When Supervision Falls Short

Posted: August 18, 2025

The Case

The College received a complaint from a patient who was referred to physiotherapy for a rehabilitation program. The patient had multiple injuries as a result of a workplace accident. They were assessed by a physiotherapist during their first appointment. After that, all care was provided by a physiotherapist assistant.

The patient reported they didn’t speak to the physiotherapist again after that initial visit. They were left to complete exercises independently with little guidance or oversight.

The patient also said they were not reassessed during their appointments at the clinic, despite worsening pain in their knee.

In response, the physiotherapist stated that the program was designed to be an independent exercise program with guidance provided as needed.

However, a review of the treatment plan found it lacked clarity and detail.

The physiotherapist said they planned to reassess the patient at the midway point of the treatment program – but the patient transferred to another clinic before that could happen.

The Standards

When a physiotherapist assigns care to a physiotherapist assistant, they remain responsible for that care. See the Working with Physiotherapists Assistants Standard for more details.

Some duties cannot be assigned and must be performed by the physiotherapist themselves. That includes anything that would require the physiotherapist assistant to change the treatment plan on their own without consulting with the physiotherapist.

For example, in this case, the treatment plan did not specify the number of exercise repetitions or which exercises could be weight-bearing. Similarly, the plan recommended stretching, but didn’t specify which areas of the body should be stretched.

By putting the physiotherapist assistant in a position where they would have to independently make choices about modifying the treatment plan, the physiotherapist failed to meet the requirement of the Working with Physiotherapist Assistants Standard.

Communication between the physiotherapist and the physiotherapist assistant also appeared to be lacking. When the patient reported worsening pain in their knee, this information was not relayed to the physiotherapist. As a result, the patient was not reassessed like they should have been.

According to the Working with Physiotherapists Assistant Standard, physiotherapists must have a written communication protocol that states how and when they will discuss patient care with the physiotherapist assistant, among other requirements.

The Outcome

After carefully reviewing the case, the committee decided to require the physiotherapist to work with a practice enhancement coach and review College resources on supervising physiotherapist assistants, communicating with patients, and ensuring clinical reasoning in treatment plans.

Record of the case will not appear on the Public Register.

Details of this case have been changed to maintain anonymity.