As from August 8, 2019, the following is imposed as terms, conditions and
limitations on the certificate of registration held by Dr. Lanval Joseph Daly
in accordance with an undertaking and consent given by Dr. Daly to the College
of Physicians and Surgeons of Ontario:
UNDERTAKING, ACKNOWLEDGEMENT AND CONSENT
("Undertaking")
of
DR. LANVAL JOSEPH DALY
("Dr. Daly")
to
COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
(the "College")
A. PREAMBLE
(1) In this Undertaking:
"Code" means the Health Professions Procedural Code, which is Schedule 2
to the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, as
amended;
"Discipline Committee" means the Discipline Committee of the College;
"LEEP" means loop electrosurgical excision procedure;
"Medicine Act" means the Medicine Act, 1991, S.O. 1991, c. 30, as
amended;
"OHIP" means the Ontario Health Insurance Plan;
"OHP" means an out of hospital premises subject to inspection by the
College pursuant to Part XI of Regulation 114/94 of the Medicine Act;
"Public Register" means the College's register that is available to the
public; and
"Restricted Procedure" means any one of the following procedures:
(i) Hysteroscopy;
(ii) Hysteroscopic myomectomy;
(iii) Hysteroscopic polypectomy;
(iv) Cold knife cone biopsy;
(v) Surgical reconstruction in female genital mutilation;
(vii) Episiotomy revision;
(viii)Perineorrhapy.
(2) I, Dr. Daly, certificate of registration number 27674, am a member of the
College.
(3) I, Dr. Daly, acknowledge that the College conducted an investigation
bearing File Number 1100285 (the "Investigation") into whether, in my
obstetrical and gynecological practice and conduct, I engaged in
professional misconduct and/or am incompetent.
B. UNDERTAKING
(4) I, Dr. Daly, undertake to abide by the provisions of this Undertaking,
effective immediately.
(5) Practice Restrictions
(a) I, Dr. Daly, undertake, subject to paragraphs (5)(b) and (7) of
this Undertaking, to restrict my practice to an office-based
obstetrical/gynecological practice (providing obstetrical care up
to but not beyond 28 weeks of gestation) limited to only the most
minor, low-level office-based procedures, such as simple biopsies;
provided, however, that any and all LEEPs performed by me must be
performed in a hospital or OHP.
(b) Notwithstanding paragraph (5)(a) above, I, Dr. Daly, understand
that I may perform a Restricted Procedure(s) but only if each and
every one of the following requirements are met with respect to
each Restricted Procedure that I perform:
(i) I perform the Restricted Procedure under the direct
supervision of a clinical supervisor or clinical supervisors
acceptable to the College (the "Clinical Supervisor" or
"Clinical Supervisors") on the terms set out in paragraph (7)
below; and
(ii) I perform the Restricted Procedure in a hospital or an OHP.
(6) I, Dr. Daly, further acknowledge and agree that I am bound by the
College's Policy on Change of Scope of Practice, a copy of which is
attached as Appendix "A" to this Undertaking.
(7) Clinical Supervision
(a) I, Dr. Daly, undertake that for each and every Restricted Procedure
I perform (if any), I shall perform the Restricted Procedure under
the direct supervision of a Clinical Supervisor.
(b) I, Dr. Daly, undertake and acknowledge that the requirement that I
perform all Restricted Procedures under the direct supervision of a
Clinical Supervisor shall cease only upon written approval from the
College in the College's sole discretion. In any event, I
acknowledge that the direct Clinical Supervision of all my
Restricted Procedures shall apply for a minimum period of six (6)
months. After a minimum of six (6) months of Clinical Supervision,
and upon the recommendation of the Clinical Supervisor, I may apply
to the College for approval to perform any or all of the Restricted
Procedures independently.
(c) I, Dr. Daly, acknowledge that I have reviewed the Clinical
Supervisor's undertaking, attached hereto as Appendix "B", and
understand what is required of the Clinical Supervisor. The
Clinical Supervisor will, at minimum:
(i) Facilitate the education program set out in the
Individualized Education Plan ("IEP"), attached hereto as
Appendix "C";
(ii) Review the materials provided by the College and have an
initial meeting with me to discuss practice improvement
recommendations;
(iii) Directly supervise and observe each and every Restricted
Procedure that I perform;
(iv) After each Restricted Procedure that I perform, review the
patient chart and discuss with me any concerns arising from
the Clinical Supervisor's direct observation of the
Restricted Procedure and the chart review;
(v) Make recommendations to me for practice improvements and
ongoing professional development and inquire into my
compliance with the recommendations;
(vi) Perform any other duties, such as reviewing other documents
or conducting interviews with staff or colleagues, that the
Clinical Supervisor deems necessary to my Clinical
Supervision;
(vii) Maintain a log of all Restricted Procedures that the Clinical
Supervisor has observed me performing; and
(viii)Submit written reports to the College at least once every
quarter, or more frequently if the Clinical Supervisor has
concerns about my standard of practice.
(d) I, Dr. Daly, undertake to cooperate fully with the Clinical
Supervision of my practice, conducted under the terms of this
Undertaking and Appendix "B" to this Undertaking, and to abide by
the recommendations of my Clinical Supervisor, including but not
limited to, any recommended practice improvements and ongoing
professional development.
(e) I, Dr. Daly, undertake to ensure that Appendix "B" to this
Undertaking is signed and delivered to the College at least
fourteen (14) days prior to me performing any Restricted Procedure.
(f) I, Dr. Daly, undertake that if a person who has given an
undertaking in Appendix "B" to this Undertaking is unable or
unwilling to continue to fulfill its provisions, I shall not
perform any further Restricted Procedure(s) unless and until I
obtain an executed undertaking in the same form from a similarly
qualified person who is acceptable to the College and ensure that
it is delivered to the College and approved by the College.
(g) I, Dr. Daly, acknowledge that if I am required to cease practise as
a result of section (7)(f) above, this will constitute a term,
condition or limitation on my certificate of registration and that
term, condition or limitation will be included on the public
register.
(8) Posting a Sign
(a) I, Dr. Daly, undertake that I shall post a sign in all waiting
rooms of all my Practice Locations, in a clearly visible and secure
location, in the form set out at Appendix "D". For further
clarity, this sign shall state as follows:
Dr. Daly's practice is restricted as follows:
1. Dr. Daly's practice is restricted to an
office-based obstetrical/gynecological practice
(providing obstetrical care up to but not beyond
28 weeks of gestation) limited to only the most
minor, low-level office-based procedures, such as
simple biopsies.
2. Any loop electrosurgical excision procedure
performed by Dr. Daly must be performed in a
hospital or Out-of-Hospital Premises.
3. Notwithstanding the above, Dr. Daly may perform
any of the following procedures provided that he
performs the procedure under the direct
supervision of a Clinical Supervisor in a
hospital or Out-of-Hospital Premises:
(i) Hysteroscopy;
(ii) Hysteroscopic myomectomy;
(iii) Hysteroscopic polypectomy;
(iv) Cold knife cone biopsy;
(v) Surgical reconstruction in female genital
mutilation;
(vii) Episiotomy revision;
(viii)Perineorrhapy.
Further information may be found on the College of
Physicians and Surgeons of Ontario website at
www.cpso.on.ca
(b) I, Dr. Daly, undertake to post a certified translation in any
language in which I provide services, of the sign described in
section (8)(a) in all waiting rooms of all my Practice Locations,
in a clearly visible and secure location, in the form set out at
Appendix "D".
(c) I, Dr. Daly, undertake to provide the certified translation
described in section (8)(b), to the College within thirty (30) days
of executing this Undertaking.
(d) I, Dr. Daly, undertake that if I elect, after the execution of this
Undertaking, to provide services in any other language, I will
notify the College prior to providing any such services.
(e) I, Dr. Daly, undertake to provide to the College the certified
translation described in section (8)(b) prior to beginning to
provide services in any language described in section (8)(d).
(9) Monitoring
(a) I, Dr. Daly, undertake to inform the College of each and every
location where I practise or have privileges, including, but not
limited to, any hospitals, clinics, offices, and any Independent
Health Facilities with which I am affiliated, in any jurisdiction
(collectively my "Practice Location" or "Practice Locations"),
within five (5) days of executing this Undertaking. Going forward,
I further undertake to inform the College of any and all new
Practice Locations within five (5) days of commencing practice at
that location.
(b) I, Dr. Daly, undertake that I will submit to, and not interfere
with, unannounced inspections of my Practice Locations and patient
charts by a College representative for the purposes of monitoring
my compliance with the provisions of this Undertaking.
(c) I, Dr. Daly, give my irrevocable consent to the College to make
appropriate enquiries of OHIP and/or any person who or institution
that may have relevant information, in order for the College to
monitor my compliance with the provisions of this Undertaking.
(d) I, Dr. Daly, acknowledge that I have executed the OHIP consent form,
attached hereto as Appendix "E".
C. ACKNOWLEDGEMENT
(10) I, Dr. Daly, acknowledge that all appendices attached to or referred to
in this Undertaking form part of this Undertaking.
(11) I, Dr. Daly, acknowledge and undertake that I shall be solely responsible
for payment of all fees, costs, charges, expenses, etc. arising from the
implementation of any of the provisions of this Undertaking.
(12) I, Dr. Daly, acknowledge that I have read and understand the provisions
of this Undertaking and that I have obtained independent legal counsel in
reviewing and executing this Undertaking, or have waived my right to do
so.
(13) I, Dr. Daly, acknowledge that the College will provide this Undertaking
to any Chief of Staff, or a colleague with similar responsibilities, at
any Practice Location ("Chief of Staff" or "Chiefs of Staff").
(14) I, Dr. Daly, acknowledge that a breach by me of any provision of this
Undertaking may constitute an act of professional misconduct and/or
incompetence, and may result in a referral of specified allegations to
the Discipline Committee.
(15) I, Dr. Daly, acknowledge that this Undertaking constitutes terms,
conditions, and limitations on my certificate of registration for the
purposes of section 23 of the Code.
(16) Public Register
(a) I, Dr. Daly, acknowledge that, during the time period that this
Undertaking remains in effect, this Undertaking shall be posted on
the Public Register.
(b) I, Dr. Daly, acknowledge that, in addition to this Undertaking
being posted in accordance with section (16)(a) above, the
following summary shall be posted on the Public Register during the
time period that this Undertaking remains in effect:
A College investigation was conducted into whether Dr. Daly,
in his obstetrical and gynecological practice and conduct,
engaged in professional misconduct and/or is incompetent. As
a result of the investigation, Dr. Daly's practice is
restricted as follows:
1. Dr. Daly's practice is restricted to an office-based
obstetrical/gynecological practice (providing
obstetrical care up to but not beyond 28 weeks of
gestation) limited to only the most minor, low-level
office-based procedures, such as simple biopsies.
2. Any loop electrosurgical excision procedure performed
by Dr. Daly must be performed in a hospital or
Out-of-Hospital Premises.
3. Notwithstanding the above, Dr. Daly may perform any of
the following procedures provided that he performs the
procedure under the direct supervision of a Clinical
Supervisor in a hospital or Out-of-Hospital Premises:
(i) Hysteroscopy;
(ii) Hysteroscopic myomectomy;
(iii) Hysteroscopic polypectomy;
(iv) Cold knife cone biopsy;
(v) Surgical reconstruction in female genital
mutilation;
(vii) Episiotomy revision;
(viii)Perineorrhapy.
D. CONSENT
(17) I, Dr. Daly, give my irrevocable consent to the College to provide the
following information to any person who requires this information for the
purposes of facilitating my completion of the Professional Education and
to all Clinical Supervisors, and/or assessors:
(a) any information the College has that led to the circumstances of my
entering into this Undertaking;
(b) any information arising from any investigation into, or assessment
of, my practice; and
(c) any information arising from the monitoring of my compliance with
this Undertaking.
(18) I, Dr. Daly, give my irrevocable consent to the College to provide all
Chiefs of Staff with any information the College has that led to the
circumstances of my entering into this Undertaking and/or any information
arising from the monitoring of my compliance with this Undertaking.
(19) I, Dr. Daly, give my irrevocable consent to any persons who facilitate my
completion of the Professional Education, and to all Clinical
Supervisors, Chiefs of Staff and assessors, to disclose to the College,
and to one another, any of the following:
(a) any information relevant to this Undertaking;
(b) any information relevant to the provisions of the Clinical
Supervisor's undertaking set out at Appendix "B" to this
Undertaking;
(c) any information relevant to any reassessment of my practice;
(d) any information relevant for the purposes of monitoring my
compliance with this Undertaking; and/or
(e) any information which comes to their attention in the course of
providing the Professional Education and which they reasonably
believe indicates a potential risk of harm to my patients.