8270 v. Registrar of Motor Vehicles, 2013 CanLII 62607

Licence Appeal Tribunal

DATE: 2013-09-23

FILE: 8270/MED

CASE NAME: 8270 v. Registrar of Motor Vehicles

Appeal under section 50(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8, from a Decision of the Registrar of Motor Vehicles pursuant to section 47(1) of that Act - to Suspend a Licence

8270 Applicant

-and-

Registrar of Motor Vehicles Respondent

REASONS FOR DECISION AND ORDER

ADJUDICATOR: David W. Hurst, M.D., Member

APPEARANCES:

For the Applicant: Self-represented

For the Respondent: Kyle Biel, Agent

Heard in Toronto: September 4, 2013

DECISION AND REASONS

This is an appeal to the Licence Appeal Tribunal (the “Tribunal”) by the Applicant respecting a decision of the Registrar of Motor Vehicles (the “Registrar”) pursuant to section 47(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8 (the “Act”).

FACTS

The Registrar’s Case

Mr. Biel presented the Registrar’s file regarding the Applicant.

The Applicant’s licensing problems began when the Ministry of Transportation of Ontario (“MTO”) received a Medical Condition Report on April 2, 2013. Under common medical conditions, a box was marked for alcohol dependence. An optional note stated that the patient was admitted in hospital for alcohol withdrawal symptoms and was unaware of the report signed by Dr. A.H.

A second page included in this initial report to MTO was a discharge summary from a neighbourhood hospital showing the day of admission as April 8, 2013, signed by Dr. A.M.

This report reads as follows:

This 61-year old man presents to the emergency department with a six day history of vomiting. He has a long history of alcohol abuse but has never had withdrawal symptoms. On this occasion, he was somewhat agitated having not drank in six days. He had tremors in his hands but no evidence of asterbds (The Tribunal cannot interpret this last word). He had some signs of chronic liver disease. His lab work revealed hyponatremia and hypokalaemia (These mean low serum sodium and low serum potassium). His white count was normal. There was no evidence of infection.

He was treated for alcohol withdrawal with large doses of benzodiazepines, and settled nicely. Nausea and vomiting resolved. He may have had a Mallory-Weiss tear as he did complain of a lot of pain on swallowing. This eventually settled with Xylocaine Viscous and Pantoloc. ECG and enzymes were negative for cardiac source of chest pain.

His electrolytes have come back into the normal range. He is ambulating. He has no symptoms presently. He is being discharged home in good condition. His discharge medications will be as on admission. He will continue on Xylocaine Viscous and Pantoloc.

FINAL DIAGNOSES:

1. Alcohol withdrawal.
2. Gastritis/esophagitis.
3. Possible Mallory-Weiss tear.

On May 9, 2013, MTO wrote to the Applicant describing the receipt of reports indicating that he had a condition that affected his ability to drive safely. The reported condition was alcohol dependence. The letter stated that the Applicant’s driving privilege was suspended under section 47(1) of the Act.

This form letter from MTO stated the requirements for reinstatement. The Applicant was asked to bring the letter to his treating physician, which required the following information to be sent to MTO:

• If the physician confirms a diagnosis of alcohol dependence, the Ministry will require confirmation that you have remained abstinent from alcohol for a period of one year. This period may be reduced if your physician confirms that you have successfully completed an alcohol treatment program and is supportive of your driving privilege;
• The enclosed forms completed in full and all questions answered.

Upon receipt of the information the Ministry will:

• Determine whether your licence can be reinstated;
• Send you a letter in approximately 30 business days, informing you of the outcome of the review.

Mr. Biel presented a copy of MTO’s Substance Abuse Assessment Form. This highly detailed document is designed to identify if an individual has a substance abuse problem and states that it must be completed by the physician in the presence of the patient.

This Substance Abuse Assessment Form was signed by the Applicant and dated May 28, 2013.

Mr. Biel reviewed this report for the benefit of the Tribunal owing to inconsistencies in its completion. (The Applicant informed the Tribunal that at least some of this report was completed separately by both the physician and the Applicant).

Mr. Biel’s review of this report is (with some summarizing) as follows:

Health History:

Gastritis – written note (by the Applicant’s physician). Viral gastritis leading to electrolyte imbalance and to hospitalization. The patient was treated in ER for alcohol withdrawal (see hospital and ER notes).

Physical Assessment and Laboratory Evaluation:

Abnormalities were noted. Laboratory tests were checked off but were not recorded and GGT not done. A history of alcohol use: Age of first and regular use is 18 years. First intoxication “high-none”. Frequency of use - five days per week. Amount consumed on each occasion - four to six beers maximum per day. Recent use - three months ago. Longest period of abstinence in last three years - blank. Date of reduction or abstinence - March 2013.

Alcohol Related Syndromes - all of these categories having to do with withdrawal problems – blank.

AUDIT – Alcohol Use Disorders Identification Test:

A list of 10 questions trying to ascertain the frequency of use of alcohol and amounts was completed, ticking the boxes for “never” and this would give the Applicant an excellent score.

Drug Abuse Screening Tests (Adult version):

A list of 20 questions and here the replies indicated no culpability on the part of the Applicant, except that the Applicant agreed that he cannot get through a week without using drugs (this would be his beer, his only source of alcohol). In essence then, the Applicant achieved a very satisfactory score in this category.

LEEDS – Dependence Questionnaire:

This section covers the Applicant’s drug use in the past month. Again, the Applicant answered all ten questions and achieved an excellent score.

Substance Dependence (DSM IV) Criteria:

The Tribunal observes that this category is designed to show a maladaptive pattern of substance use, leading to clinically significant impairment or distress as manifested by three or more of seven categories occurring at any time in the same 12 month period. This section was left blank. A second section under “Substance Abuse (DSM IV) Criteria” dwelled further on a maladaptive pattern of substance abuse and was left blank.

The treatment section was marked as N/A.

Diagnosis:

The box here was ticked for misuse, and, under other comments, the report stated that the patient cut down - no daily drinking. The date of April 2013 was given to state when the patient had been advised to reduce consumption or to abstain. Under recommendations, a note stated that the patient was treated in ER for alcohol withdrawal (see notes). The patient was found to have electrolyte imbalance and was dehydrated. The report was signed by Dr. I.A-H.

Appended to the above report was a copy of the admission note to a neighbourhood community hospital, dated April 8, 2013, and signed by Dr. A.M., M.D., FRCS(C). This admission note is reported earlier in the narrative. The Tribunal makes note of the fact that Dr. A.M. has the degree of Fellow of the Royal College of Surgeons of Canada, so is a well trained surgeon and highly capable of carrying out a satisfactory examination. Also appended to this detailed report was a discharge summary to the Applicant’s family physician indicating that his patient, the Applicant, had been discharged to home. This note stated that the reason for the hospital visit had been “Hyponatremia/Alcohol Withdrawal.”

Mr. Biel also entered the note regarding the Applicant dated April 5, 2013, and signed by Dr. S.S.

This report described a 61-year old male with a two day history of acute onset of nausea and vomiting, decreased oral intake and no associated fever. He was in his regular state of health prior to this episode. Electrolyte studies in the emergency department showed mild evidence of volume depletion. Medication almost completely resolved his nausea. Electrolytes were reported to be within normal limits and there were no significant physical findings. The diagnosis was “probable viral gastroenteritis”. The note stated that because the liver function tests were slightly elevated with AST and ALT at 86 and 57, respectively, and a total bilirubin of 28, some tests would be repeated. He was advised to return to hospital if the vomiting became a problem. The doctor noted that he had no signs of dehydration.

On June 14, 2013, MTO again wrote to the Applicant stating that his driving privilege should remain under suspension. MTO stated that it had reviewed the subsequent reports filed on the Applicant’s behalf. The diagnosis was alcohol abuse/dependence.

The requirements for reinstatement were, as always, set out in a form letter, requiring a period of abstinence from alcohol for one year. The letter stated that the family physician must confirm the Applicant has successfully completed an alcohol treatment program and is supportive of his driving privilege, plus satisfactory results regarding liver function tests. The Ministry would then review the information provided against the National Medical Standards to determine if the driving privilege can be restored.

Mr. Biel next referred to a certified copy of the Applicant’s driving record, noting the following:

• 1980 - Impaired Driving
• 1985 - Impaired Driving
• 1995 - Impaired Driving
• 2010 - Drive/Operate Commercial Motor Vehicle – no valid CVOR
• 2010 - Driving without Toll Device
• 2013 - Speeding 19KMH over the limit of 60KMH
• 2013 - Failed to surrender permit for motor vehicle offence
• 2013 - Suspended for Medical Reasons

Mr. Biel then focused on the pertinent sections of the CCMTA (Canadian Council of Motor Transport Administrators - Medical Standards for Drivers). Page 231 of this document, Section 15.6.3 re: Substance Abuse or Dependence – all drivers, states:

All drivers eligible for a licence if:

• Meets the criteria for remission and/or has abstained from the substance for 12 months.
• Earlier relicensing may be considered upon favourable recommendation from an addictions specialist and/or treating physician recognized by the licensing authority and the successful completion of a drug rehabilitation program.
• The functional abilities necessary for driving are not impaired.
• Where required, a road test or other functional assessment showing that the functional abilities for driving are not impaired.
• The reassessment routine or more frequently at the discretion of the licensing authority.
• Impaired individuals are not permitted to drive any class of motor vehicle.

Mr. Biel presented and discussed the findings of the Medical Advisory Committee (“MAC”) of MTO, regarding the latest report received May 28, 2013. The decision signed by J.E., concurring with the MAC recommendation, was dated August 26, 2013. In this report, the instructions were as per the standard form to drivers when a suspension is applied and is already described in the narrative.

The reasons reported in their entirety are as follows:

Driver admitted to hospital on April 7, 2013, as a result of alcohol withdrawal symptoms. Driver stated he ceased alcohol six days prior to admission. Diagnosis on discharge is alcohol abuse, gastritis/esophagitis and possible Mallory-Weiss tear (this is a laceration of the lining at the lower end of the oesophagus). Driver is known at hospital in having a long history of alcohol abuse. MAC does not concur with the driver’s treating physician’s diagnosis of alcohol misuse with a goal of reduced consumption, in light of:

1. Discharge summary of April 8, 2013 notes driver has a long history of alcohol abuse and Medical Condition Report authored by Dr. A., dated May 2013, notes a previous admission in March 2013, also for alcohol withdrawal;
2. Driver self reports consuming up to six beers daily, well in excess of minimal risk level of two standard drinks per day;
3. The need to continue consumption of alcohol despite serious medical consequences and hospitalization for alcohol related symptoms; further to this, MAC notes legal consequences of multiple convictions for impaired driving dating back to 1980. Driver must demonstrate 12 months of sustained abstinence prior to consideration of reinstatement. Earlier relicensing may be considered.

The Applicant’s Case

The Applicant questioned the comment about a long history of alcohol problems. Mr. Biel’s history contained in the MAC report was not very good. He stated in fact this MAC comment came from a medical report and there was no long history of abuse. The Applicant also questioned the comment about going to the hospital when in fact he went to an emergency room and was not admitted. This matter was duly noted by Mr. Biel.

The Applicant in his presentation stated that he could not remember having nausea or having been so sick. He also questioned the use of the word “withdrawal” and emphatically stated that the comments about 2-4, 4-6, 8-12 (drinks), referred to one week and not one day. He specifically mentioned a nurse’s comment that he had taken eight drinks a day and denied that this has ever happened.

The Applicant recalled a brief visit to Quebec where he consumed some beer but nothing in the range described by the medical people.

He was especially resentful of the comment that has crept into the medical narrative that he has a long history of abuse of alcohol and he has no idea where that statement came from. He stated that his company would take him back tomorrow if he had his licence. He stressed the seriousness of this set back and that if suspended for a year no company would ever hire him.

At this point, with detailed questioning from the Tribunal about the significant questions in his Substance Abuse Assessment Form, it subsequently emerged that certain parts of this questionnaire were completed either by the Applicant or the doctor not necessarily when they were together. These omissions were not properly explained.

In further questioning from the Tribunal, the Applicant described his drinking habit as one beer daily after work, and possibly two per day on Saturday and Sunday.

The Applicant described his working career as that involving transcontinental haulage with a large tractor trailer. He could not recall his drinking habit in those days up to the age of 34. He ventured to guess that his consumption of beer at that time was a matter of 10 beers a week at most. He stated that there was no real time to have a drink because he was on the road so much and simply drove, ate and slept. He denied that he had ever been seriously drunk. He explained that the three convictions for driving while impaired involved only a couple of beers, and on direct questioning, he said these episodes occurred when he was examined by the R.I.D.E. officers on the highway.

He stated that he is not an alcoholic. He said that he has never needed help regarding alcohol and that his own doctor has never expressed any concern about his beer consumption.

At the time of the vomiting episode that caused him to go to the ER, he explained that no one else in his family eating the same food had become sick, and also stated that no blood alcohol level was asked for or tested.

Mr. Biel cross-examined the Applicant in detail. He noted that the Applicant had failed to show any long interval of abstinence, and it appears that he has never been abstinent. However, the Applicant stated that he is not a steady “user” of alcohol. Mr. Biel intimated that his doctor entered this information in order to avoid the subject of steady consumption. Mr. Biel also stated that the episode of severe vomiting may have been triggered by an excessive consumption of beer while the Applicant was holidaying in Quebec, having gone to the ER four days following the trip to Quebec. The Applicant stated that he had consumed only six beers in that week while on holiday.

On the matter of the fall the Applicant had suffered injuring his forehead just before he went to the ER, the subject of Delirium Tremens came up. At this point, the Applicant’s wife, who was assisting him, stated that the paramedics who came to take the Applicant to the hospital observed that he was showing tremors and hallucinations suggestive of this condition. She said that this was due to his weakness from the excessive vomiting and that this statement by the EMS people was simply a misunderstanding.

Mr. Biel again referred to the Substance Abuse Assessment Form and confirmed that the Applicant’s doctor of 16 years had described him as a consumer of 4-6 beers a day. His wife said that this should have read as 4-6 beers a week. Mr. Biel then observed the MTO have ascertained that the numbers pertaining to the Applicant’s drinking habit are simply “all over the place”.

Mr. Biel, when questioned by the Tribunal for clarification, recalled only on one occasion the paramedics or the medical people observed that the Applicant was suffering from tremors. Mr. Biel, again dwelling on these numbers, did ascertain that there had been an interval when the Applicant “cut down” on his drinking. The Applicant volunteered that his drinking in early days was too much when he was “young and stupid”.

Mr. Biel pointed out that the Applicant’s doctor has described his patient, the Applicant, as suffering from alcohol withdrawal. Again, at this point, the Applicant noted that this part of the form had been partly completed when they were not together. He denied that he had ever been told to cut back on his drinking. Again, the Applicant said that his doctor was completely wrong in stating that he was drinking 4-6 beers a day. The Applicant then stated his most recent use of alcohol was three months previously and then amended this statement to say that he had been drinking from the end of March until June 2013.

When asked how the doctor could include so many mistakes in the Substance Abuse Assessment Form, the Applicant stated that he wasn’t present when the doctor filled out this part of the form. He said it was not a joint effort and thought that this might explain some of the blanks.

The Applicant’s wife, as a witness, informed the Tribunal that they ultimately had an opportunity to review the Substance Abuse Assessment Form and acknowledged that her husband had actually done some of the alterations, in the absence of his doctor. Mr. Biel with further questioning observed that the answers to this Form indicate that the Applicant has a problem with beer. At the hearing, the Applicant admitted that he is still consuming beer. The Applicant admitted that he would “likely quit now”.

The Applicant’s daughter gave a character reference about her father, all of which was very positive. She also said that he had been vomiting very heavily when he was taken to hospital. She admitted that he was confused but stated that this was due to his severe vomiting. She said that it is not fair to brand her father as suffering from an alcohol abuse problem.

The Applicant’s wife then presented a written statement. She was very critical of the hospital notation of the events during April 6 and 7, 2013, and noted that the hospital’s recording was quite inaccurate (the hospital notes described viral gastritis).

She admitted telling the EMS people that her husband “drank”, and claimed to have told them that his consumption was very minimal after his early years from the age of 34 on and there is no abuse of alcohol. She recalled telling the hospital people that this was not alcohol abuse even though they thought it was. She dwelt heavily on the fact that her husband’s electrolytes had become very low and that this is what was causing his problems. She stated that her husband “nearly died” because the medical people were not treating him properly. She stated that a lady psychologist or psychiatrist had confirmed that her husband was not an alcoholic. Concerning the Medical Condition Report with its inaccuracies and omissions, she stated that her husband had been an abuser of alcohol but that was long ago. She observed that there have been no previous admissions to hospital regarding alcohol abuse. Her final statement was that her husband was paying the price for the three convictions for Impaired Driving which is simply ancient history now.

In cross-examination of the Applicant’s wife, Mr. Biel again stressed the inaccuracies and omissions in the Substance Abuse Assessment Form. She admitted these errors in the Form were not favourable to her husband but that they were all mistakes by his doctor and that three different medical people all had different comments about his drinking.

Closing Submissions

Mr. Biel’s summary noted that according to section 47(1) of the Act, the Registrar had no alternative but to suspend the Applicant’s driving privilege, and that the Applicant is an alcoholic and that this is indicated in the hospital discharge summary(s). He reviewed the MAC’s report and referred to Ontario Regulation 340/94, section 14(b), which states “the Applicant must not be addicted to the use of alcohol or a drug to an extent likely to significantly interfere with his or her ability to drive a motor vehicle safely”. He stated that the three convictions for Impaired Driving create an unsatisfactory history indicating that there is still a problem of dependency. Regarding the testimony of the Applicant and his wife, he referred to the omissions in the Substance Abuse Assessment Form and indicated that the Applicant’s family doctor’s comments indicated that there is substance abuse. He also refused to accept that the medical people found no problem with the Applicant and in fact the substance abuse report indicates that this is the case.

Mr. Biel noted that the AUDIT scores in the report stated a consumption of 3-4 drinks a day, which is compatible with a diagnosis of substance abuse (alcohol). He also said the fact that while the Applicant’s doctor noted that his last consumption of alcohol was three months ago, the evidence presented at the hearing by the Applicant indicates that he has continued to drink. Mr. Biel also noted that the Applicant’s family doctor was seeing his patient during at least part of this troubled era, and details are missing from the report.

Finally, Mr. Biel observed that the nurses and doctors all indicated that a drinking problem was present. Mr. Biel would not accept the Applicant’s statements that all of this is a misunderstanding in that these highly trained individuals are skilled observers. Mr. Biel concluded that the Applicant is dependent on alcohol and that the reports indicate abuse over decades. He asked that MTO’s decision be confirmed.

ISSUES

Should the decision of the Registrar to suspend the Applicant’s licence be confirmed, modified or set aside?

In particular:

Is the Applicant addicted to the use of alcohol or a drug to an extent likely to significantly interfere with his ability to drive a motor vehicle safely?

LAW

O. Reg. 340/94, section 14 states:

(1) An applicant for or a holder of a driver’s licence must not,

(a) suffer from any mental, emotional, nervous or physical condition or disability likely to significantly interfere with his or her ability to drive a motor vehicle of the applicable class safely; or

(b) be addicted to the use of alcohol or a drug to an extent likely to significantly interfere with his or her ability to drive a motor vehicle safely.

(2) In determining whether an applicant for or a holder of a driver’s licence of any class meets the qualifications described in subsection (1), the Minister,

(a) may take into consideration the relevant medical standards for applicants or holders of that class of driver’s licence set out in the CCMTA Medical Standards for Drivers; and

(b) may require the applicant or holder to provide evidence satisfactory to the Minister that he or she is able to drive a motor vehicle of the applicable class safely, including,

(i) any reports of examinations under section 15, and

(ii) any additional medical information.

(3) Despite clause (2) (a) and unless otherwise provided in this Regulation, if there is a difference between a medical standard set out in the CCMTA Medical Standards for Drivers and a medical standard set out in this Regulation, the Minister shall take into consideration the standard set out in this Regulation instead of the standard set out in the CCMTA Medical Standards for Drivers.

(4) In this section, the CCMTA Medical Standards for Drivers means the document entitled CCMTA Medical Standards for Drivers, published by the Canadian Council of Motor Transport Administrators and dated March 2009, as it may be amended from time to time, that is available on the Internet through the website of the Canadian Council of Motor Transport Administrators.

Section 47(1) of the Act gives the Registrar the power to suspend or cancel a driver’s licence on the ground(s) set out in section 14 (1) of the Regulation set out above.

Section 50 of the Act states:

50. (1) Every person aggrieved by a decision of the Minister made under subsection 32(5) for which there is a right of appeal pursuant to a regulation made under clause 32 (14) (n) or a decision of the Registrar under section 17 or 47 may appeal the decision to the Tribunal.

(2) The Tribunal may confirm, modify or set aside the decision of the Minister or the Registrar.

APPLICATION OF THE LAW TO FACTS

The Applicant was examined in an ER on April 2, 2013, and a report was filed on April 8, 2013. A Medical Condition Report was sent to MTO stating that the Applicant suffered from alcohol dependence. An optional note stated that the patient was admitted in hospital for alcohol withdrawal symptoms. It was signed by Dr. A.H. who turned out to be the Applicant’s family doctor. On receipt of this report, the Ministry had no alternative but to suspend the Applicant’s driver’s licence.

At the time of this initial visit to the hospital, the paramedics described the Applicant as shaking and or trembling and demonstrating hallucinations. He was managed as an outpatient and returned to his home in 24 hours, only to continue vomiting at home and was admitted to hospital on April 8, 2013. A note summarizing his stay in hospital on this occasion described him as agitated with tremors in his hands but no inability to maintain his posture or position. He was described as showing some signs of chronic liver disease but without any more details. Laboratory work showed that the sodium and potassium levels in his blood were significantly below normal but no liver function tests were done at that time.

Large doses of medication were required. Benzodiazepines calmed him down and the Tribunal heard from his wife’s testimony that he suffered a fall at home before returning to hospital. The Applicant’s wife blamed the trembling as the cause of the fall. The trembling may be related to withdrawal.

The Applicant’s wife stated that the Applicant’s problems were due to his low electrolytes (sodium and potassium). It should be noted that any significant drop in the level of these two chemicals would not lead to trembling but in fact causes marked lassitude and weakness. Therefore this has to give credence to reports by the medical attendants of his shaking disability due to Delirium Tremens. No blood alcohol was ever done and liver function tests were done only once, which showed no marked signs of liver disease. In the hospital records, there were several comments by possibly three or four physicians plus nurses and EMS personnel that the Applicant’s problems were alcohol related. Their estimates of the amount of alcohol being consumed by the Applicant are markedly different from the modest amounts of beer being consumed as stated in the testimony of the Applicant and his wife.

Inadequate completion of the Substance Abuse Assessment Form with failure to follow the instructions therein, both by the Applicant and his physician, raise the possibility the information recorded on the form may have been swayed in favour of the Applicant.

The certified copy of the Applicant’s driving record causes concern respecting the convictions of driving while impaired.

Regarding the evidence in the Applicant’s favour the Tribunal notes the following:

• He appears to be a very capable operator of heavy equipment (driving large transports all over North America);
• His employer would take him back tomorrow to full duties;
• Little interest has been shown by the doctors respecting his liver disease, hence little laboratory documentation exists;
• His wife’s testimony indicating that her husband is only a mild consumer of beer and uses no other forms of alcohol;
• The last conviction for Impaired Driving in 1995 occurred when he was simply sitting in his vehicle with the keys, but not driving.

The Registrar’s position is that despite the above mentioned gaps in the information presented at the hearing, the evidence shows that the Applicant has been abusing and/or is addicted to alcohol. In support of this are several comments by the professionals who looked after the Applicant and numerous comments in the hospital records describing “withdrawal symptoms”, tremors and hallucinations. In fact, all of these problems required large amounts of mood altering drugs (Benzodiazepines) to settle the patient down. The use of these drugs was quite successful. It should be noted that these drugs are not required for someone who has vomiting. The vomiting may well have been due to gastritis, but the Tribunal is not impressed with the diagnosis of viral gastritis. The use of the term viral is frequently the refuge of the diagnostically destitute. This Tribunal Member has never seen proven viral gastritis, but is well acquainted with gastritis caused by alcohol and ensuing vomiting.

The Applicant’s wife in her testimony has completely denied the observations of several professional medical observers, including the family physician of many years standing.

Weighing the evidence on a balance of probabilities, the Tribunal finds the Applicant is suffering from alcohol abuse, which significantly interferes with his ability to operate a motor vehicle safely.

DECISION

Upon the application by the Applicant to appeal the Registrar’s decision, effective May 19, 2013, to suspend his driver’s licence pursuant to section 47(1) of the Act, and having considered the evidence filed with the Tribunal, and the submissions of the Registrar and of the Applicant;

IT IS THE DECISION OF THE TRIBUNAL pursuant to the authority vested in it under section 50(2) of the Act that the decision of the Registrar be confirmed.

LICENCE APPEAL TRIBUNAL

David W. Hurst, M.D., Member

Released: September 23, 2013