Dirk Huyer is Ontario’s Chief Coroner. Photo / Getty Images
A Canadian coroner has recorded 428 cases of malpractice by assisted dying physicians since 2018.
Dirk Huyer, Ontario’s Chief Coroner, recorded hundreds of cases of doctors and nurses breaching medical guidelines around assisted suicide, and recorded a “pattern of not following legislation”, documents seen by the Telegraph show.
In multiple cases, clinicians confessed to not waiting for the minimum period before administering lethal drugs and not recording assisted dying as patients’ cause of death.
In one incident, described as “horrible” by the Coroner, a patient was forced to “suffer tremendously” after a physician gave him the wrong drugs.
Last year, a quarter of all assisted dying providers in Ontario had at least one case of alleged non-compliance.
The number of infractions has led experts to warn of an “unregulated wild west” of assisted dying in Canada. MPs in the United Kingdom will vote on Friday local time about whether to legalise the practice.
Much of the debate in the UK has centred on whether adequate safeguards can be put in place to prevent terminally ill people from being forced into choosing an assisted death.
Under the proposed legislation a person who is expected to die within six months can be approved for an assisted death provided they have the approval of two independent doctors and a high court judge.
However, Canadian medical experts have warned of a slippery slope when it comes to enforcing safeguards.
“The fact that Ontario’s violations remain largely undisclosed further erodes public trust and demonstrates that critical safeguards are not easily enforceable,” said Dr Ramona Coelho, a family medicine practitioner based in London, Ontario.
“UK lawmakers must learn from Canada’s failures to ensure the safety and protection of their own citizens.”
Under Canadian law, assisted dying providers are required to assess whether people who request euthanasia are eligible, to uphold safeguards against abuse and to keep records.
Yet despite Ontario’s Coroner uncovering hundreds of violations of these rules, no doctors have been charged, the New Atlantis journal reported, despite the coroner accusing one of “blatant” malpractice in a private meeting of Ontario nurse practitioners.
Instead, the Coroner’s Office has deemed nearly all cases as requiring no more than an “informal conversation” with the physician or an “educational” or “notice” email.
Until 2017, patients required a 90-day assessment period to be eligible for an assisted death, followed by a 10-day waiting period before euthanisation. This applied in all but extreme circumstances – such as if they are on the verge of losing capacity to consent or an imminent natural death.
However, coroner documents first reported by the New Atlantis show physicians expedited deaths because of “persistent requests” and “inconvenient timing of the death in relation to other familial life events”.
In one 2017 case, a medical assistance in dying provider brought the wrong drugs to the home of a patient and was forced to leave the dying person’s bedside for two hours to obtain the correct medication.
“It was horrible,” Huyer noted. “The family and the deceased person suffered tremendously.”
The College of Physicians and Surgeons regulator said it was “disturbed” by the practitioner’s failures and said the doctor “continued to underestimate the magnitude of providing medically assisted death and the responsibility attached”.
In response to this and a number of other rule breaches by physicians, the Ontario Coroner’s Office in 2018 introduced a new five-tier monitoring system to tackle what Huyer called a “pattern” of providers “not following legislation”.
Speaking in a private webinar of Ontario nurse practitioners, he said: “We see a pattern of non-compliance, we see a pattern of not following legislation, a pattern of not following regulation, and frankly we can’t just continue to do education to those folks if they’re directly repeating stuff that we’ve brought to their attention.”
Despite introducing the new system, issues with compliance have rapidly increased from 76 instances in 2020 to 428 identified in total by 2024.
These included instances of patients not having the correct documentation, as well as doctors not providing assessment notes on how the decision to prescribe assisted dying was reached and not recording deaths as assisted, according to the coroner’s office.
Other breaches included doctors not carrying out the necessary capacity assessments and not waiting the mandatory 10-day timeframe, which has since been removed, to administer an assisted death.
In 2023 alone, the Ontario Coroner identified 178 compliance problems – an average of one every other day.
In certain instances where patients were not terminally ill, medical practitioners reported that they were not experts in the illness afflicting the patient, yet no outside expert was consulted.
Huyer described these cases as a “learning opportunity” in a conference presentation, the New Atlantis reported.
Meanwhile, few clinicians report their full number of assisted deaths despite a requirement to do so from the Office of the Chief Coroner of Ontario.
It comes after the Telegraph revealed last month that assisted dying is being used by patients in Canada because they are poor and lack housing.
The first official report into assisted deaths in Ontario found vulnerable people face “potential coercion” or “undue influence” to seek out the practice.
Dr Isabel Grant, professor of law at District of Columbia University, said: “Safeguards are meaningless if they are unenforceable. And thus far they have been largely unenforceable in Canada because of the lack of any oversight.
“If the colleges and coroners don’t do their part in regulating this practice, the result is an unregulated wild west of ending the lives of disabled people who may perceive themselves as an emotional or financial burden on loved ones or who may be vulnerable for other reasons.”
Coelho said: “With over 400 violations recorded in Ontario alone – the province with the most robust monitoring and oversight – it’s clear that this problem likely extends nationwide”.
Rebeccca Vachon, the programme director for Health at Cardus, a Canadian Christian think-tank, said: “The way that the legislation and the policy were set up have these inherent weaknesses”.
“You’re relying on self-reporting by doctors, and the ambiguity around many of the eligibility criteria creates a situation where you can easily have these kinds of abuses.”
Huyer was approached for comment.