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TORONTO — Toronto Public Health says it observed “many deviations from best practices” during an inspection at a gynecologist’s office that led to the agency notifying 2,500 patients of a potential exposure to blood-borne viruses.

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The agency has provided additional details about its investigation to The Canadian Press as patients voice anger and frustration towards the doctor they placed their trust in, as well as those responsible for inspecting potential lapses in infection prevention and control.

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In letters sent in mid-February, TPH suggested to patients of Dr. Esther Park that they get tested for HIV, hepatitis B, and hepatitis C if they received endometrial biopsies, IUD insertions or had cervical growths removed at her clinic between Oct. 10, 2020 and Oct. 10, 2024.

Dr. Herveen Sachdeva, the city’s associate medical officer of health, said Thursday that medical instruments such as speculums were not disassembled before they were cleaned at the clinic. Sachdeva characterized this as an “important step” to ensure all surfaces are disinfected.

She also said there was “significant overdiluting” of the disinfecting solution that the instruments were soaked in.

“As this was the last main step for reprocessing (an autoclave wasn’t used to sterilize the instruments), this presents a risk for disease transmission,” Sachdeva said in an email.

“TPH observed many deviations from best practices at this clinic during the period of inspection.”

Attempts to reach Park for comment at her office and by phone were not successful. The doctor did not respond to voice mail requests for an interview or messages left with her secretary.

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The College of Physicians and Surgeons of Ontario said it’s investigating Park in relation to infection control issues in her practice. It would not share specifics citing confidentiality. Park is allowed to practice as per the terms and conditions on her licence, a spokesperson said.

The CPSO website states Park restricted her practice in December to office-based gynecology.

As of Friday, public health said in an email there have been no infections confirmed to be attributed to the clinic’s practices. Sachdeva said in an interview Wednesday that they have results from about 100 to 200 people so far, and are fielding many calls from patients who are unsure if they should get tested.

“We understand that this is distressing to receive a letter, and then also for the patients who have gone to this practice and did not receive a letter, and for any of the patients who attended this clinic,” she said.

Sachdeva said the agency was notified of a patient complaint in September 2024, launched an investigation in October, and determined there was a lapse. Unless a complaint is filed, she said Toronto Public Health doesn’t routinely inspect health-care settings.

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“The first job of our inspectors is to make sure that — can the practice continue to operate safely? So that’s the work that happens on site, So it’s kind of the assessment that there is a lapse, there is an issue here, and I need to correct this. And so that’s what happened in October,” Sachdeva said.

Those corrective measures recommended to Park include ensuring instruments are disassembled before cleaning, appropriate use of the disinfectant solution, performing quality assurance, and setting up an autoclave — a machine that steams instruments to kill harmful bacteria — to sterilize instruments.

A report posted on Jan. 9 stated Park complied with the corrective measures. TPH said its investigation into the clinic and its practices is complete, but the case file is still active as patients undergo testing.

Sachdeva said the reason it took the agency nearly four months to notify patients is because they needed to review what procedures were done at the clinic, what instruments were used, and how each instrument was cleaned, disinfected and sterilized.

She said they consulted with Public Health Ontario on a literature search of infections that may have occurred in similar situations

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“It takes some time to evaluate and figure out — do patients need to be notified?” Sachdeva said.

“You don’t want to say that someone may be at risk when they really aren’t at risk.”

Lucie Stengs, who had visited Park in January for an IUD insertion, says she understands the agency not wanting to induce unnecessary fear and anxiety, but she also says that the ethics of withholding this information from patients should have been considered.

Stengs did not receive a letter because she didn’t have a procedure in the identified time frame, however she decided after speaking with her family doctor that she will get tested anyway.

“To me, I feel as though sometimes these overseeing bodies are very focused on their legal requirements and what is something that they have to do versus something that they should do,” said the 29-year-old west end resident. “What’s legal versus what’s ethical? And that is something that this situation has brought to light for me personally.”

As a patient who entered Park’s clinic unknowingly as an investigation was going on behind the scenes, Stengs says her trust in public health has been broken.

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She questions why infection control policies are in place if there’s no routine auditing to ensure they are kept up.

“Just because she’s changed the way that she does things doesn’t mean that she necessarily understands the importance of why those changes were necessary or the potential risk that she created in her mistakes,” she said.

Karin Martin was distraught when she received her letter from Toronto Public Health last week, but now she says, “I’m angry.”

She had three biopsies with Park last spring and summer before she was diagnosed with uterine cancer.

Her concerns have snowballed as she’s spoken to about 50 other women who went to Park’s clinic.

“I’m just one little story. There’s so many like me,” she said.

This report by The Canadian Press was first published March 15, 2025.

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

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