One Toronto pediatrician was cautioned in writing and another told to get informed consent from parents after 22-day-old Ryan Heydari bled to death following a circumcision in 2013.

Details about the complaints against the two physicians made to the College of Physicians and Surgeons, including their identities, would have been kept secret had Ryan’s parents not sought a review by an appeals panel. That is a level of secrecy that critics say must change, even as the college is promising to improve transparency.

Earlier this month, the Health Professions Appeal and Review Board (HPARB) upheld the decision made by the college’s inquiries, complaints and reports committee to “advise” Dr. Sheldon Wise, who performed the operation on Ryan following a referral by a family doctor, to document his consent procedure — including discussion of potential risks and complications around circumcision. Death following circumcision is rare, a three-member panel of the board noted.

The panel also found the committee’s order to be reasonable, that Dr. Jordan Carr, the North York General hospital pediatrician who saw Ryan after he started bleeding, should be cautioned in writing for “his failure to recognize the seriousness of the patient’s condition and to treat compensated shock.” Carr was also ordered by the committee to write a 2- to 4-page report on the possible complications of circumcision and on how to recognize and treat compensated shock.

The doctors’ lawyer, Andrew Parley, did not return requests for comment Monday. Carr and Wise could not be immediately reached by the Star.

Ryan, born on Jan. 3, 2013, was circumcised by Wise on Jan. 17, according to the HPARB decision. He bled at the office and suffered further bleeding once the family returned home. The parents called Wise, who advised them to take Ryan to North York General, and he told Carr to expect them, the ruling says.

“The baby’s condition became worse with decreased responsiveness, heart rate and oxygen saturation,” says the ruling. He was transferred the same day, in critical condition, to the Hospital for Sick Children, where he died on Jan. 25.

Wise told the complaints committee he routinely performs circumcisions, and the committee expressed no concerns about his technique or equipment, according to the HPARB decision. But it did feel that he should be obtaining and documenting informed consent before doing the operation.

In Carr’s case, the committee found that he assessed Ryan in a timely manner, but “overall, the committee was concerned by the lack of urgency and aggressiveness in (Carr’s) approach in this case, and his failure to recognize pending hypovolemic shock.”

None of this information can be found on profiles for Wise and Carr in the College of Physicians and Surgeons’ online registry, as the complaints against the doctors were made before the college changed its policies as to what information it releases to the public.

“I think most people would agree that where there was a death of a 22-day old baby, there should be public disclosure where there was criticism found with relation to care,” said medical malpractice lawyer Paul Harte, who is pushing for the college to release information about all complaints against doctors, including their identities and the disposition in each case.

College spokeswoman Kathryn Clarke said the penalty formerly known as a “written caution” no longer exists; only an oral caution, made by a panel of the complaints committee to the doctor. Since this year, this caution is included on the doctor’s profile in the college’s online registry.

But the committee can also choose to issue advice or recommendations to the physician, or request that the doctor work with the college on developing an educational plan. “Both outcomes are considered of low risk to the public, and therefore they are not included on the physician’s profile on the public register,” Clarke said.

Ryan’s parents, John Heydari and Homa Ahmadi, were seeking transparency when they appealed to HPARB, their lawyer, Brian Moher, told the Star.

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“We had Ryan circumcised for health reasons, based on the advice of our family doctor. We were initially very much against having Ryan circumcised, as we felt that Mother Nature had created us the way she had intended us to be,” they said in a statement read by Moher.

“Our family doctor convinced us though of the health benefits of this procedure, but we had no idea that the loss of Ryan’s life was one of the risks. The loss of Ryan, our only child, has made us realize that we cannot possess anything, even our hopes and dreams. We hope that this never happens to any baby, but losing your child is the only way to find out what effect this can have on your life.”