The framework for regulatory discipline operates with a graduated structure of responses calibrated to the seriousness of the underlying conduct and the protective considerations going forward. The framework recognizes that not every concern about a physician’s practice warrants formal discipline; many concerns are addressed through informal interventions including cautions from the College’s Inquiries, Complaints and Reports Committee, supervised practice agreements, mandatory education, and similar measures. Where these less restrictive interventions do not produce sustained behavior change, the framework supports formal discipline including suspension and the imposition of conditions on practice. The framework’s calibration is sometimes called progressive discipline, and it operates as a structured response to the trajectory of a physician’s engagement with the regulatory regime over time.
College of Physicians and Surgeons of Ontario v Nahas, 2026 ONPSDT 8, released by the Ontario Physicians and Surgeons Discipline Tribunal on March 4, 2026, is a recent application of the progressive discipline framework. The respondent was a family physician practising chronic pain management who faced two related sets of allegations: a pattern of clinical deficiencies across multiple patients, and a consent and communication failure during a specific patient examination. The expert evidence on the clinical deficiencies arose from review of 19 patient charts and identified multiple and serious departures from the standard of care. The consent and communication failure addressed a separate patient encounter involving inappropriate touching during a clinical examination without adequate explanation or consent. Accepting a joint submission, the Tribunal imposed a four-month suspension, substantial practice restrictions, mandatory supervision, formal reassessment, ongoing compliance monitoring, and costs.
The case is doctrinally important for several reasons. It is one of the more substantial recent applications of the progressive discipline framework, with explicit reference to the principle that penalties must increase when prior corrective measures fail. It illustrates the framework for evaluating chronic pain management practice including the standards for nerve block injections, image-guided techniques, anesthetic dosing, and individualized clinical decision-making. It addresses the framework for informed consent in the context of clinical procedures involving sensitive anatomical areas. It demonstrates the framework for practice restrictions calibrated to specific aspects of the underlying deficiencies. It applies the framework for mandatory supervision following formal discipline. And it provides a useful reference for the broader regulatory response where multiple categories of professional concern coexist.
The legal framework — progressive discipline, standard of practice, and the ICRC
A brief overview of the framework is useful for the analysis.
The graduated regulatory response framework. The framework for regulatory response to concerns about a physician’s practice operates with a graduated structure. The framework includes:
- Informal complaints handling. Where concerns are minor or can be addressed without formal proceedings, the framework supports informal resolution between the College and the physician.
- ICRC cautions and remedial requirements. Where concerns are more substantial but do not warrant formal discipline, the Inquiries, Complaints and Reports Committee (ICRC) can impose cautions, require specific remedial education, or impose supervised practice agreements. The framework operates as a less restrictive alternative to formal discipline.
- Specified continuing education or remediation. Where the framework identifies specific knowledge or skill deficits, the ICRC can require continuing education, supervised practice, or specific remedial programs to address the deficits.
- Formal discipline referrals. Where the conduct is sufficiently serious or where the less restrictive interventions have not produced meaningful change, the matter can be referred to the Discipline Tribunal for formal proceedings. The framework operates on the principle that less restrictive interventions should be tried first where appropriate.
- Tribunal sanctions. Where the Discipline Tribunal makes findings of professional misconduct or incompetence, the available sanctions range from reprimands to mandatory remedial programs to suspension to revocation. The framework supports calibrated sanctions to the specific concerns identified.
The progressive discipline principle. Where a physician has previously been the subject of informal interventions (ICRC cautions; supervised practice agreements; mandatory education) and the underlying concerns have not been resolved, the framework supports more substantial responses. The progressive discipline principle operates on the rationale that less restrictive interventions have been tried and have not produced the change required to protect the public. Where formal discipline is then imposed, the framework supports sanctions that are more substantial than would have been appropriate without the prior intervention history.
The standard of practice framework. Section 1(1) paragraph 2 of the Professional Misconduct Regulation (O Reg 856/93) treats failure to maintain the standard of practice of the profession as a category of professional misconduct. The framework operates in the regulatory discipline context the same way the standard of care framework operates in civil litigation: by reference to what a reasonable specialist in the same field would have done in the same circumstances, with expert evidence supporting the framework’s application to the specific case.
The framework can support findings of professional misconduct based on:
- A single significant departure from the standard of practice
- Multiple smaller departures that collectively reflect substandard care
- A pattern of departures across multiple patients suggesting systematic deficits
- Departures that expose patients to foreseeable harm
The informed consent framework. Consent in the medical regulatory context operates on the framework articulated in the foundational case law (including Reibl v Hughes and subsequent decisions) and in the College’s specific policies on consent. The framework requires:
- Disclosure of the nature and purpose of the procedure
- Disclosure of the material risks and benefits
- Disclosure of available alternatives
- Patient understanding of the disclosed information
- Voluntary patient agreement to proceed
For physical examinations and procedures involving sensitive anatomical areas, the framework operates with heightened sensitivity. The expectation includes specific explanation of the examination, the purpose, the parts of the body that will be examined, and the patient’s right to decline or to interrupt the examination. Failure to meet the framework can constitute professional misconduct independent of the underlying clinical conduct.
The DDU standard application. The disgraceful, dishonourable, or unprofessional standard from section 1(1) paragraph 33 of the Professional Misconduct Regulation operates as a broad capture for conduct inconsistent with professional standards. The framework can apply to consent and communication failures that do not amount to sexual abuse under the specific HPPC framework but that nonetheless constitute professional misconduct.
The sanctions framework. Section 51(5) of the Health Professions Procedural Code authorizes a range of sanctions including:
- Revocation
- Suspension (of fixed or indefinite duration)
- Conditions or restrictions on practice
- Mandatory supervision
- Mandatory remedial education
- Reprimand
- Costs
The framework supports calibrated combinations of these sanctions tailored to the specific concerns identified. Where the concerns include both clinical practice deficits and communication or consent failures, the framework can support sanctions addressing both dimensions.
The clinical context — chronic pain management
A brief clinical overview is useful for the analysis.
Chronic pain management. Chronic pain management is a specialized area of clinical practice addressing persistent pain conditions including neuropathic pain, musculoskeletal pain, headache, complex regional pain syndrome, and other conditions. The framework for clinical management is multimodal and typically includes:
- Comprehensive clinical assessment including history and physical examination
- Diagnostic workup as appropriate
- Multimodal treatment including pharmacological, interventional, physical, and psychological approaches
- Individualization of treatment to the specific clinical situation
- Ongoing monitoring and adjustment of the treatment plan
The framework requires careful clinical reasoning at each step. Chronic pain is a heterogeneous category of conditions, and the framework for treatment is not interchangeable across diagnoses.
Interventional pain management — nerve block injections. Nerve block injections involve the administration of local anesthetic (and sometimes corticosteroids) to specific anatomical locations to interrupt or modulate pain signaling. The framework for nerve block practice includes:
- Specific clinical indications based on the underlying diagnosis
- Specific anatomical targets that depend on the pain pathway being addressed
- Image guidance (typically fluoroscopy or ultrasound) for procedures near critical anatomical structures
- Appropriate anesthetic doses and volumes
- Appropriate use of corticosteroids based on the clinical indication
- Documentation of the procedure including consent, technique, and outcome
The framework has evolved significantly over time. Image-guided techniques are now the standard of practice for procedures near the spinal column and many peripheral targets. Non-image-guided (“blind”) techniques are appropriate only for specific anatomical targets where landmark-based approaches remain reliable.
Image guidance. The framework for image guidance in interventional pain management reflects both safety considerations (avoiding inadvertent damage to critical structures such as spinal cord, nerve roots, blood vessels) and efficacy considerations (ensuring the medication reaches the intended target). The framework treats image-guided techniques as the standard of practice for most spinal and many peripheral injection procedures.
Anesthetic volumes. The framework for anesthetic volumes in nerve block injections is calibrated to the target and the procedure. Inadequate volumes may fail to achieve the intended effect; excessive volumes may produce systemic toxicity or unintended effects on adjacent structures. The framework supports specific volume ranges for specific procedures.
Systemic corticosteroids. Corticosteroids can be used in pain management in several contexts including epidural injections, peripheral nerve blocks, and systemic administration for inflammatory conditions. Each context has specific clinical indications and risks. The framework for systemic corticosteroids in chronic pain is narrow; the side effect profile (including endocrine, metabolic, immune, and cardiovascular effects) requires careful clinical reasoning.
Individualized care. The framework for chronic pain management requires individualization to the specific patient. The clinical reasoning includes the underlying diagnosis, the patient’s specific anatomical features, comorbid conditions affecting treatment options, prior treatment history, and the patient’s specific goals and concerns. The framework does not support a “one-size-fits-all” approach in which the same intervention is applied across patients without individual clinical reasoning.
Consent in interventional procedures. Procedures in interventional pain management require specific informed consent reflecting the nature of the intervention, the risks, the alternatives, and the expected outcomes. Where the procedure involves examination or contact with sensitive anatomical areas, the framework operates with heightened sensitivity to explanation and consent.
The facts
The respondent. The respondent was an Ottawa-based family physician focusing on chronic pain management.
The two proceedings. The respondent faced two related sets of allegations addressed in a consolidated proceeding before the Discipline Tribunal:
- Allegations of failure to meet the standard of practice across multiple patients, supported by expert review of patient charts
- Allegations of inappropriate touching during a clinical examination without adequate warning or consent
The clinical deficiencies. The expert evidence, from a pain management specialist who reviewed 19 patient charts, identified a pattern of clinical deficiencies including:
- Performing nerve block injections in cases where the procedures were not medically indicated
- Using anesthetic volumes inadequate to achieve the intended clinical effect
- Relying on outdated, non-image-guided techniques in circumstances where image-guided techniques were the standard of practice
- Failing to take proper patient histories
- Failing to conduct adequate physical examinations
- Applying a “one-size-fits-all” approach across patients rather than individualizing treatment to the clinical circumstances
- Prescribing systemic corticosteroids without clinical justification
- Performing injections in inappropriate anatomical locations relative to the underlying pain pathway
- Failing to communicate with referring physicians
- Maintaining incomplete and inaccurate medical records
The Tribunal found that the deficiencies represented multiple and serious departures from the standard of practice in chronic pain management. The framework supported findings of professional misconduct on the standard of practice basis.
The consent and communication failure. Separately, the Tribunal addressed the framework for a specific patient encounter involving a clinical examination:
- The respondent touched the patient’s gluteal region without adequate warning or explanation
- The respondent made contact with the patient’s pelvic area without proper informed consent
- The respondent failed to ensure the patient understood what procedures were being performed
- The patient reported feeling upset and uncomfortable
The Tribunal emphasized that proper communication and informed consent are as important as the procedure itself. The framework treats consent and communication failures during clinical examinations as professional misconduct under the DDU standard, independent of any underlying inappropriate intent.
The pattern of prior concerns. The Tribunal addressed the framework of the respondent’s prior engagement with the regulatory regime:
- Multiple prior ICRC cautions relating to record-keeping, consent, and clinical practice standards
- A previous discipline finding involving inappropriate touching without adequate explanation
The framework treats the pattern of prior interventions as a significant consideration in the discipline analysis. The framework recognizes that:
- The College has previously identified concerns about the respondent’s practice
- The framework of cautions and remedial requirements has been engaged previously
- The recurrence of similar concerns suggests that less restrictive interventions have not produced sustained behavior change
The Tribunal’s analysis
The standard of practice findings. The Tribunal made findings of professional misconduct on the standard of practice basis. The framework was satisfied by the multiple categories of clinical deficiency identified across the 19 charts reviewed by the expert. The framework treats multiple departures from the standard of practice, particularly where they reflect systemic deficits in clinical reasoning, as serious professional misconduct.
The framework included specific findings on:
- Lack of knowledge and clinical skill in the chronic pain management context
- Poor clinical judgment in multiple cases
- Practices that exposed patients to risk of harm
The DDU findings on consent. The Tribunal made separate findings under the DDU standard addressing the consent and communication failure. The framework treats the failure of consent and explanation during a clinical examination, particularly involving sensitive anatomical areas, as professional misconduct independent of any underlying inappropriate intent.
The Tribunal articulated the principle that proper communication and informed consent are as important as the procedure itself. The framework recognizes that the patient’s experience of the examination depends not just on the technical aspects of the procedure but on the framework of communication, explanation, and consent that surrounds it.
The progressive discipline analysis. The Tribunal addressed the framework for progressive discipline. The pattern of prior ICRC cautions and the prior discipline finding involving similar concerns operated as significant aggravating factors. The framework supported sanctions more substantial than would have been appropriate for a first-time concern of similar substantive content.
The Tribunal articulated the principle that penalties must increase when prior corrective measures fail. The framework treats prior intervention without sustained behavior change as a significant predictor of future conduct and as supporting more substantial sanctions.
The joint submission framework. The Tribunal accepted a joint submission for penalty. The framework for joint submissions in discipline operates similarly to the framework in criminal sentencing: the Tribunal accepts the joint submission unless it would bring the administration of the regulatory regime into disrepute or is otherwise contrary to the public interest. The framework supports efficient resolution where the parties have agreed on appropriate sanctions.
The sanction
The Tribunal imposed:
- Four-month suspension of the certificate of registration
- Practice restrictions including:
- Prohibition on performing injections near the spinal column
- Prohibition on administering injections to patients on certain medications
- Prohibition on prescribing systemic corticosteroids
- Prohibition on acting as medical director of a clinic
- Mandatory clinical supervision for at least six months including:
- Direct observation of patient care
- Chart reviews
- Ongoing reporting to the College
- Formal reassessment following the supervision period
- Unannounced inspections
- Ongoing compliance monitoring
- $6,000 in costs
The practice restrictions framework. The practice restrictions reflect specific concerns identified in the expert evidence. Each restriction addresses a category of conduct that fell below the standard of practice:
- Spinal column injections (image-guidance and anatomical targeting concerns)
- Injections to patients on certain medications (interaction and individualization concerns)
- Systemic corticosteroid prescribing (clinical indication concerns)
- Medical director role (broader practice oversight concerns)
The framework operates as targeted protective measures rather than as blanket restrictions on practice. The framework permits the respondent to continue practising in areas not implicated by the identified concerns while protecting the public from the specific risks identified.
The supervision framework. The mandatory clinical supervision framework operates as ongoing oversight designed to support and verify continued compliance with the standard of practice. The framework includes:
- Direct observation of patient care to assess clinical decision-making in real time
- Chart reviews to assess documentation and treatment patterns
- Ongoing reporting to the College to support institutional oversight
The framework supports remedial change while protecting the public during the period in which the change is being established.
The reassessment and monitoring framework. The formal reassessment following the supervision period operates as a checkpoint for assessing whether the underlying concerns have been addressed. The unannounced inspections and ongoing compliance monitoring operate as longer-term safeguards.
The doctrinal anchors
Several doctrinal anchors emerge from the case.
The progressive discipline framework. Where a physician has previously been the subject of informal interventions and the underlying concerns have not been resolved, the framework supports more substantial responses. The principle is that penalties must increase when prior corrective measures fail. CPSO v Nahas is the principal recent cluster authority on the explicit application of the progressive discipline framework.
The ICRC caution framework. The Inquiries, Complaints and Reports Committee can impose cautions and remedial requirements as less restrictive alternatives to formal discipline. The framework operates as the first tier of regulatory response to concerns about a physician’s practice. The pattern of prior ICRC interventions is a relevant consideration in subsequent formal discipline.
The standard of practice framework. Section 1(1) paragraph 2 of the Professional Misconduct Regulation treats failure to maintain the standard of practice of the profession as professional misconduct. The framework supports findings based on a single significant departure, multiple smaller departures, a pattern across multiple patients, or departures exposing patients to foreseeable harm.
The chronic pain management framework. Chronic pain management is a specialized area with a specific clinical framework including multimodal treatment, individualized clinical reasoning, and ongoing monitoring. The framework requires careful clinical reasoning at each step rather than uniform application of a single approach. CPSO v Nahas is the principal cluster authority on the application of professional standards to chronic pain management.
The nerve block / injection therapy framework. Nerve block injections require specific clinical indications, appropriate anatomical targeting, appropriate anesthetic dosing, and (in most cases) image guidance. The framework supports professional misconduct findings where the practice falls below the standard on any of these dimensions.
The image-guided technique framework. Image-guided techniques are the standard of practice for most spinal and many peripheral injection procedures. The framework reflects both safety and efficacy considerations. CPSO v Nahas applies the framework to a case involving non-image-guided techniques where the standard of practice required image guidance.
The “individualized care” framework. The framework for chronic pain management requires individualization to the specific patient. The framework does not support a “one-size-fits-all” approach. CPSO v Nahas applies the framework to a case where the expert evidence identified a uniform approach across patients without appropriate individualization.
The informed consent framework for clinical examinations. Examinations involving sensitive anatomical areas require specific consent and explanation. The framework operates with heightened sensitivity and treats failure of consent and communication as professional misconduct independent of any underlying inappropriate intent. CPSO v Nahas applies the framework to a case involving examination of the gluteal and pelvic areas without adequate explanation.
The DDU standard application to consent violations. The disgraceful, dishonourable, or unprofessional standard applies to consent and communication failures during clinical examinations. The framework operates separately from the specific framework for sexual abuse under the Health Professions Procedural Code and supports findings of professional misconduct in cases involving inadequate consent regardless of intent.
The poor documentation framework. Incomplete and inaccurate medical records constitute professional misconduct. The framework recognizes that documentation supports clinical communication across providers, framework for ongoing decision-making, and the regulatory framework’s ability to assess care after the fact.
The pattern of prior misconduct framework. Where the respondent has been the subject of multiple prior interventions and the underlying concerns persist, the framework treats the pattern as a significant aggravating factor in the current discipline analysis.
The “failure of remedial intervention” framework. Where prior education, supervision, and discipline have not produced sustained behavior change, the framework supports more substantial sanctions in subsequent discipline.
The practice restrictions framework. Practice restrictions calibrated to specific aspects of the underlying deficiencies operate as targeted protective measures rather than blanket restrictions. The framework permits continued practice in areas not implicated by the identified concerns.
The mandatory supervision framework. Mandatory clinical supervision operates as ongoing oversight designed to support and verify continued compliance with the standard of practice. The framework includes direct observation, chart reviews, and ongoing reporting.
The formal reassessment framework. Formal reassessment following a supervision period operates as a checkpoint for assessing whether the underlying concerns have been addressed.
The joint submission framework. Joint submissions in professional discipline support efficient resolution where the parties have agreed on appropriate sanctions, subject to the framework that the Tribunal can decline to accept a joint submission that would bring the administration of the regulatory regime into disrepute.
Why this case matters
For patients. The case is a useful illustration of how the regulatory framework operates with concerns about clinical practice and consent.
Some practical observations:
Not all clinical procedures are appropriate. Even commonly used procedures must be clinically indicated, performed using accepted techniques, and tailored to the individual patient. Where the framework is not met, the regulatory regime can intervene.
Documentation is part of clinical care. Incomplete or inaccurate records are not just an administrative issue. The framework treats documentation as part of the clinical care provided and as a foundational element of patient safety.
Consent is fundamental. Patients have the right to understand what will be done, receive clear explanations, and provide informed consent, particularly for examinations involving sensitive anatomical areas. The framework supports professional misconduct findings where consent and communication are inadequate.
Patterns matter. Where a physician has been the subject of prior interventions with the College, the regulatory framework treats the pattern as a significant consideration in the analysis of current concerns. Recurrent issues can support more substantial sanctions than would otherwise be appropriate.
Civil claims and regulatory discipline operate on different frameworks. A regulatory discipline finding addresses the professional accountability framework but does not automatically support a civil claim. Where a patient has been harmed and the framework of standard of care, causation, and damages supports a claim, civil proceedings remain available.
For more on the framework for regulatory complaints and the broader landscape of healthcare accountability in Ontario, see A Patient’s Guide to Making Complaints About Health Care in Ontario. For the framework for civil medical malpractice claims, see Suing for Medical Malpractice in Ontario: What You Need to Know.
For physicians. A few practical observations:
The standard of practice applies to clinical reasoning, not just outcomes. The framework for evaluating clinical practice includes the clinical reasoning that produces specific decisions about indications, techniques, dosing, and follow-up. Where the reasoning is inadequate, the framework can support findings even where individual patient outcomes have not been measurably worse.
Individualization is part of the framework. The framework does not support uniform approaches across patients in areas where individualization is part of the clinical standard. Chronic pain management is one such area.
Image guidance is the standard for most spinal and peripheral injection procedures. The framework has evolved over time, and current standards generally require image guidance for procedures near critical anatomical structures. Continued reliance on non-image-guided techniques in such cases can support professional misconduct findings.
Consent and communication during examinations are foundational. Where the examination involves sensitive anatomical areas, the framework operates with heightened sensitivity. Specific explanation of the procedure, identification of the body areas to be examined, and opportunity for the patient to ask questions or decline are part of the framework.
Engaging with regulatory interventions matters. Where the College has previously engaged the physician through cautions, remedial requirements, or supervised practice, meaningful engagement supports the framework’s protective function. Where prior interventions have not produced sustained behavior change, the framework supports more substantial sanctions in subsequent discipline.
Decision Date: March 4, 2026
Jurisdiction: Ontario Physicians and Surgeons Discipline Tribunal
Citation: College of Physicians and Surgeons of Ontario v Nahas, 2026 ONPSDT 8 (CanLII)
Outcome: Joint submission accepted. Four-month suspension of the certificate of registration; practice restrictions including prohibition on performing injections near the spinal column, prohibition on administering injections to patients on certain medications, prohibition on prescribing systemic corticosteroids, and prohibition on acting as medical director of a clinic; mandatory clinical supervision for at least six months including direct observation, chart reviews, and ongoing reporting to the College; formal reassessment following the supervision period; unannounced inspections; ongoing compliance monitoring; and $6,000 in costs. The Tribunal made findings of professional misconduct on the standard of practice basis supported by expert evidence from a pain management specialist who reviewed 19 patient charts identifying multiple categories of clinical deficiency including nerve block injections without clinical indication, inadequate anesthetic volumes, outdated non-image-guided techniques, inadequate history-taking and examination, “one-size-fits-all” approach, unnecessary systemic corticosteroid prescribing, inappropriate anatomical injection locations, failure to communicate with referring physicians, and incomplete and inaccurate medical records. The Tribunal made separate findings under the DDU standard for inappropriate touching during a clinical examination without adequate explanation, including contact with the patient’s gluteal and pelvic areas without proper informed consent and without ensuring the patient understood what procedures were being performed. The Tribunal applied the progressive discipline framework, treating the respondent’s pattern of prior ICRC cautions on record-keeping, consent, and clinical practice standards, and a previous discipline finding involving inappropriate touching without adequate explanation, as significant aggravating factors. The framework supports more substantial sanctions where prior corrective measures have not produced sustained behavior change.
Key authorities: Regulated Health Professions Act, 1991, SO 1991, c 18 (foundational regulatory framework); Health Professions Procedural Code (Schedule 2 to the RHPA), particularly s 51 (discipline framework) and s 51(5) (sanctions); Medicine Act, 1991, SO 1991, c 30 (physician-specific provisions); Professional Misconduct Regulation (O Reg 856/93) under the Medicine Act, particularly section 1(1) paragraph 2 (failure to maintain the standard of practice) and section 1(1) paragraph 33 (disgraceful, dishonourable, or unprofessional standard).
