Level 28, 2-6 Gilmer Terrace, Wellington 6011 PO Box 10509, The Terrace, Wellington 6143, New Zealand Phone: 04-381 6816 Email: dgainey@hpdt.org.nz Website: www.hpdt.org.nz DECISION NO 974/Phar17/409P IN THE MATTER of the Health Practitioners Competence Assurance Act 2003 (“the HPCA Act”) BETWEEN A PROFESSIONAL CONDUCT COMMITTEE appointed by the Pharmacy Council of New Zealand. AND PARK UNG (TERRENCE WONG, registered pharmacist of Auckland. BEFORE THE HEALTH PRACTITIONERS DISCIPLINARY TRIBUNAL HEARING held at Auckland on Thursday 5 April 2018 TRIBUNAL: Ms M Dew (Chair) Ms D Vicary, Mr K Govind, Ms D Earles and Ms A Kinzett (Members, present via video conference) Miss D Gainey (Executive Officer) Mr J Roberts – Video Technician APPEARANCES: Ms A Miller for the Professional Conduct Committee (“PCC”) Ms H Stuart for the Practitioner. Introduction 1. Mr Park Ung Wong is a registered pharmacist based in Auckland. A Professional Conduct Committee (PCC) appointed by the Pharmacy Council of New Zealand has laid a charge against the practitioner before this Tribunal. 2. The practitioner faces one Notice of Charge dated 13 November 2017. The charge is that on 19 August 2016 the practitioner obtained convictions under the Crimes Act 1961 for several offences including making a false document, supply of prescription only medicines in breach of the Medicines Act 1981 and criminal nuisance. It is alleged that the convictions reflect adversely on the practitioner’s fitness to practise under s100(1)(c) of the HPCA Act. The charge 3. The particulars of the charges are set out below: “Pursuant to section 81 (2) of the Act, the Professional Conduct Committee lays a charge that on 19 August 2016 Mr Wong, a registered pharmacist, was convicted in the District Court at North Shore of the offences set out below, each of which is an offence punishable by imprisonment for a term of three months or longer: (a) Making a false document in breach of s 256(1) of the Crimes Act 1961 (forgery); and, (b) Supply of prescription only medicine in breach of s 18(2)(6) and s 78 Medicines Act 1984; and (c) Criminal nuisance (x 2) pursuant to s 145 of the Crimes Act 1961. These convictions, either separately or cumulatively, reflect adversely on Mr Wong's fitness to practise as a pharmacist. This is a ground on which a health practitioner may be disciplined under section 100(1)(c) of the Act.” The hearing 4. The hearing of the charges before this Tribunal, proceeded on the basis of an Agreed Statement of Facts and an Agreed Bundle of Documents. The Agreed Bundle of Documents included the following: (a) The Police Summary of Facts; 2 (b) Affidavit of Mr Wong dated 23 May 2016, filed in the District Court in relation to sentencing; (c) The sentencing notes of Judge Hinton dated 19 August 2016; (d) The District Court Notification of Conviction for Mr Wong dated 10 January 2017; Mr Wong’s letter to the PCC dated 4 July 2017. (e) 5. The practitioner does not dispute the charge. However, it remains for the PCC to establish the charges to the appropriate standard of proof. The facts 6. The chronology of facts set out below is based on the Agreed Statement of Facts and judgement in the District Court produced to the Tribunal. “[1] Park Ung Wong is registered with the Pharmacy Council in the pharmacist scope of practice. Mr Wong also uses the name Terrence Wong. He has been registered with the Pharmacy Council in the pharmacist scope of practice since 8 December 2010. [2] At all times Mr Wong owned and operated Birkenhead Avenue Pharmacy, in Birkenhead, Auckland (the Pharmacy). [3] On 16 July 2015, Police executed a search warrant at the Pharmacy and seized documents and electronic devices as part of an investigation into possible offences against the Medicines Act 1981. The investigation, relating to the supply of prescription and restricted medicines, was a joint operation between police and Medsafe. On 17 July 2015, police advised the Registrar of the Pharmacy Council of the investigation. [4] As a result of the investigation, in or around August 2015, Mr Wong was arrested and charged with offences relating to the sale and supply of prescription medicines, restricted medicines, and forgery. [5] On 2 September 2015, the Pharmacy Council suspended Mr Wong’s practicing certificate under s 69(2)(a) of the Health Practitioners Competence Assurance Act 2003. 3 [6] On 26 May 2016, following a sentencing indication, Mr Wong pleaded guilty to five charges relating to the sale and supply of prescription medicines and forgery. For the purpose of the sentencing indication Mr Wong prepared an affidavit which is at page 18 of the agreed bundle of documents. Mr Wong also provided the court with various references, which are set out as pages 33-65 of the agreed bundle of documents. [7] 0n 19 August 2016, Mr Wong was convicted at the District Court at North Shore of: (a) Making a false document (a prescription) in breach of s 256 of the Crimes Act 1961 (forgery); (b) Criminal nuisance relating to: the sale of the prescription medicine zoplicone to a customer; a representative charge relating to the sale of excessive quantities of restricted medicines containing codeine and ibuprofen to three customers between 11 September 2013 and 16 July 2015; and the sale of restricted medicines containing codeine to one patient on 16 July 2015, in breach of s 145 of the Crimes Act 1961 (criminal nuisance); and (c) A representative charge of supplying a prescription medicine (paracetamol + codeine) to several patients between September 2014 and 16 July 2015 in breach of s 18(2) and 18(6) and s 78 Medicines Act 1981. [9] Mr Wong was sentenced to 10 months’ home detention and 200 hours community service. [10] The Pharmacy Council subsequently appointed a PCC to investigate Mr Wong’s conviction. Mr Wong was invited to make submissions and/or to be heard on the matter. Mr Wong provided a letter to the PCC dated 4 July 2017. The PCC resolved to lay a charge before the Tribunal. [11] Mr Wong admits that his convictions reflect adversely on his fitness to practice as a pharmacist under s 100(1)(c) of the Act.” District Court sentencing notes 7. The sentencing notes of Judge Hinton set out the details of the offending as follows at paragraphs [7] to [20]: 4 “[7] The first criminal nuisance charge relates to the sale of zopiclone. Zopiclone is a prescription medicine used in the treatment of insomnia. It is recommended to be taken on a short-term basis as dependence is know to occur with prolonged use. It is known to pose various risks to the health of patients including a risk of fatal overdose. As a prescription medicine, zopiclone cannot be sold without a prescription. The Ministry of Health data sheet on this product states that a single tablet should be taken before retiring, for a maximum of two to four weeks. [8] Mr N was a customer at your pharmacy between May 2013 and January 2015. He [ ] and regularly visited your pharmacy. He had been identified as being dependent on zopiclone. A restriction notice had been issued concerning him. The notice was provided to every prescriber and pharmacist by the Ministry of Health and a copy was located at your pharmacy. You dispensed zopiclone to Mr N, who presented fraudulent prescriptions to you, despite the restriction notice having been issued precluding this. [9] On 25 February 2014, Mr N presented a particular fraudulent prescription, said to be prescribed by Dr Sandhu. You checked at the relevant medical centre and were advised that Mr N had not been prescribed zopiclone and you were informed of the restriction notice in relation to Mr N. [10] Despite being informed that the prescription was not valid, and of the restriction notice, you dispensed zopiclone to Mr N. You subsequently dispensed it to him in September and October 2014 without valid prescriptions. Again, on 5 January 2015, you dispensed zopiclone to Mr N without a valid prescription. Later, on 5 January or early on 6 January 2015, Mr N consumed zopiclone tablets. He also consumed medicines containing codeine. He had an overdose reaction. [11] On 6 January 2015, Mr N was located by his [ ] in a serious medical condition and taken to [ ] Hospital by ambulance. He had [ ] and was kept on life support throughout 6 January in order for his organs to be donated. On 7 January he was disconnected from life support and declared deceased. His death was caused by mixed drug toxicity from both zopiclone and codeine. [12] The forgery charge concerns your actions following learning of Mr N’s state of health on 6 January. On 8 January 2015, at your pharmacy, you located the previous fraudulent prescription for Mr N dated 25 February 2014 and purportedly prescribed 5 by Dr Sandhu. You photocopied the prescription covering the previous dispensing sticker label using a small white sticker. [13] Using this modified copy, you made a further photocopy, this time covering the date of the prescription and the doctor’s signature. You modified this to include the date of 5 January 2015 and forged Dr Sandhu’s signature. This made a document that appeared to be a prescription for Mr N dated 5 January for 30 zopiclone tablets. [14] The remaining two criminal nuisance charges relate to the excessive supply of restricted medicines containing codeine to three customers. First, the supply of codeine products to Mr N who would regularly purchase restricted medicines containing ibuprofen and codeine. Ibucode Plus. These were Nurofen Plus and Panafen and On the majority of occasions these products were in packet sizes consisting of 30 tablets. You sold at least 176 packets of these medicines to Mr N on at least 114 occasions. [15] As a pharmacist you knew of the risk to the health of Mr N posed by supplying the medicines to him in such high doses and on a regular basis. Specifically, you knew or ought to have known that the risks posed by zopiclone and codeine are greater when they are taken together. [16] The second customer was Ms H who was a customer between May 2014 and June 2015. She developed a strong dependency on Nurofen Plus and purchased increasing amounts of the product on a regular basis from you. There was a regular pattern of purchase of multiple packets of Nurofen Plus on a no questions asked basis. [17] In June 2015 she was admitted to [ ] Hospital with life threatening health conditions due to the excessive amount of Nurofen Plus she was consuming. During this hospital stay, she disclosed to hospital staff that she was consuming two packets of Nurofen Plus per day after obtaining easy access to the medicine. [18] The third customer was Ms D, a customer between September 2013 and July 2015, who also purchased multiple packets of Nurofen Plus on a “no questions asked” basis. [19] As a pharmacist you knew of the risks to her health posed by supplying the medicine to her in such high doses and on a regular basis and, by February 2015, you knew of Mr N’s death. The final criminal nuisance charge involves the sale of Nurofen Plus to Ms D in June and July 2015. 6 [20] The fifth charge relates to the supply of the prescription medicine, Paracetamol and codeine, without a prescription. To a particular customer, 8300 tablets were sold. To other customers, 3500 tablets were sold.” The relevant law 8. The practitioner is charged under s100(1)(c) which provides as follows: “100 Grounds on which health practitioner may be disciplined (1) The Tribunal may make any 1 or more of the orders authorised by section 101 if, after conducting a hearing on a charge laid under section 91 against a health practitioner, it makes 1 or more findings that – …. (c) the practitioner has been convicted of an offence that reflects adversely on his or her fitness to practise; or 9. The role of the Tribunal is to conduct an objective analysis of the charge measured against the standards of responsible professional peers taking into account patient 10. The Tribunal is mindful of the direction provided in the judgment of Elias J. on page 15 in B v Medical Council of New Zealand:1 “The structure of the disciplinary processes set up by the Act, which rely in large part upon judgment by a practitioner’s peers, emphasises that the best guide to what is acceptable professional conduct is the standards applied by competent, ethical and responsible practitioners. But the inclusion of lay representatives in the disciplinary process and the right of appeal to this court indicates that usual professional practice, while significant, may not always be determinative: the reasonableness of the standards applied must ultimately be for the court to determine, taking into account all the circumstances including not only usual practice but also patient interests and community expectations, including the expectation that professional standards are not to be permitted to lag. The disciplinary process in part is one of setting standards,” 11. There are two elements of the charge that must be established under s100(1)(c) of the Act, namely that: 7 (a) Mr Wong was convicted of the offence as charged under the Crimes Act 1961; and (b) That the offence reflects adversely on his fitness to practise as a registered health practitioner. 12. It is further noted that the Tribunal may only make a finding under s100(1)(c) of the Act if the conviction concerned has been entered by any court for an offence punishable by imprisonment for a term of 3 months or longer.2 13. This Tribunal and the Courts have previously considered the meaning of “fitness to practise” under s100(1)(c) of the Act, in relation to other practitioner conviction charges.3 It is clear from this body of case law, that conduct which offends the law will usually be regarded as adversely affecting the practitioner’s fitness to practise. This is certainly the case in relation to any conviction for a dishonesty offence. “Fitness to practise” in the context of a conviction is not restricted to consideration of the practitioner’s clinical ability. It involves a wider consideration of whether the practitioner’s conviction reflects adversely on their overall fitness to practise, because the conduct leading to the conviction was either immoral, unethical, or otherwise failed to uphold the law. Tribunal consideration of the charge 14. The conviction is clearly established on the basis of the Notice of Conviction issued by the District Court at North Shore. This notice confirms the practitioner’s conviction in the District Court at Auckland as charged. 15. The Tribunal is satisfied that the offences on which Mr Wong was convicted are all punishable under the Crimes Act 1961 by a term of imprisonment of 3 months or longer, as required under s100(2)(b) of the HPCA Act. The forgery conviction carries a penalty of up to 10 years imprisonment, the criminal nuisance charges carries a penalty of up to one year imprisonment, and the supply of prescription only 1 2 3 Noted in [2005] 3 NZLR 810. Section 100(2)(b) of the HPCA Act. Winefield (60Phar06/30P), Dalley (MPDT decision 8/97/4C), PCC v Martin, Gendall J HC, CIV 2006-485-1461 (27/02/07), Pellowe (137/Phar07/74P); Pollock, 95/Nur06/38P 8 medicines in breach of the Medicines Act carries a penalty of 3 months imprisonment. 16. The Tribunal is also satisfied that the offence does reflect adversely on Mr Wong’s fitness to practise. Mr Wong has failed to act in accordance with the high standards of professional conduct expected of the Pharmacist profession. It is significant that this dishonest conduct was in the course of his work as a pharmacist. The offending involves a serious lack of judgment and caused serious harm to two patients and risked serious harm to others. This must inevitably reflect adversely on his fitness to practise as a pharmacist. 17. The charge as laid against the practitioner under s100(1)(c) of the HPCA Act is established. Penalty 18. The Tribunal, once satisfied that the charges are established, must go on to consider what penalty is appropriate under s101 of the HPCA Act. 19. The Tribunal adopts the sentencing principles as contained in Roberts v Professional Conduct Committee4 in which Collins J identified the following eight factors as relevant whenever the Tribunal is determining an appropriate penalty. In particular, the Tribunal is bound to consider what penalty: (a) most appropriately protects the public and deters others; (b) facilitates the Tribunal’s important role in setting professional standards; (c) punishes the practitioner; (d) allows for the rehabilitation of the health practitioner; (e) promotes consistency with penalties in similar cases; (f) reflects the seriousness of the misconduct; (g) is the least restrictive penalty appropriate in the circumstances; and (h) looked at overall, is the penalty which is “fair, reasonable and proportionate in the circumstances.” 4 [2012] NZHC 3354 at [44]-[51] 9 Penalty submissions for the PCC 20. The PCC submits that this is an appropriate case for the ultimate sanction of cancellation of the practitioner’s registration together with censure and costs. 21. In support of this submission, the PCC invited the Tribunal to consider: (a) that the convictions involve serious criminal offending as evidenced by the maximum imprisonment penalty for forgery and criminal nuisance; (b) this was not a victimless crime, one patient died and another was hospitalised, and Mr Wong’s conduct inevitably contributed to the harm caused; (c) Mr Wong continued his offending even after learning about the first patient’s death due to an overdose; (d) The practitioner also took steps to cover up his offending by creating false prescriptions upon learning of the patient death; (e) The lengthy period of the offending for more than 18 months, and in obvious breach of his professional obligations. 22. The PCC did acknowledge mitigating features relating to both the offending and the practitioner, as being: (a) Mr Wong admitted his offending at an early stage and has cooperated with the PCC and Tribunal; and (b) He has not previously appeared before the Tribunal. Penalty submissions for the practitioner 23. Counsel for the practitioner has urged the Tribunal to see Mr Wong’s offending as part of a failure to maintain appropriate professional boundaries. It is submitted that at the time of the offending, he was still relatively young at 31 years old and that drug seekers prayed on his naivety and his difficulty in declining demanding patient requests. It is submitted that he panicked after the death of the patient and attempted to hide what he had done, only making matters worse. 24. Ms Stuart referred to the insight and remorse that Mr Wong has shown by his admission of the charge and the steps he has taken since the offending, including paying reparation to the deceased patient’s family of $30,000. 10 25. Mr Wong also produced 24 references from professional colleagues, members of his church, and friends. The references speak highly of Mr Wong and it is clear that he has strong personal support from his community. The Tribunal acknowledges these references. They are mostly dated from April 2016 and appear to have been produced for the District Court sentencing in August 2016. There is also one more recent reference from March 2018 from Mr Wong’s church pastor. There is also a letter of confirmation from the Department of Corrections that Mr Wong has completed his sentence showing a “high level of compliance”. 26. Mr Wong also produced a psychological assessment report dated 27 March 2018, prepared by Dr Annabel Clarke. This report concludes that Mr Wong’s risk of reoffending is assessed as low and that in her assessment he displays the ability to abide any conditions deemed appropriate by the Tribunal. 27. Counsel for the practitioner submits that Mr Wong has already suffered a considerable penalty as imposed by the District Court. He has also suffered a significant financial impact by the $30,000 reparation paid and the closure his pharmacy after the criminal charges were laid. He has only been able to operate the business as a health and beauty shop since 2015 and this has impacted his earnings since that time. 28. It is submitted that Mr Wong has learnt a very serious lesson from the criminal charges, that he has shown genuine remorse and insight, and has the support of his community and colleagues to return to work. 29. Counsel urged the Tribunal to impose a penalty of censure, conditions and a contribution towards costs of up to 10% - 15%. Counsel submitted that Mr Wong has already served a two-and-a-half-year period of suspension and so a further period of suspension is not warranted. 30. Comparative cases on penalty 31. The Tribunal was referred to a number of previous penalty cases for the purposes of considering a comparative penalty. 32. There are a large number of potentially relevant cases. We have set out below the cases that are most relevant to the present case, while also providing a range of more serious and less serious cases: 11 (a) Pellowe5– a pharmacist was convicted on 47 counts of fraud involving some $200,000 in overpayments. He pleaded guilty to the charges, repaid the amounts overpaid as a result of his offending and served 18 months home detention. The Tribunal recognised the heavy penalty already paid by the practitioner in the criminal court but found that despite the various mitigating factors that cancellation was the appropriate penalty given the offence of dishonesty was against HealthPac. The Tribunal noted that a clear message must be sent to the profession that such offending will be treated seriously and with significant penalty. (b) Winefield v PCC6 - Mr Winfield was a pharmacist who pleaded guilty to 22 charges of fraud relating to claims made over 3 years to a value of $10,800. He was sentenced by the Court to 200 hours community service. The Tribunal suspended him for a period of nine months and this decision was upheld on appeal. In this case no direct patient harm was caused. (c) Burton 7– a pharmacist was convicted of 58 offences of fraud under the Crimes Act involving 4 years of overclaiming for medicines either not dispensed or claimed as dispensed more frequently than they were. Mrs Burton was sentenced by the Court to 15 months imprisonment and ordered to pay reparations of some $14,700. The Tribunal ordered a penalty of nine months suspension together with conditions on practise and 30% costs. The Tribunal accepted the case sat in a range lower than Pellowe, given the sums involved were significantly less. (d) Katamat8 - The High Court upheld the Tribunal’s decision to cancel the practitioner’s registration as a pharmacist. The case involved serious professional misconduct over an 18-month period in which Mr Katamat sold prescription only medicines without a prescription, failed to properly record prescriptions and supplied prescription only medicines which he should have known had the potential for abuse or dependency including Sudomyl and codeine. 5 6 7 8 Pellowe (137/Phar07/74P) Winefield v PCC Wellington HC CIV 2006-485-2225 142/Phar07/78P Katamat v PCC [2012] NZHC 1633 12 (e) Chiew9- Mr Chiew was a pharmacist convicted of 130 charges under the Crimes Act relating to HealthPac claims. The total reparation he was required to make to HealthPac was $220,000. He was sentenced by the Court to one year’s home detention and 300 hours community service. The Tribunal suspended him from practise for 9 months and ordered him to pay costs of 30%. (e) Sasha Taylor10- Mr Taylor was an employee pharmacist working with Mr Wong. In November 2017, Mr Taylor was found guilty before this Tribunal of professional misconduct relating to his dispensing excessive quantities of controlled drugs while in Mr Wong’s employment. He was censured, suspended for 2 years and ordered to comply with conditions if he recommenced practice. Tribunal consideration of penalty 33. The Tribunal has after careful deliberation, taken the view that cancellation of registration is the only penalty that can appropriately meet the need to protect the public and maintain the high standards required for the pharmacist profession. 34. Mr Wong’s conduct is so contrary to the fundamental principles for pharmacists that it requires cancellation. The key reasons for the Tribunal taking this view are: (a) The serious patient harm involved for two patients who suffered serious consequences (one died and the other was hospitalised as a result of overdoses), undoubtedly contributed to by Mr Wong’s unlawful dispensing to them both; (b) This offending is amongst the most serious for a pharmacist as it has occurred in his professional practice and involved breaches of legal, ethical and moral obligations that placed the life and health of patients at serious risk; (c) The repeated nature of the offending that displayed a serious lack of insight over a sustained period from September 2013 through to July 2015. 9 180/Phar08/95P 13 (d) Mr Wong was made aware of the patient restriction notice and that he was presenting false prescriptions, yet he continued to dispense excessive quantities of prescriptions to him until his death; (e) Despite being made aware of his patient’s death in January 2015, Mr Wong did not cease his unsafe dispensing practice but continued to dispense unlawfully to other patients. (f) Mr Wong compounded his misconduct by subsequent attempts to hide his unlawful dispensing practice by forging a prescription in the name of a doctor to cover up the previous unlawful dispensing to the deceased patient. Mr Wong also engaged in other covert behaviour that made it clear he understood that he was acting in breach of his professional obligations. This conduct included his hiding the records of dispensing prescription medicines under “Bioglan” health products as recorded in his pharmacy records and providing his personal bank account details to patients for payment, as set out in the Police Summary of Facts. 35. The Tribunal does not accept that this conduct can simply be explained as that of a young and naïve health practitioner. The offending involved significant elements of repeated dishonesty and fundamental breaches of professional obligations. Mr Wong aggravated matters by also leading his pharmacist employee into the same misconduct.11 In our view, Mr Wong has taken advantage of his professional position for financial gain and failed in his duty to act as a gate keeper for patient safety. 36. We do recognise that Mr Wong has been able to present mitigating features regarding his guilty plea, potential for rehabilitation and that this is his first offence. However, we were not satisfied that this is an appropriate case for a rehabilitative penalty. Patient safety and the need for professional standard setting must take precedence in this case. A period of suspension would not in our view meet these objectives. As in the Pellowe12 case, a clear message must be sent to the profession that offences of dishonesty will not be tolerated and this is doubly so where that dishonesty places patients at serious risk of harm as in this case. The Tribunal considers that Mr Wong’s offending is in the same range as Pellowe and Katamat. It is easily placed with the most serious range because of the evident patient harm caused. 10 932/Phar17/388P 14 37. While the character references all speak highly of Mr Wong, it is apparent that they were also assessing his character, in part, over the same period of his dishonest behaviour. 38. The Tribunal is satisfied that censure and cancellation are the appropriate and proportionate penalties in this case. They are also in line with comparable cases referred to above. 39. It will be possible for Mr Wong to re-apply for registration at some stage with the Pharmacy Council. It is recommended that any application for re-registration not be considered for a period of two years given the serious nature of the offending. In the event that Mr Wong is granted re-registration it is recommended that conditions be imposed that require him to undertake a competency review and that he not be permitted to practice in sole practice for a period determined by the Pharmacy Council. Costs 40. The Tribunal’s costs and disbursements incurred up to and including the date of hearing are estimated at $11,300. The PCC investigation and legal costs claimed amount to $10,685. 41. While the starting point for any award of costs is generally recognised as 50% of the total costs to be paid by the practitioner, a further discount is appropriate to reflect the practitioner’s co-operation. We order that he pay 35% of the total costs of the Tribunal and the PCC. Orders of the Tribunal 42. The Orders of the Tribunal are as follows, to take effect from the date of this decision: (a) The charge is established under s100(1)(c) of the Act; (b) The practitioner is censured to mark the disapproval of his criminal offending; (c) The practitioner’s registration as a health practitioner is cancelled under s101(1)(a) of the Act; 11 12 Sasha Taylor, 932/Phar17/388P 137/Phar07/74P 15 (d) The practitioner is ordered to pay 35% of the total costs of the Tribunal and the PCC, being $3,850 payable to the Tribunal and $3,850 payable to the PCC. (e) Permanent suppression orders are made prohibiting the publication of the name and any identifying features of the patients and any of their family members named in the charge or the evidence. (f) The Tribunal directs the Executive Officer to publish a copy of this decision on the Tribunal’s website, together with a summary. It further directs that the Executive Officer publish a notice stating the effect of the Tribunal’s decision on the website of the Pharmacy Council of New Zealand and its magazine to practitioners. DATED at Auckland this 15th day of June 2018 MJ Dew, Chairperson Health Practitioners Disciplinary Tribunal 16