Agreeing to an Undertaking was not Enough to Avoid a Caution where Family Physician Inappropriately Prescribed Narcotics and Kept Poor Records

A patient of a family physician had concerns about the medical care he received, specifically, that his doctor: prescribed inappropriate amounts or combinations of narcotic medications and failed to provide adequate monitoring for signs of drug side-effects or narcotic addiction.

The Health Professions Appeal and Review Board (the Board) confirmed the decision of the Inquiries, Complaints and Reports Committee (the Committee) of the College of Physicians and Surgeons of Ontario to accept an undertaking provided by the family physician and to require him to attend at the College to be cautioned in person.

The Committee

During its investigation, the Committee requested a report from an Independent Opinion Provider (IOP). The IOP’s report indicated that the physician failed to meet the standard of practice of the profession in his care of the patient. The physician’s documentation was sparse and multiple prescriptions were mentioned but not documented. Physical examinations were rarely performed. He also demonstrated a lack of knowledge, skill and judgment in multiple arenas with respect to opioid prescribing for the patient. Specifically, the physician failed to recognize the risk with this patient – the patient had a past history of drug and alcohol abuse, ongoing psychiatric issues, and admitted he abused or misused his medications.

While the physician denied prescribing inappropriate amounts of narcotics and denied that he failed to adequately monitor the patient, the physician provided the College with an undertaking that, among other things, he ceased to practice in Ontario in 2016 and would provide the College with 45 days notice should he intend to return to practice and he would provide proof that he participated in Continuing Professional Development.

The Committee noted the significance of an undertaking and expressed its satisfaction that the undertaking addressed its concerns in part. It decided to accept the physician’s undertaking, but also to caution him in person.

The Board

The physician requested that the Board review the Committee’s decision. The Board found the Committee’s investigation to be adequate and its decision to be reasonable.

The Board noted that the physician had accepted the IOP and Committee’s concerns with his practice. In a letter the physician wrote: “I accept [the IOP’s] criticisms of my management of [the patient’s] opioid prescriptions” and that “I have accepted that my opioid prescribing in both cases fell below the required standard. . .” Further, the physician had “a relevant and significant College history” with respect to complaints and had already previously completed specified continuing education or remediation programs with respect to prescribing narcotics and recordkeeping in 2011.

The Board concluded that while the physician “might disagree with the language of the Committee’s decision, there is nothing in the Record or advanced at the Review which could lead the Board to conclude that the Committee’s determinations were unreasonable.”


Despite the significance of an undertaking, the physician’s conduct also required an in-person caution which can carry serious consequences, as the fact and substance of the caution are published on the College’s public register.

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