A former pharmacist has been found guilty of professional misconduct over her running of an IV clinic in Sydney
Former pharmacist Shadi Kazeme has been found guilty of unsatisfactory professional conduct and professional misconduct in relation to her operation of a Sydney clinic between 27 January 2016 to 14 February 2016, which offered intravenous infusions and intramuscular injections of vitamins, minerals, antioxidants and similar products.
Ms Kazeme held provisional registration as a pharmacist at the time of the conduct, although this was suspended by the Pharmacy Council of New South Wales in March 2016.
Disciplinary proceedings against Ms Kazeme have been conducted in both NSW and Victoria.
Her provisional registration was initially cancelled for two years from November 2018 in separate proceedings, after she was convicted and reprimanded in Victoria for stealing pharmaceuticals from her workplace.
According to a new order handed down this month, in relation to her running of the Sydney clinic, the NSW Civil and Administrative Tribunal has ruled that if Ms Kazeme were still registered, it would have cancelled her registration as a pharmacist for a further year commencing from November 2020.
Several patients who attended the clinic were administered intravenous infusions and intramuscular injections, some of which included glutathione, a Schedule 4 medicine.
On 13 February 2016 a patient attended the clinic and had an intravenous infusion of “Myers Cocktail” and an intramuscular injection of glutathione, felt unwell, and went home. Shortly thereafter the patient was admitted to hospital with fever, myalgia, abdominal pain and hypotension. Preliminary assessments indicated endotoxaemia.
An investigation found it was likely endotoxins were present in a single ampoule provided only to this patient.
The incident of hospitalisation was reported to the Pharmaceutical Regulatory Unit (PRU) of the NSW Department of Health.
A PRU inspection of clinic premises located a vial of Sodium Ascorbate Solution in a 100ml vial for single use only which appeared to have been used, and the remaining solution (~30ml) in the vial was stored in the refrigerator along with other single use vials for parenteral use.
The NSW Civil and Administrative Tribunal found Ms Kazeme, as the proprietor of the clinic who had prepared the procedures and protocols adopted by her nurse employee, was ultimately responsible for the nurse re-entering single use vials of sodium ascorbate solution and glutathione numerous times for use in treatment of multiple patients.
Disciplinary proceedings have also been brought separately against the nurse.
Ms Kazeme was additionally found to have supplied prescriptions to, and obtained medications from, a compounding pharmacist knowing that the dispensed medications would not be used to treat the individuals in whose names the prescriptions were prescribed.
A doctor who provided Ms Kazeme with the prescriptions acknowledged in disciplinary proceedings against him that he knew that the quantities he prescribed would predominantly be used for stock.
PRU investigators found none of the clients who purported to have received glutathione had had a prescription for glutathione for parenteral use written in their names.
According to court documents, Ms Kazeme was not aware that it was illegal to dispense medicines to a person other than the person to whom it was labelled.
She also stated she did not know that glutathione was a Schedule 4 product, or that the sodium ascorbate solution vials were single use.
Furthermore the Tribunal found Ms Kazeme signed consent forms for several patients as “medical staff” when she did not have appropriate qualifications to do so, which she agreed was a mistake.
The Tribunal concluded there was no proper basis on which informed consent was obtained from those patients whose forms Ms Kazeme signed.
There was no evidence any patient of the clinic was offered a consultation with, or actually consulted, a medical practitioner, despite at least some of those patients recording information on the patient questionnaire that suggested the treatment may have been unsafe.
Ms Kazeme denied that she was guilty of unsatisfactory professional conduct or professional misconduct, arguing that her role in the clinic was only ever administrative and she was not working as a pharmacist in operating the clinic.
However she agreed in cross examination that her role as proprietor of the clinic required her to ensure safe practices, and that as proprietor and manager she was entrusted with safe custody and distribution of pharmaceuticals. She admitted her inexperience put the health and safety of patients at risk.
The Tribunal was satisfied her conduct in relation to the clinic was conduct engaged in by her in the practice of her profession.
“The Tribunal does not accept that her role was purely administrative,” it said.
“Rather, she was entrusted with safe custody and distribution of therapeutic products, and in providing non-clinical care that impacted on the safe delivery of health services.”
Ms Kazeme was found guilty of unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of her registration.
It also found her guilty of professional misconduct and otherwise not a suitable person to hold registration as a pharmacist.
The Tribunal ordered that if she were still registered, it would have cancelled her registration as a pharmacist for a period of one year commencing from 19 November 2020, being the conclusion of the non-review period made by the Victorian Civil and Administrative Tribunal on 19 November 2018.
Ms Kazeme is prohibited from providing health services offering intravenous infusions, intramuscular injections and other forms of injectables of vitamins, minerals, antioxidants and other similar products, for the period until she obtains a reinstatement order or is re-registered as a health practitioner.
She has been ordered to pay costs to the HCCC.