Licence Appeal Tribunal File Number: 15636/MED

An appeal under subsection 50(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8, from a decision of the Registrar of Motor Vehicles to suspend a licence pursuant to Section 47(1) of the Act.

Between:

Ashley Goodfellow Craig

Appellant

and

Registrar of Motor Vehicles

Respondent

DECISION

ADJUDICATOR: Dr. Isla McPherson, Member

APPEARANCES:

For the Appellant: Ashley Goodfellow Craig, Appellant

For the Respondent: Sharon Nelson, Agent

Held by teleconference: March 7, 2024

OVERVIEW

1Ashley Goodfellow Craig (the “appellant”) appeals from the decision of the Registrar of Motor Vehicles (“Registrar”) to suspend her Class G licence under s. 47(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8 (the “Act”) after the Registrar received an unsolicited medical condition report stating that the appellant suffers from a medical condition that may affect her ability to drive a motor vehicle safely.

2The Registrar has the authority under s. 47(1)(g) of the Act to suspend or cancel a driver’s licence for any sufficient reason. Section 14(1)(a) of O. Reg. 340/94 under the Act (the “Regulation”) states that a holder of a driver’s licence must not suffer from any mental, emotional, nervous or physical condition or disability likely to significantly interfere with their ability to safely drive a motor vehicle of the applicable class safely. Under s. 14(2)(b) of the Regulation, the Minister of Transportation may require a driver to provide satisfactory evidence that they are able to drive safely.

3The Registrar takes the position that the appellant suffers from a medical condition, namely hypoglycemia unawareness, that is likely to significantly interfere with her ability to drive safely and that this provides sufficient reason to suspend her licence under s. 47(1)(g) of the Act.

4The appellant appeals the suspension under s. 50(1) of the Act. She denies that she suffers from hypoglycemia unawareness and denies that she suffers from a medical condition which interferes with her ability to drive safely.

5Pursuant to section 50(2) of the Act, after a hearing the Tribunal may confirm, modify, or set aside the decision or order of the Registrar.

ISSUES

6The issue in this appeal is whether the appellant suffers from a medical condition that is likely to significantly interfere with her ability to drive a motor vehicle safely.

7To resolve that issue, I will address the following questions:

i. Does the appellant suffer from hypoglycemia unawareness?

ii. If so, is this likely to significantly interfere with her ability to drive a motor vehicle safely?

8The Registrar bears the burden of proving on a balance of probabilities that the answer to each of the above questions is “yes.”

RESULT

9Having considered all the evidence and submissions and for the reasons that follow, I find that the Registrar has not satisfied its burden to establish that the appellant suffers from a medical condition that is likely to significantly interfere with her ability to drive a motor vehicle safely and I set aside the Registrar’s decision to suspend the appellant’s driver’s licence.

PROCEDURAL MATTERS

10At the outset of the hearing, the parties raised the issue of whether the Registrar had reviewed and responded to the latest submission from the appellant, which was a letter from the appellant’s family doctor, Dr. Q., dated February 22, 2024, as there was no response provided as part of the Registrar’s submissions.

11The respondent’s representative stated that a letter dated February 28, 2024 had been sent to the appellant on February 28, 2024, and that this letter was not filed with the Tribunal in error.

12I reviewed with the parties that this Tribunal set a disclosure date of March 4, 2024 for the Registrar to respond to any new submissions from the appellant and forward the response to the appellant and the Tribunal. The appellant confirmed that she received the respondent’s letter prior to March 4, 2024 in keeping with the procedure agreed upon by both parties at the Case Conference.

13Following this discussion, the respondent filed the letter of February 28, 2024 for this hearing. This letter listed a diagnosis of hypoglycemia unawareness, which was in contrast to the diagnosis of severe hypoglycemia that was the medical diagnosis referenced in the previous letters from the Registrar dated January 29, 2024 and February 21, 2024. The respondent was asked to clarify whether the diagnosis of severe hypoglycemia and its respective CCMTA standard were still being applied to this matter. After a recess allowing the respondent to confer with the Medical Review Section, the respondent confirmed that the medical diagnosis of severe hypoglycemia was no longer a reason for the medical suspension.

14The appellant objected to the medical condition being alleged in support of the licence suspension being changed unexpectedly following the Case Conference. She argued she had insufficient time to gather relevant medical information to address a diagnosis of hypoglycemia unawareness that the respondent relies upon in this appeal to support her licence suspension.

15I discussed whether the appellant wished an adjournment to allow for further time to gather medical information. The appellant decided to proceed with the hearing and did not request an adjournment.

ANALYSIS

Does the appellant suffer from Hypoglycemia Unawareness?

16The evidence presented at the hearing establishes that the appellant suffers from a medical condition, namely hypoglycemia unawareness.

17The Registrar’s position is supported by:

i. a Medical Condition Report Form dated January 29, 2024, from Dr. M;

ii. a Diabetes Assessment Form dated February 15, 2024, from Dr. Q.

18The Medical Condition Report (MCR) submitted by endocrinologist Dr. M., dated January 29, 2024, supports the respondent’s position that the appellant suffers from hypoglycemia unawareness. Dr. M. checked the box indicating the appellant suffered from hypoglycemia requiring intervention of a third party or producing loss of consciousness.

19The Diabetes Assessment Form (DAF) completed by family physician Dr. Q., dated February 15, 2024, also supports the respondent’s position that the appellant suffers from hypoglycemia unawareness. Dr. Q. checked a box on the DAF responding ‘yes’ to the question of whether the appellant has experienced any episodes of hypoglycemia unawareness in the past three months.

20In support of the appellant’s position, Dr. Q. responded ‘yes’ on the DAF as to whether the appellant demonstrates good knowledge of the condition [type 1 diabetes] and its management and that monitoring and assessment indicate effective blood glucose control. Dr. Q. additionally reports on the DAF that the appellant has not had more than one episode of hypoglycemia unawareness in the past 12 months, and indicates ‘yes’ to confirming that the appellant has regained adequate glycemic control.

21The appellant testified that she has had well-controlled type 1 diabetes for 15 years and she manages this disease with the use of an insulin pump and a continuous glucose monitor (CGM). She reported that on December 26, 2024, while sleeping, she experienced an episode of severe hypoglycemia that necessitated her family to notify emergency services. Paramedics arrived on scene and intervened to raise her blood sugar. She testified that the paramedics assessed her cognition, knowledge and awareness of her diabetes and decided that she did not need to be transferred to the hospital. When she reported this incident to her endocrinologist, Dr. M. during her next appointment, Dr. M. indicated to the appellant she would need to report this incident to the Ministry of Transportation and completed the MCR.

22Following the receipt of the MCR completed by Dr. M. the Registrar suspended the appellant’s driver’s licence due to severe hypoglycemia and requested the completion of the DAF.

23The appellant submitted the DAF completed by Dr. Q. Upon review of the DAF the Registrar continued the suspension and advised that, prior to reinstatement, it required confirmation that the appellant remained episode-free for three months and a recently conducted A1C result with confirmation that the level was congruent with blood logs and confirmation that stable glycemic control had been re-established.

24The appellant subsequently submitted a narrative letter dated February 22, 2024 from Dr. Q., which stated that glycemic control had been re-established since the event of December 26, 2023, the appellant had good knowledge and management of her type 1 diabetes and that as her physician she was in support of her driving privilege reinstatement.

25After submission of this narrative letter, the criteria for reinstatement for the medical condition of severe hypoglycemia had been met; however, the Registrar introduced the new medical condition of hypoglycemia unawareness to continue the suspension in a letter dated February 28, 2024. Under cross-examination, the respondent was questioned as to why the medical condition of hypoglycemia unawareness had been introduced, the respondent stated the diagnosis of hypoglycemia unawareness had been introduced following receipt of Dr. Q’s letter. The respondent was asked to clarify where this narrative letter made any reference to hypoglycemia unawareness and the respondent clarified that it was not the narrative letter that mentioned hypoglycemia unawareness, but the DAF. Although the respondent indicated that the Registrar had already reviewed the DAF prior to the Registrar’s letter of February 21, 2024, which continued the suspension only due to severe hypoglycemia, not hypoglycemia unawareness, the respondent offered no further explanation as to why the diagnosis of hypoglycemia unawareness was not provided on the February 21, 2024 letter.

26The respondent testified that the medical diagnoses of severe hypoglycemia and hypoglycemia unawareness were both in response to the event that occurred on December 26, 2023. What was now required prior to considering reinstatement was confirmation of a three-month period of being ‘episode free,’ into which the appellant is now 2.5 months.

27The appellant testifies that in her 15 years of having type 1 diabetes, the December 26, 2023 episode was the only incident of hypoglycemia requiring outside intervention. When she went to bed on December 26, 2023, her blood sugar was 4.4 mmol/L and she had no insulin on board as documented by her insulin pump. She testified that although her blood sugar was in the normal range, she took 16g of carbohydrate to ensure she did not experience an episode of hypoglycemia overnight.

28She testified that this practice of managing her blood sugar in this manner would have normally prevented nocturnal hypoglycemia, but she had recently titrated up a new prescription of Ozempic that contributed to the hypoglycemic event. The medication Ozempic had recently been prescribed and started at the end of November 2023, a couple of weeks earlier. She testified that while this medication is usually titrated every two weeks, she approached the use of this medication with caution due to the side effect of lowering blood sugars and titrated it up at a one month interval. As it is a weekly medication administration, she took the increased dose in the few days prior to experiencing the hypoglycemic event on December 26, 2023. The Ozempic was discontinued after this episode of hypoglycemia.

29The appellant’s family physician, Dr. Q., corroborates this history in the narrative letter when she wrote, “[the appellant] unfortunately suffered an episode of severe hypoglycemia (low blood sugar) on December 26, 2023 while sleeping, in the context of being started on a new medication for weight loss (Ozempic) that has a known side effect of lowering blood sugar levels. This medication was discontinued after this event. This episode, in my medical opinion, was an isolated event with an identifiable cause which has been corrected”.

30The appellant testified that she was unable to identify and treat this hypoglycemic event on December 26, 2023 without assistance, but that prior to and since this isolated event, she has never demonstrated hypoglycemia unawareness during the day nor at night. She reports that when her blood sugar drops to a range just above 4 mmol/L, which is still considered a normal range, she will start to experience symptoms of shakiness, sweating, headache, racing heart or numbness in the tongue. At this stage she has advanced warning to treat her blood sugar with fast-acting carbohydrates. She testified that she carries appropriate supplies including juice, jelly beans or Skittles and a glucometer in her purse, and has additional supplies in her vehicle.

31After consideration of the evidence before me, I take note that the medical submission from Dr. M. indicates that the appellant required third party intervention to treat a hypoglycemic event and the DAF completed by Dr. Q. indicates there was an episode of hypoglycemia unawareness. The appellant does not dispute the fact that she required assistance to treat a severe hypoglycemic episode while sleeping but maintains that she has not suffered from hypoglycemia unawareness before or since this episode. Although Dr. Q. has communicated that this was an isolated event with a contributing factor that has been addressed and glycemic control has been re-established, she does not dispute that the event occurred. Therefore, I find on the balance of probabilities, that the Registrar has established that the appellant suffered from an episode of hypoglycemia unawareness.

Is the appellant’s medical condition likely to significantly interfere with her ability to drive a motor vehicle safely?

32I find that the Registrar has not proven on a balance of probabilities that the appellant’s medical condition is likely to significantly interfere with her ability to drive a motor vehicle safely.

33The Registrar’s position is supported by The Canadian Council of Motor Transport Administrators Medical Standards for Drivers [February 2021] (the “CCMTA Standards”). Standard 7.6.5. addresses hypoglycemia unawareness for non-commercial drivers and outlines that drivers are eligible for a licence if it has been three months since the episode, a treating physician indicates glycemic awareness is regained along with stable glycemic control and the conditions for maintaining a licence are met.

34The CCMTA Standards outline that the neuroglycopenic symptoms associated with severe hypoglycemia can significantly impair the sensory, motor and cognitive functions required for driving.

35The CCMTA Standards additionally outline that while the risk of hypoglycemia is an important consideration when assessing the fitness of drivers with diabetes, research indicates that the chronic complications of diabetes are more likely to be responsible for impaired fitness to drive than episodic incidents of hypoglycemia. I take note that on the DAF, Dr. Q. does not identify any chronic complications of diabetes.

36The appellant takes the position that she does not have a medical condition that will impair her ability to drive safely and relies on her testimony and the narrative letter from Dr. Q. to support her position.

37The appellant testified that she has used a CGM for the past 10 years, and this device provides an updated glucose value every five minutes. This glucose value can be read in real time from both the appellant’s phone and watch allowing for easy awareness of her blood sugar level. The CGM also provides a directional arrow that demonstrates both the trend and the rate of change of her blood sugar, allowing for the appellant to anticipate changes to blood sugar and intervene before hypoglycemia occurs. The CGM device also provides audio alerts to notify the appellant when blood sugar is moving outside of the normal range. The appellant’s use of her CGM to manage her blood sugar is corroborated by Dr. Q’s narrative letter. This testimony and letter support the appellant’s position that through the ease and frequency of monitoring a blood sugar with a CGM she should be able to anticipate and abort a hypoglycemic event before it occurs.

38The appellant discussed in detail her approach to managing her blood sugar with driving. She testified that she does not start driving if her blood sugar is below 5 mmol/L and said she has always practiced the “5 to drive” rule as she has been taught by her diabetes team. She described that she monitors her blood sugar approximately every 15 minutes while awake, including while driving, which is facilitated by the value being present on her watch. As stated earlier, the appellant testified she experiences symptoms of shakiness, sweating, heart racing and a numb tongue consistently when her blood sugar approaches 4 mmol/L. The appellant testified she will confirm any abnormal blood sugar with her glucometer as well. The appellant acknowledged again that she keeps fast-acting carbohydrates on hand to respond to and treat a blood sugar to avoid experiencing hypoglycemia. She notes that should there be a trend in her blood sugar that suggests she will experience hypoglycemia while driving, she will pull over and treat with 15 g of fast-acting carbohydrate and wait not only until the blood sugar comes above 5 mmol/L but a longer period of time to ensure she has blood sugar stability based on the arrow on her CGM and all the cognitive functions required for driving. The appellant submits that her safe driving practices with type I diabetes are effective as she has never experienced hypoglycemia unawareness nor severe hypoglycemia while driving and has never at any time required a third party to assist with treating her blood sugar outside of the reported event of December 26, 2023.

39The appellant testified that in addition to discontinuing the Ozempic medication, she has also worked with her diabetes team and made changes to her insulin delivery to ensure that a similar incident does not occur again in the future. These changes include reducing basal insulin rates during the day, changing the insulin duration calculation on the pump from 3 to 3.5 hours and reducing the insulin to carbohydrate ratios entered on her pump which will permit the pump to deliver a lower dose of insulin for the same carbohydrate count. She testified she has worked closely with her diabetes team to institute these changes and noted she met with her family doctor January 18, 2024, her endocrinologist on January 29, 2024, her diabetic nurse February 8, 2024, her registered dietician at the diabetic clinic on February 9, 2024, her endocrinologist again on February 29, 2024 and has upcoming appointments with her family doctor on March 7, 2024 and her endocrinologist March 25, 2024. This history is also corroborated in the narrative letter from Dr. Q.

40To demonstrate the efficacy of the changes that have been made to reduce the risk of further hypoglycemic events, the appellant has submitted CGM data showing the continuous monitoring of her blood sugars for several weeks in January and February 2024, which corroborate her testimony. In addition, she has submitted HbA1c values from the past year dated in the months of April 2023, October 2023, January 2024 and February 2024 which all show the HbA1c value to be within the target range.

41The appellant stated that she has not had a concern related to driving in the past 20 years, 15 of which she has had type 1 diabetes. She highlighted that this was an isolated event with a reason for the event that has been addressed. She highlighted the fact that this episode occurred while she was sleeping and not during waking hours, let alone while driving. She testified that she has all the tools and resources in place to drive safely and is educated about safe driving protocols for type 1 diabetics. The narrative letter from Dr. Q. supports the event of December 26, 2023 as an isolated event when she states, “This episode, in my medical opinion, was an isolated event with an identifiable cause which has been corrected. It is not likely to affect her ability to drive a motor vehicle safely in the future.”

42I note the medical submission in the form of the narrative letter from Dr. Q. addresses her support for the appellant’s driving a second time when she states, “My medical opinion is that Ashley meets the requirements for safe driving and her medical condition does not pose a risk to the safe operation of a motor vehicle”.

43Section 14(2)(a) of the Regulation allows the Registrar to consider the CCMTA Standards when determining whether the requirements of s. 14(1) are met. The Tribunal may take the CCMTA Standards into consideration but are not bound by them.

44Although the CCMTA Standards are well reasoned, each case must be considered on its own merits. The overriding consideration in this appeal is whether the Registrar has proven, on a balance of probabilities, that the appellant’s hypoglycemia unawareness is likely to significantly interfere with her ability to drive a motor vehicle safely.

45After review of the CCMTA Standards and the Registrar’s position, it appears that the appellant has met all of the criteria for reinstatement with the exception that the appellant is two weeks shy of the requested three-month episode-free period. The Registrar’s position that a longer period of stability is weighed against the following evidence in support of the appellant:

i. Dr. Q. has articulated that this was an isolated event with an identifiable cause which as been corrected by discontinuing Ozempic and thus is not at risk of recurring.

ii. Despite discontinuing the Ozempic, the appellant has worked closely with her healthcare team including doctors, a diabetic nurse and diabetic dietician to make several adjustments to her insulin settings to avoid a repeated event.

iii. This is reported as the only episode of requiring outside intervention to address hypoglycemia that has taken place in the appellant’s 15-year history of using insulin to treat type 1 diabetes, which supports the statement from the appellant and Dr. Q. that this was an isolated event.

iv. The event occurred while sleeping, when CGM monitoring is not practical with high frequency. The event did not occur while she was awake nor driving when the appellant monitors several times per hour and keeps her blood sugar in range.

v. Both the appellant and Dr. Q. have communicated how she utilizes her CGM to closely monitor blood sugars to anticipate and respond to any changes to blood sugar that would fall outside of the normal range.

vi. The appellant has submitted laboratory data in the form of 1 year of HbA1c values and continuous data for several weeks leading up to the hearing which both corroborates Dr. Q.’s assessment that the appellant has well controlled diabetes and glycemic control has been re-established since the event on December 26, 2024.

vii. The appellant’s testimony demonstrates she is knowledgeable and careful in her approach to managing diabetes while driving, which is supported by the absence of any history of adverse driving events related to diabetes over a 15-year period.

viii. Dr. Q. has explicitly stated that in her medical opinion the appellant has met the requirements for safe driving and her medical condition does not pose a risk to safe operation of a motor vehicle.

46After careful consideration of the evidence before me, for the reasons cited, I am satisfied on a balance of probabilities that the appellant’s medical condition is not likely to significantly interfere with her ability to drive safely.

Conclusion

47I find that the Registrar has not established on a balance of probabilities that the appellant suffers from a medical condition, namely hypoglycemia unawareness, that is likely to significantly interfere with her ability to drive a motor vehicle safely.

ORDER

48For the reasons set out above, pursuant to subsection 50(2) of the Act, I set aside the Registrar’s decision to suspend the appellant’s driver’s licence.