The Health Professions Appeal and Review Board (HPARB) returned a matter to the Inquiries, Complaints and Reports Committee (ICR) of the College of Physicians and Surgeons of Ontario (CPSO), directing the ICR to reconsider its decision and issue a further decision with written reasons.  This came after the Applicant sought a review of the finding.

The HPARB found that the ICR’s initial decision to issue a Caution to the Applicant had been based on a mistaken belief that the Applicant had a significant history of complaints to the CPSO. In fact, there was only one previous complaint which was for a completely unrelated issue for a breach of the CPSO policy on Treating Self and Family Members

An Unfortunate Loss of a Patient

The Applicant, a physician, was the subject of a complaint by the wife of a now-deceased patient. The patient had died of a heart attack four days after surgery to relieve muscle-invasive bladder cancer and incidental prostate cancer. The operation had been performed by another urologist. The original surgeon last saw the patient in the late afternoon or early evening the day prior to his death. The surgeon was concerned with the patient’s condition but believed the situation would resolve itself. The patient’s care was then transferred to the Applicant, who was the on-call urologist. There was no communication of the original surgeon’s concerns to the on-call urologist.

There were two calls made by the nursing staff to the on-call urologist. The first was a few hours after the surgeon had seen the patient, to clarify a medication to be administered. The second call was a few hours later to report that the patient had vomited. The Applicant ordered a fluid bolus to rehydrate the patient. Vomiting was a known side effect of radical cystectomy surgery. In neither call did the nursing staff communicate to the on-call urologist that the patient was unduly sick or that he needed to be seen urgently.

The Patient’s Wife Files a Complaint

The complaint expressed her concerns as follows:

  1. That the urologist on-call did not attend her husband despite being called repeatedly by the nursing staff and told that the patient’s condition was deteriorating;
  2. That the urologist on-call did not order her husband transferred to the ICU when he did not attend;
  3. That the discharge summary for her husband was very short and did not contain the details necessary for her to judge what had happened.

The HPARB Review of the ICR’s Decision

HPARB concluded that the ICR’s investigation was adequate.

However, the HPARB found that the decision was unreasonable because it had been based on the false assumption that the Applicant had a significant history of complaints when in fact he had only one. This previous complaint had marginal relevance at best to the current complaint and that fact should have been assessed and considered by the ICR.

A Verbal Caution Carries Significant Consequences

A caution, following a disciplinary hearing, carries with it significant consequences for any health professional. The results when published on the CPSO public register can impair their reputation, their licence and hospital privileges. If there is any concern about the adequacy of the investigation or the reasonableness of the decision a health professional should seek legal advice and consider a review request.

At Wise Health Law, we focus on health and administrative law, including appealing and seeking judicial review of disciplinary committees. Our lawyers have significant trial and appellate experience and are passionate about helping regulated health professionals and healthcare organizations understand and protect their legal rights. We will guide you through the process, help you understand potential risks and legal implications, and assist you with or skillfully represent you at the proceedings. To find out how we can assist, contact us online, or at 416-915-4234 for a consultation.

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