11 June 2020

HPARB Notice of Intention Not to Proceed with Review

2020 June 11 re Dr D                                                                         Susan McPherson
In Response to Notice of Intention not to Proceed with Review by HPARB

Following is the Response I submitted on June 11 to the Notice I received from HPARB  (Health Professions Appeal and Review Boardthat they were planning not to proceed with the Review of the CPSO complaint that I had asked them to do.  I was required to submit responses to HPARB within 30 days, which I did. the case is complex, and I could see that they hadn't really understood what I had said, so I tried again to explain.  In the following document, I have omitted the names of the parties involved and other extraneous information, such as titles of attachments and their job titles, etc.

This is one of two responses I made about two doctors I had laid the complaint about to the CPSO, originally. The CPSO (College of Physicians and Surgeons), had decided not to go forward with the investigation, having saying that my complaint looked as though it was “frivolous, vexatious, made in bad faith, moot or otherwise an abuse of process.” They didn't say which. HPARB followed suit, the reason being that they do not conduct an investigation of the original complaint, only looking at the CPSO ICRC (the Committee) to see if they would have reached the same conclusion. They did, by making the same mistakes and relying on staff at LHSC to be able to explain this situation to them.

If viewers have questions, you are welcome to ask, or leave a comment. Please excuse the spelling errors. 

HPARB Notice of Intention Not to Proceed with Review
by Susan McPherson, Complainant
Dr D, Respondent
Case File: Dr D  HPARB   (CPSO, Complaint June 28, 2019)
Date:   June 11, 2020                                                
Sent by email to    

1.  The respondent, Dr D, was and possibly still is one of the health care custodians of reports and other documents about me that are related to this case; in fact, he was one of the main ones, being the person in authority, as submitter and receiver, responsible for the sending and receiving of documents from the lab he worked in at LHSC, and possibly providing authorization for some of them.

2.  I understand what HPARB is saying, that it was simply HIS name and hospital address that appeared on documents coming and going and that to him and the hospital it meant nothing. It wasn’t as though anyone was taking responsibility for what went out or was accepted in. I can see that. I already knew that. But I would like to know Dr D’s part in that, and whether he could have done better, and whether he should have been doing that job, and whether he did it to other patients, and more. Shouldn’t the hospital, and the College of Physicians and Surgeons, be accountable for their mistakes?   

3.  In the response I received from M, formerly of P   O LHSC, on May 31, 2019, she sent an explanation about the various documents that was not accurate.

4.  In the email bundle I received from HPARB on May 13, pages from M were listed under p 2, - -  that they used in determining the Decision on this case.   They are attached here.

5.  First of all (re Item 2 of the ROI) it wasn’t me who said that EMERG was involved in my path from Bronchoscopy to being TB Suspect. That information was on the Suspect form filled out by B, as well as other forms, such as the requisition form, and was an error. I don’t know how, except that almost everything she wrote on the form was incorrect. I didn’t have symptoms not able to be explained by emphysema, for instance. She just picked things up from my medical record and plopped them into the TB SUSPECT form. I state this because HPARB has accused me of being frivolous, and I don’t want them to think I just made things up out of the blue and asked M to find out about something that didn’t exist.

6.  M, P O, LHSC, thought that an “automatic notification” was “triggered” due to the “nature” of my visit to Dr M, and presumably did not involve any human action to be taken. Somebody has to put the piece of paper into the FAX machine, or lift up the telephone, or copy an email to God knows who. It doesn’t happen automatically, unless these people at LHSC are AI robots or in a daze and things get forwarded “automatically.”  Likewise with the requisition that was said not to have been sent by anyone. It simply exists, presumably and D was not responsible, you claim.  

7. Farther down on page 2 of her letter, M tried to tell me – and I am copying again for you - that “bacteria in the TB family was found during the exam.”  Actually, bacteria cannot be seen while the bronchoscopy is being carried out. It has to be discovered at the lab – presumably at the LHSC lab if possible, or if not at the Public Health lab locally or in Toronto.  Sounds like circular reasoning on her part – using the “find” as a reason to conduct tests on the sample to try to discover what it was, if anything, no matter how many labs they had to send it to.

8. HPARB and thus, CPSO, chose to refer to P O M’s response to me, received by me on May 31, 2019.  See pages 1 and 2 of her letter attached.   HPARB wrote in Section II,    of the Notice of Intention not to Proceed with Review (May 13, 20) how they understood the process, that “possible bacteria” of the TB family was present. However, it wasn’t possible for TB to be found until some reason was found for pursuing it – as with COVID-19 - such as having symptoms, or being in contact with someone who had it. In one assessment tool at MLHU that was written on, too, for no reason, the word “contact” was added.  It was thought I might have had an infection previously, but that could have been pneumonia or bronchitis. TB wasn’t suspected at the time of the bronchoscopy. If it was, no one told me, at least, not in a way that indicated what I might be up against, which was a lot more than most immigrants are. The doctor might have wondered to himself, but there was NO INDICATION that I had TB. Sure, you can say it was “possibly TB,” or possibly anything on the list of infectious diseases, or anything not infectious. It could have been - anything. But I didn’t fit the profile for TB and had no symptoms and I didn’t have close contacts so there was no reason to pursue that avenue.  

9.  It wasn’t until B filled out the form that anyone could seriously consider that I had TB, contradicting what you claim happened, that TB was suspected from the beginning. If she had filled out the form accurately, with more care, it would have been realized right away that I probably didn’t have TB and didn’t need to be tested. It is possible that once a test was done that indicated by the AFB test that TB was possible, B would have made out the inaccurate SUSPECT form, but it would take Dr D or someone to say how that test happened, and where, and when. And I don’t mean M saying she asked someone and they said this or that was a reasonable explanation. She was not a spokesperson for the LHSC and ought not be giving her word on how things happen there (and nor is Patient Relations, if that idea comes up). We are supposed to be able to put our trust in doctors, but how can people do that when things like this happen?

10. What I mean is that someone, such as Dr D, or whoever conducted the AFB test and signed the test result as being authentic and authorized by a requisition,  and received the lab report back, should be investigated by HPARB as the person being investigated should be. If CPSO did not do this, then it can be said that in this matter, the investigation they conducted was not adequate.

11. I realize that the inadequacy of the CPSO investigation of my complaint is one of the reasons I was able to request a review.  The other part was whether or not the Decision of the Investigating Committee of the CPSO was reasonable. And it was not. I cannot state what their final conclusion was because they don’t exactly say – either I was being “frivolous” or I was “abusing the process”. What was it? HPARB says the same thing, which isn’t really anything unless it was something.

12. Still looking at Item 4 of the HPARB Notice, it is stated that TB is a mycobacterium. Tuberculosis most certainly is a contagious disease on the list of reportable diseases to Public Health. However, non-TB Mycobacterium, the query that someone had in order to have sent up a sample culture to Toronto to be identified as such, is not reportable - meaning, it is not reportable to Public Health as a public health concern and need not be investigated in samples submitted by any patient, or immigrant from countries where it is most likely to occur in large numbers. Most often, the two diseases are separated, into TB and non-TB mycobacterium. The kind that was presumably found in a test culture in (date), 2018, in a sample that was taken from me during the bronchoscopy in August, ened up being non-TB mycobacterium.  It was an unusual investigation, as most immigrants do not even have the test done upon arrival in this country.  They just have a regular TB test, perhaps a sputum test, which I did not have in the first place. I was sent straith through to having the full TB mycobacterium and non-TB mycobacterium investigated.

13. Speaking of TB mycobacterium and non-TB mycobacterium as though they are in the same family – as the HPARB Notice does - may or may not be correct, legally, but they are not talked about – nor investigated – nor in the same risk category  -  in medicine.  And it distorts the issue to write about it in that manner. Where in the Notice it is written “That testing revealed the bacteria was not one that causes tuberculosis,” (Item 4, Notice . . Dr D) that is another error. It was already known by that time that the bacteria I had, if I really did have any worth mentioning, or a conclusive test result, was not TB. The sample culture was sent to Toronto to discover whether is was a non-TB mycobacterium,  not to check whether it was not one that causes TB. And I don’t even know whether proper submitting protocols for the sample were carried out.  Based on the looks of the requisition I managed to get and the lab test result that came back with no clear dates or results, nor names of authorizing doctor, and B’s methods, one would have to question whether the lab even followed proper travel protocols of the sample. 

14. And of course, as I have said, the test result of that single test was positive, and remains unconfirmed because Dr M didn’t follow standard guidelines for the testing for TB. If it was Dr M who authorized the requisition for further testing, or Dr D2, or Dr D, I would like to know. So far, it is only Dr D’s name on the requisition, as Submitter, And he was the receiver of the finished lab result. At least, for this investigation, I would like to hear from Dr D himself, what his job description is and did he not think he was supposed to check important documents like requisitions from his department before they were sent out, with the sample culture?

15. I have included the original handwritten Dr D Requisition form here so it can be compared with the typed-up data on the lab information forms located in the bundle of documents sent to me. Both those are OLIS data, with information jumbled together not making much sense unless one already had a good grasp on the details of the lab testing, etc. But both had Dr D’s name on them, one even stating that Dr D was the “Ordering physician”. The other one refers to him as the “Provider,” while the original requisition uses the term “Submitter.”   The original requisition was not obtained through M at LHSC, although one would have thought they would have saved a copy, since it was proof that the testing done in Toronto was legitimately authorized and not simply pushed through.   There is no clinician named on that original requisition order, nor a Doctor’s name to forward the results to. It all went from Dr D back to Dr D after being carried out.  The two lab reports are attached here.

16. But I do know that the requisition with Dr D’s name on it was scribbled on, after striking out the words Final AFB (a different test, done locally) and inserting the word mycobacterium, whereas if it were going to be tested for TB, then it would say TB – the title given on the back of the form to identify the test required. I imagine TB had already been cancelled out, because I didn’t have it. And so, someone came along and put  “mycobacterium” on it, so it could be sent to Toronto, without a new requisition having to be made out and having to have someone take responsibility for adding on this extra testing, which I was not informed was going to happen, nor why, preventing me from knowing what was going on. So it wasn’t meant as this being a test for TB and “mycobacterium.” It was a meant to be for a non-TB mycobacterium. so in those Item numbers where this is discussed, eg Item 4 and Item 9 in the HPARB Notice.

17. I have attached a blank general test requisition, of the kind Dr D permitted to leave his department unchecked by him, including the back of it. If you look, you can see where TB is listed, as being mycobacterium. There is no category for non-TB mycobacterium, whether because there is a different requisition form for it, or I don’t know why. I am not a doctor and it is difficult for me to get answers from OLIS or any lab on these matters because they only answer questions from doctors, they say, about procedures. Or perhaps lawyers.

18. To be accurate, the term non-TB mycobacterium probably should have been put on the requisition at that point, and someone should have signed it, or initialed it, instead of leaving it such a difficult-to-understand document.  It makes it difficult, too, because people who access it and change it, etc, don’t put dates on it, or initial it, so no one knows for sure where it was nor when, nor who.

19. I understand the CPSO does not deal with administration, but it does deal with rules about how doctors should act if they have custody of a patient’s medical record or other important documents, and this is one of them – and Dr D had the document in his office, for it to have been stamped with his name. And it deals with ethical issues – issues of accountability. That’s why I am asking.

20. If Dr D was the only person who had access to that requisition, and if he did not instruct his staff on how to deal with them (eg, read the document and if there is anything unusual about it, such as if it is an unsigned requisition, hold it for me, he could have said). Who signed the original requisition? So whose responsibility is it if his staff did not know how to deal with it?

21. The report referred to in Item 4 was the SUSPECT form, by B. I don’t know how it got to MLHU. It got there, whether by Dr D or someone else. That should have been caught, too. The name Mrs N,  B’s boss, was on the list of witnesses to interview, in the Application, but CPSO did not bother.

22. TB WAS ruled out, by the way (Item 4 of your Notice says it was NOT ruled out). This is the problem I have been telling you about, and CPSO. I did not have TB. And then someone decided to send a requisition up to Toronto so they could look into non-TB mycobacterium. I don’t think people who have TB have to have their samples checked by LHSC lab, and MLHU lab and then by Toronto’s genome lab. Someone went out of their way to have my culture sample sent up to Toronto. But non-TB Mycobacterium is not on the Reportable Diseases list of Public Health.

23. The information you give in Item 9 has fragments of truth bu in it essence is inaccurate. Non-TB Mycobacterium is not a reportable disease. I can give you lists, but it’s not on them, because there are only lists of reportable diseases, like TB, not of non-reportable ones. I gave that information to the CPSO.

24. A sample was taken from the bronchial lavage I had (and signed a consent form that enabled them to do whatever research they wanted on it.). I asked Dr D2 if I could sign the consent form and he said wait until you are in the Procedure room. By the time I got there I was lying flat on my back with my reading glasses safely tucked away. I signed under pressure! Uniformed consent. I had not realized I would be tested in ways no other patient would ordinarily be tested, not even recent immigrants who, according to their profiles, probably came came from the major continents where their ancestors were raised in mud huts and ate off the ground and thus were more susceptible to the kind of diseases these doctors and staff were investigating me for, I allege, so that they had a guinea pig they could test these poisonous drugs on.

25.  M makes it up as she goes along, in her letter of response. She couldn’t find the requisition, she didn’t know how things got from one place to another, and she says in Item 3, p 2, that the “culturing process has to be referred out  by LHSC.”  By L H S C – by the *hospital,* by magic, because no one fills out the form and no one signs it. It is all automatic!

26. Generally, people start off this process that I went through by having symptoms they go to a doctor for. I didn’t have symptoms that could [not] be explained away. I already was short of breath due to emphysema, and had a cough that went with it. Yet B of LHSC wrote on the form that I had clinical symptoms of TB.  People at LHSC say different things about the process. M says, “the reportable disease notification was sent automatically to the Middlesex Health Unit as part of our standard protocol (which adheres to legislation).”  I am explaining again because I think it takes hearing it more than once to sink in. She knew only a small part of what this was about and the most important parts she got wrong anyway. Someone was responsible. It didn’t happen “automatically.” 

27. The College didn’t conduct an investigation prior to making a Decision. In their first paragraph in their Analysis they quoted from the CPSO’s rules on reporting and left it at that, stopping at the point of the supposedly necessary TB SUSPECT report. Non-TB Mycobacterium is not a reportable disease. I can give you lists, but it’s not on them, because there are only lists of reportable diseases, like TB, not of non-reportable ones. I gave that information to the CPSO but they must have presented it to you incorrectly.  That’s why this situation was so unjust – I was subjected to this testing, which so many others do not have to have done, even though from foreign countries where it is more known. I was subjected to it, and people hid it from me, and hid the part they played in allowing it to happen.

28. The second paragraph of the CPSO Analysis  focused on lab protocols, incomplete forms, and health policies, for the most part irrelevant. The third and final paragraph was completely false. Dr D was meant to be working under the supervision of Dr C at the time this situation took place, and only to be given tasks to do that he was capable of doing satisfactorily – or complaints would be made, which I did, while he was still uder restrictions.  

29. The CPSO’s final Decision was that they would take no action with respect to the complaint. Instead, they decided that my complaint looked as though it was “frivolous, vexatious, made in bad faith, moot or otherwise an abuse of process.” They don’t say which.

30. My presence (in writing) and complaints, may leave you feeling vexatious, or show how I was feeling, but they are relevant in today’s health care system, and as far as I know, were not an abuse of process, but if they were, were made in good faith.  I put much work into this, provided extra material for the ICRC, and kept the Board up to date on the lack of attention by the CPSO to what is going on in hospital settings.

31. Doctors or not, we all know from the coronavirus pandemic that there is always some concern over patients who have symptoms and who test negative, or those who test positive and yet are asymptomatic. I only had one test and the doctor started talking about it as though I had bee diagnosed with this non-TB mycobacterium. And then other residents would mention it, as though I actually “had” it and had not simply had one unconfirmed test result. No symptoms, did not fit the profile, no contacts. Nothing! Just one test, and we don’t know whether protocols were carried out in sending it to Toronto.

32. I would like to get this matter dealt with, as it is part of a larger whole. Each piece is complex enough, so doing them all together would be impossible. I still have other people I believe need to be questioned about this. It may seem frivolous to you now, or an abuse of process, but these questions need to be asked of Dr D and others mentioned in the application, so that when I file a complaint about another doctor, you will know what has been covered. If D doesn’t respond to questions about his part in this – such as about his job description – then no one will know whether he is the one (along with Dr C) who should take responsibility and how the LHSC can become more accountable in its hiring and supervision, with the cooperation of the CPSO.

33. I am attaching what appears to be the original requisition *submitted* to PHO labs by Dr D, it states, complete with one part crossed (AFB Final) out and the word Mycobacterium written in, with no signature nor date to indicate whether it was Dr D who made the change or someone else.   No reason for the test is given. Under clinical symptoms, “respiratory symptoms” has again been listed, falsely. The patient setting was given as ER – not true. Dr D is clearly listed as the Submitter, although apparently, M may be right, No one person needs to be identified as requesting the test, or authorizing it, as a health care provider or custodian, it being a mysterious process at the best of times.

34. And who does that leave as health care custodian in this situation of documents coming to the lab and going out, if not Dr D, the one who “submitted “ the requisition to have the test in Toronto, the test that didn’t need to be done and that I was not informed about in advance! I have attached the requisition, and a copy of a blank requisition,  as well as a copy of the Fact sheet on Health care providers, since this last item, the status of Dr D, as provider, was mentioned in the responses of CPSO and HPARB to my complaint.  

35. In responding to HPARB’s decision, I would first say that there were several errors and distortions in the CPSO’s investigation, repeated in your response, to address each one in detail. I have already made this case once to the CPSO, and your making a case against me, based on what they claim I said and what they choose to believe, doesn’t do justice to my request for a review. I realize this is how a Review by the Board is undertaken, but it still doesn’t make sense. If PHARB is not analyzing the original documents from my Complaint and seeing if they come up with the same conclusion, instead of looking at CPSO’s interpretation of the Complaint, and seeing what’s wrong with it, to what purpose is having a Review?

36. An excerpt taken from my request for review, in Item 13 of the Notice, is what the HPARB has decided to hold against me, as the essence of what I am asking them to do and the reason for not proceeding with the Review. However, going back to the original Complaint I made, which presumably is what the CPSO used to base their investigation on, would be more appropriate. See attachments.  Here you will find my concerns, the start of a description, and the names of two persons who could offer more information. My concerns are not as you describe in Item 13, but this, from p 3 of my CPSO Complaint about Dr D and Dr C, which surely the CPSO used as the basis for their interpretation of my Complaint? :

37.      1. Dr D was involved in submitting information about me to MLHU in September or October 2018, that resulted in the Health Unit screening me for Tuberculosis.  After it was discovered I did not have TB, the lung sample  was sent to Toronto for further testing. I question, first, the basis on which I was deemed to be suspect for having TB, and the process by which the report was approved and sent to MLHU. Secondly, did Dr D also approve the requisition for the lungsample sent to Toronto?
             2.  My concern is that Dr D wasn’t doing his job well, and that errors were made in having my information submitted to MLHU. CPSO public information about Dr D indicates that he may practise medicine only in a setting that is approved by the Chair.  Dr C  is the Chair. I question whether he, too, was not doing his job effectively.
              3. It was the responsibility of Dr D, and thus indirectly of Dr C, to ensure that the documents sent (and received) to and from MLHU and other labs were valid and completed with accuracy. This didn’t happen with the form that was submitted by LHSC to MLHU, nor with other documents related to this situation.  If Dr D's work was not to be trusted, why was my health care entrusted to him, with no one overseeing it?

38.  As I said above, on its own, this case is not the entire story of what happened to me. This entire situation, of Drs D and C, is connected to others including Dr M, LHSC, who I have alleged mistreated me and manipulated me, with the compliance of staff and doctors including Dr D2, LHSC) employee B, Drs D and C, Ms B MLHU, and others; that said, if the participation of the various employees and physicians wasn’t done out of compliance, then it had to be out of ignorance.

39. On its own, one might see D’s actions as trivial, but connected as they are to the wider issue, of the supposed chance occurance of a patient being lied to, misrepresented, and dragged through the system to a conclusion not out of her (my) informed consent, one can see that what they did was essential to this effort by Dr M and colleagues to inveigle me into being their research subject.

40. In Item 15 of the HPARB’s Decision May /20, Dr D’s role is referred to, that HPARB is saying means he was not involved in this situation. But that is his title and address as it appears on his documents. He does do clinical work, and practical research. He has Hospital privileges at all the hosptals under LHSC. He may even have had something to do with speaking with the referring doctor (Dr M) or Dr D2, about what lab testing did they want done.

41. No, there was no doctor/patient relationship between Dr D and myself, as you suggest in Item 15 of the Notice.  I am saying he was a hac – a health care custodian. He had personal data on me (some of it incorrect) and he was the person in that environment, of the clinical lab, not as academic, who sent and received reports including requisitions, and perhaps even consulted on what kinds of lab tests could be done. He wasn’t an administrator per se. \

42.  Many professionals in hospitals have numerous titles, sometimes, as heads of Committees, and so on. Regardless of his title, whichever one it is, look at the form, reports, lab requisitions and so on. All the ones to do with me have his name on them. And the question is, regardless of whether he was away that day (see Item 15 again) should he had been a little more careful of what was happening with patients’ requisitions and lab results that had inaccurate medical information on them. It surely was his job. And of course, it was Dr C that was also at fault. I have included D’s CPSO profile as it was before it was updated.

43. Re Item 16. I am not talking about protocols in this case. I gave the CPSO the background information to my complaint. How otherwise would they have been able to comprehend what the issues were with Dr D. It wasn’t just about him. Somebody or some persons were involved in manipulating me from start to finish. If not that, then the professionals at LHSC are incompetent. And yes, again, I have given you the information on the limitations requested on Dr D on his file, before July 1. So while you are correct in what you say, “there is no persuasive information that the Respondent’s licence is restricted due to competency issues,” what you say is not correct as far as this complaint is concerned. He has a different profile now. The restrictions I was referring to were lifted.

44. On June 28, 2019, I emailed my Complaint to CPSO about Dr D and Dr C.  It was not acknowledged until Tuesday July 2, due to the long weekend.  I submitted the application before I knew what changes would be made to the restrictions on Dr D’s CPSO file but I had wanted it to be there before the file was altered and so that the CPSO and others at LHSC knew that this had happened while Dr C was supposed to be supervising him and that my Complaint was submitted before that restriction came to an end. I submitted my complaint before the restrcition was lifted. It is up to HPARB when they decide to follow up on it.

45. The damage had been done while Dr D was still under supervision, despite what HPARB believe about there not being restrictions due to his ability. He may have been competent within himself, but the question is, was he capable of overseeing incoming and outgoing documents (or even authorizing requisitions) whose existence and careless use might well have dire consequences for someone caught up in the incompetence or manipulative behaviour of others. Lacking experience, he might have been a risk being in that position.  

Thank you for taking the time to examine my response to your Notice Not to Proceed with Review. The Decision made by the board about my case against Dr D was inadequate, and was also unreasonable.

Susan McPherson    

17 Attachments follow

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