Most of the catastrophic cases that come through my office involve some kind of communication failure. The surgeon’s hand did not slip. The emergency physician did not miss the finding. The internist did not order the wrong medication. The system did. A referral that sat on a fax machine for three weeks. A test result that came back abnormal but never made it to the family physician. A handover at shift change where a critical pending issue was not communicated. A discharge summary that did not describe the abnormal finding that needed follow-up. The patient continued to live as though the system was tracking the problem when, in fact, no one was.
These are quiet failures. They do not produce dramatic narratives the way an obvious surgical error or an obvious missed diagnosis does. They produce, instead, the slow accumulation of preventable injuries and deaths that the hospital harm data picks up at the population level and the individual file picks up at the family level. The cases share structural features: multiple providers, each doing their piece more or less competently within their own four walls, but failing to communicate effectively across the boundaries between them. The patient is the one who falls into the gap.
This post covers the legal framework for communication-failure malpractice in Ontario, the major categories of communication failure that produce litigated cases, the system-level question of health information interoperability that has dominated the public discourse on this issue since 2024, and the practical considerations for families who think their care may have fallen through these kinds of cracks.
The case that animates the discussion
The Canadian public discussion of communication failures in healthcare has been carried in substantial part by the family of Greg Price. Mr. Price was a 31-year-old mechanical engineer and private pilot from Acme, Alberta. In April 2011, during a routine physical for the renewal of his pilot’s licence, a doctor noticed a thickening of the epididymis (the tube behind the testicle), a clinical sign that can be associated with testicular cancer. Over the next 407 days, Mr. Price moved through the Alberta healthcare system trying to get the workup, the diagnosis, and ultimately the surgery he needed. He died in May 2012, three days after surgery to remove the testicle, from a pulmonary embolus (a blood clot in the lung) that was a known post-surgical complication and that was misdiagnosed when he presented to an emergency department in the days before his death.
The Health Quality Council of Alberta (HQCA) conducted a detailed review of Mr. Price’s case and published its findings in December 2013 as the Continuity of Patient Care Study Report. The HQCA identified four discrete breaks in continuity of care during the 407 days. The lead investigator, Dr. Ward Flemons, characterized the case as illustrative of structural problems across the Canadian healthcare system rather than as a series of individual clinical errors. The HQCA made thirteen recommendations directed at multiple bodies including Alberta Health Services, the Alberta Medical Association, the College of Physicians and Surgeons of Alberta, and the Office of the Chief Medical Examiner of Alberta.
The Price family did not stop at the HQCA report. Mr. Price’s sister Teri Price became a patient safety advocate. The family founded Greg’s Wings Projects. They produced a short film, “Falling Through the Cracks: Greg’s Story,” that has been screened to over 130 audiences in medical schools, hospitals, and conferences. They have been one of the most consistent and effective Canadian voices on the human cost of healthcare communication failures for more than a decade.
The case is now a reference point in Canadian healthcare policy discussion. When the federal government introduced the legislation now known as the Connected Care for Canadians Act, the Price case was repeatedly cited as illustrative of the need for change. The case has appeared in CBC reporting, in Public Policy Forum reports, in CMAJ commentary, and in policy proceedings before Parliament.
I cover Mr. Price’s case here not as a comment on any specific judicial decision (none has been reported in respect of his death), but as the most recognizable Canadian illustration of the kind of communication failure pattern that produces preventable harm. The pattern is not Alberta-specific. The same pattern produces the cases I see in Ontario every year.
What “communication failure” means in clinical care
The phrase “communication failure” sounds like a soft category but it has fairly precise clinical and operational content. In modern healthcare practice, communication failures fall into several recognizable types:
Referral failures. The treating physician identifies a clinical issue that requires specialist input, sends a referral, and the referral does not reach the specialist, does not produce a response, or produces a response that does not reach the patient. The most common failure modes:
- The referral is sent but the receiving office does not log it or respond
- The receiving specialist is on leave; no out-of-office response is generated
- The receiving office responds but the response does not reach the patient
- The referral wait time exceeds the clinically acceptable window
- The patient is not informed about the referral status and assumes the system is tracking it
- Multiple referrals to multiple specialists exist in parallel, none with a complete clinical picture
Test result communication failures. A test is ordered, the test is performed, the result is generated, and the result does not reach the ordering physician or the patient. The most common failure modes:
- The result is delivered by fax to a number that is no longer monitored
- The result is delivered to a different physician than the ordering one
- The result is filed in the chart without review
- The result is reviewed but not acted on
- The result is acted on by one physician but not communicated to others who needed to know
Handover failures. A patient transitions between teams or services and the receiving team does not have the information needed for safe continuation of care. The most common failure modes:
- Pending test results not communicated
- Active monitoring requirements not communicated
- Clinical concerns not articulated
- Medication adjustments not flagged
- Family communication context not transmitted
Discharge communication failures. A patient is discharged from inpatient care and the outpatient providers (family physician, specialists) do not have the information needed for safe outpatient management. The most common failure modes:
- Discharge summary not produced or not sent in time
- Discharge summary lacks key clinical details
- Pending follow-up requirements not communicated
- Medication changes not reconciled
- Critical findings not flagged for outpatient action
Inter-physician communication failures. Two or more physicians caring for the same patient at the same time fail to coordinate effectively. The most common failure modes:
- Specialist recommendations not communicated to the primary care physician
- Primary care concerns not communicated to specialists
- Conflicting clinical plans not resolved
- Medication interactions not addressed
- Pending decisions not assigned to a responsible provider
Communication-with-patient failures. The physician does not effectively communicate clinical information to the patient or family in a way that supports informed decision-making and appropriate follow-up. The most common failure modes:
- Test results not disclosed
- Diagnosis not explained adequately
- Treatment options not presented
- Follow-up expectations not articulated
- Patient understanding not confirmed
These categories overlap. A single catastrophic case often involves multiple categories operating together. Mr. Price’s case involved referral failures, test result communication failures, inter-physician communication failures, and communication-with-patient failures all over the same 407-day period.
The “Swiss cheese” model
The framework most commonly used to think about how communication failures produce harm is the “Swiss cheese” model articulated by the British psychologist James Reason. The model treats the healthcare system as a series of protective layers, each of which has gaps (the holes in the cheese). On any given day, most patients are not harmed because the gaps in one layer are covered by the intact portions of the next layer. Adverse events occur when the gaps in multiple layers align so that a single error propagates through the whole system.
Communication failures are particularly insidious in this framework because they tend to align the holes. A test result that is not communicated to the family physician does not stay localized; it propagates forward in time and produces consequences each time the patient is next assessed. A handover failure does not just affect the immediate handover; it affects every clinical decision the receiving team makes until the information gap is closed. The same is true in reverse: an effective communication system can close gaps elsewhere in the system. If the family physician knows about an abnormal finding, she can pursue the workup even if the initial radiologist’s recommendation got lost.
For litigation purposes, the Swiss cheese model is useful in two ways. It explains why a single communication failure can produce catastrophic harm even where no individual provider’s conduct seems obviously substandard. And it supports the multi-defendant analysis that often applies in these cases: liability may be apportioned among multiple providers whose conduct contributed to the failure of the overall communication system, with each contribution potentially less than fully causal but together adding up to the harm.
The legal framework for communication-failure malpractice
Communication failures fit within the standard Canadian negligence framework: duty of care, breach of the standard of care, causation, and damages. The features that distinguish communication-failure cases:
The standard of care for communication. Each professional category has a standard of practice that includes communication elements. For physicians, the CPSO has published guidance on communication of test results, on handover and continuity of care, and on disclosure of adverse events. Provincial and federal regulators (CPSO and provincial equivalents, the Canadian Medical Protective Association, the various hospital accreditation frameworks) all address communication. Expert evidence in litigation typically identifies the published standards and assesses whether the conduct in question fell within them.
Some of the specific standards that operate:
- A treating physician has a duty to communicate clinically significant test results to the patient within a clinically appropriate timeframe
- A specialist who is consulted has a duty to communicate findings and recommendations to the referring physician
- A treating physician handing over care has a duty to communicate pending issues to the receiving provider
- A discharging hospital team has a duty to ensure that the receiving outpatient providers have the information needed for safe care
- An ordering physician has a duty to follow up on pending tests, particularly where the clinical context requires action on the result
The duties are framework principles, not absolute rules. The standard of care assessment is contextual. The reasonable physician in the same circumstances is the operative reference.
Causation in multi-step communication failures. The causation analysis in communication-failure cases is often more complex than in single-provider clinical-error cases. Where the failure involves multiple providers, the analysis must identify which providers’ conduct contributed to the harm and to what extent. Where the failure involves a chain of communications, the analysis must work through whether each link in the chain would have produced a different outcome if the failure had not occurred.
The Sacks v Ross, 2017 ONCA 773, framework on “what likely happened” causation is particularly applicable. The court identified that in cases involving cumulative or sequential failures, the trier of fact must assess what would have happened with appropriate care at each point and then determine which provider’s failure (or combination of failures) most likely caused the harm. The analysis is structured, not abstract; each step is examined; each provider’s contribution is assessed.
The Clements v Clements, 2012 SCC 32, but-for framework operates as the foundation, with the Snell v Farrell, [1990] 2 SCR 311, robust and pragmatic approach available where the precise mechanism is contested.
Multi-defendant scenarios. Communication-failure cases often involve multiple defendants. The pleading strategy must address each potential defendant’s contribution. Liability may be:
- Joint and several where the failures of multiple defendants together caused the harm and the contributions cannot be cleanly apportioned
- Apportioned where the contributions can be identified
The institutional defendants (hospitals, clinics, health authorities) may also be named where the failure reflects institutional system gaps rather than individual provider conduct. The Negligence Act, RSO 1990, c N.1, framework for apportionment applies.
Documentation as evidence. Communication-failure cases turn substantially on documentation. The chart entries, the referral letters, the test result reports, the discharge summaries, the handover notes, the inter-physician correspondence — all of it is the evidentiary record of what was communicated and what was not. Where documentation is inadequate, the trier of fact may draw adverse inferences against the defendant whose documentation should have been better. The framework was articulated in Barker v Montfort Hospital, 2007 ONCA 282, and is consistently applied in modern Ontario practice.
Examples from the cluster
Several of the cases in the Ontario malpractice library involve communication failures as part of the broader pattern of negligence. Looking across the cluster:
Failure to call the on-call specialist. Gumbley v Vasiliou, 2024 ONSC 4858, involved an internist’s failure to call the on-call intensive care specialist in time for a deteriorating asthma patient. The communication failure (not calling Dr. Warner by 21:30h or 22:00h as the standard required) was the principal breach. The trial judge constructed the counterfactual: had the call been made timely, the intensivist would have responded, followed asthma guidelines, intubated earlier, and the catastrophic hypoxic brain injury would have been avoided. The case is one of the cleanest illustrations of how a single communication failure can produce a catastrophic outcome.
Stroke diagnosis communication. Hasan v Trillium Health Centre, 2024 ONCA 586, involved delayed stroke diagnosis and treatment with communication failures contributing to the delay. The Court of Appeal applied the “evidentiary gap” framework from Goodwin v Olupona and Ghiassi v Singh in a context where the defendant’s conduct (including communication failures) had themselves created the gap in the evidentiary record.
Obstetric anaesthetic accident. Hemmings v Peng, 2024 ONCA 154, involved a maternal anaesthetic accident with delays in escalation and communication contributing to the catastrophic outcome. The plaintiff appellate affirmance turned on the trial judge’s analysis of what would have happened if the standard of care had been met, including the standard for communication and escalation in the obstetric anaesthetic context.
Administrative-clinical workflow gap. Kotorashvili v Lee, 2024 ONSC 4192, involved a clinic’s failure to communicate consent confirmation between the administrative process and the clinical process, resulting in premature revision surgery. The case illustrates the institutional communication failure that occurs between the administrative-procedural workflow and the actual clinical decision-making.
Specialist referral framework. Henry v Zaitlen, 2025 ONCA 161, involved a physician’s failure to refer to a specialist as the standard required. The “failure to investigate” framework operates in part as a communication framework: the physician’s duty to refer is also a duty to communicate the patient’s situation to a specialist who can investigate further.
These cases together illustrate that communication failures are not a soft category but a recognizable doctrinal feature of Ontario malpractice practice. They produce identifiable breaches of standards of care, can be analyzed through the standard causation framework, and can support substantial damages awards where the breach causes catastrophic harm.
The PHIPA framework
Communication failures often interact with the Personal Health Information Protection Act, 2004, S.O. 2004, c. 3, Sched. A (PHIPA) framework. PHIPA establishes:
- Patients are the data subjects with rights of access, correction, and complaint
- Healthcare providers and institutions are custodians holding personal health information on behalf of patients
- Custodians have obligations to maintain accuracy, security, and timely access
In the communication-failure context, the most useful PHIPA right for patients is the right to access their own health records. A patient who suspects communication failures in her care can request her complete records from each custodian (each treating physician, each hospital, each clinic) and assemble her own record of what was communicated and when. The records are her own information; the custodians are obliged to provide access within statutory timelines.
I covered the PHIPA framework in detail in the CPSO v Kilian post, principally in the context of regulatory production demands. The same custodian-subject distinction applies in the litigation context.
A practical implication: patients who are concerned about possible communication failures should not wait for the system to figure out what happened. They should request their own records. The records will show what was sent and what was received, what was reviewed and what was not. They are typically the best evidence of the communication pattern that occurred.
The interoperability question — from Bill C-72 to Bill S-5
The systemic dimension of the communication failure problem has been the subject of significant federal legislative attention since 2024. The picture is now more complex than it was when this post was originally written, and it is worth setting out the trajectory.
Bill C-72 — the Connected Care for Canadians Act. The federal government introduced Bill C-72 on June 6, 2024 in the 44th Parliament. The bill aimed to require health information technology vendors to ensure interoperability of their systems, to prohibit data blocking by vendors, and to support secure information sharing among healthcare providers. The bill was introduced in the context of long-running criticism that Canadian healthcare communicates substantially by fax — an observation that has become a kind of national punchline but that reflects a real operational problem with patient safety consequences. Bill C-72 passed first reading.
The bill died at prorogation (early 2025). When Parliament was prorogued in early January 2025 and the federal election was called, Bill C-72 (like all other unfinished legislation) died on the order paper. By the time the 45th Parliament was constituted later in 2025, the legislative slate was clean and previously-introduced bills had to be re-introduced.
Bill S-5 — re-introduction (February 2026). On February 4, 2026, the federal government re-introduced the Connected Care for Canadians Act, this time tabled in the Senate as Bill S-5. The substance of the bill is substantively identical to Bill C-72: a federal framework for health information interoperability; obligations on health information technology vendors; provincial application calibrated to whether the province has “substantially similar” legislation; high-level legislation with the operational detail to follow in regulations.
Where the bill stands now (as of the date of this post). Bill S-5 is moving through the Senate process. The bill’s eventual passage is not yet assured; the path through the Senate, the House of Commons, and Royal Assent takes time and depends on legislative priorities and parliamentary scheduling. Even if the bill passes, the operational detail will follow in regulations that have not yet been drafted. The practical effect of the legislation in addressing communication failures will depend on regulatory implementation, vendor compliance, and provincial uptake.
What the bill would and would not do. Even with optimistic implementation, the Connected Care for Canadians Act framework would not solve the communication failure problem on its own. The bill addresses interoperability of health information technology — the ability of different systems to exchange information. It does not address:
- Whether the individuals using the systems actually communicate effectively
- Whether the institutional cultures support effective handover
- Whether the staffing levels permit careful communication
- Whether the documentation practices capture what needs to be captured
- Whether the patient is included in the communication loop
Interoperability is a necessary condition for some kinds of communication improvement; it is not a sufficient condition for solving the problem. The most catastrophic Ontario communication-failure cases I see often involve facilities that are already nominally interoperable — the failure is operational, not technological.
The CIHI hospital harm context
The Canadian Institute for Health Information tracks preventable hospital harm at the population level. The most recent data covering 2024-2025 shows that the rate of any preventable hospital harm has held at 6.0 events per 100 hospitalizations for five consecutive years. The pre-pandemic baseline was 5.3 to 5.4. The progress has plateaued above pre-pandemic levels.
Communication failures are a substantial component of the total. The CIHI tracking framework specifically includes categories like “failure to rescue” (where deterioration is not recognized in time) and “delays in diagnosis” where communication-related delays contribute. In a 25% subset of harmed patients, more than one harmful event occurs during the same admission, suggesting the cascade effect that communication failures often produce. For a fuller discussion of the population-level data, see Is Medical Malpractice on the Rise in Canada?.
The CIHI data does not specifically subcategorize “communication failures” as a discrete harm type. The framework is centred on clinical outcomes rather than process failures. But the literature on patient safety, including the CIHI’s own publications, consistently identifies communication failures as a substantial contributor to the events the framework tracks.
Practical considerations for patients and families
A few practical observations from twenty years of seeing these cases.
Take responsibility for following up on your own referrals. If your family physician sends you to a specialist, ask when you should expect to hear back. Mark your calendar. Call to check in if you have not heard by the expected date. Do not assume that the silence means the referral is in good order. Assume that the silence means something has gone wrong and confirm.
Keep your own records. Request copies of your significant test results, your specialist letters, your discharge summaries. Build your own file. When you see a new provider, you can hand over a coherent record of what has happened. Do not assume that the system has the file or can find it.
Ask specifically about test results. When a test is ordered, ask when you will hear about the result, who will communicate it, and what to do if you do not hear. “No news is good news” is not a clinical communication principle; it is a system failure waiting to happen. Insist on actually being told the result.
Ask about handovers. When your care is transferred between teams, between facilities, or between shifts, ask the receiving team what they know about your situation. Ask them about the pending issues. Ask them about the medication you are on. The act of asking forces the handover to be explicit.
Document your own concerns. If you have raised a concern about a symptom and feel it was not addressed, write down what you said, what the response was, and the date. If something later goes wrong, your contemporaneous notes are evidence.
If something seems to have gone wrong, gather the records promptly. PHIPA gives you the right to your own records. The records are the evidentiary baseline for any subsequent legal action. The earlier you have them, the better positioned you are. For more on how to request and use records, see A Patient’s Guide to Making Complaints About Health Care in Ontario.
Get a legal opinion early. Communication-failure cases can be technically and evidentially complex. The investigation phase typically requires expert evidence from multiple disciplines (the relevant clinical specialties plus often a quality and safety expert). The earlier counsel can look at the file, the better the assessment. Limitation periods are short. For more on how I evaluate cases, see Suing for Medical Malpractice in Ontario: What You Need to Know.
What this means for clinicians and institutions
A few observations from the other side of the file, for clinicians and institutional leaders reading this.
Document the communication, not just the clinical care. Your chart should reflect not just what you did clinically but how the information moved. Who you spoke to, when, what was discussed, what was agreed. The communication documentation is part of the standard of care and part of your evidentiary protection.
Close the loop on referrals. If you refer a patient out, you have a continuing duty to monitor whether the referral has been actioned. If the expected response has not come back within the clinically appropriate window, the responsibility to follow up is yours. The framework for closing the referral loop is settled enough that the failure to close it is a recognized breach.
Use structured handover frameworks. SBAR (Situation, Background, Assessment, Recommendation) and similar frameworks reduce communication failure rates. Where your institution has not adopted a structured framework, advocating for one is meaningful patient safety work.
Communicate test results. A test that is ordered but whose result is not communicated represents a system failure for which the ordering physician carries primary responsibility. Build a practice for closing the loop on every result. Document the communication.
Include the patient. The patient is the most reliable communication channel for her own care. Where she knows the test was ordered, the result that was found, the follow-up that is needed, she can be a partner in the safe management of her own situation. Communication failures are much more often resolved by patient participation than by additional clinician effort.
Why this matters
Communication failures are the quiet category of medical malpractice. They produce some of the most preventable harm in the Canadian healthcare system. The cases I see in this category often involve patients who were not the victims of obvious negligence by any single provider but who fell through the gaps between competent providers who failed to communicate effectively across the boundaries between them. The damage in many cases is permanent; the underlying clinical situation often would have been straightforwardly treatable if it had been recognized in time.
The federal legislative response — Bill C-72 in 2024, now Bill S-5 in 2026 — represents one part of a broader effort to address the structural drivers of these failures. Whether and when the legislation passes, and whether the regulatory implementation actually produces operational change, remains to be seen. The legal framework for individual cases continues to operate in the meantime. Communication failures that meet the standard-of-care threshold and produce causally connected harm are actionable medical malpractice. The patient who has lost a family member to one of these failures has the same right to seek compensation and accountability as the patient injured by any other form of substandard care.
If you think a member of your family has been harmed by a communication failure in their care, the first conversation is free and strictly confidential. The earlier we look at the records, the better.
