DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Carly Gilchrist, RPN Chairperson
Sylvia Douglas Public Member Carolyn Kargiannakis, RN Member Lalitha Poonasamy Public Member
George Rudanycz, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) DENISE COONEY for ) College of Nurses of Ontario
- and - )
MARK RAMOS ) PHILIP ABBINK for Registration No. 0306977 ) Mark Ramos
) CHRISTOPHER WIRTH
) Independent Legal Counsel
) Heard: December 22, 2020
AMENDED DECISION AND REASONS
This matter came on for hearing before a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on December 22, 2020, via videoconference.
Publication Ban
Publication Ban
College Counsel brought a motion pursuant to s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, for an order preventing the public disclosure and banning publication or broadcasting of the name, or any information that could disclose the identity of the patient referred to orally or in any documents presented in the Discipline hearing of Mark Ramos.
The Panel considered the submissions of the parties and decided that there be an order preventing the public disclosure and banning the publication or broadcasting of the name, or any information that could disclose the identity of the patient referred to orally or in any documents presented in the Discipline hearing of Mark Ramos.
The Allegations
The Allegations
College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 2(b)(b) and 4(c)(b) in the Notice of Hearing dated October 19, 2020. The Panel granted this request. The remaining allegations against Mark Ramos (the “Member”) are as follows:
IT IS ALLEGED THAT:
- You have committed an act of professional misconduct as provided by subsection 51(1)(b.1) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, in that while practicing as a Registered Nurse at the University Health Network – Toronto General Hospital, in Toronto, Ontario (the “Hospital”), you sexually abused a patient, in that:
(a) between January 2018 and June 2018, you made remarks of a sexual nature towards [the Patient]; and/or
(b) on or about June 9, 2018, you engaged in sexual intercourse and/or other forms of physical sexual relations with [the Patient].
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that while practicing as a Registered Nurse at the Hospital, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession in that:
(a) between January 2018 and June 2018, you made remarks of a sexual nature towards [the Patient];
(b) between January 2018 and June 2018, you failed to appropriately establish and/or maintain the boundaries of the therapeutic nurse-patient relationship with [the Patient], including but not limited to:
a) you communicated by text message with [the Patient] outside of the therapeutic relationship;
b) [Withdrawn];
c) you inappropriately communicated diagnostic information to [the Patient]; and/or
d) you met with [the Patient] in person outside of the therapeutic relationship;
(c) on or about June 9, 2018, you purchased alcoholic beverage(s) for [the Patient], though her plan of care specified she avoid alcohol; and/or
(d) on or about June 9, 2018, you engaged in sexual intercourse and/or other forms of physical sexual relations with [the Patient].
- You have committed an act of professional misconduct as provided by sub-section 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and sub-section 1(7) of Ontario Regulation 799/93 in that, while employed as a Registered Nurse at the Hospital, you abused a client, verbally, physically and/or emotionally in that:
(a) between January 2018 and June 2018 you engaged in a personal and/or sexual relationship with [the Patient];
(b) in or about April 2018, you inappropriately communicated diagnostic information to [the Patient] in a manner which you knew and/or ought to have known could cause her physical, emotional, and/or spiritual harm; and/or
(c) on or about June 9, 2018, you engaged in sexual intercourse and/or other forms of physical sexual relations with [the Patient].
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while employed as a Registered Nurse at the Hospital, you engaged in conduct that would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional with respect to the following incidents:
(a) between January 2018 and June 2018, you made remarks of a sexual nature towards [the Patient];
(b) between January 2018 and June 2018, you engaged in a personal and/or sexual relationship with [the Patient];
(c) between January 2018 and June 2018, you failed to appropriately establish and/or maintain the boundaries of the therapeutic nurse-patient relationship with [the Patient], including but not limited to:
a) you communicated by text message with [the Patient] outside of the therapeutic relationship;
b) [Withdrawn];
c) you inappropriately communicated diagnostic information to [the Patient]; and/or
d) you met with [the Patient] in person outside of the therapeutic relationship; and/or
(d) on or about June 9, 2018, you purchased alcoholic beverage(s) for [the Patient], though her plan of care specified she avoid alcohol; and/or
(e) on or about June 9, 2018, you engaged in sexual intercourse and/or other forms of physical sexual relations with [the Patient].
Member’s Plea
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a), 2(a), 2(b)(a), 2(b)(c), 2(b)(d), 3(a), 3(b), 4(a), 4(b), 4(c)(a), 4(c)(c) and 4(c)(d) in the Notice of Hearing. The Member denied the allegations set out in paragraphs 1(b), 2(c), 2(d), 3(c), 4(d) and 4(e). The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.
Agreed Statement of Facts
Agreed Statement of Facts
College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which as amended and without reproducing the Appendices referenced therein reads, unedited, as follows:
THE MEMBER
Mark Ramos (the “Member”) obtained a diploma in nursing from Conestoga College in 2002.
The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on March 24, 2003 in the General Class.
THE HOSPITAL
At the time of the incidents, the Member was employed at the University Health Network – Toronto General Hospital (the “Hospital”).
The Member worked in the Liver Clinic at the Hospital as a liver disease specialty nurse who coordinated treatment and follow-up care for chronic liver disease patients under the supervision of [the Doctor].
The Member’s employment at the Hospital was terminated on June 12, 2019, following the Hospital’s investigation into the incidents described below.
THE PATIENT
-
(the “Patient”) was a 41-year-old female who was referred to the Liver Clinic at the Hospital in January 2018. She had several prior admissions to the Hospital in late 2017. She was diagnosed with alcoholic liver disease complicated by alcoholic hepatitis.
The Patient’s plan of care required her to completely abstain from alcohol. In [the Doctor]’s view, the Patient’s liver function was stabilizing but could worsen again if she were to drink regularly or binge drink.
Between January 2018 and June 2018, the Patient attended at the Liver Clinic’s day unit to receive paracentesis every few weeks, and to receive albumin infusions as needed. The Member assisted with providing the Patient care when she attended at the day unit and in coordinating her care.
The Patient died [in October 2020]. The hearing of these allegations of professional misconduct were initially scheduled to proceed before a panel of the Discipline Committee in October 2020. The hearing was adjourned following the Patient’s death.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
Text messages
The Member initially contacted the Patient by text message using his personal device. If the Member were to testify, he would state that he provided the Patient with his cell phone number written on an office business card so the Patient could contact him regarding her test results. He did not have a business cell phone. The Member’s initial contact with the Patient was professional and included the communication of bloodwork results.
Over time, the text messages the Member sent to the Patient changed in tone and content. The Member sent the Patient pictures of himself. He also sent her text messages with words to the effect of:
“How are you feeling? Do you have plans for the day?”;
“you love me! I know”;
“you know I’m good for you”;
they had a special or once in a lifetime connection;
he would take care of her;
complimenting her on her physical appearance; and
arranging to meet with her outside the therapeutic nurse-patient relationship at a bar, as described in paragraphs 17-18 below.
- Records of certain messages the Member and the Patient exchanged are attached as Appendix A. These include text messages from the Member such as:
“You love me!”;
“dont [sic] jump me right away. We need to go outfirst [sic] …may after I will maybe let you … maybe”; and
referring to the Patient as tasting like “roses”.
Inappropriate communication of diagnostic information
On one occasion, the Member sent the Patient a series of text messages in which he wrote: “All my patients that present like you” “Have not lasted 2 years”. The Patient responded, “Well then I’m going out for a drink”. The Member responded with an emoji as follows: . The Member then wrote, “Unless you get a transplant” “then you can live longer”.
The Patient found this communication incredibly upsetting, and was sobbing, inconsolable and traumatized after receiving these text messages. The Member’s comment convinced the Patient that she was dying and made her more reliant on the Member, which later made her feel manipulated, stupid and taken advantage of.
If the Member were to testify, he would state that he believed the Patient had been informed repeatedly by health care providers that if she did not stop drinking or get a liver transplant, her condition would worsen and she would likely die. The Member would further testify that his view was that his text message was in substance accurate and his intention was to convey this message in plain, understandable language.
The Member acknowledges that regardless of whether his communication about the Patient’s prognosis was accurate, the way in which he communicated this information to the Patient failed to demonstrate respect and empathy.
Meeting outside of the therapeutic relationship
The Member asked the Patient to meet him outside of the therapeutic relationship. Eventually she agreed to go with him to a bar in Toronto where the Member’s brother worked. On June 9, 2018, the Member and the Patient attended at the bar.
The text messages the Patient and the Member exchanged before attending the bar include the following:
the Member wrote to the Patient that “we do need to go to my brothers lounge you know”. The Patient stated, “Sure what’s the dress code”, and the Member responded, “casual” “whatever you want” “hence why i’m [sic] downtown tonight and to see you”.
The Patient asked the Member, “what’s our cover story? You can’t just walk into your brothers [sic] place with some hot girl”. The Member responded, “you are my friend/blogger”.
The Member wrote to the Patient, “i hope it works and if doesn’t, at least we tried” “right?” “the way you have to look at it” “and it shouldn’t hamper your health and how we met in the first place” “at least we’d figure out what we are”. The Patient responded “Hey who knows? Maybe you’re a bad kisser and it’s a no-go :)”. The Member responded, “maybe it doesn’t taste like roses then it’s a no go”. The Patient responded, “Maybe you’ll come to my ghetto apartment/zoo and you won’t like it” and the Member responded, “or maybe you wont [sic] like my body”.
At the bar, the Patient learned that the Member had a girlfriend. The Patient left the bar, and reported after that she felt manipulated and stupid. If the Member were to testify, he would state that the Patient was intoxicated, so he assisted her in getting a cab to go home.
Shortly after attending the bar on June 9, 2018, the Member told the Patient that what he had done was not right, and he told her that he felt he had to come clean to [the Doctor]. In the text messages, the Patient refers to having engaged in sexual intercourse with the Member, which conduct the Member denies. The Member and the Patient exchanged a number of text messages as follows:
The Patient wrote to the Member apparently imitating what she would say to [the Doctor]’s receptionist when she called to report the Member’s conduct: “Can I ask what this is regarding? Yes [the Member] had sex with me, bought me drinks and treated me pretty shitty and I’d like to make a complaint?” “??!” The Member responded, “Not like that. Just say you have some concerns you want to voice to [the Doctor]”. The Patient responded, “You really want me to do that?” The Member responded, “Up to you”.
The Patient wrote to the Member, “You have been my primary health care provider for months. Turned friend turned lover and you try to get rid of me after one night? I did trust you. I let you into my home and my body” … “Don’t act so innocent you were telling me for weeks what you wanted to do with me”. The Member responded, “Just getting the story straight for tomorrow”.
The Patient wrote to the Member, “I will say this one more time and then I’m not saying it anymore. You came over you fucked me and within an hour and a half one of your best friends told me you had a girlfriend: I was upset”. The Member eventually responded, “I still need to talk to him [i.e. [the Doctor]] if problems like this week arise again”.
CNO STANDARDS
CNO’s Professional Standards provides that each nurse is accountable to the public and responsible for ensuring her or his practice and conduct meets legislative requirements and the standards of practice of the profession. A nurse demonstrates this standard by providing, facilitating, advocating and promoting the best possible care for patients.
CNO’s Professional Standards further states that ethical nursing includes acting with integrity, honesty and professionalism in all dealings with the patient and other health care team members.
CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) defines a boundary in the nurse-patient relationship as “the point at which the relationship changes from professional and therapeutic to unprofessional and personal.” The TNCR Standard places the responsibility for establishing and maintaining the limits and boundaries in the therapeutic nurse-patient relationship on the nurse. The TNCR Standard provides that:
Crossing a boundary means that the care provider is misusing the power in the relationship to meet his/her personal needs, rather than the needs of the [patient], or behaving in an unprofessional manner with the [patient].
- With respect to maintaining boundaries, a nurse demonstrates having met the TNCR Standard by actions such as:
setting and maintaining the appropriate boundaries within the relationship, and helping [patients] understand when their requests are beyond the limits of the therapeutic relationship;
developing and following a comprehensive care plan with the [patient] and health care team that aims to meet the [patient’s] needs;
ensuring that any approach or activity that could be perceived as a boundary crossing is included in the care plan developed by the health care team;
abstaining from disclosing personal information, unless it meets an articulated therapeutic need of the patient;
continually clarifying her/his role in the therapeutic relationship, especially in situations in which the [patient] may become unclear about the boundaries and limits of the relationship; and
ensuring that the nurse-[patient] relationship and nursing strategies are developed for the purpose of promoting the health and well-being of the patient and not to meet the needs of the nurse, especially when considering self-disclosure.
- CNO’s TNCR Standard defines abuse as:
[T]he misuse of the power imbalance intrinsic in the nurse-[patient] relationship. It can also mean the nurse betraying the [patient]’s trust, or violating the respect or professional intimacy inherent in the relationship, when the nurse knew, or ought to have known the action could cause, or could be reasonably expected to cause physical, emotional or spiritual harm to the [patient].
Abuse may be verbal, emotional, physical, sexual, financial, or take the form of neglect. The TNCR Standard provides that sexual abuse includes, but is not limited to, sexually demeaning, seductive, suggestive, exploitative, derogatory or humiliating behaviour, comments or language toward a patient.
CNO’s TNCR Standard requires nurses to protect the patient from harm by ensuring that abuse is prevented or stopped and reported. With respect to protecting the patient from abuse, a nurse demonstrates having met the TNCR Standard by actions such as:
not entering a friendship, or a romantic, sexual or other personal relationship with a [patient] when a therapeutic relationship exists; and
not engaging in behaviours with a [patient] or making remarks that may reasonably be perceived by other nurses and/or others to be romantic, sexually suggestive, exploitive and/or sexually abusive (for example, spending extra time together outside of the [patient]’s care plan).
EXPERT OPINION
- CNO obtained an expert opinion from Dr. Ruth Gallop in this matter. The summary of Dr. Gallop’s expert opinion is attached at Appendix B.
Remarks of a sexual nature
In Dr. Gallop’s opinion, the Member’s remarks to the Patient as described in paragraphs 11 to 12 and 17 above were remarks of a sexual nature. In her view, many of the Member’s text messages were specifically or indirectly sexually suggestive and were therefore of a sexual nature. Dr. Gallop highlighted the Member’s messages about wanting physical contact with the Patient, kissing her, “maybe you won’t like my body” as being examples of remarks of a sexual nature.
In Dr. Gallop’s view, the Member’s remarks of a sexual nature directed towards the Patient constitute sexual abuse of the Patient within the meaning of “sexual abuse” in the Health Professions Procedural Code, being Schedule 2 to the Regulated Health Professions Act, 1991. Further, in her view, the Member contravened the standards of practice of the profession by making remarks of a sexual nature towards the Patient.
In Dr. Gallop’s opinion, the Member contravened the standards of practice of the profession by communicating by text message with the Patient outside of the therapeutic relationship. This conduct is a breach of the boundaries of the therapeutic relationship, and an abuse of power.
In Dr. Gallop’s view, the Patient was highly vulnerable: she had a serious life-threatening illness and a problem with alcohol. Great care needs to be taken with the vulnerable patient. The Member’s messages, in Dr. Gallop’s opinion, represented an effort to groom the Patient, building a relationship, trust and emotional connection with the Patient in order to abuse her. The Member’s conduct built a neediness and dependency in the relationship.
Communicating by text message with the Patient outside of the therapeutic relationship
- In Dr. Gallop’s opinion, the Member contravened the standards of practice of the profession by communicating by text message with the Patient outside of the therapeutic relationship. In her view, this conduct is a breach of the boundaries of the therapeutic relationship, and an abuse of power. Dr. Gallop opined that even if the text messages were not to be considered of a sexual nature (though in her view they are), a nurse engaging in personal communications with a patient outside the therapeutic relationship creates a different kind of relationship. The Member’s responsibility is to maintain a therapeutic, professional relationship, and not to enter into a friendship or other kind of relationship with the Patient.
Communication of diagnostic information
In Dr. Gallop’s opinion, the Member’s text messages to the Patient described at paragraph 13 above contravened the standards of practice of the profession.
The Member’s message to the Patient suggested that she had two or less years left to live. Even if this were an accurate diagnosis, in Dr. Gallop’s view the Member ought not to have been providing the Patient with a diagnosis.
In any event, in Dr. Gallop’s view, the Member should not have communicated this information to the Patient over text message in this manner. The Member communicated what he ought to have known would be upsetting medical information to the Patient in what Dr. Gallop described as a “nonchalant” manner. According to Dr. Gallop, the Member’s messages seemingly encouraged the Patient to have a drink and the Member appears to make a joke of the situation.
In Dr. Gallop’s view, the Member’s communications were a breach of the accountability and ethics standards. The accountability standard requires nurses to provide, facilitate, advocate and promote the best possible care for patients. The ethics standard requires the Member to act with “integrity, honesty and professionalism” in all interactions with the Patient. The Member’s conduct in the interaction as a whole encouraged the Patient to consume alcohol, was upsetting to the Patient, and highly damaging to the Patient and her health.
Further, in Dr. Gallop’s opinion, the Member emotionally abused the Patient by communicating diagnostic information to the Patient by text message as described. The Member’s communication was insensitive to the Patient and a violation of the respect or professional intimacy of the relationship, and as such meets the definition of abuse in the TNCR Standard. The Member knew, or ought to have known, that this communication could cause, or could be reasonably expected, to cause her emotional harm, which it did.
Meeting the Patient in person outside of the therapeutic relationship
In Dr. Gallop’s opinion, the Member’s conduct in meeting the Patient in person outside of the therapeutic relationship contravened the standards of the profession.
Meeting a patient outside of the therapeutic relationship is a breach of the boundaries of the therapeutic nurse-patient relationship. The TNCR Standard requires nurses to abstain from spending extra time with a patient outside of a patient’s care plan.
Dr. Gallop also expressed concern that the Member specifically arranged to meet the Patient at a bar, knowing as her treating healthcare professional that she is required to abstain from alcohol and has a chronic liver condition. This conduct contravenes the standard of accountability in the Professional Standards.
Engaging in a personal relationship with the Patient
In Dr. Gallop’s opinion, the Member emotionally and sexually abused the Patient by engaging in a personal and sexual relationship with her. His conduct was a misuse of the power imbalance intrinsic in the nurse-patient relationship and included unprofessional and personal contact which served the Member’s personal needs rather than the Patient’s needs, remarks of a sexual nature, and physical sexual contact.
Dr. Gallop expressed concern that the Member’s conduct suggested a pattern of grooming. The entire relationship was damaging to the Patient and did or could have created a neediness and dependency of the Patient on the Member. In particular, the Patient was devastated when she found out that the Member had a girlfriend.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that he committed the acts of professional misconduct as alleged in paragraph 1(a) of the Notice of Hearing, as described in paragraphs 10 to 12, 18 and 23 to 33 above, in that he sexually abused the Patient.
The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 2(a), 2(b)(a), 2(b)(c) and 2(b)(d) of the Notice of Hearing in that he contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 10 to 43 above
The Member admits that he committed the acts of professional misconduct as alleged in paragraph 3(a), in that he engaged in a personal relationship with the Patient, and paragraph 3(b), and as described in paragraphs 10 to 43 above.
The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 4 (a), 4(b) in that he engaged in a personal relationship with the Patient, paragraphs 4(c)(a), 4(c)(c), and 4(c)(d) of the Notice of Hearing, and in particular his conduct was disgraceful, dishonourable and unprofessional, as described in paragraphs 10 to 43 above.
Due to the Patient’s death, CNO led no evidence of the other acts of sexual abuse as alleged, or of the Member purchasing alcohol for the Patient as alleged.
With leave of the Discipline Committee, CNO withdraws the following allegations:
2(b)(b)
4(c)(b)
Decision
Decision
The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities based upon clear, cogent and convincing evidence.
Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1(a), 2(a), 2(b)(a), 2(b)(c), 2(b)(d), 3(a), 3(b), 4(a), 4(b), 4(c)(a), 4(c)(c) and 4 (c)(d) of the Notice of Hearing. With respect to allegations #3(a) and 4(b), the Panel’s findings of professional misconduct are with respect to the Member having engaged in a personal relationship with the Patient. As to allegations #4(a), 4(b), 4(c)(a), 4(c)(c) and 4(c)(d), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be disgraceful, dishonourable and unprofessional.
With respect to allegations #1(b), 2(c), 2(d), 3(c), 4(d) and 4(e), the Panel makes no findings and dismisses the allegations.
Reasons for Decision
Reasons for Decision
The Panel considered the Agreed Statement of Facts and the Member’s plea and finds that this evidence supports findings of professional misconduct as alleged in the Notice of Hearing.
Allegation #1(a) in the Notice of Hearing is supported by paragraphs 10 to 12, 18, 23 to 33 and 44 in the Agreed Statement of Facts. There were multiple remarks of a sexual nature by the Member. In Dr. Gallop’s expert opinion, the Member’s remarks to the Patient as described in paragraphs 11 and 12 were remarks of a sexual nature and in her view many of the Member’s text messages were specifically or indirectly sexually suggestive and were therefore of a sexual nature. As such, the Member’s remarks constitute sexual abuse of a patient.
Allegations #2(a), 2(b)(a), 2(b)(c) and 2(b)(d) in the Notice of Hearing are supported by paragraphs 10 to 43 and 45 in the Agreed Statement of Facts. The Member contravened the standards of practice in that he had a personal relationship with the Patient and communicated with the Patient by text and met with the Patient outside of work. The Member also inappropriately communicated diagnostic information to the Patient.
Allegations #3(a) and 3(b) in the Notice of Hearing are supported by paragraphs 10 to 43, 46 and 47 in the Agreed Statement of Facts. The Member between January 2018 and June 2018, engaged in a personal relationship with the Patient. The conduct of the Member was verbally and emotionally abusive to the Patient. There was a misuse of power by the Member and a power imbalance between the Member and the Patient.
With respect to allegations #4(a), 4(b), 4(c)(a), 4(c)(c) and 4(c)(d), the Panel finds that the Member’s conduct is disgraceful, dishonourable and unprofessional. There is no doubt that the Member was involved in a personal relationship with the Patient and conduct that was a breach of the boundaries of the therapeutic relationship and an abuse of power. It is the Member’s responsibility to maintain a therapeutic, professional relationship, and not to enter into a friendship or other kind of relationship with the Patient. The Panel finds that the Member’s conduct was unprofessional as it demonstrated a serious and persistent disregard for his professional obligations.
The Panel also finds that the Member’s conduct was dishonourable. He knew or ought to have known that his conduct was unacceptable and fell below the standards of a professional. The Member had an inappropriate personal relationship with the Patient when he communicated with the Patient by text and met with the Patient outside of work. The Member also inappropriately communicated diagnostic information to the Patient. This conduct by the Member did not promote the wellbeing of the Patient.
The Panel finds that the Member’s conduct was disgraceful as it shames the Member and by extension the profession. The conduct by this Member should have been a professional relationship but was an intense and personally intimate relationship which included very troubling text messages and had no therapeutic value. The Member invited the Patient, who was highly vulnerable: to meet him at a bar for his own personal gain, although he was aware that she was to abstain from alcohol. This behaviour casts serious doubt on the Member’s moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet.
Finally, the College called no evidence with respect to allegations #1(b), 2(c), 2(d), 3(c), 4(d) and 4(e) and so the Panel dismissed those allegations.
Penalty
Penalty
College Counsel and the Member’s Counsel advised the Panel that a Joint Submission on Order had been agreed upon. The Joint Submission on Order requests that this Panel make an order as follows:
Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for 18 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at his own expense and within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of sessions are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date that this Order becomes final. To comply, the Member is required to ensure that:
i. The Expert has expertise in nursing regulation and has been approved by the Director in advance of the meetings;
ii. At least 7 days before the first meeting, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
the Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;
iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):
Professional Standards,
Therapeutic Nurse-Client Relationship, and
Code of Conduct;
iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at his own expense, including the self-directed Nurses’ Workbook;
v. At least 7 days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and Nurses’ Workbook;
vi. The subject of the sessions with the Expert will include:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vii. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into his behaviour;
viii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on his certificate of registration;
b) For a period of 24 months from the date the Member returns to the practice of nursing, the Member will notify his employers of the decision. To comply, the Member is required to:
i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;
ii. Provide his employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
the Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iii. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
All documents delivered by the Member to CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
Penalty Submissions
Penalty Submissions
Submissions were made by College Counsel.
College Counsel submitted that the proposed penalty is tailored appropriately to deter similar behaviour by this Member in the future. All aspects of the Joint Submission on Order work toward deterrence going forward.
The aggravating factors in this case were:
The Member’s conduct was serious and intentional;
The Member’s conduct showed a disregard for his professional obligations;
The Member exploited his position of trust for his own needs and for personal gratification;
The Member repeatedly sent text messages to the Patient to build the relationship with her;
The Patient was seriously ill, and highly vulnerable; she had a life-threatening illness and a problem with alcohol misuse.
The mitigating factors in this case were:
The Member has no prior disciplinary history with the College;
The Member pled guilty to certain allegations and agreed to the Agreed Statement of Facts and the Joint Submission on Order.
The proposed penalty provides for general and specific deterrence through:
The oral reprimand;
The suspension of the Member’s certificate of registration for 18 months.
The proposed penalty provides for remediation and rehabilitation through:
Two meetings with the Regulatory Expert, which will allow the Member to reflect on his professional standards of practice and conduct to ensure it is not repeated. The Member will gain specific insight and knowledge which will affect his future practice;
The terms, conditions and limitations placed on the Member’s certificate of registration.
Overall, the public is protected because:
The proposed Joint Submission on Order in its totality is geared toward public protection. The order sends a message to nurses that there are consequences for their behaviour, and to the public of the profession’s ability to self-regulate;
The Member will gain specific insight and knowledge which will affect his future practice.
College Counsel submitted cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee.
College of Physicians and Surgeons of Ontario (CPSO) v. Gorman (Discipline Committee, 2007). The member had personal communication via email and phone with the patient for personal gain. This case occurred in 2002 but the hearing was in 2007. The member was given an oral reprimand, a 24 month suspension, 12 months of which would be suspended if the member completed an ethics course and continued psychotherapy for at least 2 years, along with terms, conditions and limitations on the member’s certificate of registration and a $15,000.00 fine.
CPSO v. Muirhead (Discipline Committee, 2014). The member exploited 5 patients for his own benefit. The member had breached boundaries and failed to maintain the standard or practice of the profession. The member was given an oral reprimand, an 18 month suspension, and terms, conditions and limitations on his certificate of registration which included a period of supervision on his practice and that he could not have contact with any female patient except in the presence of a female chaperone.
CPSO v. Horri (Discipline Committee, 2019). The member engaged in a sexual relationship soon after the termination of the doctor-patient relationship. The member was given an oral reprimand, a 12 month suspension, and terms, conditions and limitations on his certificate of registration requiring the member to complete a course on medical ethics.
The Member’s Counsel reviewed with the Panel the principle applicable to Joint Submissions on Order and submitted that the Member had accepted responsibility for his conduct and this shows that he is likely able to be rehabilitated and remediated.
Penalty Decision
Penalty Decision
The Panel accepts the Joint Submission on Order and accordingly orders:
The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for 18 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
The Executive Director is directed to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at his own expense and within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of sessions are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date that this Order becomes final. To comply, the Member is required to ensure that:
i. The Expert has expertise in nursing regulation and has been approved by the Director in advance of the meetings;
ii. At least 7 days before the first meeting, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
the Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;
iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):
Professional Standards,
Therapeutic Nurse-Client Relationship, and
Code of Conduct;
iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at his own expense, including the self-directed Nurses’ Workbook;
v. At least 7 days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and Nurses’ Workbook;
vi. The subject of the sessions with the Expert will include:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vii. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into his behaviour;
viii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on his certificate of registration;
b) For a period of 24 months from the date the Member returns to the practice of nursing, the Member will notify his employers of the decision. To comply, the Member is required to:
i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;
ii. Provide his employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
the Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iii. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
All documents delivered by the Member to CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
Reasons for Penalty Decision
Reasons for Penalty Decision
The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The Panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.
The Panel concluded that the proposed penalty is reasonable and in the public interest and it strikes the right balance of the goals of penalty. Specific deterrence is met with the oral reprimand and the suspension of the Member’s certificate. It addresses remediation and rehabilitation through meetings with a Regulatory expert which will ensure the Member’s conduct is not repeated. The public is protected as the Member will gain specific insight and knowledge which will affect the Member’s future practice. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility. The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection.
The penalty is in line with what has been ordered in previous cases.
I, Carly Gilchrist, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline Panel.