The College of Physicians and Surgeons of Ontario (CPSO) recently suspended the license of Dr. Kathy Frank after the Discipline Committee found that Dr. Frank committed an act of professional misconduct by failing to maintain the standard of practice of the profession. The Committee further found that Dr. Frank was incompetent in her care of 24 patients.

Suspension for Failing to Maintain the Standard of Practice of the Profession, and Incompetence

Dr. Frank is an obstetrician and gynecologist who had been practicing since 2002. Between 2009 and 2012, more than 30 patients filed complaints about the treatment they received from Dr. Frank with the CPSO. Subsequent investigations by the College revealed that Dr. Frank had failed to maintain the standard of practice of the profession, and demonstrated incompetence by:

• Failing to adequately investigate causes of patients’ symptoms prior to making decisions about surgery;
• Failing to obtain informed consent before performing surgeries or procedures;
• Failing to adequately document informed consent discussions;
• Failing to adequately document the manner in which she conducted gynecological surgeries;
• Performing surgeries and procedures in a manner inconsistent with the standards of practice of the profession; and
• Failing to adequately monitor and assess patients recovering from surgery, including those who had complications.

Specific Incidents Leading to the Suspension

The Discipline Committee’s decision outlined the details of 27 patients who had been treated by Dr. Frank and who had experienced complications, did not undergo required tests or further investigations into their symptoms, had not been properly informed about their treatment options, or had not provided informed consent. Sixteen of the complaints involved patients who had undergone hysterectomies without Dr. Frank looking into alternative forms of treatment. Other complaints included:

• A patient who visited Dr. Frank during her 34^th week of pregnancy, reporting decreased fetal movement. While Dr. Frank recorded fetal movement, there was no record of Dr. Frank measuring the movement through a kick count or advising the patient to go to the hospital to have the fetus assessed. When the patient went to the ER in her 35^th week of pregnancy, the fetus was found to be deceased and the patient was booked for an induction. Dr. Frank ordered an inappropriately high dose of the medication required for the procedure and failed to obtain the patient’s consent for the off-label use of this medication. The lack of initial documentation about this patient, the inappropriately high dose of medication, and the failure to obtain informed consent all breached the standard of practice.
• A patient whose remaining ovary was removed without discussion with the patient or her family and without the patient’s knowledge. The removal left the patient prematurely menopausal. The patient did not realize the ovary had been removed until she reviewed her medical records several years after the fact. The failure to obtain informed consent breached the standard of practice.
• A patient whose baby who could not be resuscitated following an emergency c-section was provided with a tubal ligation (i.e. surgical sterilization) immediately after the delivery and without her consent. Dr. Frank did not document any discussion about the tubal ligation with the patient, which breached the standard of practice.
• A patient who was injured following a forcep birth. She and her baby both suffered significant complications. The baby required resuscitation and had to be moved to another hospital. Following the mother’s unsuccessful attempts to push, Dr. Frank had attempted to use forceps four times (including changing the type of forceps used). Each time, Dr. Frank noted that the forceps “slipped off”. These attempts lasted about 30 minutes. Dr. Frank failed to meet the standard of practice through the multiple use of forceps. Dr. Frank also failed to document having received informed consent for the use of the forceps.

Undertakings to the CPSO

Dr. Frank had previously been the subject of a number of undertakings to the CPSO, resulting from prior complaints and practice assessments. At the time of this discipline hearing, Dr. Frank’s practice had been restricted due to undertakings or interim undertakings entered into in 2011, 2014, and 2016. These undertakings included:

• An undertaking to undergo a practice assessment and to abide by the recommendations of the assessor;
• An undertaking restricting Dr. Frank’s ability to perform obstetrical and gynecological surgery (unless part of a remediation program);
• An undertaking preventing Dr. Frank from practicing as the most responsible physician in respect of any gynecological or obstetrical patients in any hospital;
• An undertaking to be subject to a two-year period of clinical supervision;
• An undertaking to complete a program in medical ethics; and
• An undertaking not to perform ultrasound procedures without further training.

Practice Restrictions

As of the date of the discipline hearing, Dr. Frank was also subject to several practice restrictions resulting from the above undertakings. These included:

• Not being able to practice in the area of gynecological or obstetrical surgery unless she was a part of a remediation program and supervised by someone who would act as most responsible physician for all patients;
• Not being able to apply for gynecological or obstetrical surgery privileges at any hospital or engage in the practice of medicine as the most responsible doctor in respect of any obstetrical or gynecological patients;
• Not being able to perform ultrasounds on her patients unless under supervision of a clinical supervisor and where a reproductive endocrinologist and infertility specialist was always available on the premises to intervene if necessary.

If you are a regulated health professional facing a complaint, investigation, or disciplinary hearing at your College, contact the well-regarded and highly respected health lawyers at Wise Health Law. We will help you understand your rights, risks, and options, will guide you throughout the process, and will represent you at any proceedings. With offices in both Toronto and Oakville, Ontario we are easily accessible. Contact us online, or at 416-915-4234for a consultation.

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