Irwin, Paul Maxwell (CPSO#: 57194)

Current Status: Suspended as of 30 May 2018

CPSO Registration Class: Restricted as of 18 Feb 2017

Indicates a concern or additional information

Summary

Former Name: No Former Name

Gender: Male

Languages Spoken: English

Education:Queen's University, 1986

Practice Information

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

Professional Corporation Information

Corporation Name: Paul Irwin Medicine Professional Corporation

Certificate of Authorization Status: Inactive: Jan 16 2018

Specialties

Specialty Issued On Type
General Surgery Effective: 12 Nov 1991 RCPSC Specialist

Postgraduate Training

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

McMaster University, 01 Jul 1986 to 30 Jun 1987
Other - Comprehensive Internship

McMaster University, 01 Jul 1987 to 30 Jun 1988
Resident 2 - General Surgery

McMaster University, 01 Jul 1988 to 30 Jun 1989
Resident 3 - General Surgery

McMaster University, 01 Jul 1989 to 30 Jun 1990
Resident 4 - General Surgery

McMaster University, 01 Jul 1990 to 30 Jun 1991
Resident 5 - General Surgery

Registration History

Action Issue Date
First certificate of registration issued: Postgraduate Education Certificate Effective: 01 Jul 1986
Transfer of class of registration to: Independent Practice Certificate Effective: 13 Mar 1989
Transfer of class of certificate to: Restricted certificate Effective: 18 Feb 2017
Terms and conditions amended by Discipline Committee Effective: 30 May 2018
Terms and conditions amended by Discipline Committee Effective: 30 May 2018

Practice Restrictions

Registration Status: Suspended     Effective From: 30 May 2018


Imposed By Effective Date Expiry Date Status
Discipline Committee Effective: 30 May 2018 Active

Previous Hearings

Committee: Discipline
Decision Date: 30 May 2018
Summary:

On May 30, 2018, the Discipline Committee found that Dr. Paul Maxwell Irwin committed an act of 
professional misconduct, in that he has failed to maintain the standard of practice of the profession. The 
Committee also found that Dr. Irwin is incompetent.  
 
Dr. Irwin is a physician with a specialization in general surgery. 
 
Cornwall Community Hospital Investigation 
 
In 2014, the Hospital commenced an external review of Dr. Irwin’s surgical care of patients after 
concerns were raised regarding his clinical practice at the Hospital. In 2015, based on the results of the 
review indicating serious quality of care issues, the Medical Advisory Committee of the Hospital 
recommended that Dr. Irwin’s hospital privileges only be renewed if his practice was subject to a 
graduated return to practice under clinical supervision, and if he completed a six-month residency-type 
retraining program at a Canadian university centre in a surgical program approved by the hospital. While 
Dr. Irwin accepted the recommendation for a graduated return to practice under clinical supervision, he 
challenged the requirement for residency-type retraining. On March 30, 2016, the hospital’s Board of 
Directors upheld the requirement for the residency-type training as a condition of Dr. Irwin’s re-
appointment.  
 
In April 2015 the College commenced an investigation based upon the information it had received from 
the Hospital. An expert retained by the College reviewed a total of 36 charts of Dr. Irwin’s patients and 
found that Dr. Irwin fell below the standard of care in his care of 12 patients. The expert  found 
“substantial deficits” in Dr. Irwin’s knowledge and judgment and noted that he was “extremely 
concerned with the patterns of practice” he observed. Regarding the 24 charts that did meet the standard, 
the expert noted that a significant number had minor issues such as violations of hospital booking policy 
and missing dictations. 
 
Among the issues identified by the expert were the following: 
 
- Incomplete medical records. Missing operative reports, missing discharge summaries or combined 
  admission notes and discharge summaries usually indicating that these were not recorded 
  contemporaneously. 
- Unacceptable use of slang or colloquial terms in the medical record. 
- Low threshold of operation. A number of cases were hastily taken to the operating room and would 
  have benefited from more extensive preoperative work-up, further imaging and/or referral to 
  colleagues experienced in alternative techniques. 
- Multiple instances of incidental appendectomies and oophorectomies. Incidental appendectomies were 
  historically practised but are rarely indicated in this era of advanced imaging and diagnostics. The 
  frequency of incidental appendectomy was disconcerting in a small sample size of 36 cases and in one 
  of the cases led to an appendiceal stump leak — this was significant in the patient's demise. 
- Use of Demerol (meperidine). This medication has been removed from almost all hospital formularies 
  and the indication for the medication is extremely limited. Dr. Irwin prescribed this medication in 
  cases where better alternatives exist. 
- Usage of antibiotics. Best Practices in General Surgery (BRIGS) has an Ontario based website that 
  details optimal usage of antibiotics. Dr. Irwin's practice is at significant variance from the norm. 
- Use of mesh in a potentially contaminated field. Use of polypropylene mesh is contraindicated in a 
  field with open bowel. These cases reflect either a knowledge deficit or a cavalier attitude towards 
  patient care. 
 
Patient A 
 
 
 
Dr. Irwin saw Patient A several times in 2013 and in 2014 performed surgery on Patient A to detach the 
damaged bowel. About a week following the surgery, Patient A developed abdominal pain and later had 
to undergo additional surgery which was performed by another physician.  
 
In 2014, Patient A complained to the College that although Dr. Irwin was in charge of her care while she 
was in hospital, he failed to properly communicate with her and her family about her care. She said he 
visited her late in the evenings when she was on medication and did not answer her family’s questions or 
keep them informed. 
 
An expert retained by the College to provide an opinion on Dr. Irwin’s care of Patient A reported that Dr. 
Irwin’s care of the patient fell below standard and demonstrated a lack of knowledge and judgment in that 
Dr. Irwin: 
 
 -  failed to adequately justify the patient's need for colon and ovarian surgery;  
 - failed to disclose to the patient that she had both ovaries in situ identified on preoperative imaging  
 - failed to sufficiently document that he had informed, discussed and ensured that the patient had a 
  reasonable understanding of her medical and surgical management; 
 - did not further investigate the patient's abdominal pain and constipation before embarking on surgery; 
 - failed to adequately investigate whether the right ovarian cyst was responsible for any of Patient A’s 
  symptoms. At the minimum, he should have sought the opinion from a gynecologist prior to 
  consenting her for an oophorectomy, especially as the CT showed both ovaries, one of which was 
  documented to be normal; 
 - failed to display adequate judgment when he identified both ovaries intra-operatively and then 
  proceeded to resect them. No evidence was found in the documentation aside from Dr. Irwin's own 
  view that the patient requested to have both ovaries removed. Despite the patient's signed consent for 
  the removal of one ovary, the expert did not believe that she was fully aware that the recommendation 
  was for interval follow-up as per the radiologist. Prophylactic bilateral oophorectomies in 
  premenopausal women have been associated with premature death, cardiovascular disease, cognitive 
  decline and osteoporosis. Based on these facts the expert opined that Patient A’s bilateral salpingo-
  oophorectomy was not justified. The expert further opined Dr. Irwin's clinical practice in this case 
  subjected the patient to colon and ovarian surgery that may not have been entirely necessary and that 
  has resulted in complications and subsequent harm. 
       
Dr. Irwin responded to the expert’s report stating that: 
 
 - his approach to diverticular disease is non-operative, but that in his clinical judgment the patient had 
  more than simple diverticular changes;  
 - the patient consented and intended to have any remaining ovaries removed; and  
 - the patient was peri-menopausal, thus reducing the potential risks of a bilateral salpingo-
  oophorectomy.  
 
Dr. Irwin acknowledged his deficiencies in documentation. 
 
Upon review of Dr. Irwin’s response, which did not change his opinion, the expert noted that the response 
did not substantiate Dr. Irwin’s belief that the patient suffered from complicated diverticular disease, nor 
was there any documentation of a discussion with Patient A confirming the clear radiologic evidence that 
she had two ovaries, or that she understood the risks, benefits and expectations of bilateral 
oophorectomies. The expert expressed concern that Dr. Irwin’s comments reflected a lack of 

 
 
acknowledgement and lack of insight that an anastomatic leak was the cause of Patient A’s peritonitis and 
sepsis.  
 
Out-of-Hospital Premises Inspection Investigation 
 
In addition to his hospital practice, Dr. Irwin also worked at the Clinic in Ottawa where he performed 
endoscopies and administered sedation. 
 
In December, 2015, during the College’s Out-of-Hospital Premises Inspection Program conducted at the 
Clinic, the physician assessor observed Dr. Irwin performing gastroscopies and colonoscopies and had 
concerns with his technique and skill. The Premises Inspection Committee issued a Fail to the Clinic 
where patient safety issues had been revealed. The Committee had serious concerns regarding the quality 
of care that Dr. Irwin provided to his patients and referred the matter to the Inquiries, Complaints and 
Reports Committee (the “ICRC’). 
 
The expert retained by the College to provide an opinion on Dr. Irwin’s care of patients at the Clinic 
reviewed 10 patient charts and directly observed two endoscopic procedures. The expert concluded 
regarding the 10 charts reviewed that Dr. Irwin demonstrated a lack of knowledge, skill or judgment in 
his care of 8 patients, and failed to meet the standard of care in 3 patients. With respect to the two patients 
observed, the expert concluded that Dr. Irwin has several deficiencies in his skills. The expert reported the 
following:  
 
  Standard of care 
   -  fails to meet the standard of care in terms of his charting and documentation  
   -  fails to keep up to date regarding current endoscopic guidelines.  
   -  screening, surveillance and follow up of abnormal pathology should follow some formal 
      guidelines 
       
  Lack of knowledge, skill and judgment  
   -  displays lack of judgment, skill and knowledge and needs to keep up to date regarding current 
      endoscopic guidelines.  
   -  screening, surveillance and follow up of abnormal pathology should follow some formal 
      guidelines. For example, recommended guidelines for the surveillance of low grade dysplasia and 
      Barrett's esophagus were not followed 
   -  in patients with poor bowel preparation, and inadequate visualization, additional testing or a repeat 
      colonoscopy with more aggressive bowel preparation should have been offered. 
       
  Harm or injury 
   -  in reviewing Dr. Irwin's charts, it does not seem that the patients are at an increased risk of harm 
      or injury. Documentation and organization is the main deficiency.  
   -  Concerns about Dr. Irwin's endoscopic proficiency: noted deficiencies and lack of endoscopic 
      skills, which may potentially place patients at risk by missing pathology and increasing the risk of 
      complications. 
 
Breach of ICRC Order Restricting Dr. Irwin’s Practice 
 
On February 14, 2017, the ICRC ordered and directed the Registrar to impose terms, conditions and 
limitations on Dr. Irwin’s certificate of registration restricting his practice to providing small surgical 
procedures requiring local anaesthesia and surgical consultations and required that he practice with a 
clinical supervisor who will review a minimum of 20 charts per month.  
 
 
On December 12, 2017, the ICRC amended the order, increasing the frequency and intensity of 
supervision based on information received by the College. Dr. Irwin was required to provide the College 
with the addresses of all his practice locations. Dr. Irwin did not advise the College that, in addition to 
practising at clinics in Ottawa and Akwesasne, he had a “home practice” which involved visiting 
approximately 10 patients in their home. Some of the care provided by Dr. Irwin to patients in Akwesasne 
and in the home visits exceeded the restrictions on his scope of practice. There is no evidence this care 
was otherwise inappropriate or below standard. 
 
Past History 
 
In January, 2005, the College received a complaint in relation to Dr. Irwin’s care of a patient who died 
following surgery he provided for resection of a cancerous tumour. The Complaints Committee noted that 
there was no record of Dr. Irwin performing a complete clinical examination of his patient before the 
operation and that a thorough pre-operative assessment of the lesion should have been done. The 
Committee cautioned Dr. Irwin to ensure that he conducts a complete and thorough evaluation of patients 
pre-operatively, so that he can obtain properly informed consent from the patient before proceeding with 
surgery.  
 
In January 2011, the College received a complaint about the care provided to a patient who underwent 
excision of a neck lesion and supraclavicular nodes at the Hospital in late 2010. The complainant alleged 
that Dr. Irwin only obtained his consent for a biopsy of a lesion and excised the mass without consent. 
The Committee found that: 
- there was considerable confusion in the clinical record regarding what consent was provided by the 
  patient; 
- Dr. Irwin did not document the consent discussion until after the surgical procedure had been 
  performed; 
- Dr. Irwin’s dictation of his operative note was not done until two months after the procedure and after 
  the patient had complained to the College; and   
- Dr. Irwin’s operative note had virtually no detail.  
The Committee issued a written caution to Dr. Irwin on his poor consent process in the case, including his 
documentation of that process, and on his failure to ensure a timely dictation of his operative note. In 
addition, the Committee required that Dr. Irwin complete a specified continuing education or remediation 
program involving the following: 
- a course on medical ethics and informed consent; 
- educational sessions with a preceptor on charting and record-keeping; and 
- a reassessment. 
 
In November of 2014, the College received a patient complaint regarding Dr. Irwin’s care provided in 
1999 when he performed a gastroscopy, colonoscopy and incisional hernia repair at the Hospital. 
Following the procedure, the patient developed sepsis and other complications. An expert opinion 
obtained by the College found Dr. Irwin’s care met the standard and did not demonstrate a lack of 
knowledge, skill or judgment. However, the ICRC concluded that Dr. Irwin did not meet the standard 
with respect to his decision to discharge the patient when there was evidence that clearly demonstrated a 
wound infection following the surgery. The Committee found that Dr. Irwin should have diagnosed a 
wound infection and that his discharge note indicating that there were no signs of wound infection and 
her white blood cell count was normal was inaccurate. The Committee issued advice to Dr. Irwin with 
respect to his postoperative wound management and assessment before discharge, particularly in patients 
with fever and elevated white blood count.  
 

 
 
In March, 2015 the College received a complaint from a patient in relation to care he received from Dr. 
Irwin at the Hospital in 2012 when Dr. Irwin performed an elective anterior resection of his colon for 
diverticulitis. After the surgery, he developed sepsis and Dr. Irwin found an anastomotic leak and created 
a colostomy. Further complications arose thereafter. An expert opinion obtained by the College found Dr. 
Irwin’s care met the standard and did not demonstrate a lack of knowledge, skill or judgment, but did note 
that Dr. Irwin’s operating notes lacked detail. The ICRC agreed that Dr. Irwin’s documentation in the 
operative note lacked sufficient details, including details of the anastomosis and the consent discussion. It 
also concluded that there was an excessive delay in bringing the complainant back to the OR when he 
began to experience complications, particularly as he was high risk and should have been followed 
closely. The Committee issued advice to Dr. Irwin to: 
-  document thoroughly in the OR note; 
-  document the details of his consent discussion with patients; and 
-  ensure closer post-operative follow-up of high-risk patients, and noted that in this case there was 
   excessive delay in returning the patient to the OR when the patient had concerning clinical signs of 
   complication. 
 
Disposition 
 
On May 30, 2018, the Committee ordered and directed that: 
 
 - Dr. Irwin attend before the panel to be reprimanded. 
 - the Registrar suspend Dr. Irwin’s certificate of registration for a period of five (5) months 
   commencing immediately. 
 - the Registrar impose the following terms, conditions and limitations on Dr. Irwin’s certificate of 
   registration: 
    
    -  Dr. Irwin’s practice is restricted to providing small surgical procedures requiring local 
       anesthesia and surgical consultations.  
    -  Dr. Irwin shall retain a College-approved clinical supervisor or supervisors (the “Clinical 
       Supervisor”), who will sign an undertaking in the form attached hereto as Appendix “A.” [to the 
       Order]  For a period of at least six (6) months commencing on the date Dr. Irwin returns to 
       practice following the suspension of his certificate of registration, Dr. Irwin may practise only 
       under the supervision of the Clinical Supervisor and will abide by all recommendations of his 
       Clinical Supervisor with respect to his practice, including but not limited to practice 
       improvements, practice management and continuing education.  Clinical supervision of Dr. 
       Irwin’s practice may end after a minimum of six (6) months, only upon the recommendation of 
       the Clinical Supervisor and, in its discretion, approval by the College.  Clinical supervision of 
       Dr. Irwin’s practice shall contain the following elements: 
         - The Clinical Supervisor will review a minimum of fifteen (15) of Dr. Irwin’s patient charts 
          every two (2) weeks, which shall be drawn from both his surgical procedures and surgical 
          consultation areas of practice if he has engaged in both areas of practice during the period 
          under review, and any other practice area if he has expanded his scope of practice in 
          accordance with paragraph 5(xii) of this Order; and  
         - The Clinical Supervisor will meet with Dr. Irwin in person a minimum of once a month and 
          will report to the College every month, or more frequently if there is a risk of harm or other 
          concerns.  
        
    -  The Clinical Supervisor will also facilitate the education program set out in the  Individualized 
       Education Plan (“IEP”) in the form attached hereto as Appendix “B” [to the Order].  
    -  If Dr. Irwin fails to retain a Clinical Supervisor as required above or if, prior to completion of 
 
 
       Clinical Supervision, the Clinical Supervisor is unable or unwilling to continue in that role for 
       any reason, Dr. Irwin shall within twenty (20) days retain a new College-approved Clinical 
       Supervisor who will sign an undertaking in the form attached hereto as Appendix “A,” and if he 
       has not been able to do so within twenty (20) days he shall cease to practise until the same has 
       been delivered to the College. 
    -  Approximately six (6) months after the completion of Clinical Supervision, Dr. Irwin shall 
       undergo a reassessment of his practice (the “Reassessment”) by a College-appointed assessor 
       (the “Assessor”).  The Reassessment may include a review of Dr. Irwin’s patient charts, direct 
       observations and interviews with staff and/or patients, and any other tools deemed necessary by 
       the College.  The Reassessment shall be at Dr. Irwin’s expense and he shall co-operate with all 
       elements of the Reassessment.  Dr. Irwin shall abide by all recommendations made by the 
       Assessor subject to paragraph 5(vi) below, and the results of the Reassessment will be reported 
       to the College and may form the basis of further action by the College.  
    -  If Dr. Irwin is of the view that any of the Assessor’s recommendations are unreasonable, he will 
       have fifteen (15) days following his receipt of the recommendations within which to provide the 
       College with his submissions in this regard.  The Inquiries Complaints and Reports (“ICR”) 
       Committee will consider those submissions and make a determination regarding whether the 
       recommendations are reasonable, and that decision will be provided to Dr. Irwin. Following 
       that decision Dr. Irwin will abide by those recommendations of the Assessor that the ICR 
       Committee has determined are reasonable 
    -  Dr. Irwin shall consent to sharing of information among the Assessor, the Clinical Supervisor 
       and the College, as any of them deem necessary or desirable in order to fulfill their respective 
       obligations. 
    -  Dr. Irwin shall inform the College of each and every location where he practises, in any 
       jurisdiction (his “Practice Location(s)”) within fifteen (15) days of this Order and shall inform 
       the College of any and all new Practice Locations within fifteen (15) days of commencing 
       practice at that location. 
    -  Dr. Irwin shall cooperate with unannounced inspections of his practice and patient charts by a 
       College representative(s) for the purpose of monitoring and enforcing his compliance with the 
       terms of this Order. 
    -  Dr. Irwin shall consent to the College making appropriate enquiries of the Ontario Health 
       Insurance Plan and/or any person who or institution that may have relevant information, in order 
       for the College to monitor and enforce his compliance with the terms of this Order.  
   -   Dr. Irwin shall be responsible for any and all costs associated with implementing the terms of 
       this Order. 
   -   If Dr. Irwin wishes to expand his scope of practice, including to engage in general surgical 
       practice, general family medicine and/or palliative medicine, he will follow the College’s Policy 
       on Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice, a copy of 
       which is attached hereto as Appendix “C” [to the Order], and must receive approval to expand 
       his scope from the College in accordance with that policy.   
        
-  Dr. Irwin pay to the College costs in the amount of $10,180.00, in accordance with a payment 
   plan approved by the College or, in the absence of such a plan, within thirty (30) days of 
   the date of this Order.

Hearing Date(s): Hearing Dates: May 30, 2018