DECISION OF THE HEARING TRIBUNAL: FINDINGS, REASONS … Members Docum… · 2 I. INTRODUCTION A....

NOTE: THIS VERSION OF THE DECISION OF THE HEARING TRIBUNAL HAS BEEN EDITED FOR IDENTIFICATION ONLY.

IN THE MATTER OF THE VETERINARY PROFESSION ACT, RSA 2000, c V-2, AS AMENDED;

AND IN THE MATTER OF A HEARING INTO THE CONDUCT OF DR. JEFF SERFAS, A MEMBER OF THE ALBERTA VETERINARY MEDICAL ASSOCIATION;

AND INTO THE MATTER OF A COMPLAINT BY TT WITH RESPECT TO THE TREATMENT OF HER DOG “ANGEL”;

IN THE MATTER OF THE VETERINARY PROFESSION ACT, RSA 2000, c V-2, AS AMENDED;


AND INTO THE MATTER OF A COMPLAINT BY DP & VP WITH RESPECT TO THE TREATMENT OF THEIR DOG “PEANUT”;

IN THE MATTER OF THE VETERINARY PROFESSION ACT, R.S.A. 2000, c. V-2, AS AMENDED;


AND INTO THE MATTER OF A COMPLAINT BY ABVMA COMPLAINTS DIRECTOR INTO THE CONDUCT OF DR. JEFF SERFAS IN ACCORDANCE WITH SECTION 27.1 OF THE VETERINARY PROFESSION ACT;

DECISION OF THE HEARING TRIBUNAL:

FINDINGS, REASONS AND PENALTY ORDERS

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I. INTRODUCTION

A. Generally

1. This written decision relates to three Notices of Hearing in relation to alleged unprofessional conduct by Dr. Jeff Serfas, a regulated member of the Alberta Veterinary Association (the “ABVMA”) at all relevant times.

2. The events relate to Forestburg Veterinary Clinic 1989 Ltd. operating as Forestburg

Veterinary Clinic (collectively the “FVC”) owned by Dr. Serfas and which is located in Forestburg, Alberta. The proceedings involving Dr. Serfas are governed by the discipline provisions of the Veterinary Profession Act, R.S.A. 2000, c. V-2, as amended (the “VPA”).

3. The three hearings can generally be described as follows:

(a) Re: ABVMA file number 17-22 – a complaint made by VP and DP with respect to Dr.

Serfas’ treatment of their dog “Peanut” (the “Peanut Matter”);

(b) Re: ABVMA file number 17-31 – a complaint made by TT with respect to Dr. Serfas’ treatment of her dog “Angel” (the “Angel Matter”);

(c) Re: ABVMA file number 18-04 – a referral by the ABVMA Complaints Director

pursuant to section 27.1 of the VPA to treat information arising from an August 2, 2017 discipline hearing involving Dr. Serfas as a complaint (the “Section 27.1 Matter”).

4. At the request of Dr. Serfas and with the consent of the ABVMA, all three of the above

matters proceeded together and were heard by this Hearing Tribunal (the “Hearing Tribunal”).

B. The Allegations

5. The Notice of Hearing for the Peanut Matter involved the following allegations:

1. Allegation #1: That you failed to obtain appropriate and/or complete informed

consent regarding the surgical procedure that was to be performed on Peanut on April 24, 2017 from the owners.

2. Allegation #2: That you failed to obtain informed consent acknowledging the

absence of a dedicated anesthetist who is a registered veterinarian or registered veterinary technologist from the owners.

3. Allegation #3: That you proceeded with the removal of all Peanut’s teeth but two

exceeding the client’s authority to undertake a dental surgery on April 24, 2017.

4. Allegation #4: That you failed to obtain informed consent from the clients with respect to the fact that you were performing the dental surgery as well as undertaking all responsibilities regarding anesthesia of Peanut as there was no other registered veterinarian technologist available to undertake this task.

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5. Allegation #5: That you failed to undertake pre-operative blood work to determine the appropriate medical condition of Peanut prior to undertaking the dental surgery on April 24, 2017.

6. Allegation #6: That you failed to offer to the clients pre-operative blood work on

Peanut prior to undertaking the dental surgery on April 24, 2017.

7. Allegation #7: That you failed to place an intravenous catheter and provide IV fluids to Peanut prior to undertaking the dental surgery.

8. Allegation #8: In determining that you were unable to proceed with an intravenous

catheter and provide IV fluids, you continued with the dental procedure without determining whether it was appropriate to do so.

9. Allegation #9: That you undertook the dental surgery without the appropriate use

of dental blocks.

10. Allegation #10: That you undertook the dental surgery and failed to suture gingiva and/or make gingival flaps.

11. Allegation #11: That you failed to recognize and/or take action regarding Peanut’s

post-operative bleeding, including failure to place and intravenous catheter and administer IV fluids.

12. Allegation #12: Upon being advised of the death of Peanut and having two

communications with the clients, you failed to offer an autopsy on Peanut for the purposes of determining the cause of death.

13. Allegation #13: That you failed to proceed with appropriate anesthetic protocol,

including the anesthetic induction of Peanut and the monitoring thereof.

14. Allegation #14: You failed to have a designated anesthetist to monitor the anesthesia performed by you on April 24, 2017.

15. Allegation #15: That you failed to obtain appropriate radiographs prior to dental

surgery or alternatively refer Peanut to an alternate veterinary practice for radiographs.

16. Allegation #16: That you inappropriately discharged Peanut while she was still at

considerable medical risk.

17. Allegation #17: That you failed to provide the clients with proper discharge instructions.

18. Allegation #18: That you failed to provide appropriate direction to the clients,

specifically with respect to the risks to Peanut from the abnormal bleeding occurring both surgically and post-operatively.

19. Allegation #19: That you failed to create or maintain appropriate medical records

with respect to Peanut, including failure to document informed consent and the dental surgery including a dental chart.

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20. Allegation #20: That you failed to maintain an appropriate anesthetic and surgical log with respect to Peanut’s surgery on April 24, 2017.

6. The Notice of Hearing for the Angel Matter involved the following allegations:

1. Allegation #1: That you failed to utilize an appropriate anesthetic protocol on Angel

on August 10, 2017.

2. Allegation #2: That you administered a corticosteroid to Angel as treatment for a suspected foreign body ingestion when it was not appropriate to do so.

3. Allegation #3: That within 24 hours you administered both a corticosteroid and

Metacam to Angel.

4. Allegation #4: That you failed to ensure an intravenous (IV) line was in place: (a) during the monitoring of Angel on August 9/10, 2017 and (b) during the exploratory abdominal surgery on August 10, 2017.

5. Allegation #5: That you failed to monitor blood pressure during the exploratory

abdominal surgery.

6. Allegation #6: That you inappropriately discharged Angel to the owner when she was in an unstable condition.

7. Allegation #7: That you failed to properly and/or in a timely manner refer the client,

TT, for a specialist or 24-hour emergency care.

8. Allegation #8: Upon being advised of the death of Angel, you failed to properly offer an autopsy to Angel’s owner, to ascertain the cause of death.

9. Allegation #9: That you failed to create or maintain appropriate medical records

with respect to Angel. 7. The Notice of Hearing for the Section 27.1 Matter involved the following allegations:

1. Allegation #1: That you intentionally disclosed confidential discussions which

occurred on July 18, 2017 (you misrepresented the discussions which occurred with CRC in a confidential context on July 18, 2017).

2. Allegation #2: That in issuing the letter, you intentionally undermined the consent

negotiation and joint submissions made to the Hearing Tribunal on August 2, 2017.

3. Allegation #3: That in including the following paragraph in your letter (paragraph in question omitted for this summary of findings), you undermined the integrity of the profession and your responsibilities as a registered member.

4. Allegation #4: That in issuing the letter to your clients, friends and community

members, you failed to properly accept your responsibilities as a registered veterinarian, particularly as they relates to (i) serve the profession with integrity, (ii) practice veterinary medicine in a competent manner, (iii) provide appropriate quality of service to your clients and friends, (iv) be candid and honest in all your

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interactions with clients and colleagues and (v) conduct yourself in a manner characterized by courtesy and good faith.

8. Importantly, pursuant to section 35.1 of the VPA and as reflected in Exhibit 17, Dr. Serfas

made an admiss ion of unpro fess iona l conduct concern ing the Sect ion 27.1 Matter (the “Admission”). As detailed later in this Decision, pursuant to section 35.1(3) of the VPA the Hearing Tribunal accepted the Admission and determined the admitted conduct constituted unprofessional conduct and made appropriate penalty orders.

9. The Peanut Matter and the Angel Matter proceeded as contested hearings.

C. The Hearings

10. The hearings occurred at the Edmonton offices of ABVMA on the following dates:

(a) December 13 and 14, 2018 (the “December Hearings”).

(b) January 17, 2019;

(c) January 22, 2019.

11. There were no objections to the composition of the Hearing Tribunal including Ms. Rothery’s participation despite the fact that she is the public member assigned to the ABVMA’s Practice Review Board and typically does not sit on hearing tribunals. As well, there were no objections to the Hearing Tribunal’s jurisdiction to proceed. The hearing was held in public as there were no applications to close the hearing.

12. The following persons were present at the hearings:

Dr. Calvin Booker Chair, Hearing Tribunal Dr. Greg Evans Hearing Tribunal Member Dr. Navjot Gosal Hearing Tribunal Member Ms. Anne Rothery Public Member

Ms. K. Smith Counsel for the ABVMA Ms. H. Frydenlund Counsel for the ABVMA

Dr. Jeff Serfas R. Rand, Q.C. Counsel for Dr. Jeff Serfas Jamie Fitzel Counsel for Dr. Jeff Serfas

Blair E. Maxston Independent Legal Counsel for the Hearing Tribunal

Dr. Phil Buote ABVMA Deputy Registrar/Complaints Director

Dr. Darrell Dalton ABVMA Registrar

13. The following documents were accepted as Exhibits at the hearings:

(a) December 13 and 14, 2018 hearing:

1. Notice of Hearing – Angel

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2. Notice to Attend – Angel

3. Investigation Report – Angel

4. Affidavit of Service – Angel

5. Notice of Hearing – Peanut

6. Notice to Attend – Peanut

7. Investigation Report – Peanut

8. Affidavit of Service – Peanut

9. Notice of Hearing – 27.1 Complaint

10. Notice to Attend – 27.1 Complaint

11. Investigation Report – 27.1 Complaint

12. Affidavit of Service – 27.1 Complaint

13. Admission of Unprofessional Conduct 27.1 Complaint

14. Telephone Records

15. Phone Call Records

(b) January 17, 2019 hearing:

16. Letter of MS

(c) January 22, 2019 hearing:

17. Findings of Hearing Tribunal (January 21, 2019 e-mail)

18. PIPS Inspection Documents

19. Letters of Reference

20. Dr. Serfas history Documents 14. The Hearing Tribunal also received case law and memorandums summarizing evidence

from both parties.

15. The following witnesses provided testimony at the hearings:

(a) December 13 and 14, 2018 hearing:

Peanut Matter

• VP – complainant;

• DP – husband of complainant;

• KR – former RVT at FVC;

• WN - employee at FVC;

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Angel Matter

• TT – complainant;

• KW – friend of complainant;

• RS – son of complainant.

(b) January 17, 2019 hearing:

• MS – wife of Dr. Serfas;

• DB – employee at FVC;

(c) As well, Dr. Serfas testified on his own behalf.

16. In an e-mail dated January 21, 2019 from the Hearing Tribunal’s independent legal counsel and as per both party’s request, the Hearing Tribunal advised the parties of its findings (without reasons) concerning all of the allegations in the Peanut Matter, the Angel Matter and the Section 27.1 Matter. The hearing convened on January 22, 2019 to receive penalty submissions from the parties.

II. FINDINGS OF THE HEARING TRIBUNAL CONCERNING THE PEANUT MATTER,

ANGEL MATTER AND THE SECTION 27.1 MATTER

17. As described in the January 21, 2019 e-mail from the Hearing Tribunal’s independent legal counsel, the Hearing Tribunal made the following findings concerning the allegations:

(A) File 17-22 – The Peanut Matter

(a) Informed Consent:

1. Unprofessional conduct;



4. Unprofessional conduct.

(b) Diagnosis and Treatment:

5. No unprofessional conduct;








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(c) Inappropriate Anesthetic Protocol:


14. No unprofessional conduct.

(d) Radiology:


(e) Discharge:




(f) Medical Records:



(B) File 17-31 – The Angel Matter

(a) Medical and Surgical Management:




4. (a) No unprofessional conduct; (b) No unprofessional conduct;



(b) Failure to Refer:


(c) Failure to Offer Post-Mortem:


(d) Medical Records:


(C) Fil e 18-04 – The Section 27.1 Matter

1.

Unprofessional conduct;




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III. REASONS OF THE HEARING TRIBUNAL: THE PEANUT MATTER 18. After carefully reviewing the exhibits, witness testimony, Dr. Serfas testimony and the

written material and verbal submissions from legal counsel, the Hearing Tribunal made its findings of guilt and innocence in the Peanut Matter for the following reasons.

A. Allegation #1: That you failed to obtain appropriate and/or complete informed consent regarding the surgical procedure that was to be performed on Peanut on April 24, 2017 from the owners.

19. As a preliminary comment, the Hearing Tribunal concluded that allegation #1 was not a repetition of allegations #2 and #3. Allegation #1 was a separate allegation concerning distinct actions of Dr. Serfas.

20. The Hearing Tribunal heard contradictory evidence from witnesses regarding the nature

and extent of consent that was or was not provided. The Hearing Tribunal found the evidence of VP and DP to be clear and consistent on this issue and generally preferred their evidence to that of Dr. Serfas. These events were significant for VP & DP and their recollections were detailed in terms of the consent process.

21. The Hearing Tribunal accepted VP’s evidence that Dr. Serfas did not discuss the risks of

Peanut’s surgery or the potential complications arising from surgery with her prior to the surgery. The evidence suggests that WN had a discussion with MS on the day of the procedure but WN stated that her discussion did not relate to the surgical procedures themselves or associated risks (December Hearings, page 226, lines 13 to 18).

22. This supports VP’s recollection and is consistent with DP’s evidence that he overheard the

discussion between his wife and WN and that the risks of the surgery and potential complications were not discussed.

23. In addition to the evidence mentioned above, the Hearing Tribunal noted that in her

investigation interview VP consented to the withdrawal of some of Peanut’s teeth but she did not provide “blanket” consent to Dr. Serfas to remove all or most of Peanut’s teeth.

24. Although VP signed a consent form, that form is only one element of obtaining informed

consent. It was incumbent on Dr. Serfas, as the primary care provider, to take steps to ensure that he had appropriate informed consent.

25. As well, Dr. Serfas’ “Informed Consent” form does not meet the proper requirements of

informed consent in terms explaining possible anesthetic complications, surgical complications, or dental complications (such as bleeding, fractured jaw, dry socket). Also, the “Informed Consent” form lacked the signature/documentation of who reviewed the informed consent discussion with VP & DP. The informed consent discussion must occur with a registered ABVMA veterinarian or RVT.

26. Any familiarity that VP & DP may have had with other FVC consent forms that they

signed relating to prior treatment of Peanut does not relieve Dr. Serfas of his responsibility to ensure that VP was aware of the contents of the consent form she signed on April 24, 2017.

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27. The absence in the consent form of the number of teeth to be extracted, a range of teeth to be extracted or the possibility of having to remove all of Peanut’s teeth due to her pre-existing dental disease supports the finding that appropriate informed consent was not obtained.

28. The alternative remedies for Peanut’s teeth that VP previously tried do not affect Dr.

Serfas’ obligation to obtain appropriate consent for the procedures he performed on April 24, 2017.

29. Finally, there is no documentation in medical record to indicate that informed consent was

given in this case. Such actions show a lack of skill and judgement in the practice of veterinary medicine and harms the public while carrying on the practice of veterinary medicine, both all which are Unprofessional Conduct as described in Section 1(n. 1) of the VPA.

B. Allegation #2: That you failed to obtain informed consent acknowledging the

absence of a dedicated anesthetist who is a registered veterinarian or registered veterinary technologist from the owners.

30. The Hearing Tribunal’s analysis and reasons concerning allegation #1 generally apply to

allegation #2. 31. VP’s evidence was clear and convincing that she believed only Dr. Serfas would be

performing the surgical procedure and that she had no discussions with him about any other persons being present during the surgery.

32. VP was also clear in her testimony that Dr. Serfas did not inform her that he would be performing the surgery and monitoring anesthesia.

33. The Hearing Tribunal accepts DP’s evidence, which supports VP’s recollection. 34. WN’s evidence was also consistent with this when she testified that she did not discuss

who would or would not be present at the surgery with VP or DP. As a result, the Hearing Tribunal accepted WN’s evidence that Dr. Serfas’ standard practice was to perform surgery and monitor anesthetic by himself.

35. Importantly, in his testimony Dr. Serfas stated that there was no anesthetist involved

because he did not have one on staff at FVC. As well, Dr. Serfas admitted that he did not advise VP and DP that he would be performing the surgery alone and without an anesthetist (December Hearing, page 366, lines 16 to 21).

36. In summary, Dr. Serfas failed to obtain informed consent from the owner acknowledging

the absence of a dedicated anesthetist. There is no record that this was done in the medical record. The presence of dedicated anesthetist, who is a registered veterinary member, allows for proper monitoring of the patient during all aspects of surgery to detect and respond appropriately to physiological changes, which improves the probability of a favorable outcome.

37. Dr. Serfas failed to explain to Peanut’s owners the possible risks of not having a dedicated

anesthetist.

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38. Such actions show a lack of skill and judgement in the practice of veterinary medicine and harms the public while carrying on the practice of veterinary medicine, both of which are Unprofessional Conduct as described in Section 1(n. 1) of the VPA.

C. Allegation #3: That you proceeded with the removal of all Peanut’s teeth but two

exceeding the client’s authority to undertake a dental surgery on April 24, 2017.

39. The Hearing Tribunal’s analysis and reasons concerning allegations #1 and #2 generally apply to allegation #3.

40. The Hearing Tribunal accepted VP’s testimony that she provided consent to remove some

of Peanut’s teeth but not all but two of his teeth. As reflected in the incomplete consent form, the Hearing Tribunal concluded that VP was not advised about how many teeth were going to be removed or could possibly be removed.

41. This is corroborated by DP’s evidence about the number of teeth to be removed and, in

particular, the large number of teeth that were ultimately extracted. 42. Dr. Serfas’ own testimony (December Hearings, pages 366 and 367) confirms that he

never advised VP & DP that he would be removing all but two of Peanut’s teeth. It was not appropriate for Dr. Serfas to simply leave blanks on the consent form in relation to the number of teeth to be extracted simply because he was unable to determine in advance specifically how many teeth would be removed because of Peanut’s dental health. That should have formed part of the consent process.

43. In summary, Dr. Serfas did not obtain appropriate written consent from Peanut’s owners

about the extent of possible dental extractions. On the Surgical Consent Dentistry form that was offered to Peanut’s owners, the section authorizing the number of extractions that were approved by Peanut’s owners was left blank. Therefore, this implies that Peanut’s owners did not approve “any” extractions. According to that form, once Dr. Serfas began chipping away tartar and he realized the severity of Peanut’s condition, Dr. Serfas should have attempted to contact Peanut’s owners and get approval for performing an extensive number of extractions before removing all the teeth from Peanut’s mouth except two. These actions show a lack of judgement in the practice of veterinary medicine and harms the public while carrying on the practice of veterinary medicine, all of which are Unprofessional Conduct as described in Section 1(n. 1) of the VPA.

D. Allegation #4: That you failed to obtain informed consent from the clients with

respect to the fact that you were performing the dental surgery as well as undertaking all responsibilities regarding anesthesia of Peanut as there was no other registered veterinarian technologist available to undertake this task.

44. The Hearing Tribunal’s analysis and reasons concerning allegations #1, #2 and #3 generally apply to allegation #4.

45. As a result, no further analysis or reasons are necessary concerning allegation #4 except

for the Hearing Tribunal to state that, in its opinion, allegation #4 was properly advanced as a separate allegation on its own and was not a mere repetition of allegation #2.

46. Dr. Serfas’ actions represent Unprofessional Conduct as described in Section 1(n.1) of

the VPA.

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E. Allegation #5: That you failed to undertake pre-operative blood work to determine the appropriate medical condition of Peanut prior to undertaking the dental surgery on April 24, 2017.

47. This allegation relates specifically to Dr. Serfas’ failure to actually carry out pre-operative

bloodwork. 48. The Hearing Tribunal finds No Unprofessional Conduct regarding this charge.

49. Based on the patient history and physical examination (including a heart check),

Dr. Serfas determined that Peanut was in good general health and that pre-operative blood work was not necessarily indicated. As such, his professional decision not to undertake pre-operative blood work to determine the appropriate medical condition of Peanut prior to undertaking the dental surgery on April 24, 2017 was not in and of itself unprofessional conduct. However, as described in allegation 6 below, Dr. Serfas should have discussed the pros and cons of pre-operative blood work with Peanut’s owners and documented that decision in the medical record.

50. Although it may have been preferable for Dr. Serfas to take Peanut’s vitals and examine

Peanut’s mouth (even if Peanut was aggressive) his failure to do so does not rise to the level of unprofessional conduct.

F. Allegation #6: That you failed to offer to the clients pre-operative blood work on Peanut prior to undertaking the dental surgery on April 24, 2017.

51. The H e a r i ng T r i b una l r e j ec t ed D r . Serfas’ ev id enc e t h a t h e o f f e r e d p re -

operative bloodwork but that VP & DP refused it. There is no clear evidence to support his position and, as mentioned above, the medical record contains no reference to this.

52. Given Peanut’s age, size and apparent severity of dental disease, preoperative blood work

should have been offered as a minimum veterinary medical standard. There is no evidence that such preoperative blood work was offered on the informed consent form or in the medical records.

53. Failure to discuss the pros and cons of pre-operative blood work with Peanut’s owners

and to document their decision in the medical record shows a lack of skill and judgement in the practice of veterinary medicine and harms the public while carrying on the practice of veterinary medicine, all of which is Unprofessional Conduct as described in Section 1 (n.1) of the VPA.

G. Allegation #7: That you failed to place an intravenous catheter and provide IV fluids to Peanut prior to undertaking the dental surgery.

54. The Hearing Tribunal accepts Dr. Serfas’ evidence that in some manner he attempted to

place an IV catheter but could not successfully complete that process due to Peanut’s size and Dr. Serfas’ inability to locate an appropriate vein. It would not have been necessary for Dr. Serfas to shave Peanut’s leg in order to assess whether an acceptable vein could be located and to fully attempt to place an IV catheter.

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55. While an IV catheter is the medical preference, the volume of pre-op and post-op subcutaneous fluids administered when an IV catheter could not be placed demonstrates that an appropriate attempt to maintain Peanut’s hydration occurred.

56. Given that Dr. Serfas was unable to successfully place an IV catheter, it was appropriate

to not have a charge in that regard on Peanut’s bill. 57. Dr. Serfas’ actions do not constitute unprofessional conduct.

H. Allegation #8: In determining that you were unable to proceed with an intravenous

catheter and provide IV fluids, you continued with the dental procedure without determining whether it was appropriate to do so.

58. The Hearing Tribunal’s comments regarding allegation #7 apply to allegation #8 as well.

59. Also, allegation #8 is properly framed as a separate allegation compared to allegation #7 since it relates to continuing with the dental procedure after failing to administer an IV catheter and provide IV fluids.

60. As described in allegation #7 above, the volume of pre-op and post-op subcutaneous

fluids administered when an IV catheter could not be placed demonstrates that an appropriate attempt to maintain hydration occurred. Based on Dr. Serfas’ assessment, the Hearing Tribunal finds that he properly determined that subcutaneous fluids would be adequate to maintain a hydrated state because Peanut was not presented in a dehydrated state.

61. Dr. Serfas’ actions do not constitute unprofessional conduct.

I. Allegation #9: That you undertook the dental surgery without the appropriate use

of dental blocks.

62. In his own testimony, Dr. Serfas stated that using dental nerve blocks was “something as well that I would have performed if able to do it over again” (December Hearings, page 277, lines 22 to 25) and acknowledged that dental blocks may have been helpful to Peanut post-operatively (December Hearings, pages 279 to 280).

63. The Hearing Tribunal agrees with the ABVMA that Dr. Serfas should have used dental

blocks and that he essentially has no response to this allegation. 64. In summary, Dr. Serfas failed to use dental blocks on Peanut before extensive dental

extractions. The use of dental blocks in such cases facilitates a lighter plane of anesthesia, which lowers the risk of anesthetic complications. In addition, the use of dental blocks helps with post-extraction pain management, which reduces the likelihood of pawing at face during and after recovery.

65. Failure to use dental blocks in Peanut’s case reflects a lack of skill and judgement in the

practice of veterinary medicine, conduct that harms the public while carrying on the practice of veterinary medicine, and conduct that harms the integrity of veterinary profession, all of which is Unprofessional Conduct as described in Section 1 (n. 1) of the VPA.

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J. Allegation #10: That you undertook the dental surgery and failed to suture gingiva and/or make gingival flaps.

66. Dr. Serfas stated that he chose to not suture Peanut’s gums because of the amount of infection and receding gums and that he did not want to “trap” infection in the wounds. That is not a tenable clinical position.

67. Specifically, the biggest post-surgical complication that occurred in this case was

hemorrhage and severe blood loss. Dr. Serfas acknowledged this (December Hearings, page 383, line 22 and line 24). Given the extensive number of dental extractions, suturing the gingiva and/or making gingival flaps should have been strategically used in a few spots to prevent post-operative bleeding.

68. Failure to assess the need for suturing the gums, which likely led to extensive bleeding

and the death of Peanut, showed a lack of skill and judgement in the practice of veterinary medicine and harms the public while carrying on the practice of veterinary medicine, all of which is Unprofessional Conduct as described in Section 1 (n.1) of the VPA.

K. Allegation #11: That you failed to recognize and/or take action regarding Peanut’s

post-operative bleeding, including failure to place and intravenous catheter and administer IV fluids.

69. The evidence establishes that increased blood loss became apparent when Peanut was

recovering and had returned to “aggressive” behavior and that Dr. Serfas tried to stabilize the bleeding by wrapping Peanut in a blanket and applying gauze.

70. Dr. Serfas observed a slowing of the bleeding and carried out a measure of monitoring

over the next couple of hours. Significantly, Dr. Serfas stated in his testimony that Peanut had a more bleeding after dental extraction than he would normally expect (December Hearings, page 286, lines 11-13). Given Peanut’s size and age, the extensive number of extractions done, the lack of using dental blocks, non-suturing of the gingiva and/or non-use of gingival flaps, excessive post-operative bleeding from the mouth, the lack of an intravenous line with fluids, and Dr. Serfas recognition that the external bleeding was more than he expected, Dr. Serfas should have sedated the patient to adequately re- assess and intervene as appropriate rather than simply monitoring the situation. Failure to do so shows a lack of skill and judgement in the practice of veterinary medicine and harms the public while carrying on the practice of veterinary medicine, all of which is Unprofessional Conduct as described in Section 1 (n.1) of the VPA.

L. Allegation #12: Upon being advised of the death of Peanut and having two communications with the clients, you failed to offer an autopsy on Peanut for the purposes of determining the cause of death.

71. The Hearing Tribunal heard decidedly contradictory evidence concerning this allegation. 72. VP testified that a necropsy was never mentioned or offered. DP’s evidence was the same.

VP also stated that if a necropsy had been offered she would have had it performed to determine why Peanut had died.

73. Having said that, the testimony given by VP & DP reflected that t hese were traumatic

events for them and the Hearing Tribunal was concerned that the accuracy of their

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recollections of the precise issue of whether a necropsy was offered was adversely affected by the emotional stress they were under.

74. Dr. Serfas’ position was that his normal protocol would be offer a necropsy. He recalled

his April 25, 2017 early-morning and subsequent discussions with VP and stated that he offered a necropsy but VP declined.

75. Significantly, Dr. Serfas made no notes of those discussions and the patient record has

no references to a necropsy being offered and declined. 76. Ultimately, and given that there was highly contradictory evidence concerning this

allegation #12, the Hearing Tribunal determined that there was no clear or compelling evidence to establish on a balance of probabilities that Dr. Serfas failed to offer a necropsy. Accordingly, the Hearing Tribunal found no unprofessional conduct concerning allegation #12.

M. Allegation #13: That you failed to proceed with appropriate anesthetic protocol,

including the anesthetic induction of Peanut and the monitoring thereof.

77. As reflected in the Hearing Tribunal’s findings concerning allegation #2, there was no dedicated anesthetist involved in Peanut’s treatment, as there was not one on staff at FVC.

78. As well, since Dr. Serfas was monitoring the anesthesia while also doing the dental

procedure, the Hearing Tribunal found that h i s anesthetic protocol was inadequate in many aspects, including but not limited to, lack of blood pressure, oxygen saturation (SpO2), body temperature, and CO2 monitoring, as well as post-operative vital signs.

79. Failure to undertake these monitoring activities is inconsistent with an appropriate

anesthetic protocol and shows a lack of skill and judgement in the practice of veterinary medicine, which is Unprofessional Conduct as described in Section 1 (n.1) of the VPA.

N. Allegation #14: You failed to have a designated anesthetist to monitor the

anesthesia performed by you on April 24, 2017.

80. The Hearing Tribunal finds No Unprofessional Conduct regarding this allegation #14. In and of itself, this is not unprofessional conduct. As per page 47, item (e) of the PIPS bylaws, there will be situations where a registered member is both the designated anesthetist for monitoring anesthesia, as well as the veterinarian performing the surgery/procedure.

81. While legal counsel for the ABVMA argued that this provision only applies in emergency

situations, the limitation for this to occur only in emergency situations is not clearly stated in the PIPS Bylaws. In this case, the Hearing Tribunal concluded that Dr. Serfas made a reasonable assessment that Peanut’s dental disease was so severe that it was an emergency.

82. Dr. Serfas’ conduct does not constitute unprofessional conduct.

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O. Allegation #15: That you failed to obtain appropriate radiographs prior to dental surgery or alternatively refer Peanut to an alternate veterinary practice for radiographs.

83. Regardless of whether VP & DP had numerous concerns about the cost of x-rays, the

Hearing Tribunal agreed with Dr. Serfas’ testimony that taking dental x-rays in these types of circumstances was not mandatory.

84. In and of itself, failure to obtain appropriate radiographs prior to dental surgery does not

rise to the serious level of unprofessional conduct, even though it is recommended to support an accurate diagnosis and treatment plan.

85. The Hearing Tribunal found no unprofessional conduct concerning this allegation #15.

P. Allegation #16: That you inappropriately discharged Peanut while she was still at considerable medical risk.

86. The evidence of Dr. Serfas and VP & DP establishes that Dr. Serfas did not have any direct

communications with DP or VP about Peanut’s discharge and that the VP & DP left FVC before Dr. Serfas could speak with them.

87. The Hearing Tribunal finds that Dr. Serfas instructed FVC staff to provide Peanut to the

VP & DP for discharge but to also offer to have Peanut stay overnight at FVC. 88. Having said that, there was contradictory evidence about the nature and extent that

Dr. Serfas’ offer was communicated by FVC staff to VP & DP and whether Dr. Serfas actually “offered” or “recommended” that Peanut stay overnight. However, allegation #16 is focused on the question of whether Peanut was at “considerable medical risk” at the time she was discharged.

89. As a result, the Hearing Tribunal concluded that the focus of this allegation #16 was not

how VP and DP were or were not advised of Dr. Serfas’ recommendation or offer concerning Peanut staying at FVC.

90. Instead, this allegation #16 only involved an examination of Dr. Serfas’ assessment of

Peanut’s condition and whether Peanut was still at considerable medical risk at the time of the discharge.

91. The Hearing Tribunal finds no unprofessional conduct regarding this allegation. The

assessment of medical risk is a clinical judgement. Dr. Serfas was in the best position to make this clinical judgement. Based on the medical records and much of the testimony given, Peanut had sufficiently recovered from anesthesia (Peanut was alert, upright and standing in the kennel) and could be discharged. As well, there was no external evidence of ongoing hemorrhage from the mouth or other clinical signs to indicate that Peanut was at considerable medical risk.

92. The Hearing Tribunal found Dr. Serfas’ conclusion that Peanut was not at considerable

medical risk at the time of discharge to be reasonable based on Dr. Serfas’ observation and analysis of Peanut’s condition.

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Q. Allegation #17: That you failed to provide the clients with proper discharge instructions.

93. The Hearing Tribunal determined that allegation #17 was separate and distinct from allegation #18. Allegation #17 related to the general failure to provide proper discharge instructions whereas allegation #18 addresses the failure to provide direction concerning the specific risk of abnormal bleeding.

94. The Hearing Tribunal accepted the evidence of VP and WN that although Dr. Serfas

was at FVC he had no involvement with VP and DP about discharge instructions. 95. Dr. Serfas also testified that he should have contacted the VP & DP later in the afternoon

on the day of the surgery but that he did not take that step. This is highly concerning to the Hearing Tribunal.

96. Dr. Serfas also acknowledged that the discharge instructions given to the VP & DP did not

refer to concerns for them to watch out for (December Hearings, page 370, lines 22 to 26). Again, this is very concerning to the Hearing Tribunal.

97. The discharge instructions provided for this case were not adequate because there is no

reference to general follow up preventative dental care and its importance, or, specifically, complications related to the excessive post-operative blood loss that ultimately occurred.

98. In addition, the discharge instructions were not provided by a registered ABVMA member

as required. 99. Dr. Serfas’ actions reflect a lack of skill and judgement in the practice of veterinary

medicine, conduct that harms the public while carrying on the practice of veterinary medicine, and conduct that harms the integrity of veterinary profession, all of which are Unprofessional Conduct as described in Section 1 (n. 1) of the VPA.

R. Allegation #18: That you failed to provide appropriate direction to the clients,

specifically with respect to the risks to Peanut from the abnormal bleeding occurring both surgically and post-operatively.

100. Consistent with allegation #17, the evidence established that Dr. Serfas had no direct

contact with the VP &DP at time of discharge concerning the risks to Peanut, including abnormal bleeding.

101. Dr. Serfas had a clear obligation to engage in communications with the VP & DP about these

matters and he failed to do so. 102. The Hearing Tribunal found the VP’s and DP’s evidence regarding allegation #18 to be

consistent and credible and accepted it. Specifically, the Hearing Tribunal found that no discussion took place regarding any complications that occurred during surgery or recovery and that the VP & DP were only provided with written discharge instructions.

103. Similarly, the VP & DP were advised that the bleeding would stop after approximately

four hours but were not advised about excess bleeding or what to do if that occurred.

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104. In summary, the discharge instructions were not administered by a registered ABVMA member and the instructions provided failed to specifically address complications related to the excessive post-operative blood loss that occurred and what Peanut’s owners should watch for. Failure to provide adequate discharge instructions in this regard from a registered ABVMA member reflects a lack of skill and judgement in the practice of veterinary medicine, conduct that harms the public while carrying on the practice of veterinary medicine, and conduct that harms the integrity of veterinary profession, all of which are Unprofessional Conduct as described in Section 1 (n. 1) of the VPA.

S. Allegation #19: That you failed to create or maintain appropriate medical records with

respect to Peanut, including failure to document informed consent and the dental surgery including a dental chart.

105. In his testimony, Dr. Serfas described numerous deficiencies in terms of his recordkeeping

as follows:

• Dr. Serfas was recording the anesthetic log while he was also performing the dental surgery.

• There are no notes in the medical record of pre-surgical discussions or discussions

about extractions.

• There is nothing in the patient record indicating that this was a severe dental case.

• There is no comment regarding an offer of bloodwork and the VP & DP declining

that offer.

• There is no mention in the medical records of Peanut’s difficulty in eating.

• Despite this being his personal responsibility, there were no notes in the medical records throughout the course of anesthesia about Peanut’s blood pressure, temperature or profusion.

• There is no record of offering a necropsy or of trying to put an IV in Peanut.

• There is no dental charting documented.

106. Medical records are an essential component of safe and effective veterinary care and,

more specifically, are essential to ensure the continuity of care for each patient. The medical records that Dr Serfas provided in this case for several items, including but not limited to, informed consent, patient examination, dental charting, anesthesia, surgery, discharge instructions, follow up plan, or after care plan, fall far below the standard that is expected by ABVMA PIPS.

107. Also, there is no documentation of verbal discussions that may have occurred with the

client, including offering an autopsy. 108. Failure to maintain adequate medical records reflects a lack of skill and judgement in the

practice of veterinary medicine, conduct that harms the public while carrying on the practice of veterinary medicine, and conduct that harms the integrity of veterinary

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profession, all of which are Unprofessional Conduct as described in Section 1 (n. 1) of the VPA.

T. Allegation #20: That you failed to maintain an appropriate anesthetic and surgical

log with respect to Peanut’s surgery on April 24, 2017.

109. The Hearing Tribunal finds no unprofessional conduct regarding this charge. There was no information provided in the materials to assess the anesthetic and surgical logs for FVC.

IV. REASONS OF THE HEARING TRIBUNAL: THE ANGEL MATTER

110. After carefully reviewing the exhibits, witness testimony, Dr. Serfas testimony and the

written material and verbal submissions from legal counsel, the Hearing Tribunal made its findings of guilt and innocence in the Angel Matter for the following reasons.

A. Allegation #1: That you failed to utilize an appropriate anesthetic protocol on Angel on August 10, 2017.

111. Dexodom and Torbugesic were used to anesthetize Angel and she was induced with

Alfaxan. After the surgery, KR administered Antisedan to Angel to reverse the Dexodom and she also administered antibiotics.

112. As well, KR noted no complications while she maintained the anesthetic and the Hearing

Tribunal accepted her evidence. 113. The same pre-anesthetic protocol was used the previous day on Angel to do radiographs

and was well-tolerated. This protocol is acceptable based on current small animal anesthesia and surgery standards. Furthermore, the procedure was undertaken with an RVT monitoring the anesthetic.

114. The Hearing Tribunal finds no unprofessional conduct concerning this allegation #1.

B. Allegation #2: That you administered a corticosteroid to Angel as treatment for a suspected foreign body ingestion when it was not appropriate to do so.

115. There was no evidence that the corticosteroid was administered by Dr. Serfas to treat a

suspected foreign body. The differential diagnosis of Addison’s disease was made based on Dr. Serfas’ clinical judgement, and the corticosteroid was administered as a rule-out for this disease. This differential diagnosis and treatment was appropriate based on the circumstances.

116. Hearing Tribunal finds no unprofessional conduct concerning this allegation #2.

C. Allegation #3: That within 24 hours you administered both a corticosteroid and Metacam to Angel.

117. While the wording of this allegation is true, the Hearing Tribunal finds that no

unprofessional conduct is present in regard to this allegation.

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118. As previously mentioned, the corticosteroid was administered by Dr. Serfas to rule out Addison’s disease prior to establishing the need for exploratory abdominal surgery. Post- surgical pain management is certainly indicated following abdominal surgery, which was a proper rationale for the administration of Metacam post-operatively and within 24 hours of the corticosteroid.

119. Furthermore, the dose of steroids was low, and the interval between medications was

approximately 24 hours. The risk was deemed by Dr. Serfas to be low and this assessment was found to be reasonable by the Hearing Tribunal.

D. Allegation #4: That you failed to ensure an intravenous (IV) line was in place:

(a) during the monitoring of Angel on August 9/10, 2017 and (b) during the exploratory abdominal surgery on August 10, 2017.

120. The Hearing Tribunal believed that the evidence of TT, KW and RS was sincere but

placed little value on their testimony as they are not clinicians and were not (with the exception of TT being at FVC while the IV was initially placed on August 9, 2017) present during the monitoring and exploratory surgery.

121. The Hearing Tribunal accepted the evidence of Dr. Serfas (supported by KR) that on the

evening of August 9, 2017 Angel dislodged her IV, that it was replaced by Dr. Serfas and that it was still functioning at the time of the surgery when Dr. Serfas administered Alfaxan through the IV.

122. The evidence establishes that Dr. Serfas was unaware that the IV was not working until

the first incision was made. 123. KR also testified that she could not get an IV line in Angel during the surgery but that it

was more important to continue the surgery in order to remove the foreign object (December Hearings, pages 194 to 195). The Hearing Tribunal agreed with that assessment and noted that Angel had been receiving fluids for the 24-hour period prior to the surgery.

124. In summary, an intravenous catheter was in place during the hospitalization of Angel on

the evening of August 9, 2017. It had stopped working overnight, but was re-established and used for the induction on August 10, 2017. Intravenous catheters are not foolproof and the periodic loss of an intravenous line overnight can occur and is not unprofessional conduct. Once Angel was anesthetized and placed in dorsal recumbency and surgically draped, the catheter failed again. At this point, the RVT could not successfully replace the catheter. While not ideal, it would have been inappropriate to stop the potentially life- saving surgery on a critical patient to attempt to place another catheter with the dog in dorsal recumbency with an open abdomen.

125. The Hearing Tribunal finds no unprofessional conduct concerning this allegation.

E. Allegation #5: That you failed to monitor blood pressure during the exploratory abdominal surgery.

126. The evidence was definitive that FVC did not have a blood pressure monitor.

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127. The Hearing Tribunal agreed with Dr. Serfas’ testimony that in light of Angel’s deteriorating health and significant weight loss it was necessary to complete the surgery on August 10, 2017. KR’s evidence also generally supported this.

128. Monitoring of blood pressure during abdominal surgery, as well as with other surgical

procedures, is highly recommended, but not expressly required by PIPS Bylaws. It is required if no other Registered Member is available during an emergency surgery being conducted without other means of monitoring. KR, a RVT, was present and monitoring anesthesia during the exploratory abdominal surgery. Consequently, the Hearing Tribunal finds that Dr. Serfas’ actions met the minimum required standards.

129. The Hearing Tribunal finds no unprofessional conduct concerning this allegation.

F. Allegation #6: That you inappropriately discharged Angel to the owner when she

was in an unstable condition.

130. There was contradictory evidence in terms of many aspects of this allegation #6 including, most importantly, Angel’s condition when she was discharged and where Dr. Serfas or the FVC staff recommended that Angel stay at FVC over the night of August 10, 2017.

(i) Angel’s Condition

131. The critical issue for this allegation #6 is what Angel’s condition was at the time she was

discharged when Dr. Serfas could observe and assess Angel and not the events that occurred once Angel was at home.

132. KR’s evidence was that the recovery process was somewhat slow but went relatively

well (December Hearings, page 200, lines 15 to 24). 133. KR also testified that Angel walked from her kennel to the hall and that TT walked

with Angel in the front area of FVC without help. The Hearing Tribunal found this evidence to be credible (being provided by an RVT) and preferred it to TT’s evidence that Angel was wobbly in the FVC vising area.

134. There was diametrically opposed evidence regarding Angel’s ability to walk from FVC to

TT’s vehicle. 135. Dr. Serfas testified that Angel walked to TT’s vehicle and that was generally consistent

with WN’s evidence. 136. TT testified that Angel had to be carried to her car. TT also testified that once Angel

arrived at home she was unable to walk and was incoherent. RS supported that, including that Angel was carried into TT’s home. This may have been the case but, again, the Hearing Tribunal was focused on Angel’s condition at the time of her discharge from FVC.

137. As a result, the Hearing Tribunal placed little weight on the evidence of TT, KW and

RS concerning what they allege occurred after Angel arrived home.

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138. Similarly, any of their observations about the recovery or conditions of other pets at other veterinary clinics in other circumstances were those of laypersons arising from unrelated events and were not given any significant weight by the Hearing Tribunal.

139. Carrying on, the evidence was generally consistent that once Angel was at TT’s vehicle

she had to be lifted into it. 140. It was impossible for the Hearing Tribunal to definitively determine how Angel made her

way from FVC to TT’s car but the Hearing Tribunal accepted KR and Dr. Serfas evidence over the other evidence and concluded that there was a level of alertness and independent mobility on the part of Angel that supported discharging her.

(ii) Staying at FVC for the Evening of August 10, 2017

141. Based on his knowledge and experience as a veterinarian, the Hearing Tribunal accepted

Dr. Serfas’ evidence that TT was extremely attached to Angel and that it was difficult to get TT to leave Angel overnight on August 9, 2017. This is supported by TT’s testimony that she was reluctant to leave Angel at FVC.

142. The Hearing Tribunal also accepted Dr. Serfas testimony that it was against his

recommendation to let Angel leave FVC on August 10, 2017 (December Hearings, pages 325, 326 and 328).

143. This is supported by KR’s testimony, as an RVT, that she and Dr. Serfas wanted to keep

Angel at FVC for another night (December Hearings, page 202, lines 12 to 17). 144. The Hearing Tribunal preferred this evidence over TT’s evidence that a

recommendation about staying another night at FVC was never made by Dr. Serfas. 145. Additionally, the Hearing Tribunal relied on and accepted KR’s evidence that she gave TT

the discharge instructions and reviewed them with her. The fact that KR does not have an independent recollection of doing this was not significant. Specifically, the Hearing Tribunal concluded that, as an RVT, KR was following her standard procedure for these types of circumstances (December Hearings, page 201, lines 1 to 22; page 203, lines 12 to 14).

146. This is also supported by the cross-examination of TT where she indicated that she was

aware of many of the instructions on the written discharge form (December Hearings, page 67, lines 15 to 27; page 68, page 69, lines 1 to 23).

147. There was testimony about Dr. Serfas leaving on a trip at some point after Angel’s

discharge but the Hearing Tribunal concluded that there was no evidence that the future trip --- whenever it was to begin --- compromised or adversely affected Dr. Serfas’ professional judgement or actions in terms of discharging Angel.

148. For all of these reasons, the allegation that Dr. Serfas inappropriately discharged an

unstable patient is not substantiated to the satisfaction of this Hearing Tribunal on the balance of probabilities.

149. Finally, the Hearing Tribunal was satisfied that any evidence regarding TT’s monetary

concerns was not relevant to this allegation #6.

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150. The Hearing Tribunal finds no unprofessional conduct with regard to this allegation #6.

G. Allegation #7: That you failed to properly and/or in a timely manner refer the client, TT, for a specialist or 24-hour emergency care.

151. The Hearing Tribunal received conflicting evidence concerning this allegation #7. Having said that, the Hearing Tribunal preferred Dr. Serfas’ evidence over that of TT that he mentioned a referral to TT on August 9, 2017 (page 328).

152. On the balance of probabilities, given the severity of the weight loss Angel had

experienced and the size of dog, the Hearing Tribunal found that discussions regarding referral care did occur.

153. Although KR testified that she was not sure if a referral was discussed with TT, the

Hearing Tribunal accepted KR’s testimony that in her experience working with Dr. Serfas she had heard Dr. Serfas refer clients to specialty clinics and 24-hour emergency care previously (pages 205 to 207).

154. As a result, the Hearing Tribunal concluded that reviewing referrals was Dr. Serfas’

standard practice, which he followed with TT. 155. Because of their limited direct involvement, the evidence of KW and RS concerning this

allegation #7 was given little weight by the Hearing Tribunal. 156. The Hearing Tribunal finds no unprofessional conduct with regard to this allegation #7.

H. Allegation #8: Upon being advised of the death of Angel, you failed to properly

offer an autopsy to Angel’s owner, to ascertain the cause of death.

157. Again, the Hearing Tribunal received conflicting evidence with regard to this allegation #8. Because of their limited direct involvement, the evidence of KW and RS concerning this allegation #8 was given little weight by the Hearing Tribunal.

158. The only conversation that occurred between Dr. Serfas and TT after Angel was

discharged was the one while Angel was unresponsive and was receiving CPR. As Dr. Serfas was advising the owner and others about how to perform CPR and check for signs of life at this point, it seems unlikely, and inappropriate to be discussing a post-mortem at this time. Consequently, the Hearing Tribunal did not find Dr. Serfas’ testimony that he offered a necropsy during the phone call to be credible and rejected it.

159. Dr. Serfas should have followed up with TT after the crisis call to extend

condolences and this time frame would likely have been more amenable to the offer of a post-mortem. As that second phone conversation did not occur, the Hearing Tribunal concluded that an offer of a post-mortem necropsy did not occur. Therefore, the Hearing Tribunal finds this to be Unprofessional Conduct descried in Section 1(n.1) of the VPA.

I. Allegation #9: That you failed to create or maintain appropriate medical records

with respect to Angel.

160. There was significant and abundant evidence to support his allegation #9. The Hearing Tribunal finds Dr. Serfas guilty of Unprofessional Conduct with regards to the medical

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records pertaining to Angel. Had more thorough and adequate records been kept in this case, it is debatable if this complaint would have even been referred to the Hearing Tribunal in the first place.

161. Several deficiencies were noted in the medical record relating to Angel. Among the most

significant deficiencies were the following:

• Proper dental charting.

• Anesthetic monitoring sheet.

• Overnight hospitalization monitoring sheet.

• Offer of referral/declination of such.

• Waiver of discharge against medical advice.

• Provision of discharge instructions.

• Offer of necropsy/declination of such.

• Quote for surgical treatment.

162. The Hearing Tribunal also agrees with the submissions from ABVMA legal counsel

concerning KR’s evidence and Dr. Serfas’ own evidence in terms of the deficient medical records.

163. KR testified that:

• There was no recording of any perfusion during surgery and that this lack of

recordkeeping was a standard practice for Dr. Serfas.

• There was no monitoring of the amount of fluids Angel received before she ripped out her IV.

• No pre-operative temperature or vitals were recorded in terms of Angel’s surgery

and Dr. Serfas was ultimately responsible for ensuring this was done. 164. Dr. Serfas’ own evidence in terms of his medical recordkeeping included the following:

• He failed to document that an autopsy and referral were offered to TT.

• He failed to document that Angel was taken home against his recommendation on

August 10, 2017.

• He failed to record that he performed an examination or evaluation of Angel on August 10, 2017.

• The surgical anesthesia monitoring sheet in terms of pre-operative vitals is

completely blank and was not completed prior to the surgery.

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• There is no recording of the assessment of risk for the surgery on a scale of 1 to 5.

• There is no reference in the medical records for either August 9 or 10, 2017 about

the amount of hydration Angel received.

• There was no recording of an assessment of Angel’s pain on August 10, 2017.

• Despite the administration of Hydromorphone intra-operatively on August 10, 2017 to deal with post-operative pain, there was no recorded assessment of pain for that day.

• The patient record does not indicate that TT refused to accept Dr. Serfas’

recommendation for Angel to stay at FVC over the evening of August 10, 2017.

• There is no consent form for hospitalization or hospitalization treatment sheets.

• There is no record of one gram of Cefazolin being administered intravenously just

before the surgery. 165. The deficiencies in Dr. Serfas’ recordkeeping are blatant and extensive.

166. The Hearing Tribunal finds that this constitutes unprofessional conduct as described in

Section 1 (n.1) of the VPA.

V. REASONS OF THE HEARING TRIBUNAL: THE SECTION 27.1 MATTER

167. As mentioned previously in this decision, Dr. Serfas made an Admission of guilt

concerning all four of the charges arising from the Section 27.1 Matter. 168. The Admission contains minor variations when compared to the Notice of Hearing for the

Section 27.1 Matter, however, the Hearing Tribunal agreed with legal counsel for the ABVMA that the wording of the Admission was sufficient to constitute an admission for the purposes of section 35.1(1) of the VPA.

169. Accordingly, the Hearing Tribunal accepted the Admission or the purposes of

sections 35.1(2) and (3) of the VPA and found that unprofessional conduct occurred as described in Section 1 (n.1) of the VPA for all four allegations in the Section 27.1 Matter.

A. Allegation #1: That you intentionally disclosed confidential discussions which occurred on July 18, 2017 (you misrepresented the discussions which occurred with CRC in a confidential context on July 18, 2017).

170. The evidence submitted to the Hearing Tribunal, and Dr. Serfas’ Admission establ ishes unprofessional conduct concerning this allegation #1.

171. CRC discussions are to remain confidential unless agreed to by both parties. In issuing a

public letter, Dr. Serfas violated this condition and harmed the integrity of the profession in the eyes of the public.

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B. Allegation #2: That in issuing the letter, you intentionally undermined the consent negotiation and joint submissions made to the Hearing Tribunal on August 2, 2017.

172. The evidence submitted to the Hearing Tribunal, including Dr. Serfas’ Admission, establishes unprofessional conduct concerning this allegation #2.

173. As a self-governing profession, a ruling by the Hearing Tribunal must be respected and

honored. That Dr. Serfas publicly maligned the Hearing Tribunal and discipline process - -- including the penalty that he agreed to --- in a public manner is a very serious concern to this Hearing Tribunal as it undermines the integrity of the profession and its self- governing nature.

C. Allegation #3: That in including the following paragraph in your letter (paragraph

in question omitted for this summary of findings), you undermined the integrity of the profession and your responsibilities as a registered member.

174. The evidence submitted to the Hearing Tribunal, and Dr. Serfas’ Admission establ ishes

unprofessional conduct concerning this allegation #3. 175. The Hearing Tribunal recognizes it is likely that Dr. Serfas was frustrated and hurt by the

findings of the August 2, 2017 Hearing Tribunal. A discipline process is highly stressful and unpleasant for the member. However, this does not excuse the allegation in Dr. Serfas’ letter, which accuses the profession and the regulatory body, the ABVMA, of bullying. To air these grievances publicly undermines other veterinarians and the profession as a whole.

D. Allegation #4: That in issuing the letter to your clients, friends and community members, you failed to properly accept your responsibilities as a registered veterinarian, particularly as they relates to (i) serve the profession with integrity, (ii) practice veterinary medicine in a competent manner, (iii) provide appropriate quality of service to your clients and friends, (iv) be candid and honest in all your interactions with clients and colleagues and (v) conduct yourself in a manner characterized by courtesy and good faith.

176. The evidence submitted to the Hearing Tribunal, including Dr. Serfas’ Admission, establishes unprofessional conduct concerning this allegation #4.

177. The evidence supports a finding that Dr. Serfas was deflecting blame and responsibility

for his disciplinary issues from himself to the ABVMA and the previous Hearing Tribunal. To do so publicly is harmful to the profession in the eyes of its members and the public and also brings into question Dr. Serfas’ honesty and integrity.

VI. PENALTY ORDERS OF THE HEARING TRIBUNAL

A. The ABVMA’s Submissions

178. At the January 22, 2019 hearing, Ms. Smith stated that the ABVMA was seeking the following penalty orders:

1. A reprimand against Dr. Serfas.

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2. The cancellation of Dr. Serfas’ registration for a minimum five year period. Ms. Smith noted that after five years Dr. Serfas would be required to submit to a full complete application, which will include demonstration of good, character that has been lacking in Dr. Serfas’ conduct to date.

3. Dr. Serfas will pay fines of $50,000.00 over five (5) years with $30,000.00 of those

fines being allocated to the Section 27.1 Matter, $15,000.00 of those fines being allocated to the Peanut Matter and $5,000.00 of those fines being allocated to the Angel Matter.

4. Dr. Serfas be required to pay 75% of the total hearing costs within five (5) years of

the date of the Hearing Tribunal’s decision. Ms. Smith estimated that the total costs of the hearing would be $90,000.00.

5. FVC be closed effective immediately until such time as the following two conditions

are met: (i) a responsible veterinarian is assigned to the practice and (ii) that the veterinary practice entity successfully passes a practice inspection.

6. That there be publication of the Hearing Tribunal decision with names.

Ms. Smith then made extensive penalty submissions, which can be summarized as follows.

179. Ms. Smith submitted that there are five (5) main objectives in sanctioning with the most

important one being protection of the public. Following from that, in no order of importance, were deterrence to the member, deterrence to the profession, rehabilitation of the member, fairness in terms of comparable consequences for comparable comment and the integrity of the profession. Ms. Smith also reviewed the Jaswal factors and urged the Hearing Tribunal to consider them.

180. Ms. Smith argued that Dr. Serfas has a complete disregard for the authority and exercise

of professional regulatory functions, all as evidenced by the Section 27.1 Matter. 181. Ms. Smith argued that Dr. Serfas was not a new or inexperienced practitioner. Rather he

had been practicing for over 20 years at the relevant times. Ms. Smith also referred to the three prior orders against Dr. Serfas which arose as a result of discipline hearings and consent orders entered into by Dr. Serfas.

182. Ms. Smith also urged the Hearing Tribunal to carefully review the Investigation Report

relating to the previous hearing in 2014 involving Dr. Serfas and noted that there was a suspension, minor fines, continuing education, anger management and counselling sessions, all of which were significant penalties in her submission.

183. Ms. Smith also referred to the materials concerning the Section 27.1 Matter and unsafe,

violent and unprofessional conduct on the part of Dr. Serfas, some of which was reflected in the actions which the RCMP took.

184. Ms. Smith referred to Dr. Serfas’ previous suspension pending an addiction assessment

and the seriousness of the PIPS inspections from 2014 onward. Ms. Smith argued that the PIPS inspections disclosed ongoing significant deficiencies with respect to all four audits of Dr. Serfas’ practice.

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185. Ms. Smith also emphasized the suspension, which began on August 12, 2017, which was to commence three days after the events giving rise to the Angel Matter. Ms. Smith submitted that when the Angel events occurred, Dr. Serfas knew that a suspension of six months would be occurring but there was no significant change in his conduct.

186. Ms. Smith also argued that the nature of all of the findings of unprofessional conduct, the

number of findings and the period of time over which they occurred and the lack of compliance with many of the discipline orders demonstrates that there is a significant prior complaint and conviction history.

187. Ms. Smith argued that the ABVMA has a responsibility to the public to ensure the integrity

of the profession and respect for its rules and its ability to govern its members. 188. In terms of having suffered other serious financial or other penalties, Ms. Smith argued

that there was a pattern of ongoing acceleration of unprofessional conduct with increased fines, increased costs and no change in Dr. Serfas’ conduct. Ms. Smith argued that cumulatively these facts justify a finding of ungovernability.

189. Ms. Smith also argued that the various practice inspections demonstrate that FVC did not

meet the appropriate standards and that it was not the ABVMA’s responsibility continually remind Dr. Serfas about how to comply with deficiencies identified in those inspections. Rather, Dr. Serfas himself has the independent responsibility to ensure the recommendations are carried out. In short, it was not the practice inspector’s responsibility to ensure that Dr. Serfas was in compliance and to assist Dr. Serfas in achieving compliance.

B. Dr. Serfas’ Submissions

190. Mr. Rand began his submissions by emphasizing that on many of the charges guilt was

not proven and that those charges were dismissed. Mr. Rand also mentioned that it was important to remember that before the discipline history with the ABVMA that began in approximately 2014, Dr. Serfas had practiced successfully and without issue for approximately 18 years.

191. Mr. Rand reviewed the PIPS audits in the 2017 investigation and acknowledged that there

were failures in compliance on the part of Dr. Serfas. Having said that, Mr. Rand argued that one of the PIPS reports disclosed evidence of successful attempts to comply with the PIPS requirements. Mr. Rand disputed the suggestion that there was an accelerating pattern of unprofessional conduct and argued that there was strong evidence that Dr. Serfas was trying to improve his practice.

192. After reviewing Dr. Serfas’ personal history, Mr. Rand revised Dr. Serfas’ guilty pleas with

respect to the Section 27.1 Matter and the stress that Dr. Serfas was under when he was involved in discipline proceedings. Mr. Rand submitted that the timing of Dr. Serfas’ history of conflict with the ABVMA corresponded with the worst of his divorce stresses and, while that was not an excuse, it was an explanation about why Dr. Serfas did not behave appropriately.

193. Mr. Rand submitted that the Hearing Tribunal could not “punish” his client for not pleading

guilty to the charges on the Angel Matter and the Peanut Matter as he has a right to have

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a hearing. Mr. Rand reminded the Hearing Tribunal of the significant success that Dr. Serfas had in disputing the charges regarding the Angel Matter.

194. Mr. Rand went on to argue that there was overlap concerning the findings of guilt

concerning the charges in the Peanut Matter and the charges in the Angel Matter and that his client should not be overly punished for charges that relate to the same matters.

195. Mr. Rand reviewed the letters of reference that were submitted on behalf of Dr. Serfas and

argued that those letters support the argument that Dr. Serfas is doing a good job. 196. Ms. Fitzel then reviewed four discipline cases provided to the Hearing Tribunal.

197. Mr. Rand continued his submissions and strongly argued that suspension of Dr. Serfas’

licensed was not justified. 198. Mr. Rand argued that even if the PIPS reviews were not successful, Dr. Serfas was

cooperative and allowed the inspectors have access and also argued that there was evidence of continued attempts by Dr. Serfas to obtain assistance and to improve staffing and practices at his clinic.

199. Mr. Rand argued that although public protection is important the Hearing Tribunal ought

to look at the reference letters from members of the public which support Dr. Serfas. 200. Essentially, Mr. Rand invited the Hearing Tribunal to make orders that it felt were fair and

reasonable but strongly argued that there was no justification for a finding of ungovernability or to cancel Dr. Serfas’ registration.

C. The Hearing Tribunal’s Penalty Orders.

201. As part of its deliberations, the Hearing Tribunal carefully considered the applicable Jaswal

factors, which are reflected in the orders and comments that follow in this decision. As well, the Hearing Tribunal noted that Dr. Serfas was not a new or inexperienced member of the veterinary profession and had in fact been practicing for approximately 20 years. Dr. Serfas’ unprofessional conduct was not consistent with the knowledge, training and skills he should have possessed as the result of his lengthy career in the veterinary profession.

202. The Hearing Tribunal was not provided with any compelling evidence of other serious

financial or similar penalties that Dr. Serfas has suffered bearing in mind that his actions and omissions necessitated repeated and ongoing discipline proceedings, including those which are referred to in this decision.

203. The Hearing Tribunal found that Dr. Serfas’ conduct was a significant departure from the

accepted minimum professional and ethical standards for members of the veterinary profession and adversely affected the public’s confidence in the integrity of the profession.

204. After carefully considering the submissions from both parties and bearing in mind the

findings of unprofessional conduct in the Peanut Matter, the Angel Matter and the Section 27.1 Matter, the Hearing Tribunal orders the following sanctions.

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Order 1 – A reprimand shall be issued against Dr. Serfas

205. The order to issue a reprimand against Dr. Serfas emphasizes the severity of these

matters and protects the interests of the public, particularly if Dr. Serfas seeks registration as a licensed veterinarian in other jurisdictions. This written reprimand will serve as a deterrent to Dr. Serfas and other members of the ABVMA from similar unprofessional conduct in the future. In addition, this sanction protects the integrity of the profession in Alberta.

Order 2(a) – Dr. Serfas’ registration shall be suspended from the practice of veterinary medicine in Alberta for a period of one (1) year commencing on June 15, 2019.

Order 2(b) – Commencing on June 15, 2020 and contingent on meeting all other requirements in this order, as well as all applicable ABVMA requirements for licensure, for a period of 3 years Dr. Serfas’ practice will be restricted to the practice of large animal veterinary medicine in Alberta.

206. The order to suspend Dr. Serfas from the practice of veterinary medicine in Alberta for

one year emphasizes the severity of this matter. The letter that Dr. Serfas issued to his clients, friends, and community members, which was the subject of the Section 27.1 Matter is unquestionably unprofessional and inappropriate. As agreed to by Dr. Serfas in his Admission of Unprofessional Conduct and as determined by the Hearing Tribunal, Dr. Serfas’ actions in this regard were a misrepresentation of discussions, a breach of confidentiality, an attack on the integrity of the administration of the profession, an attack on the integrity of the profession as a whole, and total disregard for accepting his own responsibilities in the discipline matters that led up to his suspension in August of 2017.

207. These are extremely serious matters and this Hearing Tribunal does not take them lightly.

Hence, the issuance of a one-year suspension from the practice of veterinary medicine in Alberta, as opposed to a shorter suspension. This suspension will serve as a deterrent to Dr. Serfas and other members of the ABVMA from similar unprofessional conduct in the future. In addition, this sanction protects the integrity of the profession in Alberta.

208. Notwithstanding Dr. Serfas’ actions that are the subject of Discipline Case # 18-04, this

Hearing Tribunal did not hear evidence indicating that Dr. Serfas had been unprofessional or inappropriate in his practice of large animal veterinary medicine. As a result, the Hearing Tribunal is allowing Dr. Serfas the opportunity to resume the practice of large animal veterinary medicine after a one-year suspension. This approach allows Dr. Serfas the opportunity to earn a living as a practicing large animal veterinarian, which should serve to foster Dr. Serfas’ rehabilitation as an ABVMA member and serve the interests of large animal owners and producers in the Forestburg, Alberta area.

209. In response to the Hearing Tribunal’s findings of unprofessional conduct in the

Peanut Matter, the Angel Matter and the Section 27.1 Matter, the legal counsel for the ABVMA argued for finding that Dr. Serfas is “ungovernable” and recommended that his registration be cancelled for a period of at least five (5) years. The Hearing Tribunal also considered the coun te r -arguments p resented by t he l eg a l counse l for D r . Serfas, Dr. Serfas’ history of unprofessional conduct as a registered member of the ABVMA both

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before and after 2012, and Dr. Serfas’ responses to previous and current disciplinary proceedings and sanctions.

210. While Dr. Serfas’ actions over the last six to seven (6 to 7) years have clearly represented

unprofessional conduct on several occasions as detailed in the various disciplinary cases involving him since 2012, Dr. Serfas has been responsive to the ABVMA and the disciplinary process, including compliance with all resulting sanctions except successful and satisfactory completion of PIPS inspections. Based on our review of the overall situation to date with respect to Dr. Serfas’ history of unprofessional conduct, this Hearing Tribunal does not find Dr. Serfas to be “ungovernable” at this time.

Order 3(a) – Dr. Serfas will be suspended from the practice of companion animal veterinary medicine in Alberta for a period of 4 years commencing on June 15, 2019.

Order 3(b) – Commencing on June 15, 2023 and contingent on meeting all other requirements of these orders, as well as all other ABVMA requirements for licensure, Dr. Serfas will be eligible to practice companion animal veterinary medicine in Alberta under the immediate or direct supervision of an unrestricted ABVMA General Practice Licensee.

Order 3(c) – Commencing on June 15, 2024 and contingent on meeting all other requirements in this order, as well as all other ABVMA requirements for licensure, Dr. Serfas will be eligible to practice companion animal veterinary medicine in Alberta as unrestricted ABVMA General Practice Licensee Veterinarian.

211. The order to suspend Dr. Serfas from the practice of companion animal veterinary

medicine for four years, followed by one year of immediate or direct supervision of an unrestricted ABVMA General Practice Licensee is in response to the findings of unprofessional conduct in the Peanut Matter and the Angel Matter, as well as the findings from previous discipline cases for Dr. Serfas involving companion animals and the failure of Dr. Serfas and FVC to successfully comply with PIPS and sanctions related to ongoing PIPS inspections.

212. Considering all of these factors, the Hearing Tribunal determined that it is not in the best

interest of the public or the profession to allow Dr. Serfas to practice companion animal veterinary medicine until sufficient time has passed to allow (i) Dr. Serfas to complete the continuing education obligations described in order 6 below, (ii) FVC to fully comply with the obligations outlined in orders 4 and 5 below, (iii) the FVC to fully adopt and implement the requirements of ABVMA PIPS, and (iv) Dr. Serfas to fully adopt and implement the requirements of ABVMA PIPS after the FVC and its responsible veterinarian have already done so.

213. This will protect the public by preventing Dr. Serfas from practicing companion animal

veterinary medicine for four years and providing appropriate oversight should Dr. Serfas choose to return to companion animal practice after four (4) years.

Order 4 – FVC shall be closed effective as of the date of this decision and shall remain closed until the veterinary practice entity (VPE) passes the ABVMA PIPS inspection, there is an unrestricted ABVMA Practice Licensee assigned as the responsible veterinarian for FVC, and the PIPS Committee and the Complaints Director, acting reasonably, approve the reopening of the FVC clinic.

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214. This sanction is issued to protect the public in terms of the practice of veterinary medicine in the province of Alberta to make sure that FVC is not reopened until the above-mentioned conditions have been met. In addition, this approach is necessary to support the integrity of the profession and its self-regulating status because FVC, for a significant period of time, has not been able to achieve compliance as it relates to PIPS.

215. As a result, it is necessary to close the FVC until it is in compliance with the stated

requirements and approved for reopening by the PIPS Committee and the Complaints Director.

Order 5 – After re-opening, FVC shall be subject to an unannounced PIPS inspection by an ABVMA PIPS inspector every six (6) months for five (5) years. These inspections shall focus on, but not be limited to, medical records, anesthesia monitoring, appropriate professional staffing, proper equipment (use and maintenance), dispensing (drugs), dental procedures, and companion animal (care). Dr. Serfas shall pay the costs of these practice inspections and shall provide any and all information requested by and to the inspector. The results of each PIPS inspection shall be provided to the PIPS Committee and the Complaints Director for approval. If joint approval is not granted, the VPE will be closed immediately and remain closed until the VPE passes the ABVMA PIPS inspection.

216. This sanction is issued to protect the public and uphold the integrity of the profession. The

VPA defines who can practice veterinary medicine and who can own a practice. It also requires the ABMVA to set standards of practice and to certify clinics that meet these standards. The ABVMA PIPS requirements are in place to assure and protect the public with respect to the delivery of veterinary health care procedures in the Province of Alberta. FVC has consistently failed to fully comply with these requirements. Accordingly, ongoing inspections are necessary to ensure compliance and to foster the culture of ongoing compliance as PIPS requirements change over time.

Order 6 – Dr. Serfas shall be required to complete, at his own cost, within six (6) months from the date of this decision, the following continuing education obligations:

Order 6(a) – Complete twenty-five (25) hours of continuing education in the area of companion animal dentistry (approved by the Complaints Director).

Order 6(b) – Provide comprehensive and detailed standard operating procedure (SOPs) that describe the approach to the companion animal dentistry cases, including but not limited to, assessment, documentation, scaling, radiology, extraction, surgery, pain management, and discharge/aftercare instructions, which SOPs must be approved by the Complaints Director.

Order 6(c) – Complete ten (10) hours of continuing education in area of companion animal pain management (approved by the Complaints Director).

Order 6(d) – Complete ten (10) hours of continuing education in area of medical records (approved by the Complaints Director).

Order 6(e) – Complete ten (10) hours of continuing education in area of client communication (approved by the Complaints Director.)

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Order 6(f) – For clarification, these continuing education hours are in addition to the ABVMA’s annual requirement of twenty (20) hours of continuing education.

217. The orders to complete continuing education obligations in the areas of companion animal

dentistry, companion animal pain management, medical records and client communication are directly pertinent to the Peanut Matter and the Angel Matter, will improve Dr. Serfas’ skills in these areas, and will help Dr. Serfas to provide appropriate and professional services to the public in the future

Order 7 – Dr. Serfas shall pay fines to the association for the findings of unprofessional conduct in the maximum amount of $50,000.00 as follows, which represents $20,000.00 for Discipline Case # 18-04, $25,000.00 for Discipline Case # 17-22, and $5,000.00 for Discipline Case # 17-31. The fine for Discipline Case # 18- 04 is payable over one (1) year and is payable prior to June 15, 2020. The fines for Discipline Cases # 17-22 and 17-31 are payable over five (5) years and are payable prior to June 15, 2024.

218. The order to pay fines in the maximum amount of $50,000.00 was deemed appropriate by

the Hearing Tribunal because of the serious nature of the unprofessional conduct in each of these discipline cases. The magnitude of the fine matches the seriousness of the findings in each case and is consistent with the amounts assessed in similar types of ABVMA discipline cases with findings of unprofessional conduct. These fines will serve to deter Dr. Serfas and the membership from similar unprofessional conduct. In addition, these fines demonstrate the commitment and integrity of the profession as it pertains to dealing with unprofessional conduct by its members.

Order 8 – Dr. Serfas shall pay costs of $60,000.00 associated with these investigations and the hearing. These costs are payable over five (5) years and are payable prior to June 15, 2024.

219. The order to pay $60,000.00 in costs represents approximately 60-70% of the projected

costs of these investigations and hearings. Due to the fact that findings of unprofessional conduct occurred for only some of the allegations against Dr. Serfas, the Hearing Tribunal deemed it fair and appropriate that $60,000.00 of the hearing costs incurred by the ABVMA be borne by Dr. Serfas. The assessment of costs associated with this hearing will act as a deterrent to further such actions by Dr. Serfas or other members of the ABVMA.

Order 9 – If the Complaints Director determines that Dr. Serfas has breached any of the above penalty orders, including but not limited to, the determination that Dr. Serfas practices veterinary medicine during the period of suspension and/or restricted companion animal practice, Dr. Serfas’ registration with the ABVMA will be cancelled for of five (5) years.

220. Including the current ABVMA discipline cases, Dr. Serfas has been involved in seven

ABMVA disciplinary cases since 2012. While Dr. Serfas has been responsive to and generally cooperated with the ABVMA disciplinary process, he has yet to fully comply with successful and satisfactory completion of PIPS inspections as ordered by one of the original 2012 cases and this has directly and indirectly led to additional disciplinary cases. Dr. Serfas needs to accept full responsibility and accountability for his actions.

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221. The Hearing Tribunal has issued sanctions that are commensurate with the seriousness of the findings in each case and reflect the fact that there have been several previous findings of Unprofessional Conduct against Dr. Serfas by ABVMA Hearing Tribunals. This Hearing Tribunal has created a rehabilitation and competency improvement pathway for Dr. Serfas as it pertains to the practice of large animal veterinary medicine and companion animal veterinary medicine. However, it will be up to Dr. Serfas to decide whether he chooses to follow that pathway. If Dr. Serfas violates these Hearing Tribunal orders, it will result in a five (5) year cancellation of his ABVMA registration.

Order 10- There shall be publication of this order on a "with names" basis in the ABVMA Newsletter and these orders shall be posted on the ABVMA website until Dr. Serfas has complied with all orders of the Hearing Tribunal.

222. Publication of the findings and sanctions of this Hearing Tribunal on a "with names" basis

is deemed necessary to inform other members of the veterinary profession of the unprofessional conduct findings made in this hearing.

223. Publication will disseminate the serious nature of these offences to members of the

profession and help to deter other veterinarians from committing similar actions. Publication "with names" and posting of these orders on the ABVMA website will protect the public until Dr. Serfas and the FVC have complied with all these orders. In addition, publication on the website will serve to maintain the integrity of the profession and demonstrate that the ABVMA and its members are committed to self-regulation and public protection.

Dated this 29 day of May, 2019. Hearing Tribunal

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