ONTARIO PHYSICIANS AND SURGEONS DISCIPLINE TRIBUNAL
Tribunal File No.: 25-027
BETWEEN:
College of Physicians and Surgeons of Ontario College
- and -
Stefan Joseph Konasiewicz Registrant
FINDING AND PENALTY REASONS
Heard: February 9, 2026
Panel:
Sophie Martel (panel chair)
Jill Cross (public)
Roy Kirkpatrick (physician)
Carys Massarella (physician)
Ray Trask (public)
Appearances:
Elisabeth Widner, for the College
Eric Pellegrino, for the registrant
RESTRICTION ON PUBLICATION
Pursuant to Rule 2.2.2 of the HPDT Rules of Procedure and ss. 45-47 of the Health Professions Procedural Code, no one shall publish or broadcast the names of patients or any information that could identify patients or disclose patients’ personal health information or health records referred to at a hearing or in any documents filed with the Tribunal. There may be significant fines for breaching this restriction.
Introduction
1Dr. Stefan Joseph Konasiewicz is a neurosurgeon who practises pain medicine. This referral concerns allegations of misconduct by Dr. Konasiewicz in three respects: the reassessment findings after his completion of 12 months of clinical supervision, his treatment of Patient A who died after receiving nerve blocks, and the contravention of a term, condition or limitation placed on his certificate of registration
2In July 2022, following an investigation into his clinical practice, Dr. Konasiewicz undertook to complete 12 months of clinical supervision followed by a reassessment. The reassessment assessor was of the view that he failed to maintain the standard of practice in most of the charts reviewed. Dr. Konasiewicz did not change his treatment plan even when the patients failed to benefit from it and misused templates in his record keeping.
3Patient A died after receiving nerve blocks from Dr. Konasiewicz. There were multiple concerns about Dr. Konasiewicz’s treatment of Patient A, the most significant being the use of deficient techniques in cervical spine injections, which presented a significant risk of patient harm.
4Ater receiving the reassessment report and information about Patient A’s death, on January 31, 2025, the Inquiries, Complaints and Reports Committee (ICRC) issued an order that restricted Dr. Konasiewicz from performing certain injections and nerve blocks. The College subsequently received information that Dr. Konasiewicz had performed injections contrary to the order. As a result of the breach, on May 12, 2025, the ICRC suspended Dr. Konasiewicz’s certificate of registration.
5Relying on an agreed statement of facts and statement of uncontested facts, we concluded that Dr. Konasiewicz failed to maintain the standard of practice of the profession, contravened a term, condition or limitation on his certificate of registration, and engaged in conduct that is disgraceful, dishonourable or unprofessional.
6The parties jointly proposed that Dr. Konasiewicz be reprimanded, that his certificate of registration be suspended for six months and that terms, conditions and limitations be placed on his certificate of registration, including robust professional education and clinical supervision. These provide, among others, that Dr. Konasiewicz will practise under high-level clinical supervision that involves the direct observation of a minimum of 200 procedures. Because the proposed penalty does not bring the professional discipline system into disrepute, we made the requested order at the hearing. We also accepted the parties’ joint proposal that Dr. Konasiewicz pay costs of $6,000.
Failing to maintain the standard of practice of the profession
Registrar’s investigation – reassessment
7On July 13, 2022, following an investigation of his clinical practice, Dr. Konasiewicz signed an undertaking to complete 12 months of clinical supervision of his chronic pain practice, to be followed by a reassessment conducted by a College-approved assessor.
8Dr. Philip Chan conducted the reassessment. In his report of April 10, 2024, Dr. Chan addressed his review of 15 patient charts. He opined that Dr. Konasiewicz failed to maintain the standard of practice in 12 of 15 charts based on the following:
His treatment plan did not change depending on results obtained. He repeated multiple injections without change, weekly or biweekly, even when there was evidence that the treatment was ineffective.
His record-keeping was inadequate in that he attached the identical follow-up note to multiple visits.
He performed urine drug screens at each patient encounter for patients to whom he was prescribing opioids. His decision to do so did not vary depending on the patient’s risk factors and/or clinical course.
9Dr. Chan also opined that while Dr. Konasiewicz did not expose any of the 15 patients to harm or injury, he displayed a lack of judgment, skill or knowledge in 8 out of 15 charts, including performing sciatic nerve blocks and paravertebral injections for conditions where they were not indicated. Based on Dr. Konasiewicz’s technique description, Dr. Chan also doubted that he was correctly performing multiple different nerve blocks.
Registrar’s investigation - Patient A
10Dr. Konasiewicz first met Patient A in 2015 regarding a history of neck and shoulder pain. Dr. Kozakiewicz’s treatment plan employed a series of injections for pain management. He continued to see the patient regularly in follow up for assessment and injections. By the time of his death, Patient A also had a history of cardiac issues.
11On October 31, 2024, when Patient A was then 70 years old, Dr. Konasiewicz performed a series of nerve blocks to treat the patient’s pain. Patient A collapsed after the procedure. Despite the initiation of cardiopulmonary resuscitation, the patient could not be revived and passed away.
12The College’s Premises Inspection Committee, the committee with oversight of out-of-hospital premises, reviewed the incident and in December 2024, identified concerns about Dr. Konasiewicz’s care including the number and indication of the blocks provided during the procedure (16 blocks over a 10-minute period) as well as the documentation regarding the pre-procedural evaluation, the nerve blocks provided and the resuscitation procedure followed.
13The Office of the Chief Coroner also investigated the incident and expressed concerns about Dr. Konasiewicz’s practice in its report of January 17, 2025. The Coroner’s Office opined that Patient A had experienced an inadvertent intrathecal injection of local anesthetics.
14The College retained Dr. Geoff Alexander Bellingham to review Dr. Konasiewicz’s care of Patient A. In his report of April 25, 2025, Dr. Bellingham identified multiple areas of concern. He opined that Dr. Konasiewicz’s technique for fluoroscopic-guided cervical facet injections did not meet accepted standards of practice due to improper needle placements that posed significant risks to patient safety. Specifically, there were multiple instances where Dr. Konasiewicz directed needles toward the spinal canal (not the intended target) without confirming their final position using required lateral views or ensuring adequate imaging quality. He also identified concerns about the use of alcohol neurotomy in the cervical spine without image guidance, the use of nerve blocks not indicated for chronic pain management, and the performance of multiple injections in a single session without properly balancing the risk and benefits of such. Furthermore, the way in which he used templates in his record keeping differed from what is expected from the College’s Medical Records Documentation policy.
15Dr. Bellingham concluded that Dr. Konasiewicz’s care of Patient A did not meet the standard of practice of the profession and displayed a lack of knowledge, skill and judgment.
Conclusion
16Dr. Konasiewicz admits the facts regarding the reassessment of his practice and his care of Patient A.
17We rely on Dr. Chan’s opinion in respect of the reassessment as well as the documents referenced in the agreed statement of facts about Patient A. Dr. Konasiewicz failed to meet the standard of practice of the profession in 12 of the 15 charts reviewed by Dr. Chan. He also failed to meet the standard of practice of the profession in his treatment of Patient A. There were serious deficiencies in Dr. Konasiewicz’s decision making as to when and how many injections he performed and most significantly, there were clinical deficiencies in the techniques he used to safely perform these injections. Additionally, there were record-keeping deficiencies including the misuse of templates.
Contravening a term, condition and limitation on the certificate of registration and engaging in disgraceful, dishonourable and unprofessional conduct
18After it received the information about Patient A from the Premises Inspection Committee and the Coroner’s Office, on January 31, 2025, the ICRC directed the Registrar to impose terms, conditions and limitations on Dr. Kozakiewicz’s certificate of registration effective immediately. As a result of this order, Dr. Konasiewicz was restricted from performing, “any neuraxial, paravertebral, plexus and facet joint injections and/or nerve blocks for adult chronic pain,” and “injections along or near the spinal column.”
19The College received a patient letter on May 5, 2025, which expressed concerns that Dr. Konasiewicz had breached the order by performing injections along or near her spinal column on March 13, 27 and April 10, 2025.
20The College obtained the patient’s records that confirmed that Dr. Konasiewicz performed the injections, which the College determined were “along or near the spinal column” contrary to the ICRC order. As a result of the breach, on May 12, 2025, the ICRC suspended Dr. Konasiewicz’s certificate of registration.
21While the statement of uncontested facts indicates that he would testify that he interpreted the order terms differently, Dr. Konasiewicz does not contest the allegation that he breached the terms of the order, which also constitute disgraceful, dishonourable and unprofessional conduct.
22Relying on the statement of uncontested facts, we conclude that in performing injections along or near the spinal column on three occasions, Dr. Konasiewicz breached a term, condition or limitation placed on his certificate of registration. Failing to comply with terms, conditions or limitations imposed under an ICRC order is a serious disregard of one’s professional obligations and is conduct that would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional.
Penalty and costs
Penalty
23The parties jointly proposed a reprimand, a suspension of six months and the placement of terms, conditions and limitations on Dr. Konasiewicz’s certificate of registration.
24Our role is limited when the parties agree on penalty. We should only depart from a joint submission if the proposed penalty would bring the administration of justice into disrepute or is otherwise not in the public interest: R. v. Anthony Cook, 2016 SCC 43. This is a high threshold. A disciplinary body that rejects a joint submission on penalty must show why the proposed penalty is so unhinged from the circumstances of the case that it must be rejected: Bradley v. Ontario College of Teachers, 2021 ONSC 2303.
25We are satisfied that the proposed penalty would not bring the administration of physician regulation into disrepute. We are also satisfied that the proposed penalty appropriately balances the penalty goals: the protection of the public, general and specific deterrence, rehabilitation and expressing the Tribunal and the profession’s disapproval of the misconduct.
26The heart of the proposed order, as submitted by the College, is the remediation contemplated through professional education, clinical supervision and reassessment.
27The order provides for a minimum of 12 months of clinical supervision divided into high (minimum of two months), moderate (minimum of four months) and low level supervision (minimum of six months) by a clinical supervisor approved by the College. At high level supervision, the clinical supervisor will meet with Dr. Konasiewicz once every week and will directly observe 25 of Dr. Konasiewicz’s procedures, at least 15 of which require image guidance. The clinical supervisor will also review the corresponding patient charts and imaging and provide a report to the College once every week. During high level supervision, the clinical supervisor will observe no less than 200 procedures, including at least 120 procedures that require image guidance.
28At moderate level supervision, the clinical supervisor will meet with Dr. Konasiewicz every two weeks and again observe a minimum of 200 procedures. At low level supervision, the clinical supervisor will meet with Dr. Konasiewicz every month and observe a minimum of 90 procedures. Throughout, the clinical supervisor will select the procedures to be observed. Dr. Konasiewicz will only progress from high to moderate to low level supervision upon the recommendation of the clinical supervisor and the College’s approval.
29Approximately six months after completion of the clinical supervision, Dr. Konasiewicz will undergo a reassessment of his interventional pain practice.
30The supervision terms set out in the order differ from Dr. Konasiewicz’s previous 12-month period of supervision in that they include the direct observation of Dr. Konasiewicz’s procedures. Furthermore, the order also requires that Dr. Konasiewicz participate in and successfully complete the International Pain & Spine Intervention Society (IPSIS) Cervical Bio-Skills Lab course, which is a hands-on course. Additionally, he must successfully complete the PROBE Ethics & Boundaries Program.
31The education and the clinical supervision involving the direct observation of image guided procedures address the technique, knowledge and skill deficiencies identified by Dr. Bellingham. They fulfill the penalty goal of remediation while protecting the public and maintaining its confidence in the College’s ability to effectively govern the profession.
32The suspension of six months addresses the goals of specific and general deterrence. While neither party asked that we give credit for time already served, we note that Dr. Konasiewicz has been subject to a suspension of over eight months by virtue of the ICRC’s suspension order of May 12, 2025. He now faces an additional six-month suspension.
33The reprimand also serves as deterrence and publicly denounces the conduct. It puts Dr. Konasiewicz on notice that further deficiencies in his practice will be viewed severely.
34The supervisory terms coupled with a suspension are proportionate to other cases that involve a combination of disgraceful, dishonourable or unprofessional conduct and a failure to meet the standard of practice. See College of Physicians and Surgeons of Ontario v. Alexander, 2022 ONPSDT 41 and College of Physicians and Surgeons of Ontario v. Upadhye, 2021 ONCPSD 14.
35Ultimately, we are satisfied that the proposed order is not so unhinged from the circumstances that implementing it would bring the administration of the College’s professional discipline system into disrepute.
Costs
36Similarly, we accept the parties’ joint proposal that Dr. Konasiewicz pay costs of $6,000, which reflects the tariff rate in the Rules of Procedure.
Order
37We ordered:
Penalty
The Tribunal requires Dr. Konasiewicz to appear before the panel to be reprimanded.
The Tribunal directs the Registrar to:
a. suspend Dr. Konasiewicz’s certificate of registration for six (6) months commencing on February 10, 2026 at 12:01 a.m.
b. place the following terms, conditions and limitations on Dr. Konasiewicz’s certificate of registration effective immediately:
i. Prior to commencing practice following the expiry of the period of suspension, Dr. Konasiewicz shall retain at his own expense a clinical supervisor acceptable to the College (the “Clinical Supervisor”) who has executed an undertaking in the form attached at Schedule “A”.
Clinical Supervision
ii. For a minimum of twelve (12) months after resuming practice, Dr. Konasiewicz will practice only under the supervision of the Clinical Supervisor (“Clinical Supervision”). The period of Clinical Supervision will commence on the expiry of the period of suspension, or on the date that the Clinical Supervisor is approved, whichever is later.
iii. Dr. Konasiewicz shall remain free of any conflict of interest with the Clinical Supervisor.
iv. For a minimum of two (2) months after resuming practice, the Clinical Supervisor will meet with Dr. Konasiewicz at his Practice Location, or another location approved by the College, once every week (“High Level Supervision”).
v. During High Level Supervision, the Clinical Supervisor will directly observe twenty-five (25) of Dr. Konasiewicz’s procedures at every meeting, at least fifteen (15) of which shall be procedures that require image guidance as defined in the College’s Out-of-Hospital Premises Standard: Image Guidance When Administering Nerve Blocks for Adult Chronic Pain (the “OHP Standard”). The Clinical Supervisor shall review the patient chart and imaging that correspond to each procedure observed.
vi. During High Level Supervision, the Clinical Supervisor will provide a report to the College once every week, or more frequently if the Clinical Supervisor has concerns about Dr. Konasiewicz’s standard of practice or conduct.
vii. After a minimum of two (2) months of High Level Supervision and the direct observation of a minimum of two hundred (200) procedures (including at least one hundred twenty (120) procedures that require image guidance as defined in the OHP Standard), if the Clinical Supervisor recommends and the College approves, the Clinical Supervisor will meet with Dr. Konasiewicz at his Practice Location, or another location approved by the College, once every two (2) weeks for a minimum of four (4) months (“Moderate Level Supervision”).
viii. During Moderate Level Supervision, the Clinical Supervisor will directly observe twenty-five (25) of Dr. Konasiewicz’s procedures at every meeting, at least fifteen (15) of which shall be procedures that require image guidance as defined in the OHP Standard. The Clinical Supervisor shall review the patient chart and imaging that correspond to each procedure observed.
ix. During Moderate Level Supervision, the Clinical Supervisor will provide a report to the College once every month, or more frequently if the Clinical Supervisor has concerns about Dr. Konasiewicz’s standard of practice or conduct.
x. After a minimum of four (4) months of Moderate Level Supervision and the direct observation of a minimum of two hundred (200) procedures (including at least one hundred twenty (120) procedures that require image guidance as defined in the OHP Standard), if the Clinical Supervisor recommends and the College approves, the Clinical Supervisor will meet with Dr. Konasiewicz at his Practice Location, or another location approved by the College, once every month for a minimum of six (6) months (“Low Level Supervision”).
xi. During Low Level Supervision, the Clinical Supervisor will directly observe fifteen (15) of Dr. Konasiewicz’s procedures at every meeting, at least ten (10) of which shall be procedures that require image guidance as defined in the OHP Standard. The Clinical Supervisor shall review the patient chart and imaging that correspond to each procedure observed.
xii. During Low Level Supervision, the Clinical Supervisor will provide a report to the College once every three (3) months, or more frequently if the Clinical Supervisor has concerns about Dr. Konasiewicz’s standard of practice or conduct.
xiii. After a minimum of six (6) months of Low Level Supervision and the direct observation of a minimum of ninety (90) procedures (including at least sixty (60) procedures that require image guidance as defined in the OHP Standard), Clinical Supervision will cease if the Clinical Supervisor recommends and the College approves, in the College’s sole discretion.
xiv. Throughout Clinical Supervision, the Clinical Supervisor will select all procedures to be observed in their sole discretion. Selected procedures that require image guidance as defined in the OHP Standard (including facet joint injections) will include procedures across a distribution of anatomic regions including cervical, thoracic, and lumbar locations.
xv. When observing procedures, the Clinical Supervisor shall ensure that Dr. Konasiewicz engages in appropriate procedural assessment and planning, procedural execution, and post-procedural management.
xvi. The Clinical Supervisor will keep a log of all procedures observed, including patient identifiers.
xvii. The Clinical Supervisor will discuss any concerns arising from the direct observation or patient chart/image reviews with Dr. Konasiewicz.
xviii. The Clinical Supervisor will make recommendations to Dr. Konasiewicz for practice improvements and ongoing professional development, and will inquire into Dr. Konasiewicz’s compliance with such recommendations.
xix. Dr. Konasiewicz will reflect on and discuss the following literature/course with his Clinical Supervisor:
IPSIS Technical Manual and Atlas of Interventional Pain and Spine Procedures
IPSIS Comprehensive Bio-Skills Lab: Individualized Instruction course
xx. Dr. Konasiewicz shall cooperate fully with the Clinical Supervision of his practice, conducted under the terms of this Order, and shall abide by the recommendations of his Clinical Supervisor, including but not limited to any recommended practice improvements and ongoing professional development.
xxi. If, prior to completion of Clinical Supervision, the Clinical Supervisor is unable or unwilling to continue in that role for any reason, Dr. Konasiewicz shall retain a new College-approved Clinical Supervisor who will sign an undertaking in the form attached hereto as Schedule “A”. Dr. Konasiewicz shall cease practicing medicine until such time as he has obtained a Clinical Supervisor acceptable to the College. If Dr. Konasiewicz is required to cease practice as a result of this paragraph, this will constitute a term, condition and limitation on his certificate of registration and such term, condition and limitation shall be included on the public register.
Professional Education
xxii. Dr. Konasiewicz will, at his own expense, participate in and successfully complete the PROBE Ethics & Boundaries Program offered by the Centre for Personalized Education for Professionals, by receiving a passing evaluation or grade, without any condition or qualification.
xxiii. Dr. Konasiewicz will, at his own expense, participate in and successfully complete the International Pain & Spine Intervention Society (IPSIS) Cervical Bio-Skills Lab course.
xxiv. Dr. Konasiewicz shall complete the Professional Education listed above within three (3) months of the date of this Order or, if no satisfactory program is available by the time, by the first possible opportunity thereafter.
xxv. Dr. Konasiewicz will provide proof of his successful completion of the Professional Education to the College, including proof of registration and attendance and participant assessment reports, within one (1) month of completing it.
Reassessment
xxvi. Approximately six (6) months after completion of the Clinical Supervision as set out above in subparagraphs 2.b.ii. to xx., and completion of the Professional Education as set out above in subparagraphs 2.b.xxi. to xxv., Dr. Konasiewicz will submit to a reassessment of his interventional pain practice (“the Reassessment”) by an assessor or assessors selected by the College (the “Assessor”). The Reassessment shall include a chart review of a minimum of fifteen (15) patient charts, and may include direct observation of Dr. Konasiewicz’s care, interviews with Dr. Konasiewicz, colleagues and co-workers, feedback from patients, and any other tools deemed necessary by the College.
xxvii. Dr. Konasiewicz will co-operate fully with the Reassessment, conducted under the terms of this Order.
xxviii. The Clinical Supervisor may receive and review the findings of the Assessor and may discuss with the Assessor any issues or concerns arising from the Reassessment.
xxix. The results of the Reassessment will be provided to Dr. Konasiewicz and reported to the College and the Reassessment may form the basis of further action by the College.
Monitoring
xxx. Dr. Konasiewicz must inform the College of each and every location at which he practices, delegates, or has privileges, including, but not limited to, any hospitals, clinics, offices, and any Out-of-Hospital Premises or Independent Health Facilities with which he is affiliated, in any jurisdiction (collectively the “Practice Location” or “Practice Locations”), within five (5) days of this Order. Going forward, Dr. Konasiewicz will inform the College of any and all new Practice Locations within five (5) days of commencing practice at that location.
xxxi. Dr. Konasiewicz will submit to, and not interfere with, unannounced inspections of his Practice Locations and patient records by a College representative for the purposes of monitoring his compliance with the provisions of this Order.
xxxii. Dr. Konasiewicz shall give his irrevocable consent to the College to make appropriate enquiries of OHIP, NMS and/or any person who or institution that may have relevant information, in order for the College to monitor his compliance with the provisions of this Order and shall promptly sign such consents as may be necessary for the College to obtain information from these persons or institutions.
xxxiii. Dr. Konasiewicz shall consent to the sharing of information between the Clinical Supervisor, Assessor, the Chief(s) of Staff (or a colleague with similar responsibilities) at his Practice Location(s) and the College as any of them deem necessary or desirable in order to fulfil their respective obligations.
xxxiv. Dr. Konasiewicz shall be responsible for any and all costs associated with implementing the terms of this Order.
xxxv. Dr. Konasiewicz will, prior to returning to practice, satisfy the requirements of the College’s Changing Scope of Practice and/or Re-Entering Practice Policy.
Costs
- The Tribunal requires Dr. Konasiewicz to pay the College costs of $6,000.00 by March 9, 2026.