Health Professions Review Board  
Suite 900, 747 Fort Street, Victoria, BC V8W 3E9  
CITATION: Complainant v. College of Physicians and Surgeons of British  
Columbia (No. 1), 2022 BCHPRB 4  
FILE NO.: HPRB-HPA-21-A051, HPRB-HPA-21-A052, HPRB-HPA-21-A053, HPRB-  
HPA-21-A054, HPRB-HPA-21-A055, HPRB-HPA-21-A056 Grouped File: HPRB-HPA-  
21-G007  
DATE: March 1, 2022  
In the matter of an application (the “Application”) under section 50.6 of the Health  
Professions Act, R.S.B.C. 1996, c. 183, (the “Act”) for review of a complaint disposition  
made by, or considered to be a disposition by, an inquiry committee  
BETWEEN:  
AND:  
The Complainant  
COMPLAINANT  
COLLEGE  
The College of Physicians and Surgeons of  
British Columbia  
AND:  
A Physician  
A Physician  
A Physician  
A Physician  
A Physician  
A Physician  
REGISTRANT 1  
REGISTRANT 2  
REGISTRANT 3  
REGISTRANT 4  
REGISTRANT 5  
REGISTRANT 6  
BEFORE:  
Brenda L. Edwards, Panel Chair  
REVIEW BOARD  
HEARING  
DATE:  
Conducted by way of written submissions closing  
on November 26, 2021  
APPEARING:  
For the Complainant:  
Aman Oberoi, Legal Counsel  
Harry Saini, Co-Counsel  
For the College:  
Lisa Fong, Q.C.  
For Registrant 1:  
Nevin Fishman, Legal Counsel  
James Heelan, Q.C.  
For Registrants 2-6:  
Emily Hole, Legal Counsel  
REVIEW OF INQUIRY COMMITTEE DISPOSITION SUMMARY:  
Stage 2 hearing of an application for review of an Inquiry Committee complaint  
disposition under s. 50.6 of the HPA Disposition Confirmed.  
The Complainant asked the Review Board to review the Inquiry Committee’s disposition  
of his complaints about six Registrants who were colleagues, supervisors, or  
management during his Provisional Registration as a psychiatrist at a BC health  
authority. The Complainant said that he raised the issue of workplace gossip with his  
supervisors, but two of his supervisors did not fully apprise him of the complaints, or  
initiate a prompt and fair investigation, which denied him fair process. The Complainant  
questioned whether the Registrants’ conduct indicated systemic racism in the health  
authority. The Inquiry Committee asked the College of Physicians and Surgeons of  
Alberta to investigate the complaint because it had a possible conflict of interest. On the  
basis of this investigation it concluded with criticism three Registrants, who did not seek  
substantiation of the allegations nor interview the Complainant as they should have.  
The Panel Chair noted that that the College of Physicians and Surgeons of Alberta  
conducted a protracted investigation, which included obtaining supervisor evaluation  
reports and interviews with key individuals. The Panel Chair was satisfied that the  
investigation was adequate: The Inquiry Committee had the key information that it  
needed to understand the allegations in context, to analyse the conduct of the  
Registrants, and arrive at a disposition.  
The transparency of the Final Disposition Report would have been improved had it  
indicated whether the Inquiry Committee reviewed and approved a draft of the report;  
and if the minutes showed whether the Committee had the Expectations Policy or the  
Code of Ethics before it. However, the Inquiry Committee’s explanation of the decision-  
making process to reach the outcome was sufficiently transparent and intelligible to be  
reasonable. There was both a factual basis in the investigative results, and a legal basis  
under s.33(6)(a) and (b) of the Act, for its disposition. The Inquiry Committee could not  
determine if the Registrants’ conduct was motivated by conscious or systemic racism,  
but recommended that the College provide better support for College-approved  
supervisors. It is reasonable to expect that the College and the Registration Committee  
will act promptly to ensure that College-approved supervisors are properly trained and  
supported in their role.  
DECISION  
I
INTRODUCTION AND PROCEDURAL BACKGROUND  
[1]  
On October 29, 2018, the College received complaints about the Registrants  
from the Complainant. In general, the Complainant expressed concerns regarding the  
conduct of the Registrants toward the Complainant while he was a provisional registrant  
of the College and sponsored by a health authority.  
[2]  
On December 11, 2018, the College asked the College of Physicians and  
Surgeons of Alberta (CPSA) to investigate and provided it with the complaints.  
[3]  
On December 1, 2020, the Complainant wrote the College. He alleged that the  
College and the CPSA had treated him in a discriminatory fashion and sought an  
explanation for the delay in concluding the investigation of his complaints.  
[4]  
On December 11, 2020, after the Complainant sought an update on the status of  
the investigation of his complaints, the College advised the Complainant and the  
Registrants that it was unable to meet the deadline for completing an investigation of  
the complaints as the CPSA was still investigating the matter. The College advised the  
Complainant of his right to seek a review of the investigation by the Review Board. The  
Complainant asked that the College suspend its investigation pending a decision by the  
Review Board.  
[5]  
On January 18, 2021, the Chair of the Review Board ordered (in part) that the  
College direct the CPSA to resume the investigation, complete its investigation as soon  
as possible, and expedite the report.  
[6]  
On February 10, 2021, the College wrote the Complainant, provided him with an  
investigative report prepared by the CPSA (the CPSA Investigation Report) dated  
January 20, 2021, and advised him of his opportunity to provide a response.  
[7]  
On April 13, 2021, the Inquiry Committee met and considered the complaints and  
the CPSA Investigation Report and decided to dispose of the complaints with criticism  
of some of the registrants (Registrant 1, Registrant 2 and Registrant 6) as provided for  
in s.33(6)(b) of the Act, and no criticism of the others (Registrant 3, Registrant 4 and  
Registrant 5) as provided for in s.33(6)(a) of the Act.  
[8]  
On April 27, 2021, College staff wrote the Complainant enclosing a “Final  
Disposition Report of the Inquiry Committee” dated April 13, 2021.  
[9]  
On May 17, 2021, legal counsel to the Complainant wrote the Review Board  
requesting “a new investigation” of the Complainant’s complaints. The Review Board  
accepted the correspondence as an indication that the Complainant was applying for a  
review of the Inquiry Committee’s disposition of each of his complaints.  
[10] After writing the parties (and receiving no objection to combining the six  
applications) on June 15, 2021, the Chair of the Review Board directed that the  
applications in files: HPRB-HPA-21-A051, HPRB-HPA-21-A052, HPRB-HPA-21-A053,  
HPRB-HPA-21-A054, HPRB-HPA-21-A055, and HPRB-HPA-21-A056 be combined  
under Review Board File No. HPRB-HPA-21-G007 (the Review). The Chair requested  
that the College provide its record of the investigation of the complaints including the  
Inquiry Committee’s disposition (the “Record).  
[11] On July 16, 2021, the College provided the Record to the Review Board.  
[12] On July 29, 2021, the Review Board wrote the parties enclosing a copy of the  
Record and directing the matter to Stage 1 of the review process (i.e., based solely on  
the Record and the Complainant’s submissions). The Review Board invited the  
Complainant to provide a written Statement of Points to supplement his application by  
August 26, 2021.  
[13] On August 26, 2021, the Complainant filed a Statement of Points and Form 11 (a  
list of information or evidence that he sought to add to the Record).  
[14] I was assigned to the Review as the Panel Chair on September 3, 2021.  
II  
THE STEPS IN MY REVIEW  
(A) Direction to Stage 2 of the Review Process  
[15] On September 20, 2021, I wrote the Parties advising them that, after reviewing  
the Record and the Complainant’s Application for Review, I was unable to conclude my  
review of the matter fairly and appropriately at Stage 1. I directed the matter to Stage 2  
of the review process (with submissions from the College and the Registrants and a  
final reply from the Complainant). I set a schedule for submissions.  
[16] I directed that the College and the Registrants provide the Review Board and the  
other parties with their written submissions by October 4, 2021. I further directed that  
the Complainant provide any reply to the submissions of the College and/or the  
Registrants by October 25, 2021. In addition, I invited the College to comment in its  
submissions on specific matters regarding the Record, the investigative process and the  
Disposition. I invited the Complainant to comment on my observation that the Form 11  
documents were duplicative of documents in the Record. I also sought clarity on  
whether the Form 11 documents had been provided to the CPSA investigators. Finally, I  
invited the Registrants to comment on two issues related to supervision of the  
Complainant.  
(B) Stage 2 Submissions from the Parties  
[17] On September 22, 2021, the College sought an extension of time within which to  
file its submissions. After canvassing the parties and receiving no objections, I granted  
the College’s request and revised the schedule for submissions.  
[18] On October 12, 2021, the College and the Registrants filed their written  
submissions including their Statements of Points.  
[19] On October 25, 2021, the Complainant’s counsel sought an extension of time  
within which to file his reply submissions citing his intention to provide a “fulsome  
response” and noting the “voluminous material in this matter.” The Registrants, through  
their respective counsel objected to the Complainant’s request and noted that the  
volume of the Record was immaterial to the Complainant’s response. The College’s  
counsel consented to the Complainant’s request.  
[20] On October 26, 2021, the Complainant’s counsel wrote the Review Board again  
stating that the volume of the Record was evidence of the “wrongdoing” of the  
Registrants and the College. He asserted that “this evidence was not adequately  
considered by the Inquiry Committee” and was “the basis of (his) appeal.” He further  
asserted that an “extensive examination of the Record” was required so that the issues  
before the Review Board could be “narrowed.”  
i. Further Direction to the Parties  
[21] On October 29, 2021, I wrote the parties acknowledging the Complainant’s  
request, the other parties’ responses and the further correspondence from the  
Complainant. I noted that the Complainant had applied under s.50.6 of the Act for a  
review of the Inquiry Committee’s disposition of his complaint. I stated that a review  
under the Act is not an “appeal,” neither is it a hearing de novo (i.e., a fresh hearing of  
the complaint). I observed that my jurisdiction is described in s.50.6(5) of the Act and  
that my role is limited to considering (a) the adequacy of the investigation, and (b) the  
reasonableness of the disposition. I reminded the parties that the Act provides that a  
review is a review on the record and that the Record was already before me as were the  
Complainant’s submissions.  
[22] On November 8, 2021, the Complainant filed his submissions in reply to the  
College and the Registrants’ submissions (the “Complainant’s Final Reply”). In his Final  
Reply, the Complainant identified what he saw as the issues before the Review Board.  
He described the issues as:  
(a) Does the College’s superintending of the practice of medicine include the  
superintending of registrants in the provisional class?  
(b) If so, is it the College’s responsibility to regulate the supervisors of a  
registrant in the provisional class to regulate and enforce adequate and  
minimum professional standards with a registrant in the provisional class  
prior to that person becoming a member of the College of Physicians and  
Surgeons of British Columbia?  
(c) If so, has the College fully satisfied its duty?  
[23] Further, in his submissions, the Complainant alleges that the College owes a  
fiduciary duty “to British Columbians and the wider public” to adequately superintend  
and regulate, which includes responsibility for the regulation of supervisors. The  
Complainant adds that the College failed to regulate his supervisors by allowing them to  
deny the Complainant procedural fairness. Alternatively, he argues that the College  
granted actual authority to the supervisors such that they were in an agency relationship  
with the College. In the further alternative, the Complainant submits that the College  
should have investigated alleged complaints against the Complainant in order to protect  
the public and should have considered the Registrants’ actions as professional  
misconduct and/or conduct unbecoming.  
ii. Requests from the College and the Registrants and response from the  
Complainant  
[24] On November 9, 2021, counsel to the College wrote the Review Board seeking  
leave to submit “a substantial sur-reply” and asserting that the Complainant’s “reply” to  
the College and the Registrants raised new factual and legal issues that should have  
been raised in his Stage 1 submissions. The College added that the Complainant had  
“split his case.”  
[25] Also on November 9, 2021, counsel to Registrants 2, 3, 4, 5, and 6 wrote the  
Review Board seeking the same opportunity as the College. Counsel to Registrant 1  
wrote the Review Board objecting to the Complainant’s “so-called Reply because it  
does not reply” and (but for the argument alleging “professional misconduct”), the  
Complainant’s submissions consisted of “new argument” that was not responsive to  
Registrant 1’s submissions of October 12, 2021. Registrant 1 submitted that the proper  
recourse for the Review Board was “to have no regard to the Complainant’s so-called  
Reply.”  
[26] Further on November 9, 2021, counsel to the Complainant wrote the Review  
Board in response to the other parties’ requests. He asserted that his Final Reply did  
not raise new legal and factual issues and was responsive to the written submissions of  
the other parties. He said that he had not split his case and that it would be “against  
proper recourse and the process set by the Review Board” to disregard his Final Reply.  
iii. Further directions at Stage 2  
[27] On November 12, 2021, I wrote the Parties acknowledging receipt of the  
Complainant’s Final Reply submissions dated November 8, 2021. I noted that the  
Complainant identified what he saw as issues in the review (i.e., (a) to (c) in para 22,  
above). I further noted that the Complainant’s Final Reply raised further issues relating  
to the College and/or the Registrants (argued in the alternative) including issues of 1)  
fiduciary duties; 2) agency relationship and vicarious liability; 3) a duty to establish  
professional standards / legislative duty; 4) professional misconduct; 5) conduct  
unbecoming; and 6) acting in bad faith.  
[28] In the circumstances, I directed that the College and the Registrants could file  
further submissions (not to exceed 10 pages) addressing the legal issues raised by the  
Complainant in his Final Reply as I had identified them. I further directed that the  
Complainant could file a final submission (not to exceed 10 pages) that was to be  
responsive to the College’s and the Registrants’ further submissions. I set a schedule  
for these submissions closing on November 26, 2021. Finally, I directed that after  
November 26, 2021, submissions on this review would be closed, I would not accept  
any further submissions, and I would begin to deliberate on the matter.  
iv. Further submissions from the Parties  
[29] On November 19, 2021, the College and the Registrants filed further  
submissions in response to the Complainant’s Final Reply.  
[30] On November 26, 2021, the Complainant filed further submissions and a Form  
11 seeking to add documents to the Record. He alleged that he was only able to locate  
the documents on November 24, 2021, following a review of a disclosure he had  
received following an “FOI request.” The Complainant asked that the Review Board give  
the College and the Registrants the opportunity to respond to the additional documents  
with a final submission offered to the Complainant.  
v. Objection following the close of submissions  
[31] On November 29, 2021, counsel to Registrant 1 wrote the Review Board  
objecting to the admission of the Form 11 documents submitted by the Complainant on  
November 26, 2021. Further, Counsel to Registrants 2, 3, 4, 5, and 6 emailed the  
Review Board objecting to the admission of the additional documents and noting that  
the Complainant had been in possession of the documents since April 2016 and could  
have provided them with his initial Form 11 on August 26, 2021.  
(C) Summary of Material before the Review Board on this Review  
[32] As is evident by the steps that I have identified above, the review process has  
been protracted, my directions and clarification of my mandate have not always been  
noted, and as a result the parties have provided me with the following material for  
review:  
(a) the Record (2,939 pages) including the 41-page CPSA Investigation Report;  
(b) the Complainant’s submissions (totaling 105 pages) including: an Application  
for Review letter dated May 17, 2021 (14 pages), Statement of Points (nine  
pages); Final Reply to College dated November 8, 2021 (27 pages); Final  
Reply to Registrants 2, 3, 4, 5, and 6 dated November 8, 2021 (22 pages);  
Final Reply to Registrant 1 dated November 8, 2021 (21 pages) and  
Response to Panel Chair’s questions (two pages); Further submissions dated  
November 26, 2021 (10 pages);  
(c) the Complainant’s first Form 11 dated August 26, 2021, appending nine  
documents;  
(d) the Complainant’s second Form 11 (unsigned and undated but appended to  
his further submissions of November 26, 2021 (appending two emails and  
attachments);  
(e) the College’s submissions (totaling 47 pages) including a Statement of  
Points, dated October 12, 2021 (40 pages); and Sur-reply dated November  
18, 2021 (seven pages);  
(f) submissions filed on behalf of Registrant 1 (totaling 28 pages) including a  
Statement of Points dated October 12, 2021 (18 pages); and Sur-reply dated  
November 19, 2021 (eight pages); and a letter dated November 29, 2021,  
objecting to admission of the documents listed in the Complainant’s second  
Form 11 (two pages); and  
(g) submissions on behalf of Registrant 2, 3, 4, 5 and 6 (totaling 50 pages and  
including a Statement of Points (39 pages); Sur-Reply dated November 19,  
2021 (11 pages); and an email dated November 29, 2021, objecting to  
admission of the documents listed in the Complainant’s second Form, 11  
(one page).  
[33] I will discuss the Form 11 applications to add documents to the Record, and the  
objections to them, later in this decision.  
[34] I have carefully reviewed the entirety of the material filed in this Review, whether  
or not I reference it in this Decision.  
[35] I will begin my review with a consideration of the complaint that the Complainant  
filed with the College. I will then consider the steps that the College took to investigate  
the complaint in light of the goals of the investigation and determine whether the  
investigation was adequate. Then, I will consider the Inquiry Committee’s disposition of  
the complaint and whether that disposition is reasonable based on the facts and the  
law. Finally, I will conclude the review by determining what action I am to take, and what  
order I will make based on my review.  
III  
COMPLAINT AND INVESTIGATION  
(A) The Parties to the Complaint  
[36] The descriptor of the parties that follows is based on their status at the time of  
the complaints.  
[37] The Complainant is a foreign-trained psychiatrist who was provisionally licensed  
by the College, sponsored by a health authority (the Health Authority) and subject to  
supervision by Registrants 1, 2 and 5.  
[38] Registrant 1 was a psychiatrist based in the same community as the  
Complainant. She was the Complainant’s first co-supervisor (with Registrant 2) when he  
was sponsored by the Health Authority (2016 to 2017).  
[39] Registrant 2 was a family physician and was a co-supervisor of the Complainant  
(first with Registrant 1 and later with Registrant 5) during the time the Complainant was  
sponsored by the Health Authority.  
[40] Registrant 3 is a physician and was a senior executive at the Health Authority  
that sponsored the Complainant.  
[41] Registrant 4 was a family physician working in the same city as, and sharing  
patients with, the Complainant during the time he was sponsored by the Health  
Authority.  
[42] Registrant 5 was a psychiatrist based in a different community than the  
Complainant. He was a co-supervisor (with Registrant 2) for the Complainant (2017 to  
2018).  
[43] Registrant 6 was the Medical Director of a service-delivery area of the Health  
Authority during the time that the Registrant was sponsored by the Health Authority.  
(B) The Complaint  
[44] The Complainant appended a nine-page letter to the complaint forms that he filed  
with the College about the Registrants.  
[45] The complaints about Registrant 1, Registrant 2 and Registrant 5 are related to  
their supervision of the Complainant and reporting of same to the College.  
[46] The complaints about Registrant 6 are related to her conduct toward the  
Complainant in her role as the Medical Director of the Health Authority that sponsored  
the Complainant.  
[47] The complaints about Registrant 3 relate to his conduct toward the Complainant  
in his role as a senior executive at the health authority that sponsored the Complainant.  
[48] The complaints about Registrant 4 are related to her conduct toward the  
Complainant while they worked as colleagues in the same community within the Health  
Authority.  
[49] Specifically, the Complainant complained that:  
(a) Registrant 1 made a number of unfair and unsubstantiated allegations of  
serious impropriety against him (hugging staff members, engaging in  
unwanted touching of patients, needing psychiatric help, failing to engage in  
supervision with her, being unaware of the need to monitor patients for  
medical illness and side effects of medication).  
Further, Registrant 1 failed to provide the Complainant with details about the  
alleged improprieties.  
Still further, Registrant 1 reported that the Complainant ought to be  
chaperoned during patient encounters, should be practising at a teaching  
facility and under constant supervision, his charts should be reviewed  
weekly. However, at the same time, Registrant 1 was sending the  
Complainant texts expressing support for him and concern for his welfare.  
(b) Registrant 2 sent a supervision report to the College stating that the  
Complainant had acted unethically toward his colleagues and had made  
allegations toward them. Registrant 2 did not discuss his concerns with the  
Complainant as required by the Health Authority.  
(c) Registrant 3 failed to give the Complainant sufficient notice when ending his  
sponsorship and asked the Complainant to remove his clinic files and work  
on them from a hospital room due to concerns that other staff were  
uncomfortable with the Complainant working from the clinic over a weekend.  
Later, Registrant 3 gave the Registrant permission to continue to work from  
the clinic over the weekend.  
(d) Registrant 4 solicited a patient’s daughter to submit a complaint about the  
Complainant regarding an issue that the Complainant had resolved a year  
and a half prior. Registrant 4 included her name on the complaint letter.  
Registrant 4 also made a racial slur against the Complainant.  
(e) Registrant 5 accused the Complainant of watching YouTube videos during  
meetings, filming a medical student without their consent, and inviting a  
patient to meet with him socially.  
Further, Registrant 5 ignored information from one of the Complainant’s  
coworkers that staff were spreading unfounded rumours about the  
Complainant. Registrant 5 did not include this information in his report to the  
College nor did he tell the Complainant.  
Still further, Registrant 5 told the Complainant that if it came to a matter  
between them, he would support Registrant 1.  
Finally, Registrant 5 did not inform the Complainant or his legal counsel that  
he was no longer willing to supervise the Complainant until the last week  
before his sponsorship was to end.  
(f) Registrant 6 did not permit the Complainant to send a memo to other  
physicians informing them of his concern regarding mixing a certain  
medication with methadone.  
Further, Registrant 6 told the Complainant that she would support Registrant  
1 over him when the Complainant objected to Registrant 1 making  
unsubstantiated allegations against him. She also told the Complainant that  
nobody had to provide evidence when reporting issues about the  
Complainant during their supervision of him. In addition, Registrant 6 made  
an unsupported allegation that the Complainant had breached a patient’s  
confidentiality.  
Still further, Registrant 6 did not inform the Complainant that she was no  
longer allowing him to work with medical students. She also asked Registrant  
4 to solicit a patient’s daughter to complain about the Complainant.  
The Complainant stated that he felt that his supervision was being used as a  
tool for bullying and harassment instead of being an educational and learning  
experience.  
(C) The Investigation of the Complaint  
i. Steps in the Investigation of the complaint  
[50] On December 11, 2018, the College wrote the Complainant acknowledging his  
complaint and advising him that the “adjudication” of the matter would be completed by  
the CPSA. The College explained that this was because two of the physicians named in  
the complaint were affiliated with the Complainant’s former sponsor (the Health  
Authority) and three served as supervisors reporting to the College. The College further  
advised the Complainant that it would provide a copy of the complaint to the CPSA and  
that a CPSA investigator might contact him directly. The College stressed that “(t)he  
entire investigation will be done by the CPSA, at arms-length from (the College).”  
[51] The College further advised the Complainant that the CPSA would “adjudicate  
the matter and send us a report containing its decision.” The College noted that the  
report would then be submitted to the Inquiry Committee “for its endorsement.” The  
College added that if the Inquiry Committee endorsed a report that contained regulatory  
criticism, it would consider any CPSA recommendations for remedial or disciplinary  
action.  
[52] Also on December 11, 2018, the College wrote an Assistant Registrar and  
Complaints Director, CPSA, “on behalf of the Inquiry Committee” thanking him, in  
advance, for his willingness to have the CPSA “conduct this complaint review” for the  
College and enclosing the Complainant’s complaint filed with the College on October  
29, 2018.  
[53] The Investigation Report indicates that the College collected and provided the  
CPSA with the following documentation:  
(a) the Complainant’s letter of complaint dated October 24, 2018;  
(b) the Registrants’ responses to the complaints (March 27, 2019, to April 16,  
2019); and  
(c) Supervisor Evaluation Reports dated June 21, 2016, April 7, 2017, April 20,  
2017, November 23, 2017, and June 25, 2018.  
[54] The CPSA’s investigation included interviewing:  
(a) the Complainant on October 3, 2019;  
(b) five staff (A, B, C, D, and E) who had been employed in the Health Authority  
at the relevant time and who had been identified in either the Complainant’s  
complaints or the Registrants’ responses to the complaints as witnesses  
(July 8, 2020, to July 21, 2020). The CPSA investigators also reviewed the  
Canadian Medical Association’s Code of Ethics (2004).  
[55] The CPSA attempted to interview a sixth staff (F) in the Health Authority, but she  
did not respond to three requests to be interviewed. The CPSA considered a signed  
letter of support for the Complainant from staff member F dated June 20, 2018, The  
CPSA also reached out to two further individuals (G and H) identified by the  
Complainant as having relevant information. Neither responded to the CPSA’s interview  
requests.  
(D) Investigatory Results as set out in the CPSA Investigation Report  
i. Registrant 1  
[56] Registrant 1 responded to the complaint by stating that she was appointed by the  
College to supervise the Complainant in June 2016. She stated that she was asked by  
the College to submit a report confirming that the Complainant was “practicing to the  
standard that one would expect of a specialist in Psychiatry in British Columbia.”  
Registrant 1 further stated that she provided two supervisory reports, as requested by  
the College (July 22, 2016 and April 10, 2017) in which she noted three concerns: (1)  
diagnoses were not given in a generally acceptable manner; (2) patients who were  
taking (certain prescribed drugs) were not being monitored with laboratory work which is  
standard of care; (3) boundary issues had been identified by staff who had observed the  
Complainant touching a person when requested not to do so. Further, Registrant 1 was  
unable to commit to more frequent supervisory meetings. Finally, Registrant 1 noted  
that her reports were based on direct chart reviews and feedback from multiple staff  
members. Registrant 1 noted that the Complainant acknowledged two areas of the  
concern as valid.  
ii. Registrant 2  
[57] Registrant 2 responded to the complaint by stating that he provided a (second)  
supervisor’s report to the College regarding the Complainant in June 2018. Registrant 2  
stated that his report was based on a review of consultation reports of the  
Complainant’s patients, interviews of patients regarding their experiences, interviews of  
staff members, and conversations with Registrant 5, who was the Complainant’s  
primary supervisor at the time. Registrant 2 noted that he had a “constructive and  
amicable professional relationship” with the Complainant prior to filing the report.  
Registrant 2 noted, in hindsight, that it would have been better had he met with the  
Complainant to discuss his report, however, he believes that he fulfilled the College’s  
expectations.  
iii. Registrant 3  
[58] Registrant 3 responded to the complaint by stating that he wrote the Complainant  
a letter on July 10, 2018, on behalf of the Health Authority. In the letter, Registrant 3  
notified the Complainant that, as of September 30, 2018, the Health Authority would no  
longer sponsor the Complainant as a provisionally registered psychiatrist. In his letter,  
Registrant 3 noted that the Complainant had demonstrated in recent communication  
that he was unable to accept feedback in a constructive manner and the Health  
Authority would not ask any physician to provide supervision of him. Further, the Health  
Authority would extend its sponsorship under certain conditions, but the Complainant  
would have to find an acceptable supervisor. Registrant 3 also noted that he met with  
the Complainant on September 26, 2018, to hear “his side of the story.” On September  
27, 2018, he asked the Complainant to move his office over the upcoming weekend as  
staff had raised concerns about the Complainant’s allegedly threatening behaviour.  
After the Complainant assured Registrant 3 that he would not harm anyone, Registrant  
3 permitted the Complainant to work from his former clinic over the weekend.  
iv. Registrant 4  
[59] Registrant 4 responded to the complaint. She reported working with the  
Complainant for almost three years. During that time, she reported several concerns to  
his supervisors regarding patient care or conduct. She identified concerns including  
religious discussion and the provision of religious literature; an incident of prescription  
dosing that likely resulted in a motor vehicle accident; issues around delayed records;  
and a pattern of many patients who refused to see the Complainant. Registrant 4 stated  
that on a few occasions patients reported that they had gone off psychiatric medications  
or weaned their doses down, causing deterioration in their mental health, rather than  
see the Complainant. One patient’s daughter reported her concerns to Registrant 4 who  
advised the Complainant’s supervisor and the College.  
[60] Registrant 4 also provided information to a patient on how to report concerns to  
the College. She denied helping to compose, sign, or add her name to the complaint  
letter. She further denied contacting Registrant 6 about the complaint letter. Finally,  
Registrant 4 denied making a “racial slur” against the Complainant and stated that this  
would be “completely out of keeping with [her] moral character and deeply held beliefs.”  
v. Registrant 5  
[61] Registrant 5 responded to the complaint by stating that he agreed to take over  
supervision of the Complainant from Registrant 1. He noted that he reported information  
to the College, evaluated the Complainant, observed the Complainant’s interactions  
with staff and clients. Registrant 5 stated that he was aware that the Complainant was  
concerned about rumors concerning him, and Registrant 5 tried to keep that in mind  
when he was collecting information. Registrant 5 denied making “serious accusations  
about [the Complainant] during a supervision session.” They discussed information that  
Registrant 5 had received as part of a “360 degree” review. Registrant 5 asserted that  
he made a concerted effort to explain that much of the information was “hearsay” and it  
was not an accusation of wrongdoing.  
[62] Registrant 5 stated that he reminded the Complainant that he was acting in the  
role of supervisor on behalf of the College. Registrant 5 further stated that he made  
notes during the conversation and referred to his notes when completing his supervision  
report. He also discussed with Registrant 1 her concerns and experiences in  
supervising the Complainant. Registrant 5 noted that the Complainant was “clearly very  
upset about the supervision he had with [Registrant 1], and it was a topic that [the  
Complainant] frequently brought up.”  
vi. Registrant 6  
[63] Registrant 6 responded to the complaint by stating that as part of her role with  
the Health Authority she was instrumental in recruiting the Complainant from abroad.  
She stated that there were no physicians in the community who met all the  
requirements of an acceptable supervisor, but the College agreed to allow dual  
supervision of the Complainant by a family physician (Registrant 2) and a psychiatrist  
(Registrant 1) commencing in spring 2016.  
[64] Registrant 6 noted that both supervisors met in April 2017 which resulted in a  
“complete disagreement about the feedback.” She reported that she communicated  
frequently with the Complainant, by email and met with him, in person, at least twice.  
Registrant 6 described the Complainant as being “unable to shift his focus from arguing  
about the feedback and verbally attacking the people involved to his own role and what  
he could do about these issues.” Registrant 6 stated that, during one of the in-person  
meetings in April 2017, the Complainant “verbally attacked [Registrant 1] and attributed  
malicious intent to her actions.” Registrant 6 explained that whether the accusations  
were true or not, his response “was doing him harm…almost more than the accusations  
themselves.” The Complainant then resigned with a notice period of March to June  
2018.  
[65] Registrant 6 stated that she did not promise to investigate the validity of the  
feedback provided to the Complainant by Registrant 1. The patient complaint was being  
handled by the College and the Health Authority had not received any incident reports  
from staff.  
[66] Registrant 6 noted that after Registrant 5 became the Complainant’s primary  
supervisor, three “very concerning” events were brought to her attention: (1) the  
Complainant discussed Registrant 1 and her unfair supervision of him at a staff  
meeting; (2) after a supervisory feedback meeting, the Complainant “went up and down  
the halls knocking on doors…asking who said these things about him;” and 3) the  
Complainant spoke to a patient after learning that the patient had declined an invitation  
to complain about the Complainant. The Complainant asked the patient to put the  
details in writing, which the Complainant typed up. The Complainant then asked the  
patient’s case manager to review the document and then all three signed it.  
[67] Registrant 6 stated that she discussed the three events with the Complainant.  
She explained that gathering information from other team members was a “required part  
of the supervisor’s role and that to her mind, proof…was not the most important thing.”  
Registrant 6 made clear to the Complainant that what occurred with the patient was a  
boundary violation and was unacceptable. Registrant 6 added that after one of her  
meetings with the Complainant, he began sending emails to managers expressing his  
concern about others’ behaviours.  
[68] Registrant 6 further noted that she had concluded that the Complainant had “so  
much stress going on for him” that she asked the site coordinator for the university to  
stop scheduling students with the Complainant. She later apologized to the Complainant  
for not notifying him and explained her reasons for her decision.  
[69] Registrant 6 also noted that in February 2018, the Complainant reapplied for the  
job that he had resigned from. She gave him a written offer with an addendum of  
expectations which he later signed. Subsequently, Registrant 5 reported to Registrant 6  
that the Complainant had been verbally abusive in comments aimed at Registrant 1 and  
other team members who had provided Registrant 5 with feedback about the  
Complainant. The comments included “imitations [sic] of retaliation, and accusations of  
drug use by Registrant 1 and other team members.”  
[70] Registrant 6 reported that the Complainant sent a “very negative” email to her  
and others about Registrant 1 and other unspecified people who he believed were out  
to get him. Further on June 15, 2018, the Complainant sent a “very odd email” to most  
of the staff at his workplace which triggered the need for managers to support many of  
the staff. During this time, Registrant 6 noted that she was also receiving  
communications from Registrant 1 who was concerned for her own safety.  
[71] Registrant 6 further reported that after Registrant 5 and Registrant 6 resigned as  
supervisors and the Complainant lodged complaints to the College about Registrants 1,  
2, 5 and 6, the Health Authority decided that it could not “in good conscience” ask  
another member of its medical staff to supervise the Complainant. Registrant 6 reported  
that she later received a report from a case manager that a patient was requesting a  
transfer to another psychiatrist after reporting that the Complainant arrived late for their  
appointment and swore while discussing his concerns of being bullied and harassed on  
religious and cultural grounds by his coworkers. The patient further alleged that the  
Complainant abruptly ended the appointment after he wrote a prescription and said he  
had to speak with his lawyer. Registrant 6 asked the Complainant to discuss the  
encounter, but he declined unless he had a lawyer present. Registrant 6 emailed the  
Complainant with the Health Authority’s expectations of the Complainant. He did not  
acknowledge the email.  
[72] After the Health Authority terminated (and then extended) its sponsorship of the  
Complainant, College staff spoke with Registrant 6 and advised her that the College  
would not allow any further exceptions with respect to supervisors (i.e., having  
supervision by two physicians, one of whom was, like the Complainant, provisionally  
registered).  
[73] Registrant 6 further reported that in October 2018, the Health Authority was  
required to respond to a request for information about the Complainant’s situation from  
the Ministry of Health. Further, Registrant 6 was the subject of a Worksafe BC complaint  
for bullying and harassing the Complainant. Registrant 6 advised that the investigation  
“led to no findings supporting bullying or harassment of [the Complainant].”  
vii. Supervisory Reports  
[74] The Investigation Report summarized the content of each of the five supervisory  
reports that the Complainant’s supervisors filed with the College during the time that he  
was sponsored by the Health Authority. Overall comments were noted followed by detail  
of the ratings offered by category.  
[75] In his first report dated June 21, 2016, Registrant 2 noted no concerns regarding  
the Complainant. In his second report dated April 20, 2017, Registrant 2 stated that the  
Complainant was working well with the multi-disciplinary team and was well-liked  
among colleagues. He stated that no concerns were reported by any patients who  
Registrant 2 had referred to the Complainant. In his written comments, Registrant 2  
noted there were delays in receiving consult reports, but that was improving. He also  
noted that DSM V (diagnostic) summaries were not regularly stated in initial consult  
reports. In his third and final report dated June 25, 2018, Registrant 2 first indicated that  
the Complainant met the standard expected of a specialist in psychiatry, in British  
Columbia. Registrant 2 then noted that after speaking with Registrant 1 and Registrant  
5 and the Health Authority, he had learned that the Complainant had not acted in an  
ethical and professional manner with colleagues, other members of the health care  
team, and patients. In his written comments, Registrant 2 indicated that Registrants 1  
and 5 reported that the Complainant was struggling to receive feedback regarding  
ethical behaviour and professionalism. Further, the Complainant was said to have  
responded to feedback in an angry and defensive manner and as having accused  
multiple co-workers of false allegations. Registrant 2 further reported that he was  
informed that the Complainant had threatened retaliation against his co-workers.  
[76] In her only report to the College dated April 10, 2017, Registrant 1 stated that the  
Complainant was an “asset to the community” and “with mentoring and support would  
make a strong psychiatrist.” She reported that colleagues and peers described the  
Complainant as pleasant, flexible, accommodating, and easy to get along with.  
Registrant 1 noted issues of concern as diagnostic formulation, organic workup, and  
“boundaries.” She stated that she and the Complainant had discussed the issues. She  
also noted that the Complainant struggled to produce timely written reports but was  
open to feedback and willing to consider change.  
[77] In his only report to the College dated November 23, 2017, Registrant 5 noted no  
concerns and observed that the Complainant was continuing to work toward improving  
his practice.  
viii. Interviews of witnesses  
[78] The Investigation Report noted that all witnesses, for the most part, reported that  
the Complainant got along well with staff and patients. He was described as  
approachable, easy to talk to, and open to feedback. The witnesses described the work  
environment, however, as “toxic,” with a lot of negative rumor-spreading and gossip,  
most of which was directed at the Complainant. Two individuals were identified as  
having personal issues with the Complainant and as being “out to get him.”  
[79] One witness recalled that Registrant 1 called a meeting with all staff, including  
the Complainant, and said that there had been several complaints about the  
Complainant for inappropriate behaviour. The witness had the impression that this was  
the first the Complainant was hearing of the matter. The witness felt the meeting was  
poorly handled and without resolution. The witness reported that the talk behind the  
Complainant’s back had nothing to do with his practice as a physician. Another witness  
reported that on her first day of work the Complainant addressed all staff at a meeting  
about the rumors. She described the meeting as uncomfortable but expressed empathy  
for the Complainant. Another witness wrote that she told Registrant 5 of the disparaging  
comments and negative gossip being directed to the Complainant by staff who, when  
confronted, were not able to provide any details in support of their comments.  
ix. Findings  
[80] In its report, the CPSA investigators made the following findings with respect to  
each of the Registrants:  
1.  
Registrant 1 reported that she had discussions with the Complainant about  
boundary issues but when the Complainant denied the allegations and asked that the  
matter be looked into, Registrant 1 refused. The CPSA investigators found that “(a)s  
such, [the Complainant] appears to have been denied fair process regarding an alleged  
boundary violation.” Further, Registrant 1 did not mention in her supervisory report to the  
College (April 7, 2017) or in her discussions with Registrant 2 and Registrant 5 that she  
had raised the issue of staff speaking unfavorably about the Complainant at a staff  
meeting.  
2.  
The CPSA investigators found that Registrant 2 reported no concerns with the  
Complainant’s practice in his first two reports. He reported that the Complainant was  
well-liked and worked well with the team. In his third report, however, Registrant 2  
reported concerns that Registrant 1 and Registrant 5 expressed about ethical  
boundaries but provided no details or the Complainant’s denial of same. Registrant 2  
also reported that the Complainant struggled to accept feedback about his ethical  
behaviour and professionalism. The CPSA investigators concluded that the “evidence  
supports that while [the Complainant] continued to reject reports of ethical concerns, he  
readily accepted all other feedback and incorporated [it] (sic) into his practice.” The  
CPSA investigators also found that “(a)s such, it appears that [Registrant 2]’s reporting  
of serious behavioral concerns was unbalanced and possibly unfair.”  
3.  
The CPSA investigators found that Registrant 3 acknowledged that he asked the  
Complainant to take files from the clinic to the hospital over a weekend. Further the  
CPSA investigators noted that Registrant 3 stated that he did so after staff members  
expressed concern over their safety, however, he did not provide any evidence of  
specific concerns by specific staff members who might have occasion to go into the  
clinic on the weekend.  
4.  
The CPSA investigators found that Registrant 4 provided an opposing opinion to  
that offered by the Complainant regarding whether or not Registrant 4 said that she  
would like to meet the Complainant’s “[alternate ethnic group] wife.” The CPSA  
investigators observed that no objective evidence about Registrant 4’s exact words or  
tone was available. They further observed that Registrant 4 denied the allegation that  
she solicited a patient’s daughter to complain about the Complainant. She reported  
informing the individual that it would best be dealt with by the College and denied adding  
her name to the complaint. The CPSA investigators found that “(n)o independent  
evidence” had been provided to the investigators to support the allegations against  
Registrant 4.  
5.  
The CPSA investigators found that Registrant 6 provided an opposing narrative  
to the Complainant about Registrant 6’s statements regarding Registrant 1’s intent in  
reporting ethical concerns without details of same. The CPSA investigators observed  
that there was no independent witness to the conversation, and it could not corroborate  
either version. They further observed that Registrant 6 acknowledged telling the  
Complainant that his reaction was worse than the boundary issues themselves. The  
CPSA investigators found that this “minimized the significance of an allegation of  
boundary crossing by a psychiatrist.” They also found that the Complainant “appears to  
have been denied fair process in attempts to address an allegation of unprofessional  
conduct that would be considered particularly grievous for a psychiatrist.” The CPSA  
investigators observed that Registrant 6 and the Complainant provided opposing  
evidence regarding whether or not she asked Registrant 4 to solicit a complaint from a  
patient’s daughter. The CPSA investigators found that there was no independent  
evidence to corroborate either version.  
(E) Further steps in the Investigation  
[81] On February 10, 2021, the College provided the CPSA Investigation Report to  
the Complainant and the Registrants. Counsel for the College provided an additional  
cover letter to the Investigation Report, which noted that the Act does not require that  
the College seek the Complainant’s response to an investigation but, as he had  
expressed a desire to do so, he would be given until February 26, 2021, to provide any  
response. Complainant’s counsel sought disclosure of the underlying investigative  
materials and on February 18, 2021, the College provided him with the investigatory  
material that the CPSA had sent to the College. On February 24, 2021, the Complainant  
asked for an extension of time to provide his response to the Investigation Report.  
[82] From March 1 to March 5, 2021, after being granted an extension of time, the  
Complainant sent a series of emails to the College’s legal counsel providing his  
comments regarding each of the Registrants’ responses to the complaint. On March 8,  
2021, College counsel forwarded the Complainant’s comments to the Registrants.  
[83] On March 24 and March 25, 2021, the Registrants wrote the College responding  
to the Complainant’s comments.  
[84] Counsel to Registrant 2, Registrant 3, Registrant 4, Registrant 5, and Registrant  
6 noted that the investigation did not demonstrate any unprofessional conduct or  
conduct unbecoming on the part of these registrants. At worst, if the CPSA  
investigators’ conclusions were to be accepted (which they assert should not occur),  
some of these registrants engaged in a supervisory and review process that was  
considered to be “unbalanced” or “unfair.” Counsel noted that what the investigation  
appeared to be missing was the “clear evidence” that the Complainant did not respond  
well to criticism and engaged in conduct that was unprofessional - conduct that they  
assert continued to present. These registrants provided letters for the Inquiry  
Committee’s consideration in which they stood by their original responses to the  
complaint and disagreed with the CPSA investigators’ findings. Registrant 2 strongly  
objected to the CPSA’s conclusion that his reporting of the concerns about the  
Complainant was “unbalanced” and “unfair.”  
[85] Counsel to Registrant 1 advised the College that she harbored no malice toward  
the Complainant. Counsel noted that in his email of March 1, 2021, about Registrant 1,  
the Complainant made an “unacceptable threat” to the physical, emotional and/or  
professional well-being of Registrant 1 by stating that he “will not spare this woman.”  
Counsel asked that this matter be brought to the attention of the College. Registrant 1  
included in her response an email dated April 12, 2016, which she had received from  
the College attaching a document entitled, “Expectations of Supervisors for Provisional  
Registrants” (the “Expectations Policy). Registrant 1 noted that in the email, the  
College instructed her to document any concerns that she might have in her supervisory  
report with the source of the information used to evaluate the Complainant being left to  
her discretion.  
[86] On April 7, 2021, the Complainant emailed College counsel with his “final  
comments” about the Registrants.  
[87] On April 13, 2021, Panel C of the Inquiry Committee met to consider the  
complaint and the results of the investigation, then arrive at a decision as to how to  
dispose of the matter.  
IV  
DISPOSITION  
[88] The Inquiry Committee met on April 13, 2021. The Record includes minutes of  
that meeting (the Minutes”). The Minutes reflect the Inquiry Committee’s consideration  
of the allegations against the Registrants. The Minutes conclude with a direction to  
Registrar staff to send concluding correspondence to the Complainant and Registrants.  
Further, the Inquiry Committee stated:  
It is directed that this decision be communicated via correspondence, with criticism of  
Registrant 1, 2, and 6 pursuant to the Act s. 33(6)(b) but no formal criticism of  
Registrants 5, 3 and 4.  
[89] On April 27, 2021, the external legal counsel for the College wrote the  
Complainant advising him that the Inquiry Committee had concluded the complaints  
against Registrant 1, Registrant 2 and Registrant 6 under s.33(6)(b) of the Act, and had  
concluded the complaints against Registrant 5, Registrant 3 and Registrant 4 under  
s.33(6)(a) of the Act. The letter also stated that counsel was enclosing “a copy of the  
Committee’s disposition.” The document that was attached to the external legal  
counsel’s letter was a 6-page document entitled, “Final Disposition Report of the Inquiry  
Committee,” dated April 13, 2021, that was authored by an internal legal counsel to the  
College. The Minutes do not record a direction to legal counsel to prepare such a report,  
nor is there any indication in the Inquiry Committee’s minutes of its subsequent meeting  
dated June 8, 2021, that the Committee reviewed a draft of the report or endorsed the  
Final Disposition Report as representative of its deliberations and decision to dispose of  
the complaints as it did.  
[90] The Final Disposition Report is more expansive than the Minutes. However, as I  
am not satisfied that the Final Disposition Report reflects the Inquiry Committee’s  
discussion and conclusions with respect to the complaints, I will refer to the Inquiry  
Committee Minutes as the disposition.  
(A) The disposition as per the Inquiry Committee Minutes, April 13, 2021  
[91] The Minutes begin with a bulleted list. There is no explanation of the list, but I  
infer that it is meant to reflect the material that was collected by the College and put  
before the Inquiry Committee. The list consists of 1) the letter of complaint(s) dated  
October 24, 2018; 2) responses to the complaint from each of the Registrants; 3)  
Supervisor Evaluation Reports dated June 21, 2016; April 7, April 20, and November  
23, 2017; and June 25, 2018; 4) an email dated March 26, 2021 from the Complainant  
to outside legal counsel to the College; 5) a letter from the College’s external legal  
counsel to the Complainant, dated March 30, 2021; and 6) the Complainant’s 29-page  
supplemental response to the CPSA Investigation Report, dated April 5, 2021.  
[92] The documented list in the Minutes does not include the CPSA Investigation  
Report. It was not clear to me from the Record whether the Inquiry Committee had the  
CPSA Investigation Report before it or whether it was merely advised of the CPSA’s  
findings by staff (CPSA findings are referenced in the Minutes). I asked the College  
about the matter when directing the review to Stage 2. In her submissions, College  
counsel advised me that the CPSA Investigation Report was before the Inquiry  
Committee as one of sixty appendices to a (privileged) memorandum prepared by  
counsel to the College for presentation to the Inquiry Committee. College counsel could  
not say why the memorandum and appendices were not listed as having been put  
before the Inquiry Committee.  
[93] The Minutes then discuss the complaint before them under several headings:  
“Parties,” “Issues,” “Committee Discussion” and “Committee Direction.”  
i. Parties  
[94] Under this heading, the Inquiry Committee describes the issues of complaint  
about Registrant 1, Registrant 2, and Registrant 5 as “related to their supervision of [the  
Complainant] and reporting of same to the College” whereas the issues of complaint  
about Registrant 6 are “related to her conduct toward [the Complainant] in her role as  
Medical Director of [the Health Authority].” Further, the Inquiry Committee described the  
issues of complaint about Registrant 3 as “related to his conduct toward [the  
Complainant] in his role as [a senior executive] at [the Health Authority].” Finally, the  
Inquiry Committee described the issues of complaint about Registrant 4 as “related to  
her conduct toward [the Complainant] while they worked together in [the community].”  
[95] The Minutes add that “(f)or details of complaint, please refer to documents listed  
above (see agenda package, item 8.7).No other documents are referenced.  
ii. Issues  
[96] Under this heading, the Minutes reflect that the Inquiry Committee considered the  
issues for its consideration were related to the Registrants’ “(c)onduct, discrimination,  
(and) professionalism.”  
iii. Committee discussion  
[97] The Minutes then set out the Inquiry Committee’s discussion of the matter. The  
Inquiry Committee states that it considered the “findings of the CPSA report and the  
material in front of it.” The Inquiry Committee “noted the thoroughness of the CPSA  
investigation, including interviews with all the involved parties.”  
[98] The Committee then considered the complaints against the Registrants (in the  
order that follows):  
Registrant 1, Registrant 5, Registrant 2 were the Complainant’s College-approved  
supervisors while he practised under a provisional license. Registrant 1 was the  
Complainant’s direct supervisor, and was the first to learn of rumours regarding potential  
boundary issues. This should have prompted a prompt and fair investigation, one in  
which the Complainant was provided with particulars of the complaint and be given an  
opportunity to respond. The Committee agreed with the CPSA finding that Registrant 1  
did not afford the Complainant this right.  
The Committee was also critical of Registrant 2, the Chief of Staff, who relied on a third-  
party account when submitting his report regarding the Complainant. While the  
Committee acknowledged the many demands and responsibilities Registrant 2 faced  
due to his clinical and administrative roles, it considered that as Chief of Staff making a  
report that could affect the Complainant’s licensure, he should have sought  
substantiation of the allegations in the supervisor report and have interviewed the  
Complainant directly.  
The Committee considered that Registrant 5, who lives in a different community, was  
somewhat at a remove from these matters. The Committee accepted the CPSA findings,  
but did not conclude with criticism as it is beyond its scope to ascertain how Registrant 5  
should have weighed the different testimonies he was offered.  
The Committee was critical of Registrant 6, medical director for the Health Authority, for  
telling the Complainant that she had received a boundary complaint but not providing  
him with details that would allow him to respond to the allegation. She then stated that  
his reaction to her announcement was worse than the alleged conduct, which the  
Committee did not consider appropriate.  
The Committee accepted the findings of the CPSA in regard to Registrant 3’s  
involvement with this matter, but withheld criticism as it considered this an employer-  
employee matter outside the mandate of the College.  
In regards to Registrant 4’s conduct, the Committee noted that it had been provided with  
divergent accounts and had no objective evidence by which to judge if the comment  
ascribed to Registrant 4 was racist.  
The Committee did not have means by which to judge whether any of the conduct  
described in the complaint and the CPSA report was motivated by conscious or systemic  
racism. It did discuss the importance of providing better support and training for College-  
approved supervisors who are willing to take on this challenging role. The Committee  
requested that this recommendation be included in closing correspondence. [A Deputy  
Registrar of the College] informed the Committee that steps to this end are currently  
being explored with the goal of making improvements in the near future.  
[99] The Inquiry Committee noted that the investigation of this complaint was  
suspended when the Complainant exercised his right under the Act to request a review  
when the investigation did not conclude within the statutory time. The Review Board  
directed that the investigation was to continue with a decision being made by the Inquiry  
Committee by May 21, 2021, and the decision communicated to the Complainant within  
two weeks.  
iv. Committee direction  
[100] Under this heading, the Inquiry Committee stated that it accepted the findings of  
the CPSA Investigation Report and (as described above) focused its criticism on the  
lack of procedural fairness afforded to the Complainant after allegations were made  
against him. The Inquiry Committee then directed that “this decision” be communicated  
via correspondence with criticism of Registrant 1, Registrant 2 and Registrant 6 under  
s.33(6)(b) of the Act, but no formal criticism of Registrant 5, Registrant 3 and Registrant  
4 under s.33(6)(a) of the Act.  
[101] The Minutes then include a “Request for Action” which stated that Registrar’s  
staff were to send “concluding correspondence” to the Complainant and Registrants. As  
noted above, there is no indication in the Minutes that legal counsel was to draft and  
send the parties a six-page comprehensive report that added to the Inquiry Committee’s  
consideration of the matter, as reported in the Minutes.  
V
LEGISLATION  
[102] The Act provides for the investigation of complaints regarding the conduct or  
competence of registrants of the College.  
(A) The role of the Inquiry Committee  
[103] Section 32(1) of the Act provides that complaints against registrants must be  
made in writing and delivered to the registrar of the College. Section 32(2) of the Act  
notes that, as soon as practicable, the Registrar must deliver the complaint to the  
inquiry committee of the College together with an assessment of the complaint and any  
recommendations for disposition of the complaint. Section 33(1) of the Act mandates  
the Inquiry Committee to investigate the matter as soon as possible.  
[104] Section 33(6) of the Act sets out the Inquiry Committee’s authority, after  
investigating:  
(6) After considering any information provided by the registrant, the inquiry committee  
may  
(a) take no further action if the inquiry committee is of the view that the matter is  
trivial, frivolous, vexatious or made in bad faith or that the conduct or competence  
to which the matter relates is satisfactory,  
(b) in the case of an investigation respecting a complaint, take any action it considers  
appropriate to resolve the matter between the complainant and the registrant,  
(c) act under section 36, or  
(d) direct the registrar to issue a citation under section 37.  
[105] College bylaw 4-2 provides for investigations by a person delegated to act on  
behalf of the Inquiry Committee.  
4-2  
(1) The inquiry committee must carry out an investigation of a matter referred to it  
under section 33 of the Act by directing the registrar to investigate the matter.  
(2) When the inquiry committee directs the registrar to investigate a matter under  
section 4-2(1), the registrar, or any other person designated to investigate a  
matter on the registrar’s behalf, may  
(a) as soon as practicable, require the respondent to reply to written requests  
for information relevant to the matter under investigation, and to submit  
any practice records relevant to the matter under investigation,  
(b) request a written report or any other information from any registrant or  
other person that the registrar considers may be of assistance in  
reviewing the matter under investigation,  
(c) meet with the complainant, the respondent and any other person the  
registrar may consider necessary, to discuss the matter under  
investigation, or  
(d) attempt to resolve the complaint or other matter under investigation  
through alternative dispute resolution in accordance with section 4-3.  
(3) The committee may require the respondent to attend for interview by the  
committee or the registrar.  
(emphasis added)  
[106] The Act also provides for certain remedial actions that the Inquiry Committee  
may seek when disposing of a complaint. For example, under s.36(1) of the Act, the  
Inquiry Committee may request, in writing, that a registrant undertake to do certain  
things i.e., not to repeat the conduct to which the matter relates (s.36(1)(a)); to take  
specified educational courses [s.36(1)(b)]; consent to a reprimand (s.36(1)(c)); or  
undertake or consent to any other specified action (s.36(1)(d)).  
[107] Further, under s.36(2) of the Act if a registrant refuses to give an undertaking or  
consent requested under subsection (1) or fails to comply with an undertaking or  
consent given, the inquiry committee may direct the registrar to issue a citation for a  
hearing by the discipline committee regarding the matter.  
i. Authority under which the Inquiry Committee acted in this matter  
[108] In this instance, the Record indicates that on December 11, 2018, staff at the  
College wrote and asked that the CPSA “conduct this complaint review” on behalf of the  
College. On the same date, the College wrote the Complainant and advised him that the  
“adjudication” of his complaint would be carried out by the CPSA. An assistant registrar  
of the CPSA replied to the College’s letter on January 22, 2019, stating that CPSA staff  
would “complete the review and prepare an Investigation report.” The registrar also  
noted that he would review the report and “forward a decision to you.”  
[109] On March 1, 2019, the College wrote the Registrants and advised them that the  
“investigation and adjudication” of the complaints would be carried out by the CPSA.  
[110] Despite these communications, the CPSA did not adjudicate the matter. The  
CPSA investigated the complaint and provided a report to the College. Then, the Inquiry  
Committee of the College, as is its mandate under the Act, adjudicated the matter under  
s.33(6)(a) and (b).  
[111] I am unable to ascertain from the Record whether the College notified the  
Complainant that its original direction to the CPSA had changed (i.e., that the CPSA  
was only to investigate and report back to the College with its findings and was not to  
“adjudicate” the matter.)  
[112] In response to a question that I posed to the College when I directed the matter  
to Stage 2, counsel to the College submitted  
The original advice from the College that the (CPSA) would complete the “adjudication”  
of the matter did not account for the statutory duty of the Inquiry Committee to  
investigate and dispose of complaint matters under HPA s.33(1) and (6), subject of  
course to any prior registrar disposition under s. 32(3).  
[113] College counsel further submitted that the Inquiry Committee was the body that  
investigated the complaint as the Act obligates, but it initially carried out that  
investigation using the CPSA, acting as an external investigator. Once the CPSA  
provided the CPSA Investigation Report, the Inquiry Committee concluded its  
investigation through external legal counsel, by asking that the Complainant and the  
Registrants provide any responses to the CPSA Investigation Report.  
(B) The role of the Review Board  
[114] The Act provides the Review Board with authority to review Inquiry Committee  
dispositions of complaints: s. 50.53(1)(c).  
[115] The Review Board is a specialized tribunal, independent of the College. Review  
Board members are not members of any of the health professions: Act, s. 50.51(3). The  
Board’s purpose is to provide a neutral, arm’s length review of college registration  
committee decisions and inquiry committee dispositions.  
[116] Under s.50.6(1) of the Act, a complainant may apply to the Review Board for a  
review of a disposition of the Inquiry Committee.  
[117] Section 50.6(5) of the Act sets out the responsibility of the Review Board when  
conducting a review:  
50.6(5) On receipt of an application under subsection (1), the review board must conduct  
a review of the disposition and must consider one or both of the following:  
(a) the adequacy of the investigation conducted respecting the complaint;  
(b) the reasonableness of the disposition.  
[118] My task, on behalf of the Review Board and as described in s.50.6(5) of the Act,  
is to review the College's disposition of the complaint and to consider the adequacy of  
the investigation, the reasonableness of the disposition, or both. On completion of my  
review, I may make an order under s.50.6(8) of the Act confirming the disposition,  
directing the inquiry committee to make a disposition that it could have made on the  
matter, or sending the matter back for reconsideration with directions.  
[119] The Complainant (at times) asked that I review both the adequacy of the  
investigation and the reasonableness of the disposition. At other times he stated that  
there was “no need” to review the reasonableness of the disposition. In the  
circumstances, I have reviewed both.  
[120] Reviews conducted by the Review Board are reviews on the record: Act,  
s.50.6(6). That is to say that reviews are based on the College’s record of the  
investigation. The Review Board may consider additional evidence if it is satisfied that it  
is reasonably required for a full and fair disclosure of all matters related to the issue  
under review: Act, s.50.6(7).  
i. Additions to the Record  
[121] The Complainant has twice applied to the Review Board to add documents to the  
Record. In the first application, dated August 26, 2021, the Complainant applied to add  
nine documents to the Record (i.e., letters of reference and one email). In response to  
questions that I posed to him when directing this review to Stage 2, the Complainant  
acknowledged that seven of the documents he submitted were substantially similar to  
reference letters the authors had already provided and were included in the Record. I  
decline to add those documents to the Record. One of the reference letters dated  
September 30, 2018, was not included in the Record but could have been provided by  
the Complainant during the investigation. I do not find it is reasonably required for a full  
and fair disclosure of any matter before me and I decline to admit it.  
[122] The email from Registrant 1 to Registrant 2, Registrant 3 and Registrant 6 (and  
another person), dated June 11, 2018, includes allegations by Registrant 1 of  
wrongdoing on the part of the Complainant and states that Registrant 1 felt threatened  
by the Complainant and would be reporting the matter to the police. I accept the  
Complainant’s explanation that he only came into possession of the email as a result of  
a Freedom of Investigation request that he made to the Health Authority. I accept that  
this email might have some relevance if the College were investigating a complaint  
about the Complainant’s conduct, but it was not. The College was investigating a  
complaint about the registrants’ conduct. I find that this email was not relevant to the  
College’s investigation of the conduct of the registrants (in particular Registrant 1), and I  
am satisfied that it is not relevant to my review of the adequacy of the College’s  
investigation or the reasonableness of the Inquiry Committee’s disposition. I decline to  
admit this document as an addition to the Record.  
[123] On November 26, 2021, the Complainant filed an undated application to add two  
further documents to the Record (emails dated April 12, 2016, from College staff to  
Registrant 1 and Registrant 2 and copied to the Complainant). The emails relate to  
these registrants’ agreement to act as supervisors, on behalf of the College, of the  
Complainant. Each email states that it has attached the “Expectations of Supervisors for  
Provisional Registrant” and a “Supervisor Evaluation Report - psychiatry.” The  
Complainant has not provided the Review Board with these attachments.  
[124] In my view, the emails are relevant to the matter before me. They establish that  
Registrant 1 and Registrant 2 had agreed to act as supervisors of the Complainant in  
2016 reporting to the College - a fact has not been denied by either registrant. In that  
sense, they are of limited utility to me. The documents which were referenced as  
appended to the emails and would have set out the College’s expectations of  
supervisors at that time, were not included with the emails provided by the Complainant.  
The Complainant has obviously been aware of these emails since 2016 (as he was  
copied on the emails). He could have provided them to the College, the CPSA, or  
external legal counsel to the College during the investigation and to the Review Board  
with his application for review or his statement of points. He did not. Providing new  
documents during final reply is not a practice that the Review Board endorses. That  
said, the emails cannot be said to catch the College or the named registrants by  
surprise as they were all parties to the correspondence. I admit the emails subject to the  
limitations on their usefulness noted above.  
[125] The College also applied to add a document to the Record that ought to have  
been included, i.e., a letter dated January 22, 2021, from external legal counsel to the  
Complainant regarding “uncivil statements” that the Complainant included in  
correspondence with the College’s internal legal counsel. College counsel submits that  
the letter was before the Inquiry Committee as a schedule to the privileged memo. As  
the document was clearly before the Inquiry Committee for its consideration and is not a  
surprise to the Complainant, I am satisfied that it is relevant, and I admit it.  
VI  
ADEQUACY OF THE INVESTIGATION  
[126] As noted earlier in this decision, the parties filed voluminous submissions (and  
authorities in support of their positions) in this review. While I have thoroughly reviewed  
those submissions in their entirety, I do not intend to refer to all of the submissions in  
this decision. Instead, I will focus my review on those submissions that bear directly on  
the matters before me, i.e., whether the CPSA adequately investigated the complaints  
on behalf of the Inquiry Committee and whether the Inquiry Committee reasonably  
disposed of the matters.  
(A) The Complainant’s submissions  
[127] As noted earlier in this decision, despite the volume of material filed by the  
Complainant in this review, he did not file an “Application for Review” Form 3. That form  
clarifies whether the Complainant is seeking a review of the adequacy of the  
investigation, the reasonableness of the disposition, or both. It would have been helpful  
had the Complainant filed this preliminary document.  
[128] However, in a 14-page letter to the Review Board dated May 17, 2021, counsel  
to the Complainant stated:  
We request a new investigation regarding our client’s complaints submitted against [the  
Registrants]. Our client takes the position the Inquiry Committee…did not exercise the  
requisite degree of due diligence, care, and thoroughness in their investigation of the  
Matter.  
The BC College owes the Complainant] the duty to conduct the investigation into the  
Matter with an appropriate level of thoroughness so as to discover and address the  
underlying reasons behind each [Registrant]’s actions.  
[129] In his reply to the College’s submissions, the Complainant added,  
…if the College properly investigated and enforced professional standards by  
determining whether the allegations against the Complainant were proper and  
constituted professional misconduct and/or conduct unbecoming, [the Complainant]  
would have been granted procedural fairness. The failure of the College to investigate  
and enforce professional standards; however, indefinitely delayed [the Complainant’s]  
licensure and allowed the Registrants to allege further baseless claims.  
(B) The College’s submissions  
[130] The College submits that the investigation of the complaint was adequate. The  
College adds that the College, “through both the [CPSA] and through external counsel  
(to the College), collected documents that would ultimately form a 2,683-page  
investigation record.” The College further submits that (after accounting for duplicate  
copies in the CPSA records) the Record consists of 1,820 pages of documents.  
[131] The College states that the Inquiry Committee was entitled to conclude the  
investigation, following receipt of the CPSA Investigation Report, by gathering final  
comments about the report through the College’s external legal counsel.  
[132] The College adds that the complaints in this case did not necessitate the College  
reaching any conclusions about the truth of the negative reports that the supervisors  
(Registrants 1, 2 and 5) received while they were gathering input and before they  
reported to the College. Instead, the regulatory issues relate to whether those  
Registrants acted appropriately when reporting that information to the College.  
Nonetheless, the CPSA conducted several witness interviews. Further, the Complainant  
had ample opportunity to provide information about the events. The College submits  
that the Inquiry Committee elicited and received multiple responses from the  
Registrants, who also provided substantial supporting documentation. Still further, the  
College submits that, with respect to Registrants 3 and 6, the Inquiry Committee  
engaged in sufficient investigation to determine that much of their impugned conduct  
related to matters falling within their managerial duties with the Health Authority.  
[133] The College submits that the Inquiry Committee performed a reasonably  
adequate investigation of the matters raised by the Complainant. The College adds that  
the Inquiry Committee need not investigate conduct if it concludes that conduct, e.g.,  
carrying out managerial duties, does not contravene a professional standard.  
[134] Finally, the College submits that the Complainant is not precluded from obtaining  
relief in some other applicable forum. The College observes that the Record discloses  
that the Complainant is pursuing his concerns regarding the Registrants’ actions in at  
least nine other venues.  
(C) The Registrants’ submissions  
[135] Registrant 1 submits that the Inquiry Committee’s investigation of the complaint  
against her was adequate. She notes that the Inquiry Committee referred its  
investigation to the CPSA to avoid the possibility of any real or perceived bias due to the  
fact that some of the Registrants held supervisorial and/or council member positions  
with the College.  
[136] Registrant 1 further submits that the CPSA went to “great lengths” to seek and  
obtain the differing versions of events put forward by the Complainant, the Registrants  
and other third parties. The College then disclosed the supporting documents for the  
investigation, including the Registrants’ responses to the Complainant for reply, to which  
he made lengthy submissions. Registrant 1 submits that it cannot be said that there was  
either no investigation or only a cursory investigation that is inconsistent with the nature  
of the Complainant’s complaint. She suggests that the Review Board must defer to the  
College.  
[137] Registrant 2, Registrant 3, Registrant 4, Registrant 5 and Registrant 6 submit  
that the College’s investigation was “comprehensive and thorough” as acknowledged by  
the Inquiry Committee. They point to the steps the CPSA took to investigate (as  
described earlier in this decision). They add that there is nothing more the College could  
reasonably have done to investigate the complaint. They submit that the Complainant  
has failed to establish - or to even suggest - otherwise.  
(D) The Panel’s findings  
[138] The Review Board’s role in reviewing the adequacy of an investigation of a  
complaint by a college is to ensure accountability by the health colleges in the conduct  
of their investigations. These investigations are carried out as part of an inquiry  
committee’s role in screening complaints made to the college. The screening role was  
described in Review Board Decision Complainant v. College of Registered Psychiatric  
Nurses of British Columbia, 2018 BCHPRB 52, at para 18:  
…An inquiry committee plays a critical role in the exercise of a professional health  
college’s larger public interest mandate. “Screening” is not simply about whether to send  
the matter to a discipline hearing - a rare event. Screening also involves inquiry  
committees making provisional findings and assessments whether evidence supports a  
determination that a registrant’s conduct had fallen below the regulatory standard.  
…Screening is also about whether, in order to protect the public interest, the inquiry  
committee should seek to exercise one of the several other remedial options reflected in  
ss.33(6)(b), 33(6)(c) and 36(1) of the Act, which remedies are no less important just  
because they depend on a registrant’s consent.  
[139] Adequacy is contextual and requires a consideration of factors including the  
nature of the complaint, the seriousness of the harm alleged, the complexity of the  
investigation, the availability of evidence and the resources available to the college:  
Review Board Decision Complainant v. College of Registered Nurses of BC, 2010  
BCHPRB 6.  
[140] In The College of Physicians and Surgeons of British Columbia v. The Health  
Professions Review Board, 2022 BCCA 10 (“Dawson), the Court of Appeal has  
recently held that:  
[114] Adequacy describes a relationship between an action and a goal. An  
investigation is “adequate” if it is sufficient to meet its goals. There may be many goals of  
an investigation of a complaint against a physician. Obvious goals include public  
accountability and uncovering the truth. A further possible goal is to gather sufficient  
information to allow an effective remedy to be crafted. Scarcity of resources dictates that  
one goal of investigations will be to obtain necessary information without squandering  
resources. There are, no doubt, other goals that can be ascribed to the investigative  
process.  
[115] What is important is that there is, in the concept of “adequacy”, no implication of  
deference. Where a review board considers the “adequacy” of an investigation, it is  
entitled (as long as it does not act patently unreasonably) to characterize the goals of the  
investigation and to make judgments as to whether the efforts expended were  
commensurate with those goals.  
[141] In this case, one goal of the investigation was to avoid any real or perceived bias  
by the College. In my view, the College took adequate steps to address any real or  
perceived bias by the College given the role of some of the Registrants as supervisors  
reporting to the College or as members of the College’s board. Specifically, the College  
asked and the CPSA agreed to investigate the complaints and report back.  
[142] A further goal of the investigation was to uncover the truth of the allegations  
about the Registrants insofar as those allegations fell within the Inquiry Committee’s  
mandate. To this end, the CPSA conducted a protracted investigation of the complaints.  
The investigators appointed by the CPSA reviewed the complaint, the Registrants’  
responses and the Supervisor Evaluation Reports prepared by Registrant 1, Registrant  
2 and Registrant 5. Further, the investigators interviewed individuals who worked with  
the Complainant and attempted to interview others who were identified by the  
Complainant as having relevant information but who did not respond to the CPSA’s  
requests for an interview. The CPSA investigators then analyzed the information  
collected and considered the Registrants’ conduct in the context of the Code of Ethics  
applicable to registrants of the College. Finally, the investigators forwarded a 41-page  
CPSA Investigation Report and supporting material to the College.  
[143] I am mindful that the Complainant has at various times in his submissions either  
directly stated or suggested that the College ought to have investigated 1) the reasons  
or intentions underlying the Registrants’ actions (in reporting concerns about him in their  
supervisory reports or in soliciting complaints against him); and 2) the boundary issues  
about the Complainant to determine whether the allegations against him were founded  
(thereby giving him the opportunity to know the details of the allegations and respond to  
them). The Complainant has also implied that he has experienced systemic racism by  
the College.  
[144] It was not the goal of the CPSA to investigate whether the Registrants were  
motivated in their conduct by discriminatory views of the Complainant (or his spouse),  
nor whether there was systemic racism in the College or in the healthcare system in  
British Columbia, in general. The College (and the CPSA as its delegate) was tasked  
with investigating the complaints about the Registrants’ conduct toward the Complainant  
in their role as colleagues or supervisors of the Complainant and in the context of the  
College’s expectations of registrants. I note that the Inquiry Committee addressed the  
broader allegation (systemic racism) in its Disposition.  
[145] It was also not the goal of the CPSA to uncover the truth of the allegations about  
the Complainant. I stress that when the College received the Complainant’s complaints  
about the Registrants, it was not the College’s task to investigate the Complainant’s  
conduct. I have no way of knowing whether the College received complaints from the  
Registrants about the Complainant under a “duty to report” (Act, ss.32.1, 32.2, 32.3,  
32.4), or from any other person about the Complainant’s conduct (e.g., under s.32 of the  
Act). If it did, the College has an obligation to investigate those complaints. Further, the  
College may choose to act on its own motion to investigate the Complainant if it has  
reason to be concerned about his conduct or clinical care of patients (s.33(4) of the  
Act). Whether the College received such complaints or pursued an independent  
investigation on its own motion, those matters are not before me.  
[146] The limits on the CPSA and College’s authority to investigate are also reflected in  
my own mandate. I remind myself that the focus of my review is the College’s  
investigation of the complaints that are before me, i.e., complaints made by the  
Complainant against the Registrants. I have no mandate to investigate whether the  
College (or for that matter the Inquiry Committee or the Registration Committee) ought  
to have investigated the Complainant’s conduct as a provisional registrant or whether it  
ought to have looked into the underlying motivation behind the Registrants’ alleged  
conduct. Neither do I have a mandate to inquire into the delivery of healthcare in British  
Columbia with a view to determining whether there is systemic racism in the system. It  
is with the limits to my mandate at the forefront of my mind that I have considered the  
adequacy of the College’s investigation of the Complainant’s allegations against the  
Registrants.  
[147] In the circumstances as I have described them, I am satisfied the College’s  
investigation was adequate. The College obtained the CPSA Investigation Report and  
the responses to the report gathered by external counsel from the Complainant and the  
Registrants. By taking the steps that it did, the College ensured that the Inquiry  
Committee had the key information that it needed to understand the allegations, in  
context and to analyze the conduct of the Registrants and arrive at a disposition  
including, where appropriate, allowing it to craft effective remedies. The process  
furthered public accountability.  
VII  
REASONABLENESS OF THE DISPOSITION  
(A) The Complainant’s submissions  
[148] In his initial submissions to the Review Board, the Complainant focuses mainly  
on reiterating his complaints about the Registrants. On page 12 of his 14-page  
submissions, the Complainant first addresses his reasons for requesting a review of the  
Disposition. He states that he “disagrees with the Committee Disposition.”  
It is [his] position the Committee Disposition did not address the underlying issues of the  
systemic discrimination and targeted harassment [the Complainant] has faced for years  
by several colleagues, mentors, and supervisors in the medical field.  
[149] The Complainant then notes that the College delegated authority to the CPSA to  
investigate the complaints and acknowledged the real risk of conflicts of interest and  
biases in the investigation. He suggests that it was “inappropriate” that the Inquiry  
Committee then relied on the assurance of College staff that steps will be taken in the  
near future to address issues arising from the complaints regarding College supervisors.  
The Complainant “maintains this is a substantial conflict of interests.”  
[150] Further, the Complainant submits that the Inquiry Committee’s disposition  
“essentially wrote off” the Complainant’s complaints with a blanket acknowledgement  
that he was not afforded procedural fairness by some of the Registrants. He adds that it  
is “inadequate” for the Inquiry Committee to accept assurances from College staff  
without first acknowledging or properly investigating “the underlying reasons” for the  
Registrants’ actions. The Complainant asserts that the Registrants’ conduct is  
“unbecoming” of medical professionals.  
[151] In terms of relief sought, the Complainant asks that the Review Board act under  
either s.50.6(8)(b) of the Act to direct the Inquiry Committee to make a disposition that it  
could have made, or s.50.6(8)(c) of the Act to send the matter back to the Inquiry  
Committee for reconsideration with directions.  
[152] In his Statement of Points, the Complainant reiterates his concerns first  
expressed in his initial letter. He adds that the Disposition failed to address “notable  
instances of professional misconduct by [the Registrants]” and cites his allegation that  
Registrant 1 “called the Complainant “Harvey Weinstein” in an email” of June 11, 2018  
(added to the Record). He further submits that it is “inadequate and patently  
unreasonable” for the Inquiry Committee to conclude with criticism of Registrants 1, 2  
and 6 but no formal criticism of Registrants 3, 4 and 5 and to assert that further training  
is required absent identifying the underlying reasons for their “actions.”  
(B) The College’s submissions  
[153] The College filed a 40-page Statement of Points in response to the  
Complainant’s initial submissions. In brief, the College submits that the “actions” that the  
Complainant complains about “do not involve any crime, or any breach of clinical  
standards.” Instead, they involve how some of the Registrants discussed with the  
Complainant some of the input they received from other staff members that was  
unfavorable to him. This “purely verbal conduct” also occurred in the context of the  
Registrants occupying specific roles, e.g., as manager of the Health Authority for whom  
the Complainant was a “contractor,” other Registrants were volunteer supervisors of the  
Complainant as a provisional registrant of the College, and one was a physician for a  
patient whose daughter (as a decision-maker for her mother) had expressed concerns  
about the Complainant.  
[154] The College further submits that while it has “expectations” of supervisors (see  
Expectations of Supervisors for Registrants in the Provisional Class”) the expectations  
“do not form a standard per se.” The College says that it regulates supervisors on the  
understanding that “such roles permit and require a great deal of discretion and  
judgment.” The policy does not expressly address what level of investigation a  
supervisor must engage in, should interviews disclose possible concerns about the  
supervised registrant. The College cannot require that registrants volunteer as  
supervisors or prevent them from withdrawing their services.  
[155] The College adds that it has no authority over how registrants perform their other  
roles. Specifically, the College does not regulate how registrants exercise their  
discretion or authority as managers of a health care body; the College has no role when  
Registrants (as managers of the Health Authority) act in hiring, firing or requesting its  
contractors to act as supervisors of other contractors (such as the Complainant).  
[156] The College submits that it was reasonable for the Inquiry Committee to be  
critical of some of the Registrants under s.33(6)(b) of the Act in their role as supervisors  
as they ought to have provided the Complainant with an opportunity to respond to  
various negative reports and incorporate those responses into their supervision reports.  
The College’s expectations policy provides that supervisors should include input from  
involved professionals. That said, the policy also provides,  
The supervisor should provide constructive critical feedback to the registrant  
regarding their performance at least once per quarter, and the registrant should be  
provided with opportunities for response. A supervisor should have training in  
cultural sensitivity and diversity awareness.  
(emphasis in original)  
[157] The College submits that the Inquiry Committee concluded that some of the  
Registrants should have further investigated any concerns reported about the  
Complainant, but that conclusion “does not translate in any way to a duty that (the  
Registrants) refrain from raising such issues with the Complainant, or refrain from  
passing on concerns to the College.” Rather, the College submits, the Inquiry  
Committee criticism was that those Registrants ought to have provided qualifying  
information, if any, including responses from the Complainant. Such information would  
have provided the College with an informed basis for either the Registration Committee  
or the Inquiry Committee to investigate the Complainant’s conduct as a provisional  
registrant.  
[158] The College submits that it is not for it to regulate whether the Registrants in  
management positions ought to have believed the negative reports, or assessed,  
discussed, or acted upon information they received in their capacity as managers.  
[159] Finally, with respect to Registrant 4, the College does not prohibit registrants  
from telling patients of other members how they may file complaints under the Act. For  
all the above reasons, the College submits that the disposition was reasonable.  
[160] In response to the Complainant’s application to add an email from Registrant 1 to  
others dated June 11, 2018, the College submits that the Complainant did not provide  
that email during the investigation although he referenced two of the Registrants either  
equating him to or calling him “Harvey Weinstein.” The College speculates that even if  
the email had been available to the Inquiry Committee, it would not have altered the  
committee’s conclusions for two reasons. First, the email involves a discussion between  
Registrant 1 in her capacity as a contractor with the Health Authority, with other  
managers of the Health Authority. The College submits that the conversation “falls  
squarely within the realm of employment and other institutional matters,” is protected by  
the “defence of privilege arising under the law of defamation,” and is not prohibited “by  
some unspecified professional standard.” Second, the College submits that Registrant 1  
did not actually equate the Complainant with Harvey Weinstein. Rather, she refers to  
the possibility that multiple instances of apparent misconduct by the Complainant within  
the organization, which might become public, could result in “a Harvey Weinstein type  
expos(é).”  
[161] The College submits that all aspects of the Disposition meet the legal test for  
reasonableness as articulated in Canada (Minister of Citizenship and Immigration) v.  
Vavilov, 2019 SCC 65 (Vavilov).  
[162] First, considering the complaint in context, the Inquiry Committee acted  
reasonably in criticizing Registrants 1, 2 and 6 and in concluding that the conduct of  
Registrants 3, 4 and 5 could be resolved without criticism and by providing training for  
all supervisors. The allegations involve verbal conduct by the Registrants, in  
communicating concerns that they had learned of from third parties about the  
Complainant. The College submits that the Inquiry Committee was empowered to come  
to its own conclusions about whether the alleged conduct was motivated by malice or  
racism. The College informs the Inquiry Committee that the context within which the  
complaint was considered is informed by the College’s 2020-2021 Annual Report which  
states that the Inquiry Committee resolved 988 complaints during the one-year period  
(337 by advice or written criticism, 66 by remediation with consent, 11 by way of  
reprimand, four by consent agreements, and two matters by way of citation to the  
Discipline Committee). The Inquiry Committee applies its professional expertise and  
knowledge in order to understand, in relation to the constellation of conduct matters it  
considers, whether a matter warrants professional criticism.  
[163] The College further submits that while it is clear that the Complainant is clearly  
personally offended by the conduct of all of the Registrants, he has demonstrated that  
“he is personally offended by a great deal of conduct that does not conform to his  
understanding of events.” The College cited examples two of which I note are that when  
the Review Board declined to take over the College’s investigation, the Complainant  
called the Review Board chair “a closet racist who has exposed himself fully within his  
decision”(emphasis in original).  
[164] The College also noted that the Complainant has been quick to allege bad faith  
or malice, and to state that allegation as fact. For example, he stated to one of the  
CPSA investigators,  
You need to give me the name and contact details of your supervisor. You are an  
incapable and incompetent individual… I am now going to exhaust all legal channels to  
sort you out firstYou are engaging in blatant racism against me knowing fully well that  
the doctors (I ) have complained against are before the Human Rights Tribunal but  
despite that you are deliberately delaying this investigation.  
(emphasis in original)  
[165] The College submits that the degree of outrage that the Complainant expresses  
with respect to the complaint matters, no matter how genuine, does not circumscribe the  
degree of seriousness that the Inquiry Committee could reasonably assign to the  
matters. The College adds that the Inquiry Committee applies professional expertise  
and knowledge in order to understand, in relation to the constellation of conduct matters  
it considers, whether a matter warrants only professional criticism.  
[166] The College then submits that the Inquiry Committee was entitled to consider  
that the conduct of Registrant 5 was satisfactory, on the basis that he reasonably  
weighed different information, and reasonably reported to the Complainant. Further, the  
Inquiry Committee was entitled to consider that Registrant 5 was not present in the  
community and was removed from the situations he had to assess in providing his  
supervisor’s report.  
[167] Third, the Inquiry Committee reasonably concluded that it lacked jurisdiction over  
the workplace decisions made by Registrant 3 and Registrant 6 (i.e., to refuse  
permission to the Complainant to circulate a memo about drug interactions; to decline to  
allot students to the Complainant; to refuse to provide supervisors to the Complainant;  
and to decide where the Complainant should work to conclude his file work).  
[168] Fourth, with respect to Registrant 4, the Inquiry Committee reasonably declined  
to conclude that:  
(a) her comment that she would like to meet the Complainant’s “Irish wife” was  
made in a racist or derogatory tone (considering that the Complainant was a  
self-proclaimed naturalized citizen of Ireland, originally from [another  
country]); or  
(b) she acted inappropriately by providing information to a patient’s decision-  
maker about how to make a complaint to the College.  
(C) The Registrants’ submissions  
[169] The Registrants are unanimous in their submissions that the Inquiry Committee’s  
disposition meets the test for reasonableness as articulated in Vavilov at paras 85-86,  
i.e., that the decision is based on an internally coherent and rational chain of analysis  
and that is justified in relation to the facts and the law that constrain the decision maker  
and is justified, intelligible and transparent to the individuals subject to it.  
[170] Registrants 2 and 6 argue that the Review Board ought to show deference to the  
Inquiry Committee which, they say has a degree of expertise. These registrants submit  
that the Inquiry Committee provided clear and logical reasons for why it did not subject  
Registrants 3, 4 and 5 to regulatory criticism. Further, while Registrant 2 and Registrant  
6 “respectfully disagree” with the disposition as it relates to them, they say that it was  
reasonable, based on the evidence, to direct regulatory criticism at them and they  
respect the disposition. These registrants submit that the disposition was justified,  
transparent and intelligible in any event. They argue that the Complainant has not  
raised anything in his initial submission letter or in his Statement of Points that would  
provide a basis for the Review Board to interfere with the disposition.  
(D) The Complainant’s reply submissions  
[171] The Complainant filed voluminous submissions in reply to the College, Registrant  
1 and Registrants 2 to 6. In each of his reply submissions, the Complainant asserts that  
in its disposition, the Inquiry Committee failed to address issues that were before it. He  
further submits that the disposition does not meet the indicia of reasonableness. The  
Complainant described, at length, his view of the “Factual Background” to the complaint.  
[172] In his reply to the College’s submissions, the Complainant asks whether “the  
College’s superintending of the practice of medicine include(s) the superintending of  
registrants in the provisional class” and submits that, if so, “it is the College’s duty to  
regulate Supervisors despite the voluntary nature of their role.” The Complainant  
submits that this “duty” is a “fiduciary duty” owed “to British Columbians and the wider  
public.” Alternatively, the Complainant submits that the College granted his supervisors  
“actual authority (express or implied)” such that there was “an agency relationship”  
between the College and (some of) the Registrants. In the further alternative, the  
Complainant asserts that the College should have investigated the alleged concerns  
expressed about him in order to protect the public and should have considered the  
Registrants’ actions as “professional misconduct and/or conduct unbecoming.”  
[173] Also, in his reply to the Registrants’ submissions, the Complainant submits that  
the Inquiry Committee’s disposition of his complaint did not meet the indicia of  
reasonableness (justification, intelligibility and transparency). He asserts that there is no  
line of analysis within the disposition that could reasonably lead the tribunal from the  
evidence before it to the conclusion to only criticize Registrants 1, 2 and 6; deem the  
evaluation report submitted by Registrant 1 to be “appropriate” and require only  
additional instructions and training to Registrant 1, Registrant 3 and Registrant 6.  
[174] The Complainant further asserts that the disposition failed to consider the serious  
nature of “the character impugning allegations raised to and by [Registrant 1]” and why  
neither the College nor Registrant 1 investigated the allegations. Further the disposition  
failed to address a “central complaint,” i.e., that the Registrants were discriminatorily  
targeting the Complainant based on his heritage and being a visible minority. He says  
this is “the ultimate crux of [the Complainant’s] complaint and is not addressed by the  
Inquiry Committee, at all.” He also asserts that the Inquiry Committee failed to consider  
Registrant 3’s intention to breach patient confidentiality (when initially directing the  
Complainant to conclude his file work at the hospital) and “be alert” to the serious  
allegations raised by Registrant 4 and determine the validity of the same.  
[175] The Complainant asserts that all the Registrants failed to report him under their  
“duty to report” to the registrar as described in s.32.2 and 32.4 of the Act (i.e., duty to  
report a registrant whose continued practice might constitute a danger to the public, and  
duty to report sexual misconduct). He suggests that this “failure” constitutes conduct  
unbecoming or professional misconduct on the part of Registrant 1.  
[176] The Complainant further submits that the disposition failed to consider whether  
the behaviour of all the Registrants was “conduct unbecoming” or “professional  
misconduct.” The Complainant asserts,  
Each of [the Registrants] had, and continues to have, an independent obligation from  
their supervisory, managerial and other roles to the College and to the public. More  
specifically, each of [the Registrants] had, and continues to have, a fiduciary duty, and,  
in the alternative, a duty as a member of [the College], to investigate and report other  
physicians’ improper, dangerous and hazardous behaviour, particularly when that other  
physician acted contrary to the doctor-patient relationship, was subject to rumours [sic]  
of sexual impropriety, and was feared by staff members. Each of [the Registrants]  
breached his or her duty to the public, and, in the alternative, to the College, in bad faith  
by failing to gather evidence and report to the College, and by subseuqnelty [sic]  
perpetuating meritless comments to others about the Complainant, impugning his  
character and professional reputation. (footnote references to the Record omitted)  
[177] Further, in his reply submissions, the Complainant submits that the Inquiry  
Committee did not take the necessary steps to investigate the complaint “diligently” and  
“consider its seriousness as an unprofessional conduct complete before concluding and  
dismissing the complaint.” He submits that there is no evidence that the Inquiry  
Committee “attempted beyond the minimum to interview the Registrants or external  
parties concerning the conflicting allegations of unprofessional conduct.” He relies on  
the Review Board’s decision in Complainant v. College of Registered Psychiatric  
Nurses of BC, 2012 BCHPRB 38 at para 59 for the proposition that “the disposition  
cannot be sustained because the investigation itself was inadequate.” He then says  
there is no need to determine the reasonableness of the disposition.  
(E) The College’s final submissions with respect to the “new legal issues”  
[178] The College objects to the Complainant’s reply stating that he has “split” his case  
by making submissions about the evidence under the heading, “Factual Background”  
which he could and ought to have addressed in his Stage 1 submissions. Further, in its  
November 19, 2021 sur-reply, the College asserts that the Complainant has sought to  
import “a host of private law (contract, tort, agency, fiduciary principles) to this public  
(administrative) law matter.” The College submits that the Complainant’s reply is  
“improper, and also legally nonsensical in various ways.”  
[179] The College states that the Complainant’s reply submissions that are premised  
on the College as a fiduciary to the public, are wrong in law, distort the public law issues  
of a reasonably adequate investigation and a reasonable disposition of complaints, and  
must be rejected.  
[180] The College adds that the public law duty of the College to serve and protect the  
public does not translate into a “general, private ‘fiduciaryduty of the College (or its  
committees, or other public entities under the [Act], like the Review Board) to the  
general public.'” The College states that the Complainant has not provided any factual  
or legal basis to suggest that the College owes a fiduciary duty to, in essence,  
“exonerate the Complainant (or to impose standards on (the registrant supervisors to do  
the same) with respect to any issues raised by staff and patients about the  
Complainant, and to his supervisors.”  
[181] The College submits that the Complainant’s reply submissions that supervisors  
are “agents” of the College such that the College has an “obligation” to investigate  
concerns raised against the Complainants, are also wrong in law and must be rejected.  
The College further submits that the Complainant misunderstands agency law when he  
says the Expectations Policy gives supervisors legal powers they would not have  
otherwise. The College adds that a supervisor has no legal authority to make anyone do  
anything. Instead, various stakeholders (such as the Health Authority and the  
provisional registrant) have a direct or indirect “practical interest” in cooperating with  
supervisors who volunteer to act as the eyes and ears of the College, because the  
alternative is the registrant would be unable to practice.  
[182] The College further states that the concept of “vicarious liability” (i.e., allocating  
liability for damages caused by the wrongs of employees who have breached private  
law duties of care) has no application here. The concepts of agency and vicarious  
liability add nothing to the issue of what professional standards apply to registrants who  
volunteer as supervisors, and which, if any, of such standards have been breached by  
the Registrants.  
[183] The College observes that the Complainant conflates expectations that  
supervisors render performance reports to the College with statutory duties that all  
registrants must report other registrants respecting specific kinds of matters under  
ss.32.2 and 32.4 of the Act. Further, supervisor reporting expectations arise under  
policy and relate to a provisional registrant’s (positive and negative) performance.  
Supervisors report to staff who assist the Registration Committee. In contrast, statutory  
reporting duties are obligations legislated under the Act applicable to all registrants.  
Registrants are required under ss.32.2 and 32.4 to report to the registrar.  
[184] Still further, the College asserts that supervisors’ reports are about the  
performance of provisional registrants and, therefore, fall under the jurisdiction of the  
Registration Committee. Any “failure” of the Registration Committee (or its delegates) to  
investigate matters reported by supervisors is not a matter within the jurisdiction of the  
Inquiry Committee or the Review Board. The “threshold issue” before the Inquiry  
Committee was whether the (supervisor) Registrants contravened standards imposed  
under the Act or other standards giving rise to “professional misconduct.”  
(F)  
The Registrants’ final submissions regarding the “new legal issues”  
[185] Registrant 1 states in her final submissions that the Complainant’s “Reply  
Statement of Facts” is a clear case of him attempting to inappropriately split his case by  
introducing new legal argument in the “reply” stage of the process. So too is the issue of  
“bad faith” on the part of Registrant 1. She submits that the entirety of his reply should  
be disregarded. Alternatively, she argues that the remainder of the Complainant’s reply  
(i.e., raising issues of fiduciary duty, agency relationship and vicarious liability and a  
“legislative duty” or duty to report) is new legal argument or a reiteration of background  
and allegations made in his Statement of Points. As to the issue of “professional  
misconduct” or “conduct unbecoming,” Registrant 1 submits that the Complainant had  
multiple opportunities to raise these same arguments and the Inquiry Committee clearly  
reviewed and considered his arguments.  
[186] Registrant 1 submits that it is intrinsically unfair for the Complainant to split his  
case, and by doing so, cause the other parties to incur unnecessary expense, and delay  
the entire Review Board process.  
[187] Similarly, Registrants 2 to 6 submit that the Complainant’s reply submissions  
raise new legal issues (alleged breaches of fiduciary duty, legislative duties, allegations  
of acting in bad faith and of exhibiting conduct unbecoming or professional misconduct1)  
that did not form part of his complaint or his request for review. They, too, assert that  
the Review Board ought not to consider these legal issues, raised for the first time in  
reply and which were not before the Inquiry Committee. They further assert that the  
Complainant’s legal arguments are wrong in law and are not supported by the facts or  
the evidence.  
[188] Registrants 2 to 6 state that the Complainant’s argument that they are guilty of  
professional misconduct and/or conduct unbecoming because they failed to report the  
Complainant to the College is not only “illogical, it is wholly incorrect.” They observe that  
the Complainant appears to acknowledge in his reply submissions that his actions were  
inappropriate (see e.g., Complainant’s reply submissions at para 5 and para 95). These  
registrants note that none of them alleged that the Complainant’s actions constituted a  
danger to the public or sexual misconduct triggering a duty to report to the registrar.  
Further they add that they did not report their concerns to the registrar under ss.32.2  
and 32.4 of the Act. Registrants 2 and 5 reported their concerns pursuant to their role as  
supervisors and Registrant 4 reported her concerns regarding the Complainant’s patient  
care and “other behaviors” to the Complainant’s supervisors and to the College. That  
said, these Registrants assert that they were not aware of any actual or material harm  
to any of the Complainant’s patients which would require them to report to his patients.  
They argue that they did not commit professional misconduct or conduct unbecoming.  
(G) The Complainant’s final submissions  
1 Registrants 2 to 6 note that the Complainant raised an allegation of professional misconduct or conduct  
unbecoming with respect to Registrant 1, only, in his Statement of Points.  
[189] In his November 26, 2021 submission, the Complainant submits that his reply  
submissions did not raise new factual and legal issues. More specifically, he submits  
that (a) the College raised the issues relating to statutory duty(ies) “by completely  
rejecting it governed or otherwise oversaw supervisors of a registrant in the provisional  
class”; (b) the Registrants raised the issue of their professional conduct “by stating they  
engaged in absolutely no improper conduct and thus, the Inquiry Committee’s  
response(s) to their professional conduct was fair, reasonable and adequate”; and (c)  
the College and the Registrants provided only a partial factual background in each of  
their written submissions and failed to identify all relevant points.  
[190] Further, the Complainant submits that he did not split his case. He references his  
complaint to the College and says he raised the issues of the “wrongful, deceitful and  
bad faith actions” and/or misreporting by the Registrants and the lack of procedural  
fairness he was afforded by them because he “believed he was the subject of hate  
based on his race, colour, ancestry, place of origin and religion.”  
[191] The Complainant further submits that his reply did not raise new issues but only  
argued that the disposition was unreasonable because the Inquiry Committee did not  
consider the College’s statutory and other duties and failed to consider the Registrants’  
behaviour as conduct unbecoming and/or professional misconduct. He reiterates that  
the College and the Registrants owe a fiduciary duty to the public, the Registrants acted  
as agents/representatives of the College, and that the concept of vicarious liability is  
applicable in the circumstances to “address the systemic failures of the College, [the  
Registrants] and the underlying reasons thereof, which include racism and targeted  
harassment.”  
VIII THE PANEL’S FINDINGS  
[192] I begin my analysis by reminding myself of the Review Board’s mandate and the  
limits to my jurisdiction. The Review Board’s mandate is described on its website:  
Our Mandate  
The Review Board is an independent, quasi-judicial, administrative tribunal established  
under Part 4.2 of the Act. The Review Board has the following powers and duties under  
s. 50.53 of the Act:  
to review certain registration decisions of a college of a designated health  
profession,  
to review the failure, by the inquiry committee of a college, to dispose of a  
complaint or an investigation within the time required,  
to review certain dispositions of complaints made by the inquiry committee of a  
college, and  
to develop and publish guidelines and recommendations for the purpose of  
assisting colleges to establish and employ registration, inquiry and discipline  
procedures that are transparent, objective, impartial and fair.  
After a review of a registration decision or a disposition of a complaint made by the  
inquiry committee, the Review Board may make an order either:  
confirming the registration decision or disposition of the inquiry committee,  
directing the registration or inquiry committee to make a decision or disposition  
that could have been made by the registration committee or the inquiry committee in  
the matter, or  
send the matter back to the registration or inquiry committee for reconsideration  
with directions.2  
[193] As stated in the mandate, the Review Board is a “quasi-judicial administrative  
tribunal.” Further, the Review Board is a provincially constituted tribunal that has only  
those powers and duties conveyed on it by statute, (in particular the Act). It is our task  
to review decisions of the College’s Inquiry Committee (and Registration Committee).  
When reviewing decisions of the Inquiry Committee, the Review Board is directed by  
the Act to consider the adequacy of the investigation and the reasonableness of the  
disposition (s. 50.6(5)). The Review Board is not a court of law and has no statutory  
authority to adjudicate issues of tort, contract, or trusts. Neither is it the role of the  
Review Board to adjudicate allegations of discrimination or harassment (except to the  
extent that allegations of a breach of the College’s professional standards is  
concerned).  
[194] A review by the Review Board is a review on the record. It is not a hearing de  
novo (i.e., a new consideration of the original complaint that was filed with the College).  
Neither is it an appeal of the Inquiry Committee’s decision. Instead, as the tribunal’s  
name suggests and as the Act makes clear, the Review Board is limited to reviewing  
(on the basis of the record that was before the Inquiry Committee) whether the  
College’s investigation of the complaint was adequate, and the Inquiry Committee’s  
findings and decision to dispose of the complaint in the manner that it did, was  
reasonable in the circumstances.  
[195] I have considered that when he first applied to the Review Board, the  
Complainant asked that I direct a new investigation of his complaint. He subsequently  
has vacillated between disputing only the adequacy of the investigation and challenging  
both the adequacy of the investigation and the reasonableness of the disposition. I note  
that in his reply submissions, the Complainant asserted that there was no need to  
review the reasonableness of the disposition. However, in his final submissions in  
response to the College’s further submissions, the Complainant once again asserted  
that the disposition was unreasonable. I have decided that, in the circumstances and to  
avoid any uncertainty, after having addressed the adequacy of the investigation, I will  
also address the reasonableness of the disposition.  
[196] That said, to the extent that the Complainant’s submissions are not responsive to  
the two issues before me, i.e., the adequacy of the College’s investigation and the  
reasonableness of the Inquiry Committee’s disposition of the Complainant’s complaints  
2 http://www.hprb.gov.bc.ca/about.stm  
against the Registrants, I have no authority to consider them. For greater certainty, the  
Review Board is not mandated to determine issues of trust (fiduciary duties), contract  
(agency), tort (negligence, liability) or matters relating to discrimination and alleged  
breaches of human rights. Raising these issues under the guise of arguing the  
“reasonableness of the disposition” does not change the reality that the Review is  
constrained by the law with respect to reasonableness.  
[197] The Review Board assesses the reasonableness of a disposition in light of the  
common law interpretation of reasonableness, the contours of which have been  
established by the Vavilov: Dawson, paras. 165-166.  
[198] In considering the reasonableness of the disposition of the complaint, the Review  
Board is entitled to consider both the findings made by the inquiry committee and the  
sanctions that it imposes: Dawson, para 192; Vavilov, para 83. Where reasons are  
provided, those are the starting point for the analysis. The Review Board must pay  
respectful attention and seek to understand the reasoning process followed and the  
conclusions reached: Vavilov, paras 84 and 86. Reasonableness is concerned mostly  
with the existence of justification, transparency and intelligibility within the decision-  
making process and with whether the decision falls within a range of possible,  
acceptable outcomes defensible in respect of the facts and law: Vavilov, para 86.  
[199] As noted earlier in this decision, internal legal counsel to the College sent a  
document entitled, “Final Disposition Report of the Inquiry Committee” dated April 13,  
2021, to the Complainant and the Registrants. However, based on my review of the  
Record, including the minutes of the Inquiry Committee meetings (April 13, 2021, and  
June 8, 2021), I am not satisfied that the Inquiry Committee either directed the  
preparation, or reviewed either a draft or final version of the report. Accordingly, I do not  
consider the report to be the Inquiry Committee’s disposition. Instead, for the purposes  
of my review, I consider the Inquiry Committee minutes of the April 13, 2021, to  
represent the Inquiry Committee’s decision to dispose of the complaints as it did.  
[200] The Minutes of the Inquiry Committee are not as clear as they might have been  
in recording the material that was before the Committee. The minutes of the April 13,  
2021, meeting, list documents without explanation. The list identifies the Complainant’s  
letter of complaint to the College, the Registrants’ responses to the complaint, five  
supervisor evaluation reports, an email from the Complainant to external legal counsel’s  
assistant (March 26, 2021) and a related reply from counsel (March 30, 2021) and the  
Complainant’s “29-page supplemental response to CPSA report.” I find it reasonable to  
infer that the list is meant to identify documents that were placed before the Committee  
by College staff as a result of the investigation of the complaints.  
[201] In response to questions that I posed at Stage 2 seeking clarification as to  
whether the CPSA report was also before the Inquiry Committee, College counsel  
clarified that the Inquiry Committee also had before it a “privileged memorandum” with  
attachments (including the CPSA report). Legal counsel was unclear why the  
memorandum was not listed as being before the Inquiry Committee. In light of the  
repeated references in the minutes to the CPSA report’s “findings,” I find that the  
Committee’s failure to clearly identify the CPSA report as being before them was not  
misleading.  
[202] I am aware that the Inquiry Committee Minutes do not reflect as complete an  
analysis of the complaint, the investigative results and the College’s expectations of  
registrants in the circumstances of the Registrants, as does the “Final Disposition  
Report” authored by legal counsel. That said, I am satisfied that the Minutes summarize  
the complaint, the issues that the Inquiry Committee had to consider, (i.e., “conduct,  
discrimination, professionalism”), the Committee’s discussion of the complaint against  
each Registrant in the context of the CPSA findings (if any), and the Committee’s  
direction to staff to communicate the Committee’s decision to dispose of the complaints  
against Registrants 1, 2 and 6 under s.33(6)(b) of the Act, but no formal criticism of  
Registrants 3, 4 and 5 as provided for under s.33(6)(a) of the Act. Finally, the minutes  
reflect that the Inquiry Committee requested that “Registrar Staff” send concluding  
correspondence to the Complainant and the Registrants.  
[203] On April 27, 2021, external legal counsel to the College wrote the parties  
advising them that the Inquiry Committee considered the complaint on April 13, 2021.  
Attached to that letter was the “Final Disposition Report” authored by the College’s  
internal legal counsel “On behalf of the Inquiry Committee.”  
[204] It would have been more transparent if the Final Disposition Report had indicated  
whether the Inquiry Committee reviewed and approved of a draft of the report at its  
meeting on April 13, 2021. It would have also been more transparent if the minutes  
reflected whether the Committee had the Expectations Policy or the Code of Ethics  
before it.  
[205] Despite the shortcomings that I have noted, I am satisfied that the Inquiry  
Committee’s explanation of the decision-making process to reach the outcome was  
sufficiently transparent and intelligible.  
[206] I turn next to considering whether the outcome itself (i.e., disposing of the  
complaints with criticism of Registrant 1, Registrant 2 and Registrant 6, but without  
criticism of Registrant 3, Registrant 4 and Registrant 5) was reasonable.  
[207] I have considered that in the CPSA Investigation Report, the investigators made  
“findings” with respect to some of the Registrants but not others. It is not the role of  
investigators to make findings of fact. That said, I understand that the College’s original  
letter to the CPSA thanked that college for agreeing to adjudicate the matters. It is not  
surprising, in that context, to find the investigators used language more appropriate to a  
trial judge (tasked with making findings of fact in a civil or criminal matter) or a  
Disciplinary Committee (tasked with determining a matter under s.38(1) of the Act). By  
contrast, the Inquiry Committee is tasked only with the preliminary task of “investigating”  
(s.33(1) of the Act) and either taking “no action” or certain remedial steps (s. 33(6) of the  
Act). To the extent that the CPSA was acting on behalf of the Inquiry Committee in  
investigating the complaint for the College, it was obligated to provide the Inquiry  
Committee with “a copy of the complaint, an assessment of the complaint and any  
recommendations” regarding the disposition of the complaint (s.32(2) of the Act). I  
consider that the CPSA Report (despite differences in terminology) meets the  
requirements of the Act. I note that the CPSA Investigation Report did not include any  
recommendations.  
(A) Registrants 1, 2 and 5  
[208] As noted earlier in this decision, in its minutes, the Inquiry Committee states that  
it accepted the finding of the CPSA investigators with respect to each of these  
Registrants. Specifically, the Committee observed that Registrant 1 was the  
Complainant’s direct supervisor and was the first to learn of rumours regarding  
professional boundaries. The Committee concluded that Registrant 1 ought to have  
been prompted to start “a prompt and fair investigation” with the Complainant being  
given particulars of the complaints and the opportunity to respond. As a result, the  
Inquiry Committee was critical of Registrant 1.  
[209] The Inquiry Committee was also critical of Registrant 2 who relied on a third-  
party report in writing his report. The Committee noted that in his senior clinical and  
administrative role, Registrant 2 ought to have considered that in making a report that  
could affect the Complainant’s licensure, he should have sought substantiation of the  
allegations in his supervisor report and interviewed the Complainant directly.  
[210] While the Inquiry Committee did not reference the Expectations Policy or any  
other standard, it described its expectations of these Registrants as supervisors and  
identified how their conduct either met or fell short of that expectation. I am satisfied that  
there was a factual and legal basis for the Inquiry Committee to be critical of the  
conduct of Registrant 1 and Registrant 2 in their roles as supervisors of a provisional  
registrant (the Complainant).  
[211] Despite accepting the finding of the CPSA investigators regarding Registrant 5  
(i.e., that his reporting of serious behavioral concerns was unbalanced, and therefore,  
unfair because he made no mention of information that he received from a mental  
health worker who reported that the Complainant was being maliciously targeted in the  
workplace), the Inquiry Committee was not critical of him. Instead, the Inquiry  
Committee noted that Registrant 5 lived in a different community than the Complainant  
and “was somewhat at a remove from these matters.” The Committee added that “it is  
beyond its scope to ascertain how Registrant 5 should have weighed the different  
testimonies he was offered.”  
[212] It is difficult to reconcile the Inquiry Committee’s failure to criticize Registrant 5  
with its criticism of Registrants 1 and 2. It is unclear why the Inquiry Committee weighed  
the location of Registrant 5 as a mitigating factor in its consideration of whether he  
acted in a procedurally fair and “balanced” way in providing his Supervisor Evaluation  
Report. It is equally unclear why the Inquiry Committee measured this registrant’s  
conduct by considering that it fell outside the Inquiry Committee’s “scope” as it could not  
assess how Registrant 5 “should have weighed the different testimonies.” I have  
considered whether my difficulty in reconciling the Committee’s different treatment of  
Registrant 5 means that its disposition of the complaint regarding him was  
“unreasonable.”  
[213] My review of the Record satisfies me that Registrant 5 made a concerted effort to  
discuss concerns that were brought to his attention with the Complainant. He recorded  
and reported the Complainant’s comments and behaviours during some of their  
discussions. Clearly, it would have been better if Registrant 5 had provided information  
to the College about circumstances at the workplace that might have contributed to the  
Complainant’s behaviour and comments that were of concern. That said, I am satisfied  
that there was information in the Record that established that Registrant 5 offered the  
Complainant a fairer process than did the other two supervisors before submitting his  
supervisory report in that he met with the Complainant, heard his version of events, and  
recorded the Complainant’s reaction to the complaint. As a result, I am satisfied that  
there was a factual basis on which the Inquiry Committee could reasonably have  
decided to not be critical of Registrant 5 in his role as a supervisor of the Complainant.  
(B) Registrant 3  
[214] I have considered the Inquiry Committee’s decision to not be critical of Registrant  
3. I considered that the CPSA investigators noted that Registrant 3 acknowledged  
asking the Complainant to take files from the clinic to the hospital over a weekend on  
the basis that staff had expressed safety concerns if the Complainant were to be in the  
clinic over the weekend. The investigators also noted that Registrant 3 did not provide  
any evidence during the investigation of the concerns that were expressed to him. The  
Inquiry Committee accepted this finding but “withheld” criticism as it considered the  
matter to be an employment matter beyond its mandate.  
[215] The Inquiry Committee’s language is curious to me. It suggests both that the  
Committee had criticism but was holding it back, and that the Committee lacked the  
mandate to address the matter. It would have been clearer if the Inquiry Committee had  
stated that the allegation involved an employment matter and was not within the Inquiry  
Committee’s jurisdiction or stated that it was not critical of Registrant 3 based on the  
results of the investigation. In my view, there is a factual and legal basis for the Inquiry  
Committee to conclude that the matter arose directly in the context of the employment  
relationship between the Complainant and Registrant 3 as a senior manager of the  
Health Authority that sponsored him and was outside of the Inquiry Committee’s  
mandate. On that basis, I find that the Inquiry Committee’s disposition of the complaint  
regarding Registrant 3 was reasonable.  
(C) Registrant 4  
[216] I have considered the Inquiry Committee’s decision to not be critical of Registrant  
4. I note that the CPSA investigators made observations about the allegations regarding  
Registrant 4 but noted that there was no objective evidence to assess or support the  
allegations (i.e., that referring to the Complainant’s spouse as his “[alternat ethnic  
group] wife” was racist and that Registrant 4 solicited a complaint against the  
Complainant). The Inquiry Committee considered the matters, noted the divergent  
accounts before it and concluded that it had no objective evidence to judge whether the  
comment was racist. I am satisfied that there was a factual and legal basis for the  
Inquiry Committee’s decision to not be critical of Registrant 4 in the circumstances.  
(D) Registrant 6  
[217] I have also considered the Inquiry Committee’s decision to be critical of some of  
Registrant 6’s conduct. I note that the Inquiry Committee accepted the CPSA  
investigators’ findings with regard to Registrant 6. For instance, the investigators found  
that by telling the Complainant that his reaction to the boundary issues was worse than  
the issues themselves, Registrant 6 minimized the significance of the allegations to a  
psychiatrist. Further, they concluded that Registrant 6 appeared to have denied the  
Complainant fair process in her attempts to address an allegation of unprofessional  
conduct. The Inquiry Committee was critical of Registrant 6, in her role as a senior  
manager at the Health Authority for advising the Complainant of the boundary complaint  
but failing to provide him any details or affording him the opportunity to respond to the  
allegation. The Committee further found that it was inappropriate for Registrant 6 to  
have told the Complainant that his reaction was worse than the allegation.  
[218] I am satisfied that there was both a legal and factual basis for the Inquiry  
Committee to have been critical of Registrant 6 in the circumstances. I recognize that  
the Final Disposition Report includes considerably more detail of the Inquiry  
Committee’s discussion regarding Registrant 6. I have already stated why I am not  
satisfied that the Final Disposition Report represents the Inquiry Committee’s  
deliberations. I note that the additional detail in that report addresses why the Inquiry  
Committee concluded that certain of the allegations either were outside of its jurisdiction  
as they were “employment matters” or involved matters where the Committee was not  
critical of Registrant 6 (e.g., asking the Site Coordinator to not schedule students with  
the Complainant). I am satisfied that the Inquiry Committee’s disposition, as reflected in  
the minutes, demonstrates that it considered the key aspects of the complaint, in  
context, and reached a decision that was reasonable in the circumstances.  
[219] Finally, I am aware that the Inquiry Committee noted that it did not have means  
by which to judge whether any of the conduct described in the complaint and the CPSA  
Report was motivated by conscious or systemic racism. It then discussed the  
importance of providing better support for College-approved supervisors. Further, the  
Inquiry Committee directed that this “recommendation” be included in closing  
correspondence. I think it reasonable to expect that the College (and the Registration  
Committee, which governs the registration of provisional registrants) will give serious  
consideration to the Inquiry Committee’s recommendation and will act promptly to  
ensure that College-approved supervisors are properly trained and supported in their  
role and that both supervisors and provisional registrants are aware of what the College  
expects from them.  
[220] In sum, I find that there was both a factual basis in the investigative results, and a  
legal basis under s.33(6)(a) and (b) of the Act, for the outcomes described in the Inquiry  
Committee’s disposition.  
[221] I conclude that while not always expressed as clearly as it could have been, the  
disposition was reasonable as it was based on a comprehensive investigation which I  
have concluded was adequate. For all the reasons identified above, I am satisfied that  
both the decision-making process and the outcomes were reasonable.  
IX  
CONCLUSION  
[222] I have concluded that the investigation was adequate, and the disposition of the  
complaints was reasonable. I am exercising my authority under s.50.6(8) of the Act and  
am confirming the Inquiry Committee’s disposition.  
“Brenda L. Edwards”  
Brenda L. Edwards, Panel Chair  
Health Professions Review Board  



© 2019 IncJournal is not affiliated with or endorsed by the U.S. Securities and Exchange Commission