Most discipline decisions turn on a single failure: one patient, one procedure, one lapse in judgment. College of Physicians and Surgeons of Ontario v Hart, 2026 ONPSDT 29, is not that case. It concerns a physician whose practice was found deficient across assessment, consent, prescribing, monitoring, record keeping and billing, on the evidence of two complainants and 34 further patient charts reviewed by two independent assessors.
The detail that will stay with most readers is smaller than any of that. Before patients could be treated at the clinic, they were asked to sign a document promising not to sue the physician and not to complain about him to his regulator.
What happened
Dr. Michael Frederick Hart was the sole owner and the only physician practising at the ReadyToGo Clinic. He also practised at the Bonavista Medical Centre in Hamilton. The proceeding grew out of complaints by two patients, reports from the Ontario Health Insurance Plan, and chart reviews the College commissioned in response.
Patient A came to the clinic in 2022, interested in the use of psychedelics to manage anxiety and depression. Both of her encounters with Dr. Hart took place over the telephone. He never saw or assessed her in person. Among the intake documents was a “Ketamine Treatment Release & Acknowledgement” requiring her signature on a promise not to take legal action against the physician or the clinic, or to “make a complaint of any kind” to the College.
Dr. Hart prescribed ketamine at that first telephone consultation. The Tribunal found that he failed to explain the risks and side effects adequately, told Patient A incorrectly that oral ketamine differs significantly from intravenous ketamine, described the dose as very small, told her she would not feel any effects, and advised that she could drive within an hour of taking it. He gave no instructions for managing an adverse reaction and arranged no in-person monitoring, vital sign assessment or emergency preparation.
She took an initial dose of 75 mg of oral ketamine and experienced loss of balance, slurred speech, weakness, an increased heart rate and dissociation. She took it in the morning and the effects continued until she went to bed that night. Follow-up consisted of a single telephone call two weeks later, during which Dr. Hart repeatedly pressed her not to report him, leaving her feeling coerced and intimidated.
Patient B was treated in 2020 and 2021, again entirely by telephone, and was asked to sign the same release. The referral came from a therapist for ketamine-assisted psychotherapy, and Dr. Hart recorded her in some of his notes as “Dr. Zdyb” knowing she did not hold a doctoral degree in clinical psychology. The intake note recorded no exploration of suicidality, substance use, trauma history, psychosis or past psychiatric history, and no mental status examination, medical history, physical examination, vital signs or cardiovascular assessment.
Six months on, Dr. Hart documented that the therapy had worked during sessions but produced no sustained benefit, and that Patient B was back at baseline. He renewed the prescription anyway and supported a higher dose, without documenting a rationale for continuing an ineffective treatment. Patient B was taking a medication known to increase the effects of ketamine, and the interaction was not addressed. On a later call, Dr. Hart realized Patient B was participating from a vehicle, yelled at the patient and threatened to end the appointment.
The findings
Two independent assessors gave evidence. Dr. Jinous Hamidi, a psychiatrist, reported on the care of both complainants and separately reviewed 18 patient charts with the corresponding Narcotics Monitoring System records. She concluded that the care fell below the standard of practice in all 18, that Dr. Hart displayed a lack of knowledge, skill or judgment in all 18, and that in 17 of them the care exposed or likely exposed patients to harm. The deficiencies she found repeating were an inadequate history and symptom review, no mental status examination or assessment of suicidality, no rationale for the suitability of ketamine, an absence of informed consent and patient education, and minimal documentation.
Standard of practice in a discipline proceeding, like standard of care in a civil action, is proved by expert evidence rather than assumed. What is unusual here is not the framework but the volume. Two experts, 34 charts beyond the complainants, and findings that were close to uniform.
Dr. Ivor Teitelbaum, a general practitioner, reviewed a further 16 charts with the accompanying OHIP and Narcotics Monitoring System data and found the care below standard in nine of them. His concerns included testosterone replacement therapy prescribed without indication in six charts and where contraindicated in four, no cumulative patient profile in any of the 16, patients never seen in person in 10, missing urine drug screens for cannabis patients, mental health screening scores recorded but never interpreted, notes copy-pasted without updating, positive cocaine screens with no follow-up, and concerning test results left unaddressed.
Much of this is the ordinary architecture of safe prescribing rather than anything exotic: the assessment that establishes an indication, the contraindications that are ruled out, the interactions that are checked, the monitoring that follows. The same architecture is at issue in a very different prescribing context in the standard of care for GLP-1 prescribing, and its absence is what the assessors kept finding.
Dr. Teitelbaum also identified unsupported OHIP billings: codes requiring an in-person visit billed with no indication that one occurred, missing start and stop times for time-based codes in 15 of 16 charts, and mental health billing unsupported by the documentation in 15 of 16. From May 2021 to April 2022, Dr. Hart’s billings at Bonavista were submitted by a clinic billing agent into an account the agent controlled. He conducted no due diligence before entrusting his billing to the agent, requested no billing summaries, and took no steps to verify what was being submitted. The Tribunal noted that in 12 of the 16 charts some of the unsupported billings pre-dated or post-dated the relationship with the agent, so they cannot all be laid at the agent’s door.
The Tribunal found a failure to maintain the standard of practice contrary to Ontario Regulation 856/93 under the Medicine Act, 1991, SO 1991, c 30, and held that the failures taken together showed a serious or persistent disregard for professional obligations amounting to disgraceful, dishonourable and unprofessional conduct, applying Attallah v College of Physicians and Surgeons of Ontario, 2021 ONSC 3722.
The release drew separate treatment. Asking patients to sign away the right to sue and the right to complain, and then discouraging Patient A from complaining, was itself disgraceful, dishonourable and unprofessional. A physician may not hinder the College’s regulation of the profession in the public interest by discouraging complaints, and the privilege of practising medicine carries with it the requirement of being governed by the College. On the other conduct the Tribunal was equally short: “Yelling at a patient is never acceptable conduct for a physician.”
The penalty
The parties made a joint submission. That narrows the Tribunal’s role considerably. It is not asked what penalty it would have imposed, but whether accepting the agreement would bring the administration of the professional discipline system into disrepute, a threshold that is only crossed where the proposal is unhinged from the circumstances: R v Anthony-Cook, 2016 SCC 43, and Bradley v Ontario College of Teachers, 2021 ONSC 2303 (Div Ct).
Two features of the record made the misconduct more serious. The first was its breadth. This was not a gap in one area, and the Tribunal described fundamental problems with the physician’s approach to the practice of medicine. The second was history. Dr. Hart had been cautioned eight times by the Inquiries, Complaints and Reports Committee between 2016 and 2023, on subjects including record keeping, practice relocation, communications when prescribing cannabis, telemedicine, the monitoring and reassessment of patients on long-term dependency-producing prescriptions, advertising and social media. Committee decisions are not disciplinary findings, because that committee makes no findings of fact, but they establish that a registrant has been reminded of an obligation. Several of the obligations he had been reminded about are the ones at issue here.
Against that, the Tribunal found no evidence of intentional overbilling, which kept the case outside the line of authority under which knowingly overbilling OHIP normally attracts revocation. The no contest plea was mitigating in that it saved the College costs and spared witnesses from testifying, but the Tribunal was careful to add that, unlike an admission or an agreed statement of facts, it demonstrated neither insight nor remorse. On the comparators, the parties put forward CPSO v Sharma, 2025 ONPSDT 5, where an anesthesiologist with a discipline history received a 10-month suspension, alongside two six-month cases.
The order accepted was a reprimand, a six-month suspension commencing 8 July 2026, a permanent prohibition on prescribing ketamine and testosterone replacement therapy, signage in every practice location stating the prescribing restrictions, which must be read aloud where the encounter is by telephone, clinical supervision at a moderate then a low level with at least 15 charts reviewed at each meeting, one-on-one instruction in medical professionalism and ethics, a practice assessment roughly six months after supervision and education are complete, unannounced inspections, and costs of $6,000. The supervision does not end on a fixed date. It ends when the supervisor recommends it and the College agrees.
Why it matters for patients
The first point is the one the release was designed to obscure. A patient’s right to complain to the College is a statutory right, and no clinic intake form can take it away. The Tribunal did not treat the document as merely unenforceable. It treated the act of asking for the signature as professional misconduct in its own right. If you have ever been handed a form like this, it did not work, and the decision whether to file a CPSO complaint remains entirely yours.
Whether a release signed in advance could bar a civil claim is a separate question with its own body of law, and one I have written about in the personal injury context. Nothing in this decision resolves it. What the decision does establish is that presenting the document at all is conduct the regulator will discipline.
The second point is about what this decision is and is not. A discipline finding protects the public. It suspends, restricts, supervises and, where necessary, revokes. It does not compensate anyone. Patient A and Patient B received no damages from this proceeding, and the findings, though detailed, are findings about the standard of practice rather than findings that any particular injury was caused by the care. A patient who believes they were harmed still has to prove breach and causation with independent expert evidence in a civil action, on their own timeline and subject to their own limitation period. What a medical malpractice claim in Ontario actually involves is a separate exercise from what happened here.
That said, a decision like this one is useful to a patient in a practical way. It is public, it is detailed, and it records expert opinion on the standard of practice across 34 charts. Where discipline proceedings and a civil claim arise from the same care, the discipline record is often the first clear account a family gets of what went wrong.
The last point is the one the Tribunal chose to close on. Eight cautions across seven years did not change how this physician practised. The Tribunal said plainly that a fundamental change is now required if he is to avoid returning to face stronger penalties. Progressive regulation only protects patients if the physician on the receiving end responds to it, and the file shows how long a practice can continue substantially unchanged while the warnings accumulate.
Related cases: recent CPSO discipline decisions
Other recent CPSO discipline decisions, grouped by the issue at the centre of each:
Clinical standard of care:
- CPSO v Hart (this case: ketamine and testosterone prescribing, a no-complaints release, and a suspension)
- CPSO v Sharma (anesthesia inattention, record alteration, and OHIP billing)
- CPSO v Duic (missed sepsis; emergency department standard of care)
- CPSO v Konasiewicz (pain-medicine standard of care, a patient death, and a suspension)
- CPSO v Nahas (chronic-pain practice, consent violations, and progressive discipline)
- CPSO v Maharaj (substandard care across many patients, incompetence, and revocation)
OHIP billing and financial misconduct:
- CPSO v Li (parking permit billing; 12-month suspension)
- CPSO v Karim (non-resident OHIP use; five-month suspension)
- CPSO v Iracleous (billing for services not provided; revocation)
- CPSO v Kadri (disruptive conduct, incompetence, and inappropriate billing; revocation)
Records, privacy, and cover-up:
- CPSO v Mercado (unauthorized access to patient records)
- CPSO v Nahvi (drugging of a patient and cover-up)
- CPSO v Fenty (failing to respond to patients and the College; suspension)
Sexual abuse and boundary violations:
- CPSO v Stein (attempting to date a patient)
- CPSO v Iannantuono (inappropriate touching)
- CPSO v Peirovy (non-compliance with a sexual abuse order)
COVID-19 and the duty to cooperate:
- CPSO v Trozzi (revocation; affirmed in Trozzi v CPSO)
- CPSO v Luchkiw (refusing to cooperate with an investigation)
- CPSO v Phillips (COVID-19 communications and witness intimidation)
- CPSO v Turek (lower-end joint submission)
- CPSO v Thirlwell (mass exemption letters; revocation)
- CPSO v Kilian (refusing to produce records; ONCA on section 87)
Cross-jurisdictional discipline and reinstatement:
- CPSO v Faruqi (out-of-province fertility misconduct; cross-jurisdictional discipline)
- Doyle v CPSO (reinstatement after revocation, on strict conditions)
The full decision is available on CanLII: College of Physicians and Surgeons of Ontario v Hart, 2026 ONPSDT 29.
