A Canadian woman whose California nursing licence was revoked over "gross negligence" is working at a Greater Toronto Area hospital, CBC News has learned.

Rose McKenzie, 38, of Mississauga had her California nursing licence revoked in 2008 after being accused of overmedicating and failing to monitor a patient at California's UCSF Medical Center following a successful, routine neck surgery. She was a temp nurse employed through American Mobile Nurses Inc. at the time.

The patient, Spencer Sullivan, stopped breathing Dec. 27, 2001, due in part to the overdose, which caused brain damage and left him quadriplegic. Less than a year after the incident, McKenzie moved back to Canada and began working at the Oakville Trafalgar Memorial Hospital.

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Spencer Sullivan, 51, suffered brain damage and became quadriplegic. ((CBC)

But it wasn't until recently that the Ontario nursing regulatory body began examining McKenzie's past. 

No alert system

The case raises troubling questions about the lack of information sharing between regulatory nursing bodies across Canada and abroad.

No formal mechanism exists to require nursing boards in one jurisdiction to alert other jurisdictions about nurses they have disciplined. Nurses in Ontario, for example, are expected to report any issues themselves.

There were several times when McKenzie might have notified Ontario's College of Nurses over the past decade, including during a civil lawsuit and a disciplinary hearing in the U.S. Neither was under way when McKenzie began working at the Oakville hospital in 2002.

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A picture of Rose McKenzie from a 1996 U.S. state nursing licence document.

In 2005, a $6-million civil lawsuit, settled outside court, ascribed McKenzie with 40 per cent of the cost — or $2.4 million —  for Sullivan's botched care.

In 2008, California's Board of Registered Nursing revoked McKenzie's nursing licence  after ruling that she had "engaged in gross negligence" in her care of Sullivan. The decision was later posted online.

In his lawsuit, Sullivan's lawyer alleged that among McKenzie's missteps made during about 10 hours of post-surgery care starting the evening of Dec. 26, 2001, were:

  • Overmedicating the patient by administering drugs ordered by two separate doctors without question.
  • Failing to regularly check on him as instructed, leaving hours between visits.
  • Failing to chart any of her activities with Sullivan until the following day. McKenzie says she made notes on scraps of paper instead of on the chart.
  • Failing, along with another nurse, to respond quickly enough when Sullivan stopped breathing.

"Nurse McKenzie's care and treatment fell below accepted standards of care for a nurse," said Sullivan's lawyer Dan Hodes. "It did. There's no question about that."

Disciplinary hearing to be held

Last July, the College of Nurses of Ontario charged McKenzie  with failing to "provide complete and accurate information to the college" when she was found to have committed professional misconduct in another jurisdiction. A disciplinary hearing is scheduled for May 6.

Disciplinary hearings can result in a reprimand, fine, suspension or restriction in practice or even revocation of licence.

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The College of Nurses of Ontario will hold a disciplinary hearing for Rose McKenzie in May. ((CBC))

The Oakville hospital said McKenzie is not currently working directly with patients, but wouldn't say when that began.

McKenzie declined to talk with CBC News. "I'm sorry, I've been instructed not to make a comment," she said over the phone from her home in Mississauga.  

Hodes says Sullivan, 51, was a "high functioning, vibrant, charismatic guy" who was a nurse himself and ran a successful temp agency similar to the one that employed McKenzie. "And now he's a profoundly brain injured quadriplegic."

"He was let down by his profession," said Hodes. "And he knows that."

Sullivan's parents, Bill and Carol, both in their mid-70s, moved from their retirement home in Atlanta into a house with Sullivan in Laguna Hills, Calif., shortly after the incident and have been taking care of him ever since.

"The nurse was the first line of defence," said father Bill Sullivan. "She failed her assignment." 

Spencer Sullivan, who can speak but suffers from short-term memory loss, says he's grateful to be alive. But, he adds, if he could deliver one message to McKenzie, it would be: "Tell her I said 'Hello.' And 'Go to hell.' That's where I think she belongs."

System 'completely inadequate'

Tips?

If you have more information on this story, or other investigative tips, please email investigations@cbc.ca.

Halton Healthcare Services, which oversees the Oakville hospital where McKenzie works, said in a letter that all its employees are "vetted through a detailed, rigorous application and screening process."

The letter notes, however, that it's the college's role to ensure registered nurses meet requirements to work in Ontario.

Ontario's College of Nurses said in a written statement that its members are required to self-report within 30 days about any findings of guilt of an offence, professional negligence or malpractice and if any such proceedings are underway.

But the college also acknowledged that the fact "a nurse is name in a civil lawsuit does not have to be reported" if it's settled out of court, as was the case with McKenzie.

Nurses are required to answer questions about such issues on a "Self-reporting Form " filled out during the annual renewal of their licence.

In Canada, there is no centralized system for provincial nursing boards to check a nurse's status in other jurisdictions.

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McKenzie began working at Oakville Trafalgar Memorial Hospital after she moved back to Canada. ((CBC))

"Each jurisdiction has different legislation and rules about what information is made public," Ontario's college of nurses communications manager, Deborah Jones, wrote in an email. "Some provinces are required by legislation to send this information, others are not."

Michael McBane, national co-ordinator of the advocacy group, Canadian Health Coalition, said reliance on self-reporting is "completely inadequate."

"It's not acceptable in this day and age with this kind of technology to not to be sharing information when it's such critical information," said McBane.

Ontario's Health Minister Deb Matthews says that the nurse's college in Ontario, as a self-regulatory body, is ultimately responsible for ensuring the nurses are qualified. She told CBC news that patients need to feel confident in the credentials of their health care professionals. 

"So if we need to strengthen [the system], I'm always looking at ways to make the system better for the people of Ontario," said Matthews.

If you have more information on this story, or other investigative tips, please email investigations@cbc.ca.