Toronto doctor's obstetrical and gynecological care was neglectful, patients allege

Marie-Louise Fitrion says she was asleep in a hospital bed when she woke up to an obstetrician's hand in her vagina.

It was Oct. 25, 2018, the morning of giving birth to her second child, and she says it triggered the memory of being sexually assaulted as a child.

Fitrion is sharing her experience dealing with that doctor, Esther Park, in the wake of Dr. Park's resignation from the College of Physicians and Surgeons of Ontario (CPSO) on April 30, which came after her licence was restricted to office based gynecology on Dec. 17, 2024.

The college investigated Park's practice for "infection control issues" after Toronto Public Health found medical instruments were not properly cleaned, disinfected and sterilized at her clinic.

CBC News was first to report on Toronto Public Health warning some 2,500 people they may have been exposed to blood-borne infections at Park's Toronto gynecology office.

Since then, former patients have come to The Canadian Press with allegations that include abusive and inappropriate treatment, both at her Toronto office on 20 Edna Ave., and at a west-end hospital, St. Joseph's Health Centre, commonly referred to as St. Joe's.

The Canadian Press spoke to several patients who described traumatic experiences with Park while under her care during labour and invasive procedures including biopsies and contraception insertions.

At the time, none of the patients filed formal complaints. Like Fitrion, who says she was in "another universe of pain and suffering," these patients said they were grappling with health issues including postpartum depression, cancer and post traumatic stress, and not in a frame of mind to launch a complaint process.

"I've always regretted not reporting it officially," Fitrion said. After years of consideration, she recently did just that.

The patients believe regulatory bodies including the college and public health had not effectively monitored Park's practice, given some patient concerns date back almost a decade. Patients also fault a system that places the onus on them to report and prove harm.

Recently, some patients sent a letter to government officials calling for an independent review of regulatory bodies. While they said the province dismissed the suggestion, Toronto Public Health told The Canadian Press it would conduct an internal review.

WATCH | CBC's Talia Ricci reports on Esther Park's resignation:

A Toronto doctor has resigned after CBC Toronto was first to report that her gynecology office was linked to possible exposure to blood-borne infections like HIV and hepatitis. CBC's Talia Ricci has the latest on the investigation.

In a resignation notice posted on the CPSO website in April, Park acknowledged that two public complaints prompted an investigation by the college into her practice.

That investigation ended when she resigned. It was not shared with the public, nor were the nature of the complaints.

"Unlike with licence revocations, doctors who sign these types of undertakings will not be able to reapply for reinstatement of their licence in the future," Mickey Cirak, a communications adviser at the college, said.

Cirak said physicians are expected to abide by applicable laws, CPSO policies and clinical guidelines. "In general, college investigators may only enter a premise as part of an active investigation," he said.

Paul Harte, a medical malpractice lawyer based north of Toronto, says the reason for an investigation along with its results should be publicly available. The college posts if a doctor's licence is restricted or revoked on its website, but it does not state why it happened.

Harte argues doctors should be routinely monitored, like restaurants.

"That's the kind of proactive inspection program that I think needs to be put in place for physicians who are engaged in invasive procedures," Harte said.

Attempts to reach Park for comment at her office on three occasions, by mail, and by phone were not successful. Her answering machine stopped taking messages April 16.

Fitrion said she went to St. Joe's with spontaneous bleeding about a month shy of her due date. Because of complications with her first pregnancy, the hospital admitted her overnight and induced her.

She went to sleep with a foley catheter balloon inserted to mechanically dilate her cervix. Fitrion said she woke up to Park's hand up her hospital gown.

"There was no consent," Fitrion said. "Given I have a sexual assault history it was extra challenging for me to deal with that level of neglect."

When Fitrion asked what Park was doing, she said the doctor said she was checking the catheter's placement, and continued to do so, pulling it out of her vagina and breaking Fitrion's water without warning, nor explanation.

"I just went into hysterics," she said, recalling inconsolable sobbing in a hospital bed.

Her husband, Daniel Holloway, had gone home to sleep. "I should have been there," he said, regret still ripe in his voice.

It's standard practice in medicine to ask a patient for permission before an examination.

It's especially necessary when doing the vaginal examination of a sexual assault or domestic abuse survivor, said Dr. Naila Ramji, a maternal-fetal medicine specialist in Fredericton and assistant professor in obstetrics and gynecology with a cross-appointment in the department of bioethics at Dalhousie University.

"Certainly the patient needs to be conscious and be able to provide consent," said Ramji, who has no connection to Park, and speaks generally about standards of care in medicine, not about specific allegations.

She said spelling out exactly what you're doing and why you're doing it is key to leaving little room for misunderstanding, misinterpretation and re-traumatization for a patient.

On May 14, Fitrion filed a CPSO patient complaint.

"It's symbolic," she said, adding that she just wants the college to know what happened to her.

"I don't want to have to hold on to this story by myself. I want to put it out there and I want to let it go," Fitrion says.

She mimed off-loading a weight from her shoulder that she said felt like a boulder.

"It feels like I've been holding my breath for seven years. And I'm slowly learning to breathe again."

The Canadian Press began trying to reach Park in March, after Toronto Public Health sent a letter in February to 2,500 of her patients warning they may have been exposed to blood-borne viruses including HIV, hepatitis B, and hepatitis C. No infections have been confirmed to be attributed to Park's practices, said Dr. Herveen Sachdeva, the city's associate medical officer of health.

Sachdeva said the public health unit's investigation is independent of the college, and that it is still active, solely to followup on lab results, of which they had received 563 as of May 29.

She said TPH will be carrying out an internal review of the public health unit's response to "identify lessons learned" and "apply them to future investigations."

Sachdeva also said the public health unit met with the college early in the investigation, and is engaging with the ministry of health, and other public health units across the province, to "review and strengthen our collective approach" to managing infection prevention and control lapses in medical settings.

TPH said it was notified of a patient complaint in September 2024 and launched an investigation in October. Inspectors found medical instruments were not disassembled before they were cleaned at Park's clinic, and disinfecting solution had been significantly overdiluted.

Like the CPSO, Sachdeva said they don't routinely inspect health-care settings unless a complaint is filed.

In January, Park sent a notice to patients saying she was retiring and that her practice would close at the end of April.

"I am grateful for the trust you have shown me over the past years and for allowing me to participate in your medical care. With mixed emotions, I am announcing my plans to retire," Park said in the letter dated Jan. 23, 2025.

In March, a sign on the front door of a red brick house on Edna Avenue said: "Doctor's office closed."

A woman who identified herself as Park's secretary opened the locked door and said she could not provide comment. The Canadian Press left contact information but has not heard back.

Inside, plastic chairs lined an empty waiting room that several patients said was at times so crowded that they had to wait outside. The lights were dimmed, the window shutters closed. Contraception brochures in plastic display cases sat on a window ledge.

The doctor's office sign was gone by mid-May and a for-lease sign was planted in the lawn. The windowsill was empty of brochures and the shutters were cracked open.

That month, The Canadian Press mailed a letter to Park, which was redirected to another address, and left another in her mailbox but did not receive a response. Both Unity Health Toronto and the CPSO said they could not share Park's contact or pass on the request.

According to the CPSO's website, Park obtained her medical degree from the University of Toronto in 1993, and specialized in obstetrics and gynecology in 1998. Unity Health said she started working in obstetrics at St. Joe's in 1999 before transitioning to gynecology and surgeries. In 2006, the college authorized her to open her own clinic, its website states.

After 25 years of service, Park stopped practising at St. Joe's in July 2024 and resigned in December.

Harte, the medical malpractice lawyer, said Unity Health has a responsibility to patients treated in its facilities.

"It's absolutely incumbent upon a hospital to regularly assess the quality of care being provided to the patients at that hospital, including the quality of care provided by the physicians that they grant privileges to," Harte said.

He said quality assurance auditing should indicate if there is a systemic issue with a physician.

"When they're not being transparent, all it does is undermine the confidence of patients in our public health-care system."

A Unity Health spokesperson would not address why Park stopped practising five months before her resignation.

They also would not say if the hospital launched its own investigation but said Unity Health has "rigorous processes" in place to provide "high quality, compassionate care."

They encouraged anyone with concerns to reach out to their patient experience office.

CPSO would not say in March if it was investigating Park's practice at St. Joe's, and suggested patients speak with Ontario's Patient Ombudsman Craig Thompson.

Thompson also would not disclose if Park's patients reached out due to privacy considerations.

He said his office can get involved if a patient is not satisfied with the hospital's response to a complaint, and they'll try and help the parties reach a resolution, but ultimately the hospital bears the responsibility for the patient's experience.

The ombudsman's last annual report noted a particular rise from across the province in the number of obstetrics and gynecology related complaints, including health providers' lack of trauma-informed approaches, poor communication and lack of responsive care for pregnancy complications, miscarriages, difficult births and sexual assaults.

Some complaints were about serious incidents in which severe pain was ignored or dismissed, the report says.

"We make sure we report that. We want to make sure people understand what it is we are seeing. What is driving that is really something for the system to try to understand. We report on it and it's really then over to the various organizations and providers to understand how that might manifest itself in their circumstance," Thompson said.

It wasn't until Alejandra Sinnett returned home and showered after the birth of her daughter that she understood the severity of incisions made during delivery May 12, 2016.

The cuts ran from the top of her vagina to the back of her anus. The size came as a shock, as did the searing pain when she walked and urinated.

"I started bawling," she said, adding that she was scared to touch her own body.

Sinnett said she learned after the delivery that she had an episiotomy.

Dr. Glenn Posner, vice-chair of education for the department of obstetrics and gynecology at the University of Ottawa, said an incision of this nature would be considered an extension of an episiotomy into a fourth degree tear, which he said he's only seen twice in his career of more than 20 years.

"You wouldn't do an episiotomy into the anus on purpose," said Posner, who has no association to Park. He said painkillers and stool softeners would be given to patients in these cases.

After more than 12 hours in labour with her 9.5-pound, late-term baby, Sinnett remembers Park saying, "I'm just going to cut you a bit, OK?"

Sinnett says she said, "OK," and her husband, Nickolas Sinnett, who was in the room, adds: "There was no explanation."

He recalls blood covering the floor, the bed, the doctors, like "a murder scene in a horror film."

Afterwards, he said his wife spiralled into depression. A handwritten note his wife wrote at the time said, "I am so much more than what I have been through."

Sinnett said the lack of communication was particularly difficult because it echoes elements of abuse she had suffered in a prior relationship.

"It's the chaos. It's the, when you don't have a choice, as a domestic abuse survivor. When you're in that situation, you don't have a lot of choices. It's whatever the person says, the abuser, the abuser's in control. And it felt very vulnerable. It felt like my choices were being taken away from me just like they were when I was in that situation," she said.

She said she told Park about her history of domestic abuse at prenatal appointments. But in the end, she said, "I was completely neglected. Like completely neglected."

Sinnett said no one at the hospital came back to check on her stitches or instruct her how to manage them. Weeks later at a postnatal appointment with Park, she learned the incision was infected. She was prescribed antibiotics and told to wear skirts.

"Why weren't we given any of that information coming out of the hospital? We would have done all of those things before," her husband said.

In urgent situations, such as those when an episiotomy is needed to get a baby out quickly, there might not be as much time for a quiet and calm conversation about consent, said Ramji, speaking generally about the procedure.

"But usually you say, 'I need to make a cut for the baby's head to come out more easily.' You kind of do like an abridged version of: 'This is what I need to do. Do I have your permission to do it?"'

"You typically don't just do it."

It's also the law, said Toronto-based lawyer Jordan Assaraf. Sixteen of Park's patients have reached out to him, he says.

"You require patient consent for any medical procedure — a patient who's asleep and then woken up with a doctor inside of her — where's the consent?"

He said informed consent includes conveying the full extent of a procedure, and the potential options available to a patient. And he said it's always required, even in emergencies when there may be little time for discussion.

Sinnett never filed a patient complaint. "This goes back to being a domestic abuse survivor. I didn't report that person either," she said.

"I felt very small in the situation — like I was too small to deal with someone so big."

Claudia Gomez went to Park for a Pap test in 2020, less than a year after she moved to Canada from Colombia. She had fibroids, growths in her uterus, and menstrual bleeding so heavy that she couldn't work when she had her period.

The test was painful and long. When Gomez asked why, she said Park told her it was because she did a biopsy.

"But you didn't tell me," the 48-year-old recalls saying, and Park responding with silence.

When doctors see something suspicious during a Pap smear, they may want to do a biopsy, Ramji said. But the risks, benefits, complications and alternatives should be clearly communicated.

Jenn McIntyre, who was the executive director of Romero House at the time, an organization just a two-minute walk from Park's clinic that provides transitional housing and support to refugee claimants, recalls speaking to Gomez, a client who became a friend.

"I remember just listening to her, and hearing, and feeling so terrible for that experience because women's health is very personal, it can be very scary. So it's one of the most important areas to have really sensitive care, really good care," McIntyre said.

Gomez said she never filed a patient complaint. "I was just trying to forget about her, about the situation."

In Colombia she said her experience would be called "gynecologist violence."

"It's like the dignity of women is not respected and they were mistreated. And it is why I feel violated."

It's been just over a year since 58-year-old Esther Arbeid says she's felt like herself.

On March 21, 2024, Park removed her ovaries and Fallopian tubes at St. Joe's. Arbeid said she was told it would be a routine laparoscopic surgery involving three small incisions of the same size.

She says she was released the same day and given a handout about taking care of the incision and pain management, with no further aftercare discussed.

When she got home, Arbeid said she discovered a 1/2-centimetre-long incision on her right side, a contrast to the others, each about a centimetre.

The Canadian Press viewed a post-operative photo of Arbeid's incisions, showing the one on her right side sizably bigger than her left.

"That looks like open surgery to me," she recalls thinking. Her mother, Norma Rose, who was with her the day of the surgery, also said the scar that marked the right side of her daughter's body did not look laparoscopic.

"We go to a doctor, particularly a surgeon, with this huge amount of trust. And that trust was destroyed," said Rose.

Posner, the Ottawa physician, said an incision of that size suggests there may have been complications.

Canadian Medical Protective Association best practices state a physician is obliged to disclose unanticipated outcomes to a patient.

"People understand that doctors are human and then they're making difficult decisions. People understand that complications happen, but they don't like when they get the sense that people are avoiding them," Posner said.

He said he tells residents, "If there's a patient you don't want to go visit post-op or postpartum — that's the first patient you should go see."

Arbeid said she left three tearful voice mails at Park's clinic over a 10-day period, begging her for help. She was in too much pain to walk and could only shuffle her legs.

"I hated leaving messages on a doctor's answering machine crying. I hated it. It made me feel infantilized, ignored," she said.

Eventually, Arbeid said Park called her back and said she didn't recall the incisions being bigger than normal.

She says the pain on her right side persisted through the summer, and eventually, after visiting her family doctor in October 2024, she learned she had an incisional hernia, requiring another surgery.

An email Arbeid received from Shouldice Hospital, reviewed by The Canadian Press, showed an incisional specialist was scheduled to operate on her hernia March 19, 2025.

Weeks before Arbeid's second procedure, she filled out a CPSO patient complaint form saying she felt ghosted, gaslit and ignored, but she never filed it.

Friends, family and colleagues advised her to focus on her health.

"She was just coming up to her appointment of surgery and had to take the time to focus on that and focus on her recovery properly," her mother said.

"The first priority is always maintaining and guarding your health."

Zahra Bakhsh said she found out in September that her IUD was "just floating around" after Park inserted it at her clinic in July 2024.

The 44-year-old says another gynecologist in nearby Mississauga, Ont., made the discovery when her IUD was stuck to his glove after an exam.

Ramji said IUDs can move from their initial position, and even fall out if they've migrated low enough. A study published in Obstetrics & Gynecology in 2023 found that the overall risk of IUD expulsion is five per cent.

Since then, Bakhsh has thought a lot about who should have been responsible for the well-being of patients like herself.

She sent a letter on April 28 to Ontario Premier Doug Ford, Toronto Mayor Olivia Chow and almost 30 other politicians with another patient, Karin Martin, who had three biopsies with Park last spring and summer before she was diagnosed with uterine cancer.

Park had already stopped practising surgery at Unity Health in July, but Martin said she did not disclose this to her, delaying an urgent surgery she went into in September with another surgeon.

Bakhsh and Martin questioned whether Park's resignation at about the same time that she had planned to retire held her fully accountable.

"We need to understand whether this was an isolated regulatory lapse or indicative of a systemic problem in how patient complaints are handled in Ontario," they state in the letter.

On April 30, Bakhsh received an email from Ford, who was the only politician to respond. For a split second, she said she got excited. "By the time I made it to the second line, I was mortified. I was like, this has got to be a joke," she said.

The email thanked her for sharing her views and said that the letter would be shared with the minister of health.

"I appreciate the opportunity to read your comments and get a better understanding of your perspective," the email signed by Ford said.

"Your input is important. You can be sure our government will consider it when developing policies and deciding how to address the various challenges we face today."

The Ministry of Health told The Canadian Press that it expects every medical professional to "uphold the highest standard of patient care and the comprehensive rules regarding how health regulatory colleges, such as the College of Physicians and Surgeons of Ontario (CPSO), must handle complaints involving patient abuse."

What Martin said struck her about the health minister's response was that it stood by the current system in place. "Clearly, that does not work."

Martin said this situation should serve as a wake-up call.

In the letter, they say, "It underscores the importance of vigilant medical regulation and the grave consequences when that vigilance falters. We entrust our doctors with our health and our confidence; when that trust is violated on such a scale, it shakes public faith in the entire system."