Infection Prevention and Control (IPAC) Investigations

Hamilton Public Health may become aware of a potential IPAC lapse through:

• Complaints from patients, clients, residents, or members of the public 
• Referrals from regulatory colleges 
• Reports from health care providers or facilities 
• Communicable disease surveillance 
• Referrals from other public health units or government agencies 

Not all complaints result in an IPAC lapse being identified.

When a potential IPAC lapse is reported, Hamilton Public Health may:

• Conduct an on-site inspection 
• Review infection prevention and control practices 
• Assess cleaning, disinfection and sterilization procedures 
• Review policies, procedures and quality assurance records 
• Interview staff and operators 
• Consult with subject matter experts, including Public Health Ontario 
• Determine whether an IPAC lapse occurred

Initial Report

• Premises/Facility under Investigation (name & address): Dentistry At Fennell & Ottawa 1134-A Fennell Ave. East, Hamilton, ON L8T 1S5
• Type of Premises/Facility: Dental Clinic
• Date the Board of Health became aware of the IPAC lapse: February 20, 2025
• Date the IPAC lapse was linked to the premises/facility: February 20, 2025
• Date of Initial Report Posting: March 5, 2025
• Date of Initial Report update(s) (if applicable): N/A
• How did the Board of Health become aware of the potential IPAC lapse? Complaint
• Summary Description of IPAC Lapse:
  • Insufficient evidence of proper sterilization
  • Inadequate reprocessing records

IPAC Lapse Investigation

• Did the IPAC lapse involve a member of a regulatory college? Yes, Royal College of Dental Surgeons of Ontario
• If yes, was the issue referred to the regulatory college? Yes
• Were other stakeholders notified? (e.g. Ministry): Yes, Ministry of Health
• Description of the corrective measures required and/or implemented:
  • On February 20, 2025, the following corrective measures were required:
    • Dental appointments were cancelled,
    • The clinic was instructed to reprocess all reusable equipment and ensure sterilization follows best practices, including proper cleaning, use of Class 5 chemical indicators and biological indicators, and record keeping.
    • Ensure sterilization pouches are appropriately labelled,
    • Ensure efficacy logs for ultrasonic cleaner are appropriately maintained as per PIDAC best practices,
    • Ensure one-way workflow from dirty to clean in the reprocessing area,
    • Provide alcohol-based hand rub at the reprocessing sink and dedicate the sink for reprocessing only,
    • Staff to complete Public Health Ontario modules – Reprocessing in the Community,
    • Ensure gowns for personal protective equipment are on site,
    • Ensure current SDS are on site for cleaning and disinfecting products.
• Date and list of any Order(s) or Directive(s) that were issued to the owner/operator (if applicable):
  • Verbal Section 13 Order given February 20, 2025
  • Written Section 13 Order given February 21, 2025
• Additional Comments:
  • Due to the absence of readily available patient contact lists, a Media Release was issued to notify patients.
  • The office has been instructed to post a patient notification letter, provided by Hamilton Public Health Services, to their office door and reception desk.
  • The office was advised to discard/remove items that are no longer used and declutter the office.

Final Report

• Date of Final Report Posting: April 11, 2025
• Date and list of any Order(s) or Directive(s) that were issued to the owner/operator (if applicable):
  • Verbal Section 13 Order given February 20, 2025
  • Written Section 13 Order given February 21, 2025
• Brief description of corrective measures taken:
  • On February 21, 2025, the following corrective measures were implemented and verified by Hamilton Public Health Services:
    • Sterilization processes follow best practices, including proper cleaning, use of Class 5 chemical indicators and biological indicators, and proper record keeping.
    • Sterilization pouches are appropriately labelled,
    • Efficacy logs for ultrasonic cleaner are maintained in accordance with PIDAC best practices,
    • A one-way workflow from dirty to clean is established in the reprocessing area,
    • Alcohol-based hand rub (ABHR) is available at the reprocessing sink, and there is a dedicated sink for hand hygiene
    • Gowns are available on-site as part of the required personal protective equipment (PPE).
  • On February 24, 2025, the following corrective measures were implemented and verified by Hamilton Public Health Services:
    • Staff completed the Public Health Ontario (PHO) module Reprocessing in the Community, and a certificate of completion has been provided.
    • Current Safety Data Sheets (SDS) have been initiated and are available on site
• Date all corrective measures were confirmed to have been completed: February 24, 2025
• Additional Comments: Due to the absence of readily available patient contact lists, a Media Release was issued to notify patients. See the Media Release on the City of Hamilton’s website here. 

If you have any further questions, please contact: 
Kyle Snooks, Manager
Infection Prevention and Control Program, Hamilton Public Health
905-546-2063 or [email protected]

Initial Report

• Premises/Facility under Investigation (name & address): SUGO - Specialized Ultrasound in Gynecology and Obstetrics - Ultrasound Clinic 305-200 James Street South Hamilton, ON L8P 3A9
• Type of Premises/Facility: Medical Diagnostic Imaging Centre
• Date the Board of Health became aware of the IPAC lapse: June 12, 2026
• Date the IPAC lapse was linked to the premises/facility: June 16, 2026
• Date of Initial Report Posting: August 20, 2026
• Date of Initial Report update(s) (if applicable): N/A
• How the Board of Health become aware of the potential IPAC lapse: Complaint
• Summary Description of IPAC Lapse:
  • Improper reprocessing of critical equipment/devices
  • Improper reprocessing of transvaginal ultrasound probes
  • Lack of one-way workflow in the reprocessing area, including no physical separation between contaminated and clean areas
  • Lack of documented reprocessing records

IPAC Lapse Investigation

• Did the IPAC lapse involve a member of a regulatory college? Yes, College of Physicians and Surgeons of Ontario
• If yes, was the issue referred to the regulatory college? Yes
• Were other stakeholders notified? (e.g. Ministry): Yes, Ministry of Health and Public Health Ontario
• Description of the corrective measures required and/or implemented:
  • On June 16, 2026, the following corrective measures were required:
    • Cease and desist all sterilization within the premises until the sterilization process has been approved by Hamilton Public Health.
    • Ensure staff responsible for reprocessing complete education and training appropriate to their reprocessing responsibilities.
    • Cease the use of multi-use lubricating gel for transvaginal ultrasound probes.
    • Ensure that the clinic complies with the Infection Prevention and Control Checklist for Clinical Office Practice: Reprocessing of Medical Equipment/Devices (as current) and published by Public Health Ontario.
• Date and list of any Order(s) or Directive(s) that were issued to the owner/operator (if applicable):
  • Verbal Section 13 Order given June 16, 2026
  • Written Section 13 Order given June 18, 2026
• Additional Comments: Clinic replaced re-usable medical instruments with single-use devices.

Final Report

• Date of Final Report Posting: August 20, 2026
• Date and list of any Order(s) or Directive(s) that were issued to the owner/operator (if applicable):
  • Verbal Section 13 Order given June 16, 2026
  • Written Section 13 order given June 18, 2026\
• Brief description of corrective measures taken:
  • On July 15, 2026, the following corrective measures were implemented and verified by Hamilton Public Health:
    • Clinic is now using sterile, single-use lubricating gel packages for transvaginal ultrasound probes.
    • Reprocessing and sterilization processes follows current best practices.
    • Documentation logs for reprocessing and sterilization have been implemented.
  • On July 23, 2026, the following corrective measures were implemented and verified by Hamilton Public Health:
    • Staff responsible for reprocessing have completed education and training appropriate to their reprocessing responsibilities.
• Date all corrective measures were confirmed to have been completed: July 23, 2026
• Additional Comments: N/A

If you have any further questions, please contact:
Kyle Snooks, Manager
Infection Prevention and Control Program, Hamilton Public Health
905-546-2063 or [email protected]

Not necessarily. An IPAC lapse indicates that a deviation from best practices occurred. The risk to patients varies depending on the circumstances of the investigation.

An IPAC lapse means that a problem with infection control practices was identified. It does not necessarily mean that an infection was transmitted or that anyone was exposed to an infectious disease. Many IPAC lapses are identified before any illness is known to have occurred. Public Health assesses each situation to determine the level of risk and whether any follow-up actions, such as patient notification, are needed.

Investigation timelines vary depending on the complexity of the concerns identified and the corrective actions required.

If Hamilton Public Health determines patient notification is necessary, efforts will be made to notify affected individuals.

Reports remain posted for 24 months from the date of initial posting.

Yes. Members of the public can report concerns to Hamilton Public Health by calling 905-546-2063 or emailing [email protected].

Yes, please visit hamilton.ca/FOI.

You can visit hamilton.ca/healthinspection