The Health Professions Appeal and Review Board has released five concurrent decisions1 confirming that the care provided to an Ontario family physician by several specialists at Hamilton General Hospital was reasonable and met professional standards. These cases arose following a catastrophic horse riding accident in April 2021 that left the patient, herself a practicing physician in Guelph, with life-threatening internal injuries. The patient’s father, Dr. Balakrishna Naidoo, a retired paediatrician and former coroner, initiated the legal reviews after the College of Physicians and Surgeons of Ontario declined to take disciplinary action against the five doctors involved in his daughter’s treatment. The Board’s rulings, issued on January 5, 2026, address a complex web of allegations including medical negligence, failure to acknowledge severe respiratory distress, and concerns regarding systemic racial bias in the treatment of Black patients within the provincial healthcare system.
The narrative of this legal dispute began on April 27, 2021, when the patient was thrown from a horse and subsequently stepped on by the animal. The impact resulted in blunt abdominal trauma, causing internal bleeding and significant damage to her liver and pancreas. Initially treated at Guelph General Hospital, she was quickly transferred to Hamilton General Hospital for specialized trauma care. Over the course of her nearly month long stay in Hamilton, she was treated by a rotating team of physicians, including general surgeons Dr. Timothy John Rice, Dr. Niv Sne, and Dr. Edward Martins Passos, as well as hematologist Dr. Menaka Pai and respirologist Dr. Sophie Lynne Corriveau. Each of these physicians became the subject of a formal complaint by Dr. Naidoo, who contended that the care provided was suboptimal and influenced by unrecognized cultural biases.
In each of the five reviews, Dr. Naidoo presented a consistent list of grievances regarding the clinical management of his daughter. He argued that the physicians rejected a diagnosis of blunt abdominal trauma despite it being the reason for her admission. He further alleged that the medical team ignored evidence of atelectasis, a condition where the lungs partially collapse, and failed to properly monitor her breathing despite her repeated reports of distress. A significant portion of the complaint focused on the medical team’s reliance on pulse oximetry. Dr. Naidoo argued that this method is known to be less reliable in individuals with dark skin and that the physicians should have verified the results with arterial blood gas sampling. He also raised concerns about fluid accumulation in the patient’s abdomen and lungs, the management of low sodium levels, and a perceived lack of empathy for the patient’s physical and emotional suffering.
The first phase of the patient’s care at Hamilton General Hospital was overseen by the trauma service, with Dr. Niv Sne serving as the trauma team leader upon her arrival and Dr. Timothy John Rice acting as the most responsible physician from April 28 to April 30. During this initial window, the primary goal was to monitor the patient for the necessity of emergency surgery. The Board noted that while Dr. Naidoo was critical of the team for not listing blunt abdominal trauma as a diagnosis, the physicians correctly identified it as a mechanism of injury. The medical records showed that the team focused on the specific clinical results of that trauma, including a high grade liver laceration and mesenteric hematoma. The Board found that Dr. Rice and Dr. Sne appropriately prioritized surgical monitoring and that the patient remained hemodynamically stable under their watch.
As the patient’s stay progressed into early May, her condition became more complex, involving complications such as thrombosis and potential sepsis. Dr. Menaka Pai, a specialist in hematology and internal medicine, was consulted from May 7 to May 9 to address blood clots found in the patient’s veins. In her review, the Board emphasized that Dr. Pai’s role was strictly limited to her area of expertise. Dr. Pai spent approximately one hour with the patient and her father to discuss the risks of bleeding versus the benefits of treating small clots. The Board determined that because Dr. Pai was not the admitting physician and was only a consultant for thrombosis, she was not responsible for the broader issues of respiratory care or fluid management raised in the complaint. The records confirmed that Dr. Pai acted within her scope by deciding that no immediate treatment for the clots was necessary while promising to reassess if the clinical situation changed.
During the second week of May, the patient’s condition took a downward turn. Dr. Niv Sne returned as the attending trauma physician from May 7 to May 14. It was during this period that the patient developed increased respiratory difficulties and required oxygen. Dr. Naidoo alleged that the team failed to act with urgency, but the Board noted that when the patient’s condition deteriorated on May 8, the team organized a repeat CT scan and involved infectious disease and interventional radiology specialists. This led to the insertion of chest tubes and abdominal drains to remove several litres of fluid. The Board found that this intervention was a direct and appropriate response to the imaging results and the patient’s clinical signs. The medical records supported the conclusion that Dr. Sne and the trauma team were monitoring the fluid collections and intervened when it became clinically necessary.
The final phase of the patient’s care in Hamilton was managed by Dr. Edward Martins Passos, who served as the most responsible physician from May 14 until the patient’s transfer back to Guelph on May 19. During these final days, the dispute centered on the management of the patient’s sodium levels and her continued respiratory issues. Dr. Sophie Lynne Corriveau, a respirologist, was also involved as a consultant during the last 48 hours. Dr. Naidoo claimed that his daughter was severely dehydrated and that the team mismanaged her low sodium levels. However, the Board reviewed records showing that the physicians were managing a condition known as syndrome of inappropriate antidiuretic hormone secretion, which requires fluid restriction rather than increased intake. The Board found that Dr. Passos and Dr. Corriveau appropriately involved the internal medicine service to manage these delicate electrolyte imbalances.
A central theme across all five cases was the allegation of racial bias. Dr. Naidoo argued that his daughter, a Black female physician, faced hostility and dismissiveness that would not have been present had she been of a different demographic. He suggested that the doctors’ failure to verify pulse oximetry readings with arterial sampling was a direct result of ignoring the known inaccuracies of the technology for dark skinned patients. In response, several of the physicians expressed deep concern and professional distress over the allegations. Dr. Corriveau and Dr. Pai specifically noted their commitment to equity, diversity, and inclusion initiatives within the hospital system. The physicians maintained that their clinical decisions were based purely on the patient’s vital signs, imaging, and physical examinations.
In analyzing the reasonableness of the College’s decision to take no action, the Board highlighted the importance of contemporaneous medical records. The Board noted that health records are legal documents created at the time of care, before any legal process begins, and are therefore highly reliable sources of truth. In each case, the Board found that the records contradicted the applicant’s assertions of neglect. For example, while Dr. Naidoo felt the patient’s lungs were not being checked, the records contained multiple entries of chest auscultations and documented breath sounds. Regarding the pulse oximetry, the Board accepted the expert view that because the patient’s oxygen saturation remained at 97 percent on room air, there was no clinical indication for more invasive arterial sampling, regardless of skin pigmentation concerns.
The Board ultimately concluded that the investigation conducted by the College was adequate and the decision to not discipline the doctors was justified. The Board observed that the physicians functioned as part of a multi disciplinary team where roles were clearly defined. While the patient and her father perceived the care as dismissive, the Board found no evidence of clinical errors or lack of care that would warrant a referral to a discipline tribunal. The Board did, however, recognize the applicant’s perception of the events. By confirming the College’s decision, the Board also upheld a formal statement of expectation. This statement reminds the involved physicians, and the medical community at large, of the ongoing requirement to treat every patient with equal respect and compassion, specifically highlighting the need to remain vigilant against discriminatory factors such as race and socioeconomic status.
The five decisions effectively close the regulatory chapter of this dispute, affirming the actions of the trauma and internal medicine teams at Hamilton General Hospital. The rulings serve as a detailed examination of the standards of care expected in high pressure trauma environments and the challenges of managing complex cases where the patient and family are themselves medical professionals. While the clinical outcomes and the professional conduct of the five respondents were upheld, the cases underscore the significant impact that communication and perceived empathy have on the patient experience. The Board’s final confirmation of the no action decisions reinforces the reliance of the legal system on documented clinical evidence while acknowledging the broader systemic conversations regarding bias in healthcare.
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