Mr Samuel Green - Professional misconduct

27th November 2018

The Health Care Complaints Commission prosecuted a complaint before the NSW Civil and Administrative Tribunal (“the Tribunal”) against Samuel Green, a former pharmacist who had surrendered his registration on 1 June 2016.

The allegation was that Mr Green engaged in unsatisfactory professional conduct and professional misconduct, including that he failed to comply with the requirements of the Poisons and Therapeutic Goods Regulation 2008, because:

- He inappropriately dispensed dexamphetamine, a Schedule 8 drug, to himself on prescriptions which were not valid as they did not include the necessary prescriber authorisation number.
- He dispensed Sildenafil, Viagra (Sildenafil) and Vedafil (Sildenafil), a Schedule 4 drug, to a patient on numerous occasions in the absence of a valid prescription.
- In developing a system for storing and dispensing a Schedule 8 drug Biodone (a sugarless form of methadone syrup) he:
- Made modifications to the standard container that were not approved by the Director-General of the NSW Ministry of Health, as required.
- Transferred contents from the manufacturer’s bottles of Biodone and mixed these into a large plastic container. Different batches were mixed together and therefore  there was a risk that part of the mixture may pass its expiry date, endangering patient safety.
- Exposed the Biodone liquid to environmental contamination.
- He failed to keep any records of product batch numbers or expiry dates of Biodone liquid mixed in using the modified methadone dose system, so that in the event of recall, any relevant product could be identified and appropriately managed.
- He failed to keep accurate records, for Biodone and more generally.

The Tribunal published its decision on 12 November 2018 and found that unsatisfactory professional conduct and professional misconduct were proved. The Tribunal made the following orders:
(1)   If Mr Green were still registered, the Tribunal would have cancelled his registration.
(2)   Mr Green is disqualified from being registered as a pharmacist for a period of 18 months.
(3)   The National Board is to record in the National Register the fact that the Tribunal would have cancelled Mr Green’s registration.
(4)   The Registrar is requested to notify the Pharmacy Council of NSW and the Australian Health Practitioner Regulation Agency of Orders 1, 2 and 3 above as soon as practicable.
(5)   Mr Green is to pay the costs of the Health Care Complaints Commission of and incidental to these proceedings as agreed, and failing agreement as assessed under the Legal Profession Uniform Law Application Act 2014 (NSW).

The decision is available at NSW Caselaw.

Further Information

For further information, contact the Executive Officer of the Health Care Complaints Commission, on 9219 7444 or send an email to

The information in this media release is correct at the time of publication. Orders may change; for example, conditions may no longer apply. For current information regarding the status of a registered health practitioner, including any conditions that currently apply, please check the National Register at