Executive Summary: Key Legal and Evidentiary Issues

• Reasonableness of the ICRC’s decision to impose a remedial SCERP on Dr. Saeed.
• Effect of focusing the assessment on high-risk ASA III and adverse-event charts, and whether this skewed the portrayal of his practice.
• Alleged reasonable apprehension of bias arising from the assessor’s initial tone, extrapolations, and misunderstanding of the clinic’s patient mix.
• Dispute over whether a Royal College anesthesiology specialist was an appropriate assessor for a general practice anaesthesiologist.
• Adequacy of the ICRC’s consideration of competing expert evidence, alleged misstatements of Dr. Saeed’s history, and incomplete records.
• Application of the Vavilov reasonableness standard to determine if the ICRC’s reasons were justified, transparent, and intelligible.

Facts and regulatory setting

Dr. Muhammad A. Saeed is a general practice anaesthesiologist and Medical Director at the London Scoping Centre, an out-of-hospital premises (OHP) providing endoscopic procedures in Ontario. The clinic is regulated by the College of Physicians and Surgeons of Ontario, whose Inquiries, Complaints and Reports Committee (ICRC) screens complaints and investigations and may order remedial measures that appear on the public register. Beginning in October 2022, the College received multiple adverse event reports from the clinic, including a serious incident involving patient LL, who suffered complications during a colonoscopy and required transfer to hospital intensive care, as well as later adverse events involving several other patients. These events raised concerns about anesthesia care, particularly in relation to higher-risk ASA III patients, the highest-risk category permitted at an OHP endoscopy clinic.

In February 2023, the Registrar appointed an assessor, Dr. Teddy Lim, a Royal College anesthesiology specialist, to investigate Dr. Saeed’s practice. The College requested charts for recent adverse-event patients and the last seven ASA III patients, giving the assessor a total of 12 charts. Dr. Saeed, through counsel, objected that Dr. Lim was not a suitable comparator for a general practice anaesthesiologist, but the College proceeded and indicated that these objections would be considered by the ICRC.

Assessment, responses, and ICRC decision

In his December 2023 report, Dr. Lim concluded that Dr. Saeed failed to meet the standard of practice in most of the 12 cases, showed deficiencies in knowledge, skill, or judgment in several, and in a number of charts exposed or risked exposing patients to harm. He criticized record keeping, triage decisions for higher-risk patients, delegation to an anaesthetic assistant, and aspects of clinical judgment in managing complications. Dr. Saeed responded in detail, acknowledging documentation issues and conceding that in at least one case his decision to proceed at the OHP was legitimately open to question.

In a March 2024 addendum, Dr. Lim clarified that he had initially treated the ASA III charts as representative of the clinic’s overall caseload but now understood that they were a College-selected subset. He nonetheless remained satisfied that improvements in documentation and triage were being made. Dr. Saeed then filed further submissions alleging procedural unfairness and bias, and produced an expert report from Dr. Cino, who agreed that many records were too incomplete—especially in terms of vital-sign documentation—to support a clear assessment of clinical care.

On July 5, 2024, the ICRC issued a 13-page decision. It emphasized that the assessor’s opinion was only one part of the material and that it was free to accept or reject it in whole or in part. The Committee noted that it was aware of unnecessary extrapolations in the original report and disregarded them, and that it considered the addendum explaining the skewed sample. It rejected the challenge to Dr. Lim’s qualifications, holding that the standard of care for sedation in an OHP is the same regardless of whether the anaesthesiologist is a specialist or a general practitioner. The ICRC found the management of patient LL to be a serious concern, particularly Dr. Saeed’s failure to promptly intubate a hypoxic patient and reliance on less qualified emergency responders, which it considered to pose an unacceptable risk. It also identified a pattern of poor documentation across multiple charts, echoing both experts’ concerns that missing and confused records, especially vital signs in serious adverse events, undermined safe care and prevented proper assessment.

As a screening body, the ICRC chose a remedial rather than disciplinary response. It ordered Dr. Saeed to complete a Specified Continuing Education and Remediation Program (SCERP) consisting of three meetings with a clinical supervisor over three months, self-study, and a reassessment. Dr. Saeed was required to pay the costs of the SCERP and to notify employers, with the program noted on the College’s public register.

Judicial review and final outcome

Dr. Saeed sought judicial review in the Ontario Divisional Court, arguing that the ICRC’s decision was unreasonable and procedurally unfair. There is no statutory appeal from an ICRC decision under a Registrar’s investigation, so the challenge proceeded under the Judicial Review Procedure Act. Both parties accepted that the merits would be reviewed for reasonableness under Vavilov, with procedural fairness assessed under the framework in Baker. Dr. Saeed claimed the focus on ASA III and adverse-event charts unfairly skewed the assessment, that the assessor’s report was biased, that a Royal College specialist was unsuitable as assessor, that the ICRC mischaracterized aspects of his regulatory history, and that it failed to consider all relevant evidence, including some charts and his interview recording.

The Divisional Court dismissed these arguments. It held that the College and ICRC have broad discretion over which records to review and that focusing on higher-risk cases was reasonable given that the investigation arose from serious adverse events in such patients. The court stressed that the ICRC, not the assessor, was the final decision maker; that it explicitly recognized and discounted problematic extrapolations in the original report; and that there was no evidence of bias on the part of the Committee. The court agreed that a Royal College anesthesiologist was suitably qualified to assess anesthesia standards in an OHP and that there is no right to a particular type of assessor. Any misstatements about Dr. Saeed’s past were treated as minor and not outcome-determinative. On the evidence, the court found that the serious deficiencies in the LL case, combined with a clear pattern of poor record keeping acknowledged by both experts and by Dr. Saeed himself, provided a rational basis for ordering a modest remedial SCERP. In the result, the Divisional Court dismissed the application for judicial review. The College of Physicians and Surgeons of Ontario was the successful party, and, pursuant to the parties’ agreement on costs, the court ordered Dr. Saeed to pay the College a total of CAD $10,000 in costs, with no additional damages or monetary awards.