DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Sherry Szucsko-Bedard, RN Chairperson Lynda Carpenter Public Member Wendy Cheuk, RN Member Todd Hillhouse Public Member Kerrie Naylor, RPN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) ALYSHA SHORE for ) College of Nurses of Ontario
- and - )
KATHLEEN REBECCA LINDENFIELD ) DANIEL LIBMAN for Registration No. JE03805 ) Kathleen Rebecca Lindenfield ) ELYSE SUNSHINE ) Independent Legal Counsel
) Heard: July 10, 2025, ) via videoconference
DECISION AND REASONS
Publication Ban
By Order of the Discipline Panel dated July 10, 2025, pursuant to subsection s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, no one shall disclose, publish or broadcast the name(s) of the patient(s), or any information that could disclose the identities of the patients, referred to orally or in any documents presented at the Discipline hearing of Kathleen Rebecca Lindenfield.
This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on July 10, 2025.
The Allegations
The allegations against Kathleen Rebecca Lindenfield (the “Member”) as stated in the Notice of Hearing dated April 22, 2025, are as follows:
IT IS ALLEGED THAT:
- 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 you were employed as a Registered Practical Nurse at London Health Sciences Centre in London, Ontario, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to accessing personal health information without consent or other proper authorization, for one or more of the following patients on or about the dates indicated below:
Patient Name
Date of Access
[A]
June 15, 2021
[B]
June 25, 2021 July 8, 2021 August 10, 2021 August 11, 2021 August 24, 2021 September 14, 2021 October 13, 2021 October 19, 2021 October 26, 2021 October 27, 2021 November 3, 2021 December 2, 2021
[C]
July 5, 2021
[D]
July 6, 2021
[E]
August 18, 2021 September 14, 2021 October 26, 2021
[F]
November 19, 2021
[G]
December 2, 2021
[H]
December 2, 2021
and/or;
- 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 you were employed as a Registered Practical Nurse at London Health Sciences Center in London, Ontario, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional with respect to accessing personal health information without consent or proper authorization, for one or more of the following patients on or about the dates indicated below:
Patient Name
Date of Access
[A]
June 15, 2021
[B]
June 25, 2021 July 8, 2021 August 10, 2021 August 11, 2021 August 24, 2021 September 14, 2021 October 13, 2021 October 19, 2021 October 26, 2021 October 27, 2021 November 3, 2021 December 2, 2021
[C]
July 5, 2021
[D]
July 6, 2021
[E]
August 18, 2021 September 14, 2021 October 26, 2021
[F]
November 19, 2021
[G]
December 2, 2021
[H]
December 2, 2021
- 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 you were employed as a Registered Practical Nurse at London Health Sciences Centre in London, Ontario, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to accessing personal health information without consent or other proper authorization, for one or more of the following patients on or about the dates indicated below:
Patient Name
Date of Access
Patient A
April 28, 2020 May 13, 2020 July 8, 2020
Patient B
June 14, 2021
Patient C
October 4, 2021
Patient I
March 24, 2021
- 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 you were employed as a Registered Practical Nurse at London Health Sciences Center in London, Ontario, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional with respect to accessing personal health information without consent or proper authorization, for one or more of the following patients on or about the dates indicated below:
Patient Name
Date of Access
Patient A
April 28, 2020 May 13, 2020 July 8, 2020
Patient B
June 14, 2021
Patient C
October 4, 2021
Patient I
March 24, 2021
Member’s Plea
The Member admitted the allegations set out in paragraphs 1, 2, 3, and 4 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 reads, unedited and without exhibits mentioned therein, as follows:
THE MEMBER
Kathleen Rebecca Lindenfield (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on June 30, 2005.
The Member has no prior disciplinary findings with CNO.
THE FACILITY
The Member was employed in the Pediatric Medical Day Unit of London Health Services Centre (the “Facility”) from July 18, 2005, until her resignation on or around March 30, 2022.
The Facility uses an electronic medical records (“EMR”) system that tracks staff members’ access to patient records, including the date and time of the accesses.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
In or around November 2021, Patient A requested the Facility check whether the Member had accessed her personal health information. Patient A knew the Member as they each had a personal relationship with Patient B.
In response to Patient A’s request, the Facility conducted an initial audit which showed that the Member had inappropriately accessed Patient A’s health record as well as records belonging to several other people, including Patient B.
In December 2021, the Facility conducted a fact-finding interview with the Member during which she admitted to having accessed Patient A and B’s records but denied knowledge of any other unauthorized accesses. The Member told the Facility that she had accessed Patient A’s records because she wanted to check if Patient A was pregnant and that Patient B had given his permission for the Member to look at his records to obtain test results. The Member was placed on leave while the Facility continued its investigation.
The Facility completed a wider audit of the Member’s EMR accesses and identified the following inappropriate accesses:
The Member accessed Patient A’s records twice on June 15, 2021.
The Member accessed Patient B’s records a total of fourteen times across June 25, July 8, August 10, August 11, August 24, September 14, October 13, October 19, October 26, October 27, November 3 and December 2, 2021.
The Member accessed Patient C’s records on July 5, 2021. Patient C was […].
The Member accessed Patient D’s records on July 6, 2021. Patient D is […].
The Member accessed Patient E’s records on August 18, September 14 and October 26, 2021. Patient E is […].
The Member accessed Patient F’s records on November 19, 2021. Patient F is […].
The Member accessed Patient G’s records on December 2, 2021. Patient G is […].
The Member accessed Patient H’s records on December 2, 2021. Patient H is […].
The Member resigned her employment with the Facility on March 30, 2022.
In October 2023, the Facility conducted a wider audit of the Member’s accesses dating back to 2019. This audit revealed additional breaches, in particular:
The Member had accessed Patient A’s records on three earlier occasions, on April 28, May 13, and July 8, 2020.
The Member had also accessed Patient B’s records on June 14, 2021.
The Member had also accessed Patient C’s records on October 4, 2021.
The Member had accessed another patient, Patient I’s, records on March 24, 2021. Patient I is […].
- The Member did not have consent or other proper authorization for any of the above accesses. She was not part of the circle of care for any of these patients and had no professional purpose for accessing their personal health information.
THE PERSONAL HEALTH INFORMATION PROTECTION ACT, 2004
- The Personal Health Information Protection Act, 2004 (“PHIPA”) governs health care information in Ontario. Under PHIPA, hospitals and their agents, including nurses, must obtain consent in order to collect, use or disclose an individual’s personal health information, subject to limited exceptions. PHIPA defines “use” as including viewing, handling or otherwise dealing with personal health information.
CNO STANDARDS
Code of Conduct
- CNO’s Code of Conduct is a standard of practice describing the accountabilities all Ontario nurses have to the public. The Code of Conduct consists 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.
CNO’s Code of Conduct provides, in relation to the principle requiring nurses to maintain patients’ trust by providing safe and competent care, that nurses are accountable to, and practice under, relevant laws and CNO’s standards of practice.
CNO’s Code of Conduct provides, in relation to the principle requiring nurses to act with integrity to maintain patients’ trust, that nurses protect the privacy and confidentiality of patients’ personal health information.
CNO’s Code of Conduct also provides, in relation to the principle requiring nurses to maintain public confidence in the nursing profession, that nurses are accountable for their own actions and decisions.
Attached as Appendix “A” is a copy of the Code of Conduct in force at the time of the incidents.
Professional 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 the profession. It 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.
CNO’s Professional Standards provides, in relation to the ethics standard, that ethical nursing care means promoting the values of patient well-being, respecting patient choice, assuring privacy and confidentiality, respecting the sanctity and quality of life, maintaining commitments, respecting truthfulness and ensuring fairness in the use of resources.
Attached as Appendix “B” is a copy of the Professional Standards in force at the time of the incidents.
Confidentiality and Privacy: Personal Health Information
- CNO’s Confidentiality and Privacy: Personal Health Information standard (the “Privacy Standard”) largely incorporates PHIPA. The Privacy Standard provides that nurses have ethical and legal responsibilities to maintain the confidentiality and privacy of patient health information obtained while providing care. It requires that personal health information be kept confidential and secure. Nurses comply with this standard by:
Seeking information about issues of privacy and confidentiality of personal health information;
Maintaining confidentiality of patients’ personal health information with members of the healthcare team, who are also required to maintain confidentiality, including information that is documented or stored electronically;
Accessing information for her/his patients only and not accessing information for which there is no professional purpose; and
Safeguarding the security of computerized, printed or electronically displayed or stored information against theft, loss, unauthorized access or use, disclosure, copying, modification or disposal.
Attached as Appendix “C” are copies of the Privacy standard in force at the time of the incidents. The Privacy standard was revised in November 2021.
The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards and Privacy standard when she accessed personal health information without consent or other proper authorization.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1 of the Notice of Hearing, in that she contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to accessing personal health information without consent or other proper authorization, as described in paragraphs 5-24 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 2 of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 5-11 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3 of the Notice of Hearing, in that she contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to accessing personal health information without consent or other proper authorization, as described in paragraphs 5-23 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 4 of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 5-11 above.
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, 2, 3 and 4 of the Notice of Hearing. With respect to allegation #4, the Panel found that the Member’s conduct would reasonably be regarded by members of the profession to be 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.
Allegations #1 and #3 in the Notice of Hearing, regarding a failure to meet the standards of practice between June and December 2021 and between April 2020 to October 2021, are supported by paragraphs 5 – 24 and 26 of the Agreed Statement of Facts. In November 2021, the Facility conducted an initial audit in response to a request from Patient A, who believed that the Member had accessed her health records. The Facility’s initial audit demonstrated that the Member had accessed Patient A’s personal health information on multiple occasions. The Member initially admitted to the Facility that she had accessed the records of Patients A and B; however, she denied any other unauthorized access to patient health records. The Facility conducted a wider audit, which identified several inappropriate accesses of personal health information, which are set out in paragraph 8 of the Agreed Statement of Facts. The Member resigned her employment from the Facility in March 2022. Thereafter, the Facility uncovered additional privacy breaches by the Member dating back to 2019. The Panel found that the Member’s conduct in accessing at least 21 different patients charts when she was outside of their circle of care and without consent or other proper authorization breaches the standards of practice of the profession, including the College’s Code of Conduct, the Professional Standards, and the Privacy Standard.
Allegations #2 and #4 in the Notice of Hearing are supported by paragraphs 5 – 11, 25 and 27 of the Agreed Statement of Facts. The Member’s conduct in accessing personal health information for numerous patients without consent or proper authorization between June and December 2021 was relevant to the practice of nursing, as the Member had access to this health information through her clinical practice and employment. The Panel finds that this conduct would reasonably be regarded by members of the profession as unprofessional, as it demonstrated a serious and persistent disregard for her professional obligations in breaching the Code of Conduct, the Professional Standards and the Privacy Standard. The Panel also finds that the Member’s conduct was dishonourable, as it demonstrated an element of moral failing. The Member knew or ought to have known that her conduct in accessing the personal health information of individuals when she was outside of their circle of care, and without consent or proper authorization contrary to Facility policies and the standards of practice, was unacceptable and fell well below the standards of a professional.
Penalty
College Counsel and the Member’s Counsel/Member advised that a Joint Submission on Order had been agreed upon and requested that the Panel make the following order:
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 3 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) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at the Member’s own expense and within 6 months from the date of this Order. If the Expert determines that a greater number of sessions are required, the Expert will advise CNO 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 of this Order. To comply, the Member is required to ensure that:
i. The Expert has expertise in nursing regulation and has been approved by CNO in advance of the meetings;
ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this 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 Practice Reflection Worksheets, online learning modules and decision tools (where applicable):
Code of Conduct, and
Confidentiality and Privacy: Personal Health Information;
iv. Before the first meeting, the Member reviews Circle of Care: Sharing Personal Health Information for Health-Care Purposes, as released by the Information and Privacy Commissioner of Ontario;
v. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Practice Reflection Worksheets;
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 their report to CNO, 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 the Member’s 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 the Member’s certificate of registration;
b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify the Member’s employers of the decision. To comply, the Member is required to:
i. Inform any employer of the decision prior to commencing or prior to resuming employment in any nursing position;
ii. Ensure that CNO 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;
iii. Provide the Member’s employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iv. 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 CNO, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify CNO 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.
College Submissions on Penalty
College Counsel submitted that the penalty should protect the public and enhance public protection. This goal is achieved though specific deterrence, general deterrence and where appropriate, rehabilitation. The proposed penalty takes all of those considerations into account. Public protection would be achieved through the suspension, employer notification, and remediation. General deterrence would be achieved through the significant suspension, which demonstrates to other members of the profession that such conduct will result in significant consequences. All of the elements of the proposed penalty achieve specific deterrence to ensure that the Member does not engage in this kind of conduct again. The Member would be rehabilitated though the meetings with the Regulatory Expert, to provide her with a better understanding of her professional obligations moving forward.
College Counsel submitted that in considering the proposed penalty, the Panel should take into account the following mitigating factors:
The Member has been a long-standing member of the College and has no previous disciplinary history;
The Member cooperated with the College by entering into an Agreed Statement of Facts and Joint Submission on Order, which avoided the need for a contested hearing;
The Member has admitted to the misconduct thereby taking accountability for her actions; and
The Member did not disclose patient information to a third party.
The aggravating factors in this case were:
The Member’s actions were not an isolated incident but a pattern of conduct which occurred over a lengthy period of time,
The Member’s conduct related to people she knew and were a breach of trust; and
The Member’s conduct was intentional and involved repeated dishonesty and deceit bringing discredit to the profession.
Counsel submitted the following cases to the Panel, which demonstrate that the proposed penalty falls within the range of similar cases from this Discipline Committee: CNO v. Trudel (Discipline Committee, 2018), and CNO v. Church-Labrie, (Discipline Committee, 2020).
Member’s Submissions on Penalty
The Member’s Counsel indicated that he agreed with the College’s submissions. The Member’s Counsel emphasized that the Panel should consider the Member’s prior unblemished record of 20 years and that there is no reason to believe she would ever appear before the Discipline Committee again. Counsel further highlighted that the Member had cooperated with the College, taken responsibility for her conduct and saved the College the time and expense of a contested hearing.
Penalty Decision
The Panel accepted the Joint Submission on Order and made the order requested.
Reasons for Penalty Decision
There is a high threshold for departing from a Joint Submission on Order established by the Supreme Court of Canada in R. v. Anthony-Cook, 2016 SCC 43. Departing from a joint submission would require a finding that the proposed penalty would bring the administration of justice into disrepute or is otherwise contrary to the public interest.
The Panel concluded that the proposed penalty is not contrary to the public interest and does not bring the administration of justice into disrepute.
The Panel concluded that the proposed penalty is reasonable and in the public interest. It promotes public confidence in the ability of the College to regulate nurses.
The Panel finds that the proposed penalty satisfies the penalty goals of specific and general deterrence, rehabilitation and remediation, and public protection.
The proposed penalty provides for general deterrence through the three-month suspension, which sends a clear message to the profession that unauthorized access to personal health information is a serious breach and will not be tolerated.
The proposed penalty provides for specific deterrence through the three-month suspension and the oral reprimand, which should deter the Member from repeating this type of professional misconduct in the future.
The proposed penalty provides for remediation and rehabilitation through the two meetings with Regulatory Expert, which will provide the Member with the opportunity and knowledge to improve her practice by re-education in the areas of professional standards. The areas outlined in the review will allow the Member to reflect on her errors in judgment and learn from her experience.
Overall, the public is protected through the 12 months of employer notification and because all aspects of the penalty address the most critical issue of public protection. The penalty sends a powerful message that this conduct is not acceptable and will not be tolerated by the profession. The Member will have an opportunity to reflect on her conduct, gain insight into her actions and improve her practice. Nurses have legal and ethical obligations to maintain the confidentiality and privacy of patients.
The Panel acknowledges that the Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility, which is a mitigating factor.
The penalty is in line with the range of what has been ordered in previous similar cases.
I, Sherry Szucsko-Bedard, 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.