THE FOLLOWING INFORMATION WAS OBTAINED FROM THE FIND A DOCTOR SECTION OF THE WEBSITE OF THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO WWW.CPSO.ON.CA

Date: 16/01/2018 4:51:28 AM

Leung, Kelvin Wing-Ming (CPSO#: 65257)

Current Status: Suspended as of 18 Dec 2017

CPSO Registration Class: Restricted as of 10 Feb 2017

Indicates a concern or additional information

Summary

Former Name: No Former Name

Gender: Male

Languages Spoken: English

Education:University of Toronto, 1992

Practice Information

Primary Location of Practice
Practice Address Not Available
View Professional Corporation Information

Professional Corporation Information

Corporation Name: Dr. Kelvin W. M. Leung Medicine Professional Corporation

Certificate of Authorization Status: Issued Date:  Jun 03 2004

Shareholders:
Dr. K. Leung ( CPSO# 65257 )

Business Address:
Unit 4A
62 Overlea Boulevard
Toronto ON  M4H 1C4
Phone Number: (416) 425-8800

Postgraduate Training

Please note: This information may not be a complete record of postgraduate training.

University of Toronto, 15 Jun 1992 to 14 Jun 1993
Resident 1 - Family Medicine

University of Toronto, 01 Jul 1993 to 30 Jun 1994
Resident 2 - Family Medicine

Registration History

Action Issue Date
First certificate of registration issued: Postgraduate Education Certificate Effective: 15 Jun 1992
Transfer of class of registration to: Independent Practice Certificate Effective: 18 Jun 1993
Transfer of class of certificate to: Restricted certificate Effective: 10 Feb 2017
Terms and conditions amended by Discipline Committee Effective: 11 Dec 2017
Suspension of registration imposed: Discipline Committee Effective: 18 Dec 2017

Practice Restrictions

Registration Status: Suspended     Effective From: 18 Dec 2017


Imposed By Effective Date Expiry Date Status
Discipline Committee Effective: 18 Dec 2017 Active

Previous Discipline Hearings

Committee: Discipline
Decision Date: 11 Dec 2017
Summary:

On December 11, 2017, the Discipline Committee found that Dr. Kelvin Wing-Ming Leung 
committed an act of professional misconduct, in that:  he has he has failed to maintain the standard 
of practice of the profession; and, he has engaged in an act or omission relevant to the practice of 
medicine that, having regard to all the circumstances, would reasonably be regarded by members as 
disgraceful, dishonourable, or unprofessional. 
 
2014 Mandatory Report 
 
In December 2014, the College received a mandatory report from a family physician expressing 
concern about Dr. Leung’s treatment of hemorrhoids in an 18 yr. old patient who had attended at 
Dr. Leung’s office for a follow up for chlamydia. The patient did not consent to be identified in the 
report. 
 
Patient A 
 
In December 2014, Patient A presented at Dr. Leung’s office with left knee pain. On examining her 
left hip and lower abdomen, Dr. Leung queried a potential ovarian abnormality. Dr. Leung 
conducted a vulvar, pelvic and visual peri-anal examination of Patient A, during which he noted an 
internal hemorrhoid, which he proceeded to incise and cauterize.  
 
In January 2015, following Patient A’s complaint, the medical expert retained by the College 
opined that while the recommended  plan to use anti-in?ammatories and to participate in physical 
therapy seemed appropriate, Dr. Leung did not meet the standard of practice of the profession in his 
care of Patient A including: poor record keeping, examining the patients lower abdomen when not 
indicated, a pelvic exam when not indicated, a peri-anal exam in an asymptomatic patient, and 
subsequently recommending and performing a hemorrhoid treatment that was neither indicated nor 
evidence based. The medical expert concluded that Dr. Leung’s treatment of Patient A fell below 
the standard of practice of the medical profession and that providing this patient with a non-
indicated pelvic exam and subsequently a non-indicated hemorrhoid treatment exposed this patient 
to harm. He further concluded that Dr. Leung`s knowledge and judgment with respect to 
hemorrhoid treatments and performing non indicated peri-anal and pelvic exams falls well below 
the standard of practice of the profession.  
 
Dr. Leung retained a medical expert who pointed out that Patient A acknowledged during an 
interview with the College that nothing seemed out of the ordinary about the pelvic examination 
and in her mind, it was like a normal vaginal examination. 
 
The Investigation 
 
The College conducted an investigation pursuant to s. 75(1)(a) of the Health Professions 
Procedural Code of Dr. Leung’s practice of hemorrhoid treatment. When advised of the 
Investigation and the potential concerns regarding the appropriateness of his hemorrhoid 
procedures, Dr. Leung voluntarily stopped performing all hemorrhoid procedures and has not 
performed any hemorrhoid procedures since that time. He has agreed not to perform any such 
procedures in the future. 
 
Upon reviewing 10 female patients’ charts, the medical expert retained by the College made 
positive findings including:  Dr. Leung appropriately treated one patient and she was comfortable 
with the care provided for genital warts; a patient’s UTI was treated appropriately; a third patient 
had an appropriate pelvic exam and vaginal swab and education about conservative measures; a 
fourth patient had an appropriate pelvic exam and Dr. Leung displayed a good knowledge base 
regarding the differential diagnosis of pelvic pain; regarding a fifth patient, there was no concern 
regarding Dr. Leung’s knowledge, judgment or skill and he is not exposing patients to harm 
regarding prenatal care; in a sixth patient, plantar wart treatment was well documented and 
appropriate; a seventh patient was treated appropriately for peri anal warts. The medical expert 
concluded that Dr. Leung fell below the standard of care expected by the profession in 9 of the 10 
charts reviewed; his knowledge and judgement with respect to hemorrhoid treatments fell below the 
standard of care of the profession; and providing these treatments exposed 9 patients to potential 
harm. Specific concerns included: 

-  Dr. Leung performing intimate exams (rectal, peri-anal) without clear indication and consent 
-  Multiple rectal area exams and hemorrhoid treatments did not have clear explicit indications 
-  Lack of informed consent to perform intimate exams and hemorrhoid treatments 
-  Dr. Leung’s record keeping in all ten charts fell below the standard expected. 
 
Upon reviewing 10 male patients’ charts, the medical expert made positive findings including:   
Dr.  Leung appropriately  recommended  conservative  measures  for  one  patient’s  anal 
complaint; regarding treatment of hemorrhoid concerns in four patients, Dr. Leung met the 
standard of practice of the profession, did not display a lack of knowledge, lack of skill, nor 
a lack of judgment and did not expose patients to harm. However, the expert opined that Dr. 
Leung's record-keeping fell below the standard of practice of the profession in all 10 cases. 
Dr. Leung met the standard of practice in his care of 4 out of 10 patients. In 5 of 10 patient 
charts reviewed, Dr. Leung displayed a lack of knowledge and judgment with respect to the 
hemorrhoid treatment. He was over treating hemorrhoids without a period of conservative 
measures; the treatment protocol was not evidence-based and is not the standard of practice. 
Dr. Leung exposed 5 out of 10 patients to potential harm in performing a procedure on the 
perineum that was not indicated. 
 
The medical expert retained by Dr. Leung indicated that genital urinary (GU) examinations were 
performed on 5 of the female patients for legitimate reasons. 
 
2017 Interim Order of the ICRC 
 
On January 18, 2017, allegations of Dr. Leung's professional misconduct were referred to the 
Discipline Committee. On February 10, 2017, the Inquiries, Complaints and Reports Committee 
(ICRC) made an interim order which included, among other things, the following requirements:  
 
-   Dr. Leung is not to perform hemorrhoid procedures; 
-   Dr. Leung is to post a sign in his office indicating that Dr. Leung must not perform hemorrhoid 
    procedures; 
-   Dr. Leung is not to engage in any professional encounters except in the presence of a Practice 
    Monitor;  
-   Dr. Leung is to post a sign in his office indicating that Dr. Leung must not have any 
    professional encounters with any patients unless a practice monitor is present and that Dr. 
    Leung must not be alone with any patients in any examination or consultation room; 
-   Dr. Leung is to notify patients of the details of the restriction to practice unless a Practice 
    Monitor is present; 
-   Dr. Leung is to maintain a log of all intimate examinations conducted and the indication for the 
    examination and ensure his Practice Monitor verifies the accuracy; 
-   Dr. Leung is to practice under the guidance of a clinical supervisor; and 
-   Dr. Leung is to consent and submit to monitoring by the College. 
 
Dr. Leung billed for all of the services at issue. 
 
Compliance and Monitoring 
 
On March 1, 2017, Compliance Monitoring and Supervision conducted an unannounced 
compliance visit to Dr. Leung’s office. It was observed that the Practice Monitor did not have her 
own username for the electronic medical records (EMR) system and was signing off patient 
encounter notes under Dr. Leung’s username. Once Dr. Leung was informed that he must provide 
the Practice Monitor with her own password that is unknown to other clinic users, he contacted the 
EMR vendor to make arrangements. On March 8, 2017, the Practice Monitor informed the College 
that Dr. Leung had provided her with her own a username. Dr. Leung provided the Practice Monitor 
with her own password by March 23, 2017. 
 
On March 29, 2017, the College received a document from the Practice Monitor that Dr. Leung had 
given the Practice Monitor, authored by Dr. Leung, in which Dr. Leung expressed his feelings with 
respect to the College process. 
 
On May 2, 2017, an additional allegation was referred to the Discipline Committee that Dr. Leung 
engaged in disgraceful, dishonourable or unprofessional conduct in his conduct in implementing the 
s.37 Order, including in his dealings with his practice monitor and patients.  
 
The following facts were presented during the penalty portion of the hearing:   
-  Dr. Leung has not had any prior allegations referred to the Discipline Committee or findings 
   made against him.  
-  Dr. Leung has had a Practice Monitor present for every patient encounter since February 10, 
   2017. 
-  Since the Interim Order has been in place, Dr. Leung has had to arrange for 5 different Practice 
   Monitors acceptable to the College. He has had up to four Practice Monitors at one time in order 
   to have adequate coverage but currently only has two Practice Monitors because of Practice 
   Monitors leaving for other positions.  
-  Dr. Leung has paid all of the costs associated with the practice monitoring.   To date, the costs 
   of practice monitoring are approximately $29,500. 
 
 
 
 
 
 
Disposition 
 
On December 11, 2017, the Committee ordered and directed that: 
 -  the Registrar suspend Dr. Leung’s Certificate of Registration for a two month period 
    commencing December 18, 2017. 
 -  the Registrar impose the following terms, conditions and limitations on Dr. Leung’s Certificate 
    of Registration: 
    a) Practice Restriction 
       (i)  Dr. Leung shall not perform hemorrhoid procedures. 
       Posting a Sign (Practice Restriction) 
       (ii) Dr. Leung shall post a sign in the waiting room(s) of all his Practice Locations, in a 
            clearly visible and secure location, in the form set out at Appendix “A.”  For further 
            clarity, this sign shall state as follows: “Dr. Leung must not perform hemorrhoid 
            procedures. Further information may be found on the College of Physicians and 
            Surgeons of Ontario website at www.cpso.on.ca”. 
       (iii) Dr. Leung shall post a certified translation(s) in any language(s) in which he provides 
            services, of the sign described above in the waiting room(s) of all his Practice 
            Locations, in a clearly visible and secure location, in the form set out at Appendix 
            “A.”  
       (iv) Dr. Leung shall provide the certified translation(s) to the College within thirty (30) 
            days of the date of this Order. 
       (v)  If Dr. Leung elects, after the date of this Order, to provide services in any other 
            language(s), he will notify the College prior to providing any such services.  
       (vi) Dr. Leung shall provide to the College the certified translation(s) prior to beginning 
            to provide services in the language(s) described in (v) above. 
   b) Practice Monitor and Patient Log 
       (i) Dr. Leung shall not engage in any professional encounters of any kind (the “Patient 
           Encounter”) with patients, unless the Patient Encounter takes place in the continuous 
           presence of and under the continuous observation of a monitor who is a regulated 
           health professional acceptable to the College (the “Practice Monitor”).  
       (ii) At all times, Dr. Leung shall ensure that the Practice Monitor shall: 
            (a) Provide reports (as described in the Practice Monitor’s undertaking) to the College 
              on a monthly basis;  
            (b) Remain present at all times during all Patient Encounters, even if another person 
              is accompanying the patient, and carefully observing all of Dr. Leung’s  Patient 
              Encounters including, but not limited to, physical examinations.  It is Dr. Leung’s 
              obligation to ensure that the Practice Monitor’s view of his examinations is 
              unobstructed at all times;  
            (c) Refrain from performing other functions, except those required in the Practice 
              Monitor’s undertaking attached as Appendix “B”, while observing all Patient 
              Encounters; 
            (d) Maintain a log of all Patient Encounters in the form attached as Appendix “C” 
              (the “Log”); 
            (e) Initial all corresponding entries in the records of patients noted in the Log; and 
            (f) Submit the original Log to the College on a monthly basis. 
               
       (iii) Dr. Leung shall maintain a copy of the Log at all times, and shall make it available to 
            the College upon request. 
  Posting a Sign (Practice Monitor) 
  (iv) Dr. Leung shall post a sign in his waiting room(s) and each of his examination and/or 
       consulting rooms, in all of his Practice Locations, in a clearly visible and secure 
       location, in the form attached hereto as Appendix “D” that states: “Dr. Kelvin Wing-
       Ming Leung must not have any professional encounters with any patients unless under 
       the continuous observation of a practice monitor acceptable to the College of Physicians 
       and Surgeons of Ontario. Further information may be found on the College website at 
       www.cpso.on.ca.”  
  (v)  Dr. Leung shall post a certified translation(s) in any language(s) in which he provides 
       services, of the sign described in (xi) above, in his waiting room(s) and each of his 
       examination and/or consulting rooms, in all of his Practice Locations, in a clearly 
       visible and secure location. 
  (vi) Dr. Leung shall provide the certified translation(s) described in (xii) above to the 
       College within 30 days of the date of this Order. 
  Notifying Patients 
  (vii) Dr. Leung is to directly notify each patient scheduled for an appointment with him, prior 
       to the appointment, and at least within seven (7) days after the appointment is booked, 
       of the details of the restriction described in section b(i) above or section d(ii) below. 
c) Clinical Supervision: Indication for Intimate Examinations 
   Intimate Examination Log 
   (i)   Dr. Leung shall maintain an up-to-date daily log listing every patient seen by him in 
         his family practice, including the patient’s name, date of birth, OHIP number, date of 
         appointment or visit, reason for visit, any intimate examination(s) conducted and the 
         indication for the examination in the form attached as Appendix “E” (the “Intimate 
         Examination Log”).   
   (ii)  Dr. Leung shall ensure that his Practice Monitor verifies the accuracy of each entry 
         and initials the Intimate Examination Log after every patient encounter. 
   Supervision 
   (iii) For a period of six months from the date of resumption of practice following 
         suspension, Dr. Leung shall practise under the guidance of a clinical supervisor(s) 
         acceptable to the College in respect of the indication for intimate examinations in his 
         family medicine practice (the “Clinical Supervisor(s)”), at his own expense. 
   (iv)  Dr. Leung shall meet with the Clinical Supervisor(s) once every two weeks, which 
         shall consist of the Clinical Supervisor reviewing Dr. Leung’s Intimate Examination 
         Log, with reports to be provided to the College at least monthly by the Clinical 
         Supervisor(s).  The Clinical Supervisor shall examine the relevant patient charts if 
         and when there is concern about the indication of any intimate examination 
         conducted.  
   (v)   Dr. Leung shall provide his Clinical Supervisor(s) with full access to his OHIP 
         billings, his appointment scheduling book/program, and the Intimate Examination 
         Log.  He shall maintain the original Intimate Examination Log and shall send a copy 
         to the College at the end of every calendar month. 
   (vi)  Dr. Leung shall ensure that the undertaking of the Clinical Supervisor(s) attached at 
         Appendix “F” to this Order is delivered to the College within ten (10) days of the 
         date of this Order.  If Dr. Leung has not delivered the Clinical Supervisor(s)’ 
         undertaking to the College by that date, Dr. Leung shall cease to practise family 
         medicine until delivery of the undertaking, and the fact that he has done so will 
         constitute a term, condition or limitation on his certificate of registration.  
   (vii) Dr. Leung shall fully cooperate with the clinical supervision of his family medicine 
         practice, and shall abide by any recommendations of his Clinical Supervisor(s).   
   (viii) If a Clinical Supervisor(s) who has given an undertaking in Appendix “F” to this 
         Order is unable or unwilling to continue to fulfil its terms, Dr. Leung shall, within 
         ten (10) 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.   
   (ix)  If Dr. Leung is unable to obtain a Clinical Supervisor in accordance with this Order, 
         he shall cease practising family medicine immediately until such time as he has done 
         so, and the fact that he has done so will constitute a term, condition or limitation on 
         his certificate of registration until that time. 
d) Reassessments 
   Six Month Reassessment 
    
   i) At six (6) months following from the date of resumption of practice following 
      suspension, Dr. Leung shall submit to an assessment of his practice by an assessor or 
      assessors selected by the College (the “Assessment”).  The Assessment may include 
      chart reviews, direct observation of Dr. Leung’s care, interviews with colleagues and co-
      workers, feedback from patients and any other tools deemed necessary by the College.  
      Dr. Leung shall abide by all recommendations made by the assessor(s), and the results of 
      the Assessment will be reported to the College and may form the basis of further action 
      by the College; 
   ii) In the event the reassessment is positive, the practice restriction set out at b(vii) above 
      can be varied to: Dr. Leung shall not engage in any breast, pelvic, genital, urinary, 
      perineal, perianal and rectal examinations  of  patients, unless the examination  takes 
      place in the continuous presence of and under the continuous observation of a monitor 
      who is a regulated health professional acceptable to the College (the “Practice 
      Monitor”).  
   iii) If and when the role of the practice monitor is reduced, Dr. Leung shall post a sign in his 
      waiting room(s) and each of his examination and/or consulting rooms, in all of his 
      Practice Locations, in a clearly visible and secure location, in the form attached hereto as 
      Appendix “G” that states: “Dr. Kelvin Wing-Ming Leung must not conduct breast, 
      genital, urinary, or rectal examinations except under the continuous observation of a 
      practice monitor acceptable to the College of Physicians and Surgeons of Ontario. 
      Further information may be found on the College website at www.cpso.on.ca.”  
   iv) The Undertaking of the Practice Monitor is attached at Appendix “H” to this Order. 
   Eighteen Month Reassessment 
    v) At eighteen (18) months following from the date of resumption of practice following 
       suspension, Dr. Leung shall submit to a further assessment of his practice by an assessor 
       or assessors selected by the College (the “Assessment”).  The Assessment may include 
       chart reviews, direct observation of Dr. Leung’s care, interviews with colleagues and 
       co-workers, feedback from patients and any other tools deemed necessary by the 
       College.  Dr. Leung shall abide by all recommendations made by the assessor(s), and 
       the results of the Assessment will be reported to the College and may form the basis of 
       further action by the College; 
    vi) In the event the reassessment is positive, Dr. Leung will no longer be required to 
       conduct breast, pelvic, genital, urinary, perineal, perianal and rectal examinations in the 
       presence of a practice monitor. 
e) Education 
    i) Dr. Leung will successfully complete, within six months of the date of this Order, a one 
       on one educational session to address the sensitivity of patients with regards to intimate 
       examinations. 
    ii)  Dr. Leung will successfully complete instruction in medical record keeping within six 
       months of the date of this Order. 
f)  Costs 
   i)  Dr. Leung shall be responsible for any and all costs associated with implementing the 
       terms of this Order 
g) Monitoring 
   (i)   Dr. Leung shall inform the College of each and every location that he practices or 
         has privileges including, but not limited to, hospital(s), clinic(s) and office(s), in any 
         jurisdiction (collectively the “Practice Location(s)”), within five (5) days of this 
         Order.  Going forward, he shall inform the College of any and all new Practice 
         Locations within five (5) days of commencing practice at that location. 
   (ii)  Dr. Leung shall consent to the College to make appropriate enquiries of the Ontario 
         Health Insurance Plan and/or any person or institution who may have relevant 
         information in order for the College to monitor Dr. Leung’s compliance with the 
         terms of this Order and shall promptly sign such consents as may be necessary for 
         the College to obtain information from these persons or institutions; 
   (iii) Dr. Leung shall submit to, and not interfere with, unannounced inspections of his 
         Practice Locations and to inspections of patient charts by the College and to any 
         other activity the College deems necessary in order to monitor Dr. Leung’s 
         compliance with the terms of this Order; 
   (iv)  Dr. Leung shall consent to the College providing any and all information to the 
         Practice Monitor and Clinical Supervisor that the College deems necessary or 
         desirable in order to assist the Practice Monitor and Clinical Supervisor in fulfilling 
         their Undertakings and in order to monitor Dr. Leung’s compliance with the terms of 
         this Order; 
   (v)   Dr. Leung shall consent to all Practice Monitors and Clinical Supervisor to disclose 
         to the College, and to one another, any information relevant to this Order, relevant to 
         the terms of the Practice Monitor’s or Clinical Supervisor’s Undertaking and/or 
         relevant for the purposes of monitoring Dr. Leung’s compliance with this Order; and 
   (vi)  Dr. Leung shall consent to the College providing the Order to any Chief(s) of Staff, 
         or a colleague with similar responsibilities, at any Practice Location where he 
         practices or has privileges (“Chief(s) of Staff”), and to provide said Chief(s) of Staff 
         with any information the College has that led to this Order and/or any information 
         arising from the monitoring of his compliance with this Order. 
-  Dr. Leung appear before the panel to be reprimanded. 
-  Dr. Leung pay costs to the College in the amount of $5,500.00 within thirty (30) days of the 
   date of this Order.

Hearing Date(s): Hearing Dates: December 11, 2017

Concerns

Source: ICR Committee
Active Date: September 20, 2017
Expiry Date:
Summary:
Specified Continuing Education and Remediation Program:

A summary of a decision of the Inquiries, Complaints and Reports Committee in which the disposition includes a Specified Continuing Education and Remediation Program (“SCERP”) is required by the College By-laws to be posted on the register, along with a note if the decision has been appealed. A SCERP is one of the dispositions that the College’s Inquiries, Complaints and Reports Committee may make in connection with a matter before it, and this disposition requires the member to complete an education and remediation program specified for the member. A note will also be posted when all the elements of the SCERP have been completed. The summary will be removed from the register if the decision is overturned on appeal or review. Note that this requirement only applies to decisions arising out of a complaint dated on or after January 1, 2015 or if there was no complaint, the first appointment of investigators dated on or after January 1, 2015.

See PDF for the summary of a decision made against this member in which the disposition includes a SCERP:
Download Full Document (PDF)