DISCIPLINE SUMMARIES
sion relevant to the practice of medicine that would
reasonably be regarded by members as disgraceful,
dishonourable or unprofessional, and has failed to
maintain the standard of practice of the profession.
At the relevant times, Dr. Bray was the sole
physician and the Medical Director of an Out-of-
Hospital Premises (OHP), providing gastroenterol-
ogy services.
Dr. Bray contravened Out of Hospital Premises
Inspection Program (OHPIP) standards and disre-
garded his responsibilities as a medical director by
administering propofol to patients in the absence of
an anesthesiologist or other physician qualified to do
so. The Committee is greatly concerned that Dr. Bray
did not inform the OHPIP assessors of his clinic’s
use of propofol. Although the assessors reviewed with
Dr. Bray his practices and procedures with respect to
sedation and controlled substances, Dr. Bray did not
inform them that he was using propofol. A subse-
quent unannounced visit to the premises prompted
by an unannounced report to the College confirmed
that Dr. Bray was administering propofol to patients
without an anaesthesiologist present. This was con-
firmed by the College expert, who found in 11 out
of 25 charts reviewed that Dr. Bray had administered
propofol.
Dr. Bray failed to maintain the standard of practice
in his administration of intravenous propofol as ad-
ditional sedation during procedures and displayed a
moderate lack of judgment both in his role as Medi-
cal Director of the OHP and as most responsible
physician to the patients in question.
ORDER
The Discipline Committee ordered: a four-month
suspension on Dr. Bray’s certificate of registration; a
public reprimand; and payment of hearing costs to
the College in the amount of $6,000.00.
For complete details of the Order, please see the
full decision at www.cpso.on.ca. Select Find a Doctor
and enter the doctor’s name.
At the conclusion of the hearing, Dr. Bray waived his
right to an appeal and the Committee administered the
public reprimand.
DR. JEFFREY MARLOWE BROWN
PRACTICE LOCATION: Thornhill
AREA OF PRACTICE: General Practice (Weight Loss and
Complementary/Alternative Medicine)
HEARING INFORMATION: Admission; Agreed Statement of
Facts; Joint Submission on Penalty
On May 10, 2019, the Discipline Committee found
that Dr. Brown committed an act of professional
misconduct, in that he engaged in an act or omis-
sion relevant to the practice of medicine that would
reasonably be regarded by members as disgraceful,
dishonourable or unprofessional, and failed to main-
tain the standard of practice of the profession.
The College commenced an investigation into Dr.
Brown’s practice in 2014, followed by investigations
into two public complaints received in 2014 and
2017. Dr. Brown’s care was reviewed by three experts
retained by the College, who identified a number of
deficiencies in Dr. Brown’s record-keeping:
• Dr. Brown’s charts were disorganized, with test re-
sults and patient history profiles inserted through-
out the chart and sometimes duplicated, and with
no way to identify who made a particular chart
entry other than Dr. Brown;
• Dr. Brown’s chart entries were frequently illegible;
• In a number of charts, Dr. Brown did not docu-
ment physical examinations, or record in the chart
key relevant information about weight loss patients
such as height, body mass index (BMI), or relevant
diagnoses such as diabetes or metabolic syndrome;
• Dr. Brown did not clearly document informed pa-
tient consent to receive Complementary/Alternative
Medicine in accordance with College Policy #3-11,
Complementary/Alternative Medicine;
• Dr. Brown did not have complete Cumulative Pa-
tient Profiles in a number of charts;
• Dr. Brown failed to clearly state prescription and
supplement additions in a number of patient
charts;
• Dr. Brown did not always record tests that he or-
dered or lab work received in the patient charts;
ISSUE 3, 2019 DIALOGUE
53