An Ontario court has dismissed1 a patient’s legal challenge against the professional bodies that oversee physicians, but not before issuing a pointed warning about the potential for doctors’ disciplinary measures to be structured in a way that avoids public transparency. In a decision released on August 8, 2025, the Ontario Superior Court of Justice’s Divisional Court upheld a non-public remedial action for a psychiatrist, Dr. Leigh Solomon, while simultaneously raising concerns that the arrangement may have been crafted to sidestep public disclosure requirements meant to protect patients.
The case originated from a series of events in March 2022, when the applicant, Elaine Welkoff, sought help at the North York General Hospital Emergency Department. Court documents state she was experiencing a mental health crisis, expressing a desire to commit suicide and requesting a medical assistance in dying procedure. Ms. Welkoff, who had a history of mental health issues but had not needed psychiatric treatment for a significant time, was facing numerous stressors including recent health problems, personal losses, a move, and the isolating effects of the COVID-19 pandemic. She was admitted on a voluntary basis to the hospital’s psychiatry unit, where she came under the care of Dr. Solomon.
Dr. Solomon met with Ms. Welkoff on March 21 and 22, 2022. Her initial consultation note, completed the following day, provided a diagnostic impression of persistent depressive disorder with dependent and borderline personality features. Almost immediately, the doctor began discussions about discharging Ms. Welkoff, proposing a date of Friday, March 25. During the brief admission, a prescription for Prozac was offered but Ms. Welkoff declined it, having tried the medication previously. Hospital notes indicate that Ms. Welkoff grew unhappy with the care she was receiving from Dr. Solomon.
After Dr. Solomon agreed to let her stay through the weekend, Ms. Welkoff understood another psychiatrist would be taking over her care. However, on Monday, March 28, 2022, Dr. Solomon was on the unit and made the decision to discharge her. Ms. Welkoff resisted the discharge and was ultimately escorted from the hospital by security guards.
Five months later, on August 25, 2022, Ms. Welkoff filed a formal complaint with the College of Physicians and Surgeons of Ontario (CPSO). She alleged that Dr. Solomon had treated her improperly, claiming the doctor told her she should never have been admitted, profiled her, refused to offer appropriate outpatient supports, made untrue statements in her records, and had her forcibly removed from the hospital while she was actively suicidal. She further alleged that falsehoods in the discharge summary worsened her mental state and negatively impacted subsequent care she received.
The Inquiries, Complaints and Reports Committee (ICRC), a screening body of the College, investigated the complaint. While the ICRC did not uphold every one of Ms. Welkoff’s specific allegations, it identified numerous and significant concerns with Dr. Solomon’s assessment and treatment. The committee found there was no support in the medical records for Dr. Solomon’s diagnosis of persistent depressive disorder and borderline personality. It expressed concern that the doctor’s notes failed to address “any real diagnostic issues or suicidal risk factors in a patient who said she wished to die.” The ICRC stated it would expect a more thorough consultation note from a psychiatrist trying to understand a new patient.
The committee was also troubled by the discharge, noting that Ms. Welkoff had clearly told various staff members she was not ready to leave and felt she was not being listened to. With notes from other team members documenting the patient’s suicidal thoughts the day before her discharge, the ICRC found the records suggested it “could be considered a premature discharge” that may have put a vulnerable patient at risk. The discharge planning itself was deemed inadequate, with the committee describing the discharge note as “curt” and the follow up instructions as a “short notation.”
Furthermore, the ICRC placed much of the blame for the poor doctor-patient relationship on the physician. It found that Dr. Solomon’s notes were sparse and suggested she did not understand the patient’s “help rejecting” behavior in the context of her also “help-seeking.” The committee also questioned why another antidepressant was not tried. Critically, the ICRC noted that Dr. Solomon had a previous written caution from the College related to the discharge of a patient without proper planning. Given this history, the committee stated the doctor “should be aware that proper discharge is fundamental to proper treatment.”
Ultimately, the ICRC concluded that Dr. Solomon would benefit from further education. It resolved the complaint by accepting a “Remedial Agreement” from the doctor. This agreement required Dr. Solomon to conduct a self-study on the management of personality and depressive disorders and on discharge planning, and to submit a 2000-word report to the College.
Dissatisfied with this outcome, Ms. Welkoff appealed to the Health Professions Appeal and Review Board (HPARB), which in August 2024 upheld the ICRC’s decision. The HPARB found the investigation was adequate and the decision to use a remedial agreement was within the range of reasonable outcomes. This led Ms. Welkoff, now representing herself, to seek a judicial review from the Divisional Court, arguing the investigation was inadequate, the process was unfair, and the decision was unreasonable.
The Divisional Court dismissed Ms. Welkoff’s application. It found that the HPARB’s conclusion on the adequacy of the investigation was reasonable, as the ICRC is not required to conduct an exhaustive investigation or interview all potential witnesses. It also found no breaches of procedural fairness.
However, on the issue of the reasonableness of the remedial agreement, the three-judge panel raised a serious concern of its own accord. The judges noted that under Ontario law, a remedial agreement is a non-public outcome. In contrast, a more formal order for a physician to take a remedial program must be posted on the College’s public register. The court questioned why a non-public resolution was chosen in this case, given the gravity of the ICRC’s findings. The judges wrote that the ICRC found Dr. Solomon “prematurely discharged the applicant who had suicidal thoughts and intentions, including the day before she was discharged.” Paired with the doctor’s prior caution for a similar issue, the court questioned why this situation would not “fall into the more serious or greater risk category requiring a disposition that must be disclosed publicly.”
The court stated that if such dispositions are “crafted for the purpose of avoiding the transparency provisions” of the law, this practice “will undermine the openness and public scrutiny of the College’s regulation and governance of physicians which the legislation seeks to ensure and may result in the disposition being found to be unreasonable.”
Despite this stark commentary, the court chose not to overturn the decision. It reasoned that since Dr. Solomon had already completed the remedial program in 2023, it was no longer “sensible or necessary” to send the case back to the HPARB. The application was dismissed with no order for costs. The court concluded its analysis with a clear warning, stating, “We raise this issue in case the practice becomes more widespread and is a systemic issue.”
Read more cases about proceedings in regulated professions here.
