practitioner.

35.	On or around 21 December 2017, [AEB] prescribed temazepam to her son, [Patient D], as his treating medical practitioner.

ALLEGATION SEVEN

36. 	That [AEB], a registered medical practitioner, engaged in:

(a) 	professional misconduct within the meaning of paragraph (a) of the definition in section 5 of the National Law; and/or

(b) 	unprofessional conduct within the meaning of the definition in section 5 of the National Law;

in that, on or around 9 November 2014, [AEB] provided medical care as the
treating medical practitioner to her husband, [Patient E] in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.

Particulars

37. 	The particulars at paragraphs 13 to 15 and 17 above are repeated.

38. 	On or around 9 November 2014, [AEB] prescribed oxazepam to her husband, [Patient E], as his treating medical practitioner.

ALLEGATION EIGHT

39. 	That [AEB], a registered medical practitioner, engaged in:

39.1 	professional misconduct within the meaning of paragraphs (a) and/or (b) and/or (c) of the definition in section 5 of the National Law; and/or

39.2 	unprofessional conduct within the meaning of the definition in section 5 of the National Law;

in that, between 1 January 2003in or around September 2004 and on or about 3 December 2011, [AEB] provided medical care as the treating medical practitioner to her grandfather, [Patient F] in circumstances where this was avoidable and contrary to the relevant and applicable standards and codes of conduct for registered medical practitioners.

Particulars

40. 	The medical care services included, among other things, consulting and treating [Patient F], as [AEB]'s patient, for long-term chronic medical conditions, referrals to specialists, and prescribing various medications to treat various medical conditions.

41. 	The particulars at paragraphs 13 to 15 above are repeated.

42. 	In 2002 the Medical Practitioners Board of Victoria published a Bulletin for all registered medical practitioners in Victoria, which states, among other things, that "The Board considers that treatment should be provided by a person's general practitioner or specialist, and discourages treatment of family members by a doctor, whether that doctor is retired or not. Most doctors exercise due responsibility and limit prescriptions for family members to repeats of previously prescribed medication".

Schedule 1

No. 	DATE [OF SCRIPT] 	DRUG 	QTY 	PRESCRIBER

1. 	6/02/2009 	Pethidine 100mg injections 	5 		[AEB]
2. 	12/02/2009 	Pethidine 100mg injections 	5 		[AEB]
3. 	29/05/2009 	Pethidine 100mg injections 	5 	[AEB]
4. 	31/07/2009	Pethidine 100mg injections 	5 	[AEB]
5.	09/09/2009 	Pethidine 100mg injections 	5 	[AEB]
6. 	02/11/2009 	Pethidine 100mg injections 	5 	[AEB]
7. 	1/01/2010 	Pethidine 100mg injections 	5 	[AEB]
8. 	23/04/2010 	Pethidine 100mg injections 	5 	[AEB]
9. 	07/05/2010 	Pethidine 100mg injections 	5 	[AEB]
10. 	05/08/2010 	Pethidine 100mg injections 	5 	[AEB]
11. 	23/04/2010 	Pethidine 100mg injections 	5 	[AEB]
12. 	7/05/2010 	Pethidine 100mg injections 	5 	[AEB]
13. 	05/08/2010 	Pethidine 100mg injections 	5 	[AEB]
14. 	27/04/2011 	Pethidine 100mg injections 	5 	[AEB]
15. 	07/02/2012 	Pethidine 100mg injections 	5 	[AEB]
16. 	31/05/2012 	Pethidine 100mg injections 	5 	[AEB]
17. 	28/06/2012 	Pethidine 100mg injections 	5 	[AEB]
18. 	13/03/2013 	Pethidine 100mg injections 	5 	[AEB]
19. 	09/07/2013 	Pethidine 100mg injections 	5 	[AEB]
20. 	14/03/2014 	Pethidine 100mg injections 	5 	[AEB]
21. 	16/09/2014 	Pethidine 100mg injections 	5 	[AEB]
22. 	23/08/2014 	Pethidine 100mg injections 	5 	[AEB]
23. 	29/09/2014 	Pethidine 100mg injections 	5 	[AEB]
24. 	19/11/2014 	Pethidine 100mg injections 	5 	[AEB]
25. 	02/07/2015 	Pethidine 100mg injections 	5 	[AEB]
26. 	11/01/2016 	Pethidine 100mg injections 	5 	[AEB]
27. 	13/04/2016 	Pethidine 100mg injections 	5 	[AEB]
28. 	19/05/2016 	Pethidine 100mg injections 	5 	[AEB]
29. 	02/08/2016 	Pethidine 100mg injections 	5 	[AEB]
30. 	05/10/2016 	Pethidine 100mg injections 	5 	[AEB]
31. 	31/10/2016 	Pethidine 100mg injections 	5 	[AEB]
32. 	21/11/2016 	Pethidine 100mg injections 	5 	[AEB]
33. 	19/12/2016 	Pethidine 100mg injections 	5 	[AEB]
34. 	03/01/2017 	Pethidine 100mg injections 	5 	[AEB]
35. 	23/01/2017 	Pethidine 100mg injections 	5 	[AEB]
36. 	27/02/2017 	Pethidine 100mg injections 	5 	[AEB]
37. 	13/03/2017 	Pethidine 100mg injections 	5 	[AEB]
38. 	07/04/2017 	Pethidine 100mg injections 	5 	[AEB]
39. 	12/05/2017 	Pethidine 100mg injections 	5 	[AEB]
40. 	15/05/2017 	Pethidine 100mg injections 	5 	[AEB]
41. 	17/05/2017 	Pethidine 100mg injections 	5 	[AEB]
42. 	19/05/2017 	Pethidine 100mg injections 	10 	[AEB]
43. 	23/05/2017 	Pethidine 100mg injections 	10 	[AEB]
44. 	07/06/2017 	Pethidine 100mg injections 	10 	[AEB]
45. 	30/06/2017 	Pethidine 100mg injections 	10 	[AEB]
46. 	20/07/2017 	Pethidine 100mg injections 	10 	[AEB]
47. 	07/08/2017 	Pethidine 100mg injections 	10 	[AEB]
48. 	15/08/2017 	Pethidine 100mg injections 	10 	[AEB]
49. 	04/09/2017 	Pethidine 100mg injections 	10 	[AEB]
50. 	22/09/2017 	Pethidine 100mg injections 	10 	[AEB]
51. 	05/10/2017 	Pethidine 100mg injections 	10 	[AEB]
52. 	20/10/2017 	Pethidine 100mg injections 	10 	[AEB]
53. 	06/11/2017 	Pethidine 100mg injections 	10 	[AEB]
54. 	21/11/2017 	Pethidine 100mg injections 	10 	[AEB]
55. 	04/12/2017 	Pethidine 100mg injections 	10 	[AEB]
56. 	13/12/2017 	Pethidine 100mg injections 	10 	[AEB]
57. 	29/12/2017 	Pethidine 100mg injections 	10 	[AEB]
58. 	07/01/2018 	Pethidine 100mg injections 	10 	[AEB]
59. 	10/04/2018 	Pethidine 100mg injections 	10 	[AEB]
60. 	24/04/2018 	Pethidine 100mg injections 	10 	[AEB]
61. 	08/05/2018 	Pethidine 100mg injections 	10 	[AEB]
62. 	15/05/2018 	Pethidine 100mg injections 	10 	[AEB]
63. 	25/05/2018 	Pethidine 100mg injections 	10 	[AEB]
64. 	04/06/2018 	Pethidine 100mg injections 	10 	[AEB]
65. 	14/06/2018 	Pethidine 100mg injections 	10 	[AEB]
66. 	26/06/2018 	Pethidine 100mg injections 	10 	[AEB]
67. 	01/07/2018 	Pethidine 100mg injections 	10 	[AEB]
68. 	06/07/2018 	Pethidine 100mg injections 	10 	[AEB]
69. 	15/07/2018 	Pethidine 100mg injections 	10 	[AEB]
70. 	20/07/2018 	Pethidine 100mg injections 	10 	[AEB]
71. 	25/07/2018 	Pethidine 100mg injections 	10 	[AEB]
72. 	24/08/2018 	Pethidine 100mg injections 	10 	[AEB]