The Civil and Administrative Tribunal of NSW has suspended a doctor’s registration for six months after he mistakenly gave oxycodone instead of Panadol to a six-day old patient. Dr Sharier was found guilty of unsatisfactory professional conduct and professional misconduct.
In issue
- The Health Care Complaints Commission prosecuted a complaint against Dr Mohammad Salah Uddin Sharier, a general practitioner. Dr Sharier was alleged to have inappropriately administered the Schedule 8 drug, oxycodone, to a newborn patient, and failed to urgently and appropriately communicate his mistake to the patient’s parents. The Civil and Administrative Tribunal of NSW considered whether Dr Sharier’s actions were serious enough to constitute unsatisfactory professional conduct and professional misconduct.
The background
Dr Sharier was first registered as a medical practitioner in NSW in 2009 and he opened his own medical practice at the Gentle Procedures Clinic in Revesby in 2022, where he exclusively performed circumcision procedures.
On 1 March 2023, Dr Sharier performed a circumcision procedure on a six-day old patient without any complications. Following the procedure, he provided the patient’s father with an unlabelled syringe of what he believed contained 0.5mL of Panadol Children, but was in fact liquid OxyNorm, an opioid. The patient’s mother administered the syringe on the patient when he arrived home.
Shortly afterwards, Dr Sharier realised his error and called the father telling him that he may have given the patient ‘big kids Panadol’. However, he notably failed to tell the patient’s father to immediately take the patient to hospital, nor did he answer his mobile phone when the patient’s father called him numerous times. When the patient could not be roused, his parents took him to Liverpool Hospital, where he was given two doses of Naloxone to reverse the effects of the opioid overdose.
The decision
The Tribunal found that Dr Sharier’s ‘casual attitude’ towards the legal requirements relating to Schedule 8 medications was gravely problematic. During an investigation by the Pharmaceutical Regulatory Unit following the medication error, investigators found an open bottle of OxyNorm next to the Panadol bottles, instead of in the drug safe where it should have been stored.
This led to Dr Sharier being convicted of supplying poison (oxycodone) that was not packaged in accordance with regulations, and failing to keep a drug register. Dr Sharier had subsequently failed to notify the National Board of these criminal charges.
It was further found that Dr Sharier had inappropriately written two prescriptions for oxycodone under the name ‘Mr Test Tester’ and presented the prescriptions to a pharmacy for the drug to be dispensed for use in his practice. In addition, the Tribunal found that Dr Sharier had failed to maintain adequate records of the above.
Ultimately, the Tribunal found Dr Sharier guilty of unsatisfactory professional conduct and professional misconduct, and suspended his registration for six months with conditions imposed on his registration. Some of the conditions included a requirement to complete an education course, to submit to a practice and medical record audit, and to practice under supervision. He was also prohibited from possessing or supplying any Schedule 4D or Schedule 8 substances.
The Tribunal found that upon realising his mistake, Dr Sharier failed to provide clear information on the medication he had provided and instead gave unsafe instructions to observe for symptoms, rather than conveying the immediate need to transport the patient to hospital.
The Tribunal also noted that Dr Sharier failed to prioritise ongoing communication with the patient’s parents during the day, and failed to contact the hospital to inform them of the approaching emergency and provide relevant clinical details, all of which amounted to unsatisfactory professional conduct.
While the patient made a full recovery, this was not due to any intervention or assistance from Dr Sharier.
Implications for you
Medical practitioners should always keep accurate and contemporaneous records of patient attendances and medications prescribed, particularly when prescribing Schedule 8 medications. When storing and dispensing Schedule 8 medications, it is crucial to keep a drug register in accordance with the Poisons and Therapeutic Goods Regulation 2008.
Further, Schedule 8 medications are to be stocked at the lowest practical level in patient care areas. Over recent years, we have seen regulators crack down on Schedule 8 and Schedule 4D prescribing, making it imperative for medical practitioners to be familiar with and comply with the relevant regulations.1
Where a medical practitioner makes a mistake in the course of clinical practice, they must prioritise patient safety and address the patient’s immediate needs, while keeping a detailed record of events. The principles of open disclosure should be followed at all times. We often see regulators criticise medical practitioners for the steps taken after the relevant event, highlighting that patient safety must be the main priority.
If a health practitioner becomes aware of a ‘relevant event’, which includes being charged with or convicted of a scheduled medicine offence or an offence punishable by 12 months imprisonment or more, they must give their respective National Board written notice of the event within seven days.2 In addition to informing the Board, medical practitioners must engage in open disclosure with any affected patients and follow-up with appropriate care.
Human error is an unavoidable reality in medical practice, even among the most diligent practitioners. However, it is important to remember that the way practitioners respond to a mistake is just as significant as the mistake itself. This case is a prime example of how a medical practitioner failed to act appropriately following their mistake, endangering the patient and as a result, facing consequences.
Health Care Complaints Commission v Sharier [2025] NSWCATOD 124
1 NSW requirements for approval to prescribe or supply Schedule 8 medicines; List of Schedule 8 medicines.
2 Health Practitioner Regulation National Law (NSW) s 130.
