This is not the original version of this decision. It is a revised version that has been edited for public disclosure
to protect confidential and third party personal information.
Dr. Frances Forrest-Richards, Member Counsel for Appellant
Heard at Port Alberni, B.C. on July 9 & 10, 1990, in Vancouver, B.C. on January
14 & 15, 1991 and at Nanaimo, B.C. on April 12, 1991.
Majority Opinion
T.C. Marshall
This is an appeal from the order of the Board of Trustees of West Coast General
Hospital of Port Alberni, B.C. (the “Hospital”) made on Feb. 9, 1990 whereby the
Hospital Board concurred in the recommendation of the Medical Advisory
Committee that the Appellant not be granted admitting privileges as a Member of
the Associate staff “on the grounds of significant concerns regarding her
interpersonal and clinical skills.” The grounds of the appeal dated March 15,
The Appellant is of good character, is duly qualified, and is a
member in good standing of the B.C. College of Physicians
and Surgeons, and as such is entitled to privileges at the
The Board of Trustees of the hospital erred in ruling that
interpersonal skills were proper grounds on which to deny the
Appellant’s application for privileges.
There is no evidence to substantiate the conclusion reached
by the Board that the Appellant’s clinical skills are inadequate.
By an amendment to the Notice of Appeal, dated May 14, 1990 a further ground
In the alternative, if there is some evidence that either the
Appellant’s interpersonal or clinical skills are deficient, that
deficiency is not of a sufficient degree to warrant a denial of
The first ground of appeal was abandoned by Counsel at the commencement of
In her Answer dated April 17, 1990 counsel for the Hospital set out as the
reasons for the Hospital Board’s decision to refuse privileges;
inadequate clinical skills, including but not limited to failure to
diagnose, misdiagnosis, pharmacological mismanagement,
poor medical judgment, excessive us of diagnostic tests,
overly aggressive treatment, and insufficient understanding of
lack of adequate, pertinent positive references and existence
poor interpersonal skills and conduct such that effective
communication between professional staff, administrative
personnel, and the Appellant was jeopardized.
are interpersonal skills a proper ground for denial of hospital
was there some evidence to support the conclusion that the
Appellant’s clinical skills were inadequate?
It is common ground that an appeal to this Board is, by virtue of the Hospital Act and Regulations, an appeal de novo. This Board must strive to place itself in the
shoes of the Hospital Board and consider all of the evidence placed before it and
any additional evidence coming to light between Feb. 9, 1990 and the hearing
before this Board. In light of the Notice of Appeal and Answer it became the duty
of this Board, in essence to determine whether the Appellant was sufficiently
competent, as a family practitioner, to be granted admitting privileges at the
Hospital and secondly, whether in any event her “interpersonal skills” were so
The Appellant’s curriculum vitae (Ex 1, Tab 3) discloses that she received her
early education at Duncan, Tzoulhalem, Vancouver and Victoria, mostly in Roman
Catholic schools. In 1962, at age 19, she entered the Child Jesus convent in
North Vancouver as a novitiate and remained there for three years, studying
French, Philosophy, Theology and History and teaching Latin in Grades 9 and 11.
For several years she followed a teaching career and then enrolled in university,
graduating from the University of Saskatchewan in 1971 with a B.Sc. in the pre-
medical program. Following her graduation in 1975 she did electives in several
hospitals in Toronto, Regina, Rosetown and Humboldt and in 1976 – 1977 a
rotating internship in St. Paul’s hospital, Saskatoon, devoting several months
each to Surgery, Medicine, Paediatrics and Obstetrics, Emergency and
In 1983 she received a B.A. degree, majoring in Philosophy and Psychology. She
left her Catholic Order that same year and is now a member of the Sisters for
Christian Community. Under the aegis of the former Order she went where she
was ordered and had no right to any earnings. This is no longer the case since
The Appellant has had a varied working career, doing locums in Ontario and
British Columbia and serving in many capacities under the appointments made
by her former Order, in Africa, including six months in 1980 in Monrovia, Liberia
where she obtained experience in Obstetrics and Gynecology, Medicine, Surgery
and Paediatrics. Following a brief return to Canada, where she did some work in
Ontario and later in Vancouver at St. Vincent’s Hospital and Vancouver General
Hospital she went to South Africa for three years and on her return again to
Canada she did a locum in Fort St. Jean for three months in 1987. Later that
year she successfully applied for a post at Baffin Regional Hospital in Iqaluit,
N.W.T. as a G.P./Anaesthetist. She spent eight months in this posting and then
did a three months’ locum at Williams Lake. Late in 1988 she underwent major
surgery and was on the sick list until May 17, 1989 when she first applied for
admitting privileges at the Hospital on the basis of doing a locum for Dr. N who
had been chronically ill and unable to carry on with his comfortably large
practice. The period of her privileges as a locum tenens was from May 23 to
The Credentials Committee recommended her for temporary locum tenens
privileges, noting that written references had been requested although
satisfactory telephone references had been obtained.
The privileges the Appellant sought were Family Practice, Obstetrics, Emergency,
On the date of application she signed the usual declaration whereby she agreed
to abide by the constitution and Bylaws of the Hospital and by the bylaws of the
Medical/Dental Staff. She also stated she had never been denied privileges. She
had applied at Nanaimo, Duncan and Ladysmith but each of this hospital had
required proof of her doing a locum first, hence her application in Port Alberni.
The Appellant testified that, other than a very brief, 15 minute tour of the
Hospital, conducted by the wife of Dr. N, she received no orientation. She said
she was not really informed what, as a locum she would be permitted to do. But
on a further document dated June 14, 1989, unsigned by the Appellant but
bearing the signature of the Chairman of the Credentials Committee and entitled
“Procedural Privileges” there is ticked off “Normal Labour and Delivery” as the
sole area of her obstetrical privileges.
In June, 1981, the Hospital composed a manual for physicians employing locum
tenens and physicians practising in locum tenens. Paragraph 3 provides:
The employing physician is responsible for designating a
colleague from the active staff to be made available to
provide advice and information to his locum tenens.
The manual goes on to state that privileges awarded to G.P. locums are
restricted. In order to obtain more specialized privileges in obstetrics, surgery,
medicine etc. a locum must demonstrate his or her skills to designated members
of the active medical staff, preferably the Chiefs of the various departments.
There is then listed the procedures locums may do and what they may not do.
The guidelines further provided that a doctor must be in attendance at the
Hospital within 10 minutes of being called. This will be further alluded to. The
document finally provided that any significant problems with a locum are to be
reported to the Chief of Staff and Head of the Credentials Committee.
Ms. F (Administrative Assistant) testified that she gave a copy of these Rules to
the Appellant. Under cross-examination she said she was 90% sure she had
done so although no receipt was given. The Appellant denied she had received a
copy. Whether she did or not, there was evidence before us that the whole
system was undergoing changes due to accreditation requirements and that the
administration was in a state of flux due to a change of administrators.
Nevertheless the Appellant ought to have made sure that she read and
understood the Medical Staff Bylaws and the instructions for locums.
On June 14, 1989 the Acting Administrator informed Admitting, Maternity and
Nursing departments that the Appellant had been granted privileges in Obstetrics
for normal Labour and Delivery. Meanwhile on June 9, Dr. K informed the
Credentials Committee that he had supervised a delivery done by the Appellant
requiring outlet forceps and that he was “exceptionally pleased with her
performance.” It should be noted that at this point, June 9 she had no
privileges. Her appointment was not approved by the Board of Trustees until
On June 27 she wrote a handwritten note to the Head of Surgery requesting
permission to do twenty procedures. (Ex. 1 Tab 6B). On July 21 she addressed a
more formal letter to the Surgical Committee requesting permission to do a large
number of procedures. In the field of Obstetrics with which this appeal is largely
concerned she requested, under that heading:
In an accompanying form she also requested privileges in many other areas with
She testified that while the first four of the obstetrical procedures were not
included in her privileges the last two were included. She said her other locums
had permitted her to do an episiotomy as a part of normal delivery but admitted
that every hospital is different in this respect. She said she performed low
forceps deliveries, episiotomies and induction when she thought they were
required and that no one had challenged her. She said she had done these
The Appellant’s initial term was extended to December 1989. In November she
terminated her locum for Dr. N and considered purchasing another practice which
During the latter months of 1989 complaints against her were expressed by the
nursing staff and it was alleged that she had over-subscribed for laboratory tests
(See Ex. 1 Tab 9) to the extent of costing more than all the other physicians
combined. Her choice of drugs was challenged by the Nursing staff. (See Ex. 1
Tab 10) and her alleged failure to obtain a consultation in the case of fetal
distress involving passage of meconium was also noted. On November 28 a
report from Dr. HN of the medical staff (Ex. 1 Tab 12) stated that the Appellant
had admitted a patient suffering from depression on November 22. The patient
had a history of drug abuse. Dr. HN was called in to discharge him on November
23 since the patient appeared to have recovered from his acute emotional
distress. Dr. HN concluded, after seeing the patient that he was entitled to
discharge. He said the Appellant had refused to sign or do the patient’s
summary report and he had hesitated to do so since the Appellant knew him
better. His report concluded that, on her return from vacation, the Appellant
confronted him in a hostile manner, accusing him of improperly discharging a
patient who had a severe suicide wish. His report indicates that at least one
member of the medical staff expressed his concern about the Appellant’s alleged
Meanwhile an obstetrical audit had been carried out for the period of May 1 to –
October 31, for the purpose of comparing the Appellant’s practice with that of the
remaining Hospital staff and that of the Krikke & Bell studies (Ex. 1, Tab 13). In
this audit the Appellant did not come off too well and in an in-hospital study
conducted by Dr. W, Head of Obstetrics, it was alleged that the average length of
stay by the Appellant’s patients was 5.4 days as against 2.3 days for the patients
of other doctors. The audit also indicated that she induced more patients than
the rest of the medical staff. The methodology employed was not, in our view,
without serious flaws and the Appellant’s pattern of practice cannot be judged by
these tests alone. A further audit, prepared in February or March, 1990 and
unavailable to the Hospital Board, (Ex. 1 Tab 14) examined the Appellant’s use of
the drug Dilantin during the months of July and August, 1989. The information
was taken from patient charts. It revealed a mean length of stay for the
Appellant’s patients of 8 days (adjusted) as against 3.5 for other patients, a
greater number of drug levels and tests per patient and a greater number of drug
changes. We were asked to conclude that this represented either muddled
thinking or a deficient knowledge of pharmacology on the part of the Appellant.
Again, we are not persuaded this evidence, taken by itself, is proof of inadequate
As time went on the medical staff became increasingly concerned with her work.
It first surfaced on October 6 in the form of a memorandum from Dr. W,
Chairman of the Obstetrics Committee, to the Chief of Staff, Dr. M (Ex. 1 Tab
15). It concerned a patient, S, and represented that the members of the
Committee were unanimous in finding that the clinical judgment in this case was
poor. Even more damning was the statement:
… there was a consensus that this may be a more widespread and
pervasive problem concerning this physician which would not be
easily remedied by a brief trip to a teaching environment
The last paragraph set the stage for what was to follow:
The Chairman of the Credentials Committee may wish to advise this
physician that should there be further applications for privileges at
(this hospital) they will be subjected to a critical review and should
be accompanied by letters of support from the department heads.
We note that the Appellant’s application was for a three month’s period only.
This would have expired at the latest, on October 11, being three months after
the formal approval by the Hospital Board, or, at the earliest, on August 22,
being three months after the recommendation of the Credentials Committee.
The administrative procedure left something to be desired as there was, in our
view, some doubt as to the Appellant’s status in the autumn of 1989 (Ref. Ex. 1
The MS case was exhaustively analyzed by Dr. W, Dr. H, head of the UBC
Department of Family Practice, and Dr. R, former Chief of Staff of Nanaimo
General Hospital. The first two were critical of the Appellant’s clinical skills. Dr.
R, with a wide experience in Obstetrics and Gynecology, less so. The patient had
been admitted to the Hospital in her first trimester suffering from hyperemesis
and losing weight. Intravenous Imferon was prescribed but was subsequently
cancelled by Dr. W who was of the opinion that since the patient did not have
anaemia Imferon was not indicated. He suggested that the Appellant should use
the drug Diclectin instead and directed her to some medical literature which dealt
with the use of this drug (Ex. 1 Tab 10) and recommended that “the drug should
be used during pregnancy only when the potential benefits justify the possible
risks to the fetus.” Dr. H agreed, in her written opinion and in her oral evidence,
that there was no justification for the use of Imferon unless there was severe
Dr. W testified that the matter had been brought to his attention by the Nursing
Staff on the ward who questioned the order for Imferon. Following this matter
the Committee undertook an audit of all the deliveries performed in the Hospital
from May to October, 1989. From a total of 18 or 19 cases of the Appellant, 6 or
7 attracted his interest because they included “matters that I didn’t think were
handled quite correctly” (Transcript, p. 4l). This represented about one-third of
the total charts examined and, according to Dr. W, was “much higher than the
average pattern of practice in this hospital” (Transcript, p.42).
The other cases referred to hereinafter identified by initials only may be
A.D.: A 17 year old girl who appeared at the Hospital, complaining of
constipation. She was sent to the Appellant who examined her but failed to
detect that the girl was pregnant, although she used her stethoscope. Twenty-
four hours later she appeared at the Hospital and gave birth to a healthy baby at
the entrance, still clad in her track suit which had to be cut in order to effect the
delivery. Another physician on staff delivered the baby then sent the mother up
to the case room with the placenta still inside. Dr. H was critical of the Appellant,
saying she should have carried out a more thorough examination. Dr. R observed
there was little a doctor can do when a patient will not cooperate. The patient
chart shows that the nursing staff had asked her when she was due, that the girl
asked “what do you mean?” She was asked “you are pregnant, aren’t you” and
Dr. W further testified that the Appellant was annoyed that she had not been
called and was concerned about the billing and who was going to be able to claim
As an aftermath, the patient did not wish to breast-feed her baby. The Appellant
prescribed Diazyde which Dr. H criticized as it causes a loss of fluid in the entire
body and that Parlodel was the drug of choice since it has few side effects.
S.K.: This patient, who had already had one baby, was admitted in her
37th week with ruptured membranes for 17 hours. The Appellant ordered
Prostiglandin. The patient went into what Dr. W described as “tumultuous
labour.” He said the Appellant telephoned to the Hospital and ordered Demerol
and Gravol. The Appellant then came to the Hospital and examined the patient
who proceeded into a short second stage of ten minutes during which period the
fetal heart rate dropped. Dr. W concluded that the use of Prostiglandin in this
type of situation is not well advised. Dr. H referred to its use as not a common
practice. Instead, i.v. Oxytocin is more easily controlled and maintains a
balance. Dr. R, on the other hand stated that Prostiglandin was used correctly.
Dr. W contended that induction by the use of this drug does not fall within
“normal labour and delivery” which was included in the Appellant’s privileges.
Dr. R observed that whether or not to induce is a judgment call and that there is
L.M.: This patient had ruptured membranes for 12 1/2 hours at thirty-
eight weeks on admission. Prostiglandin was ordered. This -patient went into
strong labour and delivered after eight minutes. Dr. W said the use of this drug
accounted for her very fast second stage. Dr. R agreed with the use of this drug.
Dr. H said its use is not common practice for induction but added that some
consultants would agree with the decision to induce.
N.M.: This patient had had a caesarian section in 1979 and three
subsequent deliveries, two of them complicated, Dr. W claimed that the whole
subject of vaginal birth after a caesarian is new and controversial in Canada and,
since they had no back-up material from the hospital where the caesarian had
been performed. he felt it desirable to have had a consultation during labour.
One had been obtained earlier from a physician in Nanaimo. Dr. R disagreed with
Dr. W, testifying that vaginal deliveries after a caesarian are not new and have
reached 85% level in some centers and, further, that a second consultation
would have been redundant. Dr. H supported Dr. W’s view that a consultation
during labour would have been advisable. Dr. W also criticized the Appellant’s
choice of Phenobarbital as a sedative and Dr. H referred to it as “not the current
drug of choice.” The Medical Staff Regulations of the Hospital (Ex. 1 Tab 1 p. 5)
provide that consultations must be obtained in
all cases undergoing a first caesarian section and in all cases with a
history of a previous caesarian section undergoing a trial of labour,
and complicated deliveries (e.g. twins, breach etc.) where the
medical care is not being provided by a qualified specialist
S .S.: When admitted she was in spontaneous labour and six centimeters
dilated. Her first stage lasted 61 minutes and her second stage 25 minutes, not
unusual for a multiparous according to Dr. W. A vacuum extractor was used
instead of forceps. The Appellant prescribed Phenobarbital as a sedative which
was criticized by both Dr. W and Dr. H. The use of the extractor was justified by
the Appellant because she said the fetal heart rate had dropped but Dr. W said it
was fine until five minutes before delivery. Dr. R did not comment directly on this
case. No fetal monitoring strip was produced at the hearing and this case
remains open, to some extent, to conjecture.
K.R.: This was the case, on which the Appellant has been supervised by
Dr. K. The delivery required the use of outlet forceps, and this procedure would
ordinarily have required the approval of the Obstetrics Committee and two
obstetricians to be present. Dr. W provided more details. A fetal monitor was
applied to the patient’s abdomen but the strip was undecipherable and so Dr. W
concluded there was insufficient data to justify the use of forceps. Dr. H merely
referred to it as “probably unnecessary” Dr. R said the case was well handled.
The Appellant said she had to use low forceps because the fetal heart rate had
Dr. W also testified that the privileges form which was a part of the application
process has a special area for induction of labour and augmentation and that the
Appellant had not been granted such privileges. In other words she was acting
beyond the scope of her authority as a locum. He testified that “normal
deliveries” would exclude forceps deliveries, caesarian sections, breach
deliveries, manual removals of placenta and twin pregnancies. This was his
interpretation although admittedly a definition of “normal delivery” was not
When asked by Ms. Dillon what procedure would be required to expand a locums
privileges he admitted that at that time the procedure was “somewhat unclear”
(Transcript, p.36) but added they would expect the locum to provide evidence of
further training, to provide further references and “possibly being supervised.”
He went on to admit that the question of obstetrical privileges for locums had
presented a recurring problem. He said (Transcript. p. 36):
… unfortunately obstetrics is one area where things can go wrong
rather rapidly and so the pendulum has swung between locums not
doing any obstetrics whatsoever to locums being allowed to do what
they feel they are able to do provided they can demonstrate
The Appellant, in her evidence, stated she had always, on the basis of her
experience, felt totally capable of doing all the procedures she had done.
The second area of the Obstetric Committee’s audit concerned the
pharmacological knowledge of the Appellant. Dr. W referred to her use of
Phenobarbital in each of the 19 charts reviewed and stated she seemed to
prescribe 30 milligrams at night whereas Halcion, Dalmane or Restoril are
generally regarded as the current hypnotics of choice. He said Pheonobarbitol
was not prescribed in the Hospital as a sedative but rather as an anti-convulsant
and it appeared odd to him if all the Appellant’s patients were in a continuous
state of convulsions. He said her orders kept changing from day to day and in
some cases she had left the dosage in the hands of the nurses who generally do
not make such decisions. Dr. W was also critical of her use of the drug Dilantin.
He said the normal practice, is to change the dose and then wait for up to 10
days before another drug level is done and then possibly change the dose again.
The charts studied indicated that some of her patients were having their Dilantin
changed or their anticonvulsant levels changed every day “rather like one who
would manage a diabetic who is very unstable, on insulin” (Transcript, p.63).
None of the charts indicated that any of these patients were so unstable as to
warrant sending them to a secondary-care facility. Hence the frequent changes of
Dr. W also carried out an audit with respect to the Appellant’s use of Vermox, a
drug which he testified was used to de-worm patients. Because worm infection
in this part of the world is very low it is not carried in the Hospital pharmacy. He
said the Appellant had prescribed Vermox for two patients during her time at the
Hospital but “no one had demonstrated the presence of worm eggs in the stools
of the patients before the drug was prescribed” (Transcript, p.67). He agreed it
was a safe drug but maintained the treatment of worms does not require the
In cross-examination he agreed that Dr. C, an internist had ordered Vermox
Dr. W also looked into the Appellant’s use of Deferoxamine in the case of one
patient who had been admitted for investigation of liver nodules. This drug, he
said, is a chelating agent which removes iron from serum and is useful in the
treatment of acute iron poisoning in children. The Appellant’s diagnosis of iron
overload was based on only one measurement of the serum ferritin, a protein in
the blood which reflects the levels of iron in the iron stores. Asked if there had
been an established diagnosis prior to the prescription of this drug he said:
There had been no established diagnosis of hemochromatosis in the
In cross-examination Dr. W was questioned by Mr. Giovando in respect to the
Dilantin audit and agreed there were really only two cases which were beyond
the normal range. He was closely questioned concerning the methodology used
in preparation of the Dilantin audit. Nothing is to be gained by a line by line
review of this evidence. We entertain serious doubts as to its probative value
and our conclusion is not based either on that audit alone or on the obstetrical
audit alone. But we note that while the obstetrical audit was available for the
Hospital Board, the Dilantin audit was not completed until march 1990 and
therefore constituted fresh evidence before this Board.
Turning now to the evidence of the two expert witnesses, Doctors H and R, the
former stated in her opinion letter of July 4, 1990 (Ex. 5B) that the use of
phenobarbital for a patient with jaundice of pregnancy was not an appropriate
choice. She wrote that the Appellant’s use of Dilantin with multiple drug changes
indicated a lack of understanding of the pharmacology of the drug. As to the use
of Vernlox for treatment of worm infestation she was of the view that it would
have been appropriate to order stool samples and await treatment. She said the
chart did not make it clear why treatment was not delayed. And she referred to
Deferoxamine as an unusual drug to be used by a family physician and that a
single measure of Ferritin is insufficient investigation prior to using the drug.
Dr. H found the Appellant to be more interventionist than the general practice at
this Hospital or in low risk settings as described by the Krikke & Bell study which,
although presenting a fair standard for a hospital obstetric unit, may have
presented a flawed result having in mind the small number of records (19) for
the Appellant compared with the much larger number used in the study itself. In
her oral testimony she admitted under cross-examination that she had never
practised in a rural setting and that such a practice differs from her experience.
But in re-examination she said her work takes her around the Province a good
deal so she does have knowledge of rural problems. She agreed she had no
expertise beyond family practice. She. was not aware that A.D. had concealed
her pregnancy until she saw a copy of Dr. R’s letter of October. 24, 1990 (Ex. 11)
or heard it from him verbally. In the N.M. case she was not aware that a
paediatrician had seen her in Nanaimo and said she felt more comfortable when
she learned of this. Similarly she was not aware that Dr. K had been present
during the K.R. delivery and had assisted the Appellant.
In his opinion letter Dr. R dealt with the Appellant’s drug problems in some
detail. He wrote that for decades Syntocin has been virtually the only drug
available for induction. But it has to be given i.v. and requires someone to sit
with the patient during administration to ensure tetanic contractions do not occur
and patients vary in sensitivity. He felt that doctors being conservative by
nature, they have become used to the drug. He concluded however, that as
more doctors became used to Prostiglandin it will gain wider use. In his
comment on the use of Phenobarbital he wrote that it has been used for h.s.
Sedation for a very long time but has now fallen from favour. He said he does
not like Halicion, favoured by the Hospital, as it is a potent drug and produces
He wrote that while Diazide does no good, neither does it do any harm. He said
Parlodel, acts on the pituitary gland, has become the drug of choice but he does
not favour such a potent drug as he is not convinced of its value to dry up
Dr. R confessed some difficulty regarding a comment on the use of Demerol in
the S.K. case – without seeing the patient. He concluded the Appellant’s use of it
was basically sound. He referred to her use of it as really a judgment call.
He commented on the induction of labour at some length. He said episiotomy is
very controversial in obstetrics, natural birth being a modern cult. He himself
does not agree with this trend. He wrote that an episiotomy can shorten labour
and, even though it can cause complications in later life most women welcome it.
He saw nothing wrong with the Appellant’s intervention. He concluded his
opinion by stating that her practice of obstetrics was acceptable and would not be
a reason to deny her privileges. This of course is a matter for this Board to
We will later deal with the Appellant’s evidence regarding the allegations of poor
practice and mismanagement but meanwhile return to a narrative of the events
leading up to the Hospital Board meeting of February 9, 1990.
On June 27, 1990 the Appellant wrote, presumably to the Head of Surgery,
requesting privileges to do some 20 items of minor surgery for which she had not
applied previously and on July 21 she addressed a typewritten letter to the
Surgical Committee requesting permission to do a number of minor surgical
procedures and, as well, the following procedures under the heading of
Obstetrics: caesarean section, breach delivery, forceps delivery – to and mid,
manual removal – placenta, induction of labour – medical and normal labour and
delivery. As already indicated she had previously been granted privileges for
As time went on the Appellant testified that she became increasingly frustrated
over not being able to obtain satisfactory information from the medical staff as to
the limit of her privileges, particularly in Obstetrics. She testified that she was
not really informed what she could do. She said she believed all the foregoing
procedures came under the heading of “normal labour and delivery” as well as an
episiotomy. In her other locums she had been permitted to do an episiotomy
which she considered to be a part of normal delivery. She admitted she had
performed low forceps deliveries, episiotomies and other forms of induction at
other hospitals and no one had challenged her.
Her initial three months’ locum was extended for a further three months which
brought it to the year-end. Finding that she liked Port Alberni and her work in
the Hospital she terminated her locum for Dr. N and negotiated with another
doctor to take over his practice for what was apparently a nominal price. She
acquired the practice on December 1 and is still carrying on that practice with a
substantial number of patients but without admitting privileges of any kind.
On November 14 the Appellant completed a four page hospital form in which she
ticked off both surgical and obstetrical privileges she wished to have (Ex. 1 Tabs
16B and C). Dr. JF, Chairman of the Surgical Committee replied in writing on
November 16 (Tab 18) stating he had reviewed her request personally, wished to
discuss the item of colonoscopy with her but that he would recommend the
approval of her application pro forma and forward the recommendation to the
Credentials Committee. On November 21 a meeting was arranged by the Chief
of Staff for the Appellant to meet with her, the Chairman of the Manpower and
Credentials Committee, the Administrator and Doctors ME and HU. The Chief of
Staff testified that she said the Hospital was having some difficulties with the
Appellant and would be seeking further information for extending her locum
status. She said she told her they already had concerns and the Credentials
Committee was involved and was looking at these concerns. She went on to
[the Appellant] asked us to be specific as to what our concerns
were, and we felt that as this was an informal meeting to clarify to
her that we did already have concerns, we did not want to proceed
with any detail as to specific cases that we were concerned about
and sources of reference. (Transcript, p.15 1.)
The Appellant testified that at this meeting she repeatedly asked for reasons why
they were concerned. She said the Chief of Staff held something in writing but
did not disclose the contents. She told the Appellant she should have waited
until she obtained privileges before buying a practice. The Chairman of the
Manpower Committee confirmed that the Appellant asked several times what the
problems were, what it was specifically that was of concern. He said the Chief of
Staff told her that it was not the purpose of the management to discuss
individual matters. He said the Chief pointed out to the Appellant that no
application (from the Appellant) had been received and no application had been
reviewed, hence it was inappropriate to discuss specifics. Significantly, he
The purpose of the meeting was merely to provide [the Appellant]
with as much insight and forewarning as we thought we could give
and we believed that we were doing what was in [the Appellant’s]
Dr. S further testified that as Chairman of the Credentials Committee, he told the
Appellant, that he personally had some concerns about her practice of medicine
and that should she apply for Associate status her application would be reviewed
in great detail. She asked him what his particular concerns were but again he
told her that as Chairman of the Credentials Committee, since no application was
before him he could not discuss specifics. He then suggested to her that she
should obtain letters of reference from the Chiefs of Staff of all the hospitals in
British Columbia in which she had worked. He warned her that on the basis of
the information he had it was his opinion that the Credentials Committee would
have difficulty in recommending the granting of privileges.
Dr. S testified that he had, prior to this meeting received the letter from the
Chief of Staff at Cariboo Memorial Hospital in Williams Lake which appears at Tab
19. The letter was dated November 17 and is addressed to the Chief of Staff.
There is no doubt in our minds that this letter influenced those at the November
21 meeting and for this reason we quote excerpts. The Chief of Staff at Cariboo
The doctors who arrange the slates for anaesthetics in the operating
room found [the Appellant] virtually impossible to get along with.
There were some reservations expressed at the Quality Assurance
Committee about her ability to practice medicine.
Perhaps, with upgrading in trauma, acute medical emergency care
and obstetrical care, [the Appellant] could do well in a practice.
However, without this upgrading I would be very reluctant to
recommend her for medical staff privileges.
This letter was not shown to the Appellant either at the meeting or afterward.
The Appellant stated that she was very upset at the meeting and was at one
point reduced to tears when she failed to elicit any specific charges against her.
On the day following the meeting Dr. HU, Secretary to the Medical Staff
Executive, wrote letters requesting references, to Baffin Regional Hospital, and
Fort St. John General Hospital (Tabs 21 & 22).
On November 24 the Appellant wrote to Dr. W requesting an answer to her
second request for obstetrical privileges. She had apparently given him the
official form for procedures and she asked him to pass it on to Administration.
On December 6, Dr. W addressed a letter to Dr. S, Chairman of Manpower and
Credentials. Dr. S reported that his committee had met on November 30 to
review her obstetrical practice. He stated:
Severe reservations were expressed concerning her knowledge,
judgment and obstetrical skills. In addition she would appear to
have problems with interpersonal relationships. (Tab 25)
On the same day he informed the Appellant in writing that he had reported to the
Credentials Committee in regard to her application for privileges but did not
On December 8 the Appellant directed a note to “Dear Doctor and Executive”,
requesting an appointment to the Associate Staff (Ex. Tab 16A).
This, then, was the situation at year’s end. While, strictly speaking, her status
was in some doubt she had made application for appointment to the Associate
Staff, inquiries were being made and she was carrying on with her extensive
Sometime after January 24, 1990 a reply was received from Baffin Regional
Health Board over the signature of Dr. MN. Dr. S was not sure whether he
received it before or after the Hospital Board hearing of February 9, 1990 but
said he was certain he did not place either of these letters before that Board.
The reference attached, addressed “To Whom it May Concern”, referred to the
Appellant as being a conscientious, competent and caring physician, but one
… did lose her temper quickly at times (but) she cooled off just as
rapidly and she had a good relationship with the nursing staff and
her colleagues when she left … I found [the Appellant] a very
reasonable colleague. Her clinical knowledge and scientific
awareness was well above average. (Tab 33 B)
The letter of transmittal provided additional information, apparently in response
to a telephone call from Dr. S concerning the Appellant’s interpersonal skills, in
particular, whether there had been any disputes. Dr. MN wrote:
In the last 2-3 months that she was here our then surgeon swung
from being totally in favour to antagonistic. He had got braver in
the kind of cases he was booking and [the Appellant] had remained
as cautious about accepting high risk patients. The surgeon as then
Chief of Staff felt he could “order compliance. (Tab 33A)
Dr. MN appeared before this Board to give evidence. Her comments generally
about the Appellant’s personality and her medical skills were all very positive and
she blamed the doctor concerned for the one incident referred to in her letter.
She referred to the Appellant’s clinical skills as very good, her knowledge of
drugs and medications as above average and her record and chart keeping as
very good. She said the Appellant strove to keep her medical knowledge current.
She said her obstetrical skills were “very adequate” and she had been involved in
In cross-examination she said when the Appellant lost her temper it was usually
when she had a problem with someone and she felt that things were not
happening appropriately. She had had confrontations with the nurses about
medication that had not been given or orders that had not been followed. She
I then said to her something along the lines of, you know, if your
anger goes on, sometimes people stop listening because you are
angry and you have a resistance there. (Transcript, p. 130)
What emerges from this evidence is that the Appellant got on reasonably well
with the nursing and medical staff but there were occasions when she became
extremely upset at what she considered to be incompetence and lost her temper.
Dr. MN also said that she cooled off in a few minutes.
Sometime in December, 1989 the Appellant composed a 2 1/2 page summary of
her complaints about the nursing staff in the Obstetrics ward at the Hospital (Tab
28). It is addressed to no one in particular but various initials indicate it was
directed to or seen by Doctors M and S and by the Administrator. It would
appear to have been received on January 2, 1990. Even allowing for the fact
that the Appellant was frustrated over not being able to get a straight answer
from the medical staff together with the fact that she was in an emotional frame
of mind, the lengthy tirade is astonishing. In cross-examination she admitted
that she wrote it in frustration and in hurt. It can perhaps be compared with a
possible reply and counterclaim she might have filed in response to actual
charges made against her because she concluded by writing that since she was
unaware of why she was being denied privileges she was showing what problems
she had had with that one Department and that there was nothing in it to show
any reason why she should not be able to practice medicine in the Hospital.
In eight numbered paragraphs the Appellant itemized her alleged difficulties with
the nursing staff, covering most of the cases referred to earlier in the Obstetrical
In each case she alleged the nurse involved had acted improperly or
unprofessionally. Many of her comments confirmed her anger. She referred to
an outburst from the Head Nurse as a “show of power.” Her comment on
another patient about the nurse in charge was “obvious bias.” And she added:
When I discuss it with another nurse I get blamed for being rude
and argumentative. I say same to her. Why don’t you curtail her
In regard to the M.S. case she wrote that the nurses had given the patient and
herself a hard time and that the Head Nurse, had even goaded the patient into
going home though she was still sick but that she realized the patient was not
ready when the Appellant got to talk to her.
A further confrontation occurred in regard to the patient M.I. where the Appellant
and the Head Nurse had speeded up the i.v. drips which brought on a seizure.
She said the nurse phoned her, because an Incident Report would have to be
filled and the nurse felt the patient should not have been on her floor. The
Appellant wrote that she told her all she had to do was watch an i.v. Her note
That’s when she turned on me about the patient described in case 6
(M.S.). Then she turned sweet again once she thought she had
Her final complaint involved a delivery she had planned to do but the patient was
early. She booked on a Thursday for Saturday morning. The patient stated she
wanted the baby circumcised but the Appellant had not yet received a response
to her earlier application for surgical privileges and she said Dr. S had allegedly
phoned her to tell her she couldn’t do it as she was still a locum. Having no
answering service, she said she did not know about it until the nurse told her
when she arrived. She had a further complaint to make about Dr. S in regard to
their periods of being on call. She said she was the victim of an uneven trade
and that is when she realized Dr. S was unfair. She said she had never had an
Initially she said she had given the memo to someone in Administration and they
discussed how to handle it. The latter asked the Appellant what she wanted
done with the memo. She said it was intended for further discussion only and
that she was disappointed and felt it was a breach of trust that the memo had
been circulated. The fact is, however, that it was circulated and must have
affected the ultimate decision of the medical staff to not recommend her for
associate privileges. It was material that was properly before the Hospital Board
Her application eventually came before that Board on February 9, 1990. The
circumstances were somewhat unusual. She had been informed, she said, by a
patient that the matter was on the agenda for a meeting of the “Committee of
the Whole” to be held on February 1 at 9:35 p.m. The title given this meeting is
unusual but in any event it was attended by most Board Members including Dr.
M. Between items 2 and 3 on the agenda, according to the copy of the minutes
filed but not marked as an exhibit, the Chairman said the Appellant had asked
permission to speak to the board about her privileges. On a motion, leave was
[The Appellant] asked about her hospital admitting privileges and
was advised by Mr. MK (Chairman) that the Board had not received
a recommendation from the Credentials Committee … and therefore
The Appellant testified she asked for reasons but none were forthcoming. She
was told her case would be dealt with later in the evening. She was not invited
to remain and so left the meeting. The minutes indicate that later in the meeting
there was considerable discussion with regard to the Credentials Committee’s
recommendation that she not be granted privileges. The members felt there was
not enough information available to render a decision. On Motion it was then
resolved that a special meeting of the Board of the Credentials Committee be set
up to discuss the Committee’s decision. The minutes do not show what, if any,
written material was placed before the Hospital Board at this meeting.
Prior to this meeting, however, Dr. HU had received a-reply from Fort St. John
General Hospital (Tab 29). It was not complimentary. It referred to some of her
treatments as being unusual and gave as examples:
Treating newborn jaundice with Phenobarbital.
Stimulating milk production with Chlorpromazine.
Treating minor head injuries (concussions) with
Other questionable uses of Corticosteroids.
The writer, Dr. L, said he had tried to discuss these matters with the Appellant
but his comments were not well received. His letter concluded with this
I must say … that [the Appellant] did raise more red flags in the
hospital setting than the number we have normally observed in
This letter was made available to the Hospital Board. In addition the findings of
the Credentials Committee meeting held on January 9 must have been disclosed
to the meeting of the Hospital Board on February 1. Dr. S, in his evidence
(Transcript, pp 187-188) informed this board that the Committee had reviewed
all the information then available to them. They discussed a number of incidents
where the Appellant had apparently crossed swords with some of the medical
staff and reviewed information they had received from Doctors B and RB, both
radiologists. These doctors were not called on to give evidence, however, and
we do not know what their complaints, if any, were. But the Committee did
review the letter from Dr. K, the Obstetrical audit (but not the Dilantin audit) and
Dr. W reviewed the cases dealt with on that study as well as the Krikke & Bell
Dr. S said they spent a good deal of time discussing the lengthy memorandum
prepared by the Appellant and reviewing the cases it referred to. The committee
also looked at Dr. L’s letter and Dr. S reported on his telephone conversation
with Dr. MN from Baffin Island. Her written reference had not yet been received.
The committee also reviewed the letter from the Chief of Staff in Williams Lake
and the other references the Appellant had supplied. Dr. S said the references
were not too helpful. What the committee was seeking was references from those
who had had a longer working relationship with, and a long term knowledge of,
the Appellant. They regarded the letters from Dr. L and the Chief of Staff in
Williams Lake as “very significant” and in support of their own feelings based on
The Committee voted unanimously to recommend that privileges not be granted
to the Appellant. The Chairman communicated this decision to the Chairman of
the Quality Assurance Committee for his committee to review the Appellant’s
hospital practice in detail. The Medical Advisory Committee held a meeting on
January 10. The negative recommendation was presented to it and accepted and
the recommendation went to the February 1 meeting of the Hospital Board. Dr. S
I attempted as carefully and properly as I could to present to the
Board all the information both in writing and of an informal verbal
nature that I or other members of the Committee had been aware
of at the time that we made our decision to not recommend
granting of privileges on January 9. (Transcript, p. 190.).
The letter from Dr. MN which arrived subsequent to January 10 was never
disclosed to the Hospital Board, nor was any other communication or other
None of the information received by the Committee was passed on to the
Appellant either before or after the Hospital Board meeting on February 1 and it
was only made available to her for the purpose of this Appeal.
A special meeting of the Hospital Board was held on February 9. Doctors S and M
were both present. Dr. M presented the recommendation of the Medical Advisory
Committee and Dr. S reviewed the information which formed the basis for the
report. Both doctors answered questions put to them by Board members and
then, upon motion, the Medical Advisory Committee’s report was accepted. The
Appellant was not invited to this meeting and was not informed of it. The
allegation that the Appellant was seriously lacking in interpersonal skills was
referred to in part by several members of the Nursing Staff.
Nurse O was Head Nurse in the Obstetrics Department at the material times.
She recounted an instance involving the Appellant requesting that Demerol be
given to a multiparous patient who was at six centimetres of dilation. Nurse O
said the Appellant wanted the nurse on duty to give the patient the drug without
checking the patient first and Nurse O told her to make a note of it, which she
did, but the note was subsequently thrown away. She said the nurses were
concerned about the Appellant prescribing Imferon. The opinion of Pharmacy
was sought and it was their opinion that the patient’s condition did not justify the
risk involved in using this drug. Nurse O said four other nurses had been
reluctant to administer Imferon in this case. She mentioned another case in
which the Appellant had ordered medication for a patient who was admitted
pregnant and with toxemia but no high blood pressure and the nurse felt
uncomfortable about giving the medication. She was critical of the Appellant
ordering Demerol in case No. 1 referred to in Tab 28 and said it was not accepted
nursing practice to give it at this stage of pregnancy. She questioned the
Appellant’s decision not to give Parlodel in the case of A.D. as well as her not
noticing that the patient was pregnant. She responded to the Appellant’s
complaint referred to in paragraph 3 of Tab 28 by admitting she may have said
something similar to what the Appellant alleged because it was against hospital
rules to take a premature baby and she said she had referred the Appellant to
She further commented on the L.B. case. She was critical of the Appellant being
in Nanaimo when she was on call and that she had arrived six minutes after the
delivery. She was also critical of the Appellant performing a circumcision when,
clearly, this surgical procedure was not included in a locum’s privileges.
Nurse K, who was acting head nurse in the Obstetrical ward from early March to
early July, was directly involved in an incident concerning a patient, L.B. The
Appellant, having stayed overnight in Nanaimo while on call, had been unable to
arrive at the Hospital in time for the delivery. She said the Appellant told her
they could use the doctor on call in Emergency but Nurse K told her that wouldn’t
do since often there was only a locum in Emergency without obstetrical
privileges. The Appellant said she was only 50 minutes away but the nurse told
her that was well beyond the time limit for on-call, which should be 10 or 15
minutes. She said she agreed with the warning given the Appellant regarding
the use of Imferon. Nurse K had fourteen year’s experience behind her in the
Hospital. In cross-examination she expanded on the L.B. incident. She said it
was a heated discussion that she was only stating the Hospital policy but the
Appellant became angry and yelled at her loud enough to be heard across the
hall. The Appellant denied this. In answer to questions from the Chair Nurse K
said the duty nurse or head nurse can question a medication but one must
consult with the doctor first. She had had occasion to do so over the years but
usually about a wrong dose rather than the wrong drug.
Dr. AF a general practitioner gave evidence regarding an incident involving a
male patient, V.H. He had been called by the duty nurse to change an order
previously written by Dr. C. She had been unable to reach him. The request
was to change the order from intramuscular to Demerol by mouth. He so
ordered and said it was a perfectly straightforward matter. He referred to it as a
non-issue. The next morning the Appellant approached him in the Medical
Records room, demanding to know why he had changed the order. He explained
why. He described her manner as “slightly aggressive” and “a one-sided sort of
approach.” Following this incident, he said the Appellant had ordered both
Demerol and Gravol but had not specified the route they were to be given. He
said she seemed upset at his “interference.” He felt that the Medical Records
room was not an appropriate place for a conversation of this nature. In answer
to questions from Mr. Farquhar he said that he found it difficult to explain to the
Appellant the reason for his changing the order and to interact in any meaningful
conversation during the “little lecture” she was giving him. In fairness, Dr. AF,
conceded he got on all right with her at other times.
Finally Dr. JF was called by the Hospital. At the material times he was chairman
of the Surgical Committee and had been at the Hospital for seven years. He
confirmed he had approved the procedures the Appellant had requested at
February 16 save for colonoscopy. She had assisted him in appendectomies and,
in cross-examination, he said he was satisfied, that her diagnoses were
reasonable, and he described her referrals in relation to other doctors
“sometimes better, sometimes worse.” He had found nothing bizarre about her
treatments and said he had found no case where her prescribed medication was
inappropriate. He agreed with Mr. Giovando’s suggestion that it is not possible to
get along with everyone who is working in the Hospital and agreed there are
often personality conflicts. He confirmed that the recommendation made to the
Credentials Committee was that she be granted admitting privileges for those
In our review of the evidence it is clear that the Appellant got off to a bad start.
We refer to the absence of an orientation program and the uncertainty as to what
actual material, if any, she was given to read. But she had several years of
practice behind her in various sized hospitals and must have been aware that
there was partly a duty on her part to familiarize herself with the procedures she
could undertake as a locum. Her failure to learn the Hospital rules for being on-
call is inexcusable. The 50 minutes’ drive from Nanaimo was well outside the
limits imposed by the Medical Staff Bylaws. Admittedly, part of her experience
was in Africa where one can assume she worked in sometimes primitive
conditions and as the result probably had little time for the niceties of hospital
organization. But that considerable prior experience must surely have taught her
that all hospitals have rules and regulations. We view the Appellant as a person
of considerable energy, intelligence and devotion to her profession but lacking in
the tact that is so essential in the modern hospital setting. As well, she displayed
considerable, antagonism to anyone who disagreed with her.
It seems that fairly early her clinical judgment and pharmacological knowledge
came to the attention of the medical staff. Despite the evidence of the staff
doctors who were called, the evidence of Doctor H, and the evidence of the two
nurses we are unable to conclude that on those grounds alone the Hospital
Board’s refusal was justified. But the letters from Fort St. John Hospital and
Cariboo Memorial Hospital which were not before the Hospital Board but form
part of the material introduced in evidence at this hearing provide some
confirmation for the view that there was a reason to question some areas
involving her practice and procedures. In our view she seems to lack some
understanding of the value of certain more modern drugs, those referred to by
several witnesses as the “drug of choice.” This may be attributable in some
Dr. AF found her work satisfactory but this was in relation to surgery only
whereas most of the complaints stemmed from her Obstetrical practice. The
evidence disclosed that she acted beyond the scope of her privileges but this was
largely due to her interpretation of the term “normal labour and delivery.” It was
not carefully delineated for he, but, again, we are of the view that she had
enough prior experience to have alerted her to find out. It is not good enough
for her to say simply that she knew she was capable of doing what she did.
Many of her references supplied to the Credentials Committee and subsequently
to the Hospital Board were, in many instances, several years old or non-
committal, arose from entirely different circumstances or covered brief periods of
time only. The principal positive reference was the one from Frobisher Bay,
supplemented by the oral evidence of Dr. MN. But even this carried a strong hint
of personality clashes and it was only the telephone conversation between Dr. S
and Dr. MN that was reported to the Hospital Board. Most of these references
were seen by the latter and must have been taken into account.
We find that the Hospital’s concern with the Appellant’s lack of interpersonal
skills was in itself a compelling reason for the refusal of privileges. We refer in
particular to some, if not all, of the nurses’ evidence, her unjustified ignorance of
the rules relating to discharge of patients, the unfortunate incident related to Dr.
AF and the extraordinary memo she composed, which contained innuendo, glib
comments and unprofessional statements. Despite her alleged frustration at the
time – she said she felt a sense of hurt – it was tactless and ill advised. The
doctors and the Administrator who met with her on November 21 did so in order
to have a frank and perhaps helpful chat with her. They were not required to cite
chapter and verse to her. They made it clear that they had concerns about her
patterns of practice and warned her against buying a practice before she was
assured of privileges. We question what more they could have done. Thereafter
the matter followed a more or less conventional course. She applied for
Associate status, referrals were made to the Committees concerned and
eventually it came before the Hospital Board, February 9 at a special meeting,
apparently called to consider only two matters of which this was one.
We reject the findings of the Obstetrical and Dilantin audits for the reasons
previously given. And we are not persuaded that the Laboratory report of the
Appellant’s billings necessarily provides compelling proof of her over-use of
It is trite law that a hospital board’s duty, in selecting doctors for its medical
staff, is to have regard to the whole person, not merely that person’s
qualifications and skills but the applicant’s character and personality as well.
Every hospital has a duty imposed on it by the Hospital Act, RSBC 1979. Ch. 176.
to provide a high level of patient care. That duty is owed to the community
which, in this country, supplies through taxes, the greater portion of the costs of
operating the public hospitals. The onerous task faced by a hospital board is to
ensure that the institution is run competently and efficiently. It is a delicate
mechanism. If the total trust, cooperation and general team work of any of its
constituent parts breaks down the result can be unfortunate for the hospital and
community. This has been demonstrated in other appeals before this Board.
There was no evidence before us that the Hospital Board acted capriciously or
maliciously or that the medical staff, whose duty it was to make a
recommendation to the Hospital Board exhibited bias toward the Appellant
Theirs was a judgment call and we are satisfied that they arrived at their
judgment honestly and fairly. Although, prima facie, it seemed that the medical
staff was unfair to the Appellant in refusing her particulars of their concern, they
had no duty to do so either at the November 21 meeting or later. After the
Appellant filed her application for Associate status the matter was, in our view,
handled correctly and in accordance with the Hospital Act Regulations as well as
the Hospital Bylaws. The Regulations do not create a right for an Appellant to be
heard the first time around. If an Appellant so chooses he or she may appeal the
initial finding to the Hospital Board where he or she is entitled to appear with
Counsel. In this case the Appellant, as she is entitled to, chose to appeal directly
to this Board. Thus we must place ourselves in the shoes of the Hospital Board
and consider all of the evidence adduced before it. We must also have regard to
those letters of reference which came in subsequent to February 9.
In considering the Appellant’s suitability for Associate privileges the Hospital
Board, and the medical staff whose duty it was to give or deny approval, had a
duty to consider what was best for this Hospital, not whether the Appellant’s skill
and knowledge were adequate in other hospitals (See Re: Board of Governors of the Scarborough General Hospital and Schiller (1974) 4 O.R. (2nd) at p-212. In
Although we do not base our judgment alone on her patterns of practice, the
concerns with her pharmacological knowledge, the Laboratory use or the
Obstetrical and Dilantin audits, these factors, coupled with what, in our view, was
a questionable inability to employ tact and a somewhat insensitive response to
criticism is justification for a denial of privileges. The Hospital Board acted
correctly and with the benefit of the additional material and evidence before us
during the course of a five day hearing we cannot find reasons to reverse their
We would add that the Appellant, who continues to practice in Port Alberni, has
requested the College of Family Practice to audit her practice. She has also
taken a number of courses to upgrade her skill and knowledge. She sat for
written and oral examinations over a period of three days in April 1990, covering
the entire range of general practice including drugs, geriatrics, paediatrics,
obstetrics and gynecology. It may well be that her additional studies will prove
For the foregoing reasons however we would dismiss the Appeal. Dated May 24, 1991
Dissenting Opinion
With respect, I dissent from the majority opinion for the reasons which follow. I
have dealt with the many issues raised under separate headings.
The Appellant supplied the Hospital with nine favourable references in May and
June 1989. The references dated from 1979 to 1989 (Ex. 1, Tab 3H to 3N, 4B,
4C). In October, 1989, the Appellant was told that she would need to provide
more references if she intended to apply for Associate Staff. She then provided
about 14 positive references dating from 1976 to 1987 (Tab 34). The Hospital
independently sought references and received two unfavourable references, one
of which was politely unsupportive (Tab 29) and one which was strongly negative
(Tab 19). One was strongly supportive (Tab 20).
The Appellant did not receive copies of the unfavourable references and was
never given an opportunity to defend herself. The Hospital also received a
favourable reference dated January 20th and a memo January 24th 1989 (Tab
33), which it interpreted as negative, although in answer to questions from Mr.
Marshall, Dr. S acknowledged that the letter was in part positive and in part
neutral (Transcript, p. 203). The negative references were seen as “very
significant” and the positive references were deemed “not pertinent” by the
Credentials Committee (Transcript, pp. 189 and 200).
The Appellant was criticized for being “aggressive” in her obstetrical practice. Dr.
R, a retired specialist obstetrician and expert witness, reviewed six of her cases
and felt that “her practice of obstetrics is acceptable” and would not be a reason
to deny her hospital privileges. His report (Ex. 11) states:
Of the case M.S., “The treatment of hyperemesis can be frustrating but
fortunately it is usually self-limiting no matter what is done.” He did say of
this case, “…there was no indication to give parenteral iron” but he “would
not be concerned with it being harmful to the pregnancy.”
Of the case A.D. who refused examination he said there is little a doctor
Of the case S.K. he said, “Prostin was used correctly.”
Of the case L.M. he said, “Correct action was taken.”
Of the case N.M. he said, “The case was adequately handled with a
Of the case K.R. he said it was monitored by Dr. K and he was
“exceptionally pleased” with the Appellant’s performance.
The Hospital’s senior general practitioner/obstetrician, Dr. K, supervised a
delivery and stated in a letter of June 9, 1989 (Tab 8) that he was “exceptionally
pleased” with her performance. The Appellant was granted privileges in
Obstetrics for normal labour and delivery by administration in a letter dated June
14, 1989 (Tab 7). Dr. K commented that the Appellant used outlet forceps and
“put them on in a very sleek fashion” (Transcript, p. 98). He also gave in
evidence that he had “no objection if anybody wants to use outlet forceps. … It is
The Appellant was also criticized for a high incidence of episiotomy. Dr. R
described the damage to underlying tissues during delivery without an
episiotomy which causes problems in later life. He also added that episiotomy
can shorten labour. He said “I see nothing wrong with [the Appellant’s]
In its obstetrical audit (Tab 13) the hospital used a reference which is misleading.
It compares the obstetrical practice of the Hospital with that of the University
Hospital in Edmonton as described in the Krikke & Bell article (Canadian Medical
Association Journal March 15, 1989). The two hospitals are not comparable.
This Hospital is a class one hospital, and the University Hospital is a class three
hospital as well as being a University teaching hospital. Of 4,463 deliveries the K
& B article studied, 32% of these deliveries or 1,456 were “low-risk pregnancies.”
The West Coast General Hospital studied all of its deliveries not just low-risk
pregnancies. The Edmonton Hospital had 50% midwives in the Obstetrical Unit
and the West Coast General Hospital had 20% midwives (Transcript, p. 94).
Although this obstetrical audit was used as part of the grounds for not granting
privileges, it was acknowledged at the appeal that “there was too small a sample
size for meaningful analysis.” The Appellant had “18 to 19” deliveries of which “6
or 7” were cause for concern (Transcript, pp. 41 and 42). It was also stated in
evidence by the Chairman for Obstetrics, Dr. W, that the Appellant “ had
relatively straightforward and easy deliveries to handle (Transcript, p. 58).”
The Appellant was also criticized for the use of Demerol during delivery and other
The Appellant was criticized for using Prostin instead of Syntocinon. Dr. R felt
that she had “used it correctly to induce labour successfully in two patients.” The
Krikke & Bell article cites the use of oxytocin or prostaglandin as used by both
obstetricians and family physicians. Dr. W stated that he would use, in some
cases, prostaglandin overnight and Syntocinon the next day (Transcript, p. 80).
The Appellant was criticized for the use of Vermox when evidence showed that
Dr. C, a specialist internist at the Hospital, had done the same (Transcript, p.
A nursing report was made out because the Appellant had ordered Demerol for a
woman in labour who was six centimetres dilated (Transcript, p. 149). The nurse
refused to give the order. (This is item 1 in the Appellant’s angry rebuttal of
January 2, 1990 – Tab 28.) One medical witness said she would give Demerol if
the patient was five centimetres dilated. Dr. R in his review said “dilatation
cannot be taken as a single entity.” He also added “A dose of analgesic at this
time can be very effective. If the Demerol should affect the baby adversely an
antidote can be given.” In any event the Appellant’s use of analgesics was less
than the rest of the staff as shown in the obstetrical audit: 50% of her primips
compared to 68% of the medical staff, and 10% of her multips compared to 35%
of the total medical staff (Tab 13), (Transcript, p. 57).
The Appellant was criticized for her use of phenobarb. Dr. R notes that she uses
this for “h.s. sedation in a low dose for a short time.” He adds “phenobarb has
been used in this way without problems,” for a long time. Dr. W gave evidence
that Halcion was the drug of choice at the Hospital. Both expert witnesses, Dr. H
and Dr. R, felt that Halcion was not recommended.
The Appellant was told that Parlodel was the drug of choice in the Hospital and.
this again led to another nursing report and another angry retort by the
Appellant in her incident report of January 2, 1990. Dr. W acknowledged in his
evidence that diuretics were used before 1975 but since then Parlodel was the
drug of choice at the Hospital. Dr. R testified that Dyazide was not harmful and
not beneficial and said that Parlodel was a potent drug. He added, “I am not
convinced such a potent drug is proper for a benign self-limiting problem.”
In reviewing the chart of patient M.S., Dr. R reported “parenteral iron was
ordered because oral iron was not tolerated as expected.” However, there was in
the chart “no indication to give parenteral iron.” He added however, because of
his wide experience with parenteral iron, “I would not be concerned with it being
There is no evidence as to why this iron chelating agent was used. The patient
was said to have had a serum ferritin level done (Transcript, p. 68) but no lab
report is available. The diagnosis was said to be iron overload (Transcript, p.
An audit was done at the Hospital in July and August 1989 (Tab 14) to compare
Dilantin levels and drug changes and length of stay of the Appellant’s patients
with those of other medical staff. During the hearing before this Board an error
was found in this audit which was corrected for the Board but presumably the
Medical Advisory Committee reviewed the original. No diagnoses were given on
any of the patients and the number of seizures per patient per day, if any, was
not given so that it was not possible to judge the significance of the length of
hospital stays or the significance of the frequency of drug levels or drug changes.
Dr. H has a Fellowship in the College of Family Practice. She is an Associate
Professor at the University of British Columbia in the family practice teaching
field. Her expertise, according to the evidence, lies in teaching and research in
the field of sexual assault, hypnosis and stress management. She travels widely
to give lectures and interviews on these subjects. She is based at a large city
Although he retired from active practice in 1987, Dr. R has a long history of
practice as a certified specialist in Obstetrics and Gynecology. He practised in
the Nanaimo area since 1959. Although the Nanaimo hospital is larger than the
West Coast General Hospital it acts as a regional hospital for the smaller
hospitals in that area. As well as being on the Active Staff of the Nanaimo
Regional General Hospital, he was also on the Consulting Staff to the West Coast
Because of Dr. R’s special expertise in the area of Obstetrics, more weight must,
in my opinion, be given his evidence. His experience is also more relevant to the
In the case of Kelowna General Hospital & Dr. T.J. O’Neil, heard by this Board in
1975, the Board held that the Appellant received fair and reasonable notice of
the hearing before the Medical Advisory Committee, … “That he was made aware
of the charges against him and was given every opportunity to speak to them.”
The Appellant, although she attempted to speak to the Hospital Board February
1, 1990 was not given permission to speak and was not told about the next
Board meeting of February 9th at which the decision was made. She asked in
October and again in November 1989 as to what were the charges, but she was
never told and was not given an opportunity to present her case (Transcript, p.
She was not given copies of the unfavourable letters of reference and was not
given an opportunity to refute them or defend herself (Transcript, p. 196). On
January 10, 1990, a meeting of the Medical Advisory Committee was held as a
meeting of the whole medical staff, to which she was not invited “because she
was not a member of the medical staff’ (Transcript, p. 32). In Dr. D.R. Loewen and Cariboo Memorial Hospital heard by this Board October 8, 1985, the
Appellant was not a member of the Medical Staff and yet had attended some 50
No consideration was given the fact that the Appellant had been off work because
of back surgery from 1988 until May 14, 1989 and began work at the Hospital
May 23, 1989 on very short notice because of Dr. N’s illness (Tab 4A, 4B).
Although the Hospital instructions state that locums must be given an orientation
and instructions in Hospital procedures by the hiring doctor or his substitute, she
had no orientation other than a tour of the physical layout conducted by Dr. N’s
wife. The instructions also state: “The employing physician is responsible for
designating a colleague from the Active Staff to be available to provide advice
and information to his locum tenens.” There is no evidence that this was done
by anyone on behalf of Dr. N who was ill.
It is acknowledged that the hospital administration was in a state of confusion, if
not chaos, a few days after her arrival. There were changes of department heads
in both Chief of Obstetrics, Chief of Staff and in Administration.
The Hospital presented a study of lab tests done at a laboratory in the
community. The hearing before this Board was given no report of lab tests done
in the hospital laboratory. Although the Board was told that this report was not
relevant since it had to do with practice outside the hospital, this study had
already had some influence with the Medical Advisory Committee.
In the case of patient A.D., an adolescent who concealed her pregnancy from her
parents and her doctor, the Appellant failed to diagnose pregnancy. This patient
delivered on July 21, 1989. The Appellant’s privileges were renewed for the
period September 1989 to December 1989. The expectation, therefore, was that
this failure to diagnose had been forgiven. Dr. R said of this case: “She refused
to be examined. … there is little a doctor can do when a patient will not
The complaints against the Appellant seemed to have arisen out of her
relationships with the nurses, particularly in the Obstetrical Unit. The evidence
seems to show that the Hospital attacked this problem not by meeting with the
nurses and the Appellant to work out problems but rather, by examining the
Appellant’s clinical expertise. This led to an obstetrical audit which, because of
serious flaws, worked to the prejudice of the Appellant.
There was evidence that the Appellant tended to lose her temper but it was
described as short-lived and her “irritation and reaction was appropriate”
(Transcript, p. 132). One of the nurses referred to an “angry conversation”
between the Appellant and Dr. AF but the latter referred to it as a “conversational
tone” and “only slightly aggressive in nature”. At the time he thought of it as an
“isolated incident” and did not feel it necessary to report it until requests came in
for reports concerning the Appellant (Transcript, pp. 139-140 and p. 142). He
also testified that on September 3, 1989 he was “lectured at,” by the Appellant
but also said that at other times she was “passively pleasant” (Transcript, p.
The incident involving Dr. HN is another instance in which the nurses seemed to
be more upset about the verbal attack than the doctor. He did not report on it
until “asked to” (Transcript, pp. 103 and 104). Dr. HN’s duty was to write the
discharge summary. He did this. Nevertheless there was no excuse for the
The Appellant revealed her temperament in her incident report concerning the
nurses of the obstetrical department, January 2, 1990 (Transcript, p. 28). This
report can only be described as irritable, angry, accusatory and mean-spirited.
Nevertheless, it must be read in the context of a doctor who has been warned in
October 1989 that her practice is going to be critically examined if she applied for
Associate privileges. Accusations had been levelled against her and she was
frustrated in not being able to find a forum to defend herself and discuss these
In the Kelowna General Hospital & O’Neill case (supra), the Appellant was
described as “abrasive, adamant, arrogant and dogmatic.” In spite of this he
It might be said that since the Appellant was never on the permanent staff, the
Hospital has no obligation to accept her. Nevertheless her locum status was
renewed after three months, for a further three months extension, and this must
have given her an expectation that she could continue to apply and expect a
favourable result. She had applied for privileges to three other hospitals in the
area but each had required proof of her having done a locum first. Therefore,
having done a locum at West Coast General Hospital, the expectation would be
that application for Associate Staff would be a natural progression of events and
that preference might be given doctors who had done a locum there.
Legal Authorities Cited By Hospital’s Counsel
In Re Board of Governors of the Scarborough General Hospital & Schiller (Tab 4),
of the Hospital’s legal authorities and reported in 4 O.R. (2nd) 201, it was the
case of a specialist surgeon. The hospital showed that it had no need for another
specialist. This case has no relevance for the present case in which the Appellant
Andreas & Edmonton Hospital Board (Tab 5), and reported in (1944) 4 D.L.R.
747, is the case of a physician who was not already a member of the staff and “it
made all the difference in the world” (page 752). The Appellant, although not a
member of the Active or Associate staff, but as a locum whose term of three
months was renewed for a further three months, had an expectation of
The case of Tanhueco & Prince George Regional Hospital (Tab 8), an appeal
heard by this Board in October, 1986 is not comparable. It concerned a physician
not trained in a Canadian medical school, as was the Appellant. The case of
Iqbal & Mission Memorial Hospital, an appeal heard by this Board in February,
1974, is also not relevant as the physician was never on staff and surgical
The case of Loewen & Cariboo Memorial Hospital (Tab 10), an appeal heard by
this Board in October, 1985, also concerned a physician who was never
previously on staff and the evidence suggests he planned to use the appointment
Griswold & Great Victoria Hospital Society (Tab 11), an appeal heard by this
Board in 1986, concerned a specialist and is not, in my view, relevant for a
The Respondent has not proven that the Appellant’s clinical skills are inadequate.
The Appellant’s interpersonal skills are deficient but could be remedied and are
In my opinion the Appellant should be granted admitting privileges as an
Associate Member of the Medical Staff. During the period of probation, the
Appellant must accept the Hospital’s standard of care as well as its Rules,
Regulations and By-Laws. Where she disagrees she must bring her concerns to
the appropriate Committees and when necessary to the Medical Staff meetings
by proper motions duly presented and debated and she must accept the majority
vote. She must not verbally castigate either nurse, staff or peers but carry
complaints through appropriate channels. The issue of “coverage” must be
In my opinion she should be reinstated to give her an opportunity to rectify any
errors in communication the Hospital sees, and to give the Hospital an
A. D. COLEMAN 465 VAN DUZER STREET STATEN ISLAND, NEW YORK 10304-2029 USA T: (718) 447-3280 / F: (206) 350-1786 Email: adc@nearbycafe.com Web: http://nearbycafe.com CURRICULUM VITAE Full name: Allan Douglass Coleman Born: New York City, December 19, 1943 Educational background: Doctoral studies, New York University; Communications Theory, 1982-1990 M.A., S
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