File # 21-CRV-0242  
HEALTH PROFESSIONS APPEAL AND REVIEW BOARD  
PRESENT:  
Anna-Marie Castrodale, Designated Vice-Chair, Presiding  
Jean Bédard, Board Member  
Mitchell Toker, Vice-Chair  
Review held on May 10, 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:  
SONY POULOSE, R.Ph  
Applicant  
and  
JO-ANNE WHITEMAN  
Respondent  
Appearances:  
The Applicant:  
For the Ontario College of Pharmacists:  
Sony Poulose, R.Ph  
Marwa Al Orbani  
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 Ontario College of Pharmacists to issue Sony  
Poulose, R.Ph advice/recommendations and require him to complete specified  
remediation (SCERP) as detailed in paragraphs #2 and #3 below.  
2.  
The Ontario College of Pharmacists issued the following advice/recommendations to  
Sony Poulose, R.Ph:  
The Panel is of the view that Advice/Recommendations will assist the Member in  
how he may be more thoughtful in his practice when performing checks and  
developing policies and procedures which staff follow at all times. The Panel  
therefore takes this opportunity to advise the Member of his specific obligations  
under the NAPRA Model Standards of Practice and particularly advises the  
Member of the following:  
Standard #1: Expertise in medications and medication-use.  
General Standard  
Pharmacists apply their medication use expertise while performing their daily  
activities.  
Model Standard of Practice  
Pharmacists regardless of the role they are fulfilling:  
…
5. use evidence from relevant sources to inform their activities  
6. critically evaluate medication and related information  
…
Model Standard of Practice  
Pharmacists, when responsible for medication distribution/supply:  
…
38. ensure that quantities dispensed are correct  
…
Standard #3: Safety and Quality  
General Standard  
Pharmacists undertake continuing professional development, quality assurance  
and quality improvement.  
Model Standard of Practice  
Pharmacists regardless of the role they are fulfilling:  
…
3. ensure that staff or support personnel for whom they are  
responsible are delegated and undertake pharmacy related  
activities appropriate to their training and consistent with  
legislation, regulations and policies  
4. ensure that staff or support personnel working under their direct  
supervision competently perform delegated pharmacy-related  
activities  
…
Model Standard of Practice  
Pharmacists, when managing a pharmacy:  
…
2
8. develop policies and standard operating procedures that support  
staff’s ability to continuously improve the safety and quality of  
patient care provided  
…
General Standard  
Pharmacists respond to safety risks.  
Model Standard of Practice  
Pharmacists, when managing a pharmacy:  
…
16. develop and implement policies and procedures that minimize  
errors, incidents and unsafe practices, including supporting staff in  
their obligation to report adverse events and close-calls  
Standard #4: Professionalism and Ethics  
General Standard  
Pharmacists demonstrate professionalism and apply ethical principles in their  
daily work.  
Model Standard of Practice  
Pharmacists, when providing patient care:  
…
7. maintain the patient’s best interest as the core of all activities  
…
3.  
The Ontario College of Pharmacists required Sony Poulose, R.Ph to complete the  
following specified remediation (SCERP)  
The Committee requires the Member to successfully complete the following at his  
own expense, within 12 months of the date of this decision, and provide proof  
thereof to the College:  
The online course, Medication Safety Considerations for Compliance Packaging,  
offered by the Institute for Safe Medication Practices Canada; and The  
Designated Manager e-Learning module, offered by the College.  
As part of this requirement, the Member will participate in remediation follow-up  
which will be conducted by College staff within 24 months following his  
successful completion of the remediation program noted above. This follow-up  
may take place at the Member’s current place of practice and will involve a  
review of what the Member learned from the remediation program and what  
changes he has made to his practice as a result.  
4.  
This decision arises from a request made to the Health Professions Appeal and Review  
Board (the Board) by Sony Poulose, R.Ph (the Applicant) to review a decision of the  
3
Inquiries, Complaints and Reports Committee (the Committee) of the Ontario College of  
Pharmacists (the College). The decision concerned a complaint by Jo-Anne Whitman (the  
Respondent) regarding the conduct and actions of the Applicant. The Committee  
investigated the complaint and decided to issue the Applicant advice/recommendations  
and require the Applicant to complete a SCERP as set out above.  
II.  
BACKGROUND  
5.  
The Respondent reported concerns regarding prednisone dispensed to her mother (the  
patient) in July 2019.  
6.  
7.  
The prednisone was dispensed weekly, based on a prescription dated April 2, 2019.  
The Applicant was a pharmacist and the Designated Manager (DM) at the pharmacy that  
dispensed the medication (the pharmacy) until May 18, 2019.  
8.  
9.  
The Applicant completed clinical verifications of the prescription on April 30 and May 7,  
2019.  
The complaint investigation involved more than one member and each member’s role  
was examined independently.  
The Complaint and the Response  
The Complaint  
10.  
11.  
The Respondent reported concerns to the College regarding medication dispensed to her  
mother.  
The Respondent provided the following context:  
4
On April 2, 2019, the patient was prescribed five 1mg tablets of  
prednisone daily for 30 days, to be reduced by 1mg every 30 days;  
On July 22, 2019, the patient received a compliance aid with two 1mg  
tablets of prednisone daily, instead of three 1mg tablets, while the label  
indicated that there were three 1mg tablets;  
On July 29, 2019, the patient again received a compliance aid with two  
1mg tablets of prednisone daily, instead of three 1mg tablets; the label  
indicated that there were 21 tablets in the compliance aid when there were  
only 14; and  
The patient did not receive the correct dose of prednisone and experienced  
painful adverse effects.  
The Response  
12.  
The Applicant provided a written response to the complaint which included the following  
information:  
He apologized for the medication incident.  
He had been operating this pharmacy as a franchisee since 2008. In February  
2019, he decided to step down. The office asked him to stay until May 18,  
2019 to ensure a smooth transition. From mid-April to May 18, his activities  
were primarily focused on paperwork and inventory transfer. He also took  
some vacation during this time.  
At this location, they had about 150 patients on compliance packs, with  
around 800 prescriptions weekly. Every prescription is processed weekly and  
electronically sent to a Central Fill Pharmacy for packaging. Due to the large  
volume of prescriptions in compliance packaging, he hired a registered  
pharmacy technician, Ms. S., to complete the technical aspects of the  
compliance pack prescriptions.  
Her responsibilities included data verification of all compliance pack  
prescriptions and product checking of compliance packaging.  
5
To effectively integrate a registered pharmacy technician into the workflow,  
the pharmacist’s responsibility in the compliance pack workflow is limited to  
clinical verification.  
A flowchart of the compliance pack workflow, with corresponding  
responsibilities, is as follows:  
Step 1: Data entry – pharmacy assistant / registered pharmacy technician;  
Step 2: Data verification – registered pharmacy technician – all aspects of  
technical verification including patient information, drug, prescriber  
information, quantity, direction, repeats, etc.;  
Step 3: Clinical verification – pharmacist – checking the therapeutic  
appropriateness of the prescription including drug interaction;  
Step 4: Upload the prescriptions for central filling, product check is done  
by central fill; and  
Step 5: Modification of compliance packs and product check of modified  
compliance packs – registered pharmacy technician.  
The usual process for prednisone tapering for patients who are on compliance  
packs is to make a calendar of tapering schedule. The Applicant could not  
remember whether a prednisone tapering schedule was made for this patient  
or not. Typically, the registered pharmacy technician will manage the  
quantities based on the prednisone schedule. At the time of writing his  
response, he did not have access to the pharmacy’s records.  
For the prednisone prescriptions filled on April 30, 2019 and May 7, 2019, he  
performed the clinical verification only. During this activity, he does not  
check the quantity, as that check is already performed by the pharmacy  
technician.  
In his new practice, he has adopted a new practice for the prednisone tapering  
in compliance packaging as follows:  
Enter a separate prescription for each prednisone dose and place the future  
doses on hold.  
Enter a start date and stop date for each dose of prednisone in the  
direction.  
Enter a stop date for each prednisone prescription in the system.  
13.  
In response to a letter from the College providing the Applicant with the opportunity to  
respond to the complaint in his capacity as the DM of the pharmacy, and asking about  
6
what policies, procedures and safeguards the Applicant had in place for dispensing  
titrating prescriptions, the Applicant provided further information including the  
following:  
The pharmacy assistant who processes the prescription involving tapering  
doses of medication will generate a calendar using the option in the  
pharmacy’s computer system. This will generate a calendar with the number  
of tablets for each day.  
This calendar is used as a reference every week to adjust the number of the  
tablets in the blister packs.  
This calendar is kept in the blister pack folder of the concerned patient.  
After launching the batch, the pharmacy assistant will go through the patient’s  
prescriptions and adjust the number of tablets and dosage grid based on the  
calendar.  
The pharmacy technician/pharmacist who is responsible for data verification  
will refer to the calendar to verify the number of tablets and sign off the data  
verification part of the prescription verification process.  
It is an expectation that for data verification, the pharmacy  
technician/pharmacist must refer to the calendar each week prior to the sign  
off of the Data Verification part of tapering medications.  
As far as he can remember, the patient had been getting prednisone for years,  
and most of the time, tapering doses are involved. They were using the  
calendar all the time.  
He recollects several other patients being on a prednisone taper and they have  
followed the same process each time.  
The Committee’s Decision  
14.  
The Committee investigated the complaint and decided to issue the Applicant  
advice/recommendations and to require the Applicant to complete a SCERP as set out  
above.  
7
15.  
The Committee summarized the Respondent’s complaint. Furthermore, the College’s  
investigation identified a concern that on April 30 and May 7, 2019, the Applicant  
authorized incorrect instructions sent to the Central Fill Pharmacy for a prescription for  
prednisone for the patient.  
16.  
17.  
The Committee summarized the Applicant’s response.  
The Committee noted that the errors identified by the Respondent were representative of  
a series of errors related to the patient’s prescription from April 2, 2019. The Committee  
observed that:  
the original prescription was for a tapering dose of prednisone beginning at 5mg  
daily and reducing by 1mg every 30 days;  
the initial entry into the Pharmacy’s computer system was correct in that the  
directions were correct and the total quantity of tablets, 450, was correct,;  
however, the dispensing records between April and July 2019 indicated that  
dispensing errors were made;  
the tapering schedule prescribed did not match the dispensing schedule; and  
while the original prescription indicated to dispense 5mg daily for 30 days, the  
5mg dose was dispensed for a total of 42 days, and the 4mg dose was dispensed  
for 49 days; the 3mg dose was dispensed for one week.  
18.  
19.  
The Committee further noted changes made by pharmacy staff to the July 22 and July 29,  
2019 compliance aids as a result of the previous errors.  
The Committee identified that there did not seem to be an appropriate process in place at  
the pharmacy to manage tapering doses for compliance aid patients, which resulted in  
these errors occurring. It noted that data entry, including the quantity to be dispensed,  
data verification, and clinical verification, were completed by pharmacy staff prior to  
submitting the information to the Central Fill Pharmacy, and that there is a product check  
at the pharmacy prior to releasing the compliance aid.  
8
20.  
21.  
The Committee noted that the Applicant performed the clinical verification on April 30  
and May 7, 2019 and failed to notice and correct the error in the tapering dose.  
The Committee observed that according to the processes at the pharmacy, data entry and  
data verification were the responsibility of the pharmacy technician, and that pharmacist  
responsibility was for clinical verification. The Committee noted that the clinical  
verification is an opportunity to review the quantity dispensed and emphasized that:  
the Applicant must exercise appropriate due diligence when checking a  
compliance aid to ensure that the dose schedule matches the prescriber’s orders;  
it is the responsibility of the pharmacist to ensure the accuracy of the information  
prior to submitting orders to the Central Fill Pharmacy;  
the Applicant ought to have checked the information against the original  
prescription, and he assumed that the information was correct since other staff  
members had checked the information at different points;  
the Applicant ought to have ensured that he checked the dose of prednisone each  
week to ensure that the taper was correctly implemented;  
the Applicant should ensure that he thoroughly performs the checks for which he  
is responsible regardless of the involvement of other staff, as an error can be  
overlooked by a number of people despite checking processes; and  
more vigilance must be exercised during the checking and dispensing process for  
patients using compliance aids who are red-flag patients and rely on the accuracy  
of their pharmacist more than other patients.  
22.  
The Committee also noted that the Applicant was the DM until May 2019, and that he  
was in this role when errors occurred. The Committee observed that:  
the Applicant provided the processes for managing tapering doses, which  
included a calendar;  
these processes were not followed and it was the Applicant’s responsibility as DM  
to ensure that the processes were followed;  
9
the process in place at the pharmacy for data and clinical verification was also not  
followed by staff;  
there may have been some confusion among staff members regarding what the  
responsibilities of the clinical versus the data checks involved;  
all information sent to the Central Fill Pharmacy was to be verified, with a  
pharmacy technician completing the data verification and a pharmacist  
completing the clinical verification;  
based on the information from staff, the responsibilities regarding each check  
were not clear;  
according to the processes, the data verification included a check of the quantities  
and the clinical check was a check of therapeutic appropriateness; and  
in the circumstances before the Committee, the error was not identified during  
data verification and as the Applicant and other staff assumed that the quantity  
had already been checked, they did not do so.  
23.  
The Committee observed that the Applicant, in his response, outlined the processes in  
place at the pharmacy but did not engage in a discussion of his responsibilities as a DM,  
and it felt that the Applicant did not demonstrate his understanding of his responsibilities  
as DM. The Committee acknowledged, however, that the Applicant has made positive  
changes to his practice.  
24.  
For these reasons, the Committee issued the Applicant advice/recommendations and  
required him to complete specified remediation as noted above.  
III.  
REQUEST FOR REVIEW  
25.  
In a letter dated May 4, 2021, the Applicant requested that the Board review the  
Committee’s decision.  
10  
IV.  
POWERS OF THE BOARD  
26.  
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;  
c) require the Committee to exercise any of its powers other than to request a  
Registrar’s investigation.  
27.  
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 specified allegations to the Discipline Committee that would not,  
if proved, constitute either professional misconduct or incompetence.  
V.  
ANALYSIS AND REASONS  
28.  
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.  
29.  
30.  
In conducting a complaint review, the Board assesses the adequacy of the investigation  
and the 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.  
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  
and skill and programs to promote continuing improvement among the members, and to  
serve and protect the public interest.  
11  
31.  
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.  
32.  
33.  
The Respondent did not attend the Review. The Board notes there is no legislative  
requirement for parties to attend a review and draws no inference from the Respondent’s  
non-attendance.  
The Board has considered the submissions of the Applicant, examined the Record of  
Investigation (the Record), and reviewed the Committee’s decision.  
Adequacy of the Investigation  
34.  
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.  
35.  
The Committee obtained the following documents:  
the Respondent’s complaint and subsequent communications, including a  
reply to the responses of other members to the complaint;  
the Applicant’s response and subsequent communications, including an  
additional response;  
the pharmacy records;  
information from staff at the pharmacy;  
12  
the Applicant’s conduct history with the College; and  
the Ontario College of Pharmacists Code of Ethics and NAPRA Model  
Standards of Practice for Pharmacists.  
36.  
37.  
38.  
The Applicant did not submit that there is further information that the Committee should  
have gathered for its investigation.  
The Board finds that the Committee’s investigation was adequate for the following  
reasons.  
The Committee obtained the Respondent’s communications with the College, including  
her complaint, photographs of the patient’s medication, subsequent communications with  
the investigator, and a memorandum of a telephone conversation between the investigator  
and the Respondent. The Committee obtained the Applicant’s response to the complaint  
and further comments from the Applicant in answer to questions raised by the  
Committee. The Committee obtained information from staff at the pharmacy in the form  
of their responses to the complaint and provided the Applicant and the Respondent the  
opportunity to provide further information and comments based on these responses. In  
summary, the parties were offered opportunities to submit information to the Committee,  
and both parties did so. The Committee obtained the patient’s pharmacy records and had  
before it the Applicant’s history with the College and the College’s Code of Ethics and  
NAPRA Model Standards of Practice for Pharmacists.  
39.  
40.  
The Board finds that the Committee gathered the essential, relevant information with  
which to consider the Respondent’s complaint about the Applicant’s conduct.  
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.  
13  
Reasonableness of the Decision  
41.  
In determining 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. Rather, the  
Board considers the outcome of the Committee’s decision in light of the underlying  
rationale for the decision, to ensure that the decision as a whole is transparent, intelligible  
and justified. That is, in considering whether a decision is reasonable, the Board is  
concerned with both the outcome of the decision and the reasoning process that led to  
that outcome. It considers whether the Committee based its decision on a chain of  
analysis that is coherent and rational and is justified in relation to the relevant facts and  
the laws applicable to the decision-making process.  
The Applicant’s Submissions at the Review  
42.  
43.  
44.  
At the Review, the Applicant re-iterated the information in his response regarding the  
compliance pack workflow and responsibilities.  
The Applicant referred to legislation and regulations establishing the role of registered  
pharmacy technicians in Ontario and allowing their regulation by the College.  
The Applicant also referred the Board to NAPRA Professional Competencies for  
Canadian Pharmacy Technicians at Entry to Practice and NAPRA Model Standards of  
Practice for Pharmacy Technicians.  
45.  
The Applicant submitted that the College has clearly defined the role and responsibilities  
of registered pharmacy technicians, and that as regulated health care professionals,  
pharmacy technicians are accountable and responsible for the technical aspects of  
dispensing new and refill prescriptions. The Applicant further submitted that integrating a  
pharmacy technician into a pharmacy practice allows pharmacists to focus on clinical  
services, while remaining responsible for the therapeutic and clinic verification of  
prescriptions.  
14  
46.  
47.  
48.  
The Applicant disagreed with the Committee’s determination that the clinical verification  
of a prescription is an opportunity to review the quantity dispensed, on the basis that the  
pharmacy technician and the pharmacist have distinct roles and there is no need for a  
pharmacist to “double check” the work of another regulated health care professional, in  
this case, the pharmacy technician.  
Furthermore, the Applicant disagreed with the Committee’s determination that he must  
exercise appropriate due diligence when checking a compliance aid to ensure that the  
dose schedule matches the prescriber’s orders. He submitted that in this case, this check  
was already done and signed off by the pharmacy technician, and therefore, there was no  
need for him to repeat this step.  
The Applicant disagreed with the Committee’s comment that he should ensure that he  
thoroughly performs the checks for which he is responsible regardless of the involvement  
of other staff, as an error can be overlooked by a number of people despite checking  
processes. He submitted that he understands that an error occurred during the data  
verification step by a pharmacy technician, and that compliance aids are red flags;  
however, he is in disagreement with this comment made by the Committee because  
checking was performed by a pharmacy assistant before the prescription came to him.  
49.  
The Applicant disagreed with the Committee’s determination that the process in place at  
the pharmacy for data and clinical verification was not followed by staff and that there  
may have been some confusion among staff members regarding what the responsibilities  
of the clinical versus the data checks involved. He submitted that the error was in the data  
verification by the pharmacy technician and stated that the software system cannot send  
this prescription to the central filling without each of the separate sign-offs.  
50.  
The Applicant also disagreed with the Committee’s finding that he did not demonstrate  
an understanding of his responsibilities related to his role as DM, and he submitted that  
communication was paramount during the time that he was the DM of the pharmacy.  
15  
51.  
52.  
He concluded that the decision was unreasonable because the Committee repeatedly said  
that a pharmacist is responsible for technical aspects of a prescription where a pharmacy  
technician has already signed off, and thus the panel failed to recognize the role of a  
pharmacy technician.  
In response to questions from the Board, the Applicant acknowledged that there was an  
error in filling the patient’s prescription as identified by the Committee and that at least  
one of the recurring prescriptions for which he performed the clinical verification (May 7,  
2019) contained an incorrect dose of the medication.  
The Board’s Analysis  
53.  
The Board notes that the Committee’s identification of a series of errors in filling the  
patient’s prescription is supported by the Patient Medical History contained in the  
pharmacy records in the Record, and not disputed by the Applicant.  
54.  
The Board further notes that information in the Record, including the Patient Medical  
History, supports the Committee’s determination that the Applicant performed clinical  
verifications on April 30 and May 7, at least one of which involved an incorrect dose, and  
that this was acknowledged by the Applicant at the Review.  
55.  
56.  
The Applicant’s main concern in both his written and oral submissions is regarding the  
Committee’s determination that he had an obligation as a pharmacist involved in this  
prescription to review work that had already been performed by a pharmacy technician.  
In its decision, the Committee clearly and repeatedly stated that the Applicant had such a  
responsibility, as noted above in paragraph 20, including that the Applicant ought to have  
checked the information sent to the Central Fill Pharmacy against the original  
prescription, regardless of the involvement of other staff.  
16  
57.  
In his submissions at the Review, the Applicant highlighted for the Board the  
responsibilities of pharmacy technicians set out in the NAPRA Model Standards of  
Practice for Pharmacy Technicians and argued that based on the scope of practice of  
pharmacy technicians, he should not have to check their work when completing a  
prescription, as another health care professional has already done so and this would  
duplicate their work.  
58.  
The Applicant did not direct the Board to College standards or policies regarding a  
pharmacist’s responsibilities when working with a pharmacy technician, nor to any  
standard or policy regarding whether when dispensing drugs, pharmacists can rely on a  
pharmacy technician to conduct certain checks without the necessity of review by the  
pharmacist.  
59.  
60.  
The Board notes that the College considered and addressed the Applicant’s  
responsibilities when working with a pharmacy technician in this matter.  
The Board further notes that the College had before it its Code of Ethics and the NAPRA  
Model Standards of Practice for Pharmacists, which set out the responsibilities of  
pharmacists, including when dispensing medications.  
61.  
The Board notes that in the advice/recommendations that the Committee issued to the  
Applicant, it specifically referred to a Model Standard of Practice under Standard #1:  
Expertise in Medications and Medication-Use, which states that “Pharmacists regardless  
of the role they are fulfilling: … 5. use evidence from relevant sources to inform their  
activities and 6. critically evaluate medication and related information.”  
62.  
In the advice/recommendations, the Committee also specifically referred to another  
Model Standard of Practice under Standard #1: Expertise in Medications and  
Medication-Use, which states that “Pharmacists, when responsible for medication  
distribution/supply: … 38. ensure that quantities dispensed are correct.”  
17  
63.  
Regarding the interaction between pharmacists and pharmacy technicians, the Committee  
referred to a Model Standard of Practice under Standard #3: Quality and Safety which  
states “Pharmacists regardless of the role they are fulfilling: … 3. ensure that staff or  
support personnel for whom they are responsible are delegated and undertake pharmacy-  
related activities appropriate to their training and consistent with legislation, regulations  
and policies and 4. ensure that staff or support personnel working under their direct  
supervision competently perform delegated pharmacy-related activities.”  
64.  
The Board notes that the Committee applied its knowledge and expertise related to the  
expected standards of the profession when assessing the Applicant’s conduct. There is no  
information before the Board that the Committee incorrectly understood the information  
in the Record, or misinterpreted College standards and the responsibilities of the  
Applicant in this situation.  
65.  
Regarding the Applicant’s role as DM, the Board finds that the Committee considered the  
errors that were made, and the timing of those errors, and reasonably found that errors  
occurred while the Applicant was DM. The Committee then reviewed the information in  
the Record, including a supplementary response from the Applicant to questions raised  
by the College about his responsibilities as DM. The information reviewed by the  
Committee in this regard is set out in paragraph 21 above. The Board finds that the  
Committee’s note that the Applicant did not engage in a discussion of his responsibilities  
as DM was supported by the Record.  
66.  
67.  
Accordingly, the Board finds it reasonable that the Committee determined that the  
Applicant did not demonstrate his understanding of his responsibilities related to his role  
as DM, while acknowledging that he has made positive changes to his practice.  
The Board finds that the advice/recommendations issued by the Committee to the  
Applicant directly relate to concerns identified by the Committee. Regarding the SCERP,  
the Board notes that the Committee required the Applicant to complete Medication Safety  
Considerations for Compliance Packaging, offered by the Institute for Safe Medication  
18  
Practices Canada, and The Designated Manager e-Learning module, offered by the  
College, both of which relate to the concerns identified by the Committee.  
68.  
In conclusion, 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. The Committee’s decision as a whole is  
transparent, intelligible, and justified. The Committee’s decision addresses the concerns  
raised in the complaint and is based on the information in the Record. The Board finds  
that the Committee conducted an adequate investigation and reached a reasonable  
decision.  
VI.  
DECISION  
69.  
Pursuant to section 35(1) of the Code, the Board confirms the Committee’s decision to  
issue the Applicant advice/recommendations and require the Applicant to complete a  
SCERP as set out above.  
ISSUED July 7, 2022  
Anna-Marie Castrodale_________  
Anna-Marie Castrodale  
Jean Bédard__________________  
Jean Bédard  
Mitchell Toker________________  
Mitchell Toker  
Cette décision est aussi disponible en français. Pour obtenir la version de la décision en français, veuillez contacter  
[email protected]  
19  


© 2022 IncJournal is not affiliated with or endorsed by the U.S. Securities and Exchange Commission