COURT FILE NO.: CV-15-146-00

DATE: February 2, 2022

ONTARIO

SUPERIOR COURT OF JUSTICE

BETWEEN:

DIANNE HEIKAMP and DOUG TACKABERRY Plaintiffs

– and –

RENFREW VICTORIA HOSPITAL, DR. ROBERT DUGGAN and DR. GREG CAZA Defendants

COUNSEL:

Joe Dart and Warren Whiteknight, for the Plaintiffs

Stephanie Pearce and Justin McCarthy, for the Defendant, Dr. Greg Caza

HEARD: September 27, 28, 29, October 1, December 8 and 10, 2021

REASONS FOR JUDGMENT

MUSZYNSKI J.

[1] These reasons relate to a medical malpractice action that proceeded to trial via Zoom on September 27, 28, and 29, October 1, December 8 and 10, 2021. The only remaining defendant at the time of trial was Dr. Gregoire Caza, an emergency room physician at the Renfrew Victoria Hospital. The claims against the other defendants were dismissed on consent previously.

[2] The trial proceeded solely on the issue of liability as the parties were able to reach agreement on damages.

[3] The plaintiff in this case, Dianne Heikamp, alleges that Dr. Caza provided her with deficient discharge instructions following her attendance with him in the Renfrew Victoria Hospital where he assessed her fractured left wrist. Ms. Heikamp alleges that the inadequate discharge instructions caused a delay in accessing treatment by an orthopedic surgeon which in turn caused unnecessary complications and a poor recovery more generally. Dr. Caza takes the position that he appropriately discharged Ms. Heikamp to her family health team when she declined a referral to an orthopedic surgeon in Ottawa, and submits that he met the requisite standard of care of an emergency room physician in similar circumstances in doing so. Doug Tackaberry is Ms. Heikamp’s common law spouse and advances a claim pursuant to the Family Law Act R.S.O. 1990, c. F.3.

ISSUES

[4] During the trial, there were several evidentiary rulings required that are addressed throughout these reasons, including:

a. the scope of the opinion evidence of the plaintiffs’ expert, Dr. Pichora;

b. whether the defendant’s expert, Dr. Drummond, should be permitted to give evidence from the contents of his third report, which was only served on the plaintiffs on September 10, 2021; and

c. whether leave should be granted to permit the plaintiffs to file affidavit evidence of Ms. Heikamp’s treating nurse practitioner due to the unavailability of the witness to give viva voce evidence at trial.

[5] As in most medical malpractice cases, the two central issues that I must decide are:

a. whether Dr. Caza fell below the standard of care expected of a normal, prudent physician with comparable training and experience in the same circumstances; and

b. if Dr. Caza did breach the requisite standard of care, did this departure cause or contribute to Ms. Heinkamp’s poor outcome?

RESULT

[6] For the reasons that follow, I find that Dr. Caza fell below the standard of care expected of a normal, prudent physician with comparable training and experience in the same circumstances and that this breach caused or contributed to Ms. Heikamp’s poor outcome.

BACKGROUND FACTS / EVIDENCE AT TRIAL

[7] Many of the facts in this case are not controversial and were either admitted and filed into evidence as part of an agreed statement of fact or were undisputed.

[8] The parties agree that this action centres on Ms. Heikamp’s April 2, 2013 attendance with Dr. Caza in the Renfrew Victoria Hospital emergency room. There is no allegation that the diagnosis or treatment provided by Dr. Caza was deficient in anyway. Rather, the plaintiffs claim that Dr. Caza’s negligence was in his failure to give adequate discharge instructions and arrange for appropriate orthopedic follow-up.

Undisputed / Admitted Facts

[9] Dianne Heikamp was born on August 24, 1950 and at the material time lived near Cloyne, Ontario.

[10] On Friday March 29, 2013, Ms. Heikamp fell in her home while trying to dust a light fixture and sustained an injury to her left wrist.

[11] The same day as her fall, Ms. Heikamp attended at Renfrew Victoria Hospital emergency room and was examined by Dr. Robert Duggan. X-rays were completed, the arm was casted, and Ms. Heikamp was diagnosed as having a “dorsally angulated impacted radius fracture and an ulnar styloid fracture in good position.” This type of fracture is otherwise known as a Colles fracture. Dr. Duggan instructed Ms. Heikamp to follow up with her family physician and return to the emergency room if needed.

[12] Ms. Heikamp was a registered patient at Lakelands Family Health Team Clinic in Denbigh, Ontario. On Monday April 1, 2013, she attended at the family health clinic and was seen by Nurse Practitioner, Susan Peters. Ms. Heikamp’s family physician, Dr. Tobia, was not available that day. After consulting with the physician that was working that day, Dr. Wilson, Nurse Peters instructed Ms. Heikamp to return to the Renfrew Victoria Hospital for further imaging and to have a physician check the alignment of her wrist. Nurse Peters provided Ms. Heikamp with a diagnostic imaging requisition to take with her to the hospital that said: “check alignment in POP cast. Pt. casted Friday 29 March.” Nurse Peters also sent a Release of Information form to Renfrew Victoria Hospital the same day by fax requesting x-ray and ER reports related to the March 29, 2013 visit and inquiring: “Does pt require F/U prior to cast coming off in 6-8 weeks?”

[13] On April 2, 2013, Ms. Heikamp returned to the Renfrew Victoria Hospital emergency room. This time, she was seen by Dr. Caza. Ms. Heikamp was triaged at 6:06 p.m., was seen by Dr. Caza at 6:35 p.m., and was discharged at 6:45 p.m. Dr. Caza ordered repeat x-rays of Ms. Heikamp’s left arm, which were taken through her cast. The x-rays revealed that the fracture was well aligned. Dr. Caza provided Ms. Heikamp with a copy of her x-rays on a disc when she was discharged from the emergency room. The emergency room chart includes the following hand-written notes from the triage nurse and Dr. Caza:

“advised to have cast removed & have wrist re aligned” [Nurse note]

“as above; repeat x-ray; # well aligned; f/u clinic -> suggest ortho f/u” – [Dr. Caza note]

[14] There is no dispute that:

a. Dr. Caza did not receive the April 1, 2013 note from Nurse Peters asking whether Ms. Heikamp required follow-up prior to her cast coming off in 6-8 weeks;

b. the Lakelands Family Health Team Clinic did not receive a copy of Ms. Heikamp’s April 2, 2013 emergency room chart; and

c. Renfrew Victoria Hospital did not have an orthopedic surgeon on staff at the material time.

[15] Ms. Heikamp contacted her family health clinic following the April 2, 2013 emergency room attendance with Dr. Caza and was instructed to drop off the disc containing the x-ray images. Ms. Heikamp attended at the family health clinic on or about April 8, 2013 and provided Nurse Peters with the disc.

[16] On May 8, 2013, Ms. Heikamp went to the family health clinic where she was examined by Nurse Peters. Nurse Peters referred Ms. Heikamp to the fracture clinic at Belleville General Hospital for cast removal and an opinion on fracture management by an orthopedic surgeon.

[17] Ms. Heikamp was seen by an orthopedic surgeon, Dr. Steinitz, at Belleville General Hospital on May 13, 2013. On that date, the cast was removed and Dr. Steinitz observed that the fracture had healed in a malposition. Dr. Steinitz told Ms. Heikamp that due to the malposition, she could opt for surgery or a more conservative method that would involve physiotherapy.

[18] Ms. Heikamp ultimately decided to proceed with surgery. On June 13, 2013, Dr. Steinitz performed a left distal radius osteotomy and open reduction internal fixation of the distal radius.

Evidence of Diane Heikamp

[19] Ms. Heikamp’s evidence is she attended at the Renfrew Victoria Hospital on April 2, 2013 because she was told by Nurse Peters to do so. It was Ms. Heikamp’s understanding that she needed to have her cast removed on that date to allow for further x-rays to see if her wrist needed to be realigned. When she saw Dr. Caza, according to Ms. Heikamp, he did not understand why she was there requesting more x-rays and why she was instructed to have her cast removed. Ms. Heikamp was sent for x-rays, which Dr. Caza advised could be done through her cast. When she returned, Dr. Caza told her that everything was “fine”, it was “aligned”, it looked “good”, and that the doctor that put the cast on had done an “excellent job.”

[20] According to Ms. Heikamp, Dr. Caza said that she would be given a copy of the x-rays on a disc and then started to walk away. Ms. Heikamp gave evidence that she then asked Dr. Caza if she had to return to Renfrew Victoria Hospital to have her cast removed, since she had it put on there. Ms. Heikamp then testified that Dr. Caza said the following:

“That won’t be for six weeks. The cast has to stay on for six weeks.”

When asked whether she would have to return to Renfrew Victoria Hospital, Ms. Heikamp’s evidence is that Dr. Caza said:

“That’s going to be up to you. But it will be six weeks. And at that time, we refer you to the orthopedic surgeon in Ottawa.”

[21] At that point, Ms. Heikamp testified that she told Dr. Caza that she would ask her nurse practitioner whether she could go to Napanee or Belleville instead of Ottawa, which was closer to home. In response, according to Ms. Heikamp, Dr. Caza said:

“Like I said, it’d be up to you. But as I said before, that won’t be for another six weeks.”

Dr. Caza then left the room. A nurse came back and gave Ms. Heikamp a disc of the x-rays to take with her. It was Ms. Heikamp’s evidence that she felt like she had wasted Dr. Caza’s time and that he was in a hurry.

[22] Further, Ms. Heikamp testified that Dr. Caza did not:

a. ask who her family physician was;

b. tell her why she would need to see an orthopedic surgeon;

c. tell her about any risks associated with her fracture or cast;

d. tell her what to say when she returned to her family provider with the x-rays;

e. tell her what would happen if she did not see an orthopedic surgeon;

f. tell her how soon she needed to see someone;

g. mention anything happening within a week or 7 to 10 days.

[23] Ms. Heikamp’s evidence is that she did not refuse a referral to an orthopedic surgeon in Ottawa. She testified that if Dr. Caza had insisted she attend in Ottawa she would have done so because she followed every direction she was given regarding her wrist.

[24] When she left Renfrew Victoria Hospital on April 2, 2013, it is Ms. Heikamp’s evidence that after her interaction with Dr. Caza, she understood that she was supposed to see Nurse Peters to make arrangements to see an orthopedic surgeon to get her cast removed in six weeks.

[25] Indeed, Ms. Heikamp spoke with Nurse Peters when she dropped off the x-rays at the clinic a few days later. Ms. Heikamp testified that she relayed the information from Dr. Caza about getting the cast removed in six weeks. Ms. Heikamp asked Nurse Peters if the cast could be removed in Napanee or Belleville instead of Ottawa and Nurse Peters agreed that she could make those arrangements.

Evidence of Dr. Caza

[26] In April of 2013, Dr. Caza was a family physician with a one-year specialty in anesthesia. He graduated from medical school at the University of Ottawa in 1998 and then completed a two-year rural family medicine program in Sudbury. In 2001, Dr. Caza became independently licensed by the College of Physicians and Surgeons of Ontario. Since that time, Dr. Caza has mainly been working as a family physician in the Ottawa Valley and works in the Renfrew Victoria Hospital as an emergency room physician one day a week.

[27] Dr. Caza had some limited recollection of his interaction with Ms. Heikamp on April 2, 2013. He testified that he understood that Ms. Heikamp visited the emergency room because she was told to have her cast removed and wrist realigned. This information was relayed to a triage nurse from Ms. Heikamp and appeared on the emergency room chart where Dr. Caza also made his own notes.

[28] Dr. Caza’s evidence is that he sent Ms. Heikamp for x-rays and observed that the fracture was still in a good position and that conservative management was still appropriate (i.e. no surgery was required at that time). He testified that his standard practice in these circumstances was to offer Ms. Heikamp follow-up care with an orthopedic surgeon in Ottawa. In this case, Dr. Caza did not initiate a call to CritiCall, which he testified was the method of obtaining a referral to an orthopedic surgeon at the time. He did not do so because:

“…after a discussion with the patient, the patient did not want to have follow-up in Ottawa.”

[29] In terms of specific memory of the interaction with Ms. Heikamp, Dr. Caza stated:

“I remember the, the discussion of, of orthopedics, going down to Ottawa for orthopedics. The timing of, of that would be in there, but not much more. I remember her refusing that, and then I remember us having a conversation of figuring out what we’re going to do next, given given her refusal. I can’t tell you exactly what that conversation had, I’d have to go by my chart about the fact that I actually had those conversations with her, about the clinic follow-up, about suggesting ortho and what I told, again, hundreds of patients.”

[30] It is Dr. Caza’s evidence that Ms. Heikamp asked if her family doctor could arrange for orthopedic follow-up closer to her home, which he thought was reasonable.

[31] Dr. Caza gave further evidence as follows:

a. “I would tell her exactly what I would tell her if I sent her to ortho, that the, that as follow-up, the follow-up needs to happen within that, that, in this case a week, which would be day 10 from the time of the fracture. And, and at, at that stage your family doctor, you know, will determine the next, the next best step in regards to the treatment of this, this fracture.”

b. He did not tell Ms. Heikamp that the cast would have to stay on for six weeks and then she would be referred to Ottawa.

c. “…the initial plan was to send her to Ottawa at that one-week mark. So I wouldn’t change that plan if it was her family physician.”

d. “…six weeks for a follow of a cast care is so far outside of the standard of practice that it’s not something I would’ve, I would’ve discussed with the patient.”

e. He would not have told a patient with a Colles fracture when the cast would be removed as this is something that the orthopedic surgeon would discuss with the patient.

f. Ms. Heikamp’s family physician, Dr. Tobia, would have been listed on the emergency chart. At the material time, Dr. Caza had never met Dr. Tobia and did not know whether Dr. Tobia was comfortable dealing with fracture care or not.

g. At the material time, he did not know Nurse Susan Peters or whether nurse practitioners had the capability of taking care of a fracture.

h. He did not know Dr. Wilson.

i. It would not change Dr. Caza’s discharge plan if he knew that Ms. Heikamp was following up with a nurse practitioner as opposed to a physician.

j. If Ms. Heikamp’s family physician was not comfortable treating fractures, he or she would have been able to arrange orthopedic follow-up in their geographic area.

k. At the material time, Dr. Caza did not know that Belleville had an orthopedics department.

[32] Dr. Caza gave evidence that the usual practice is for the emergency room chart to be sent to the patient’s family physician by the hospital medical records department following the attendance.

[33] He did not provide Ms. Heikamp any written discharge instructions to provide to her family physician with his recommendations.

[34] On cross-examination, Dr. Caza testified:

a. His emergency department chart notes do not say anything about Ms. Heikamp declining a referral to Ottawa.

b. His preference would have been that Ms. Heikamp would have seen an orthopedic surgeon within 7-10 days of the injury.

c. The reason for a referral to an orthopedic surgeon in this time frame is that the fracture alignment might shift which could require surgery.

d. It is important to make the patient understand their health situation, so they know why recommendations are being made.

e. He was responsible for the quality of care provided during Ms. Heikamp’s visit to the Renfrew Victoria Hospital emergency room on April 2, 2013.

f. He did not tell Ms. Heikamp about the foreseeable risk that the fracture alignment might shift or the reason why she needed to see an orthopedic surgeon within this time frame because he is “not the one who does the follow-up care.”

g. Ms. Heikamp was discharged from the emergency room on April 2, 2013 with a disc of x-ray imaging and verbal instructions.

h. Ms. Heikamp’s family health clinic should have received the emergency room charts from March 29, 2013 and April 2, 2013, the disc with x-rays, and information directly from Ms. Heikamp about the verbal instructions he provided to her in the emergency room.

i. He has had patients misunderstand verbal instructions.

j. Being in pain or a stressful situation like an emergency room can affect a patient’s ability to understand verbal instructions.

k. There was sufficient time that day to record that Ms. Heinkamp had declined the referral to Ottawa in the emergency room chart.

l. The emergency room chart from April 2, 2013 does not say anything about a time frame for follow-up.

m. If Ms. Heikamp’s family health clinic had received a copy of the emergency room chart from April 2, 2013, it would have provided no direction on a time frame for follow-up.

n. The direction that Ms. Heikamp received, which he understood to be from her family health clinic, to have her cast removed on April 2, 2013 was a bad idea because removing the cast would jeopardize the stability of the fracture.

[35] At trial, Dr. Caza testified that, while he has no specific recollection, his normal practice would have been to tell a patient with this type of fracture that they would need to see an orthopedic surgeon within 7-10 days of the injury. At examinations for discovery, however, Dr. Caza did not mention this time frame to see an orthopedic surgeon but testified that he was content with the discharge plan that Ms. Heikamp was going to follow up with her family physician in the circumstances.

[36] At trial, Dr. Caza gave evidence that he knew that Ms. Heikamp lived in Cloyne, which is far from Renfrew and even farther from Ottawa. The typical practice is to refer patients attending at the Renfrew Victoria Hospital who need orthopedic follow-up to Ottawa through CritiCall. However, when a patient attends in his emergency room from out of the area, such as a cottager who lives elsewhere, the usual practice is to discharge the patient to the care of their family doctor with a consult note specifying what needs to happen next.

[37] Dr. Caza agreed that when a patient declines standard follow-up, it is of heightened importance to document the recommendations provided, the refusal by the patient, and that the risks associated with declining the recommended follow-up was explained to the patient.

Evidence of Dr. David Pichora

[38] Dr. Pichora is an orthopedic surgeon with a special interest in upper extremities and the current president and CEO of Kingston Health Sciences Centre. The plaintiffs sought to qualify Dr. Pichora as an expert in orthopedic surgery permitted to speak on: interpretation of x-ray images; causation of orthopedic injury; performance of wrist orthopedic surgery; the necessary timing and acceptable methods of orthopedic referrals and orthopedic follow-up; the standard of care applicable to arranging follow-up care and ongoing assessment of orthopedic injuries; the standard of care applicable to communicating discharge and ongoing instructions and health information regarding orthopedic injuries to patients, as common to all medical doctors; the standard of care applicable to communicating a patient’s ongoing care needs with other medical professionals as common to all medical doctors; and the standard of care applicable and common to all physicians charting in patient encounters.

[39] Counsel for the defendant conceded that Dr. Pichora was qualified to give opinion evidence in orthopedic surgery, the interpretation of x-ray images, causation of an orthopedic injury, the acceptable methods of orthopedic referrals and follow-up, and the standard applicable to arranging follow-up and ongoing assessment of orthopedic injuries. Counsel for the defendant objected, however, to Dr. Pichora’s ability to give opinion evidence on the standard of care of communicating discharge and ongoing instructions regarding orthopedic injuries, the standard of care in communicating patients ongoing care needs to other medical professionals, as well as the standard of care of physicians charting new patient encounters. The objection was based on the fact that Dr. Pichora, an orthopedic surgeon, is not a physician of comparable training and experience in the same circumstances as Dr. Caza, a family physician working in an emergency room setting.

[40] For oral reasons given, I qualified Dr. Pichora to give opinion evidence in the areas as requested by the plaintiffs subject to the caveat that the evidence of the other expert witnesses being called, both emergency room physicians, might be weighted more heavily than the evidence of Dr. Pichora on the issue of discharge instructions or charting generally. Further, I directed that Dr. Pichora not give opinion evidence on the standard of care of an emergency room physician.

[41] Dr. Pichora authored expert reports dated October 16, 2015 and July 3, 2019 in relation to this litigation. In addition to conducting a physical examination of Ms. Heikamp, Dr. Pichora reviewed: Ms. Heikamp’s medical records; the defence expert report of Dr. Drummond; and the discovery transcripts of Ms. Heikamp and Dr. Caza.

[42] It is Dr. Pichora’s opinion that a wrist fracture, like the one sustained by Ms. Heikamp, required follow-up by an orthopedic surgeon within 7-10 days. The time frame allows for the opportunity to intervene early and repair the fracture if it is required due to shifting or re-displacement that may occur. Shifting or re-displacement can be identified with weekly imaging studies. Beyond the 7-10 day time frame, the opportunity for early intervention is lost as healing takes place. Once healed in a poor position, surgery is typically required.

[43] Dr. Pichora testified that had Ms. Heikamp been seen by an orthopedic surgeon within 7-10 days, earlier intervention would have been offered which, more likely than not, would have provided her with a better outcome which could have included a “full recovery or close to it.” An example of early intervention is a closed reduction, colloquially referred to by some of the witnesses in this case as realignment, which can obviate the need for surgery.

[44] With respect to Dr. Caza’s decision to discharge Ms. Heikamp to her family health clinic, Dr. Pichora noted that nurse practitioners do not have the experience or expertise to manage a fracture and further, “it would be a step along the way that might delay access to orthopedic care.” If a patient with a Colles fracture is discharged into the care of a family physician or nurse practitioner, it is important for the patient to be informed and for the receiving professional to be informed and provided with clear instructions on what should happen next (i.e. attend at a fracture clinic within 7-10 days).

[45] In his experience working as an orthopedic surgeon at Kingston General Hospital, Dr. Pichora would often receive referrals from emergency room physicians in other jurisdictions. Those referrals may be received by fax, by direct connection with the emergency room doctor, or the patient may be instructed to attend at the Kingston General Hospital emergency room and request to be seen in the fracture clinic with specific instructions to be seen by an orthopedic surgeon on an urgent time frame.

[46] In cross-examination, Dr. Pichora was questioned about Renfrew Victoria Hospital’s use of CritiCall to obtain specialist appointments in 2013. Dr. Pichora testified that, in his experience, CritiCall was not typically used to obtain specialist appointments in situations other then those involving acute emergencies. However, Dr. Pichora acknowledged that he did not know the referral procedure in place at Renfrew Victoria Hospital at the material time.

[47] Further, in cross-examination, Dr. Pichora agreed that, while it does have the negative effect of introducing an extra step in the process, sometimes the most practical way to make an orthopedic referral is to discharge the patient to their family physician’s office with the information that is necessary to ensure that they get to the right destination (i.e. orthopedic surgery) as soon as possible.

Evidence of Dr. Peter Graves

[48] At the request of the plaintiffs, Dr. Graves, an emergency room physician, authored two reports, dated June 1, 2021 and August 9, 2021, that provide opinions as to whether Dr. Caza met the requisite standard of care in the circumstances of this case.

[49] Dr. Graves graduated from medical school from the University of Ottawa in 1991 followed by residency in family medicine with a specific competence in emergency medicine. The bulk of Dr. Graves’ career since 1994 has been in the emergency room, mostly at the Queensway Carleton Hospital in Ottawa. Dr. Graves has been involved in teaching residents since 1994 and has been an assessor with the College of Physicians and Surgeons of Ontario from 2016 to present. Since 2014, Dr. Graves has been the president of Medical Scribes of Canada which works to train non-physician scribes to work alongside emergency room physicians taking notes.

[50] The plaintiffs sought to qualify Dr. Graves as an expert to give opinion evidence on the standard of care expected of an emergency physician as it relates to the diagnosis of wrist fractures, the management and treatment of wrist fractures in the emergency room setting, and the nature, content and timing of follow-up required by an emergency room physician treating wrist fractures. There was no objection to the qualification of Dr. Graves to give opinion evidence as proposed by the plaintiffs. Taking into account Dr. Graves’ qualifications and experience, I qualified Dr. Graves to give expert opinion evidence in the proposed areas.

[51] Dr. Graves was provided with information from counsel for the plaintiffs, including: the medical records from Renfrew Victoria Hospital; the medical records from the family health clinic; the discovery transcripts of Ms. Heikamp and Dr. Caza; and, in advance of his second report, the report of Dr. Drummond.

[52] Dr. Graves confirmed that Ms. Heikamp’s minimally displaced fracture was treated appropriately when she initially attended at the Renfrew Victoria Hospital emergency room on March 29, 2013. Dr. Graves further testified that on Ms. Heikamp’s subsequent visit to the emergency room on April 2, 2013, Dr. Caza appropriately kept the cast in place and completed additional x-rays which confirmed the fracture was still minimally displaced and did not require realignment.

[53] Although the treatment that Dr. Caza provided was appropriate, Dr. Graves expressed concerns about the lack of timely follow-up by an orthopedic surgeon. It was Dr. Graves’ evidence that, for this type of fracture, a patient should be seen by either an orthopedic surgeon, or another health care provider that is comfortable managing cast care and fractures, between 7-10 days of the injury. Dr. Graves testified that this 7-10 day time frame is something that is common knowledge for emergency room physicians.

[54] With respect to communicating the appropriate follow-up care to a patient, Dr. Graves gave evidence that, while it is preferable for a patient to receive written discharge instructions after attending the emergency room, it is not always practical or possible in the emergency room setting to provide each patient with written instructions when they leave. Instead, Dr. Graves testified that a combination of verbal instructions and charting is sufficient to ensure that patients and receiving physicians understand the next steps. Specifically, Dr. Graves stated:

a. The patient must understand why it is important for follow-up to happen.

b. There should be an opportunity for the patient to ask questions.

c. The required follow-up must be “clearly documented as to what’s going to happen next for the provider and also for situations like this, so it’s clearly written down as to what the discharge disposition, time frames and management that are case-specific, are documented.”

d. If there is a difference between what the doctor is recommending and what a patient wants to do, it is important to document what has been discussed and the implications of not following recommendations.

e. “You’ve got to make sure things are well-communicated and then document that, that communication was clearly understood.”

f. The physician that receives the chart should have a good clear understanding of expectations.

[55] At the Queensway Carleton Hospital, where Dr. Graves works, there is an orthopedic surgeon on staff and an internal referral process whereby patients attending with fractures in the emergency room get scheduled into see an orthopedic surgeon in accordance with the acceptable time frame for follow-up. However, Dr. Graves also testified that, commonly, patients who come to the emergency room with fractures, will want to have follow-up arranged closer to their home. If this happened in 2013, the patient would be provided with a disc containing digital imaging of the x-rays, a copy of the emergency room chart, and clear verbal instructions as to what needs to happen next and why.

[56] Dr. Graves testified that an emergency room physician cannot assume that all family doctors or nurse practitioners have the requisite skills to deal with a Colles fracture. If a patient is being discharged to a family health clinic, it is important to have clear directions to the receiving health care provider and the patient as to what follow-up is required. When Nurse Peters saw Ms. Heikamp after her April 2, 2014 visit with Dr. Caza, Dr. Graves’ evidence is that she did not have adequate information from Dr. Caza to provide Ms. Heikamp with timely orthopedic follow-up.

[57] Dr. Graves’ opinion was that Dr. Caza fell below the requisite standard of care of an emergency room physician with respect to the disposition and ongoing follow-up that was required. In support of this opinion, Dr. Graves testified that when the patient asked if she could be referred to someone closer to her home and asked to return to her family health clinic, Dr. Caza “failed to provide adequate discharge instructions both to the family physician and to the patient as to what needed to be done and when.” More specifically, Dr. Graves stated: “…I would have written on the chart that there was, the patient is unable to follow-up with ortho as, as suggested and will follow-up with a family physician. And then I’d say, patient should be reassessed within a 7 to 10-day framework for the fracture for potential movement.”

[58] With respect to the specifics of this case, Dr. Graves testified that the fact that Renfrew Victoria Hospital is “rural” does not affect his opinion regarding the discharge instructions that should have been provided to Ms. Heikamp. Similarly, the fact that emergency rooms are often busy may result in abbreviated charting by emergency room physicians, but this is not “an acceptable reason not to have proper discharge instructions. Patient’s care needs to be clearly defined as to what’s going forward…”.

[59] On cross-examination, Dr. Graves confirmed that patients have a role to play in their own care and that Dr. Caza’s decision to refer Ms. Heikamp back to her family health clinic in this case was an acceptable option, provided there was a clear understanding of the discharge plan, which is not supported in this case by Dr. Caza’s contemporaneous notes.

Evidence of Dr. Alan Drummond

[60] Dr. Drummond was called to give expert opinion evidence by the defendant on “the standard of care expected of an emergency room physician for the diagnosis of wrist fractures in the emergency room setting and the nature, content and timing of the follow-up required of an emergency room physician in those circumstances” as well as the “standard of care of an emergency room physician specifically applicable to patient charting in the emergency room setting.”

[61] Dr. Drummond is a family and emergency room physician in Perth, Ontario. He received his medical degree from McGill University in 1978. Dr. Drummond is a family physician with a one-year certificate of special competence in emergency medicine. He works approximately 70% of the time in family practice and the remainder of the time in the emergency room. In addition to his regular work schedule, Dr. Drummond is a member of the Canadian Association of Emergency Physicians where he sits on a Committee for rural emergency room medicine. In his involvement in these associations, Dr. Drummond has made recommendations for standards in emergency room departments. He has also been an examiner for examinations in emergency medicine and taught medical residents. Dr. Drummond has been previously qualified by this court to give expert opinion evidence in the areas of emergency room medicine and family medicine.

[62] Counsel for the plaintiffs agreed that Dr. Drummond is qualified to give opinion evidence as set out in his reports dated October 9, 2018 and July 13, 2021 but takes issue with the most recent report, that being the report of September 10, 2021, which the plaintiffs submit was outside the time frame provided for in the Rules of Civil Procedure. Based on his education, training, and experience, I qualified Dr. Drummond to give expert evidence in the areas proposed by counsel. For oral reasons given at trial, I allowed Dr. Drummond to testify about the opinions expressed in his September 10, 2021 report due to the unique circumstances in this case which include: the unexpected and sudden death of Dr. Caza’s original lawyer; the absence of prejudice to the plaintiffs; and the fact that there will be no further delay associated with the late service of the report.

[63] Dr. Drummond gave evidence that there was an unacceptable delay in making a referral for Ms. Heikamp to see an orthopedic surgeon, which he concedes resulted in a poor outcome. However, unlike the other expert witnesses, Dr. Drummond’s opinion is that it was not Dr. Caza’s negligence that resulted in the late referral to orthopedics and that Dr. Caza met the requisite standard of care of an emergency room physician in the circumstances of this case.

[64] Dr. Drummond testified that it was Ms. Heikamp’s family health clinic that “assumed responsibility” of caring for the fracture and it was the responsibility of the family health clinic to ensure Ms. Heikamp received a timely referral to an orthopedic surgeon. According to Dr. Drummond, this referral to an orthopedic surgeon should have occurred within 10-14 days of the injury.

[65] In coming to the conclusion that Dr. Caza met the standard of care, Dr. Drummond gave evidence that Dr. Caza:

a. assessed the patient appropriately;

b. took a history;

c. performed x-rays;

d. suggested orthopedic follow-up in Ottawa, which was declined; and

e. ultimately referred Ms. Heikamp back to her family health clinic to get a more appropriate referral.

[66] Dr. Drummond’s opinion is premised on his understanding that Dr. Caza provided verbal instructions to Ms. Heikamp and that she seemed to understand those verbal instructions. While Dr. Caza’s emergency chart notes are brief in this case, Dr. Drummond testified that emergency chart notes are generally brief due to the nature of the environment. Dr. Drummond called the charting standards of the College of Physicians and Surgeons of Ontario (the “CPSO”) “aspirational.”

[67] During cross-examination, Dr. Drummond reaffirmed that Dr. Caza never assumed responsibility for the ongoing care of Ms. Heikamp’s fracture. According to Dr. Drummond, referring Ms. Heikamp back to her family physician was appropriate as a family physician should know to refer Ms. Heikamp to an orthopedic surgeon within 10-14 days of her injury. Dr. Drummond ultimately agreed, however, that an emergency room physician cannot assume that a family doctor is competent to manage this type of fracture.

[68] Dr. Drummond emphatically testified that emergency room physicians do not have the capacity to provide the continuity of care to follow patients after they leave the emergency room. He emphasized that there would be profound implications on emergency rooms throughout the country to require emergency room physicians to take on this responsibility. Once Ms. Heikamp was discharged to follow up with her family health clinic and left the emergency room, Dr. Caza had no further obligation.

[69] When questioned about Dr. Caza’s discharge instructions, Dr. Drummond gave evidence:

a. Providing patients with written discharge instructions after an emergency room encounter was not the standard in 2013.

b. Emergency room charts should define the essential elements of the patient encounter.

c. There is no mention in this chart about a time frame for follow-up.

d. There is no mention in this chart about what type of “ortho” follow-up was required.

e. There is no mention in this chart about a time frame for further imaging, or that further imaging was required.

f. There is no mention in this chart that the risks associated with the fracture shifting were explained.

g. There is no mention in this chart that Ms. Heikamp declined a referral to an orthopedic surgeon in Ottawa.

h. If someone that was not fluent in fracture management read this chart, they would not know a time frame for what needed to happen next.

i. Dr. Caza’s chart does not reach the standard of what the CPSO would expect, it is deficient.

j. Although deficient, this chart is really nothing out of the ordinary for an emergency room interaction.

[70] Dr. Drummond accepted that his reports did not address the discrepancy between Dr. Caza’s recollection of the patient encounter, his usual practice, and what Ms. Heikamp testified that she understood when she left the emergency room in terms of follow-up instructions. Dr. Drummond confirmed that the failure to address this discrepancy is a “fair criticism” with respect to his report but does not change his ultimate opinion that it was the family health clinic, not Dr. Caza, that caused the delay in a timely orthopedic referral.

[71] Dr. Drummond further testified that if Ms. Heikamp had been his emergency room patient on April 2, 2013, he would have told her that there was no need to have further investigations at that time and would have sent her away with instructions to follow up with an orthopedic surgeon within 7-10 days.

LAW AND ANALYSIS

Should leave be granted to permit the plaintiffs to file affidavit evidence of Nurse Peters at trial?

[72] In 2013, Nurse Susan Peters worked at the family health clinic where Ms. Heikamp was a patient. Ms. Heikamp saw Nurse Peters on several occasions in 2013 in relation to her fractured wrist.

[73] At the time of trial, Nurse Peters was not available to testify by any means due to health issues. The plaintiffs brought a motion seeking leave to file affidavit evidence of Nurse Peters at trial based on the principled exception to the hearsay rule, which was opposed by the defendant. The proposed evidence of Nurse Peters is in the form of a letter containing five brief bullet points attached to an affidavit sworn by Nurse Peters. Only two of the bullet points are allegedly controversial, including:

a. “On April 1, 2013, I consulted with the physician on staff at the clinic since I am a Nurse Practitioner that has not participated in an advanced training course to develop an expertise in the management of orthopedic fractures. Based on this consultation, it was decided that we should seek instruction from the RVH physicians regarding follow-up care and future management of the fracture.”

b. “I did not receive information at any time either the hospital or Ms. Heikamp suggesting that anything further needed to be done prior to 6-8 weeks post-fracture.”

[74] The parties agree that in determining whether to grant leave, I must consider whether the proposed evidence is necessary and reliable: R. v. Khelawon, 2006 SCC 57 [Khelawon]. However, before applying the necessity and reliability criterion to this case, it is worth stepping back and considering the probative value of the proposed evidence.

[75] After hearing the entirety of the evidence at trial, I am not persuaded that the proposed affidavit evidence of Nurse Peters is sufficiently relevant to the issues before the court to outweigh the prejudice to the defendant associated with their inability to cross-examine the witness. The most pressing issue in this trial is whether Dr. Caza fell below the requisite standard of care with respect to Ms. Heikamp’s discharge instructions. Given the evidence at trial, the reason why Nurse Peters instructed Ms. Heikamp to reattend at the Renfrew Victoria Hospital on April 2, 2013, I find, is not particularly relevant to Dr. Caza’s liability.

[76] Dr. Caza testified that he understood that Ms. Heikamp came to the hospital to have her cast removed, further imaging, and to have her wrist realigned. Dr. Caza testified further that at the material time he did not know whether anyone at Ms. Heikamp’s family health clinic had the necessary skills to manage a Colles fracture. It is Dr. Caza’s understanding that is relevant in this case, not Nurse Peter’s. Whether Nurse Peters received information from the hospital or Ms. Heikamp about a referral to orthopedics prior to 6 weeks is also not sufficiently probative to render it admissible. It became evident during the trial that Dr. Caza’s emergency room chart never reached the family health clinic, and, Ms. Heikamp’s report to Nurse Peters about what Dr. Caza told her would be stacking on yet another layer of hearsay.

[77] Because the probative value of the proposed evidence of Nurse Peters is negligible at best, it is unnecessary to go through the Khelawon test for admissibility. The plaintiffs’ motion seeking leave to file the affidavit evidence of Nurse Peters at trial is dismissed.

Did Dr. Caza fall below the standard of care expected of a normal, prudent physician with comparable training and experience in the same circumstances?

[78] In a medical malpractice action, the plaintiff has the onus of proving, on a balance of probabilities, that the defendant physician fell below the requisite standard of care: Bafaro v. Dowd, [2008] OJ No. 3474 (ONSC) at para 22, aff’d 2010 ONCA 188.

[79] The standard against which the physician is to be measured is not of perfection, but rather a realistic and reasonable standard which could be “expected of a normal, prudent practitioner of the same experience and standing…”: Crits v. Sylvester, 1956 CanLII 34 (ON CA), [1956] OR 132 (ONCA) at para 13, aff’d 1956 CanLII 29 (SCC), [1956] SCR 991.

[80] There is no dispute that Dr. Caza’s assessment and treatment of Ms. Heikamp during the April 2, 2013 visit to the Renfrew Victoria Hospital emergency room was appropriate. Further, there is no dispute that Ms. Heikamp required timely follow-up with an orthopedic surgeon that did not happen. The question is whether Dr. Caza’s discharge instructions met the standard of care expected of an emergency room physician in similar circumstances.

[81] The expert witnesses agreed that there are three main ways of communicating discharge instructions to a patient:

a. verbal instructions;

b. written instructions; and

c. written notes in an emergency room chart.

[82] All of the physician witnesses agreed that it was reasonable for Dr. Caza to refer Ms. Heikamp back to her family health clinic for follow-up. There were other options that could have accelerated Ms. Heikamp’s referral to an orthopedic surgeon, but a referral back to the family health clinic was one reasonable option open to an emergency room physician in the position of Dr. Caza. I find that, generally, the referral of Ms. Heikamp back to her family health team was appropriate.

[83] I accept the evidence of Dr. Graves and Dr. Drummond that providing emergency room patients with written discharge instructions was not the standard in 2013. Dr. Caza’s failure to provide Ms. Heikamp with written discharge instructions was not a breach of the requisite standard of care.

[84] With respect to the emergency room chart, I accept the evidence of Dr. Graves and Dr. Drummond that Dr. Caza’s notes are deficient and fall below the standard set out by the CPSO. I appreciate that the emergency room environment can be busy and chaotic, but I do not accept that those factors excused Dr. Caza from his obligation to record the basics of the patient encounter. Dr. Caza failed to record: Ms. Heikamp’s request for a referral closer to home; any indication of a time frame for follow-up; any reference to a discussion about the risks involved with a delay in obtaining orthopedic follow-up. Given that Ms. Heikamp was not following the traditional referral regime, I find that it was even more important for these details to be recorded so that a receiving health care provider could understand what had to happen next and why.

[85] Dr. Graves, Dr. Caza and Dr. Drummond gave evidence that providing patients with verbal discharge instructions can be acceptable in certain circumstances. In this case, Dr. Caza testified that he had no recollection of Ms. Heikamp’s level of sophistication or ability to understand instructions. He testified that Ms. Heikamp was willing to return to her family physician and he thought that was reasonable in the circumstances.

[86] With respect to time frame for follow-up, at trial, Dr. Caza testified that, although he has no specific recollection, he would have provided Ms. Heikamp with verbal instructions to follow up with an orthopedic surgeon within 7-10 days which was his usual practice.

[87] It is unreasonable to expect a physician to recall details of every patient interaction, this is why, evidence about a physician’s invariable practice carries significant weight: Belknap et al v. Meakes, 1989 CanLII 5268 (BC CA), [1989] BCJ No 2187 (BCCA) at para 39; Bafaro v. Dowd, [2008] OJ No 3474 (ONSC) at para 29, aff’d 2010 ONCA 188.

[88] The challenge, however, is that while at trial Dr. Caza testified that his usual practice was to refer patients with this type of injury to an orthopedic surgeon within 7-10 days, by Dr. Caza’s own evidence, this was not a usual case. Dr. Caza testified that this was the only time that a patient with an orthopedic injury refused a referral to Ottawa. Further, at examinations for discoveries, Dr. Caza’s evidence was that he would have told Ms. Heikamp to follow up with her family physician. Ms. Heikamp denies that Dr. Caza ever gave her verbal instructions to see an orthopedic surgeon within 7-10 days. Given the contrary evidence in this case, and lack of written documentation of any time frame for follow-up in Dr. Caza’s notes, I decline to accept that Dr. Caza followed his stated invariable practice on this occasion.

[89] Ms. Heikamp testified that if Dr. Caza had instructed her to see an orthopedic surgeon within 7-10 days she would have done so. The evidence at trial confirms that Ms. Heikamp diligently followed the instructions of her health care providers. I find that Ms. Heikamp was a compliant patient and I accept her evidence that Dr. Caza did not provide her with verbal instructions to see an orthopedic surgeon within 7-10 days.

[90] Both Dr. Caza and Dr. Drummond gave evidence that once Ms. Heikamp was discharged from Renfrew Victoria Hospital and followed up with Nurse Peters, the family health team assumed carriage of Ms. Heikamp’s fracture management and became the “most responsible physician.” It is for this reason that Dr. Drummond ultimately concludes that Dr. Caza is absolved of liability and that the delay in a timely orthopedic referral lies with the family health clinic. I disagree. Regardless, at this trial, the liability of Ms. Heikamp’s other health care providers is not before me and “the hypothetical negligence of a third party should not provide a defence”: Ghiassi v. Singh, 2018 ONCA 764 at para 18.

[91] The physician witnesses in this case all testified that this Colles fracture needed follow-up by an orthopedic surgeon or a family physician with knowledge of fracture management somewhere between 7-14 days after the initial injury. I accept this evidence and find that Ms. Heikamp required a referral to an orthopedic surgeon or a family physician with knowledge of fracture management somewhere between 7-14 days after her injury.

[92] I further accept the evidence of Dr. Caza, Dr. Graves and Dr. Drummond that an emergency room physician cannot assume that every family physician has the knowledge base to manage an orthopedic injury such as a Colles fracture. This is simply not a skill that every family doctor has in their repertoire. I accept Dr. Caza’s evidence that, as of April 2, 2013, he did not know Dr. Tobia, Dr. Wilson, or Nurse Peters, and that he did not know whether nurse practitioners had the skills to manage orthopedics injuries. He simply did not know anything about Ms. Heikamp’s family health clinic.

[93] When Ms. Heikamp attended at the emergency room on April 2, 2013, she came with instructions to have her cast removed. According to Dr. Caza, and the other physician witnesses at trial, that was bad advice given that the cast was in good condition and there was no sign of swelling. I accept the evidence of the physician witnesses in this regard. I find that the instructions Ms. Heikamp received to have her cast removed at this stage to have been inappropriate and evidence that supports an inference that Ms. Heikamp’s treating health care providers at the family health clinic did not the skills necessary to manage her fracture.

[94] Given that he did not know Ms. Heikamp’s family health clinic, coupled with the dubious instructions Ms. Heikamp received to have her cast removed for no good reason, when Ms. Heikamp was discharged on April 2, 2013, Dr. Caza should have taken steps to ensure that Ms. Heikamp and her family health clinic clearly understood what needed to happen next and why. I find that Dr. Caza failed to do so.

[95] I find that Dr. Caza did not provide Ms. Heikamp with verbal instructions about a 7-10-day time frame for following up with an orthopedic surgeon and did not explain the risks associated with a delay in being assessed by an orthopedic surgeon. I find that Dr. Caza’s verbal instructions to Ms. Heikamp were deficient for failing to identify this time frame or to explain risks. Ms. Heikamp was not provided with sufficient information to allow her to seek appropriate treatment, which, I find, she would have done.

[96] Notably, Dr. Drummond testified that if he had seen Ms. Heikamp in the emergency room on April 2, 2013, he would have declined to treat her altogether and provided her instructions to see an orthopedic surgeon within 7-10 days. Dr. Drummond also agreed: it is important to provide patients with information; a more fulsome discussion about a time frame for an orthopedics referral should have happened between Dr. Caza and Ms. Heikamp; and that Dr. Caza’s emergency chart was deficient. It is difficult to reconcile these admissions by Dr. Drummond with his insistence that Dr. Caza met the requisite standard of care in this case. For this reason, I give Dr. Drummond’s ultimate conclusion little weight.

[97] Dr. Caza testified that in addition to the verbal instructions provided to Ms. Heikamp, the family health clinic would have received a copy of his emergency room chart and a copy of the x-rays. In this case, through no fault of Dr. Caza, the family health clinic did not receive a copy of the emergency room chart. Regardless, even if Dr. Caza’s emergency room chart had been received by Ms. Heikamp’s family health clinic, it would have not provided any information about the time frame for orthopedic follow-up. While the x-rays were received by the family health clinic, they contained no information about time frame for orthopedic follow-up.

[98] Counsel for the plaintiffs pointed out that there were many ways in which Ms. Heikamp’s interaction with Dr. Caza could have been improved upon. For example, it is submitted that Dr. Caza could have:

a. contacted CritiCall and requested a referral to an orthopedic surgeon closer to Ms. Heikamp’s home as opposed to Ottawa;

b. contacted hospitals closer to Ms. Heikamp’s home directly to inquire as to whether they accept orthopedic referrals;

c. provided Ms. Heikamp with written discharge instructions that clearly set out what needed to happen next and why;

d. provided Ms. Heikamp with a copy of the emergency room chart that clearly set out a time frame for orthopedic follow-up; or

e. sent a consult note to the family health team confirming that Ms. Heikamp needed to be referred to an orthopedic surgeon within a 7-10 day time frame.

[99] However, it is not the role of this court to judge Dr. Caza with the benefit of hindsight or against a standard of perfection, but rather in light of the knowledge that should have been reasonably within his possession at the time: Bafaro v. Dowd, [2008] OJ No 3474 (ONSC) at para 30, aff’d 2010 ONCA 188.

[100] Discharging Ms. Heikamp to her family health clinic would have been appropriate if Dr. Caza had confidence that the receiving health care providers were capable of managing this type of fracture, and Ms. Heikamp was properly informed as to what needed to happen next and why.

[101] In this case, I find that Dr. Caza fell below the standard of care expected of an emergency room physician in similar circumstances because, without knowing whether Ms. Heikamp’s family health clinic had knowledge and experience in fracture management:

a. he failed to provide Ms. Heikamp with verbal instructions to see an orthopedic surgeon within 7-10 days;

b. he failed to explain to Ms. Heikamp the significance of seeing an orthopedic surgeon within a 7-10-day time frame or the risks associated with not doing so; and

c. he failed to document in his emergency room chart notes that Ms. Heikamp should be seen by an orthopedic surgeon within 7-10 days.

Did Dr. Caza’s negligence cause or contribute to Ms. Heikamp’s poor outcome?

[102] The issues of factual and legal causation where not strenuously argued at trial, particularly after Dr. Drummond volunteered in his testimony that Ms. Heikamp had a poor outcome which was caused by a delay in a timely referral to an orthopedic surgeon. Dr. Drummond further confirmed that this poor outcome was a foreseeable consequence to a delayed orthopedic referral.

[103] Dr. Pichora, the only orthopedic surgeon to give evidence at this trial, testified that if Ms. Heikamp had obtained timely orthopedic follow-up, she would likely have achieved a highly satisfactory outcome, with little or no functional deficits. I accept Dr. Pichora’s evidence in this regard and find that Ms. Heikamp’s poor outcome occurred due to the fracture healing in a bad position. I find that had there been a timely referral to an orthopedic surgeon, it is more likely than not that the malposition would have been discovered earlier which would have required less invasive steps to correct. I further accept Dr. Pichora’s evidence that it was reasonable for Ms. Heikamp to pursue a surgical option once it was determined there was a malunion.

[104] Ms. Heikamp was a compliant patient. If Dr. Caza had instructed her to see an orthopedic surgeon within 7-10 days of the April 2, 2013 attendance, I find that Ms. Heikamp would have taken the steps necessary to make it happen, including relaying this important information to her family health clinic to get a timely referral closer to home.

[105] Since Dr. Caza’s emergency chart was never received by the family health clinic, and there is no evidence that Ms. Heikamp saw the emergency chart, I cannot conclude that the deficiencies in his notes caused or contributed to Ms. Heikamp’s poor outcome.

[106] Rather, I find that Ms. Heikamp’s poor outcome was caused by Dr. Caza’s failure to provide his patient with verbal instructions to see an orthopedic surgeon within 7-10 days and failure to explain the significance of seeing an orthopedic surgeon within a 7-10-day time frame or the risks associated with not doing so. I further find that the plaintiffs have shown that it is more likely than not that, but for Dr. Caza’s negligence, Ms. Heikamp’s unfavourable outcome would have been avoided: Mustapha v. Culligan, 2008 SCC 27 at para 3; Beldycki v. Jaipargas, 2012 ONCA 537 at para 44.

CONCLUSION AND JUDGMENT TO ISSUE

[107] I find that Dr. Caza fell below the standard of care when he failed to provide Ms. Heikamp with verbal instructions to see an orthopedic surgeon within 7-10 days, failed to explain the significance of seeing an orthopedic surgeon within a 7-10-day time frame or the risks associated with not doing so, and failed to document in his emergency room chart notes that Ms. Heikamp should be seen by an orthopedic surgeon within 7-10 days. Further, I am satisfied on a balance of probabilities that but for the first two breaches, Ms. Heikamp would not have suffered the poor outcome that she did.

[108] Judgment shall issue in favour of the plaintiffs for the agreed-upon amount of damages.

COSTS

[109] Costs are reserved. If the parties cannot come to an agreement on costs of the action, on or before February 18, 2022, counsel shall file written submissions in accordance with the following schedule: the plaintiffs shall serve and file their costs submission on or before March 4, 2022; the defendant shall serve and file responding submissions or before March 25, 2022; the plaintiffs may serve and file reply submissions, if any, on or before April 11, 2022 after which time I will determine the issue of costs based on the material filed.

[110] Counsel shall file their written submissions by sending them by email to the Superior Court of Justice trial coordinator in Kingston assigned to this matter.

Muszynski J.

Released: February 02, 2022

Heikamp v. Renfrew Victoria Hospital et al., 2022 ONSC 780

ONTARIO

SUPERIOR COURT OF JUSTICE

BETWEEN:

DIANNE HEIKAMP and DOUG TACKABERRY Plaintiffs

– and –

RENFREW VICTORIA HOSPITAL, DR. ROBERT DUGGAN and DR. GREG CAZA Defendants

REASONS FOR JUDGMENT

Muszynski J.

Released: February 2, 2022