Sisters Cathy Stewart-Mott and Tracey Townsend at Cathy’s home in Woodstock, Ont., on May 21. Their brother Bradley Stewart died by MAID in September, 2024.Nick Iwanyshyn/The Globe and Mail
The family of an Ontario man who resumed breathing after being declared deceased during a medically assisted death say they are alarmed that the physician involved is allowed to continue providing MAID despite complaints against him.
Dr. James MacLean, a family physician in London, Ont., had to return to the home where loved ones of Bradley Stewart, 67, were gathered to complete the procedure after the man was found to still be alive.
Mr. Stewart, who had liver cancer, died at home in Beachville, Ont., in September, 2024. His family later complained to the province’s physicians’ regulator that Dr. MacLean failed to administer the complete drug regimen and that the doctor was insensitive and made what they described as a callous remark after returning to find Mr. Stewart still breathing.
After this incident and another complaint involving a 2024 MAID death in London, Dr. MacLean was investigated by the regulator, the College of Physicians and Surgeons of Ontario, which conducted a review of his practice and found “serious concerns.”
The college’s review determined that Dr. MacLean displayed a lack of judgment and focused on urgency versus process, including by using a backup MAID medication kit after the one he ordered for Mr. Stewart wasn’t ready when he went to collect it from the pharmacy.
The names of the complainants and the two patients who died were not made public by the college. The Globe and Mail confirmed their identities through interviews with family members. Both families said they believe the college’s sanctions against Dr. MacLean were too lenient.
Dr. MacLean did not respond to phone messages, e-mails or a letter detailing The Globe’s questions about the complaints and the college’s findings. A staff member at his London practice said Dr. MacLean declined to comment. In documents reviewed by The Globe, he defended his MAID practice and agreed to take steps to improve it. He stated that he used his best judgment and sought to honour his patients’ wishes.
In relation to Mr. Stewart’s death, the college’s Inquiries, Complaints and Reports Committee this spring issued Dr. MacLean a caution and accepted his voluntary undertaking to comply with practice restrictions. These include six months of clinical supervision and unannounced inspections of his practice locations and patient records.
Bradley Stewart died at home in September, 2024. In this family photo taken approximately a year before his death, he holds a photo of his father at the Legion in Beachville, Ont.Supplied
Tracey Townsend, one of Mr. Stewart’s three sisters, said the college’s sanctions did not go far enough, and that the family plans to appeal the decision.
“What happened was traumatic and unacceptable,” she told The Globe. “We would like to see policy change. The way MAID is done right now is not safe enough.”
A caution – in which a doctor must appear before the committee to receive direction about specific issues – is not disciplinary action but rather a remedial step the committee can take if it is concerned about a physician’s practice or conduct.
Dr. MacLean was also cautioned after a review of the London death of Thomas Dillon in 2024. Dr. MacLean assessed Mr. Dillon for MAID outside of a Tim Hortons, exchanged dozens of text messages with Mr. Dillon and drove him to the MAID location – conduct the college said crossed boundaries and risked looking like coercion.
Dr. MacLean was issued a third caution following a broader investigation into his general practice, which found that his conduct “exposes or is likely to expose patients to harm or injury in five out of twenty [patient] charts reviewed,” a decision this spring by the inquiries committee said.
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Two of Mr. Stewart’s sisters spoke to investigators for the college and the coroner’s office, as well as The Globe. The Globe also spoke to the third sister and another relative about the events. The sisters said they supported their brother and were all present when he received MAID, but the experience has left them with concerns about oversight.
On Sept. 25, 2024, Dr. MacLean was summoned to provide MAID to Mr. Stewart, who had become unresponsive but had signed a waiver consenting to the procedure if he lost capacity.
Coroner’s records show the physician ordered a MAID medication kit from a pharmacy, but it was not ready when he arrived to collect it. He proceeded with a previously obtained kit instead of waiting for the new one.
At 10:15 a.m., Dr. MacLean administered a sedative but did not administer rocuronium, which causes the patient to stop breathing, because he could not locate it and because he felt it unnecessary given the patient’s frail state, the college’s decision says.
He listened to Mr. Stewart’s chest, reported no heart sounds and pronounced him dead at 10:18 a.m.
Mr. Stewart sits on his newly built deck, which his family says he enjoyed for a few months before he died, being outside and visiting with people who stopped by.Supplied
But Mr. Stewart’s palliative-care physician, standing in the doorway, observed his chest still rising, according to the coroner’s review. When the palliative-care doctor raised the concern, Dr. MacLean said he could not hear heart sounds and considered Mr. Stewart deceased, the review states. He left the home 10 minutes later.
According to the review, a friend saw that Mr. Stewart was still breathing.
“My sister Tracey could hardly breathe, she was so upset,” Karen Stewart, Mr. Stewart’s eldest sister, said in an interview. “It didn’t work. It didn’t work,” she recalled her saying. “He’s still alive.”
According to the coroner’s review, a family friend contacted Dr. MacLean at 10:44 to advise him that Mr. Stewart was still alive. Dr. MacLean then returned.
Ms. Townsend alleged in her complaint that he entered smiling and said: “Well, this is a first, is he still breathing?”
Another of Mr. Stewart’s sisters, Cathy Stewart-Mott, told the coroner’s investigator that Dr. MacLean tapped her brother on the forehead and said: “This is on both of us – me for my misstep, and you for being so strong.” The coroner’s review does not note a response from Dr. MacLean on this comment.
Dr. MacLean administered a complete MAID kit and pronounced Mr. Stewart dead a second time at 11:16 a.m.
He told the college the situation was urgent and stressful and that he believed asking whether the patient was still breathing was reasonable in the circumstances. He said he did not intend the remark to be callous.
He said he does not believe the delay in completing the procedure caused Mr. Stewart any suffering.
Ms. Townsend said she retreated to a room upstairs after the failed procedure. In her complaint to the college, she alleged Dr. MacLean entered the room without knocking and refused her repeated requests to leave until her husband told him to do so.
Ms. Townsend alleged that Dr. MacLean offered her “something to help [her] relax” while shaking an unlabelled medication bottle at her.
Dr. MacLean denied to the college that he entered Ms. Townsend’s room uninvited or offered unidentified medication. He said a family member asked him to speak with her because she was distressed, and that he brought Ativan in case it was helpful, but left immediately when asked.
The college said given the competing versions of events, it “cannot come to a definitive conclusion about some specifics of these concerns.”
Cathy Stewart-Mott sits with Bart and Jade, two of the chihuahuas that belonged to her brother.Nick Iwanyshyn/The Globe and Mail
Dr. MacLean told investigators the situation was more stressful than usual, and different from most MAID provisions because he did not have nursing assistance owing to the urgency of the request.
He acknowledged the standard of care would have been to wait for the pharmacy to prepare the MAID kit and said not having all medications ready was a mistake. He said he was under a lot of stress at the time and was “not as meticulous as usual.”
The college’s register shows that Dr. MacLean’s licence has been subject to conditions since Oct. 1, 2025, while the inquiries committee investigated the complaints. Records reviewed by The Globe state that Dr. MacLean has been practising under supervision since October. Following the college’s findings this spring, Dr. MacLean agreed to a six-month supervision period, beginning April 15, 2026, and other monitoring requirements.
Once the supervision period is over, Dr. MacLean will submit to an assessment, which will rely on chart reviews and may include feedback from patients and, potentially, direct observation of care.
Ms. Townsend said in an interview the events surrounding her brother’s death left lasting emotional scars. Her physician diagnosed her with post-traumatic stress disorder and prescribed sleeping medication. She took a three-month leave from work.
Ms. Stewart-Mott said her brother – who was known as “Stewie” to loved ones and worked at a cardboard box manufacturer for 47 years – hosted big, rowdy Christmas dinners, barbecues and pig roasts. He was a lay leader with his church and ran a snowmobile club out of a shed on his property, where friends would gather around a woodstove before heading onto trails cut through the surrounding farmland.
The circumstances of his death, Ms. Stewart-Mott said, felt “like an affront to the person he was.”