Bradley v Wang: SIRVA, Injection Landmarking, and the Resident Physician Standard of Care

Intramuscular injections are among the most common procedures performed in Canadian healthcare. Every year, millions of Canadians receive vaccinations, antibiotic injections, anti-inflammatory injections, and other intramuscular medications. The procedure is taught at every level of medical, nursing, and allied health training. It is generally regarded as a routine task that can be safely performed by clinicians at every stage of their training. The framework conceals an important reality: when intramuscular injections are administered improperly, the patient can be left with a chronic and disabling injury. The injury pattern is recognized in the medical literature. It has a specific name: shoulder injury related to vaccine administration, or SIRVA. The framework for liability where SIRVA is established is increasingly well-developed.

Bradley v Wang, 2025 ONSC 2267, released by the Ontario Superior Court of Justice on April 29, 2025, is a recent application of the framework. The plaintiff was a registered nurse who presented for a routine tetanus immunization and received the injection from a first-year family medicine resident. The injection was placed too high on the upper arm, near the shoulder joint rather than in the middle of the deltoid muscle as the standard of practice required. The plaintiff developed immediate and persistent shoulder pain that progressed to a chronic condition substantially affecting her ability to work as a nurse. The court found that the resident had breached the standard of care, that the breach had caused the injury, and that the damages exceeded $1,000,000, with the largest components attributable to lost income and pension consequences over the balance of her nursing career.

The case is doctrinally important for several reasons. It is a clear articulation of the standard of care for intramuscular deltoid injections, including the specific anatomical landmarking required. It addresses the SIRVA framework as a recognized injury pattern distinct from the much rarer non-negligent inflammatory reactions that can occasionally follow vaccinations. It applies the specialist-equivalent standard of care to a first-year resident performing a routine procedure, and rejects the defence that absence of feedback during training is exculpatory. It illustrates the substantial damages that can flow from a non-catastrophic injury when the plaintiff’s pre-injury earning capacity is high and the injury permanently affects that capacity. And it adds the first vaccine-administration case to the developing cluster of Ontario malpractice trial authorities.

The clinical context — intramuscular injections and SIRVA

A brief clinical overview is useful for the analysis.

The deltoid intramuscular injection. The deltoid muscle is the rounded muscle covering the upper part of the shoulder. It is the standard site for adult vaccination because it is easily accessible, has minimal subcutaneous fat in most patients, and is associated with appropriate immune response to most vaccines. The standard of practice for deltoid intramuscular injection includes specific anatomical landmarking.

The landmarking procedure. The recommended technique for deltoid injection involves identifying anatomical landmarks to ensure the injection is placed in the safe and effective zone of the muscle. The standard approach:

• The patient’s shoulder is exposed
• The acromion (the bony tip of the shoulder) is identified by palpation
• The injection site is identified approximately two to three finger widths below the acromion, in the centre of the visible deltoid bulk
• The injection is administered at a 90-degree angle to the skin into the muscle belly

The framework can be described slightly differently in different texts and protocols, but the central principle is consistent: the injection should be in the middle of the deltoid muscle, well below the shoulder joint and well above the radial nerve and humeral structures.

The consequences of poor landmarking. When the injection is placed too high (close to the acromion or into the area overlying the shoulder joint), it can enter the subdeltoid bursa, the subacromial space, or the joint capsule itself rather than the muscle belly. Medications deposited in these structures can produce inflammation, irritation of the rotator cuff tendons, bursitis, and chronic shoulder pain. When the injection is placed too low or too posterior, it can affect the radial nerve or other neural structures. When the injection is placed too deep, it can affect the humerus or surrounding structures. The framework recognizes that injection placement matters.

SIRVA — Shoulder Injury Related to Vaccine Administration. SIRVA is the recognized clinical entity describing shoulder injuries that follow improper vaccine administration. The framework typically describes:

• The pain begins within hours of the injection (often immediately)
• The pain is persistent and progressive rather than transient
• The clinical pattern is consistent with inflammation of the bursa, tendons, or other peri-articular structures rather than with the modest local soreness that follows a properly administered injection
• The pain often does not respond to conservative measures and can become chronic
• The disability can extend to limitations in range of motion, weakness, and persistent functional impairment

SIRVA is not the same as the rare inflammatory reaction that can occasionally follow properly administered vaccinations. The framework distinguishes between:

• The recognized inflammatory reaction: delayed onset (typically hours to days), generally self-limited, modest severity, no specific injection-site pathology
• SIRVA: immediate onset, persistent and progressive course, specific pathology in peri-articular structures (bursitis, tendinitis, rotator cuff inflammation, joint capsule irritation), often chronic

The distinction is doctrinally important because it allows the trier of fact to identify cases that are attributable to improper administration rather than to the inherent risks of vaccination.

Diagnosis. The diagnosis of SIRVA is typically made through:

• Clinical history (immediate pain onset following the injection; persistent and progressive course)
• Physical examination (shoulder tenderness, limited range of motion, signs consistent with bursitis or rotator cuff pathology)
• Imaging (ultrasound or MRI showing specific changes consistent with the framework)
• Exclusion of alternative explanations (degenerative shoulder disease, traumatic injury, systemic inflammatory conditions)

The natural history. The natural history of SIRVA varies. Some patients recover with conservative management (rest, anti-inflammatory medications, physical therapy). Some patients develop chronic pain that is refractory to conservative measures. Some patients require interventional procedures (corticosteroid injections, surgery). The prognostic factors include the severity of the initial injury, the time to diagnosis, the response to early treatment, and patient-specific factors including age and pre-existing shoulder conditions.

The standard of care for resident physicians

The case raises the framework for the standard of care applicable to resident physicians performing routine procedures.

The general framework. Canadian malpractice law applies the specialist standard of care to all physicians providing care within a particular field, regardless of their level of training. A first-year family medicine resident performing a deltoid injection is held to the standard of a reasonable family physician performing a deltoid injection. The framework does not provide for a reduced standard for resident physicians or for trainees more generally.

The rationale. The framework reflects the principle that patients receiving care do not bear the risk of the physician’s training stage. A patient who consents to a deltoid injection consents to a procedure that meets the standard of practice. The patient does not consent to a procedure that is performed below the standard because the physician is still learning. Where the procedure falls below the standard, the patient is entitled to the same recourse regardless of the physician’s training status.

The exception that proves the rule. The framework does recognize some flexibility in the analysis of supervision arrangements. Where a resident is supervised and the supervision is appropriate, the supervising physician may share liability or may be solely liable for the outcome. The framework does not, however, permit the resident’s training status to operate as a categorical defence to a SOC claim.

The “absence of feedback during training” defence. A common defence raised in resident-physician malpractice cases is that the resident received feedback during training and was never told the technique was incorrect. The framework treats this defence with limited weight. The reasoning is that:

• The supervisors may have observed the resident performing the technique correctly on other occasions
• The absence of feedback does not establish that the technique was always correct
• The standard of practice is defined by reasonable practitioners in the field, not by what supervisors did or did not say
• A specific instance of poor technique may have occurred even where the general training was adequate

The framework was applied in Bradley v Wang to reject the defence that Dr. Wang had never been told his technique was incorrect during his clerkship.

The facts

The patient. Ms. Bonnie Bradley was a registered nurse with extensive professional experience administering and receiving vaccinations. Her background is doctrinally significant in two ways: her testimony about the injection technique carries weight because she has professional knowledge of the procedure, and her career as a nurse drives the substantial economic damages analysis.

The setting. On December 1, 2015, Ms. Bradley presented for a routine tetanus immunization. The injection was given by Dr. Richard Wang, a first-year family medicine resident.

The immediate event. During the injection, Ms. Bradley experienced immediate pain in her arm. She turned her head and observed that the needle appeared to be placed in the wrong location, higher on the arm than where she would have expected based on her own professional understanding of the procedure.

The course of the pain. In the weeks following the injection, Ms. Bradley’s shoulder pain persisted and worsened. The pattern was inconsistent with the modest local soreness that typically follows a properly administered injection.

The clinical investigations. On December 9, 2015 (just over a week after the injection), Ms. Bradley was referred by Dr. Brankston to a specialist, Dr. Mason, due to concerns about possible nerve injury. Dr. Mason performed a neurological examination, which did not reveal nerve damage. Ms. Bradley reported persistent and worsening pain, limited mobility, and tingling in her thumb and index finger. She specifically reported that the injection had been given over her shoulder joint and that the pain had begun immediately.

The diagnosis. Dr. Mason’s examination revealed shoulder tenderness and limited movement due to pain (with improvement when the shoulder was supported). The diagnosis was rotator cuff inflammation, with the clinical picture suggesting that the injection had been placed too high near the shoulder joint, producing inflammation in the rotator cuff and surrounding structures.

The functional consequences. Ms. Bradley’s shoulder pain became chronic and substantially limited her ability to work. As a registered nurse, her work required physical capacity (lifting, supporting patients, performing procedures, and so on) that her shoulder condition affected. The functional consequences extended through the period leading up to trial.

The action. Ms. Bradley brought a civil action against Dr. Wang alleging negligence in the administration of the injection.

The expert evidence

Both sides called expert evidence on the standard of care and on causation.

The plaintiff’s experts.

• A family medicine expert addressed the standard of care for administering intramuscular deltoid vaccinations, including the associated risks, benefits, and potential side effects.
• A physical medicine and rehabilitation expert addressed the cause and severity of soft tissue and musculoskeletal injuries, the framework for chronic pain and myofascial pain, the concept of nerve sensitization, the functional consequences of these conditions on work and daily activities, and possible treatment options.

The defence experts.

• A family medicine expert addressed the standard of care expected of family physicians when administering intramuscular deltoid injections, including the potential side effects and complications that can arise from improper technique.
• An orthopaedic expert addressed causation, including specifically the SIRVA framework, the likely cause of Ms. Bradley’s shoulder pain following the injection, and whether the injection site could be determined from her clinical history and symptoms.

The structure of expert disagreement. The expert disagreement converged on two principal questions:

• Was the injection administered with the correct technique? This was the SOC question.
• Was the patient’s chronic shoulder pain caused by the injection or by some other process? This was the causation question.

The defence theory was that the injection had been administered correctly and that the patient’s subsequent pain was either a rare inflammatory reaction (not attributable to negligence) or an exacerbation of pre-existing shoulder pathology. The plaintiff’s theory was that the injection had been administered improperly (too high near the joint), that this had caused the rotator cuff inflammation, and that the chronic pain had followed directly.

The court’s analysis

The court found in favour of the plaintiff. The reasoning proceeded in several steps.

The temporal pattern of pain onset. The court emphasized that the patient’s symptoms had started immediately during the injection. The timing was inconsistent with the typical pattern of a rare inflammatory reaction, which has a delayed onset and a generally self-limited course. The immediate onset, the severity of the pain, and the persistent and progressive course were all consistent with improper administration rather than with the rare non-negligent reaction.

The “not a rare and unfortunate event” finding. The court characterized the injury as not simply a rare and unfortunate event. The clinical pattern indicated improper vaccine administration rather than an uncommon inflammatory reaction. This framing is doctrinally significant: it distinguishes between cases where the injury falls within the recognized non-negligent risk profile and cases where the injury falls outside that profile and is attributable to improper technique.

The standard of care. The court found that the appropriate standard of care required correct identification of the injection site. Dr. Wang had failed to follow this step. The injection had been placed in the wrong location, too high and near the shoulder joint rather than in the middle of the deltoid muscle.

The credibility analysis. The court found Ms. Bradley’s testimony credible and consistent with the medical evidence. Her account of the immediate pain, her observation that the injection appeared to be in the wrong location, and her subsequent reporting of the pattern of symptoms to her treating doctors all aligned. The treating doctors’ contemporaneous documentation supported her account.

The pre-existing condition defence. The court rejected the defence argument that Ms. Bradley’s prior history of back and shoulder problems undermined her credibility. The framework recognized that her new symptoms were distinct in nature, location, and severity from any pre-existing injuries. Where the plaintiff’s symptoms post-incident are distinguishable from pre-existing symptoms, the pre-existing condition does not displace the causation analysis.

The “absence of feedback” defence. The court did not accept the defence argument that Dr. Wang’s training (including several deltoid intramuscular injections during clerkship without correction) established that his technique met the standard. The framework treats the absence of feedback as inconclusive: it does not establish that the technique was always correct, and a specific instance of poor technique can be established by the available evidence in the case.

The conclusion. The court found that Dr. Wang had breached the standard of care by failing to landmark properly and by administering the vaccination in the wrong location. The court further found that the breach had caused Ms. Bradley’s injuries.

The damages award

The court’s damages assessment reflects the structure of damages in chronic pain cases with significant occupational consequences.

General damages: $70,000. The general damages component (sometimes called non-pecuniary damages) compensates for pain and suffering, loss of enjoyment of life, and similar non-economic consequences. The award of $70,000 reflects the chronic and disabling nature of the shoulder pain. The Canadian framework for general damages is constrained by the Supreme Court of Canada’s “trilogy” (the Andrews v Grand & Toy, Thornton v Prince George School District No 57, and Arnold v Teno decisions from the late 1970s), which established a cap on non-pecuniary damages that has been adjusted for inflation. The cap, as it currently stands, is in the range of $440,000 for catastrophic injury cases. A chronic pain case without catastrophic disability typically attracts general damages in the range of $50,000 to $150,000, calibrated to the severity and functional impact.

Past and future lost income: $931,585. This is the largest single component of the award. The framework reflects the calculation of the plaintiff’s lost earning capacity:

• Past lost income from the date of injury through trial
• Future lost earning capacity over the balance of her working life
• Reductions for non-negligent risks of future absence from work (illness, retirement, and so on)

As a registered nurse, Ms. Bradley had substantial earning capacity. The chronic shoulder pain limited her ability to perform the physical components of nursing work. The framework supports recovery of the difference between her pre-injury earning trajectory and her actual earning trajectory.

Pension loss: $361,600. Loss of pension consequences typically arises where the plaintiff would have been entitled to a defined-benefit or defined-contribution pension and where the injury has shortened or reduced their pensionable employment. The pension calculation can be substantial in cases involving healthcare workers and other unionized employees.

Out-of-pocket expenses and OHIP subrogated interest. These categories cover the actual out-of-pocket expenses incurred for treatment and the subrogated interest of the provincial health insurance plan (which has paid for medical care and is entitled to reimbursement under the Health Insurance Act, RSO 1990, c H.6).

Future care: to be determined separately. The future care component covers the cost of ongoing medical care, physiotherapy, medications, equipment, and other expenses related to the chronic condition. Future care assessments can be substantial in chronic pain cases and are typically the subject of additional expert evidence.

Total: over $1,000,000. The total reflects the cumulative effect of the chronic pain on a high-earning healthcare professional with significant career trajectory ahead of her. The case illustrates that non-catastrophic injuries can give rise to substantial damages where the functional consequences affect the plaintiff’s earning capacity.

The doctrinal anchors

Several doctrinal anchors emerge from the case.

The “landmark properly” framework for intramuscular injections. The standard of practice for intramuscular deltoid injection requires correct anatomical landmarking. The injection should be placed in the middle of the deltoid muscle, well below the acromion and the shoulder joint, in the area of greatest muscle bulk. Bradley v Wang is the principal cluster authority on the framework.

The SIRVA framework. Shoulder Injury Related to Vaccine Administration is a recognized clinical entity describing shoulder injuries following improper vaccine administration. The framework distinguishes SIRVA from the rare non-negligent inflammatory reactions that can occasionally follow properly administered vaccinations. The distinction supports the negligence finding where the clinical pattern is consistent with SIRVA.

The “immediate onset as evidence of improper administration” framework. Where the patient experiences immediate pain during or immediately after an injection, the temporal pattern is consistent with improper administration rather than with the delayed-onset profile of typical inflammatory reactions. The framework supports the causation inference.

The “not a rare and unfortunate event” framework. The court can distinguish between cases where the outcome falls within the recognized non-negligent risk profile (and is therefore not actionable as negligence) and cases where the outcome falls outside that profile (and is therefore amenable to a negligence finding). The framework is the doctrinal mirror of the recognized complication framework articulated in O’Brien v Lochab. Both frameworks recognize that some outcomes are attributable to recognized non-negligent risks, but they apply the analysis to determine whether the specific case falls within that profile.

The resident physician standard of care framework. Resident physicians are held to the specialist standard for the procedures they perform. The framework does not provide for a reduced standard during training. Bradley v Wang is the principal cluster authority on the framework as applied to a first-year resident performing a routine procedure.

The “absence of feedback in training is not exculpatory” framework. The defence that the resident had performed the technique many times without being told it was incorrect is given limited weight. The framework recognizes that the absence of feedback may reflect supervisors observing the technique correctly performed on other occasions rather than establishing that the technique was always correct.

The pre-existing condition / distinguishable new injury framework. Where the plaintiff has a pre-existing condition that the defendant argues explains the post-incident symptoms, the framework allows the trier of fact to compare the pre-existing and post-incident symptoms and to determine whether the post-incident symptoms are distinguishable. Where the post-incident symptoms are distinct in nature, location, and severity, the pre-existing condition does not displace the causation analysis. The framework is generalizable across chronic pain and soft tissue injury cases.

The “credibility supported by treating doctors and contemporaneous documentation” framework. Where the plaintiff’s testimony is supported by the contemporaneous documentation from treating doctors and by the consistent clinical pattern recognized in the medical evidence, the credibility finding is on stable ground. The framework supports plaintiff trial wins in cases where the historical record aligns with the plaintiff’s account.

The substantial damages for non-catastrophic injury framework. Chronic pain conditions affecting a high-earning healthcare professional can give rise to substantial damages even without catastrophic disability. The framework reflects that the damages are calibrated to the functional and economic consequences rather than to a categorical severity threshold. Bradley v Wang illustrates a case where the total award exceeded $1,000,000 driven principally by income and pension loss.

The chronic pain causation framework. Soft tissue and musculoskeletal injuries can produce chronic pain through several mechanisms including bursitis, tendinitis, myofascial pain, and nerve sensitization. Expert evidence in physical medicine and rehabilitation can support the causation analysis where the framework is applied to a specific patient’s trajectory. Bradley v Wang applies the framework to a SIRVA case.

Why this case matters

For patients who have experienced injection-related injuries. The case is a useful illustration of how the SIRVA framework can support a successful malpractice claim.

Some practical observations:

Immediate pain during an injection is significant. Where pain begins immediately during an injection and persists or worsens in the days that follow, the temporal pattern is consistent with improper administration. Reporting the pain to treating physicians early and getting it documented is important for the subsequent analysis.

Treating documentation matters. The treating doctors’ contemporaneous documentation can be critical evidence. Where the plaintiff reports the immediate pain and the apparent injection location to a treating specialist soon after the event, the documentation supports the subsequent legal analysis.

The SIRVA framework is recognized. The medical and legal frameworks both recognize SIRVA as a category of injury attributable to improper vaccine administration. The framework is doctrinally available; the question in any specific case is whether the clinical pattern supports the framework.

Pre-existing conditions do not categorically defeat the claim. Where the plaintiff has pre-existing shoulder or back problems, the framework still permits recovery where the post-incident symptoms are distinguishable from the pre-existing condition. The careful clinical and expert analysis of the symptom pattern is critical.

Significant damages can flow from non-catastrophic injuries. Where the chronic condition affects the plaintiff’s ability to work, the income loss component can drive substantial total damages even without paralysis or other catastrophic disability. The framework calibrates damages to functional and economic consequences.

For more on the general framework for evaluating medical malpractice cases, see Suing for Medical Malpractice in Ontario: What You Need to Know.

For clinicians and healthcare teams. A few practical observations:

Landmarking matters. The standard of practice for intramuscular deltoid injection requires correct anatomical landmarking. The technique should be reviewed, taught, and practiced as a specific clinical skill, not just as a routine task.

Resident physicians are held to the specialist standard. The framework does not provide for a reduced standard during training. Trainees performing routine procedures are held to the standard of practice for the procedure regardless of their training stage. The implication is that supervision arrangements should be calibrated to ensure that trainees are performing procedures to the standard.

Immediate patient reports of pain warrant attention. Where a patient reports immediate pain during or immediately after an injection, the report warrants attention rather than dismissal. The pattern is consistent with improper placement and may warrant immediate clinical assessment to identify any potentially correctable factor.

Documentation supports both the patient and the clinician. Detailed contemporaneous documentation of the injection (the specific landmarks used, the location, any patient reports of pain during the procedure) supports both the patient’s care and the clinician’s professional record. Where the documentation is sparse, the framework can permit inferences to be drawn against the clinician.

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Decision Date: April 29, 2025

Jurisdiction: Ontario Superior Court of Justice

Citation: Bradley v Wang, 2025 ONSC 2267 (CanLII)

Outcome: Judgment for the plaintiff. The court found that the defendant first-year family medicine resident had breached the standard of care for intramuscular deltoid injection by failing to landmark properly and by administering the tetanus injection in the wrong location, too high near the shoulder joint rather than in the middle of the deltoid muscle. The court further found that the breach had caused the plaintiff’s chronic shoulder injury, which manifested clinically as rotator cuff inflammation consistent with the framework for Shoulder Injury Related to Vaccine Administration (SIRVA). The court rejected the defence arguments that the plaintiff’s pre-existing back and shoulder problems undermined her credibility and that the resident’s training (including several deltoid injections without correction during clerkship) established that his technique met the standard. The court awarded damages of $70,000 in general damages, $931,585 for past and future lost income, $361,600 for pension loss, reimbursement for out-of-pocket expenses, and OHIP’s subrogated interest. The cost of future care was to be determined separately. The total award exceeded $1,000,000.

Key authorities: Wilson v Swanson, [1956] SCR 804 (specialist standard); Crits v Sylvester, [1956] OR 132 (medical practitioner standard); ter Neuzen v Korn, [1995] 3 SCR 674 (specialist standard and common practice); Andrews v Grand & Toy Alberta Ltd, [1978] 2 SCR 229 (general damages cap framework); Snell v Farrell, [1990] 2 SCR 311 (robust and pragmatic causation); Clements v Clements, 2012 SCC 32 (but-for causation framework); Health Insurance Act, RSO 1990, c H.6 (OHIP subrogated interest).