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Doctor’s lapse of judgment leads to disciplinary action

25 October 2017 | Vinay Pandaram, Senior Claims Manager, Avant

A recent West Australian case involving a doctor who fraudulently prescribed a Schedule 8 (S8) medication to a patient who was a notified drug addict, serves as an important reminder to all doctors to adhere to professional and ethical standards of conduct.

The doctor, who was an experienced psychiatrist without any prior disciplinary complaints, has been reprimanded for professional misconduct after inappropriately prescribing hydromorphone to a patient, and falsely writing a prescription in another patient’s name.

Patient history

Patient A visited the psychiatrist for the first time in 2000. The patient had a complex history of depression, adult Attention Deficit Hyperactivity Disorder, psycho-social issues and a long-standing addiction to alcohol and narcotics.

In 2015, the patient was admitted to hospital with an infected left knee prosthesis. The psychiatrist saw the patient several times during the hospital stay. The patient’s condition deteriorated to the extent that they expressed an intention to commit suicide using pentobarbitone.

The patient was discharged from hospital on several medications a few weeks later.

Doctor advised patient is a notified drug addict

In October 2015, the psychiatrist prescribed Patient A hydromorphone (64mg tablets). The psychiatrist wrote another three prescriptions for the patient for hydromorphone on 19, 23 and 26 November.  

Under Western Australia’s poison’s regulations:  

a. a prescription for the supply of a drug of addiction should include the name and date of birth of the patient

b. a person must not prescribe or supply a drug of addiction for the treatment of a person who is a drug addict unless the person is authorised to do so 

c. a medical practitioner may prescribe or supply a drug of addiction for the treatment of a person who is a drug addict if the medical practitioner has been authorised to do so for that drug addict.

After 26 November, the psychiatrist received a letter from the Pharmaceutical Services Branch of Western Australia’s Department of Health (DoH) advising that:

a. the psychiatrist prescribed hydromorphone to Patient A in October in circumstances where Patient A’s details correspond with those of a notified drug addict

b. Patient A’s general practitioner holds a current authorisation to prescribe Schedule 8 medications to Patient A; and

c. should  Patient A present to the clinic again, Patient A should not be prescribed Schedule 8 medications.

Prior to receiving this letter, the psychiatrist was not aware that Patient A was a notified drug addict.

Doctor’s error of judgment

In December, Patient A presented to the psychiatrist’s clinic without a scheduled appointment. It was the psychiatrist’s last day of work before their practice closed for the Christmas break. The patient described severe knee pain and asked the psychiatrist for a prescription for hydromorphone. The psychiatrist informed the patient about the letter from DoH and confirmed that without the requisite authority, they were unable to prescribe the patient with hydromorphone.

The patient advised the doctor that their GP was on leave and unable to prescribe the hydromorphone. Patient A told the psychiatrist they were suicidal and in severe pain. Patient A then suggested that the psychiatrist should issue a script for hydromorphone for themselves in the name of another patient (B) who patient A resided with at the time.

The psychiatrist accepted this suggestion and wrote a script for 30 tablets of hydromorphone (32 mg) in patient B’s name with their date or birth.

In January 2016, Patient A was found unconscious at his home by police with a 14-tablet blister pack of hydromorphone, labelled with Patient B’s name.

Patient A was subsequently hospitalised having suffered an overdose of hydromorphone.

Behaviour found to constitute professional misconduct

The tribunal determined that the psychiatrist had engaged in professional misconduct by inappropriately prescribing hydromorphone to Patient A using Patient B’s name and date of birth. The psychiatrist wrote the prescription despite knowing that Patient A was a notified drug addict, not being authorised to prescribe hydromorphone to Patient A, and where he/she knew or ought to have appreciated the potential for misuse, abuse or psychological and/or physical dependency.

The psychiatrist was also found to have breached The Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia (The Code of Conduct), for failing to display a standard of behaviour that warrants the trust and respect of the community.

Mitigating factors

The psychiatrist admitted they had behaved inappropriately and acknowledged they had committed a serious error of judgment by prescribing hydromorphone to Patient A. However, they said they did so in circumstances where the authorised prescriber, the patient’s GP, was unavailable.

The psychiatrist said they were placed in a difficult position due to the busy time of year and the patient’s suicidal state. The psychiatrist was also under significant personal pressure at the time.  

The decision

The tribunal ordered that the psychiatrist be reprimanded and have conditions imposed on their registration. The conditions require the psychiatrist to undertake further education on the prescribing of drugs of addiction and the management of patients with substance abuse problems and/or drug seeking behaviour. In addition the psychiatrist was ordered to submit to an audit of their prescription of opiates and benzodiazepines. He was also ordered to pay $2,400 in costs.

Key lessons

The Code of Conduct clearly sets out doctor’s moral, ethical, professional and legal duties in relation to their paramount obligation to practise medicine safely and effectively. Doctors may regularly find themselves in a position where they wish to help a patient, but are restricted from doing so. Doctors should not put themselves at risk of disciplinary action despite these pressures, and seek to find a suitable resolution for the patient, carefully explaining the situation and proposed actions.

The Code outlines the values and behaviours expected of doctors and provides professional and ethical guidance to help manage complex and sensitive issues that can arise in clinical practice. It also assists doctors to recognise the importance of setting boundaries to protect against potentially compromising situations. In the event of ethical dilemmas - such as a suicidal patient proposing an illegal action in this case – doctors should seek advice, for instance, from senior colleagues or by calling Avant’s Medico-legal Advisory Service on 1800 128 268.

This case reminds doctors of the importance of complying with the prescribing legislation in your state or territory. To avoid the issues outlined in this case:

  • Only prescribe S8 medications, including opioid medications for chronic pain, in accordance with prescribing guidelines and the appropriate state or territory authority. You require approval from the relevant state or territory authority if you wish to prescribe a drug of dependence:
    • In most states, to a patient for more than two months (this time frame includes prescribing by previous doctors)
    • If the patient requiring the drug is considered ‘drug dependent’
    • Before prescribing certain drugs e.g. amphetamines or methadone.
The requirements of the state and territory authorities differ slightly. If in doubt, contact your local authority for further information.
  • Be mindful of your ethical obligations. Doctors have a duty to make the care of their patients their first concern and to practise medicine safely and effectively. Doctors must at all times conduct the practice of medicine in an ethical and trustworthy manner.
  • Where a patient displays warning flags of addiction or prescription shopping, prescribers should contact the S8 Prescriber Information Service in their state, to obtain the patient’s S8 prescribing history. 
  • In no circumstances should a prescription be issued to a patient in a different patient’s name.

More information

For more information, download our factsheet Prescribing drugs of dependence or complete our eLearning course, Prescribing: principles and practices. You can also read our article.

For advice when prescribing S8 drugs, visit our website or call our Medico-legal Advisory Service (MLAS) on 1800 128 268 for expert advice, 24/7 in emergencies.

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