On October 5, 2016, the Discipline Committee of the College of Physicians and Surgeons of Ontario found that Dr. Janice Louise Ruggles has committed an act of professional misconduct in that she has engaged in an act or omission relevant to the practice of medicine that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable, or unprofessional, and in that she failed to maintain the standard of practice of the profession.
Dr. Ruggles, an obstetrician-gynecologist, practised at a private office in Pickering and held hospital privileges at the Rouge Valley Health System in the Greater Toronto Area.
2011 College Investigation
On January 31, 2011, the College received information from a pharmacist that Dr. Ruggles had written prescriptions for large quantities of OxyContin over the past several years to a non- patient with whom Dr. Ruggles had a work-related association. The College launched a section 75(1)(a) investigation under the Health Professions Procedural Code.
Dr. Ruggles sent a response to the College investigation dated June 14, 2011, acknowledging that she had provided prescriptions to the individual (“Individual 1”), and promised to treat and/or prescribe only to those with whom she has a doctor/patient relationship and in circumstances where she has conducted a complete assessment.
The Inquiries, Complaints and Reports Committee (“the ICRC”) cautioned Dr. Ruggles in writing regarding inappropriately prescribing narcotics and treating a person with whom she had a work-related association, including by prescribing narcotics to that individual. The ICRC noted that Dr. Ruggles’ prescription of narcotics and other medications to a person with whom she had a work-related association was clearly inappropriate; that this was an isolated event in Dr. Ruggles’ practice; and that Dr. Ruggles admitted to the indiscretion and agreed to appropriate remediation. The ICRC also required Dr. Ruggles to complete a boundaries course and a narcotics prescribing course, which she completed in 2012.
Current College Investigation
In May 2013, another individual with whom Dr. Ruggles had a work-related association
(“Individual 2”) called the College to advise that Dr. Ruggles had been prescribing narcotics to that individual.
The College commenced a s. 75(1)(a) investigation and obtained pharmacy records, which demonstrated that Dr. Ruggles had written the following prescriptions for Individual 2:
July 6, 2011: Clonazepam 5mg, 180 tablets, with 2 repeats
Nov 3, 2011: Azithromycin (Zithromax) 500 mg po OD, then 250mg po 4 days
July 25, 2012: Macrobid, 100mg for 7 days
Naproxen 500mg po tid, 80 tablets, with 1 repeat;
Oxy IR 10mg, 60 tablets, with 1 repeat
Nov 20, 2012: Oxy IR 10mg, 60 tablets, with 1 repeat;
Naproxen 500mg po tid no substitution, 80 tablets, 1 repeat
2
Dec 10, 2012: Tamiflu, 75mg, 5 day supply
In her response to this investigation, Dr. Ruggles admitted to treating Individual 2 and to providing these prescriptions to Individual 2 during their work-related association.
Dr. Ruggles wrote the first prescription for Individual 2 within weeks of her June 14, 2011 response to the College’s previous investigation. Dr. Ruggles wrote the additional prescriptions for Individual 2 both before and after she completed the boundaries and narcotics prescribing courses required by the College, and both before and after she received the ICRC decision cautioning her for this behaviour.
Expert Report
The College retained an expert to review Dr. Ruggles’ care of patients in her office practice, who stated that the main issues of concern, ordering much larger amounts of narcotics than commonly prescribed, in particular, Oxycodone, Clonazepam, and Ativan, were found in three of the 24 charts reviewed and the related prescription analysis.
One of these 3 charts was that of Individual 2. The care Dr. Ruggles provided to Individual 2 did not meet the standard of practice. The expert noted: “A large amount of narcotics and sedatives were prescribed… She did not show good judgment and her management of this patient fell below the standard of practice. The same can be said about the Doctor’s failure to recognize the conflict of interest and potential harm created by continuing to keep [Individual 2] as a patient …Dr. Ruggles also failed to maintain proper boundaries in this relationship.” With respect to a second patient, the expert stated: “I find it concerning that the patient was seen only twice within 1 month and had 2 prescriptions for a total of 300 Oxy RI [sic] tabs, 200 Ativan tabs, and 180 Rivotril tabs. Based on the above information, I feel that in this case the standard of care was not met. The Physician was not likely prescribing within her scope of practice and did not show good judgement.”
With respect to a third patient, the expert noted that the patient was given a prescription of 200 Percocets in March 2011, and 60 Percocets and 60 Toradol in June 2011. 30 more Percocets were prescribed in November 2011. The expert concluded that this was overly generous prescribing and that Dr. Ruggles did not meet the standard of care as she prescribed an excessive amount of narcotics, putting the patient at risk.
The expert opined that Dr. Ruggles demonstrated a lack of knowledge and judgment in respect of these three cases, and that, in respect of the first and second cases, Dr. Ruggles was not likely prescribing within her scope of practice.
With respect to the 21 other patients reviewed, the expert opined that the care provided by Dr. Ruggles met the standard of practice.
On September 29, 2014, in response to this investigation and the expert report, Dr. Ruggles volunteered to cease all prescriptions of narcotics other than to patients seen in her hospital
3
practice. Dr. Ruggles also offered to undertake to no longer treat or have any clinical dealings with those people with whom she had work-related associations.
PENALTY
On October 5, 2016, the Discipline Committee ordered and directed that:
- the Registrar suspend Dr. Ruggles’ certificate of registration for a two (2) month period, to commence at 12:01 a.m. on October 13, 2016 and concluding at 12:01 a.m. on December 13, 2016.
- the Registrar impose the following terms, conditions and limitations on Dr. Ruggles’ certificate of registration:
Prescribing Privileges
(1) Dr. Ruggles shall not issue new prescriptions or renew existing prescriptions for any of the following substances:
(a) Narcotic Drugs (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
(b) Narcotic Preparations (from the Narcotic Control Regulations made under the Controlled Drugs and Substances Act, S.C., 1996, c. 19);
(c) Controlled Drugs (from Part G of the Food and Drug Regulations under the Food and Drugs Act, S.C., 1985, c. F-27);
(d) Benzodiazepines and Other Targeted Substances (from the Benzodiazepines and Other Targeted Substances Regulations made under the Controlled Drugs and Substances Act., S.C., 1996, c. 19); or (A summary of the above-named drugs [from Appendix I to the Compendium of Pharmaceuticals and Specialties] is attached hereto as Schedule “A”; and the current regulatory lists are attached hereto as Schedule “B”); and
(e) All other Monitored Drugs (as defined under the Narcotics Safety and Awareness Act, 2010, S.O. 2010, c. 22 as noted in Schedule “C”); and as amended from time to time.
(2) Dr. Ruggles will return any supplies of the substances referred to in paragraph (1) above that are presently in her possession, in any place, to a pharmacy in a safe and secure manner, as stipulated in the College's Policy Number 8-12,
"Prescribing Drugs."
(3) Notwithstanding paragraph 5.(1):
(a) Dr. Ruggles may prescribe the above-noted substances to her in-patients only, during the course of their in-patient stay through the hospital pharmacy; and
(b) Dr. Ruggles may issue prescriptions to patients she treats in the emergency department while on call, hospital outpatients or hospital inpatients on discharge of only:
(i) Tylenol #3 (to a maximum of 10 tablets, with no repeats); or
(ii) OxyIR 10 mg (to a maximum of 10 tablets, with no repeats).
And said prescriptions may only be issued to emergency department patients, hospital outpatients or to hospital inpatients on discharge in relation to the following procedures:
4
(i) Caesarean Sections;
(ii) Complex Vaginal Deliveries;
(iii) Laparoscopic Surgery;
(iv) Open Abdominal Surgery; or
(v) Perineal/Vaginal procedures.
Posting a Sign
(4) Dr. Ruggles shall post a sign in the waiting room(s) of her office, in a clearly visible and secure location, in the form set out at Schedule “D”. For further clarity, this sign shall state as follows: "Dr. Ruggles shall not prescribe Narcotic Drugs, Narcotic Preparations, Controlled Drugs, Benzodiazepines and Other Targeted Substances, or any other Monitored Drugs. Dr. Ruggles shall not provide any medical advice, recommendations, consultations, treatment or prescriptions to any of her employees. Further information may be found on the College of Physicians and Surgeons of Ontario website at www.cpso.on.ca".
(5) Dr. Ruggles shall post a certified translation in any language in which she provides services, of the sign described in paragraph 5.(4) above, in the waiting room(s) of her office.
(6) Dr. Ruggles shall provide the certified translation(s) described in paragraph 5.(5), to the College within thirty (30) days of this Order.
(7) Should Dr. Ruggles elect to provide services in any other language(s), she must notify the College prior to providing any such services.
(8) Dr. Ruggles shall provide to the College the certified translation(s) described in paragraph 5.(5) prior to beginning to provide services in the language(s) described in paragraph 5.(7).
Prescription Log
(9) In the event that Dr. Ruggles writes a prescription pursuant to paragraph 5.(3), she shall record this prescription and other specified information in a prescription log in the form attached as Schedule “E”, which shall be made available to the College at the College’s request. Dr. Ruggles shall also append to the prescription log a copy of each prescription she issues under paragraph 5.(3).
(10) Dr. Ruggles shall provide a document in the form set out at Schedule “F” to each patient to whom she prescribed in accordance with paragraph 5.(3). The patient shall initial the document, and Dr. Ruggles shall append a copy of the initialed document to the log referred to in paragraph 5.(9).
Treating Family Members or Employees
(11) Dr. Ruggles will not treat any office or hospital employees or family members in any manner whatsoever, except in an emergency situation. This includes, but is not limited to, providing advice, consultations, treatment, prescriptions or treatment recommendations.
Coursework
(12) At her own expense, Dr. Ruggles shall participate in and successfully complete, within 6 months of the date of this Order, individualized instruction in medical ethics satisfactory to the College, with an instructor selected by the College. The instructor shall provide a summative report to the College including his or her conclusion about whether the instruction was completed successfully by Dr. Ruggles.
5
Reassessment
(13) Dr. Ruggles shall undergo a reassessment of her practice approximately twelve
(12) months from the date of this Order.
Compliance
(14) Dr. Ruggles must inform the College of each and every location that she practises or has privileges, including, but not limited to, hospital(s), clinic(s) and office(s), in any jurisdiction (collectively the "Practice Location(s)"), within fifteen (15) days of commencing practice at that location.
(15) Dr. Ruggles shall be solely responsible for payment of all fees, costs, charges, expenses, etc. arising from the implementation of any of the terms of this Order.
(16) Dr. Ruggles shall co-operate with unannounced inspections of her Practice Location(s) and patient charts by the College and to any other activity the College deems necessary in order to monitor her compliance with the terms of this Order.
(17) Dr. Ruggles shall provide her irrevocable consent to the College to make appropriate enquiries of the Ontario Health Insurance Plan ("OHIP"), the Drug Program Services Branch, the Narcotics Monitoring System ("NMS") implemented under the Narcotics Safety and Awareness Act, 2010 and any person or institution that may have relevant information, in order for the College to monitor her compliance with the terms of this Order.
(18) Dr. Ruggles acknowledges that the College may provide this Order to any Chief(s) of Staff, or a colleague with similar responsibilities, at any Practice Location where she practices or has privileges ("Chief(s) of Staff"), or other person or individual as necessary for the implementation of this Order and shall consent to the College providing to said Chief(s) of Staff, person or organization with any information the College has that led to this Order and/or any information arising from the monitoring of her compliance with this Order.
- Dr. Ruggles appear before the panel to be reprimanded;
- Dr. Ruggles pay to the College its costs of this proceeding in the amount of $5,000.00 within thirty (30) days from the date of this Order.
Terms and conditions imposed on certificate by: Inquiries, Complaints and Reports Committee