College of Nurses of Ontario v. Patricia McCaig, 2024 CanLII 107213

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Tyler Hands, RN Chairperson

Morgan Krauter, NP Member Lalitha Poonasamy Public Member

Michael Schroder, NP Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) ALYSHA SHORE for

) College of Nurses of Ontario

• and - )

PATRICIA MCCAIG (FORMERLY LEDREW) ) CARINA LENTSCH for

Registration No. 0456079 ) Patricia McCaig

) KIMBERLEY ISHMAEL

) Independent Legal Counsel

) Heard: March 18, 2024

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 March 18, 2024, via videoconference.

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 public disclosure and banning the publication or broadcasting of the name of the patient, or any information that could disclose their identity, referred to orally or in any documents presented at the Discipline hearing of Patricia McCaig.

The Panel considered the submissions of College Counsel and the Member’s Counsel and decided that there be an order preventing public disclosure and banning the publication or broadcasting of the name of the patient, or any information that could disclose their identity, referred to orally or in any documents presented at the Discipline hearing of Patricia McCaig.

The Allegations

College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1(a), 2(a), 3(a) and 4(a) in the Notice of Hearing dated February 1, 2024. The Panel granted this request. The remaining allegations against Patricia McCaig (the “Member”) are as follows:

IT IS ALLEGED THAT:

1. 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 registered with the College of Nurses of Ontario as a Registered Nurse and/or while employed at the Mino Ayaa Ta Win Health Centre and Withdrawal Management Services (the “Program”), you sexually abused a patient, in that:

(a) [withdrawn]; and/or

(b) between in or about June 2020 and July 2020, you made remarks of a sexual nature towards [the Patient] within one year of [the Patient]’s discharge from the Program.

2. 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 registered with the College of Nurses of Ontario as a Registered Nurse and/or while employed at the Mino Ayaa Ta Win Health Centre and Withdrawal Management Services (the “Program”) you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession in that:

(a) [withdrawn];

(b) between in or about March 2020 and July 2020 you provided funds and/or gifts to [the Patient] within one year of [the Patient]’s discharge from the Program;

(c) between in or about June 2020 and July 2020, you made remarks of a sexual nature towards [the Patient] within one year of [the Patient]’s discharge from the Program;

(d) between in or about March 2020 and April 2021, you engaged in a personal relationship with [the Patient] within one year of [the Patient]’s discharge from the Program; and/or

(e) in or around June 2020, within one year of [the Patient]’s discharge from the Program, you consumed alcohol and/or other substances with [the Patient] and/or encouraged [the Patient} to consume alcohol and/or other substances, at a time when [the Patient] had recently received treatment for substance use.

3. 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 subsection 1(7) of Ontario Regulation 799/93 in that, while registered with the College of Nurses of Ontario as a Registered Nurse and/or while employed at the Mino Ayaa Ta Win Health Centre and Withdrawal Management Services (the “Program”), you abused a patient, verbally, physically and/or emotionally in that:

(a) [withdrawn]; and/or

(b) between in or about June 2020 and July 2020, you made remarks of a sexual nature towards [the Patient] within one year of [the Patient]’s discharge from the Program.

4. 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 registered with the College of Nurses of Ontario as a Registered Nurse and/or while employed at the Mino Ayaa Ta Win Health Centre and Withdrawal Management Services (the “Program”), you engaged in conduct that would reasonably be regarded by members as disgraceful, dishonourable or unprofessional with respect to the following incidents:

(a) [withdrawn];

(b) between in or about March 2020 and July 2020 you provided funds and/or gifts to [the Patient] within one year of [the Patient]’s discharge from the Program;

(c) between in or about June 2020 and July 2020, you made remarks of a sexual nature towards [the Patient] within one year of [the Patient]’s discharge from the Program;

(d) between in or about March 2020 and April 2021, you engaged in a personal relationship with [the Patient] within one year of [the Patient]’s discharge from the Program; and/or

(e) in or around June 2020, within one year of [the Patient]’s discharge from the Program, you consumed alcohol and/or other substances with [the Patient] and/or encouraged [the Patient] to consume alcohol and/or other substances, at a time when [the Patient] had recently received treatment for substance use.

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(b), 2(b), (c), (d), (e), 3(b) and 4(b), (c), (d) and (e) in the Notice of Hearing. 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 admissions were voluntary, informed and unequivocal.

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 reads, unedited without exhibits, as follows:

THE MEMBER

1. Patricia McCaig (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on April 16, 2004 in the Temporary Class and on July 26, 2004 in the General Class. The Member entered the Non-Practising Class from December 20, 2023 to January 26, 2024. The Member resigned her certificate of registration with CNO on January 26, 2024.

2. The Member initially registered with CNO under the name Patricia LeDrew. The Member changed her name to Patricia McCaig and this was reflected on CNO’s public register on November 28, 2022.

3. At the time of the incidents, the Member was employed at the Mino Ayaa Ta Win Healing Centre and Withdrawal Management Services (the “Program”) which is a part of the Fort Frances Tribal Authority Health Services Inc. in Fort Frances, in Northwest Ontario. The Member worked for the Program on a full-time basis in the position of Withdrawal Management Coordinator, RN. Her employment with the Program was terminated without cause in November 2020.

THE PROGRAM

4. The Program offers a voluntary residential treatment program and withdrawal management services that lasts 28-days. Patients are not assigned to a particular nurse, but nursing care is available to them 24 hours a day.

5. The Member provided direct nursing care to patients of the Program in her capacity as Withdrawal Management Coordinator and when covering as a line shift nurse.

THE PATIENT

6. (the “Patient”) entered the Program’s voluntary residential treatment program in early February 2020 and commenced his 28-day stay on or about February 10, 2020, when he was 27 years old. In his application to the Program, the Patient reported issues with alcohol use (6-10 beers daily) and hydromorphone use (12-24 mg per day), as well as a history of use of cocaine, marijuana, prescription opioids. The Patient also reported a mental health history of tension, anxiety, and depression. His self-stated goal in attending treatment was “to find a way to live a healthy substance free lifestyle”.

7. The Patient met the Member while he was in the Program and the Member provided nursing care to him. If the Member were to testify, she would state that her direct interactions with the Patient at the Program were brief.

8. The Patient graduated and was discharged from the Program on March 9, 2020.

9. On April 11, 2021, a little more than one year following his discharge from the Program, the Patient passed away from an overdose.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Personal Relationship

10. Within one year of the Patient’s discharge from the Program, the Member and the Patient engaged in a personal relationship, which the Member admits and acknowledges.

11. If the Member were to testify, she would state that before meeting the Patient at the Program, she knew several members of the Patient’s family. The Member would further testify that the Patient’s stepfather has been her common law partner since 2020 and sometime after the Patient was discharged from the Program, she began to consider the Patient as a part of her family.

12. The Member admits and acknowledges that she used her personal cell phone to contact the Patient after his discharge from the Program. The Member and the Patient began exchanging text messages on March 9, 2020, the day of his discharge from the Program.

13. If the Member were to testify, she would state that she called the Patient on March 9, 2020 to ask him about a canoe paddle that had been left behind at the Program. The Member would further testify that later in March 2020, the Patient contacted the Member on her personal number to ask if she could give him a ride to a job-interview. The Member would further testify that she agreed and at the Patient’s request, she purchased a new shirt for the Patient to wear to the job interview and drove him to the interview in her car.

14. If the Member were to testify, she would state that, in or around March or April 2020, the Member learned that the Patient was planning to move out of his current rental unit (the “Property”) and she asked the Patient whether she could rent the Property. The Member subsequently entered into an agreement with the Patient to sub-let the Property and paid rent to the Patient.

15. On or around June 15, 2020, the Member gave the Patient an iPhone. Between June 15, 2020 and April 8, 2021, the Member and the Patient exchanged over 3,500 text messages, including many text messages of a personal nature.

16. The text messages available from June 15, 2020, onwards, between the Member and the Patient reflect an extensive and intense personal relationship within one year after the Patient’s discharge from the Program, as detailed below:

• The Member suggested that the Patient not drink “all day everyday. Drink a few casual on days off. Not hard core starting in morning. Smoking Cut back … Drugs. Don’t do em. Get clean for your test.”;

• The Member sent the Patient several images of herself with her cleavage prominently displayed and asked him about her outfit choice;

• The Member told the Patient “I’m super fuckedup. But still making sure I check on you … see you are my best friend ”;

• The Member texted the Patient “…all I. could think of her dirty texts about you choking her and her having to change her wet panties and the excitement of sucking your cocka Pi”,“Sucking your cock while sitting on your face”;

• The Member described the Patient as being “still handsome” after he sustained an injury to his face;

• The Member told the Patient “I love you crazy guy. Just you want you to live your best life”; and

• On the one-year anniversary from the Patient graduating from the Program, the Member texted the Patient “I am so fucking proud of you.” “I really really am.” “One year yesterday since you got out of treatment.” “Lots has changed. I am thankful we became friends”. The Patient responded “me too”. The Member then responded “Wasn’t an easy road getting here. But ultimately we are family. And things will work out. I promise”.

17. The Member and the Patient exchanged text messages on June 27, 2020 as follows:

• The Member texted “Sex well it was sex. I know I gave wicked head and I ensured I gave it all. First time was good. You were a good lay. Second time in car felt like a pity fuck. Same pretty much the third. I knew you weren’t into me when I started Mc playing with your cock in the morning and you pushed me away ……”.

• The Patient responded, “K I’m done talking sorry but I can’t Your [sic] a great person I just can’t be with you Your too up and down and you just keep trying you’re a friend that’s it that’s all I appreciate everything you’ve done for me I really do”.

18. If the Member were to testify, she would state that she was in an inebriated state when sending many of the above-noted messages to the Patient, and she deeply regrets communicating with the Patient in this very inappropriate manner. The Member would further testify that despite the appearance of the text messages, she and the Patient never engaged in any romantic or physical relationship.

19. Following the Patient’s discharge from the Program, the Member continued to give the Patient advice about his health, substance use and about accessing health care services, including in text messages she sent to the Patient as outlined below:

• The Member offers the Patient advice on an “issue” relating to his consumption of cocaine and its effect on his sexual activity;

• The Member offers the Patient advice on how to deal with pain and offers to call the emergency room for him to ask for a letter to excuse him from work;

• The Member suggests to the Patient that he is “cuncussed [sic]” and “detoxing” and suggesting that he needs to “push fluids. Lots of fruit. Dark green leavy veg. Add some fish and chicken”. She later suggests that she will call “first thing tomorrow” because she is worried he is concussed;

• The Member offers to call the Patient’s work and says, “I could just say I am a friend who is also an RN and I’m taking you to emerg for concerns related to a concussion and that you had called your nurse and she advised that you are not fit for work and need to get a note”;

• The Patient asks the Member “I started taking my meds again I’ve been off them for a lil bit is it normal for them to kinda make me feel fucked up?”;

• The Patient asks the Member to get him “drug tests” from work; and

~~• ~~The Member makes a telephone appointment for the Patient for health issues he was experiencing.

Gifts and Money

20. Within one year of the Patient’s discharge from the Program, the Member also provided money and gifts to the Patient.

21. On November 28, 2020, the Member and the Patient became involved in an argument via text message over money owed by the Patient to the Member’s partner at the time. The Member provided a list of the items that she had paid for the Patient including:

• On or around June 1, 2020, she paid for the Patient’s cell phone bill;

• On or around June 18, 2020, she gave a Father’s Day gift for the Patient on behalf of his children, which included a Pflueger Reel and St. Croix Fishing Rod;

• On or around June 18, 2020, she purchased an iPhone for the Patient;

• In or around June 2020, she purchased beer for the Patient;

• In or around July 2020, she purchased cigarettes for the Patient; and

• On various occasions, she provided money to the Patient, including for rent.

Consuming Alcohol with the Patient

22. Within one year of the Patient’s discharge from the Program where he had received treatment for substance use, the Member attended family gatherings with the Patient and consumed alcohol with the Patient at those gatherings.

23. The Member and the Patient also discussed alcohol and drugs frequently in their text messages. For example, in one message the Patient asked the Member if she has any pills she gave him “a while back” and any “weed”. The Member responded “I can drop some pills off. I’m out of weed too. Just ordered.” In addition, on June 15, 2020, the Member suggested that when her partner, and the Patient’s stepfather, get home “we will do a big bonfire bash” and she will bring “beers, tequila”.

24. If the Member were to testify, she would state that the gathering she referred to as a “big bonfire bash” never actually took place, she did not in fact provide weed to the Patient at any time, and the “pills” she referred to were regular over the counter pain medications, including “Aleve”.

Member’s Remorse

25. If the Member were to testify, she would state that she deeply and sincerely regrets her lack of insight and takes responsibility for her conduct, including her failure to maintain appropriate boundaries with the Patient, engaging with the Patient on a deeply personal level, and communicating with the Patient using inappropriate and sexual language, all within one year after his discharge from the Program, which she admits and acknowledges was completely inappropriate and unacceptable conduct for a nurse.

26. The Member would further testify that she sincerely cared for the Patient, considered him to be a part of her family, and that she never intended to cause any harm to him or those who loved and cared for him.

HEALTH PROFESSIONS PROCEDURAL CODE

27. The Health Professions Procedural Code (Schedule 2 to the Regulated Health Professions Act, 1991 SO 1991, c 18 (“Code”) defines sexual abuse of a patient by a member in s. 1(3) as:

(a) sexual intercourse or other forms of physical sexual relations between the member and the patient,

(b) touching, of a sexual nature, of the patient by the member, or

(c) behaviour or remarks of a sexual nature by the member towards the patient.

28. For the purposes of the definition of “sexual abuse”, the Code defines “patient” as including an individual who was a member’s patient within one year or such longer period of time as may be prescribed from the date on which the individual ceased to be the member’s patient.

29. The Member admits that certain text messages she sent to the Patient, including those described in paragraphs 16 and 17 above, were remarks of a sexual nature and therefore amount to sexual abuse as defined by the Code.

CNO STANDARDS

Code of Conduct

30. CNO’s Code of Conduct is a standard of practice describing the accountabilities all Ontario nurses have to the public. The Code of Conduct consist of six principles including:

• Nurses respect the dignity of patients and treat them as individuals;

• Nurses work together to promote patient well-being;

• Nurses maintain patients’ trust by providing safe and competent care;

• Nurses work respectfully with colleagues to best meet patients’ needs;

• Nurses act with integrity to maintain patients’ trust; and

• Nurses maintain public confidence in the nursing profession.

31. Regarding the principle requiring nurses to act with integrity to maintain patients’ trust, CNO’s Code of Conduct provides that nurses maintain professional boundaries with patients. In addition, CNO’s Code of Conduct defines boundaries as:

The points when a relationship changes from professional and therapeutic to unprofessional and personal. Therapeutic nurse-patient relationships put patients’ needs first. Crossing a boundary means a nurse is misusing their power and trust in the relationship to meet personal needs, or behaving in an unprofessional manner with the patient. Crossing a boundary can be intentional or unintentional.

32. Attached as Exhibit “A” is a copy of CNO’s Code of Conduct that was in force at the time of the incidents.

Professional Standards

33. CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.

34. CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring their practice and conduct meets the legislative requirements and the standards of the profession. Nurses are responsible for their actions and the consequences of those actions as well as for conducting themselves in ways that promote respect for the profession. Nurses demonstrate this standard by actions such as ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation.

35. CNO’s Professional Standards further provides, in relation to the ethics standard, that ethical nursing includes acting with integrity, honesty and professionalism in all dealings with the patient and other health care team members. A nurse demonstrates having met this standard by actions such as identifying ethical issues and communicating them to the healthcare team.

36. CNO’s Professional Standards provides, in relation to the relationship standard and the therapeutic nurse-patient relationship, that a nurse demonstrates this standard by:

• Maintaining boundaries between professional therapeutic relationships and non-professional personal relationships;

• Ensuring [patients’] needs remain the focus of nurse-[patient] relationships; and

• Ensuring his or her personal needs are met outside of the therapeutic nurse-[patient] relationships.

37. In addition, CNO’s Professional Standards further provides, in relation to the leadership standard, that a nurse demonstrates leadership by actions such as role-modelling professional values, beliefs and attributes.

38. Attached as Exhibit “B” is a copy of CNO’s Professional Standards that was in force at the time of the incidents and has since been retired.

Therapeutic Nurse-Client Relationship Standard

39. CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) contains four standard statements which describe nurses’ accountabilities with respect to therapeutic communication, patient-centred care, maintaining boundaries and protecting the patient from abuse. The TNCR Standard provides that the nurse-patient relationship is built on trust, respect, empathy, professional intimacy and requires the appropriate use of power inherent in the care provider’s role.

40. CNO’s 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.” CNO’s TNCR Standard places the responsibility for establishing and maintaining the limits and boundaries in the therapeutic nurse-patient relationship on the nurse. CNO’s 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].

41. CNO’s TNCR Standard provides, in relation to maintaining boundaries, that nurses meet this standard by:

• Setting and maintaining the appropriate boundaries within the relationship, and helping [patients] understand when their requests are beyond the limits of the therapeutic relationship;

• 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, giving a gift to or accepting a gift from a [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;

• Abstaining from disclosing personal information, unless it meets an articulated therapeutic need of the [patient];

• Abstaining from engaging in financial transactions unrelated to the provision of care and services with the [patient] or the [patient’s] family/significant other;

• Consulting with colleagues and/or the manager in any situation in which it is unclear whether a behaviour may cross a boundary of the therapeutic relationship; and

• Documenting [patient]-specific information in the [patient’s] record regarding instances in which it was necessary to consult with a colleague/manager about an uncertain situation (non-[patient] related information, such as a letter of summary or incident report, should be documented on the appropriate confidential form).

42. 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].

43. CNO’s TNCR Standard provides that abuse may be verbal, emotional, physical, sexual, financial, or take the form of neglect. The TNCR Standard further 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.

44. 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).

45. Attached as Exhibit “C” is a copy of CNO’s TNCR Standard that was in force at the time of the incidents.

46. The Member admits and acknowledges that she contravened Professional Standards, the TNCR Standard and the Code of Conduct when she, within one year of the Patient’s discharge from the Program provided funds and/or gifts to the Patient, made remarks of a sexual nature towards the Patient, engaged in a personal relationship with the Patient and consumed alcohol with the Patient and/or encouraged the Patient to consume alcohol and/or other substances, at a time when the Patient had recently received treatment for substance use.

ALLEGATIONS OF PROFESSIONAL MISCONDUCT

47. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1 (b) of the Notice of Hearing in that she sexually abused the Patient when she made remarks of a sexual nature towards the Patient, as described in paragraphs 16 to 17 and 27 to 29 above.

48. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2 (b), (c), (d) and (e) of the Notice of Hearing in that she 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 46 above.

49. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3 (b) of the Notice of Hearing in that she emotionally abused the Patient, as described in paragraphs 10 to 26 and 42 to 46 above.

50. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 4 (b), (c), (d) and (e) of the Notice of Hearing, and in particular her conduct was disgraceful, dishonourable and unprofessional, as described in paragraphs 10 to 46 above.

OTHER

51. With the leave of the Panel of the Discipline Committee, CNO withdraws the remaining allegations in the Notice of Hearing, which are as follows:

• 1(a);

• 2(a);

• 3(a); and

• 4(a).

College Counsel’s Submissions on Liability

College Counsel asked the Panel to accept the Agreed Statement of Facts, as well as the Member’s admissions to all the allegations as set out in paragraphs 47, 48, 49 and 50 of the Agreed Statement of Facts and, on the basis of those facts and admissions, make findings of professional misconduct with respect to the allegations in the Notice of Hearing.

With regard to allegation 1(b), there is sufficient evidence that the Member made comments of a sexual nature within one year of [the Patient] being in the care of the Member and comments of a sexual nature constitute sexual abuse according to the Health Professions Procedural Code and the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”).

With regard to allegations 2(b), (c), (d) and (e), the relevant College standards that were breached were the College’s Code of Conduct, the Professional Standards and the TNCR Standard.

With regard to allegation 3(b), there is sufficient evidence within the Agreed Statement of Facts that the Member’s conduct amounted to emotional abuse.

With regard to allegations 4(b), (c), (d) and (e), College Counsel submitted that the Member’s conduct while employed at the Mino Ayaa Ta Win Healing Centre and Withdrawal Management Services (the “Program”) was disgraceful, dishonourable and unprofessional. The parties agreed that the Member’s conduct was relevant to her practice of nursing since the conduct began as a result of the nurse-patient relationship and occurred within a year following [the Patient]’s discharge from the Program. The Member’s conduct was unprofessional as it displayed a serious and persistent disregard for her professional obligations. The conduct was dishonourable as there is an element of moral failing and the Member knew or ought to have known that her conduct fell below the standards of a professional when she engaged in a personal relationship with [the Patient]. The Member’s conduct is disgraceful as the conduct brings shame on the Member, and by extension, the profession.

College Counsel submitted the case of CNO v. Ramos (Discipline Committee, 2020) which proceeded by way of an Agreed Statement of Facts. In this case, there were allegations of sexual abuse by way of sexual remarks to a patient. The panel made findings of sexual abuse through the remarks and comments made by the member by text message to the patient. The panel made findings that the conduct was disgraceful, dishonourable and unprofessional.

The Member’s Counsel’s Submissions on Liability

The Member’s Counsel submitted that the Member has cooperated with the College through her admissions as set out in the Agreed Statement of Facts. The Member’s Counsel submitted that boundary crossing as outlined in the TNCR Standard can be intentional or unintentional. The Member’s Counsel submitted that while not all of the Member’s conduct contained in the Agreed Statement of Facts was intentional, it is still considered a breach of the College’s TNCR Standard.

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(b), 2(b), (c), (d), (e), 3(b) and 4(b), (c), (d) and (e) of the Notice of Hearing. With respect to allegation #3(b), the Panel finds that the Member emotionally abused [the Patient]. As to allegations #4(b), (c), (d) and (e), 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.

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(b) in the Notice of Hearing is supported by paragraphs 16, 17, 27-29 and 47 in the Agreed Statement of Facts. The Member provided nursing care to [the Patient] while he was in the Program from February 10, 2020 to March 9, 2020. From June 15, 2020 onwards, there were multiple remarks of a sexual nature made by the Member via text message to [the Patient]. The Member’s remarks constitute sexual abuse of [the Patient].

Allegation #2(b) in the Notice of Hearing is supported by paragraphs 10-46 and 48 in the Agreed Statement of Facts. In June and July 2020, the Member paid [the Patient]’s cell phone bill, gave a gift to [the Patient] on behalf of his children and purchased beer and cigarettes for [the Patient]. In November 2020, there was an argument between [the Patient] and the Member regarding repayment of the funds. By making purchases and giving gifts to [the Patient], the Member breached the College’s TNCR Standard and the Code of Conduct by failing to maintain the boundaries of the nurse-patient relationship.

Allegation #2(c) in the Notice of Hearing is supported by paragraphs 10-46 and 48 in the Agreed Statement of Facts. On June 27, 2020, the Member sent [the Patient] a sexually suggestive text message. In doing so, the Member breached the College’s Code of Conduct, the TNCR Standard and the Professional Standards as she failed to maintain appropriate professional boundaries and by failing to ensure that the Member’s personal needs were not met within the nurse-patient relationship.

Allegation #2(d) in the Notice of Hearing is supported by paragraphs 10-46 and 48 in the Agreed Statement of Facts. Following [the Patient]’s discharge from the Program, the Member reached out to him on March 9, 2020 to return a canoe paddle and a personal relationship ensued. The personal relationship involved exchanging many phone calls and text messages, giving [the Patient] a ride to a job interview, purchasing a shirt and iPhone for him, subletting property from him and providing him with health advice. In doing so, the Member breached the College’s Code of Conduct, the TNCR Standard and the Professional Standards by failing to maintain the boundaries of the nurse-patient relationship through entering into a friendship with [the Patient] and failing to ensure that her personal needs were not met within the nurse-patient relationship.

Allegation #2(e) in the Notice of Hearing is supported by paragraphs 10-46 and 48 in the Agreed Statement of Facts. In June 2020, which was within a year of [the Patient]’s discharge from the Program, the Member consumed alcohol with [the Patient] at a family gathering and provided him with pharmaceuticals. The Member breached the College’s Code of Conduct, the TNCR Standard and the Professional Standards by failing to act with integrity through exposing [the Patient] to an environment that was not conducive to recovery from a substance use disorder.

Allegation #3(b) in the Notice of Hearing is supported by paragraphs 10-26, 42-46 and 49 in the Agreed Statement of Facts. From June 15, 2020 onward, the Member sent a number of text messages to [the Patient] which were of a sexual nature. The Member’s conduct was emotionally abusive toward [the Patient]. A power imbalance existed between the Member and [the Patient] and the Member exploited this for her own personal gain.

Allegations #4(b), (c), (d) and (e) in the Notice of Hearing are supported by paragraphs 10-46 and 50 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in entering into a personal relationship with [the Patient] within 1 year of him being discharged from the Program was relevant to the practice of nursing. The Member misused the power and professional intimacy inherent in the nurse-patient relationship to enter into a personal relationship with [the Patient]. The Member had a responsibility to maintain a therapeutic relationship with [the Patient] for at least a year after him being discharged from the Program. The Member’s conduct was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations in contravening the Code of Conduct, the Professional Standards and the TNCR Standard.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing by initiating and maintaining a personal relationship with [the Patient] when she met with him outside of work, communicated with him by text message and purchased gifts for him. The Member’s conduct was not therapeutic and rather served to meet her own needs. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.

Finally, the Panel finds that the Member’s conduct was disgraceful as it shames the Member and by extension the profession. The Member had an obligation to maintain a professional relationship with [the Patient] in all her encounters with him following one year of his discharge from the Program. The Member developed a personal relationship with [the Patient] which involved purchasing beer for him and consuming alcohol with him. The Member’s communications with [the Patient] involved sending a number of sexually suggestive text messages. The Member exploited [the Patient] through putting her needs ahead of his. 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.

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:

1. Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

Penalty Submissions

College Counsel’s Submissions

College Counsel submitted that the Joint Submission on Order also provides in Appendix “A” an undertaking and agreement by the Member for the Member’s permanent resignation as a member of the College effective March 18, 2024 (the “Undertaking”). Pursuant to this Undertaking, the Member undertakes, acknowledges and agrees to:

a) Permanently resign as a member of the College, effective from the date that the Order made by the Discipline Committee in accordance with the Joint Submission on Order becomes final;

b) Not apply for membership with the College as a Registered Nurse or Registered Practical Nurse at any time in the future;

c) Agree that the public portion of the College’s Register will indefinitely reflect that the Member entered into an Undertaking with the Executive Director to permanently resign as a member of the College as part of an agreed resolution of allegations of professional misconduct;

d) No longer have a right to the issuance or reinstatement of a Certificate of Registration from the College;

e) No longer have a right to use the title “Nurse”, “Registered Nurse”, “Registered Practical Nurse”, “RN”, “RPN” or a variation, an abbreviation or an equivalent in another language;

f) No longer have a right to hold herself out as a Nurse, Registered Nurse, Registered Practical Nurse or as a person who is qualified to practise in Ontario as a Nurse, Registered Nurse or Registered Practical Nurse;

g) No longer have a right to engage in the practice of nursing in any capacity; and

h) Agree the College is authorized to and may, in its sole discretion, provide a copy of the Undertaking and/or its terms to a governing body that regulates nursing in Canada or elsewhere in response to an inquiry or otherwise.

The aggravating factors in this case were:

• The serious nature of the Member’s conduct;

• The egregious breach of the nurse-patient therapeutic relationship by the Member;

• [The Patient] was vulnerable given his mental health and substance abuse diagnoses;

• The Member’s conduct was intentional and self-serving;

• The Member’s conduct occurred over a lengthy period of time;

• The Member knew or ought to have known that her conduct was improper; and

• The Member’s conduct brings shame on the nursing profession.

The mitigating factors in this case were:

• The Member has cooperated with the College; and

• The Member has taken responsibility for her actions by admitting to her conduct and entering into an Agreed Statement of Facts and a Joint Submission on Order with the College.

Specific deterrence is not essential in this case because the Member has already undertaken to permanently resign from the practice of nursing. In such circumstances, the penalty of an oral reprimand is sufficient.

General deterrence is achieved through the oral reprimand and the fact that the findings will be publicly posted indefinitely and sends a clear message to other members of the profession that there are serious consequences for similar misconduct.

Rehabilitation and remediation are not essential components of the penalty in this case given the Member’s permanent resignation. There is no public interest served in including remedial terms in the penalty.

Overall, the public is protected by the resignation of the Member’s certificate of registration and the ability of the College to communicate this to any governing body that regulates nursing in Canada or elsewhere. Accordingly, the Panel does not need to impose further conditions in order to achieve protection of the public.

College Counsel submitted the following case to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee:

CNO v. Frazer (Discipline Committee, 2021): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case involved allegations of a breach in the therapeutic nurse-client relationship through the member’s physical and romantic relationship with the patient. The penalty included an oral reprimand and the member signed an undertaking to permanently resign as a member of the College.

The Member’s Counsel’s Submissions

The Member’s Counsel submitted that a mitigating factor in this case is the Member’s remorse which was contained in paragraphs 25 and 26 in the Agreed Statement of Facts. If the Member were to testify, she would express her deep and sincere regrets for her actions and lack of insight at the time. The Member has taken responsibility throughout the process by cooperating with the College with respect to the proposed resolution.

The Member’s Counsel submitted that the Member acknowledges the risk of breaching nurse-client boundaries given the close-knit relationships and connections that exist in the context of the small Northwestern Ontario community where the events took place.

Penalty Decision

The Panel accepts the Joint Submission on Order and accordingly orders:

1. The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

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. In the normal course, 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. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility.

In this case, because the Member has undertaken to permanently resign, the oral reprimand is a sufficient penalty and no other specific deterrence is required.

Furthermore, because of the Member’s resignation, it is not necessary to consider remediation and rehabilitation in determining the appropriate penalty.

General deterrence is also addressed as the Panel concluded had the Member’s situation been different and no Undertaking given, the Panel would have ordered a suspension, and terms, conditions and limitations on the Member’s certificate of registration which would have been in line with previous penalties.

Finally, the penalty of reprimand is appropriate because the public is already protected through the permanent resignation and the Undertaking to never apply for registration as a nurse in Ontario or engage in the practice of nursing in any capacity.

The penalty is also in line with what has been ordered in previous cases in similar circumstances as demonstrated by the cases submitted and referred to by College Counsel.

I, Tyler Hands, RN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.