Ontario (College of Veterinarians) v BUTTERWORTH, 2026 ONCVO 3

DISCIPLINE COMMITTEE OF THE COLLEGE OF VETERINARIANS OF ONTARIO

Indexed as: Ontario (College of Veterinarians) v BUTTERWORTH, 2026 ONCVO 3

Decision Date: 2026-03-06

BETWEEN:

THE COLLEGE OF VETERINARIANS OF ONTARIO

-and-

DR. EDWIN BUTTERWORTH

PANEL:

Dr. Kerry Lissemore, Member, Chairperson Dr. Atul Pakhwala, Member Dr. Yashvir Varma, Member Dr. Arif Memon, Member Mr. Doug Reynolds, Public Member

Appearances

Bernard C. LeBlanc and Carly Waisglass, Counsel for the College of Veterinarians of Ontario (the “College”)

Neil M. Abramson and Lujza Csanyi, Counsel for (the “Member”)

Edward Marrocco, Independent Legal Counsel to the Panel

Heard: September 9-10, 2025

DECISION AND REASONS

1This matter came on for hearing before a Panel of the Discipline Committee of the College of Veterinarians of Ontario (the “College”) over two days on September 9-10, 2025. The hearing was conducted by way of videoconference with further written submissions filed in late January 2026. Dr. Butterworth represented himself for the merits hearing and oral phase of the penalty proceedings but retained counsel in December 2025. Prior to retaining counsel, the penalty phase of the proceedings was contested. After retaining counsel, Dr. Butterworth and the College resolved their differences on penalty and collaborated to present a joint submission. That joint submission was filed in writing with the Panel’s leave on January 23, 2026, while deliberations as to penalty had been paused by agreement. These are the Panel’s reasons on the contested merits phase which it decided orally back in September of 2025 as well as its decision and reasons on the joint submission.

Overview

2These proceedings were commenced by a Notice of Hearing dated September 13, 2024, referring specified allegations of professional misconduct against Dr. Edwin Butterworth to the Discipline Committee under sections 24 and 30 of the Veterinarians Act, R.S.O. 1990, c. V.3 (the “Act”). The allegations against Dr. Butterworth arise out of his care of a Great Dane named Starr. It was alleged that Dr. Butterworth failed to properly assess or reassess Starr on December 14, 2020; failed to contact Starr’s owner on December 14, 2020; failed to reassess, adequately monitor and/or treat Starr on December 15, 2020; and failed to maintain proper records. These particulars were alleged to constitute professional misconduct under paragraphs 2 (failure to maintain the standard of practice), 27 (failure to make or retain required records), 44 (disgraceful, dishonorable, or unprofessional conduct), and 45 (conduct unbecoming) of subsection 17(1) of O. Reg. 1093 under the Act.

The Allegations

3The Notice of Hearing particularizes the allegations against Dr. Butterworth as follows:

Statement of Allegations

1. Dr. Edwin Butterworth was, at all material times, a veterinarian licensed to practise veterinary medicine in the Province of Ontario. Dr. Butterworth practised at Timmins Animal Hospital (TAH) in Timmins, Ontario.

Summary of the Facts

2. DB’s Great Dane, Starr, was, at all material times, a patient of Dr. Butterworth

3. On Sunday, December 13, 2020, Starr developed an unexplained rapid heartbeat and breathing as well as unproductive retching. That evening DB called TAH to discuss the case and obtain advice.

4. After speaking with a staff person, DB eventually spoke with Dr. Butterworth and explained Starr’s condition. Dr. Butterworth suggested that DB look for barrel-chesting for possible gastric dilatation-volvulus (GDV). He also advised DB to monitor Starr for the next couple of hours and to call back if Starr’s condition worsened.

5. The next morning, Monday, December 14, 2020, DB called TAH to ask if he could bring Starr in for an emergency visit. TAH staff advised DB that he could, but there was no guarantee that Starr would be seen.

6. When DB attended TAH with Starr at approximately 8:35 a.m., he reported that Starr’s symptoms remained largely the same - tachypnea, tachycardia, disinterest in food or drink, restlessness, weakness, non-productive retching, and she was also more lethargic.

7. While at TAH that day, Starr was examined, blood was drawn for CBC/biochemistry and abdominal radiographs including a Barium series were taken.

8. As DR did not receive a call from TAH that day, he called just after 4:00 p.m. for an update. The person who answered the phone indicated that they were unsure of Starr’s status. They reported that Starr had barium x-rays, but they were unsure of the results. They indicated that they would call back with an update soon.

9. Shortly thereafter, TAH called DB and advised that he could pick up Starr.

10. When DB attended to pick up Starr, Dr. Butterworth’s auxiliary advised DB that they did 3 barium x-rays, but Dr. Butterworth had not had a chance to review them yet. DB was advised to bring Starr back the next morning at 8:00 a.m. so that they could continue doing tests. In the meantime, Starr’s condition largely remained the same.

11. At no time did Dr. Butterworth contact DB to discuss Starr’s case on December 14, 2020.

12. On Tuesday, December 15, 2020, Starr had more difficulty getting up than previously, to the extent that DB had to physically help her get into the vehicle. He dropped Starr off again at TAH at 8:00 a.m. A receptionist advised DB that they would take Starr to the back where she could wait to be seen by Dr. Butterworth.

13. While at TAH, further abdominal and chest x-rays were taken.

14. Shortly after 3:00 p.m., Dr. Butterworth called DB and advised that they ran some tests and he believed that the problem has something to do with a lung infection. He asked if DB had been doing any painting or renovations in the house or if there was any way that Starr had gotten a lung infection, but DB was unaware of any such potential cause.

15. Dr. Butterworth then indicated that he would prescribe antibiotics and antihistamines and that DB could pick Starr up in about a half hour when the prescription was filled out.

16. Shortly after this conversation, at approximately 3:18 p.m., Dr. Butterworth called back and indicated that “Sky” was found dead by the veterinary technician who went to get her. He added that he was not sure what happened, but that it appeared that Starr coughed up some blood. Dr. Butterworth added that she was fine on the 12 o'clock rounds so he was not sure what happened. He then asked if DB wanted Starr cremated there. DB asked Dr. Butterworth if he meant to refer to Starr or if this is a mix-up. Dr. Butterworth responded, "Oh yeah Starr I mean", or words to that effect.

Allegations of Professional Misconduct

17. Dr. Butterworth engaged in professional misconduct in that he:

a. failed to properly assess Starr, and/or failed to reassess Starr’s condition once tests were performed, on December 14, 2020;

b. failed to contact DB to discuss the case on December 14, 2020;

c. failed to reassess, adequately monitor and/or treat Starr on December 15, 2020;

d. failed to maintain proper records.

18. Dr. Butterworth thereby engaged in professional misconduct within the meaning of paragraphs 2 (failing to maintain the standard of practice of the profession), 27 (failing to make or retain the records required by the regulation), 44 (an act or omission relevant to the practice of veterinary medicine that, having regard to the circumstances, would be regarded by members as disgraceful, dishonourable or unprofessional) and 45 (conduct unbecoming a veterinarian) of subsection 17(1) of O Reg 1093 under the Veterinarians Act.

Member’s Plea

4Dr. Butterworth entered a plea at the outset of the merits hearing denying all allegations.

The Evidence

5The College tendered viva voce and documentary evidence from Starr’s owner, David Burtch, and opinion evidence from an expert in veterinary standards of practice, Dr. Mark Wallar. In response to the College case, Dr. Butterworth testified on his own behalf.

David Burtch

6Mr. Burtch, a registered nurse and crisis worker, testified regarding Starr’s presentation and his communications with Timmins Animal Hospital between December 13 and 15, 2020. He described calling the emergency line on the evening of December 13 concerned about Starr’s rapid breathing, unproductive retching, and distress. After first speaking with staff, he spoke to Dr. Butterworth, who recommended monitoring and to call back if Starr deteriorated.

7On Monday, December 14, Mr. Burtch brought Starr to the clinic, and she was admitted for testing. Mr. Burtch did not receive any direct communication from Dr. Butterworth that day about Starr’s results or status. Late in the day on December 14, he was told to pick Starr up and return the next morning for further testing.

8On December 15, he returned Starr to the clinic in the morning. Shortly after 3:00 p.m., Dr. Butterworth called to say he suspected a lung infection and would prescribe antibiotics and antihistamines, advising Starr could be picked up shortly. Minutes later, Dr. Butterworth called again to report that a technician had found Starr deceased. Mr. Burtch testified that in making the second call, Dr. Butterworth initially referred to Starr by the wrong name before correcting himself. There was no cross-examination of Mr. Burtch. In response to a Panel question, Mr. Burtch indicated he had not been provided any differential diagnoses or “rule-outs”.

9The Panel found Mr. Burtch to be a credible and reliable witness regardless of the absence of cross-examination. His testimony was internally consistent, aligned with contemporaneous records to the extent they existed, and of course was not materially challenged. It established, among other things, the absence of direct veterinarian-client communication on December 14 and the sequence of two calls on December 15 moments apart, which the Panel considered on the issues of reassessment, monitoring, and communication.

Dr. Mark Wallar

10The College tendered Dr. Mark Wallar as an expert in the standards of practice of veterinary medicine and expressly whether Dr. Butterworth’s care met those standards. The Panel received and marked Dr. Waller’s engagement letter, dated August 29, 2023, and acknowledgment of expert duty. The Panel qualified Dr. Wallar to provide opinion evidence consistent with the scope requested by the College noted above. His report was also filed as an exhibit without objection.

11Dr. Wallar summarized his understanding of the factual chronology of events, including the December 13 triage call, Starr’s admission and testing on December 14, the lack of direct communication with the owner that day, and the events of December 15.

12He opined that the initial telephone triage and plan to monitor on December 13 were acceptable. He considered Dr. Butterworth’s misnaming of Starr during the December 15 call to be below the standard expected, albeit not of extreme magnitude in isolation. The core of his opinion addressed reassessment, monitoring, communication, and record-keeping. He noted that once gastric distension or “GDV” was effectively ruled out on imaging on December 14, the persistent findings of respiratory distress and tachycardia required a timely reassessment and alternative diagnostic focus - which did not occur.

13With respect to the documentation of Starr’s treatment, he further opined that the medical records-particularly on December 15-were seriously deficient. He testified that vital parameters (e.g., heart and respiratory rates) were not quantified, there was no documented assessment of stability, and no coherent plan could be discerned from the chart. He concluded that overall monitoring and care, the failure to communicate directly with the owner for nearly 48 hours, and the record-keeping fell below the standards of practice and “far below” in his view in relation to the record keeping.

14On cross-examination by Dr. Butterworth, Dr. Wallar acknowledged that in his career he practiced within multi-veterinarian clinics, had backup support from staff, and that occasional omissions in charting can occur in busy practices. Dr. Wallar did not accept that these contextual factors altered the applicable standards.

15On re-examination, Dr. Wallar confirmed that the standards of practice do not vary by geography or practice model and are consistent for all members. In response to a Panel question, he confirmed his ultimate opinion that the standards of practice were not met in this case.

Dr. Butterworth

16Dr. Butterworth testified in his own defence and was the sole witness in response to the College case. Critically, Dr. Butterworth did not meaningfully contest the core chronology or clinical steps, and he acknowledged that elements of the care and records “could have been done” better.

17In his evidence, Dr. Butterworth attributed aspects of the events relating to Starr to staffing shortages and workload during the COVID-19 period. He indicated that auxiliaries typically handled client communications and that he performed only cursory morning checks on hospitalized patients. He agreed that he did not speak with Mr. Burtch on December 14, that interpretations of December 14 testing were not charted, and that there were no examination findings entered on December 15. He also accepted that he told Mr. Burtch shortly after 3:00 p.m. on December 15 that he suspected a lung infection and prepared prescriptions without documenting the conversation. There was no dispute that minutes later a technician found Starr deceased.

18Dr. Butterworth acknowledged initially misnaming Starr during the call to advise Mr. Burtch of her death. Dr. Butterworth suggested that disseminated intravascular coagulation likely caused Starr’s death but conceded he neither communicated that opinion to Mr. Burtch nor recorded it in the medical record.

19In the course of his testimony and in response to cross-examination, Dr. Butterworth ultimately agreed with several of Dr. Wallar’s conclusions, including that he should have spoken with Mr. Burtch more and that the monitoring and records were inadequate.

20Dr. Butterworth was candid in his testimony. The Panel did not have concerns in respect of his credibility or reliability. He made fair concessions where appropriate and did not offer a factual narrative that significantly departed from Mr. Burtch’s evidence or the contemporaneous documents entered in evidence. Although he denied the allegations at the outset of the proceedings, by the time he finished his testimony, his opposition had clearly lessened. While this did not relieve the College of the burden of proving its case, this ultimately was not a hearing which required a credibility contest between different versions of events between the witnesses.

Findings and Reasons on the Merits

21The evidence was completed on the first hearing day and enabled the Panel to deliberate on the merits immediately. Having considered the evidence and submissions, the Panel found professional misconduct proven on substantially all particulars, with two limited exceptions.

22With respect to the particulars, the Panel found that the College proved that Dr. Butterworth: (i) failed to reassess Starr’s condition once tests were performed on December 14, 2020; (ii) failed to contact Mr. Burtch on December 14, 2020; (iii) failed to reassess, adequately monitor, and treat Starr on December 15, 2020; and (iv) failed to maintain proper records. The Panel concluded that this conduct constituted professional misconduct within the meaning of paragraphs 2 (standard of practice), 27 (records), and 44 (disgraceful, dishonorable, or unprofessional conduct) of subsection 17(1) of O. Reg. 1093.

23The Panel did not find professional misconduct within the meaning of paragraph 45 (conduct unbecoming). The Panel also did not find proven, on a balance of probabilities, the first portion of the alleged particular that there was a failure to properly assess Starr on December 14, 2020. However, the Panel did find proven, as above, the failure to reassess once tests were performed on that date.

24In reaching these conclusions, the Panel considered the factual chronology, the significance of timely reassessment following diagnostic testing, the need for effective and timely communication with the client, and the requirements for adequate medical record-keeping in companion animal practice. The cumulative deficiencies established, particularly in reassessment, monitoring, communication, and records, met the threshold for findings under paragraphs 2, 27, and 44 of the Regulation.

Penalty Phase

25The Panel advised the parties of its decision on the merits orally and the penalty phase of the proceedings began immediately on the second hearing day, September 10.

26The penalty phase was initially contested. The College sought an order including a recorded public reprimand; a four-month suspension (running uninterrupted and continuing until successful completion of remediation); mandatory remediation comprised of an initial assessment, two-day mentorship, online module in medical record keeping, a follow-up assessment; and eight peer reviews over 24 months upon any return to practice.

27The College’s initial penalty submissions emphasized the statutory jurisdiction under section 30(5) of the Act and the principles of specific and general deterrence, denunciation, remediation, and protection of the public interest. The College also submitted that there were aggravating factors, including a prior discipline history as well other complaints concerning standards and record-keeping.

28Dr. Butterworth, still representing himself at that time, responded to the College position arguing that the penalty sought was excessive. He emphasized that the issues in relation to Starr’s treatment arose out of issues with technical staff during COVID and that he had been over-extended at the time trying to keep his support team working properly and reporting to him. He acknowledged that his record-keeping was “not what it should be” and indicated an intention to do better. He disagreed with the College that a four-month suspension was needed – expressing his view that that was too long. He did not oppose any of the remedial items proposed by the College.

29The Panel rose to begin deliberations and indicated that a decision on penalty would be released in writing at a later date.

30In December of 2025, the Panel was contacted by independent legal counsel on the joint request of all parties and advised that Dr. Butterworth had retained counsel. Dr. Butterworth’s lawyer was requesting leave to file a written response to the College’s position on penalty. On December 19, the Panel issued a direction granting both the College and counsel for Dr. Butterworth an opportunity to make further submissions in writing only. It was directed that all submissions would be delivered to independent legal counsel on a specific timetable with a complete set of submissions being forwarded to the Panel on January 23, 2026. Deliberations by the Panel paused accordingly.

Joint submission – January 2026

31Upon delivery of the written materials on January 23, the parties had reached an agreement on penalty, and the Panel was presented with one set of written materials in the form of a joint submission.

32The joint submission was predicated on an enclosed, executed, undertaking from Dr. Butterworth signed on December 9, 2025, promising to resign from the College by no later than February 10, 2026, and to refrain from seeking to re-apply in Ontario or elsewhere (the “Undertaking”). The Undertaking acknowledges, among other things, that the findings and decisions of the Panel, along with the Undertaking, will be posted to the public register; that the College may rely on those materials in any future registration context; and that the College retains jurisdiction to prosecute a breach of the Undertaking notwithstanding Dr. Butterworth’s resignation.

33The parties argued together that the joint submission would provide immediate and enduring protection of the public and that the traditional rationales for penalty would be satisfied or otherwise rendered unnecessary.

34With respect to specific deterrence, the parties argued that it is not engaged where the member has permanently left the profession and undertaken not to reapply. Similarly, that remediation has no utility if the member will not practice in the future and would not serve the public interest in these circumstances.

35It was also jointly submitted that general deterrence and maintenance of public confidence are meaningfully advanced by publication of the findings, this decision, and the Undertaking on the College’s public register. Transparency, the parties argued, would communicate the College’s and the Panel’s response to the substantiated misconduct and demonstrates ongoing protection of the public.

36Public protection is fully met, the parties argued, by the immediate cessation of practice and the binding, enforceable nature of the Undertaking, including the College’s continuing jurisdiction in the event of a breach by Dr. Butterworth.

37The College fairly acknowledged that, although it initially sought a significant suspension coupled with remediation, it jointly submits that, considering the permanent resignation and the robust protections in the Undertaking, no further order is necessary.

38The parties conclude by arguing that measured against the applicable standard for joint submissions, the proposed disposition does not risk bringing the administration of justice into disrepute and is not otherwise contrary to the public interest. To the contrary, it addresses, they say, the need for public protection in a manner proportionate to the misconduct found and Dr. Butterworth’s present and future status.

Decision on Penalty

39The Panel accepts the joint submission and agrees that no further order shall be made. We are satisfied that the joint submission advances the public interest for three reasons.

40First, Dr. Butterworth will not be serving any members of the public again and to the extent that there needs to be assurance of public protection – that goal is achieved. The Undertaking indeed eliminates any prospect of future practice by Dr. Butterworth, obviating the need for remediation and specific deterrence. Even when the matter was contested on penalty, the College could not obtain (and was not requesting) an order which would have resulted in Dr. Butterworth’s permanent departure from the practice of veterinary medicine. The Undertaking has in that regard obtained a result that is even broader than what would have been available initially.

41Second, public posting of the findings, decision, and Undertaking ensures transparency, general deterrence, and maintenance of confidence in the College’s regulatory processes. There will be no mystery surrounding the decision made in this matter or why the Panel was prepared to accept the joint submission in these specific circumstances. These are indeed unique circumstances arising out of a particular case in which a member represented themselves unsuccessfully, then retained counsel and pursued a compromise. The merits hearing and penalty phase, although contested, were completed in less than 1.5 hearing days with both sides conducting themselves professionally and efficiently. This will not, and should not, be interpreted as a precedent which supports that any member facing a penalty can fight unsuccessfully and then resign to avoid an order or to prevent the risks of having to pay costs. Whether a joint submission is consistent with the public interest or risks undermining the perceived integrity of the tribunal must be assessed on a case-by-case basis. In this case, the Panel has no concerns.

42Third, the College’s reassessment of its penalty position considering the Undertaking is principled and consistent with its objectives of ensuring professional regulation of veterinarians in Ontario. We have received a joint package of written submissions which not only explains why the parties propose the joint submission but also provides insight into why the College determined it would be appropriate to change its previous position and adopt the joint position. The College’s reasons not only reflect the items we highlight above but also advert to the efficiencies and reduced enforcement costs that flow from having a final disposition based on the Undertaking. The College’s position is reasoned and logical. Had that explanation been missing, the Panel may have required the parties to attend and answer questions before accepting this proposal.

43In the end, the proposed disposition is consistent with the jurisprudence governing joint submissions, and we see no basis to reject it. Acceptance of the joint submission does not bring the administration of justice into disrepute or otherwise undermine the public interest. We are mindful of the case law and the high threshold required to refuse a jointly submitted penalty. That threshold is not reached, and we accept the proposal accordingly.

44The merits of this matter are decided as noted above and there shall be no further order.

I, Dr. Kerry Lissemore, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline panel as listed below:

March 6, 2026

Chairperson

Date

Names of Panel Members

Dr. Kerry Lissemore Dr. Atul Pakhwala Dr. Yashvir Varma Dr. Arif Memon Mr. Doug Reynolds