Most of the regulatory cases that come out of the Ontario Physicians and Surgeons Discipline Tribunal involve breaches of the standard of practice that are recognizable as professional failures: practising outside one’s scope, failing to maintain adequate records, prescribing in unsafe ways, failing to manage a boundary in a therapeutic relationship. The conduct is misconduct precisely because the regulatory framework defines it as misconduct. The physician disputes the finding or accepts it; the panel calibrates the penalty; the system moves on.
A small number of cases are different. They involve conduct that no regulatory framework should ever have to anticipate because the conduct sits outside the entire scaffolding of what professional practice is supposed to be. The conduct is wrong not because the College rules forbid it but because it is wrong as a matter of basic human conduct, and the regulatory finding of professional misconduct is essentially a confirmation that what the physician did was incompatible with the practice of medicine in any form. College of Physicians and Surgeons of Ontario v Nahvi, 2024 ONPSDT 31, is one of these cases.
The OPSDT decision, released December 13, 2024, accepted a joint submission from the College and Dr. Shahab Nahvi (a family and emergency medicine physician) on uncontested facts. The OPSDT found that Dr. Nahvi had surreptitiously administered Flunitrazepam (the benzodiazepine commonly known as Rohypnol) and Lorazepam (the benzodiazepine commonly known as Ativan) to a patient/employee, that he had left her in an incapacitated state in a basement room of his clinic for approximately two hours without seeking medical assistance, and that he had subsequently taken a series of steps to conceal his conduct including the self-administration of Flunitrazepam in the days before he was scheduled to provide samples for toxicological analysis. The OPSDT delivered a reprimand and accepted Dr. Nahvi’s resignation of his certificate of registration together with his undertaking never to re-apply for registration as a physician in any jurisdiction. Costs of $6,000 were ordered.
This post covers the OPSDT proceeding and decision, the regulatory framework that produced the outcome, the framework for civil remedies that may run in parallel to a case of this kind, and the broader implications of the case for the cluster of physician discipline matters. As a preliminary observation: the post is about the regulatory dimension of the matter. The conduct as described in the OPSDT findings raises distinct questions of criminal liability. The disposition of any criminal proceedings is not addressed in the OPSDT decision and is not the subject of this post. The three tracks (regulatory, criminal, civil) operate independently of each other; findings in one do not bind the others.
The OPSDT decision in summary
The parties. The College of Physicians and Surgeons of Ontario, exercising its statutory authority under the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, and the Medicine Act, 1991, S.O. 1991, c. 30, brought disciplinary proceedings against Dr. Shahab Nahvi, a family and emergency medicine physician who held a certificate of registration with the College. Dr. Nahvi was represented by counsel.
The procedural posture. The matter proceeded on a Statement of Uncontested Facts. The parties had reached a joint submission on disposition. The OPSDT’s role was to determine whether the conduct met the standard for professional misconduct under the regulations and whether the proposed disposition was within the range of reasonable outcomes.
The findings. The OPSDT found Dr. Nahvi engaged in professional misconduct under paragraph 1(1)33 of Ontario Regulation 856/93: an act or omission relevant to the practice of medicine that, having regard to all the circumstances, would reasonably be regarded by members of the profession as disgraceful, dishonourable, or unprofessional. The OPSDT found that the surreptitious administration of an illegal substance to a patient, the failure to assist her once she became impaired, and the dishonest attempt to cover up the conduct, each constituted serious misconduct. The panel had no hesitation in making this finding.
The disposition. The OPSDT accepted the joint submission. The disposition included:
- A reprimand
- Acceptance of Dr. Nahvi’s resignation of his certificate of registration
- Dr. Nahvi’s undertaking that he would never apply for registration as a physician in any jurisdiction
- Costs payable to the College in the amount of $6,000
The resignation + permanent undertaking framework functions as the equivalent of revocation for practical purposes. Dr. Nahvi cannot practise medicine in Ontario or elsewhere in Canada (or, by the terms of the undertaking, anywhere in the world) absent a future order varying the undertaking. The undertaking is enforceable as a binding agreement; breach of it would constitute further professional misconduct in any jurisdiction where Dr. Nahvi attempted to practise.
The facts as found
I summarize the facts here on the basis of the OPSDT decision. The conduct described is the conduct that Dr. Nahvi acknowledged on the Statement of Uncontested Facts.
The relationship. The patient (referred to in the decision as Patient A) had been a patient of Dr. Nahvi from October 2015 to January 2021. In August 2019, while still his patient, she was hired to work as a Registered Nurse and receptionist at Dr. Nahvi’s North York clinic. The relationship was therefore dual: she was both a former patient (the formal patient relationship ended in January 2021) and a current employee.
The lunch. On May 21, 2021, Dr. Nahvi asked Patient A whether she wanted to order pizza for lunch. When Patient A entered the room, the pizza was set out and two cups of orange juice were already poured. The juice cup in front of her was already full. When she went to drink it, Dr. Nahvi poured more on top. Before she entered the room, and without her knowledge, Dr. Nahvi had added quantities of Flunitrazepam and Lorazepam to the food and drink.
The two drugs are clinically distinct but operationally similar in this context. Flunitrazepam is a potent benzodiazepine that has been associated with use as an agent to facilitate sexual offences. In Canada, Flunitrazepam is no longer prescribed or approved for medical use and possession is illegal. Lorazepam is a benzodiazepine commonly prescribed for short-term anxiety management; it is legal with a prescription. Both produce sedation; both produce some degree of anterograde amnesia (impairment of memory formation after the drug has taken effect); the combination of the two is particularly potent.
The onset. Within approximately 15 minutes of eating, Patient A began experiencing significant physical and mental impairment. She felt sleepy and dizzy. She communicated this to Dr. Nahvi. He told her he was also feeling unwell. He grabbed her wrist and told her she should go downstairs to a couch in one of the basement rooms. She found this instruction odd because she was already on a couch in his consultation room.
The basement period. Dr. Nahvi moved Patient A to a basement room of the clinic that was typically used for cosmetic injections. She was dizzy and did not have the strength to get up. She lost continuous memory between approximately 1:00 pm and 9:00 pm. She woke up later that evening in her own bed, in her pyjamas, with no recollection of how she had got home or how her clothes had been changed.
The clinic had a video surveillance system that was reviewed by the OPSDT. The surveillance footage showed Patient A in the basement room in an impaired state for approximately two hours. During that period, Dr. Nahvi entered and exited the room seven times. At no point during the two hours did he seek medical assistance for her, despite her visible sedation, staggering, and slurring.
The discovery. The next morning (May 22), Patient A was unable to balance or walk well. She noticed multiple bruises on her leg, which she suspected were from falling. A friend who came to see her noticed her condition and was concerned. The friend took her to a nearby medical clinic. She subsequently attended a hospital and provided blood and urine samples for toxicology screening. The samples tested positive for both Flunitrazepam and Lorazepam.
The complaint. Patient A reported the conduct to the police. The OPSDT decision does not address criminal proceedings.
The cover-up
The OPSDT findings on the post-event conduct are doctrinally distinct from the findings on the underlying drugging. The post-event conduct was found to be a separate ground of professional misconduct.
The May 27 police interview. Dr. Nahvi attended the police station for an interview on May 27, 2021. On arrival he advised that he was not experiencing any health issues. After the detective informed him that the toxicology screen on Patient A had returned positive for Flunitrazepam and Lorazepam, Dr. Nahvi changed his account. He stated that he, too, had been unwell on the afternoon of May 21; that he had experienced amnesia; that he did not remember seeing patients in the afternoon; and that his last clear memory was eating pizza with Patient A.
The patient evidence. The patients who had attended Dr. Nahvi’s clinic in the afternoon of May 21 did not corroborate his account of impairment. They reported that he had seemed physically well during their consultations. One patient noted that Dr. Nahvi was “sweating and anxious” during the appointment but reported no impairment.
The EMR evidence. A forensic analysis of the clinic’s Electronic Medical Records (EMR) for the afternoon of May 21 showed that Dr. Nahvi had been accessing and adding information to patient charts during the time period for which he claimed to have no memory. The EMR activity was inconsistent with his account.
The hospital presentation. Shortly after the police interview, Dr. Nahvi attended the emergency department of the hospital where he had privileges. He reported that he had suspected food poisoning from pizza he had eaten at his clinic on May 21 and was still feeling unwell. He reported symptoms of vomiting, dizziness, and complete amnesia in the afternoon of May 21. He had not sought any medical attention before this presentation, six days after the alleged onset of symptoms.
The toxicology screen. Dr. Nahvi provided urine and blood samples on May 27 and 28. The urine sample tested positive for Flunitrazepam.
The OPSDT’s inference. The OPSDT found that the positive Flunitrazepam result on Dr. Nahvi’s own toxicology screen was the product of his having administered Flunitrazepam to himself at some point between May 21 and May 27-28. The inference is supported by:
- The patients who saw him in the afternoon of May 21 reporting that he appeared well
- The EMR activity inconsistent with amnesia
- The delay of nearly a week before he sought medical attention
- The timing of his hospital presentation immediately after the police interview revealed the toxicology evidence against him
- The clear motive to fabricate a parallel impairment narrative
The OPSDT framed the conduct as a “dishonest attempt to cover up his actions.”
The legal framework
Several distinct legal frameworks operate in cases of this kind. Understanding them separately is necessary because they have different standards, different processes, and different remedies.
The regulatory framework. The College of Physicians and Surgeons of Ontario regulates physicians under the Regulated Health Professions Act, 1991. The Medicine Act, 1991 governs the specific profession of medicine. Professional misconduct is defined in the regulations to the Medicine Act (specifically Ontario Regulation 856/93). The OPSDT is the discipline tribunal that adjudicates allegations of professional misconduct.
The standard of professional misconduct under O. Reg. 856/93, s. 1(1)33 — the “disgraceful, dishonourable, or unprofessional” (DDU) standard — is one of the most general grounds for finding misconduct. It captures conduct that, having regard to all the circumstances, would reasonably be regarded by members of the profession as falling outside acceptable professional conduct. The standard is broad. Where a physician’s conduct is clearly outside the bounds of professional practice, even if not specifically enumerated in other paragraphs of the regulation, the DDU ground operates as a backstop.
In Nahvi, the DDU finding was uncontroversial. The OPSDT panel had “no hesitation” in concluding that the conduct met the standard. Three separate categories of conduct contributed:
- The administration of an illegal substance and a prescription sedative to a person without her knowledge
- The failure to seek medical assistance when she became impaired in a way that was visibly dangerous
- The deliberate and elaborate concealment of the conduct, including self-administration of the same illegal substance to fabricate parallel impairment
The criminal framework (in parallel). The conduct described in the OPSDT findings raises distinct questions of criminal liability under the Criminal Code. Without addressing the disposition of any specific criminal proceedings (which is not within the scope of the OPSDT decision and is not the subject of this commentary), the categories of criminal offence potentially engaged by conduct of this kind include:
- Administering a noxious thing under section 245 of the Criminal Code
- Assault under section 265
- Sexual assault under section 271 (where the surrounding circumstances and intent support the charge)
- Possession of a Schedule I substance under the Controlled Drugs and Substances Act (Flunitrazepam is a Schedule III substance under the CDSA, with possession governed by section 4)
- Obstruction of justice under section 139 (in respect of the cover-up conduct)
- Forcible confinement under section 279(2) (where the circumstances of the basement period meet the threshold)
Whether any of these were ultimately the subject of charges and the disposition of any such proceedings is not addressed in the OPSDT decision. The regulatory finding and the criminal disposition (if any) operate independently. A regulatory finding does not establish criminal liability; a criminal disposition does not bind the regulator.
The civil framework (also in parallel). Patient A would have civil causes of action against Dr. Nahvi for the conduct as described. The torts potentially engaged:
- Battery — the unconsented administration of substances to her body is a classic battery
- Assault — separately actionable where present
- False imprisonment — the two-hour period in the basement room, in a state of incapacity, where she was not free to leave, may support this
- Intentional infliction of mental suffering — flagrant, calculated, and extreme conduct producing actual harm
- Negligence — the failure to seek medical assistance when she became impaired
- Breach of fiduciary duty — both the physician-patient relationship and the employer-employee relationship are fiduciary; the conduct is a flagrant breach of both
The damages framework would include both pecuniary damages (lost income, medical expenses, future care) and non-pecuniary damages (pain and suffering, loss of dignity, mental distress, loss of enjoyment of life). Where conduct is found to be high-handed, malicious, or oppressive, aggravated damages may also be awarded. Where the conduct exhibits a level of moral culpability that warrants punishment beyond compensation, punitive damages may also be awarded.
Civil and regulatory proceedings operate independently. A civil action does not require a prior criminal conviction or regulatory finding. The standard of proof in civil proceedings (balance of probabilities) is lower than the standard in criminal proceedings (beyond reasonable doubt) and is the same as the standard in regulatory proceedings.
The resignation + permanent undertaking framework
The disposition in Nahvi — resignation plus permanent undertaking — is a specific OPSDT outcome that warrants separate discussion.
The functional equivalence to revocation. The OPSDT has the authority to revoke a certificate of registration as a sanction for professional misconduct. Revocation is the most severe regulatory sanction available. It removes the physician’s authority to practise medicine in Ontario. In some cases, however, the same end result is achieved through a different procedural path: the physician resigns the certificate of registration and provides an undertaking not to re-apply. Where the undertaking is permanent and covers all jurisdictions, the practical effect is the same as revocation.
The advantage of the resignation + undertaking framework for the parties:
- The physician avoids the formal record of revocation (though the undertaking is itself a matter of public record on the College register)
- The College achieves the regulatory outcome efficiently without the resource demands of a contested hearing
- The matter is concluded without the need for the patient to give live evidence (since the proceeding is on uncontested facts)
The framework is recognized in OPSDT practice and is regularly used in cases where the physician concedes the conduct and the parties agree that the physician should not practise. The OPSDT must still satisfy itself that the disposition is within the range of reasonable outcomes given the conduct. In Nahvi, the panel had no difficulty doing so.
The cross-jurisdictional dimension. Dr. Nahvi’s undertaking extends to “any jurisdiction.” This is significant. Without the cross-jurisdictional dimension, a physician who is revoked or who resigns in Ontario can in principle seek registration elsewhere (subject to the receiving regulator’s own assessment, which would consider the Ontario history). The “any jurisdiction” undertaking removes this option. A future application to any regulator anywhere would constitute a breach of the undertaking and would itself be a ground for refusal.
The public protection function. The resignation + permanent undertaking framework serves the public protection function of regulatory discipline. The purpose of regulatory sanction is not punishment of the individual physician (that is the function of the criminal system if criminal liability is established). The purpose is the protection of the public. Where the physician is removed from practice permanently, the public is protected from the conduct continuing. The framework achieves that goal whether the path is revocation or resignation with undertaking.
The evidentiary anchors
A few features of the evidentiary record in Nahvi are worth highlighting because they recur in regulatory and civil proceedings.
The Statement of Uncontested Facts. The proceeding was decided on uncontested facts. Dr. Nahvi acknowledged the conduct. Where the physician contests the conduct, the College must prove its case at hearing through witnesses, documents, and expert evidence. The Statement of Uncontested Facts shortcuts this process and produces a more efficient resolution. The practice is common in OPSDT proceedings where the physician’s counsel has concluded that the conduct is supportable on the available evidence.
Video surveillance evidence. The clinic had a video surveillance system. The system captured Patient A in the basement room for approximately two hours and captured Dr. Nahvi’s entries and exits. The video surveillance was reviewed by the OPSDT. In many regulatory cases involving allegations of physical conduct in a clinical or near-clinical setting, video surveillance becomes important evidence. Where it exists, it is often decisive. The practice implication: clinics with surveillance systems should be aware that the recordings are admissible in subsequent proceedings.
Toxicology evidence. The toxicology screens on both Patient A (positive for Flunitrazepam and Lorazepam, taken within hours to a day of the incident) and Dr. Nahvi (positive for Flunitrazepam, taken six to seven days later) were operative evidence. The temporal pattern of the two positive results — one consistent with the index event and one consistent with a more recent administration — was important to the OPSDT’s inference that Dr. Nahvi had self-administered.
EMR data. The forensic analysis of the clinic’s EMR showed Dr. Nahvi was actively charting on the afternoon when he later claimed he had been impaired with amnesia. EMR data has metadata: timestamps, user identities, the specific actions taken (creation, edit, save, view). Where a physician’s account is inconsistent with the EMR metadata, the metadata is typically more reliable. Physicians whose conduct is the subject of regulatory or civil scrutiny should expect that EMR forensic analysis will be conducted and that inconsistencies will be identified.
Witness evidence from contemporaneous patients. Several patients who saw Dr. Nahvi in the afternoon of May 21 provided evidence about his apparent state. The evidence was important because it contradicted his account of impairment. The principle is generalizable: where a physician asserts a particular state during a clinical period, the patients who saw him during that period are potential witnesses to that state. The clinic environment produces witnesses.
Cluster integration
The OPSDT discipline cluster. The cluster currently includes:
- CPSO v Trozzi (COVID-era misinformation; revocation; Divisional Court affirmance in Trozzi v CPSO, 2024 ONSC 6096)
- CPSO v Luchkiw (COVID-era; substantial suspension)
- CPSO v Kilian (COVID-era; 12-month suspension; ONCA on s. 87 in CPSO v Kilian, 2024 ONCA 52)
- CPSO v Kustka (COVID-era; penalty June 2025)
- CPSO v Nahvi (boundary violation; drugging; permanent resignation)
A doctrinal distinction. Nahvi is doctrinally distinct from the COVID-era cluster. The COVID cases involve physicians whose alleged misconduct related to clinical practice positions, public commentary, or regulatory dissent. Each of those cases involved contested issues about the boundary between physician autonomy and regulatory authority, the Doré framework for Charter values in professional regulation, and the framework for assessing professional misconduct in the context of public health emergencies. Nahvi does not engage any of those issues. The conduct is wrong in a more elemental way. The regulatory finding confirms what is already evident.
The boundary violation cluster. Nahvi is the principal cluster authority on the most serious form of physician-patient boundary violation. The dual relationship (former patient + current employee) is itself a risk factor. The setting of the clinic and the equipment that was available (sedative drugs from the clinic supply, a basement room used for cosmetic injections) were features of the professional context that the physician exploited. The case is a cluster reference point for the proposition that the most serious boundary violations occur where the physician’s professional position and clinic infrastructure are themselves part of the harm.
The framework for parallel proceedings. Nahvi illustrates how regulatory, criminal, and civil proceedings operate independently. The OPSDT proceeding was concluded by joint submission on uncontested facts. The civil proceeding (if any) would be a separate action by Patient A. The criminal proceeding (if any) would be a separate Crown prosecution. The three tracks have different standards of proof, different procedures, and different remedies, but they all draw on the same factual record and they all serve different functions in addressing the conduct.
For an overview of the regulatory complaint and other complaint pathways available to patients, see A Patient’s Guide to Making Complaints About Health Care in Ontario. For the civil remedies framework, see Suing for Medical Malpractice in Ontario: What You Need to Know.
Why this case matters
For prospective clients. The vast majority of medical malpractice cases involve clinical errors. A surgeon who applies excessive force during a procedure. An emergency physician who misses a presentation. A family physician who does not refer in time. The framework for those cases is the standard of care, the breach, the causation, and the damages. The conduct may be careless, even reckless, but it is not deliberate in the sense of intent to harm.
Nahvi is a different kind of case. The conduct is deliberate. The harm is intentional. The framework for assessing the conduct is not the standard of care of a reasonably competent physician (the conduct sits outside any plausible standard) but the broader frameworks of battery, intentional infliction of mental suffering, and breach of fiduciary duty. The civil action that would arise from conduct of this kind is structurally different from a typical medical malpractice action.
I want to be clear that cases of this kind are very rare. The overwhelming majority of physicians in Ontario practise ethically and within the boundaries of their profession. The fact that a case like Nahvi exists does not say anything about the profession as a whole. It says only that even within a regulated and generally trustworthy profession, the occasional case of profound boundary violation occurs and the regulatory and legal systems have to address it.
If a patient has been the victim of deliberate harm by a physician — drugging, sexual assault, fraudulent care, deliberate maladministration of medication, anything that crosses from incompetence into deliberate harm — the regulatory complaint to the CPSO is one available path. The criminal complaint to the police is another. The civil action for damages is a third. The three can run in parallel. The first conversation with civil counsel about the available options is confidential and at no cost to the prospective client.
For physicians and clinic operators. A few practical observations:
- Video surveillance has real evidentiary implications. Many Ontario clinics have surveillance for security reasons. The recordings can become evidence in subsequent proceedings. They can be used both to inculpate and to exculpate. The fact of having surveillance is not in itself problematic; physicians and clinic operators should be aware of what the recordings would show in any given period.
- EMR access logs are forensic evidence. Every login, every chart view, every edit is timestamped and attributed. EMR systems produce a detailed forensic trail of professional activity. Where a physician’s verbal account is inconsistent with the EMR record, the EMR record is typically more reliable. Plan accordingly.
- The DDU standard is broad. The “disgraceful, dishonourable, or unprofessional” ground for professional misconduct is intentionally broad. It captures conduct that is wrong even where no specific rule is broken. The standard is one the OPSDT applies based on what members of the profession would reasonably regard as falling outside acceptable conduct.
- Cover-up conduct is itself misconduct. The OPSDT analysis in Nahvi treated the cover-up conduct as a separate ground of misconduct from the underlying drugging. The same principle operates in other contexts: the false statement to investigators, the document alteration, the obstruction of inquiry, can each be a separate basis for regulatory finding regardless of whether the underlying conduct is also established.
- Boundary management is foundational. The dual relationship (former patient as current employee) was a structural risk factor in Nahvi. The CPSO has published practice guidance on physician-patient boundaries and on the management of dual relationships. The practice point is that the physician owes ongoing duties of professional boundary management even after the formal patient relationship has ended, and especially where the former patient enters a different relationship with the physician that re-engages the professional dynamic.
Decision Date: December 13, 2024
Jurisdiction: Ontario Physicians and Surgeons Discipline Tribunal
Citation: College of Physicians and Surgeons of Ontario v Nahvi, 2024 ONPSDT 31 (CanLII)
Disposition: Joint submission accepted. Finding of professional misconduct under paragraph 1(1)33 of Ontario Regulation 856/93 (disgraceful, dishonourable, or unprofessional conduct). Reprimand delivered. Acceptance of resignation of certificate of registration. Permanent undertaking by the physician never to apply for registration as a physician in any jurisdiction. Costs of $6,000 payable to the College.
Key authorities: Ontario Regulation 856/93 made under the Medicine Act, 1991, S.O. 1991, c. 30 (particularly section 1(1)33); the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, Schedule 2 (Health Professions Procedural Code) (governing the OPSDT processes and authority).
