Note: This article was originally published in our Autumn 2020 edition of our On Call newsletter, and has not been updated.

Discipline Committee Decision Summary

On July 22, 2020, a panel of the Discipline Committee of the College of Midwives of Ontario found that Sandra Knight (the Member) engaged in professional misconduct by practising the profession while the member is in a conflict of interest; engaging in conduct that would reasonably be regarded by members as conduct unbecoming a midwife; and engaging in conduct or performing an act or omission relevant to the practice of the profession that, having regard to all the circumstances, would reasonably be regarded by members as unprofessional.

Publication Ban

The Panel made an order that no person shall publish, broadcast or in any manner disclose the name of the Client or the baby referred to during the hearing or in documents filed at the hearing, held July 22, 2020, or any information that would disclose the identity of the Client or the baby. The publication ban applies to the exhibits filed and to the Panel’s decision and reasons.

Please note that this summary has been drafted to comply with the publication ban ordered by the Discipline Committee and therefore some facts that could identify the Client or the baby have been omitted.

Facts

The Member admitted that she engaged in professional misconduct and the Member and the College jointly agreed to the facts that were presented to the panel.

The allegations in this case involved a blurring of professional and personal boundaries.

The Client contacted the Practice through the Practice’s online intake form. The Client advised that she had recently learned that she was pregnant. The Client indicated that she wanted to terminate the pregnancy, but she was advised by other health care practitioners that she would not be able to do so. The Client was in a vulnerable position. 

The Member contacted the Client and arranged to meet her at a coffee shop. They met on October 12, 2018. The Member informed the client she was not there as a midwife but rather, a woman wanting to help another woman in a time of need. The Client and the Member spoke for approximately 5 hours. During the course of this meeting, the Member discussed various care and treatment options, including midwifery, obstetric care and a Caesarean section. The Member also offered to have a non-professional relationship with the Client. 

After this meeting, the Member documented in a narrative note that she offered to stay on call for the Client as a midwife in the event anything urgent occurred since the Client had not had prenatal care since early September.

The Member admits that it was unprofessional to meet the Client at a coffee shop and to discuss the Client’s pregnancy and care options in these circumstances.

On October 13, 2018, the Client contacted the Member and complained of pain. The Member advised her to go to the hospital, but the Client refused to go due to past negative experiences. The Member then offered to pick her up and take her to the hospital, and the Client agreed.

While at the hospital, the Member introduced the Client to the other midwife at the practice who would act as the primary midwife if the Client decided to enter midwifery care. The Client indicated that she would like to become a patient of that midwife. That midwife was assisting another patient in active labour and was therefore unable to provide care to the Client at that time.

The Member provided midwifery care to the Client including:

• Taking the Client’s history;
• Completing documentation relating to the Client’s care, including the Ontario Perinatal Record;
• Ordering lab work;
• Prescribing medication to the Client; and
• Speaking to the obstetrician about the Client delivering the baby by planned Caesarean section.

On October 15, 2018, the Member documented in the Client’s midwifery chart that the Member would have a non-professional relationship with the Client and that the Member would no longer be involved clinically in the Client’s care. Thereafter, the Client was cared for by a different midwife at the Practice.

The Member acknowledges that it was unprofessional to offer to have a non-professional relationship with a person in a vulnerable position who was requesting pregnancy-related care from the Practice and to later provide care, even if limited, to that Client.

Findings of Professional Misconduct

The Panel found that the agreed facts supported the findings of professional misconduct.

The Panel determined that the Member was a practising midwife at the time of the events and as such the Member problematically blurred the line between acting as an individual and acting as a midwife in a professional capacity. Firstly, had it not been for the Member being a midwife and working within a midwifery practice at the time, the Member would never have had access to the Client nor would they have been aware of the Client at all. In this respect, when the Member contacted the Client, the Client might have reasonably interpreted that the Member was acting as a midwife responding to her email and not as an individual. The Panel found this problematic and felt that the Member could have reasonably anticipated that this involvement could cross boundaries since their involvement with the Client came through their practice in the first place. The Panel also felt that the Member themselves understood that this could be problematic by initially attempting to clarify to the Client that they were not acting as a midwife.

The Panel agreed that the Member acted unprofessionally in choosing to meet the Client at a coffee shop on October 12, 2018, rather than in their clinic or a more professional setting. While the Member believed that this more casual and public setting was for the Client’s comfort and that this would also reinforce the idea that the Member was acting as an individual rather than as a midwife, the discussion that took place in the coffee shop was of a professional and private nature and should have been conducted in a suitable environment to protect the Client’s privacy and health information. In discussing health care options with the Client at this time the Panel concluded that the Member blurred the lines between being a private individual who only wanted to help and being a member of a healthcare profession.

The Member’s offer to have a non-professional relationship with the Client put the Member in a conflict of interest right away and would reasonably be regarded by the membership and the public at large as unprofessional. Although the Client stated that they did not feel pressured by the Member’s conduct, the appearance to the public may be one of the Member taking advantage of a vulnerable client. The Panel was concerned that these actions led to the perception by the public that midwives are unprofessional or untrustworthy.

With respect to the care provided by the Member to the Client on October 13, 2018, the Panel concluded that this was a conflict of interest and thus constituted professional misconduct. The Panel determined that when the Member agreed to be on call for the Client subsequent to their meeting at the coffee shop, the Member was already in conflict of interest as midwifery community standard is that midwives are on call for people who are already in their professional care.

Thus, the Member offering to be on call for the Client in this case would be perceived by the professional community and midwifery clients as the Member having taken on the professional role for this Client while both parties were contemplating a non-professional relationship as well. It would have been more appropriate for the Member at this time to have provided the Client with another midwife from the practice. It was this on-call provision that led to the Member providing care to this Client on October 13, 2018. Once the Member met the Client at the hospital and the Client decided to come into midwifery care, the Member should have recused herself and called in another midwife from the practice since the midwife who would ultimately take over care was unavailable at that time.

The fact that the Member had access to the Client’s chart and documented in that chart on more than one occasion is problematic. An individual without a professional relationship with this Client would not have had access to the private healthcare information of the Client, nor would they be charting on the record.

The Panel did believe that the Member was trying to act in an altruistic and caring manner and was not trying to take advantage of the situation. The Panel acknowledged that once the Client had decided to officially come into midwifery care and had decided to have a non-professional relationship with the Member, the Member did take steps to remove themselves from the Client’s care and to ensure that the Client was taken care of by others within their practice. However, while this was appropriate to do, the Panel found that the Member should have been more aware of the potential conflicts of interest and the blurring of the boundaries that could and in fact did take place.

Penalty

The Panel accepted the parties’ Joint Submission as to Penalty and accordingly made the following order:

• Ms. Knight is required to appear before a panel of the Discipline Committee to be reprimanded, with the fact of the reprimand to appear on the public register of the College;
• The Registrar is directed to impose the following terms, conditions and limitations on Ms. Knight’s certificate of registration:
• Within six months of the date of the Discipline Committee’s Order, Ms. Knight is required to successfully complete, at her own expense and to the Registrar’s satisfaction, an individualized ethics and professionalism course that is pre-approved by the Registrar; and
• Within two months of the date of the completion of the above-noted ethics and professionalism course, Ms. Knight is required to prepare and submit a 1,500-word paper, to the satisfaction of the Registrar, in which Ms. Knight demonstrates her reflection on the importance of establishing and maintaining professional boundaries with persons in a vulnerable position; and
• Ms. Knight is required to pay to the College costs in the amount of $2,500 within 12 months of the date of the Discipline Committee’s Order.

The Panel concluded that the proposed penalty was reasonable and in the public interest.

The reprimand, individualized ethics and professionalism course, and reflective paper serve the goal of specific deterrence and are rehabilitative in nature. In addition, the reprimand being posted on the public register of the Member protects the public interest and serves as a general deterrent to the membership.

The Panel considered that the Member had no prior discipline issues at the College; the Member cooperated with the College; the Member has acknowledged her behaviour amounted to professional misconduct and accepted responsibility for her actions; and from the Agreed Statement of Facts, her intentions were perceived by the Panel as altruistic.

Professional Boundaries

This case deals with a conflict of interest and a blurring of professional boundaries. The Professional Standards for Midwives (Standards) defines conflict of interest as a situation that arises when a midwife, entrusted with acting in the best interests of a client, also has professional, personal, financial, or other interests or relationships with third parties which may undermine the midwife’s professional judgment and affect their care of the client. Boundaries are defined in the Standards as a clear separation between professional conduct aimed at meeting the needs of a client and the midwife’s personal views, feelings, and relationships which are not relevant to a client-midwife relationship.

There are five mandatory principles outlined in the Standards that define the fundamental, ethical and professional standards that the College expects all practices and individual midwives to meet when providing midwifery services. Under the principle of Integrity, it states that integrity demands that midwives consistently model appropriate behaviour, recognize the power imbalance inherent in the midwife-client relationship, and maintain the reputation and values of the profession.

As this matter involved a vulnerable client, the Discipline Panel expressed concern in their reprimand that the conduct could have led to the public perception that the midwife was taking advantage of their client.

Furthermore, the Panel communicated to the member the importance of understanding how easy it can be to blur the boundaries between personal actions and acting as a midwife, and how this can lead to a public perception of midwives being unprofessional or untrustworthy.

Members are responsible to be familiar with and comply with the Professional Standards for Midwives. Members must use their judgment in applying the principles to the various situations they will face as a midwife. The College encourages members to review the Professional Standards for Midwives on a regular basis.