ORDER PO-4763

Appeal PA22-00397

Queensway Carleton Hospital 

November 20, 2025

Summary: An individual made a request under the Freedom of Information and Protection of Privacy Act  to Queensway Carleton Hospital . The requester asked for general records relating to its Emergency Department directives and standard operating procedures and specified protocols. The hospital identified records and granted the requester full access. The hospital explained that records relating to a contrast media protocol do not exist.

The requester believes that additional records should exist and appealed the hospital’s decision.

In this order, the adjudicator finds that the hospital conducted a reasonable search, as required by section 24 of the Act and dismisses the appeal.

Statute Considered: Freedom of Information and Protection of Privacy Act , R.S.O. 1990, c. F.31 , as amended, section 24.

OVERVIEW:

[1] This order addresses whether the Queensway Carleton Hospital  (the hospital) conducted a reasonable search for records relating to protocols for specified diagnostic imaging and the administration of contrast media, in response to a request made under the Freedom of Information and Protection of Privacy Act  (the Act ).

[2] An individual made a request to the hospital under the Act  for the following:

1. Emergency Department Directives.
2. Standard Operating Procedures for the Emergency Department.
3. Details about the following protocols – most referenced in [specified hospital] health records:

• Vital Signs Protocol referred to as ZINCE2SC100
• CT Scan Pre and Post scan Hydration protocols
• COVID-19 screening protocol in use on March 12 and 13 2022
• ARI Protocol referred to as PERIPACARI
• Transfer of Accountability protocol referred to as ZGNTOA00

[3] After submitting this request, the requester stated that she was also requesting access to all directives and protocols referenced in a 107-page Patient Order summary. The hospital provided the Patient Order summary to the requester in response to an unrelated request under the Personal Health Information Protection Act.

[4] The hospital advised the requester that the information she was seeking would be located in different medical directives and provided a list of its approved medical directives. The requester confirmed which records from the list she is seeking access to.

[5] The hospital issued a decision to the requester granting full access to the responsive records that it had identified. In relation to some of the records sought in the request, the hospital provided some further information to the requester. Relevant to this appeal, the hospital provided the following information regarding a protocol that the requester had identified in the Patient Order summary:

With respect to the protocol of Omnipaque 350, the Diagnostic Imaging Department indicated that the protocol for the contrast media used at [the hospital] for CT Scanning of the Body (Omnipaque 350) is defined by the vendor (GE Healthcare) and is automatically calculated by injection equipment that provides consistent flow. As such, there is no hard-copy protocol document available to be provided.

[6] The requester believes that additional records ought to exist, including records of the protocols for Omnipaque 350 and/or the administration of contrast media. The requester (now appellant) appealed the hospital’s decision to the Information and Privacy Commissioner of Ontario (IPC) to challenge the reasonableness of the hospital’s search.

[7] A mediator was appointed to explore resolution of the appeal. During mediation, the appellant requested a copy of a diagnostic imaging directive from the hospital. The hospital decided to grant the appellant full access to it. The hospital advised that there is no additional documentation related to Omnipaque 350 or guidance on the administration of contrast media.

[8] The appellant maintains that additional records relating to the protocol for Omnipaque 350 and/or the administration of contrast media should exist. As a mediated resolution was not achieved, the file was transferred to the adjudication stage of the appeal process, where an adjudicator may conduct an inquiry.

[9] I decided to conduct an inquiry and sought and received representations from the parties.

[10] In this order, I find that the hospital has conducted a reasonable search for the Omnipaque 350 protocol, as required by section 24  of the Act . Accordingly, I uphold the hospital’s searches.

DISCUSSION:

[11] The sole issue in this appeal is whether the hospital conducted a reasonable search for records, including records relating to a protocol referenced in a patient order for Omnipaque 350. If a requester claims additional records exist beyond those found by an institution, the issue is whether the institution has conducted a reasonable search for records as required by section 24  of the Act .[1]

[12] If the IPC is satisfied that the search carried out was reasonable in the circumstances, it will uphold the institution’s decision. Otherwise, it may order the institution to conduct another search for records.

[13] Although a requester will rarely be in a position to indicate precisely which records the institution has not identified in its search, they still must provide a reasonable basis for concluding that such records exist.[2]

[14] The Act  does not require the institution to prove with certainty that further records do not exist.[3] However, the institution must provide enough evidence to show that it has made a reasonable effort to identify and locate responsive records;[4] that is, records that are “reasonably related” to the request.[5]

Hospital’s representations

[15] The hospital’s position is that it has conducted a reasonable search.

[16] The hospital states that the appellant sought access to multiple directives and protocols, including those related to Omnipaque 350 and contrast media. The hospital states that it communicated with the appellant about the request before issuing a decision letter in which it advised that the Diagnostic Imaging department had indicated that the protocol for contrast media used for CT scanning with the Omnipaque 350 was defined by the vendor, GE Healthcare, and automatically calculated by injection equipment. The hospital explained that there was therefore no hard copy protocol document available.

[17] The hospital states that the appellant made a further broader request under the Act  for a list of its Diagnostic Imaging policies, procedures, protocols and directives in use on specified dates. The hospital states that the “department-specific” request was referred to the Director of Diagnostic Imaging (the Director). The hospital states that given the broad nature of the request, the Director communicated with the appellant to clarify the request and provide a list of Diagnostic Imaging Policies and Directives.

[18] The hospital explains that during the appeal process, the appellant expressed dissatisfaction that there was no written protocol for the administration of Omnipaque 350. The hospital states that the appellant requested a document entitled “Administration of Contrast Media/Intravenous Drugs (II-=80)”, which was included in the list of diagnostic imaging directives provided under the later request.

[19] The hospital states that it provided the appellant with a document that made generic reference to the administration of contrast media but acknowledged that it consisted of only a short statement of policy rather than a detailed protocol. The hospital explains that at the time of the discussion with the appellant, which was during the mediation stage of the appeal process, the document was under review and scheduled for revision as part of a wholesale policy updating process in advance of a hospital accreditation visit.

[20] As part of its representations, the hospital also submitted an affidavit from the Director describing its searches and explaining why the record that the appellant is seeking does not exist.

Director’s affidavit

[21] The Director sets out his experience in his position as Director of Diagnostic Services at the hospital. The Director states that for 10 years he has been in leadership positions in that department. The Director states that he has considerable knowledge and experience in writing, reviewing and approving protocols for Diagnostic Services.

[22] The Director states that he is fully apprised in the locations holding policies, protocols and other documentation that support his department.

[23] Regarding his response to the request for records relating to Omnipaque 350 and/or the administration of contrast media, the Director states that he consulted with staff members to review the department’s processes, protocols and other documentation. The Director states that they determined that the hospital does not possess any written records relating to Omnipaque 350. The Director states that all dosage information associated with the administration of Omnipaque is executed from within the power injectors.

[24] Regarding the searches carried out by hospital staff, the Director states that searches were carried out by him and the Manager of Diagnostic Services. The Director states that they searched the policy binder, the departmental electronic policy folder and the hospital’s corporate electronic policy folder.

[25] The Director states that he contacted the Senior CT Technologist and the CT Technologist during the searches and searched all files relating to contrast, image optimization and CT imaging protocols.

[26] The Director states that the searches did not locate any written policies or protocols specific to Omnipaque 350 or CT contrast and that no such written policies or protocols have ever existed at the hospital. The Director states that Diagnostic Services policies, protocols and directives (including updates and revisions) are retained indefinitely at the hospital.

Appellant’s representations

[27] The appellant’s position is that the hospital’s search is unreasonable. The appellant submits that the context of her access request has been “overlooked.”

[28] The appellant’s representations provide background and commentary on hospital staff responsibilities concerning reference to protocols and medical directives when conducting CT scans with the Omnipaque 350 and technical information for contrast media in general. Below, I summarise the appellant’s submissions relevant to the issue in this appeal but assure the appellant that I have read all her representations.

Clarification of the request

[29] The appellant states that it was not possible for the hospital to conduct a reasonable search because the scope of her request is “not yet clarified.” The appellant submits that she wrote to the hospital clarifying that in her request she seeks “directives and protocols referenced in the patient record that were leveraged” by hospital staff, including those referenced in the Patient Order summary. The appellant’s position is that there was no “meaningful exchange” regarding the hospital’s protocols. Rather, the appellant states she was surprised to receive a decision letter and documents after her email seeking clarification.

[30] The appellant states that she did not agree to narrow her search to only records of Omnipaque 350 protocol, nor to records relating to how a power injector handles Omnipaque 350.

Location of the sought protocols

[31] The appellant makes representations about different definitions of the term “protocol” and reiterates that she wants all protocols referenced in the Patient Order summary. Relying on the Patient Order summary, guidance from the vendor (GE healthcare) and information from health care systems in other jurisdictions, the appellant suggests locations where the protocol might be found.

Inadequate affidavit evidence

[32] The appellant states that the hospital has not provided affidavits from all the individuals who conducted the searches and the Director’s affidavit lacks key information about the searches. For example, the appellant submits that the Director lists the names of the individuals who undertook searches but it is not clear from the affidavit what types of files were searched, key words used or the result of each search.

[33] The appellant submits that the Director does not give the dates of the searches. The appellant states that different searches were conducted at different times in response to her different access requests. The appellant states that the Director’s affidavit is vague and brief. The appellant states that there is “no mention of exploring obvious locations” and cites diagnostic systems where approved protocols are “typically housed.” The appellant provides screenshots of workflow systems where she submits the protocol referenced in the Patient Order summary may be located.

More recent version of the “Administration of Contrast Media Intravenous Drugs” document

[34] The appellant submits that she believes that a more recent version of the document released to her by the hospital during the mediation stage of the appeal, ought to exist. The appellant states that the file name of the record, entitled “Administration of Contrast Media Intravenous Drugs”, includes the suffix “(003).docx”, which she believes indicates a different version exists. The appellant states that the record released to her is dated 1992 and submits that it is reasonable to expect that after 30 years, this document has been reviewed and updated. The appellant states that a “review cycle” is typically every few years.

[35] The appellant cites information from the hospital’s website, including job postings, that she submits support her belief that documented procedures and protocols exist.

[36] In summarising her position, the appellant states:

I therefore continue to believe that there is information available that could actually be responsive to my request about the protocol referred to in the Patient Order Summary medication order entry, protocol leveraged by staff – in the form of a different version of “Administration of Contrast Media Intravenous Drugs” that was relevant in March 2022 and which has detailed steps of relevant procedure/protocol, relevant medical directives, After Hours procedures, Emergency patients procedures, etc., that includes meaningful, practical content that is used by health professionals of this modern era (i.e. not of 30 years ago). In a 2024 context this also means electronically housed information, not just hard copies in a physical binder.

Hospital’s reply representations

[37] In its reply representations, the hospital reviewed the email correspondence with the appellant regarding the context for the appellant’s request. The hospital acknowledged that the appellant had asked:

They (radiologists) would nonetheless select certain parameters for the [Omnipaque 350] right? Would this GE Healthcare document be a reference point for the [hospital’s] Diagnostic Imaging department?

[38] The hospital stated that it could not locate a response from the Diagnostic Imaging department to the appellant’s query.

[39] The hospital confirmed that in relation to the document entitled “Administration of Contrast Media Intravenous Drugs”, a revised document is being developed however it has not been approved for use, is still in draft form and cannot be provided for disclosure.

Analysis and findings

[40] For the reasons that follow, I find that the hospital has conducted a reasonable search in response to the appellant’s request. I am also satisfied that the hospital has explained why no record has been identified that relates to the reference “per protocol” for the Omnipaque 350 order in the Patient Order summary that the appellant is seeking.

[41] A reasonable search is one in which an experienced employee knowledgeable in the subject matter of the request makes a reasonable effort to locate records that are reasonably related to the request.[6] I am satisfied that the Director has the requisite experience and knowledge in diagnostic imaging to oversee the hospital’s searches to locate the protocol records that the appellant is seeking.

[42] While I acknowledge that the hospital has not provided affidavit evidence from each of the individuals involved in its searches, I am satisfied that, in the circumstances of this appeal, the hospital has demonstrated that reasonable efforts have been used to locate responsive records. Given the breadth of the appellant’s request, I am also satisfied that the hospital has corresponded with the appellant to clarify the requested records. Contrary to the appellant’s submission that the context of her request has been overlooked, I find that the hospital has provided the appellant with lists of the responsive directives and policies that it has located and has used reasonable efforts to explain why other records the appellant has identified, could not be located.

[43] With respect to the reference to “per protocol” in the Patient Order for Omnipaque 350, the hospital contacted the relevant department and advised that the protocol for contrast media in the case of Omnipaque 350 is defined by the vendor and automatically calculated by injection equipment to provide consistent flow. I am satisfied that this explanation is supported by the affidavit evidence of the Director that when staff in the Diagnostic Imaging department conducted searches for a physical or electronic protocol record, no written policy or protocol for Omnipaque or CT contrast was found.

[44] I accept the Director’s evidence that staff in the Diagnostic Imaging department reviewed its processes and protocols and determined that all dosage information associated with the administration of Omnipaque 350 is executed from within the power injectors. I find that this is a reasonable explanation for why no record relating to the protocol has been located.

[45] I am also satisfied that the Director’s affidavit provides details about the types of records searched, which included policy binders and folders, including the department’s electronic policy folder and the hospital’s electronic policy folder.

[46] I do not agree with the appellant’s submission that the hospital’s search is unreasonable because she had not “clarified” her request or narrowed the search to only records of Omnipaque 350 protocol. I find that the hospital has demonstrated that it understood the context for the request by addressing all the directives and protocols referenced in the Patient Order summary in its responses. I am also satisfied that the hospital did not narrow its searches to locate only the Omnipaque 350 protocol. In particular, the hospital refers to its email exchanges with the appellant in the decision letter. In the decision letter, the hospital itemises the records that the appellant has requested from the list of directives that it provided and sets out detailed responses for the other policies, protocols and directives that the appellant seeks. I am satisfied that this demonstrates that the hospital has neither narrowed the request nor adopted a narrow interpretation when conducting its searches.

[47] I acknowledge that the appellant wrote to the hospital and in one email, she sought clarification. However, I am not satisfied that the questions posed by the appellant in that email related to the scope of her access request. From my review of the appellant’s questions, the appellant is asking about the procedure followed by the radiologists. The appellant asks:

They (the radiologists) would nonetheless select certain parameters for the machine, right? Would this GE Healthcare document be a reference point for the [hospital’s] Diagnostic Imaging Department?

[48] In her emails with the hospital, the appellant clarified that her request included the protocols and directives referenced in a specified Patient Order summary. I find that in her query quoted above, the appellant asks about the use of the record she is seeking by technical staff in the Diagnostic Imaging department. I am satisfied that notwithstanding the fact that the hospital did not follow up on the appellant’s email, it did not relate to the scope of the appellant’s request. Accordingly, I find that the fact the appellant’s email was unanswered does not render the hospital’s search unreasonable.

[49] I have carefully reviewed the appellant’s representations and the information she has provided in support of her submission that documented protocols in respect of the Omnipaque 350 should exist. These submissions include suggestions for alternative locations where the protocols might be found, technical information relating to the role of radiologists, ordering of medications, calculation of contrast media and the operation of power injectors. It is beyond the scope of this appeal for me to make findings on these technical matters and I am not persuaded that it is necessary for me to do so to dispose of the issue in the appeal.

[50] The appellant’s representations do not relate to the hospital’s records relating to diagnostic imaging, which are the records at issue in this appeal. The hospital has conducted searches of the policy and protocol folders in its Diagnostic Imaging department, which I am satisfied is the location where its written protocols, if they exist, are likely to be found. There is no reasonable basis for me to find that responsive records should exist elsewhere, as the appellant suggests.

[51] The hospital has provided me with evidence from the Director of its Diagnostic Imaging department, informed by discussions with other staff in the department about dosage information associated with the Omnipaque 350, the fact that it is defined by the vendor and administered through the power injector to ensure consistent flow. There is no reasonable basis for me to find, and it is not necessary for me to find, that the power injector on the Omnipaque 350 operates in a different manner so that additional responsive records should exist.

[52] I have determined that the Director is an experienced employee with the requisite knowledge of the subject matter of the appellant’s request, namely diagnostic imaging. I have accepted the Director’s evidence about why no record exists in relation to the Omnipaque 350 order in the patient order summary that forms the context for the appellant’s request. I am not persuaded that the appellant’s representations provide a reasonable basis for me to reject the Director’s evidence.

[53] Finally, I do not agree with the appellant’s submission that the hospital’s search is unreasonable because different more recent versions of the document provided to her during mediation, ought to exist. The appellant requested a copy of the document entitled “Administration of Contrast Media/Intravenous Drugs (II-=80)” from a list of diagnostic imaging directives. Neither party has identified this document as the record relating to a protocol for Omnipaque 350 referenced in the Patient Order summary, which the appellant is seeking.

[54] I accept the Director’s statement that the document entitled “Administration of Contrast Media/Intravenous Drugs (II-80)” is under review and a revised policy relating to the administration of contrast media intravenous drugs is being developed. Accordingly, I find that whether or not an updated version of this document exists does not assist me in disposing of the issues in this appeal and is not a reasonable basis for finding that the hospital did not conduct a reasonable search.

[55] For all these reasons, I find that the hospital has conducted a reasonable search in response to the appellant’s request, as required by section 24  of the Act . Accordingly, I uphold the hospital’s search.

ORDER:

Appeal dismissed.

Original Signed by:		November 20, 2025
Katherine Ball
Adjudicator