Toronto Pharmacist Ordered to Write Essay After Patient Nearly Went Without Miscarriage-Prevention Medication

An Ontario pharmacist has been ordered to write a reflective essay after a pregnant patient nearly went without medication prescribed to help prevent a miscarriage. On September 10, 2026, the Health Professions Appeal and Review Board (HPARB) upheld an Ontario College of Pharmacists (OCP) decision against Rizwan Champsi, the designated manager of a Shoppers Drug Mart in Toronto. The college had ordered Champsi to complete a remediation program focused on patient communication and issued him an oral caution. The case is most directly relevant to community pharmacy teams handling refills of time-sensitive, medically necessary prescriptions, and to pharmacy managers responsible for staff communication practices.

According to the board's filing, the case stems from a complaint by a patient who filled a prescription for Crinone gel -- a progesterone gel sometimes prescribed to specific high-risk patients to help prevent miscarriage -- at Champsi's pharmacy in September 2023. The patient was using it twice a day and told the college she risked a miscarriage if she went without it. When she picked up her first prescription in late September, she had already asked whether she could buy more than one box; she was told she could only get one at a time, but that "there was no need to be concerned since they would keep the medication in stock for her."

The patient requested a refill through the Shoppers Drug Mart app on October 4 and went to pick it up on October 7. She was told the medication was not in stock and to try again on October 10, after the Thanksgiving long weekend, and said she was "asked to move aside for the next client." She told the college she called every open pharmacy herself and found one with the medication in stock; Champsi disputed this, saying a pharmacy assistant had located a supply before the patient transferred her prescription. The committee could not determine which account was correct, but concluded both the patient and pharmacy staff had searched for another supply option. It nonetheless found fault with how the pharmacy initially handled the situation, stating "staff should have been more aware of the Respondent's circumstances and should have addressed the issue without prompting from her," and that the pharmacy's initial response caused the patient "unnecessary stress" because Champsi and his staff "did not appear concerned."

The case was not Champsi's first communication-related matter before the college: of seven previous decisions involving him, three involved communication issues, all in 2023. The committee said "change did not appear to have occurred" and found no indication he recognized a need to improve. In addition to the oral caution, Champsi must write a reflective essay of at least 500 words on how he plans to improve patient communication and care, and college staff can follow up within 24 months to review the changes he has made.

Practice guidance for pharmacists

• When a patient raises a concern about running out of a time-sensitive medication in advance, document it clearly and flag it for follow-up rather than only offering verbal reassurance that stock will be available later.
• If a refill can't be filled and the patient has previously identified the medication as urgent or risk-bearing (as with a miscarriage-prevention prescription), staff should proactively help locate alternate supply rather than waiting for the patient to ask or push back.
• Treat a stock-out for a medically necessary, time-sensitive prescription as requiring the same urgency regardless of day of week -- "try again after the long weekend" is not an acceptable default response when a gap in therapy carries real clinical risk.
• Pharmacy managers should review how staff are trained to recognize and escalate exactly this kind of situation, particularly where a patient has already expressed concern about continuity of supply.
• A pattern of repeated communication-related complaints, even when each individual incident seems minor, is treated by the college as evidence that remediation has not been effective -- track and act on complaint patterns at the pharmacy level, not just case by case.

HPARB's role in this case was to review whether the OCP's original decision was reasonable, not to re-investigate the underlying facts; its upholding of the college's remediation order means Champsi's essay and follow-up review will proceed as ordered.