In CNO v. Lindsey Coyle, the Discipline Committee of the College of Nurses of Ontario addressed one of the most serious forms of professional misconduct: alteration of medication records, misappropriation of narcotics, and a patient death that followed.
The case serves as a stark reminder of how falsified documentation and improper medication practices can have catastrophic consequences.
The patient was a 76-year-old woman admitted to La Verendrye Regional Hospital in Fort Frances with complex medical issues, including chronic pain, renal failure, and recent opioid overdose requiring Narcan.
By January 1, 2015, her physician had ordered 2–5 mg of morphine every two hours as needed. She had been receiving relatively low doses prior to January 3.
On January 3, 2015, during a day shift:
She then documented administering seven 10 mg doses of morphine that day.
In reality, the patient had received less — or none — of the morphine documented. The morphine was misappropriated rather than administered to the patient.
The altered MAR remained in place at shift change.
That night:
The Office of the Chief Coroner concluded, on a balance of probabilities, that the death was due to morphine toxicity from the 20 mg administered overnight.
In August 2022, the nurse pled guilty to criminal negligence causing harm in relation to the death.
The disciplinary hearing occurred more than ten years after the incident due to the timing of criminal proceedings.
The College found that the nurse:
The Panel emphasized that:
The nurse entered into an undertaking to:
The Panel made it clear that permanent removal from the profession was the only acceptable outcome in a case of this magnitude.
This decision highlights several key medico-legal themes:
1️⃣ Documentation Is a Patient Safety Tool
Medication records are not administrative paperwork — they are clinical communication instruments. Altering them compromises every subsequent clinical decision.
2️⃣ Narcotic Misappropriation Creates Lethal Risk
When controlled substances are diverted, patients are exposed to unpredictable dosing and unsafe care pathways.
3️⃣ End-of-Life Care Requires Heightened Vigilance
Patients receiving opioids for pain management are medically vulnerable. Dose changes without oversight can rapidly become fatal.
4️⃣ Professional Accountability Is Relentless
Even though the nurse surrendered her certificate in 2016, the College retained jurisdiction because the conduct occurred while she was registered.
From a civil litigation standpoint, this case would raise issues such as:
Unauthorized alteration of physician orders
Falsification of clinical records
Medication diversion
Institutional oversight and supervision
Causation in opioid toxicity deaths
In Ontario medical negligence claims, documentation integrity and medication safety protocols are often central to determining liability.
The Discipline Committee described the conduct as an “extraordinary breach of trust.”
Patients and families place immense trust in healthcare professionals — particularly in vulnerable, end-of-life situations. This case underscores how quickly that trust can be shattered when professional standards are abandoned.
If you or a loved one has concerns about unsafe medication practices or unexplained clinical deterioration in hospital, early legal review can be critical.
Decision Date: August 21, 2025
Jurisdiction: College of Nurses of Ontario Discipline Committee
Citation: College of Nurses of Ontario v Coyle, 2025 CanLII 146790 (ON CNO)
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