Lucas, Jan Pieter (CPSO#: 19577)

Current Status: Expired: Resigned from membership as of 01 Jan 2013

CPSO Registration Class: None as of 01 Jan 2013

Indicates a concern or additional information

Summary

Former Name: No Former Name

Gender: Male

Languages Spoken: Dutch, English

Education:University of Amsterdam, 1960

Practice Information

Primary Location of Practice
Practice Address Not Available

Specialties

Specialty Issued On Type
Anesthesiology Effective: 01 Jan 1968 RCPSC Specialist

Registration History

Action Issue Date
First certificate of registration issued: Postgraduate Education Certificate Effective: 12 Jul 1960
Transfer of class of registration to: Independent Practice Certificate Effective: 30 Jun 1965
Expired: Resigned from membership. Expiry: 01 Jan 2013

Previous Discipline Hearings

Committee: Discipline
Decision Date: 27 Oct 2016
Summary:

On October 27, 2016, the Discipline Committee of the College of Physicians and Surgeons of 
Ontario found that Dr. Jan Pieter Lucas has committed an act of professional misconduct in that 
he has failed to maintain the standard of practice of the profession, including with respect to his 
infection control practices, documentation, and preoperative assessments. 
 
Dr. Lucas, an anesthesiologist who received his certificate of independent practice in Ontario in 
1965, provided anesthesiology services at Downsview Endoscopy Clinic (“DEC”) in Toronto. 
He resigned his CPSO membership in 2013, when he was 83 years old, and has not practised 
medicine since. 
 
In August 2014, the College received a letter from Toronto Public Health reporting that three 
patients had been infected with Hepatitis C virus after undergoing endoscopy procedures at DEC. 
The letter led to the initiation of a s. 75(1)(a) investigation by the College. 
 
TORONTO PUBLIC HEALTH INVESTIGATION 
 
On June 6, 2013, a patient who had undergone a colonoscopy at DEC on December 7, 2011 was 
reported to Toronto Public Health as Hepatitis C virus positive (“Patient 1”). Toronto Public 
Health commenced an investigation.  
 
By matching patient lists and records of reported Hepatitis C virus cases, Toronto Public Health 
determined that three other patients who had undergone endoscopic procedures at DEC on 
December 7, 2011 were also Hepatitis C virus positive. Two of those patients (Patient 2 and 
Patient 3) were reported Hepatitis C virus positive after their procedures at DEC. The other 
patient (“Patient 0”), who had been seen prior to Patients 1, 2, and 3, was determined to be the 
source of the Hepatitis C virus outbreak. Patient 0’s Hepatitis C virus was genetically highly 
related to that of Patients 1, 2 and 3.  
 
Dr. Lucas acted as the anesthesiologist for the procedures on each of the four patients on the date 
in question, December 7, 2011. 
 
Toronto Public Health provided the College with its interim report of August 21, 2014 and final 
report of October 6, 2014, both of which concluded that Patients 1, 2 and 3 acquired Hepatitis C 
virus during their endoscopic procedures at DEC on December 7, 2011 and that Patient 0 was the 
source of the outbreak.   
 
Toronto Public Health noted that Hepatitis C virus transmission has often been documented as 
being linked to mishandling of multi-dose injectable medications. It concluded that it is possible 
that either a vial of propofol anesthetic or a vial of lidocaine (used to reduce the sting of the 
anesthetic) became contaminated after being used on the source patient.  
 
Dr. Lucas administered propofol anesthetic and lidocaine to all four patients during the 
procedures in question on December 7, 2011. Dr. Lucas acknowledged it was his practice to 
reuse syringes containing fentanyl between patients, only changing the needle. Toronto Public 
Health concluded that the contamination of fentanyl leading to transmission to all three patients 
did not seem likely. 
 
COLLEGE INVESTIGATION 
 
In written responses to the College investigation, Dr. Lucas admitted that it was not his practice 
to swab multi-dose vials before withdrawing medication. The propofol anesthetic and lidocaine 
used at DEC were contained in multi-dose vials.  
 
The College retained two experts in infection prevention and anesthesiology as Medical 
Inspectors to assist in its investigation.  
 
The first medical inspector concluded that: 
   -  Dr. Lucas did not meet the standard of practice with respect to infection control 
      procedures, documentation, and preoperative assessment, including: 
         -  No documentation of pre-procedure vitals, patient weight, NPO status, airway 
            assessment, physical examination, or post-procedure vitals or level of 
            consciousness; 
         -  No pre-operative blood glucose, despite the history of diabetes and oral 
            hypoglycemic medication; 
         -  Incomplete medication list; 
         -  Incomplete pre-anesthetic assessment; 
         -  Hypotension not treated on arrival and blood pressure not reassessed post-
            procedure to ensure it had returned to normal; and 
         -  Re-using fentanyl syringes between patients. 
   -  Dr. Lucas displayed a lack of skill and a lack of knowledge regarding appropriate 
      infection control practices in the setting of medication administration, including not being 
      aware of the risks involved in reusing syringes between patients; 
   -  Dr. Lucas’ clinical practice exposed his patients to harm, including by: 
         -  providing deep sedation without an appropriate pre-procedure assessment; 
         -  reusing syringes between patients. 
 
The first expert further opined: “It is well-established that syringes are easily contaminated 
especially when injecting directly into a saline lock. It is clearly below standard of care for a 
physician to re-use syringes or needles between patients and to be unaware of risk to 
patients…Theoretically, the top of the vial could become contaminated as a result of poor hand 
hygiene after the intravenous insertion. The medication inside could possibly become 
contaminated if the top of the vial was not appropriately cleaned before re-entering. There is no 
evidence that vials were deliberately contaminated.” 
 
The second expert concluded that Dr. Lucas did not meet the standard of practice with respect to 
infection control procedures. Dr. Lucas reused syringes of fentanyl between patients, only 
changing the needle. This posed significant risk to his patients. Further, Dr. Lucas’ care 
displayed a lack of skill and knowledge. Dr. Lucas should have been aware of the risks of 
reusing a syringe of medication between patients. This deficit was significant. 
 
Dr. Lucas has executed an undertaking never to engage in the practice of medicine again. 
 
PENALTY 
 
In light of Dr. Lucas’ undertaking never to engage in the practice of medicine again, on October 
27, 2016, the Discipline Committee ordered and directed that: 
   -  Dr. Lucas appear before the panel to be reprimanded; and 
   -  Dr. Lucas pay to the College costs in the amount of $5,000.00 within 30 days of the date 
      of this Order.

Decision: Download Full Decision (PDF)
Hearing Date(s): October 27, 2016

Concerns

Source: Member
Active Date: October 27, 2016
Expiry Date:
Summary:
Summary of the Undertaking given by Dr. Jan Pieter Lucas to the College of Physicians and Surgeons of Ontario, effective October 27, 2016:

Dr. Lucas was referred to the Discipline Committee on allegations of failing to maintain the standard of practice and incompetence. In the face of these allegations, Dr. Lucas has agreed never to apply or reapply for registration as a physician in Ontario or any other jurisdiction.
Download Full Document (PDF)