The case of a nurse who lost her licence in California for "gross negligence" but got a licence to practise in Ontario reveals a significant gap in the safety net of background checks in the province, Ontario's College of Nurses says.

But the disciplinary panel in Toronto ruled Wednesday that Rose McKenzie could keep her licence in Ontario and her job at  Oakville Trafalgar Memorial Hospital.

The panel also ordered McKenzie to get additional training before resuming work directly with patients.

McKenzie was accused of over-medicating and failing to monitor a patient at California's UCSF Medical Center after a successful, routine neck surgery.

The fact her licence was revoked in California in 2008 never reached authorities in Ontario when she returned to Canada. A year after the incident, McKenzie moved to Canada and began working at Oakville Trafalgar Memorial Hospital.

"Ms. McKenzie’s case illustrates a gap in the safety net," Linda Rothstein, a lawyer for the college, said during the hearing. "It’s not her fault, but it is true. Each regulator makes its own decision regarding sharing information with respect to disciplinary proceedings based on its specific statutory framework and available resources.

"The result, regrettably, is there is no comprehensive North American mechanism in place to ensure regulators report findings of professional misconduct to regulators in other jurisdictions. In the college’s view, this gap is significant."

Nurse deeply sorry

The college said it is working to plug the loophole, but hasn't accomplished that yet.

McKenzie agreed that the care she gave Spencer Sullivan 10 years ago in California would have fallen short of the standard of care required in Ontario. Sullivan stopped breathing Dec. 27, 2001, partly because of the overdose, which caused brain damage and left him quadriplegic.

McKenzie was emotional Wednesday as she said she was deeply sorry for what happened to him.

"I would do anything to go back in time to December 2001 and to do things differently," she said.

"I will live forever with the knowledge and severe regret that my actions as Mr. Sullivan’s nurse contributed to this devastating outcome for him and his family."

The panel was told the statement had also been delivered to the Sullivan family.

The disciplinary panel concluded it wasn’t clear Mackenzie even knew her U.S. licence had been revoked because the letter had been sent to the wrong address in Canada.