In Ibrahimova v. Cavanagh, 2025 ONSC 4808, the Ontario Superior Court of Justice considered whether emergency physicians met the standard of care by taking a conservative approach instead of urgently referring a 17-week pregnant patient who presented with vaginal bleeding and a “gush of fluid.” The patient ultimately became septic due to ruptured membranes and suffered life-altering injuries.
The case confirms four critical principles for establishing the standard of care in a medical malpractice action:
- the importance of precise diagnosis when a vague diagnosis obscures the true risk of a patient’s situation;
- the standard of care will generally require an immediate referral when a “watch and wait” approach risks a catastrophic outcome;
- physicians cannot rely on a conservative approach being the “common practice” when that practice is fraught with obvious risks;
- patient choice of treatment must be informed to be valid.
Factual Background
Ms. Ibrahimova, 17 weeks pregnant, presented to three different emergency physicians between May 3–6, 2019 with symptoms including vaginal bleeding and, at one point, a “gush of fluid.” Each time, she was diagnosed with “threatened miscarriage” or “second trimester bleed,” and was discharged without referral to an obstetrician. She was told to “watch and wait” and return if her symptoms escalated.
Ms. Ibrahimova was in fact suffering from ruptured uterine membranes which led to a catastrophic infection. On May 7, 2019, she returned to the hospital in septic shock. She suffered catastrophic injuries including a stroke, amputations, and kidney failure.
The Plaintiffs’ position was that had Ms. Ibrahimova been referred to an obstetrician (particularly on May 4, 2019) and informed of the grave risk of her condition, she would have chosen treatment, even if it meant terminating her pregnancy, and this would have prevented her injuries.
Competing expert opinions on the Standard of Care
Both sides called qualified emergency physicians, who disagreed on what the applicable standard of care was in the circumstances.
The Plaintiffs’ experts emphasized that ruptured membranes present an entirely different risk profile than threatened miscarriage. A “gush of fluid” should have triggered immediate suspicion of rupture. Because ruptured membranes provide a pathway for infection, the standard of care required immediate referral to an obstetrician who would have instituted antibiotic treatment and performed a dilation and evacuation (D&E) procedure. A D&E unfortunately would have terminated the pregnancy but would have significantly reduced the chance of infection spreading.
The Defence expert argued that Ms. Ibrahimova’s case fit within a “continuum” of threatened miscarriage and that the explicit diagnosis of rupture of membranes was not necessary in her case. Therefore, expectant management—monitoring and discharge without urgent referral—was reasonable. He suggested that her wish to continue the pregnancy supported this conservative approach. He framed this as reflecting the “common practice” of community physicians.
Court’s rejection of the Defendant’s standard of care
The Court rejected the defence framing, and made the following key points:
- The standard of care required the precise diagnosis of ruptured membranes: The Court found that a “gush of fluid” was a clear indicator of ruptured membranes. The defendants’ failure to recognize this, and their persistence in diagnosing threatened miscarriage, was unreasonable.
- Urgent referral was required: Given the risks associated with ruptured membranes, the proper course was referral to an obstetrician on May 4. This was a novel and high-risk presentation, requiring specialist input.
- “Common practice” was no defence: The Court found that the standard of care proposed by Dr. McMurray was “not at all responsive to the risk presented by ruptured membranes”.
Moreover, even if community physicians did routinely manage such cases without referral, that practice was unsafe and “fraught with obvious risks”. Even if that was the common practice, conformity would not exonerate the Defendants.[1]
Causation
The Court found that had Ms. Ibrahimova been referred to an obstetrician on May 4, she likely would have been seen the same day. Moreover, while she expressed a desire to save her pregnancy, this was before being advised of the grave risks.
Both Ms. Ibrahimova and her husband testified that with proper counselling, she would have elected treatment, even if this meant termination. Had this occurred, the Court found Ms. Ibrahimova would not have proceeded to sepsis.
Important takeaways
- Diagnostic precision is critical
The Court found “threatened miscarriage” and “ruptured membranes” are not interchangeable or simply part of a “continuum” as the defence proposed. The diagnosis of ruptured membranes was required in the circumstances, and failing to make it obscured the grave risk faced by Ms. Ibrahimova.
- Referral to specialists is necessary in high-risk situations
In novel or high-risk scenarios, the standard of care often demands referral. Lawyers should probe whether defendants had access to specialists (even by phone) and whether they used those resources.
- “Common practice” is not always safe practice
While the finding in this case was ultimately that the Defence’s standard of care was not common practice, the Court’s comments in the alternative are an important example of a “common practice” that would still breach the standard of care due to being “fraught with risk”. Defendants cannot hide behind routine community practice if that practice exposes patients to obvious risks.
- Patient choice must be informed
While this was not an “informed consent” case per se, it is an important reiteration of the necessity of patients being fully informed. Expressions of wanting to continue a pregnancy (or similar patient choices) carry little weight unless the patient has been fully advised of risks.
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