Drugs and poisons investigation


This case study concerns a general practitioner who was contacted by the State Drugs and Poisons Unit of the Department of Health. 

The issue related to the treatment of a now deceased 40-year old male who was prescribed Kapanol, a Schedule Eight drug. A permit is required to prescribe Kapanol to ensure that treatment is coordinated and monitored and concurrent prescribing by other practitioners is avoided. The permit system also serves to reduce the possibility of deliberate misuse or iatrogenic dependence.

The member was contacted by the Drugs and Poisons Unit to provide written responses to a number of questions relating to the member’s prescribing and the sequence of events. Further information was required in relation to prescription knowledge, checking of existing permits held by other medical practitioners, the frequency of administration (which was in excess of the maximum quantity specified in the current permit) together with all medical record information.

The Drugs and Poisons Units investigation was concluded with a lengthy interview. The DPU findings were then brought to the attention of the Medical Board for consideration of the medical practitioner’s professional judgment and conduct. Of main concern was the frequency and quantities of morphine prescribed prior to realising that the patient was being concurrently provided scripts by another practitioner. This had continued after the member had obtained a permit and became the patient’s sole prescribing practitioner. Drugs and Poisons were concerned about the member’s difficulty is grasping the significance of the noncompliance to the safe treatment of the patient. 

It was only at this point the member appreciated the possible consequences of DPUs referral to the Board and contacted MIPS for further advice. 

Representation was provided to the member by MIPS to assist with the response to the Medical Board. On completing its investigations the Board referred the matter to a professional standards panel to conduct a hearing into the member’s professional conduct. The member was found guilty of unprofessional conduct, but as the incident was found not to be of a serious nature, the panel decided to sanction the member issuing a caution.

It is a condition of membership that you notify MIPS when you first become aware of any claim, investigation or proceeding against you in connection with the provision of health care. Handling such matters yourself may in fact escalate concerns. Failure to notify MIPS may also jeopardise your access to the benefits of membership including cover under the MIPS Members’ Medical Indemnity Insurance Policy.


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