A London, Ontario, physician is under new professional restrictions after two separate complaints related to Medical Assistance in Dying (MAID) procedures, including one case where an assessment was conducted outside a Tim Hortons and another in which a patient briefly resumed breathing after being declared dead.

The College of Physicians and Surgeons of Ontario has agreed to place Dr James MacLean under at least six months of mandatory clinical supervision, along with ongoing monitoring of his MAID work and professional education requirements. The measures come from an investigation into two public complaints reviewed by the regulator’s Inquiries, Complaints, and Reports Committee, reports the National Post.

Under the agreement, MacLean will also face chart reviews and training focused on consent, documentation, boundaries, and professional conduct. After six months, his practice will be reassessed, and the findings may lead to further regulatory action, according to the CPSO. “The undertaking imposes extensive oversight and monitoring requirements on Dr. MacLean’s practice,” said CPSO spokesperson Laura Zilke.

“The college takes any complaints brought to our attention extremely seriously as part of our mandate to serve the public interest and ensure safe, ethical and competent medical care for all Ontarians.”

One of the complaints involved a patient, Thomas Dillon, with Crohn’s disease and a history of mental health and substance use issues.  According to the regulators’ summary decision, MacLean carried out part of the MAID assessment outside a Tim Hortons location and later personally drove the patient to the site where the procedure was carried out. The CPSO found concerns over the communication settings and said sensitive discussions took place in public. It also said there were issues with messaging between MacLean and the patient, and the absence of documented input from family members who were reportedly trying to raise concerns.

In another case, the regulator reviewed care provided to a cancer patient who had signed a waiver of final consent. The CPSO said MacLean administered medication but initially did not use a neuromuscular-blocking drug. The patient was later pronounced dead, but resumed spontaneous breathing after MacLean left the residence, according to the committee summary. He returned, administered additional medication, and again pronounced death.

The regulator also did a broader review of MacLean’s patient charts, finding in multiple cases that he “did not meet the standard of practice of the profession, displayed a lack of judgment and that his conduct exposes or is likely to expose patients to harm or injury in five out of twenty charts reviewed.”

Dr. Ramona Coelho, a family physician and former member of Ontario’s MAID death review committee, said oversight remains inconsistent. “What is striking is not only the seriousness of the concerns identified in these cases, but the limited regulatory response,” she said.