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

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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.