A Bangladeshi doctor has been banned from practicing for six months for accidentally giving a baby the powerful opioid oxycodone after a circumcision at his clinic in western Sydney instead of a children’s painkiller.
Dr Mohammad Salah Uddin Sharier, who runs the Gentle Procedures Clinic in Revesby, had his registration suspended by the NSW Civil and Administrative Tribunal on Tuesday over the March 1 2023 incident.
Sharier was previously convicted of three criminal charges – supply of a poison not packaged in accordance with proper policy, failure to keep a drug register, and failure to properly store a drug of addiction – and fined $2,500.
The tribunal heard that the circumcision procedure on the six-day-old baby was performed without complication, but Sharier then gave the boy’s father a syringe containing 0.5ml of what he thought was Panadol Children, but was in fact liquid OxyNorm, a brand name for oxycodone.
Sharier then realised his mistake and called the parents, but they had already injected their son with the opioid. When the baby would not wake up they rushed him to Liverpool Hospital where he was given two doses of Naloxone and kept overnight for observation. He has since made a full recovery.
The tribunal heard there was a “significant dispute” about what Sharier told the father after calling to inform him about the medication error, with the father testifying that Sharier did not tell him to take the baby to hospital and the doctor insisting that he did.
The parents had tried repeatedly to call Sharier after the first conversation, but when he did not answer his phones the mother called a midwife, Ms Hogan, at Westmead Hospital who told them to take their newborn to the nearest emergency room immediately.
While on the way to hospital the parents again tried unsuccessfully to get through to Sharier in order to find out what medication their son had been given, and he eventually answered and texted the mother the information.
A doctor working as a neonatal intensive care consultant on the day the baby was admitted noted in a statement that “no one from the circumcision clinic called Liverpool Hospital to follow up or see how [the baby] had progressed” and that as far as she was aware did not contact the parents while the infant was still admitted the following day either.
The tribunal ruled that it preferred the evidence of the father to Sharier where they conflicted, and wrote “we cannot see any reason why the father would not have taken [the baby] to hospital immediately if that was what Dr Sharier had said”.
“The surrounding circumstances do not support Dr Sharier being overly concerned about the medication error he had made. He says he told the father to contact him if he became concerned, but he admits he did not monitor his mobile,” the tribunal wrote.
“Dr Sharier did not take any proactive steps to facilitate a hospital admission, such as contacting the hospital to ensure that they were aware of the urgency of the situation and the precise details of the medication administered, but rather continued working.”
The tribunal further found that Sharier’s conduct was “a very significant and serious departure from an acceptable response to the crisis which he had created” by not staying in mobile phone conduct or being in contact with the hospital.
Sharier explained his conduct in an affidavit in June that he was having an “unusual and stressful” day because his wife was sick with the flu, he was down a staff member at the clinic due to his wife’s illness, and the shower at his new-build home was leaking and flooding the house.
The tribunal said it was “concerned about the explanation”, noted the Sharier texted the father by mistake about the plumbing while the parents were at the hospital.
“We consider that any orders that we make should assist Dr Sharier to gain further insight into how, on 1 March 2023, his decision making became significantly impaired by what we consider to be the type of stressors which everyone experiences from time to time, so that it does not occur again,” the tribunal wrote.
The tribunal also heard that the parents were forced to wait for 15 to 20 minutes in the Liverpool Hospital Emergency Department with their baby still waking up, and were only seen when they again called Ms Hogan, who spoke to hospital staff and demanded to know why a baby suffering a suspected opioid overdose was not being seen immediately.
Sharier was provided character references from three other doctors, including a Dr Islam who co-founded the Australia Bangladesh Health Forum with him.
Dr Islam said Sharier was held in high regard, and had witnessed his “capacity to show great empathy towards those from diverse backgrounds and challenging life circumstances”.
The tribunal found Sharier guilty of professional misconduct, but decided it was not necessary or appropriate to cancel his registration, and suspended it for six months on the condition he completes a tailored education course and is subject to a medical and practice audit.
“On the day Dr Sharier made the medication error, he did not recall he had three other bottles of oxycodone on the premises, he did not have a drug register, the drugs were not properly stored, and the opened bottle was next to Panadol Children in his treatment room,’ the tribunal ruled.
“In that context, the medication error, while it may have been the result of momentary inattention on an unusually stressful day, it was a foreseeable consequence of a cluster of failures in relation to drug safety that continued unchecked until the risk the regulations were designed to avoid materialised.
“He then failed to take any reasonable steps to address the potentially grave consequences which could have flowed from the medication error, by proactively intervening to ensure that [the baby] received appropriate and timely treatment.”
Header image: Dr Mohammad Salah Uddin Sharier (supplied).
