On 12 October 2018, the New South Wales Civil and Administrative Tribunal found a GP, Dr Nguyen, guilty of unsatisfactory professional conduct and professional misconduct and found that he should be reprimanded and protective orders should be made arising from prescribing and administration of medication to a patient who died from misadventure relating to multi-drug toxicity.

Background Facts

Dr Nguyen became a fellow of the Royal Australian College of General Practitioners in 1999. Since 2001, Dr Nguyen has worked at the Mount Annan Medical Centre. Patient A was regularly seen by Dr Nguyen at the Mount Annan Medical Centre from 16 February 2002 to 22 April 2010. Patient A also saw other treating medical practitioners during this time.

On 1 May 2010, patient A was found dead at her home, having died of multi-drug toxicity. The Deputy State Coroner recorded in her report in relation to the inquest into patient A's death that on a post-mortem examination:

"Toxicology identified a lethal level of morphine, toxic levels of pethidine and quetiapine, therapeutic/non-toxic levels of several benzodiazepine drugs and a high level of alcohol"

The Coroner found that the cause of patient A's death was misadventure.

The Complaints

The Health Care Complaints Commission (HCCC) brought a total of three complaints against Dr Nguyen. There were two complaints of unsatisfactory professional conduct and one complaint of professional misconduct in relation to his treatment of patient A. The complaints related to Dr Nguyen's administration of pethidine to patient A, his prescription and administration of diazepam to patient A, and prescribing diazepam to patient A in an inappropriate combination with pethidine on three occasions and a failure of maintain adequate records during the period from February 2002 to April 2010 in relation to patient A.


The Tribunal accepted that Dr Nguyen's conduct was of a sufficiently serious nature to justify suspension or cancellation of his registration. They stated that it does not necessarily follow that suspension or cancellation is the appropriate protective order. In considering Dr Nguyen's case, the Tribunal considered the following factors relevant:

  1. The nature and extent of Dr Nguyen's conduct the subject of the Complaints;
  2. Dr Nguyen's remorse, insight and subsequent conduct; and
  3. Other matters which included references from other medical practitioners.

Dr Nguyen had expressed regret in respect to his treatment of patient A, had met his quality improvement and continuing professional development requirements and had completed a number of online courses by Avant Mutual Group prior to the hearing. Dr Nguyen had undertaken further training in relation to treating patients with chronic pain and mental health issues.

The Tribunal stated that while they accepted the conduct was serious and extended over 8 years, "in the light of the time that has elapsed since the conduct, his remorse and insight, the steps taken by Dr Nguyen to change his approach and practices, the education and training he has undertaken and is willing to undertake, the high regard in which he is held by other practitioners in the area and the unlikelihood of his being a risk to the health and safety of the public in future, the Tribunal believes it is not appropriate to suspend his registration".


  1. The respondent be and hereby is reprimanded under s 149A(1)(a) of the Health Practitioner Regulation National Law (NSW).
  2. The conditions set out below in the schedule headed "Health Care Complaints Commission v Dr Howard Van Nguyen – Conditions" (the Conditions) be imposed on the respondent's registration to be operative 28 days after the making of these orders.
  3. The Conditions may be altered, varied or removed at the discretion of the Medical Council of New South Wales, and the Council is the appropriate review body for the purposes of Division 8 of Part 8 of the Health Practitioner Regulation Law (NSW).
  4. Sections 125 to 127 of the Health Practitioner Regulation National Law (NSW) are to apply while Dr Howard Van Nguyen's principal place of practice is anywhere in Australia other than in New South Wales, so that a review of the Conditions can be conducted by the Medical Board of Australia.
  5. The respondent is to pay the costs of the applicant agreed in the sum of $30,000.00.

The conditions referred to in Order 2 included conditions relating to education that Dr Nguyen had to undertake, supervision for a period of 6 months and he is required to submit an audit of his medical practice by a random selection of his medical records within 3 months of the conditions taking effect.