File # 21-CRV-0054  
HEALTH PROFESSIONS APPEAL AND REVIEW BOARD  
PRESENT:  
Mitchell Toker, Vice-Chair, Presiding  
Maria Capulong, Board Member  
Bonita Thornton, Board Member  
Review held on March 9, 2022 in Ontario (by teleconference)  
IN THE MATTER OF A COMPLAINT REVIEW UNDER SECTION 29(1) of the Health  
Professions Procedural Code, Schedule 2 to the Regulated Health Professions Act, 1991, Statutes  
of Ontario, 1991, c.18, as amended  
B E T W E E N:  
SHELLEY WHITE  
Applicant  
and  
MELISSA MAISONNEUVE, RRT  
Respondent  
Appearances:  
For the Applicant:  
The Respondent:  
For the Respondent:  
Jennifer Brown  
Melissa Maisonneuve, RRT  
Amanda Lawrence-Patel, Counsel  
Cosimo Morin (Student-at-Law)  
For the College of Respiratory  
Therapists of Ontario:  
Shaf Rahman and Sophia Rose  
DECISION AND REASONS  
I.  
DECISION  
1.  
The Health Professions Appeal and Review Board confirms the decision of the Inquiries,  
Complaints and Reports Committee of the College of Respiratory Therapists of Ontario  
to take no further action while reminding Melissa Maisonneuve, RRT of her professional  
obligation to adhere more strictly to the College of Respiratory Therapists of Ontario  
Standards of Practice; specifically, that communication with the patient and the patient’s  
healthcare team must be conducted in a timely manner and documented.  
2.  
This decision arises from a request made to the Health Professions Appeal and Review  
Board (the Board) by Shelley White (the Applicant) to review a decision of the Inquiries,  
Complaints and Reports Committee (the Committee) of the College of Respiratory  
Therapists of Ontario (the College). The decision concerned a complaint regarding the  
conduct and actions of Melissa Maisonneuve, RRT (the Respondent). The Committee  
investigated the complaint and decided to take no further action.  
II.  
BACKGROUND  
3.  
The patient was diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and  
was receiving home respiratory care through Praxair-Medigas (“Medigas”).  
4.  
5.  
The Respondent was employed by Medigas. She saw the patient on August 23, 2019, for  
a routine home oxygen assessment. She saw the patient again on August 30, 2019.  
When the Respondent arrived at the patient’s home on August 30, 2019, the patient was  
having trouble breathing, experiencing low oxygen saturation levels, cyanosis in her  
fingers and nose, shortness of breath and inability to walk. The Respondent made  
adjustments to the patient’s oxygen saturation levels to help improve her breathing.  
6.  
The following day, the Applicant called an ambulance, and the patient was admitted to  
Hawkesbury General Hospital (the hospital).  
7.  
8.  
Sadly, the patient passed away September 15, 2019.  
The Applicant is the patient’s niece. At the relevant time, the Applicant and AB, the  
patient’s son, were the patient’s Power of Attorney for Personal Care.  
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The Complaint and the Response  
The Complaint  
9.  
The Applicant complained to the College about the respiratory therapy care the  
Respondent provided to the patient on August 30, 2019. Specifically, the Applicant  
complained that the Respondent:  
(i) failed to abide by the orders of the patient’s doctor by inappropriately or  
incorrectly raising the patient’s oxygen flow rate from the ordered rate flow of .5-  
1 L/ minute to 5-8L/minute without consultation with the doctor, causing the  
patient to suffer acute hypercapnic respiratory failure, resulting in her  
hospitalization;  
(ii) failed to see a significant deterioration in the patient’s health status from the  
previous visit or to call for an ambulance when she discovered that the patient was  
short of breath, slow to respond, and unable to get up or walk, with edema in her  
feet and legs;  
(iii) failed to notify the patient’s doctor of the Respondent’s intervention and expected  
the patient to notify the doctor of such; and  
(iv) was dismissive of the concerns and wishes of the Powers of Attorney for Personal  
Care of the patient by not calling an ambulance as they requested.  
10.  
The Applicant added context to her complaint including the following:  
The Applicant is a Registered Nurse.  
The patient’s neighbour, JP and the patient’s sisters, SL and RL were at the  
patient’s home on August 30, 2019. When they arrived, they found the patient  
cyanotic, with blue fingers and nose, unable to walk and strained to speak.  
3
While the Applicant was not present at the patient’s home on August 30,  
2019, she was on the telephone with the patient’s neighbour during the  
relevant period of time.  
After arriving at the patient’s home on August 30, 2019, and following an  
assessment of the patient, the Respondent increased the oxygen flow rate to 8  
LPM, leaving it at that rate, and left a note on the fridge indicating to increase  
flow rates when walking, until the patient’s oxygen saturation level was 88%  
to 92%.  
The Applicant noted that the patient could not get up or walk and her oxygen  
saturation level was rarely that high even during a previous hospital stay.  
The Applicant felt that the Respondent’s assessment of the patient should  
have led her to call an ambulance for her and that the Respondent’s  
intervention was contradictory to the doctor’s order upon the patient’s  
previous discharge from the hospital.  
The Applicant acknowledged that the atmosphere in the patient’s home on  
August 30, 2019, was “incredibly stressful, loud, emotional, confrontational,  
and had to be awful for [the Respondent].” While two of the patient’s sisters  
were onsite during the Respondent’s visit on August 30, 2019, and agreed  
with the Respondent’s intervention, the Applicant and AB (neither of whom  
were at the patient’s home at the time) disagreed with the Respondent’s  
decision to raise the patient’s oxygen flow rate to 8 LPM and requested that  
the Respondent call an ambulance.  
The Respondent was dismissive of this request, responding that the patient did  
not want to leave her home.  
4
The Applicant inquired whether the Respondent could change flow rates  
without an order from the doctor. The Respondent stated she could, as long as  
the doctor was notified soon after. The Applicant stated that the Respondent  
told her that the patient would call her doctor the following Monday (which  
was three days later).  
The following day, the Applicant called an ambulance and had the patient  
admitted to the hospital.  
The hospital’s admission document stated that the patient had “hypercapnia  
due to the oxygen being turned up too high, she was confused and in  
respiratory failure.”  
The Applicant followed up with Medigas to complain about the Respondent’s  
care of the patient but felt that the company did not take her complaints  
seriously, that she was ignored and that they did not review their practices,  
policies or procedures as a result of her complaint.  
The patient died on September 15, 2019, in the hospital.  
The Applicant stated that she felt the actions of the Respondent were the  
reason the patient’s life “ended so quickly” and that the Respondent should  
have listened to the Applicant and AB, as the patient’s Powers of Attorney for  
Personal Care.  
The Response  
11.  
The Respondent provided information in response to the complaint. The following is a  
summary of the Respondent’s information.  
5
12.  
13.  
The Respondent was employed as a respiratory therapist with Medigas, for approximately  
three and a half years. As a Register Respiratory Therapist (RRT) her responsibilities  
include the initiation and follow up of home oxygen therapy provided to individuals in  
their homes.  
At her initial visit to the patient’s home on August 23, 2019, the Respondent performed a  
routine initial clinical assessment and assessed the patient’s oxygen therapy equipment.  
At this visit, the patient appeared stable at her prescribed oxygen flow of 1Lpm at rest  
and 4Lpm on exertion. The patient indicated that she would like a portable oxygen  
concentrator (“POC”), which the Respondent agreed to deliver. Also present during this  
visit was the patient’s son (AB), who also indicated that he was satisfied with the oxygen  
equipment.  
14.  
15.  
The purpose of the Respondent’s visit to the patient on August 30, 2019, was to provide  
the POC the patient had requested and to test it to ensure that the patient’s breathing  
would trigger the POC pulse dose.  
When she arrived at the patient’s home on August 30, 2019, at 11:45 a.m., she met the  
patient’s two sisters. The Respondent observed that the patient looked a little tired and  
presented with peripheral and central cyanosis (i.e., bluish colour on her nose and  
fingers). The patient’s saturation as indicated by the oximeter was 68% on 1Lpm 02. In  
response to the Respondent’s questions, the patient indicated that for the past couple of  
days she had felt more tired and more out of breath than usual.  
16.  
17.  
The Respondent told the patient that she would increase her oxygen flow rate to help her  
breathing and to increase her oxygen level. Based on her assessment of the patient and  
her professional judgement, the Respondent increased the patient’s oxygen flow to 5Lpm  
02.  
The Respondent stated that as an RRT, she is permitted to increase oxygen flow to a  
patient.  
6
18.  
19.  
According to the Respondent, shortly after increasing the oxygen flow, the patient’s  
blood oxygen saturation was 91-92%, her colour returned and she indicated that she felt  
better and that her breathing was much better.  
The Respondent advised the patient and her two sisters that the patient should go to the  
hospital and be seen by a physician given that increasing the patient’s oxygen flow was  
only a temporary solution to her low oxygen saturation. In response to the patient  
declining to go to the hospital, the Respondent repeated her recommendation that the  
patient should go to the hospital and that the Respondent could call an ambulance for her.  
The patient continued to refuse the Respondent’s advice.  
20.  
While recognizing that a hypoxic individual may be confused, the patient gave no reason  
to believe that she may have been confused or that her judgement was diminished. She  
responded accurately to every question the Respondent asked her and appeared at all  
times to be sound of mind.  
21.  
22.  
The Respondent tested the patient’s oxygen flow on exertion. After two tests, the patient  
indicated that she felt less shortness of breath on the second walk.  
In response to the Applicant’s statement that the patient “couldn’t walk or get up out of  
the chair”, the Respondent indicated that the patient was able to walk to and from the  
kitchen and her bedroom with the aid of her walker.  
23.  
As the Respondent was finishing the second test of the patient’s oxygen flow, the  
patient’s son, AB called. AB told the Respondent that she had no right to increase the  
patient’s oxygen and that only a doctor is allowed to do so. According to the Respondent,  
AB stated that the patient has COPD and that increasing her oxygen level is “dangerous”.  
AB told the Respondent to decrease the patient’s oxygen to 1Lpm and that if she did not,  
then he would “press charges”. The Respondent stated that AB was yelling loudly and  
not allowing her an opportunity to speak.  
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24.  
When she could speak, the Respondent explained that as a RRT she is authorized to  
increase the patient’s oxygen level. The Respondent indicated that AB continued to  
disagree with the Respondent. AB told the Respondent to bring her oxygen back to a  
normal level and that if the patient wanted more oxygen, she needed to go to the hospital.  
The Respondent told AB that had advised the patient to go to the hospital, but she had  
refused.  
25.  
The Respondent stated that AB and the patient continued to speak and argue over the  
telephone. The patient told AB that she wanted the oxygen flow to kept at 5Lpm because  
she felt much better. The patient also told AB that she did not want to go to the hospital  
and instructed the Respondent to leave her oxygen flow on 5Lpm.  
26.  
27.  
The Respondent described that an ongoing, intense family dynamic between the patient,  
two sisters and AB (who was on the telephone) continued for a period of time.  
The Respondent stated that she reiterated to the patient that she should go to the hospital  
because increasing her oxygen flow is a temporary solution to correct her hypoxemia and  
she needs to see a physician to determine the cause of her hypoxemia. The Respondent  
offered to call an ambulance for the patient to which the patient responded that she  
wanted to “wait a little bit” and if she felt worse, she would go to the hospital, and  
regardless, she would call her family physician first thing Monday morning.  
28.  
Before she left the patient’s home, the Respondent indicated that a Medigas homecare  
service representative would provide her with a high flow concentrator in order to  
provide oxygen flow at 5Lpm at rest and 8Lpm on exertion. The Respondent also showed  
the patient and her sisters how and when to reduce the oxygen flow based on the patient’s  
oxygen saturation in order to avoid C02 retention, so long as the reduced flow was within  
the prescribed oxygen flow rate.  
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29.  
30.  
Before she left, the Respondent asked one of the patient’s sisters to help convince the  
patient to go to the hospital.  
The Respondent stated that later that day, she received a call from the Applicant,  
expressing concern about the patient’s health. The Respondent explained what has  
occurred at the patient’s earlier that morning and explained her reasons for increasing the  
patient’s oxygen flow. The Respondent indicated that conversation with the Applicant  
was calm and polite and that it was the last time she spoke with the Applicant and any of  
the patient’s family members.  
31.  
The Respondent explained that since August 30, 2019 fell on the Friday of the Labour  
Day long weekend and that she understood that the patient’s prescribing physician’s  
offices were closed over the long weekend, she telephoned the prescribing physician’s  
office on Tuesday, September 2, 2019, to notify of the flow rate change and to have the  
physician issue a revised prescription. She followed up with a further telephone call and  
facsimile on Monday, September 9, 2019.  
32.  
In summary, the Respondent wrote that she acted in accordance with the College’s  
standards of practice in assessing and providing care to the patient during the August 30,  
2019, visit. The Respondent indicated that at all times during this visit the patient was  
lucid and communicated clearly. The Respondent reiterated that she repeatedly urged the  
patient to go to a hospital or call an ambulance so that she could be seen by a physician  
who could assess the cause of her hypoxia.  
Section 75 Investigation  
33.  
On March 16, 2020, the College’s Registrar and CEO approved the appointment of an  
investigator pursuant to section 75 of Health Professions Procedural Code1.  
1
Schedule 2 to the Regulated Health Professions Act, 1991, Statutes of Ontario, 1991, c.18, as amended.  
9
34.  
As part of the section 75 investigation, both the Applicant and Respondent provided  
additional information to the investigator (including the Respondent’s response  
summarized above). As well, the investigator obtained statements from the Applicant,  
Respondent, the patient’s son (AB), the patient’s sisters (SL and RL) and the patient’s  
neighbour (JP) and the patient’s medical records from Medigas and the hospital.  
35.  
36.  
The section 75 investigation report was shared with the Applicant and Respondent on  
June 3, 2020.  
The Respondent did not provide any further comments. The Applicant provided a further  
written response on June 18, 2020, in which she stated that there are many  
inconsistencies in the investigation report regarding the accounts of the events that  
needed to be clarified and/or corrected. The Applicant also stated that she had questions  
and concerns regarding the role of RRTs at Medigas and requested further information  
with respect to Medigas’ RRT job description and various policies and procedures.  
37.  
In response to these questions and requests for further information, a supplementary  
investigation report was prepared on August 10, 2020 and sent to the Applicant and  
Respondent. This supplementary report included additional information with respect to  
Medigas’ RRT job description and Medigas’ policies and procedures for:  
controlled acts, particularly with respect to the controlled act “administrating a  
prescribed substance by inhalation;  
initiating, titrating and discontinuing oxygen;  
changing a prescribed oxygen concentration and the definition of “a reasonable”  
time for notifying the prescribing physician of the change in the amount of  
oxygen and the reasonable method(s) of notifying the prescribing physician; and  
calling for assistance, i.e., ambulance, supervisor, etc.  
10  
The Committee’s Decision  
38.  
The Committee investigated the complaint and concluded that the information did not  
support a breach of the standards of practice of the College in relation to the allegations  
brought forward in the Applicant’s complaint. For this reason, the Committee decided to  
take no further action.  
39.  
The Committee did note minor concerns with the Respondent’s delay in providing the  
faxed information to the patient’s doctor and in not documenting in a more fulsome  
manner her conversation with the patient and decided to remind the Respondent of her  
professional obligations with respect to timely and documented communications with the  
patient and the patient’s healthcare team.  
40.  
In reaching its decision the Committee addressed each of the Applicant’s concerns as  
detailed below.  
Respondent failed to abide by the orders of the patient’s doctor by inappropriately or  
incorrectly raising the patient’s oxygen flow rate from the ordered rate flow of .5-1 L/ minute  
to 5-8L/minute without consultation with the doctor, causing the patient to suffer acute  
hypercapnic respiratory failure, resulting in her hospitalization.  
41.  
42.  
43.  
The Committee was of the view that the information did not support the allegation that  
the Respondent failed to abide by the doctor’s order and inappropriately or incorrectly  
raised the patient’s oxygen titration level.  
In reaching this conclusion, the Committee noted that RRTs are permitted to  
independently titrate oxygen therapy for patients in the homecare setting, without  
consultation with a doctor.  
The Committee observed that the patient’s sisters and the Respondent’s statements  
supported that the patient’s condition had deteriorated: the patient was short of breath, the  
patient’s nose and fingers where cyanotic and the patient’s O2 saturation level was low.  
11  
44.  
The Committee concluded that the Respondent’s intervention to increase the oxygen flow  
rate demonstrates that she used her knowledge, skill and judgement when providing care  
to the patient.  
Respondent failed to see a significant deterioration in the patient’s health status from the  
previous visit or to call for an ambulance when she discovered that the patient was short of  
breath, slow to respond, and unable to get up or walk, with edema in her feet and legs.  
45.  
46.  
47.  
The Committee was of the view that the information before it did not appear to support  
the allegation that the Respondent failed to recognize that the patient’s condition had  
deteriorated.  
In reaching this conclusion, the Committee noted that the information before it appeared  
to support that the Respondent recognized the change in the patient’s condition  
immediately and took action by increasing the patient’s oxygen flow rate.  
The Committee concluded that based on the information before it, the deterioration in the  
patient’s condition was an issue of oxygenation that would not be solved by  
administration of the patient’s inhalers and would have been the beyond the scope of the  
Respondent’s visit to provide education about the patient’s inhaler.  
48.  
With respect to the concern that the Respondent should have called an ambulance, the  
Committee was of the view that the information before it indicated that the Respondent  
was following the patient’s expressed wishes in not calling for the ambulance. The  
Committee noted that patients have the right to refuse proposed treatment and care when  
offered. The Committee observed that while a RRT can advise a patient as to their  
recommended course of treatment, it would not be appropriate for an RRT to disregard  
the patient’s wishes when the patient is determined to be able to make their own  
decisions as evaluated by an RRT.  
49.  
The Committee reminded the Respondent of her responsibility to document all relevant  
conversations and interactions with patients and their families in the health record, which  
12  
would include a patient’s request not to call an ambulance when an ambulance would  
otherwise be warranted.  
50.  
For the foregoing reasons, the Committee was of the view that the information before it  
did not support a contravention of the standards of practice with respect to these  
concerns.  
Respondent failed to notify the patient’s doctor of the Respondent’s intervention and expected  
the patient to notify the doctor of such.  
51.  
The Committee was of the opinion that the information before it did not support the  
allegation that the Respondent failed to notify the doctor of the Respondent’s intervention  
and expected the patient to notify the doctor of such.  
52.  
In reaching this opinion, the Committee noted that the Respondent left a voicemail for the  
patient’s physician on Tuesday September 2, 2019, as the doctor’s office was closed on  
the Monday for the long weekend. The Committee further noted that when the physician  
did not return the Respondent’s phone call, the Respondent faxed the assessment and  
request for a revised prescription on September 9, 2019, and also noted on the facsimile  
the patient’s oxygen saturation statistics and settings as well as the Respondent’s  
recommendation to the patient to seek medical attention as the patient had not felt well  
for the past couple of days.  
53.  
54.  
The Committee also stated that it was not unreasonable for the Respondent to wait until  
after the long weekend to follow up with the patient’s physician, and that it was not  
unreasonable for the message to reach the physician until the doctor’s office reopened.  
The Committee did express some concern regarding the delay in the Respondent’s  
facsimile follow-up with the patient’s doctor and the fact that the Respondent did not  
expressly state the urgency of care needed from the physician in the facsimile. The  
Committee stated that it did not believe that this action rose to the level of concern that  
required any action from the College, the Committee stated that it wished to stress to the  
13  
Respondent that it would have been prudent for her to have followed-up the second time  
in a more timely manner.  
Respondent was dismissive of the concerns and wishes of the Powers of Attorney for Personal  
Care of the patient by not calling an ambulance as they requested.  
55.  
The Committee affirmed that a Power of Attorney would only come into effect when the  
patient has been deemed incapable to make their own decisions. The Committee  
concluded that based on the information before it, there was nothing to support that the  
patient was unable to make her own decisions on August 30, 2019. The Committee noted  
that the statements from the patient’s sister as well as the Respondent’s assessment of the  
patient indicated that the patient was alert, responding appropriately, and clearly  
expressed a wish to remain at home and not go to hospital.  
56.  
The Committee noted that under such a circumstance, the Respondent would be expected  
to honour the patient’s decisions regarding her own care, even when those decisions  
contradicted the wishes of family members. The Committee further noted that statements  
from the patient’s sisters indicated that the Respondent was calm and professional in her  
response to the AB, the patient’s son.  
57.  
For these reasons, the Committee was of the view that the information before it did not  
appear to support the allegation that the Respondent behaved inappropriately or otherwise  
contravened the College’s standards of practice.  
Applicant’s additional concerns that:  
Respondent failed to document that she attempted to convince the patient to attend a  
hospital on August 30, 2019.  
Patient was brought to the emergency room on August 31, 2019, with a diagnosis of  
acute hypercapnic respiratory failure, severe bronchospasm, and that the patient  
passed away September 15, 2019.  
58.  
The Committee also addressed additional concerns that were raised by the Applicant over  
the course of the investigation.  
14  
59.  
With respect to the Respondent’s documentation of her discussion with the patient, while  
agreeing that the Respondent did not document specifically that she had advised the  
patient to attend the hospital, the Committee concluded that based on the information  
before it, it was clear the patient did not want to go to the hospital, and the Respondent’s  
failure to document her advice to the patient did not give rise to any serious concerns  
about the Respondent’s practice or represent a serious risk to the patient.  
60.  
In deciding to take no action regarding the Applicant’s information that the patient was  
brought to the emergency room on August 31, 2019, with a diagnosis of acute  
hypercapnic respiratory failure, severe bronchospasm, the Committee noted that the  
hospital’s discharge note of September 15, 2019 indicated a diagnosis of “acute  
respiratory failure,” which is not the same as respiratory failure secondary to a hypoxic  
drive to breathe (O2 toxicity). The Committee also noted that acute respiratory failure can  
be prompted by a number of different causes, including the patient’s baseline lung  
function. Finally, the Committee reiterated its view that the Respondent was correct in  
her assessment of low spO2 and in her intervention to increase LPM O2 because  
hypoxemia must be treated in all patients.  
III.  
REQUEST FOR REVIEW  
61.  
In a letter dated February 3, 2021, the Applicant requested that the Board review the  
Committee’s decision.  
IV.  
POWERS OF THE BOARD  
62.  
After conducting a review of a decision of the Committee, the Board may do one or more  
of the following:  
a) confirm all or part of the Committee’s decision;  
b) make recommendations to the Committee;  
15  
c) require the Committee to exercise any of its powers other than to request a  
Registrar’s investigation.  
63.  
The Board cannot recommend or require the Committee to do things outside its  
jurisdiction, such as make a finding of misconduct or incompetence against the member,  
or require the referral of allegations to the Discipline Committee that would not, if  
proved, constitute either professional misconduct or incompetence.  
V.  
ANALYSIS AND REASONS  
64.  
Pursuant to section 33(1) of the Health Professions Procedural Code (the Code), being  
Schedule 2 to the Regulated Health Professions Act, 1991, the mandate of the Board in a  
complaint review is to consider either the adequacy of the Committee’s investigation, the  
reasonableness of its decision, or both.  
65.  
66.  
At the Review, the Applicant stated that she did not have any questions or concerns  
regarding the adequacy of the investigation.  
The Applicant submitted the Committee’s decision was not reasonable and cited the  
following reasons in support of this argument.  
The Applicant reiterated the concerns raised in the original complaint to the  
College.  
The Applicant maintained that the Committee’s decision focused too much  
attention on the Respondent’s documentation rather than the actual care that was  
provided to the patient on August 30, 2019.  
The Applicant maintained that the Respondent’s care of the patient fell below the  
standard of care expected of RRTs by failing to find that the patient was in  
16  
respiratory failure, failing to recognize the patient required medical attention and  
leaving the patient in distress.  
The Applicant further submitted that the Respondent acted beyond her scope of  
practice when she increased the patient’s oxygen level.  
The Applicant maintained that the Committee failed in its mandate to review the  
Respondent’s standard of care.  
The Applicant questioned the credentials of the Committee members and  
submitted that they were biased in their decision.  
The Applicant stated the Committee underestimated how critical the situation was  
on August 30, 2019 and emphasized that the patient was not capable of making  
her own decisions.  
67.  
At the Review, Counsel for the Respondent submitted that the Committee’s investigation  
was adequate, and its decision was reasonable. She submitted that the Board should  
confirm the Committee’s decision.  
68.  
69.  
The Board has considered the submissions of the parties, examined the Record of  
Investigation (the Record), and reviewed the Committee’s decision.  
In conducting this complaint Review, the Board assesses the adequacy of an investigation  
and reasonableness of a Committee decision in reference to its role and dispositions  
available to it when investigating and then assessing a complaint filed about a member’s  
conduct and actions.  
70.  
In this regard, the Committee is to act in relation to the College’s objectives under section  
3 of the Code, which include, in part, to maintain programs and standards of practice to  
assure the quality of the practice of the profession, to maintain standards of knowledge  
17  
and skill and programs to promote continuing improvement among the members, and to  
serve and protect the public interest.  
71.  
The Committee’s mandate is to screen complaints about its members. The Committee  
considers the information it obtains to determine whether, in all of the circumstances, a  
referral of specified allegations of professional misconduct to the College’s Discipline  
Committee is warranted or if some other remedial action should be taken. Dispositions  
available to the Committee upon considering a complaint include taking no action with  
regard to a member’s practice, issuing a caution or directing other remedial measures  
intended to improve an aspect of a member’s practice or referring specified allegations of  
professional misconduct or incompetence to the Discipline Committee, if the allegations  
are related to the complaint.  
Adequacy of the Investigation  
72.  
An adequate investigation does not need to be exhaustive. Rather, the Committee must  
seek to obtain the essential information relevant to making an informed decision  
regarding the issues raised in the complaint.  
73.  
The Committee obtained the following documents:  
the Applicant’s letter of complaint;  
memoranda of conversations between the investigator and the Applicant and the  
investigator and the Respondent;  
the Respondent’s response;  
contemporaneous notes and records from the Respondent’s August 23 and 30,  
2019 visits to the patient;  
hospital records from the patient’s admission to the hospital on August 31, 2019;  
written summaries of interviews with the Applicant, Respondent, patient’s son,  
sisters and neighbour;  
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Medigas’ documents including the RRT job description and relevant policies and  
procedures;  
College of Respiratory Therapist of Ontario - Standards of Practice;  
College of Respiratory Therapist of Ontario Professional Practice Guidelines for  
Authorized Acts and Documentation; and  
Ontario Regulation 753/93 (Professional Misconduct), Respiratory Therapy Act  
1991.  
74.  
Both the Applicant and Counsel for the Respondent submitted that the Committee  
gathered the relevant information to assess the Applicant’s complaint.  
75.  
76.  
The Board finds the Committee’s investigation was adequate for the following reasons.  
The Board notes that the Committee obtained the Applicant’s complaint, additional  
information from the Applicant, the Respondent’s response as well patient’s medical  
records from the Respondent and from the hospital. The parties were offered  
opportunities to submit information to the Committee and both parties did so. In addition,  
through the appointment of an investigator under section 75, the Committee obtained  
additional information including statements from witnesses involved in the events on  
August 30, 2019, leading up to this complaint and additional information from Medigas  
related to relevant policies and procedures.  
77.  
78.  
The Board finds that the Committee gathered the essential, relevant information with  
which to consider the Applicant’s complaint about the Respondent’s standard of care.  
There is no indication of further information that might reasonably be expected to have  
affected the decision, should the Committee have acquired it. Accordingly, the Board  
finds that the Committee’s investigation was adequate.  
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Reasonableness of the Decision  
79.  
In considering the reasonableness of the Committee’s decision, the question for the Board  
is not whether it would arrive at the same decision as the Committee, but whether the  
Committee’s decision can reasonably be supported by the information before it and can  
withstand a somewhat probing examination. In doing so, the Board considers whether the  
decision falls within a range of possible, acceptable outcomes that are defensible in  
respect of the facts and the law.  
80.  
81.  
In reaching its decision, the Committee reviewed all of the information related to the  
Applicant’s concerns. The Committee considered each of the Applicant’s identified  
concerns separately on its own merits and considered additional issues that were raised  
by the Applicant over the course of the investigation.  
The Board will first address submissions advanced by the Applicant at the Review and  
then address the concerns as outlined by the Committee.  
Committee composition and bias  
82.  
83.  
At the Review, the Applicant questioned the credentials of the Committee members and  
submitted that they were biased in their decision.  
The Counsel for the Respondent submitted that there is neither any basis to question the  
credentials of the Committee, nor any reason to suggest the Committee was biased in any  
manner.  
84.  
The Board is not persuaded that the composition of the Committee’s panel rendered the  
decision unreasonable. Section 25(2) of the Code prescribes that a panel of the  
Committee investigating a complaint, shall be composed of at least three persons, at least  
one of whom shall be a public member. In this complaint, the Committee was comprised  
of three RRTs and one member of the public. The Board concludes that the composition  
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of the Committee met the requirements of the Code and that the Committee members had  
the requisite knowledge and expertise to review the Respondent’s conduct and actions in  
light of the Applicant’s complaint to the College.  
85.  
The Board finds no information to support for the Applicant’s assertion that the  
Committee was biased. Rather, as set out in detail below, the Committee’s decision was  
based on the information in the Record.  
Respondent failed to abide by the orders of the patient’s doctor by inappropriately or  
incorrectly raising the patient’s oxygen flow rate from the ordered rate flow of .5-1 L/ minute  
to 5-8L/minute without consultation with the doctor, causing the patient to suffer acute  
hypercapnic respiratory failure, resulting in her hospitalization  
86.  
Regarding the first concern, the Committee concluded that the information did not  
support the allegation that the Respondent failed to abide by the doctor’s order and  
inappropriately or incorrectly raised the patient’s oxygen titration level.  
87.  
The Board finds that the Committee’s conclusion was supported by the information in the  
Record including the Respondent’s statement to the section 75 investigator, the  
Respondent’s progress notes from August 30, 2019 and the statements by the patient’s  
sisters who were both present on August 30, 2019. The Board finds that all of this  
information supports the Committee’s conclusion that at the time in question the patient’s  
condition had deteriorated to the point where her O2 saturation level was low.  
88.  
Further, in the Board’s view, the circumstances of this concern required the Committee,  
which included three professional RRT members, to rely on its knowledge and expertise  
related to the expected standards of the RRTs in assessing the Respondent’s conduct and  
actions. The Board finds that it was reasonable for the Committee to rely on its expertise  
in confirming that RRTs are permitted to independently titrate oxygen therapy for  
patients in the homecare setting, without consultation with a doctor.  
Respondent failed to see a significant deterioration in the patient’s health status from the  
previous visit or to call for an ambulance when she discovered that the patient was short of  
breath, slow to respond, and unable to get up or walk, with edema in her feet and legs.  
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89.  
90.  
With respect to these concerns, the Committee concluded that the information did not  
support the allegation that the Respondent failed to recognize that the patient’s condition  
had deteriorated or failed to call for an ambulance.  
The Board notes that in reaching this conclusion, the Committee reviewed the  
information before it, including the witness statements of the Applicant, Respondent,  
neighbours and the patient’s son, the Respondent’s contemporaneous notes and her  
response to the Committee. The Board finds that it was reasonable for the Committee to  
conclude that the Respondent indeed recognized the change in the patient’s condition  
immediately and took action by increasing the patient’s oxygen flow rate.  
91.  
The Committee was not concerned that the Respondent did not call an ambulance to take  
the patient to the hospital. In reaching this conclusion the Committee stated that patients  
have the right to refuse proposed treatment and care when offered and that while a RRT  
can advise a patient as to their recommended course of treatment, it would not be  
appropriate for an RRT to disregard the patient’s wishes when the patient is determined  
to be able to make their own decisions as evaluated by an RRT.  
92.  
93.  
The Board finds that it was reasonable for the Committee to rely on its knowledge and  
expertise in acknowledging that RRTs cannot disregard the patient’s wishes when the  
patient is determined to be capable to make their own decisions.  
The Board also finds that it was reasonable for the Committee to remind the Respondent  
of her responsibility to document all relevant conversations and interactions with patients  
and their families in the health record, which would include a patient’s request not to call  
an ambulance when an ambulance would otherwise be warranted. The Board observes  
that in reminding the Respondent, the Committee had before it the College’s Standards of  
Practice with respect to record keeping.  
94.  
In her submissions at the Review, the Applicant stated it was not reasonable for the  
Committee to conclude that the patient was capable at the relevant time. The Board finds  
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that the Committee’s conclusion that the patient was capable at the relevant time is  
reasonable. It is clear from the Committee’s decision that it considered the information  
from all of the witnesses who were present in the patient’s home on August 30, 2019. The  
Board notes that there is no indication anywhere in the record that the patient was not  
capable to make her own decision with respect to whether an ambulance should have  
been called.  
Respondent failed to notify the patient’s doctor of the Respondent’s intervention and expected  
the patient to notify the doctor of such.  
95.  
96.  
The Committee concluded that the information before it did not support the allegation  
that the Respondent failed to notify the doctor of the Respondent’s intervention.  
The Board finds that the Committee’s decision to take no action is reasonable. It is clear  
from the Committee’s decision that it considered the information in the Record. For  
example, in reaching its decision, the Committee relied in part on the Respondent’s  
September 9, 2019, facsimile to the patient’s physician that stated “the [patient] was seen  
[…] on August 30th, 2019. Upon arrival client was saturating on 1 Lpm 02 with presence  
of peripheral cyanosis. Oxygen flow was increased to 5LPM for Sp02 91-92% at rest and  
she required 8Lpm for Sp02 91% on exertion. […] I did recommend her to seek medical  
attention,”  
97.  
The Board observes that the Committee did express some concern with the delay in the  
Respondent’s follow-up with the patient’s doctor. In light of this concern, the Board finds  
that it was reasonable for the Committee to stress to the Respondent that it would have  
been prudent for her to have followed-up the second time in a more timely manner.  
Respondent was dismissive of the concerns and wishes of the Powers of Attorney for Personal  
Care of the patient by not calling an ambulance as they requested.  
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98.  
99.  
Regarding this concern, the Committee determined that the information before it did not  
appear to support the allegation that the Respondent behaved inappropriately or otherwise  
contravened the College’s standards of practice.  
For the reasons detailed above, the Board finds that it was reasonable for the Committee  
to conclude that there was no information before the Committee to support that the  
patient was unable to make her own decisions on the date of the incident. Having made  
this determination, the Board finds that the Committee’s conclusion that the Power of  
Attorney had not come into effect, is reasonable.  
Respondent failed to document that she attempted to convince the patient to attend a hospital  
on August 30, 2019.  
100. In considering this complaint, the Committee concluded that the Respondent’s failure to  
document her advice to the patient to go to the hospital, did not give rise to any serious  
concerns about the Respondent’s practice or represent a serious risk to the patient. The  
Board finds that it was reasonable for the Committee to rely on its expertise in reaching  
this conclusion.  
Patient was brought to the emergency room on August 31, 2019, with a diagnosis of acute  
hypercapnic respiratory failure, severe bronchospasm, and that the patient passed away  
September 15, 2019.  
101. In declining to take any action regarding this complaint, the Committee noted that the  
patient’s presenting diagnosis at the hospital evolved as further investigations were  
undertaken. Moreover, the Committee reiterated its finding that the Respondent was  
correct in her assessment of the patient’s low spO2 and her intervention to increase LPM  
O2 because hypoxemia must be treated in all patients.  
102. In making this finding the Board finds that the Committee relied on the patient’s hospital  
records in the Record and that it was reasonable for the Committee to rely on its  
knowledge and expertise in finding that the Respondent’s actions were appropriate when  
faced with a hypoxemic patient.  
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Conclusion  
103. In conclusion, the Board finds that the investigation was adequate, and the Committee’s  
decision is reasonable. The Committee’s decision makes it clear that it considered the  
Applicant’s concerns with respect to the Respondent, addressed those concerns and  
provided coherent reasons for its conclusions. While the Board acknowledges that the  
Applicant disagrees with the decision, having considered the submissions of the parties,  
the information in the Record and the Committee’s decision, the Board finds that the  
Committee’s decision demonstrates a coherent and rational connection between the  
relevant facts, the outcome of the decision and the reasoning process that led it to that  
outcome, and that the decision as a whole is transparent, intelligible and justified.  
104. The Board wishes to extend its condolences to the Applicant on the loss of her aunt.  
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VI.  
DECISION  
105. Pursuant to section 35(1) of the Code, the Board confirms the Committee’s decision to  
take no further action while reminding the Respondent of her professional obligation to  
adhere more strictly to the College of Respiratory Therapists of Ontario Standards of  
Practice; specifically, that communication with the patient and the patient’s healthcare  
team must be conducted in a timely manner and documented.  
ISSUED July 7, 2022  
Mitchell Toker  
___________________________  
Mitchell Toker  
Maria Capulong  
___________________________  
Maria Capulong  
Bonita Thornton  
___________________________  
Bonita Thornton  
Cette décision est aussi disponible en français. Pour obtenir la version de la décision en français, veuillez contacter  
[email protected]  
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