A Burlington physiotherapist, Kelly-Lynne Neale, has been suspended after she sold an illicit cannabis cream to an undercover patient for cash, telling the patient, “You’re not allowed to report me to the physio college, because this isn’t legit.” The Discipline Committee of the College of Physiotherapists of Ontario found Neale, in a case cited as Ontario (College of Physiotherapists of Ontario) v Neale, 2025 ONCPO 75 (CanLII), guilty of multiple acts of professional misconduct, including contravening federal law, failing to maintain professional standards, and engaging in dishonourable conduct.
The case against Ms. Neale, the co-owner and principal of MOVE Physiotherapy and Massage Therapy, began to unfold in the summer of 2021. On July 27, 2021, an individual posing as a patient attended the clinic for an assessment with Ms. Neale, reporting lower back pain and a history of knee pain and headaches. The patient expressed an interest in non-pharmaceutical pain relief, at which point Ms. Neale mentioned she had a CBD cream that could help. The patient returned for a second appointment on August 12, 2021, and again inquired about the cream.
During this second visit, which the patient audio and video recorded, Ms. Neale produced the cream and made several incriminating statements. “This is the cream. You’re not allowed to report me to the physio college, because this isn’t legit,” Ms. Neale was recorded saying. She later added, “It’s not illegal for me, but I just feel like from a College of Physio’s perspective, I… because it’s not an illegal stuff, but it hasn’t been tested by the FDA and all that.” She also remarked, “But a guy I know makes it. Oh my gosh, I sound so black market.” Following this exchange, Ms. Neale sold the cream to the patient for $50 in cash. Ms. Neale later admitted she believed the cream, which smelled of cannabis, contained both CBD and THC and was not government approved or regulated.
The College of Physiotherapists of Ontario received a report from a member of the public about the matter on December 31, 2022. This prompted an investigation, and on May 25, 2023, a College investigator visited Ms. Neale’s clinic. The investigator served her with a cease and desist letter ordering her to stop selling any cannabis products and seized the clinical records for twelve of her patients, including the undercover patient. While the investigator did not find any of the illicit cream sold to the patient, they did find three small, lip-balm sized samples of a different CBD product in a cupboard. Ms. Neale stated she had been given these samples but had declined to promote or sell them at the clinic.
The investigation into the twelve patient charts revealed significant and widespread deficiencies spanning a period from January 2018 to April 2023. Ms. Neale admitted that her records failed to meet the standards of practice. Among the issues, two of the charts contained only invoices with no clinical notes whatsoever. The other ten charts lacked adequate assessments, treatment plans, or patient goals. Furthermore, the records were often illegible, did not document patient consent to treatment, and failed to identify which physiotherapist or assistant provided the care. Some charts even contained the personal identifying information of other patients. The Discipline Committee noted these records were insufficient to allow another healthcare professional to take over care. Ms. Neale also admitted that her treatment of the undercover patient failed to meet the standard for informed consent when she touched the patient and applied the cream.
At a virtual hearing on June 5, 2025, Ms. Neale admitted to all allegations through an Agreed Statement of Facts. The Discipline Committee found her guilty of professional misconduct for failing to maintain the standards of practice, contravening the federal Cannabis Act and the provincial Cannabis Control Act, engaging in conduct that would be regarded by peers as disgraceful, dishonourable, or unprofessional, and failing to maintain proper records.
The committee accepted a joint submission on penalty from Ms. Neale and the College. Ms. Neale will receive a formal reprimand and her certificate of registration will be suspended for six months. She is required to serve four months of that suspension, split into two-month blocks during the summers of 2025 and 2026. The remaining two months of the suspension will be held in abeyance, provided she completes required remediation. This remediation includes an extensive review of nineteen separate standards, guidelines, and e-learning modules on topics ranging from record keeping and consent to professional ethics and billing. She must also successfully complete the ProBE ethics course at her own expense and participate in a two-year practice coaching program focusing on her areas of deficiency. Additionally, Ms. Neale was ordered to pay $7,000 in costs to the College.
In its reasons for the decision, the panel expressed significant concern, stating that the penalty was lenient and that it would have imposed a harsher one had it not been a joint submission. The panel noted the unique nature of the case and its worry about setting a precedent. The panel’s formal reprimand to Ms. Neale was pointed. “Ms. Neale, you are a very lucky person today. Had it not been for a joint submission by you and the College, this panel would have imposed a much stricter penalty on your actions,” the reprimand began. “There is an inherent danger to the public by performing unverified treatment and providing an illicit substance degrades the profession in the eyes of the public… Practising physiotherapy is a privilege, not a right. While serving your suspension, it is the expectation that you will reflect on this fact.”
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