News Release

2014 - 11 - 27 Discipline Committee Decisions

Dr. Vijay Sharma; Dr. Eleazar Humberto Noriega; Dr. Rob Joseph Kamermans; Dr. Dolly Teresa Nahri

Nov 27, 2014

The College of Physicians and Surgeons of Ontario (“the College”) released the results of its most recent disciplinary hearings.  The College is the licensing and disciplinary body for physicians in Ontario.  Hearings are held to review allegations of professional misconduct and incompetence, and are open to the public.  The following are brief summaries of recent discipline hearing results.  The Discipline Committee’s full decisions and reasons for decisions are posted on the College’s website as they become available.  Full decisions are located by entering the doctor’s name in the Doctor Search section of the College’s website at www.cpso.on.ca.

Dr. Vijay Sharma, Toronto.  On September 24, 2014, the Discipline Committee found that Dr. Sharma committed acts of professional misconduct, in that he failed to maintain the standard of practice of the profession; and he has engaged in disgraceful, dishonourable or unprofessional. Dr. Sharma admitted to the allegations.

The College commenced an investigation into Dr. Sharma's practice in about July 2012, after it received information that raised concerns about Dr. Sharma's anesthesiology practice.

Dr. X, the independent expert retained by the College, reviewed 26 patient charts and found that Dr. Sharma failed to meet the standard of practice in the following respects:

  1. His record-keeping fell below the standard of care in respect of eight patients.
  2. In respect of Patient A, although Dr. Sharma monitored this intubated patient in the PACU over the course of a 31 minute period, he failed to properly hand over care to the on-call anaesthesiologist prior to leaving the hospital.
  3. In respect of Patient B, an elderly patient who was undergoing an urgent repair of a hip fracture and was found on preliminary echo study to have moderate aortic stenosis and insufficiency, Dr. Sharma administered spinal anesthesia but did not place an arterial line, which would have permitted close hemodynamic monitoring.
  4. In respect of Patient C who was assessed as having a potentially difficult airway, Dr. Sharma intubated the patient by administering a long-acting muscle relaxant (rocuronium) instead of a short-acting muscle relaxant.
  5. In respect of Patients D and E who were undergoing caesarean sections, Dr. Sharma administered 10 units of oxytocin as requested by an obstetrician, in circumstances in which this dosage may have caused a drop in blood pressure.
  6. In respect of Patient D, Dr. Sharma administered both intrathecal and epidural opioids (first administering 0.1 mg morphine during a combined spinal epidural prior to caesarean section followed several hours later in ICU by 0.125% marcaine infusion with opioid starting at 4 cc/hour) in a patient having a classical caesarean section in the presence of fibroids with a large midline incision and with severe hypertension, pre-eclampsia and pulmonary edema.
  7. In respect of Patient F, an asthmatic patient with a history of duodenal ulcer and for whom Dr. Sharma documented a history of GERD, Dr. Sharma used a laryngeal mask airway instead of an endotracheal tube for sinus surgery.

In respect of the finding of disgraceful, dishonourable and unprofessional conduct:

Dr. Sharma has on occasion left the operating room while his patients were undergoing procedures under anesthesia in a manner not in accordance with the then-current standard of practice in that he sometimes failed to appropriately communicate with others in the operating room.

In June 2007, one of Dr. Sharma's colleagues called in sick and therefore was not available to provide anesthesia in the operating room as scheduled. Dr. Sharma was scheduled to provide anesthesia services in the endoscopy suite that day. Dr. Sharma proceeded to provide anesthesia for the operating room cases rather than the list being cancelled. Instead of giving up the cases in the endoscopy suite, Dr. Sharma also provided IV conscious sedation for some patients in the endoscopy suite.

In the past, Dr. Sharma has on occasion used a computer for personal purposes in the operating room during surgery for which he was the attending anesthesiologist.

Dr. Sharma advised, and it was confirmed by the evidence of one of the nurses interviewed by the College, that he no longer uses a computer for personal use in the operating room.

Throughout the course of the College's investigation, Dr. Sharma showed ample promptness and cooperation with requests made by the College investigator, and, following receipt of Dr. X's reports, advised that he has incorporated positive changes into his practice in consideration of Dr. X's opinions.

He had a positive performance appraisal in April 2014. Dr. Sharma volunteered to assume the role of CME coordinator for the department of anesthesia and arranged four grand rounds in the first six months of 2014.

The Discipline Committee ordered a public reprimand and directed that the Registrar impose a number of terms, conditions and limitations on Dr. Sharma's certificate of registration, which are summarized as follows:

  1. Dr. Sharma shall complete, at his own expense, an educational program on communications facilitated by the College;
  2. Dr. Sharma shall, within 30 days from the date of this Order, retain a College-approved clinical supervisor, for a period of 12 months. Dr. Sharma will abide by all recommendations of his clinical supervisor with respect to practice improvements and/or professional development;
  3. Upon completion of this period of supervision, Dr. Sharma shall undergo a reassessment of his clinical practice by a College-appointed assessor. The results of the reassessment shall be reported to the College, which may use the reassessment results to ground further investigations or proceedings if appropriate; and
  4. Dr. Sharma shall be responsible for any and all costs associated with implementing the terms of this Order.

Dr. Sharma was further ordered to pay the College costs of the proceeding in the amount of $4,460.

Dr. Eleazar Humberto Noriega, Toronto. On November 3, 2014, the Discipline Committee found that Dr. Noriega committed acts of professional misconduct, in that he has engaged in sexual impropriety with a patient and he has engaged in disgraceful, dishonourable or unprofessional conduct.

The Committee found that Dr. Noriega inappropriately rubbed the clitoris of a teenage female patient during a medical appointment at a teen health clinic in 1979.

On November 25, 2014, Dr. Noriega appealed the decision on finding of the Discipline Committee to the Superior Court of Justice (Divisional Court).

The penalty hearing is scheduled for January 7, 2015.

Dr. Rob Joseph Kamermans, Coe Hill.  On November 7, 2014, the Discipline Committee found that Dr. Kamermans committed an act of professional misconduct, in that he failed to maintain the standard of practice of the profession. The Committee also found that Dr. Kamermans is incompetent.

Dr. Kamermans failed to maintain the standard of practice of the profession in his care and treatment in the Emergency Department of six patients (Patients 1 to 6) and in his medical documentation regarding nine patients (Patients 1 to 6, 12, 14, and 22). Dr. Kamermans' deficiencies in his care and treatment of the six patients displayed a lack of knowledge and judgment of a nature and to an extent that the allegation of incompetence was proved.

Regarding Patient #1, a child who presented with fever, stomach ache and vomiting, Dr. Kamermans failed to maintain the standard of practice in his documentation and care. Dr. Kamermans failed to do an ultrasound to rule out appendicitis, a significant differential diagnosis, and was deficient in his assessment and treatment of what he described as pharyngitis. Dr. Kamermans' deficiencies in his care of this patient displayed a lack of knowledge and judgment.

Regarding Patient #2, an adult patient with rectal bleeding, rectal pain and a recent diagnosis of metastatic rectal cancer, Dr. Kamermans' documentation and care failed to meet the standard of practice. Dr. Kamermans failed to properly evaluate the rectal bleeding and failed to adequately manage the rectal pain. Dr. Kamermans displayed a lack of knowledge and judgment in his investigation and management of the patient and in his inability to outline his approach to this patient.

Regarding Patient #3, an elderly patient with chest tightness, intermittent shortness of breath for the preceding twelve hours, heart rate of 162 and an implanted pacemaker/defibrillator, Dr. Kamermans diagnosed supraventricular tachycardia (SVT), rather than the correct diagnosis of ventricular tachycardia (VT), and prescribed Diltiazem, a medication which was contraindicated for this patient. When his treatment failed and the patient's symptoms worsened, Dr. Kamermans called in a consultant who properly treated the patient. The Committee found that Dr. Kamermans' care and documentation for this patient failed to meet the standard of practice and that he displayed a lack of judgment and a cavalier attitude considering the urgency of the situation. The Committee found that Dr. Kamermans demonstrated a lack of knowledge and judgment that the evidence established persists to the present day.

Regarding Patient #4, a child with respiratory distress, shortness of breath, a slightly dusky appearance and moderate to severe croup, Dr. Kamermans' care of this patient failed to meet the standard of practice both in terms of documentation and treatment of this sick child. Dr. Kamermans used medication that was not helpful for croup and was not up to date with the current medication standards. The Committee found that Dr. Kamermans demonstrated a lack of knowledge and judgment with regard to the treatment of croup and that his knowledge deficits are current.

Regarding Patient #5, a child who was brought to Emergency with a history of possible antifreeze ingestion, Dr. Kamermans failed to maintain the standard of practice and was cavalier in the treatment of this patient. Dr. Kamermans appropriately obtained information from the Poison Control Centre but did not use it. He failed to order the recommended blood work, he failed to order an adequate observation period, and he assumed the child had not ingested much without any grounds to make that assumption, and he failed to appreciate the serious risk to the child of ingesting even a small amount. It was the Committee's view that Dr. Kamermans' knowledge and judgment deficiencies persist with respect to how to properly address the issue of the ingestion of antifreeze by a child.

Regarding Patient #6, an elderly patient with dementia who presented to the Emergency after an unwitnessed fall, Dr. Kamermans failed to maintain the standard of practice in his investigation, evaluation and documentation.  The Committee found Dr. Kamermans' investigation of the causal factors rudimentary. Although he said his physical examination of the heart would rule out some cardiac causes, he did not do an ECG, which would have been indicated. Similarly, he did not do further x-rays or a CT scan of the neck, which was indicated by Canadian standards. The Committee found Dr.  Kamermans' knowledge and judgment in the care of this patient deficient, and that those deficiencies are current.

A penalty hearing is yet to be scheduled.

Dr. Dolly Teresa Nahri, Ottawa.  On November 25, 2014, the Discipline Committee found that Dr. Nahri committed an act of professional misconduct, in that she has failed to maintain the standard of practice of the profession, and she has engaged in disgraceful, dishonourable or unprofessional conduct. Dr. Nahri admitted to the allegations.

In March 2007, Dr. Nahri acquired her own clinic where during the material time she provided family physician services, including walk-in services. Dr. Nahri’s staff included international medical graduates who were not Ontario licensed physicians, who were directly involved in patient care. Dr. Nahri inadequately supervised these individuals and did not delegate care to them appropriately. While delegation is permissible under College policy if certain criteria are met and procedures are followed, Dr. Nahri failed to familiarize herself with her professional obligations in this regard.

In October 2010, the College received a complaint from Patient A, a patient in Dr. Nahri’s family practice who saw Dr. Nahri once regarding her pregnancy and received further pregnancy-related care from a staff member on three occasions in 2010. Dr. Nahri was not present in the office for any of the appointments between the staff member and Patient A. Dr. Nahri reviewed Patient A’s chart and discussed Patient A’s care with the staff member during this time period, but this was not documented. Patient A believed that the staff member was a registered physician.

The staff member had never been registered to practise medicine in Ontario. Initially Dr. Nahri accompanied her into the examination room to see patients, but over time the staff member came to receive minimal direct supervision, including while performing controlled acts. Dr. Nahri did not provide medical directives, but did review the staff member’s care and orally approve or correct it. The staff member identified herself to patients as “Dr.,” as did Dr. Nahri’s staff. Services performed by her were billed to the Ontario Health Insurance Plan under Dr. Nahri’s billing number. The fees received were shared between Dr. Nahri and the staff member who received a 35% share.

The College retained an independent expert who opined that the clinical outcome experienced by Patient A was not adversely affected by the care provided by the staff member. However, Dr. Nahri demonstrated lack of knowledge regarding appropriate delegation, lack of skill in appropriately obtaining patient consent and providing appropriate supervision, and lack of judgment with respect to the use of stamped prescription pads. Harm or injury might occur in light of the degree to which Dr. Nahri was delegating roles and responsibilities in a clinical setting without appropriate supervision.

In September 2010, the College initiated a broad investigation into Dr. Nahri’s practice. Private investigators posed as patients seeking care and were seen at Dr. Nahri’s clinic by individuals who were not registered physicians. College investigators interviewed workers and learned that Dr. Nahri had left pre-signed prescription pads, requisition pads, and consultation requests for use by staff providing patient care, and that office staff billed the Ontario Health Insurance Plan using Dr. Nahri’s billing number for services provided by staff members. Information was provided that supervision was sometimes provided by telephone. The College retained the independent expert as a Medical Inspector to evaluate the care provided by Dr. Nahri, including with respect to her supervision of and delegation to staff. Dr. X reviewed information obtained during the investigation, as well as the charts of 28 patients (including those of the private investigators retained by the College who attended at Dr. Nahri’s clinic).

Dr. X found, among other things:

  • Supervision of staff and delegation of controlled acts fell below the expectations and the standards of the profession. Dr. Nahri’s clinical practice, behaviour and conduct in this regard exposed her patients to potential harm or injury.
  • It was difficult to determine from the charts who was providing the care, as notations were not signed. Charting was below the standard of practice of the profession. Dr. Nahri failed to document patient consent to be examined and treated by a staff member. In many cases management of continuity of care was below the standard of practice.

Dr. Nahri cooperated throughout the College investigation. In her response to Dr. X’s report, Dr. Nahri acknowledged that she had not provided adequate supervision and delegation to the individuals working in her clinic during the period in question. She stated that as a result of the College investigation she had “made many positive changes in her practice,” including reducing the size of her practice and ceasing to provide walk-in care. In addition, she described improvements made to her record-keeping, including with regard to completion of cumulative patient profiles, diabetic flow sheets, well baby growth charts, and immunization records.

After investigators attended at the clinic in November 2010, Dr. Nahri agreed to enter into an interim undertaking with the College to protect patients while the College investigation was ongoing, or until any allegations against her were finally determined by the Discipline Committee. As a result, Dr. Nahri ceased to employ international medical graduates or other unregulated workers to provide patient care.

The interim undertaking obliged Dr. Nahri to review the records of all patients who had received patient care directly from staff members, and to document having done so. Dr. Nahri did undertake such a review as required. However, initially she failed to adequately document her review, in breach of her undertaking. After being alerted to the problem by the College in 2011, Dr. Nahri took steps to document her review.

Since entering into her interim undertaking with the College, Dr. Nahri has reduced the size of her practice and has become a sole practitioner. Dr. Nahri has never before been the subject of discipline proceedings. Prior to the investigations underlying this matter, Dr. Nahri had been the subject of one public complaint since receiving her certificate of independent practice in 1993, in an unrelated matter with respect to which no action was ultimately taken.

The Committee ordered a public reprimand and a six-month suspension of Dr. Nahri’s certificate of registration that will commence on January 1, 2015.  Furthermore, a number of terms, conditions and limitations were imposed on Dr. Nahri’s certificate of registration, that are summarized as follows:

  1. Dr. Nahri shall successfully complete a one-on-one educational program in ethics acceptable to the College.
  2. Dr. Nahri shall, before June 1, 2015, retain a College-approved clinical supervisor. Commencing on the day that Dr. Nahri resumes practice following her suspension, Dr. Nahri may practice only under the supervision of the clinical supervisor and will abide by all recommendations of her clinical supervisor with respect to her practice, including but not limited to her record-keeping, practice improvements, practice management, and continuing education. Dr. Nahri shall no longer be subject to this term, condition and limitation after a period of at least 12 months, and shall be released therefrom only upon receipt of satisfactory report(s) from her clinical supervisor and approval, in its sole discretion, by the College.
  3. If Dr. Nahri fails to retain a clinical supervisor as required above or if, prior to the completion of the required period of supervision above, Dr. Nahri’s clinical supervisor is unable or unwilling to continue in that role, Dr. Nahri shall retain a new College-approved clinical supervisor, failing which she shall cease to practice until such time as she has retained a College-approved clinical supervisor.
  4. Approximately 12 months following the completion period of supervision, Dr. Nahri shall undergo a reassessment of her practice by a College-appointed assessor. Dr. Nahri shall abide by all recommendations made by the assessor, who shall report the results of the assessment to the College.
  5. Dr. Nahri shall consent to sharing of information among the assessor, the clinical supervisor, the College and the provider of the educational program in ethics.
  6. Dr. Nahri shall inform the College of each and every location where she practices until the report of the assessment of her practice has been reported to the College.
  7. Dr. Nahri shall cooperate with unannounced inspections of her practice and patient charts by a College representative(s); and to the College making enquiries of OHIP and/or any person who or institution that may have relevant information for the purpose of monitoring and enforcing her compliance with the terms of this order.
  8. Dr. Nahri shall be responsible for any and all costs associated with implementing the terms of this order.

Dr. Nahri was further ordered to pay the College costs in the amount of $4,460.