On August 22, 2025, a judge of the Ontario Superior Court of Justice found emergency medicine physician Dr. Angela Cavanagh negligent for not referring a 17 week pregnant mother who had just had a possible rupture of membranes (pPROM) for an urgent obstetrical assessment that may have led to antibiotics and a dilation and curettage (D&C) procedure to prevent a potential ascending infection.
Unfortunately, without the benefit of an obstetrical assessment and subsequent treatment following her pPROM, the patient developed sepsis and went into septic shock. As a result, Ms. Ibrahimova suffered an amputation of her left leg below the knee, partial amputation of her right foot, kidney failure leading to a transplant, stroke, compromised ability to use her right arm and seizures.
Damages were partially settled before trial.
Tamara Ibrahimova, 17 weeks pregnant, visited the Kincardine hospital on May 3, 2019, and was diagnosed with a threatened miscarriage by Dr. Cavanagh. She returned the next day, reporting a “gush of fluid,” which indicated a possible rupture of membranes (pPROM).
Despite noting the likelihood of amniotic fluid leakage, Dr. Cavanagh discharged her without referring her to an obstetrician or initiating further treatment. Over the following days, Ms. Ibrahimova’s condition worsened, leading to sepsis and septic shock.
The court found that timely intervention, including antibiotics and a D&E procedure, would likely have prevented these complications.
At issue was whether the Defendants fell below the standard of care by not referring the patient to an obstetrician, and if so, whether such a referral would have avoided the sequelae of the septic shock.
Dr. Douglas Munkley was qualified to provide opinion evidence on the standard of care of an emergency medicine physician. Dr. Munkley graduated in medicine from the University of Toronto in 1978. He did a one-year internship in Montreal, and then began practicing emergency medicine. In 1985, he obtained a certificate of special competence in emergency medicine from the College of Family Physicians of Canada. He has published articles, including in the Annals of Emergency Medicine and The New England Journal of Medicine.
Dr. Talan was qualified to provide opinion evidence on the standard of care of an emergency medicine physician. Dr. Talan received his medical degree at the University of Illinois in 1981. From 1984 to 1986, he did an emergency medicine residency at the UCLA Medical Centre in Los Angeles. Dr. Talan is board certified in both emergency medicine and infectious diseases.
Dr. McMurray is a family / emergency medicine physician who testified on the issue of standard of care. Dr. McMurray had a family practice in Brockville from 1985 until 2018. As part of that practice, he worked in the emergency department of the local hospital and provided obstetric care. The Brockville hospital serves a population of approximately 90,000 people. From 1997 to 2012, he also served as an emergency physician at a hospital in Watertown, New York, which was a larger medical facility serving a population of approximately 200,000 people.
Dr. Zain Chagra is an expert in infectious disease and testified one behalf of the defence. Dr. Chagla received his medical degree from Queen’s University in 2009. He completed a Master of Sciences degree in Infectious Diseases from the London School of Hygiene and Tropical Medicine in 2012. He then completed a fellowship in infectious diseases at McMaster University in 2014. He has specialist designations in internal medicine and infectious diseases from the Royal College of Physicians and Surgeons of Canada.
The court found that Dr. Cavanagh breached the standard of care because of the following:
Failure to Refer to an Obstetrician:
Inadequate Response to a High-Risk Situation:
The Court further found that the standard of care was not met by Drs. Kalaichandran and Ponesse. As per paras. 112-113 of the decision,
I conclude that the standard of care required Dr. Cavanagh to consult, or refer Ms. Ibrahimova to, an obstetrician prior to 7:45 on May 4, being the time she was discharged from the hospital. This is on the basis that:
a) She should have diagnosed rupture of membranes and realized that, with the increased risk of infection, a referral to an obstetrician was required; AND
b) Knowing Ms. Ibrahimova presented with pPPROM, a rare condition she had never encountered, this was a new or novel presentation such that a referral to an obstetrician was required.
It follows, that Dr. Kalaichandran and Dr. Ponesse similarly breached the standard of care.
The court applied the “but for” test to determine whether Dr. Cavanagh’s breach of the standard of care directly caused Ms. Ibrahimova’s injuries. It concluded that, but for Dr. Cavanagh’s failure to diagnose ruptured membranes (pPROM) and refer Ms. Ibrahimova to an obstetrician, the severe complications would have been avoided.
Expert testimony established that if Ms. Ibrahimova had been referred to an obstetrician on May 4 or 5, she would have received antibiotics and undergone a D&C procedure. These interventions would have prevented the progression to sepsis and septic shock.
The court found a direct causal link between the failure to act on the signs of pPROM and the resulting infection and complications. The delay in treatment allowed the infection to progress, leading to septic shock and significant harm.
In conclusion, the court determined that Dr. Cavanagh’s breach of the standard of care was the direct cause of the injuries suffered by Ms. Ibrahimova. The Court found no causal connection between the substandard care of Drs. Kalaichandran and Ponesse because it was too late to make any difference by the time they had become involved in the patient’s care
The parties agreed on the quantum of damages for non-pecuniary damages, past and future income loss, special damages, and all subrogated claims.
The court addressed claims for past and future care needs and housing modifications, which were not agreed upon.
The Court made the following specific wards:
Decision Date: August 22, 2025
Jurisdiction: Ontario Superior Court of Justice
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