Medical regulatory discipline in Ontario operates through a system of profession-specific colleges, each with authority over its members under the framework of the Regulated Health Professions Act and the specific professional Act for that profession. The case comment series on this site has focused primarily on physician discipline through the College of Physicians and Surgeons of Ontario. The framework for nursing discipline operates in parallel through the College of Nurses of Ontario, with substantially similar procedural and substantive structures. The cases that reach the Discipline Committee of the College of Nurses of Ontario reflect the same range of conduct that arises in physician discipline, calibrated to the specific clinical and professional context of nursing practice.
College of Nurses of Ontario v Coyle, 2025 CanLII 146790 (ON CNO), released by the Discipline Committee on August 21, 2025, is one of the most serious nursing discipline decisions on the Ontario record. The respondent was a registered nurse who altered the medication administration record of an elderly patient to authorize substantially higher morphine doses than the physician had ordered, documented administration of doses that were never given to the patient, and misappropriated the controlled substance for her own purposes. The altered medication order remained in effect at shift change. The incoming night nurse relied on the altered order and administered morphine consistent with it. The patient became unresponsive and died of morphine toxicity. The respondent later pleaded guilty to criminal negligence causing harm. The Discipline Committee imposed a permanent undertaking that operates as the equivalent of revocation in the nursing regulatory framework.
The case is doctrinally important for several reasons. It is one of the most serious applications of the nursing discipline framework on the Ontario record. It articulates the framework for findings of patient abuse under the Therapeutic Nurse-Client Relationship standard. It addresses the framework for medication administration record integrity and the implications of unauthorized alteration of physician orders. It illustrates the framework for narcotic and controlled substance handling in clinical practice. It demonstrates the framework for the permanent undertaking as the nursing regulatory equivalent of revocation. It addresses the continuing jurisdiction of the College over former members for conduct that occurred during membership. And it illustrates the interface between criminal proceedings and regulatory discipline where both arise from the same underlying conduct.
A note on the underlying facts. The patient was a 76-year-old woman with significant medical complexity, in care for chronic pain and other serious conditions, whose death was caused by morphine administered consistent with a medication record that had been altered without authorization. The decision discussed below addresses the regulatory response to the conduct, not the underlying clinical care of other providers or the institutional framework that may also have contributed to the outcome. Civil claims arising from a death of this kind would raise additional questions of standard of care, causation, and institutional accountability that are not addressed in the discipline framework.
The legal framework — the College of Nurses of Ontario and the nursing discipline framework
A brief overview of the legal framework is useful for the analysis.
The Regulated Health Professions Act foundation. The Regulated Health Professions Act, 1991, SO 1991, c 18 (the RHPA) is the foundational framework for the regulated health professions in Ontario. The framework establishes the structure of the colleges, the discipline procedures, the procedural protections for members, and the appellate framework. The framework operates uniformly across most regulated health professions with profession-specific provisions in the individual professional Acts.
The Nursing Act. The Nursing Act, 1991, SO 1991, c 32 is the profession-specific framework for nursing in Ontario. The Act establishes the College of Nurses of Ontario (CNO) as the regulatory body for the nursing profession, the scope of practice for the various nursing classes (registered nurses, registered practical nurses, and nurse practitioners), and the framework for professional conduct.
The College of Nurses of Ontario. The CNO operates as the regulatory body for the nursing profession. The framework includes registration, continuing competence, professional conduct standards, complaints handling, and discipline. The CNO publishes practice standards that operate as the framework for professional conduct expectations.
The CNO practice standards framework. The College publishes specific practice standards including:
- The Therapeutic Nurse-Client Relationship standard, addressing the professional framework for the nurse-patient relationship
- Medication practice standards addressing safe medication administration
- Documentation standards addressing the integrity of clinical records
- The Ethics standard addressing the professional values framework
- Several other practice-area-specific standards
The framework is intended to articulate the operative professional standards in a form that is accessible to members and that supports both ongoing professional practice and the discipline framework when conduct falls below the standards.
The Health Professions Procedural Code. Schedule 2 to the RHPA establishes the Health Professions Procedural Code, which governs discipline procedures across the regulated health professions. The framework includes the categories of professional misconduct, the framework for findings of incompetence, the framework for sanctions including revocation, and the framework for appeals.
The professional misconduct framework. Professional misconduct in nursing is defined in the Professional Misconduct Regulation (O Reg 799/93) under the Nursing Act. The framework includes specific categories of misconduct ranging from clinical failings (failing to maintain the standard of practice; failing to keep records) to a catch-all addressing conduct that would reasonably be regarded by members of the profession as disgraceful, dishonourable, or unprofessional. The framework operates similarly to the equivalent framework for physicians under the Medicine Act.
The patient abuse framework. Section 51 of the Code includes specific provisions addressing patient abuse, which is defined to include physical abuse, sexual abuse, verbal abuse, psychological abuse, and financial abuse of a patient. The framework treats patient abuse as among the most serious categories of professional misconduct and supports the most serious sanctions including revocation. The framework applies the abuse categories in light of the specific professional context, including the power asymmetry inherent in the therapeutic relationship.
The continuing jurisdiction framework. The framework permits the College to discipline former members for conduct that occurred while they were registered, even where the member has subsequently resigned. The framework reflects the principle that professional accountability does not depend on continued membership; conduct during membership remains subject to the discipline framework. CNO v Coyle is a recent application of the framework, with the discipline hearing occurring after the respondent had surrendered her certificate of registration in 2016.
The criminal-regulatory interface. Where the same underlying conduct gives rise to both criminal proceedings and regulatory discipline, the framework typically supports the criminal proceedings being resolved first. The reasons include preservation of fair trial rights, the higher standard of proof in criminal proceedings, and the practical efficiency of using established factual findings in the subsequent regulatory analysis. Where the criminal proceedings result in conviction, the conviction can be relied upon in the regulatory framework as evidence of the underlying conduct. CNO v Coyle applies the framework with the discipline hearing occurring more than ten years after the underlying conduct because of the timing of the criminal proceedings.
The clinical context — medication administration, controlled substances, and end-of-life care
A brief clinical overview is useful for the analysis.
The medication administration framework. The framework for medication administration in clinical settings includes specific procedural steps designed to support patient safety:
- A physician’s order specifying the medication, dose, frequency, and conditions of administration
- The Medication Administration Record (MAR) documenting both the order and each administration of the medication
- The nurse’s professional responsibility to administer the medication consistent with the order
- The framework of double-checks for high-risk medications including controlled substances
- The framework for documentation of administration including time, dose, and any related clinical observations
The MAR as a clinical communication tool. The Medication Administration Record is not administrative paperwork. It is a clinical communication instrument that supports the framework of safe medication administration across multiple shifts and multiple providers. The framework relies on the integrity of the MAR for several functions:
- Communication of the current order to subsequent providers
- Documentation of administered doses to prevent double-dosing
- Documentation of clinical observations related to the medication
- Support for clinical decision-making by subsequent providers who rely on the MAR to understand the patient’s medication history
Where the MAR is altered without proper authorization, the framework for safe medication administration is compromised. Subsequent providers relying on the altered MAR are operating on false information, and the framework of clinical decision-making can produce harmful outcomes.
The controlled substances framework. Narcotics and other controlled substances are subject to additional framework requirements including:
- More restrictive procurement and storage frameworks
- Witnessed administration in some clinical settings
- Specific documentation of administration including any wastage
- Detailed inventory and reconciliation requirements
- Audit frameworks designed to detect diversion
The framework reflects both the clinical risk of controlled substances (overdose; respiratory depression; death) and the public health concern about diversion of controlled substances for non-medical use.
The medication diversion framework. Where a healthcare provider misappropriates controlled substances from clinical settings (often through documentation of administration to a patient with the substance actually retained by the provider), the framework treats this as a serious patient safety concern, a serious controlled substances concern, and a serious professional integrity concern. The framework includes:
- Patient safety risk (the patient may not receive the intended medication, or may receive medication consistent with a falsified order)
- Public health risk (controlled substances entering non-medical circulation)
- Professional integrity risk (the foundational framework of trust in healthcare records is compromised)
The end-of-life care framework. Patients receiving opioids for pain management, particularly in end-of-life or chronic pain contexts, operate at the intersection of pain management and respiratory depression risk. The framework for clinical management includes:
- Careful titration of opioid doses
- Monitoring of respiratory status and level of consciousness
- Recognition of the cumulative effects of opioids
- Consideration of comorbid conditions (renal failure; respiratory conditions) that affect opioid metabolism
- The clinical principle of “start low, go slow” in opioid management
Where the framework breaks down (including through unauthorized alteration of orders or improper administration), the consequences can be rapid and irreversible.
The vulnerable patient framework. Elderly patients with significant medical complexity (chronic pain; renal failure; recent overdose history) are particularly vulnerable to medication safety failures. The framework for care in these populations operates with heightened scrutiny of medication choices, doses, and monitoring.
The facts
The patient. The patient was a 76-year-old woman admitted to La Verendrye Regional Hospital in Fort Frances. She had complex medical issues including chronic pain, renal failure, and a recent opioid overdose that had required reversal with naloxone (Narcan).
The physician’s order. By January 1, 2015, the patient’s physician had ordered 2 to 5 milligrams of morphine every two hours as needed for pain. The order operated within the framework of conservative opioid management appropriate to the patient’s complex clinical picture, including the renal failure (which affects opioid metabolism and increases risk of toxicity) and the recent overdose history.
The patient had been receiving relatively low doses of morphine consistent with the physician’s order in the days prior to January 3, 2015.
The day shift on January 3, 2015. During her day shift on January 3, 2015, the respondent made a series of changes that the Discipline Committee found constituted serious professional misconduct:
- The respondent hand-altered the Medication Administration Record to increase the allowable dose from 2 to 5 milligrams to 5 to 10 milligrams every two hours as needed
- The alteration was made without a corresponding physician’s order or any other authorization
- The respondent then documented administering seven 10-milligram doses of morphine to the patient during her shift
The Discipline Committee accepted on the evidence that the respondent had not actually administered the morphine she documented. The morphine was misappropriated rather than given to the patient. The patient received less than the documented amount, or in some cases no morphine at all.
The shift change. When the day shift ended, the altered Medication Administration Record remained in effect. The framework for communication between shifts relied on the record. The incoming night shift nurse had no basis on the available information to know that the record had been altered without authorization.
The night shift. The incoming night nurse, acting in good faith on the altered record, administered morphine consistent with the altered order:
- A 10-milligram dose at 21:30 (9:30 p.m.)
- A 10-milligram dose at 1:30 (1:30 a.m.)
The cumulative 20 milligrams over the four-hour period, in the context of the patient’s renal failure and recent overdose history, was sufficient to produce significant respiratory depression. The patient became unresponsive.
The death. The patient died at 6:11 a.m. on January 4, 2015. The Office of the Chief Coroner concluded, on the balance of probabilities, that the death was due to morphine toxicity from the 20 milligrams administered overnight.
The criminal proceedings. In August 2022, more than seven years after the death, the respondent pleaded guilty to criminal negligence causing harm. The criminal conviction was based on the same underlying conduct addressed in the regulatory discipline framework.
The regulatory timeline. The discipline hearing before the College of Nurses of Ontario occurred in August 2025, more than ten years after the underlying conduct and more than three years after the criminal conviction. The timeline reflects the framework of resolving criminal proceedings before regulatory discipline where the same conduct gives rise to both.
The intervening surrender of registration. The respondent had surrendered her certificate of registration with the College in 2016. The College retained jurisdiction to address the underlying conduct because it occurred while she was registered. The framework for continuing jurisdiction supported the discipline proceedings notwithstanding the surrender of registration nine years earlier.
The Discipline Committee’s findings
The Discipline Committee made findings of professional misconduct on several grounds.
Patient abuse under the Therapeutic Nurse-Client Relationship standard. The framework for the Therapeutic Nurse-Client Relationship treats abuse of a patient as among the most serious categories of professional misconduct. The Discipline Committee found that the respondent’s conduct constituted patient abuse, reflecting:
- The administration framework was used to facilitate misappropriation of narcotics, with the patient as the framework’s nominal beneficiary but in practice exposed to harm
- The integrity of the patient’s care framework was compromised in a way that exposed the patient to foreseeable risk
- The cumulative conduct, including the alteration of the order and the consequent administration that contributed to the patient’s death, constituted abuse within the meaning of the framework
Falsification of documentation. The Discipline Committee found that the respondent had falsified clinical documentation by:
- Altering the MAR without authorization to authorize doses different from the physician’s order
- Documenting administration of doses that were not in fact given to the patient
- Compromising the integrity of the clinical record framework that supports subsequent decision-making
Conduct disgraceful, dishonourable, or unprofessional. The framework for the DDU standard (consistent with the equivalent framework for physicians under O Reg 856/93) treats the conduct as a whole and asks how members of the profession would reasonably view it. The Discipline Committee found that the conduct as a whole, including the alteration of the order, the misappropriation of narcotics, the falsification of records, and the foreseeable consequence including the patient’s death, met the DDU standard.
The framework’s specific observations. The Discipline Committee made several specific observations about the framework engaged by the case:
- Altering a medication order without authorization constitutes a misuse of professional power. The framework of medication administration relies on the integrity of physician orders and the nurse’s professional responsibility to administer consistent with those orders. Unauthorized alteration of the order framework subverts both the physician’s clinical decision-making and the patient’s safety framework.
- Falsifying records undermines the foundation of safe care. The framework of clinical documentation supports communication between providers, decision-making over time, and the safety net of clinical reasoning that depends on accurate information. Falsified records compromise all of these functions.
- Misappropriating narcotics represents a serious moral failing. The framework treats the diversion of controlled substances as a profound breach of the trust framework that supports professional access to these substances. The framework recognizes both the patient safety dimension and the public health dimension of the conduct.
- The conduct resulted in a patient death and brought shame to the profession. The framework for sanction analysis considers both the harm caused and the broader implications for public trust in the profession.
The sanction
The respondent entered into an undertaking that operates as the nursing regulatory equivalent of revocation:
- Permanent resignation from the College of Nurses of Ontario
- Never reapply for registration
- Never practise nursing in Ontario
- Never use the title “nurse,” “RN,” or “RPN”
The permanent undertaking framework. Where the conduct is sufficiently serious that no return to practice is appropriate, the framework supports a permanent undertaking that operates as the functional equivalent of revocation. The framework includes commitments not to reapply, not to practise under any title, and not to engage in the regulated activities of the profession. The framework operates as the most serious sanction in the nursing regulatory regime.
The Panel’s framing. The Panel made clear that permanent removal from the profession was the only acceptable outcome in a case of this magnitude. The framework recognizes that some conduct is sufficiently incompatible with the foundational framework of the profession that nothing short of permanent removal adequately protects the public and maintains the integrity of the regulatory regime.
The doctrinal anchors
Several doctrinal anchors emerge from the case.
The CNO discipline framework. The Discipline Committee of the College of Nurses of Ontario operates under the framework of the Regulated Health Professions Act, the Nursing Act, and the Health Professions Procedural Code. CNO v Coyle is the principal recent cluster authority on the framework.
The Nursing Act framework. The Nursing Act, 1991 establishes the framework for nursing regulation in Ontario, including the College’s authority, the scope of practice for the nursing classes, and the framework for professional conduct.
The Therapeutic Nurse-Client Relationship standard. The CNO’s practice standard articulates the professional framework for the nurse-patient relationship. The framework includes the categories of patient abuse and the broader framework of professional obligations within the therapeutic relationship. CNO v Coyle applies the framework to a case involving alteration of medication orders, narcotic misappropriation, and a resulting patient death.
The professional misconduct framework for nurses. The Professional Misconduct Regulation (O Reg 799/93) under the Nursing Act defines the categories of professional misconduct for nurses. The framework operates similarly to the equivalent framework for physicians and includes both specific categories of misconduct and the broad DDU standard.
The patient abuse framework. The framework treats abuse of a patient as among the most serious categories of professional misconduct. The framework supports the most serious sanctions including revocation and the permanent undertaking. CNO v Coyle applies the framework to conduct that subverted the medication administration framework and contributed to a patient’s death.
The medication administration record (MAR) integrity framework. The framework for medication administration relies on the integrity of the MAR as a clinical communication instrument. Unauthorized alteration of the MAR constitutes a serious breach of the framework and exposes patients to foreseeable harm through the framework’s reliance on its integrity by subsequent providers.
The narcotic and controlled substance handling framework. The framework for controlled substances includes additional procedural requirements designed to support both patient safety and public health objectives. Misappropriation of controlled substances violates both dimensions of the framework.
The unauthorized alteration of medication orders framework. The framework for medication orders treats the order as the clinical decision of the prescribing physician. The nurse’s professional responsibility is to administer consistent with the order. Unauthorized alteration of the order subverts the framework of clinical decision-making and exposes the patient to risks the physician did not authorize.
The permanent undertaking framework. The framework for permanent undertaking operates as the nursing regulatory equivalent of revocation. The framework is reserved for conduct that is sufficiently serious that no return to practice is appropriate. CNO v Coyle applies the framework to conduct involving falsified documentation, narcotic misappropriation, and a resulting patient death.
The continuing jurisdiction framework. The framework permits the College to discipline former members for conduct that occurred while they were registered. The framework operates on the principle that professional accountability does not depend on continued membership. CNO v Coyle applies the framework where the respondent had surrendered her certificate of registration nine years before the discipline hearing.
The criminal-regulatory interface framework. Where the same conduct gives rise to both criminal proceedings and regulatory discipline, the framework typically supports criminal proceedings being resolved first, with the criminal conviction available as evidence in the subsequent regulatory analysis. CNO v Coyle applies the framework with the discipline hearing occurring three years after the criminal conviction.
The vulnerable patient framework. Elderly patients with significant medical complexity are particularly vulnerable to medication safety failures. The framework for care in these populations operates with heightened scrutiny.
The end-of-life care framework. Patients receiving opioids for pain management operate at the intersection of pain management and respiratory depression risk. The framework requires careful clinical management.
The “extraordinary breach of trust” framework. Where the conduct constitutes a profound breach of the trust framework that supports the professional relationship, the framework supports the most serious sanctions. The framework recognizes that some conduct is sufficiently incompatible with the foundational framework of the profession that nothing short of permanent removal is appropriate.
Why this case matters
For patients and families. The case is a useful illustration of how the regulatory framework operates to protect patients in the most serious cases of professional misconduct.
Some practical observations:
Medication safety is a foundational patient safety concern. The framework of medication administration is calibrated to support safe care across multiple shifts and multiple providers. Where the framework breaks down through unauthorized alterations or improper administration, the consequences can be catastrophic.
Vulnerable patients are particularly at risk. Elderly patients with complex medical issues, patients receiving opioids, and patients in end-of-life care are particularly vulnerable to medication safety failures. The framework supports heightened scrutiny in these populations.
Regulatory discipline does not replace civil remedies. A regulatory discipline finding addresses the professional accountability framework but does not directly provide a civil remedy to the patient or family. Where a patient has been harmed by professional misconduct, civil proceedings remain available subject to the framework of the standard of care, causation, and damages.
Criminal proceedings, civil proceedings, and regulatory discipline operate in parallel. The same conduct can give rise to all three frameworks. Each operates with its own procedural rules and substantive standards. CNO v Coyle involved criminal proceedings (resulting in a guilty plea for criminal negligence causing harm) and regulatory discipline (resulting in the permanent undertaking). Civil proceedings would address additional questions of damages and institutional accountability.
Institutions and other providers may also have responsibility. Where a patient has been harmed by individual professional misconduct, the institutional framework may also engage. Hospital policies on medication administration, controlled substance handling, audit frameworks, and inter-shift communication can affect the institutional accountability analysis. Civil proceedings against the institution operate on a separate framework from the individual provider’s discipline.
For more on the framework for regulatory complaints and the broader landscape of healthcare accountability in Ontario, see A Patient’s Guide to Making Complaints About Health Care in Ontario. For the framework for civil medical malpractice claims, see Suing for Medical Malpractice in Ontario: What You Need to Know.
For nurses and other healthcare professionals. A few practical observations:
The framework for medication administration is foundational. The integrity of physician orders, the accuracy of the MAR, and the framework of documentation are foundational professional obligations. Departures from the framework can have catastrophic consequences for patients and the most serious consequences for the professional.
Controlled substances require strict framework compliance. The framework for controlled substances is more rigorous than for ordinary medications. Compliance with the procurement, storage, administration, documentation, and audit framework is a continuing professional obligation.
Documentation integrity is non-negotiable. Clinical records are the framework for safe care across multiple providers and over time. Alteration or falsification of records is among the most serious professional misconduct and is consistently treated as such by the discipline framework.
Continuing jurisdiction is the rule. The framework permits the College to discipline former members for conduct that occurred while they were registered. Surrender of registration does not foreclose the framework. Professional accountability does not depend on continued membership.
The framework for the criminal-regulatory interface. Where the same conduct gives rise to both criminal proceedings and regulatory discipline, the framework typically supports criminal proceedings being resolved first. A criminal conviction is available as evidence in the subsequent regulatory analysis.
Decision Date: August 21, 2025
Jurisdiction: Discipline Committee of the College of Nurses of Ontario
Citation: College of Nurses of Ontario v Coyle, 2025 CanLII 146790 (ON CNO)
Outcome: Permanent undertaking imposed by the Discipline Committee. The respondent agreed to permanently resign from the College, never reapply for registration, never practise nursing in Ontario, and never use the title “nurse,” “RN,” or “RPN.” The Discipline Committee made findings of professional misconduct on three grounds: patient abuse under the Therapeutic Nurse-Client Relationship standard; falsification of clinical documentation; and conduct that was disgraceful, dishonourable, and unprofessional. The findings arose from the respondent’s hand-alteration of an elderly patient’s Medication Administration Record on January 3, 2015 to increase the authorized morphine dose from 2 to 5 milligrams to 5 to 10 milligrams every two hours as needed, without a physician’s order. The respondent then documented administering seven 10-milligram doses during her day shift, when in fact the morphine was misappropriated rather than administered to the patient. The altered medication order remained in effect at shift change. The incoming night nurse, relying on the altered order in good faith, administered two 10-milligram doses during the night shift. The patient became unresponsive and died at 6:11 a.m. on January 4, 2015. The Office of the Chief Coroner concluded on the balance of probabilities that the death was due to morphine toxicity from the 20 milligrams administered overnight. The respondent pleaded guilty to criminal negligence causing harm in August 2022. The discipline hearing occurred more than ten years after the underlying conduct due to the timing of the criminal proceedings. The College retained jurisdiction notwithstanding the respondent’s surrender of her certificate of registration in 2016 because the conduct occurred while she was registered. The Panel found that permanent removal from the profession was the only acceptable outcome in a case of this magnitude.
Key authorities: Regulated Health Professions Act, 1991, SO 1991, c 18 (foundational regulatory framework); Health Professions Procedural Code (Schedule 2 to the RHPA); Nursing Act, 1991, SO 1991, c 32 (nursing-specific provisions); Professional Misconduct Regulation, O Reg 799/93 under the Nursing Act (defining acts of professional misconduct for nurses); CNO Therapeutic Nurse-Client Relationship practice standard (framework for the professional nurse-patient relationship and patient abuse).
