Executive Summary: Key Legal and Evidentiary Issues

• Characterization of the 396 letters as true “medical exemption” letters rather than mere records of informed consent or educational advice.
• Compliance of the nurse practitioner’s conduct with the College’s standards of practice, including assessment, documentation, nurse–client relationship, diagnosis, and follow-up obligations.
• Reliance on Directive 6, College guidelines on consent and decision-making, and international principles (e.g., the Nuremberg Code) as a justification for issuing blanket exemption letters.
• Adequacy of the Discipline Committee’s reasons, including whether it sufficiently engaged with the appellant’s evidence and submissions and whether credibility findings were required.
• Allegation of procedural unfairness through supposed bias and “collusion” between the Discipline Committee and the RNAO in connection with funding for legal representation.
• Continuation of a publication ban to protect non-party patients’ personal health information under the Health Professions Procedural Code and the open court/sheriff Estate framework.

Facts of the case
The case arises from the professional conduct of Melissa Dore, a nurse practitioner in Ontario, during the COVID-19 pandemic. Between September 2021 and February 2022, she issued 396 exemption letters intended to be used by clients to avoid mandatory COVID-19 vaccination requirements. These letters were mostly provided after clients emailed her to confirm they had watched an informational slide presentation she created about COVID-19 vaccines and related issues. The appellant’s practice model during this period did not involve individualized in-person or virtual clinical assessments for each client. Instead, access to an exemption letter was tied primarily to watching the slide presentation and then requesting a letter by email. The Discipline Committee later found that, in several instances, letters extended to persons who had not even viewed the presentation themselves, such as a client and her four children after only the client observed part of the presentation by Zoom.
There were three general forms of letters. Two were given to the vast majority of clients. One type stated that the client was exempted from taking the COVID-19 vaccine “due to current medical circumstances, and informed consent.” The other type recorded that the client “had been advised against this vaccine as a result of medical history,” expressly describing the letter as a “medical exemption from taking the COVID-19 vaccine.” A small group of clients received a third version which simply indicated that attending an educational session qualified them for a vaccine exemption, without explicit reference to a medical exemption or informed consent. In all cases, the appellant signed the letters in her capacity as a nurse practitioner, and they were plainly intended for use with employers or other institutions enforcing vaccination requirements.
The appellant maintained that she was acting primarily as an educator rather than a primary care provider. She described her role as supplying information so that patients could make their own decisions about vaccination, emphasizing patient autonomy and her ethical view that individuals who did not wish to be vaccinated should not be forced to receive the vaccine. She asserted that the slide presentation provided sufficient information for patients to give or withhold informed consent, and that the resulting letters were, in substance, “informed consent exemptions” — not medical determinations that a vaccine was clinically contraindicated.

Directive 6 and other guidance relied on by the appellant
Central to the appellant’s justification was her reliance on provincial pandemic-related guidance, particularly “Directive 6” issued by Ontario’s Chief Medical Officer of Health. Directive 6 imposed vaccination policies on specified “covered organizations” such as public hospitals, certain home and community care providers, Local Health Integration Networks, and ambulance services. Under those policies, employees who declined vaccination could, in some circumstances, do so after completing an “approved” educational session about the vaccine. The appellant believed her slide presentation satisfied the educational standards noted in Directive 6 and asserted that she was aligning her practice with that directive.
In addition to Directive 6, she invoked College practice guidelines on consent and decision-making and authority to perform procedures, as well as the Health Care Consent Act. She also argued that her approach was consistent with the Nuremberg Code, emphasizing that voluntary consent is essential in the context of what she characterized as medical experimentation; she highlighted the absence of long-term safety data and the existence of risk warnings in product monographs for the COVID-19 vaccines. In her view, these sources collectively supported a broad conceptualization of informed consent that justified issuing exemption letters to clients who, being “fully informed” by her materials, chose not to be vaccinated.

Discipline Committee findings on professional misconduct
Following an investigation and a hearing, the Discipline Committee of the College of Nurses of Ontario released a merits decision on October 27, 2024, concluding that Ms. Dore had committed professional misconduct. The Committee treated the letters as medical exemption letters. This characterization was grounded in their wording, especially the explicit references to “medical exemption,” “medical history,” and being “ineligible for taking the COVID-19 vaccine due to current medical circumstances, and informed consent.” The Committee found that whatever educational information had been provided, the pivotal act for regulatory purposes was the issuance of letters purporting to exempt patients from vaccine requirements on medical grounds.
The Committee held that the appellant’s conduct breached multiple standards of practice for nurse practitioners. It found that her documentation was inadequate, lacking the individual assessments, clinical reasoning, and follow-up planning that would be expected when granting a medical exemption. It also determined she had failed to establish the therapeutic nurse–client relationship required to justify such exemptions. In numerous instances she did not meet patients individually, did not take a full history or conduct examinations, did not reach diagnoses, and did not ensure ongoing follow-up or appropriate referrals. As a result, the Committee concluded that she had issued medical exemptions that were “not indicated and/or appropriate” in light of patients’ actual clinical circumstances and the applicable professional standards.
Beyond technical standards breaches, the Committee further characterized her conduct as unprofessional, dishonourable, and disgraceful. It emphasized that she had shown “a serious and persistent disregard for her professional obligations” by repeatedly issuing exemption letters in this manner, and that her actions put clients at risk. However, one allegation did not succeed: the Committee dismissed the claim that she had charged excessive fees for the letters, indicating that its concerns centred on the professional and clinical basis for the exemptions rather than the amounts billed.

Penalty imposed by the Discipline Committee
In a separate penalty decision, the Discipline Committee ordered that the appellant attend to be reprimanded and that her certificate of registration be revoked. When deciding on penalty, the Committee noted that her certificate had already been suspended on an interim basis and concluded that she had not demonstrated insight into the seriousness of her conduct during that period. Citing the repetitive nature of the wrongdoing and her apparent unwillingness to conform to regulatory expectations, it found that she was “ungovernable.” Revocation was considered necessary both to protect the public and to maintain confidence in the profession’s self-regulation.
On appeal, the appellant chose not to directly challenge the penalty. Her notice of appeal sought only to have the findings of professional misconduct quashed and did not seek relief from the revocation or other aspects of the penalty order. At the hearing of the appeal, she expressly acknowledged that if the Discipline Committee’s findings on misconduct were upheld, she accepted the penalty imposed. That procedural stance meant that, before the Divisional Court, the only live issues related to the correctness and reasonableness of the Discipline Committee’s findings on misconduct and related procedural fairness questions.

Issues and standard of review before the Divisional Court
The matter came before the Ontario Divisional Court (Shore, O’Brien and I. Smith JJ.) as an appeal from the Discipline Committee’s decision. The court applied the established appellate framework for reviews of administrative tribunal decisions. Questions of law, including allegations of procedural unfairness and reasonable apprehension of bias, attracted the standard of correctness. Questions of mixed fact and law, where no discrete legal principle could be separated from the factual matrix, were subject to a deferential standard of palpable and overriding error, reflecting the tribunal’s expertise and primary role in assessing the professional conduct evidence.
The appellant raised four principal arguments. First, she claimed the Committee had mistakenly conflated the roles of “nurse educator” and “primary care provider,” and that the letters were wrongly categorized as medical exemptions rather than expressions of informed consent. Second, she argued that, especially in the absence of specific College guidance on COVID-19 vaccine exemptions in September 2021, she had properly relied on Directive 6, practice guidelines, and broader consent principles. Third, she asserted that the Committee had failed to properly engage with her evidence and submissions, including her reliance on the Health Care Consent Act and specific practice documents, and had not made necessary credibility findings. Fourth, she alleged procedural unfairness in the form of bias and collusion between the Committee and the Registered Nurses’ Association of Ontario (RNAO), particularly in light of RNAO’s timing in providing financial assistance for legal representation during the discipline hearing.

Court’s treatment of the “medical exemption” characterization and Directive 6
On the first issue, the Divisional Court held that the Committee committed no reviewable error in treating the letters as medical exemption letters. The court noted that the allegations of misconduct were directed not at her role as an educator per se, but at her act of issuing letters that would be read by third parties (such as employers) as medical exemptions from vaccination requirements. The explicit phrasing of the letters, including references to “medical exemption,” “medical history,” and “current medical circumstances,” made it entirely reasonable for the Committee to view them as clinical determinations that vaccination was contraindicated, rather than as neutral documentation of a patient’s choice following informed consent. It was squarely within the Committee’s professional expertise to interpret the letters in that way, and on the record there was no palpable and overriding error warranting appellate intervention.
Regarding Directive 6 and the other guidance relied on by the appellant, the court endorsed the Committee’s conclusion that Directive 6 could not justify her conduct. Directive 6 applied to specific “covered organizations,” a defined list that included public hospitals, certain home care and community service providers, Local Health Integration Networks, and ambulance services, but did not extend to nurse practitioners working independently in the community. Moreover, the directive required that any educational session be “approved” by a covered organization. The appellant’s slide presentation was not approved in this fashion, meaning she could not reasonably claim to be operating within Directive 6’s framework. The court found ample evidence supporting the Committee’s factual conclusions that she had failed to comply with core standards of practice in assessment, documentation, nurse–client relationship, diagnosis, and follow-up, and that neither Directive 6 nor general consent principles displaced those obligations.

Consideration of the appellant’s evidence and arguments
The court rejected the contention that the Discipline Committee’s reasons were deficient for failing to mention every document and argument advanced by the appellant. It reiterated the principle that an administrative decision-maker is not required to expressly refer to every piece of evidence, provided the reasons demonstrate engagement with the party’s central arguments. Here, the Committee had squarely acknowledged the appellant’s reliance on patient autonomy and informed decision-making, her invocation of the College’s Ethics standard, and her argument that it was unethical to force vaccination on unwilling individuals. It also specifically addressed her reliance on Directive 6 and explained why that directive did not apply to her circumstances.
The court concluded that, read fairly and as a whole, the Committee’s reasons showed that it had considered and rejected her primary thesis that the letters were “about informed consent” rather than medical exemptions. Its conclusion that she breached multiple standards of practice was supported by the uncontested facts concerning how the letters were generated and the absence of individualized clinical assessment. The court further held that there was no need for explicit credibility findings, because the key misconduct findings did not hinge on whose version of events to believe; rather, they turned on largely undisputed facts about the volume and manner of issuing exemption letters and the contents of those letters.

Allegations of bias and collusion with the RNAO
The appellant also alleged that the College had prosecuted her maliciously and that there was collusion between the Discipline Committee and the RNAO, rooted in the RNAO’s initial refusal to fund her legal defence and its eventual grant of assistance on May 1, 2024, when the hearing was almost complete. She suggested that the funding decisions showed institutional hostility and bias that tainted the Committee’s decision-making.
The Divisional Court dismissed these allegations as entirely without merit. It emphasized the strong presumption that tribunal members act without bias or prejudice. It also noted the procedural rule that a party alleging reasonable apprehension of bias must raise it before the tribunal so that it can be addressed at first instance. In this case, the appellant did not formally allege bias before the Discipline Committee, even though her concerns with RNAO funding crystallized before the hearing concluded (the final day being May 14, 2024). Most importantly, the court found no evidentiary link between the RNAO’s separate role as her professional association and the impartiality of the Discipline Committee. There was simply no foundation for concluding that Committee members colluded with RNAO or were improperly influenced by its funding decisions.

Publication ban and protection of patient privacy
Finally, the Divisional Court addressed a publication ban originally ordered by the Discipline Committee under s. 45(3) of the Health Professions Procedural Code, which forms part of the Regulated Health Professions Act, 1991. That ban prohibited the publication of patients’ names and any information that could reveal their identities. The record before the Committee contained sensitive personal health information of patients who were not parties to the discipline proceedings.
Applying the Supreme Court of Canada’s framework in Sherman Estate v. Donovan, the court held that the test for an exception to the open court principle was met. The patients were strangers to the proceeding and had not voluntarily placed their health information into the public domain. Preserving confidentiality served an important public interest by allowing the Discipline Committee to carry out its regulatory function without causing undue harm to third parties. The Divisional Court therefore continued the publication ban in its own proceedings, both to avoid undermining the Committee’s order and to protect the privacy of the affected patients.

Overall outcome and financial consequences
The Ontario Divisional Court dismissed the appeal in its entirety, upholding the Discipline Committee’s findings that Melissa Dore had committed professional misconduct in issuing hundreds of COVID-19 vaccine exemption letters without appropriate clinical assessment, documentation, or nurse–client relationships, and rejecting her reliance on Directive 6, consent-based arguments, and alleged bias. As a result, the underlying penalty — including the revocation of her certificate of registration and a formal reprimand — remained in force, as she had accepted that penalty contingent on the misconduct findings being sustained. The College of Nurses of Ontario thus emerged as the successful party on appeal, and the court ordered the appellant to pay the College all-inclusive costs in the amount of $5,000, which was the total quantified monetary award made in the proceeding.