‘A cluster of failures’: Sydney GP gave newborn high-strength opioid instead of Panadol

1 week ago 3

A Sydney doctor has had his registration suspended after he mistakenly gave a six-day-old child a high-strength opioid instead of Panadol.

Dr Mohammad Salah Uddin Sharier, who owns the Gentle Procedures Clinic in Revesby, will be barred from practising for six months and required to complete a course on clinical decision-making and medication storage following a decision by the NSW Civil and Administrative Tribunal on Tuesday.

The Health Care Complaints Commission (HCCC) brought the case against Sharier after he performed a circumcision on the unnamed newborn in March 2023.

There were no complications with the procedure itself, but Sharier provided the father with a syringe containing what he thought was 0.5ml Panadol children.

The substance was actually the scheduled opioid oxycodone.

Dr Mohammad Salah Uddin Sharier, who owns the Gentle Procedures Clinic in Revesby.

In a statement to the tribunal, the mother said her son stopped crying and appeared to sleep almost immediately after she gave him the medication. She put him down for a nap.

Sharier said he realised his mistake when he went to perform the next procedure.

“I looked at the bench and I found the two bottles together … I didn’t recall the opening of the paper box of the Panadol, so I instantly realised I have made mistake,” he told the tribunal in 2023.

When he called, the father told him the boy’s mother had already given him the medication.

According to the mother’s statement, the boy’s father got off the call and said Sharier had told him the boy may have been given “big kids’ Panadol” and to see if he was drowsy or tired. She tickled his toes, but he would not wake up.

When the parents called the midwifery service at Westmead Hospital, a midwife told them to go to the nearest hospital and to get the name of the medication from his GP.

They rushed their newborn to Liverpool Hospital, where he was given two doses of the overdose medication naloxone. He remained in hospital overnight for observation.

The tribunal found Sharier guilty of unsatisfactory professional conduct, and were particularly critical of his failure to store addictive medication properly, his inadequate medical records, and lack of urgency when he realised his mistake.

Sharier disputed the family’s claim he did not tell them to take their newborn to hospital. But the tribunal said the fact he continued working, failed to answer his phone, and did not proactively seek a hospital admission for the newborn showed he was not overly concerned by the situation.

The tribunal criticised Sharier for not have a drug register, the drugs not being properly stored, and the opened bottles of opioid being stored next to the children’s Panadol on the premises. This mishandling had led to criminal charges and justified suspension of Sharier’s cancellation, the tribunal found.

“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,” they said.

Sharier and Gentle Procedures Clinic have been contacted for comment.

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