As from March 30, 2017, the following is imposed as a term, condition and
limitation on the certificate of registration held by Dr. Joseph Thomas
Gleeson, in accordance with an undertaking and consent given by Dr. Gleeson to
the College of Physicians and Surgeons of Ontario:
UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
("Undertaking")
of
DR. JOSEPH THOMAS GLEESON
("Dr. Gleeson")
to
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
(the "College")
A. PREAMBLE
(1) In this Undertaking:
"Code" means the Health Professions Procedural Code, which is Schedule 2
to the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, as
amended;
"ICR Committee" means the Inquiries, Complaints and Reports Committee of
the College;
"OHIP" means the Ontario Health Insurance Plan;
"Public Register" means the College's register that is available to the
public.
(2) I, Dr. Gleeson, certificate of registration number 77134, am a member of
the College. The College has received information regarding my standard
of practice.
(3) I, Dr. Gleeson, acknowledge that an external review of my obstetrical
practice at Muskoka Algonquin Healthcare ("MAH") was conducted, resulting
in a report received by the College on October 3, 2013. The external
review identified concerns about my obstetrical practice.
(4) I, Dr. Gleeson, acknowledge that I voluntarily relinquished my
obstetrical privileges at MAH in February 2013, and have not practised
obstetrics since that time. I confirm I have no obstetrical privileges at
any other hospital.
(5) I, Dr. Gleeson, acknowledge that the College initiated an investigation
bearing File Number 7213622 (the "Investigation") into my standard of
practice. This investigation resulted in a report dated October 6, 2016.
The Independent Assessor identified concerns about my obstetrical
practice.
B. UNDERTAKING
(6) I, Dr. Gleeson, undertake to abide by the provisions of this Undertaking,
effective immediately.
(7) Residency Program
(a) I, Dr. Gleeson, undertake to successfully complete a three month
residency program in Advanced Skills Low Risk Obstetrics at a
location suitable to the College as set out in the Individualized
Education Plan ("IEP"), attached hereto as Appendix "A".
(8) Practice Restriction
(a) I, Dr. Gleeson, agree that prior to the completion of the Advanced
Skills Low
Risk Obstetrics Residency Program, I shall not return to
independent obstetrical practice in any jurisdiction. For great
certainty, this restriction shall not prevent or preclude me from
completing the Residency Program described in (7) above.
(9) Clinical Supervision
(a) I, Dr. Gleeson, upon successful completion of the Advanced Skills
Low Risk Obstetrics Residency Program, undertake to practise under
the guidance of a clinical supervisor(s) acceptable to the College
(the "Clinical Supervisor(s)"), for nine (9) months ("Clinical
Supervision").
(b) I, Dr. Gleeson, acknowledge that I have reviewed the Clinical
Supervisor(s)'s undertaking, attached hereto as Appendix "B", and
understand what is required of the Clinical Supervisor(s). The
Clinical Supervisor(s) will, at minimum:
(i) Facilitate the education program set out in the IEP attached
as Appendix "A";
(ii) Meet with me at my Practice Location, or another location
approved by the College, once every month;
(iii) Review at least twenty (20) of my patient charts at every
meeting or in the event that I have seen less than twenty
patients in that month, review all of my obstetrical charts;
(iv) Directly observe a minimum of ten (10) deliveries and comment
on these;
(v) Discuss any concerns arising from the chart reviews;
(vi) Make recommendations to me for practice improvements and
ongoing professional development and inquire into my
compliance with the recommendations;
(vii) Perform any other duties, such as reviewing other documents
or conducting interviews with staff or colleagues, that the
Clinical Supervisor(s) deem necessary to my Clinical
Supervision; and
(viii)Submit written reports to the College at least once every
three (3) months, or more frequently if the Clinical
Supervisor(s) has concerns about my standard of practice.
(c) I, Dr. Gleeson, acknowledge that the charts reviewed shall be
selected by the Clinical Supervisor(s) based on the educational
needs identified in the IEP, attached hereto as Appendix "A", as
well as the areas of concern identified in the report of the
external review and the report of the medical inspector dated
October 6, 2016, and concerns that may arise during the period of
Clinical Supervision.
(d) I, Dr. Gleeson, undertake to cooperate fully with the Clinical
Supervision of my practice, conducted under the term of this
Undertaking and Appendix "A" and "B" to this Undertaking, and to
abide by the recommendations of my Clinical Supervisor(s),
including but not limited to, any recommended practice improvements
and ongoing professional development.
(e) I, Dr. Gleeson, undertake to ensure that Appendix "B" to this
Undertaking is signed and delivered to the College within thirty
(30) days of the date I commence obstetrical practice.
(f) I, Dr. Gleeson, undertake that if a person who has given an
undertaking in Appendix "B" to this Undertaking is unable or
unwilling to continue to fulfill its provisions, I shall, within
twenty (20) days of receiving notice of same, obtain an executed
undertaking in the same form from a similarly qualified person who
is acceptable to the College and ensure that it is delivered to the
College within that time.
(g) I, Dr. Gleeson, undertake that if I am unable to obtain a Clinical
Supervisor on the provisions set out under sections (9)(f) and/or
(g) above, I will cease practising obstetrics until such time as I
have obtained a Clinical Supervisor acceptable to the College.
(h) I, Dr. Gleeson, acknowledge that if I am required to cease
practicing obstetrics as a result of section (9)(g) above this will
constitute a term, condition or limitation on my certificate of
registration and that term, condition or limitation will be
included on the public register.
(10) Professional Education
(a) I, Dr. Gleeson, undertake to participate in and successfully
complete all aspects of the detailed IEP, attached hereto as
Appendix "A", including all of the following professional education
(the "Professional Education"):
(i) Complete the : "Alarrn" and "MOREOB" Courses, if available,
or if not, alternate courses acceptable to the College; and
(ii) review and complete a written summary of CPSO Policy on
"Consent to Treatment" and CMA "Code of Ethics".
(b) I, Dr. Gleeson, undertake to complete this requirement within six
months or, if no satisfactory program is available by that time, by
the first possible opportunity thereafter.
(11) Reassessment of Practice
(a) I, Dr. Gleeson, undertake that, approximately twelve (12) months
after the completion of the Clinical Supervision set out in section
(9) above and Appendix "A" and "B" to this Undertaking, I will
submit to a reassessment of my practice ("the Reassessment") by an
assessor or assessors selected by the College (the "Assessor(s)").
I acknowledge that the Reassessment may include a chart review,
direct observation of my care, interviews with colleagues and
co-workers, feedback from patients and any other tools deemed
necessary by the College.
(b) I, Dr. Gleeson, undertake to co-operate fully with the
Reassessment, conducted under the term of this Undertaking.
(c) I, Dr. Gleeson, acknowledge that my Clinical Supervisor(s) may
receive and review the findings of the Assessor(s), and may discuss
with the Assessor(s) any issues or concerns arising from the
Reassessment. I also acknowledge that the results of the
Reassessment will be provided to me and reported to the College and
the report may form the basis of further action by the College.
(d) I, Dr. Gleeson, acknowledge that if I am of the view that any of
the Assessor(s)'s recommendations are unreasonable, I will have
thirty (30) days following my receipt of the recommendations within
which to provide the College with my submissions in this regard. I
further acknowledge that thereafter, the ICR Committee will
consider my submissions and make a determination regarding whether
or not the recommendations, or any of them, are reasonable and if
so, whether they, or any of them, constitute limitations or
restrictions on my practice, and that decision will be provided to
me.
(e) I, Dr. Gleeson, undertake that, following the decision referenced
in section (11)(d) above, I will abide by those recommendations of
the Assessor(s) that the ICR Committee has determined are
reasonable.
(f) I, Dr. Gleeson, hereby consent to any of the following being
included on the public register as terms, conditions or limitations
on my certificate of registration, for the purposes of section 23
of the Code:
(i) any recommendations of the Assessor(s) which are terms,
conditions or limitations on my practice; and
(ii) any recommendations of the Assessor(s) which the ICR
Committee has identified in its decision referenced in
section (11)(d) as terms, conditions or limitations on my
practice.
(12) Monitoring
(a) I, Dr. Gleeson, undertake to inform the College of each and every
location that I practise or have privileges, including, but not
limited to, hospital(s), clinic(s) and office(s), in any
jurisdiction (collectively my "Practice Location(s)"), within five
(5) days of executing this Undertaking. Going forward, I further
undertake to inform the College of any and all new Practice
Locations within five (5) days of commencing practice at that
location.
(b) I, Dr. Gleeson, undertake that I will submit to, and not interfere
with, unannounced inspections of my Practice Location(s) and
patient records by a College representative for the purposes of
monitoring my compliance with the provisions of this Undertaking.
(c) I, Dr. Gleeson, give my irrevocable consent to the College to make
appropriate enquiries of OHIP, and/or any person who or
institution that may have relevant information, in order for the
College to monitor my compliance with the provisions of this
Undertaking.
(d) I, Dr. Gleeson, acknowledge that I have executed the OHIP form(s),
attached hereto as Appendix "C".
C. ACKNOWLEDGEMENT
(13) I, Dr. Gleeson, acknowledge that all appendices attached to or referred
to in this Undertaking form part of this Undertaking.
(14) I, Dr. Gleeson, acknowledge and undertake that I shall be solely
responsible for payment of all fees, costs, charges, expenses, etc.
arising from the implementation of any of the provisions of this
Undertaking.
(15) I, Dr. Gleeson, acknowledge that I have read and understand the
provisions of this Undertaking and that I have obtained independent legal
counsel in reviewing and executing this Undertaking, or have waived my
right to do so.
(16) I, Dr. Gleeson, acknowledge that the College will provide this
Undertaking to any Chief of Staff, or a colleague with similar
responsibilities, at any Practice Location ("Chief(s) of Staff").
(17) I, Dr. Gleeson, acknowledge that a breach by me of any provision of this
Undertaking may constitute an act of professional misconduct and/or
incompetence, and may result in a referral of specified allegations to
the Discipline Committee of the College.
(18) I, Dr. Gleeson, acknowledge that this Undertaking constitutes terms,
conditions, and limitations on my certificate of registration for the
purposes of section 23 of the Code.
(19) Public Register
(a) I, Dr. Gleeson, acknowledge that, during the time period that this
Undertaking remains in effect, this Undertaking shall be posted on
the Public Register.
(b) I, Dr. Gleeson, acknowledge that, in addition to this Undertaking
being posted in accordance with section (19)(a) above, the
following summary shall be posted on the Public Register during the
time period that this Undertaking remains in effect:
A College investigation was conducted into Dr. Gleeson's
obstetrical practice. As a result of the investigation:
* Dr. Gleeson will complete a three (3) month residency
in obstetrics.
* Dr. Gleeson has agreed not to return to independent
obstetrical practice in any jurisdiction until he has
completed the residency program.
* Further to the completion of the residency program, Dr.
Gleeson will practice under the guidance of a Clinical
Supervisor acceptable to the College for nine (9)
months.
* Dr. Gleeson's practice will be reassessed by an
assessor selected by the College within twelve (12)
months of the end of the period of Clinical
Supervision.
D. CONSENT
(20) I, Dr. Gleeson, give my irrevocable consent to the College to provide the
following information to any person who requires this information for the
purposes of facilitating my completion of the Professional Education and
to all Clinical Supervisors, and/or Assessors:
(a) any information the College has that led to the circumstances of my
entering into this Undertaking;
(b) any information arising from any investigation into, or assessment
of, my practice; and
(c) any information arising from the monitoring of my compliance with
this Undertaking.
(21) I, Dr. Gleeson, give my irrevocable consent to the College to provide all
Chief(s) of Staff with any information the College has that led to the
circumstances of my entering into this Undertaking and/or any information
arising from the monitoring of my compliance with this Undertaking.
(22) I, Dr. Gleeson, give my irrevocable consent to any persons who facilitate
my completion of the Professional Education, and to all Clinical
Supervisors, Chiefs of Staff and Assessors, to disclose to the College,
and to one another, any information:
(a) relevant to this Undertaking;
(b) relevant to the provisions of the IEP at Appendix "A" and the
Clinical Supervisor's undertaking set out at Appendix "B" to this
Undertaking;
(c) relevant to the Reassessment;
(d) relevant for the purposes of monitoring my compliance with this
Undertaking; and/or
(e) which comes to their attention in the course of providing the
Professional Education and which they reasonably believes indicates
a potential risk of harm to my patients.