Thomas Dillon's MAiD assessment took place outside a Tim Hortons after a psychiatrist had raised the option with him. He died at 45, his mental illness and addictions largely untreated. Bradley Stewart's MAiD procedure failed: he resumed breathing, and the provider returned to complete the procedure.

For years, pro-MAiD lobby groups have dismissed concerns about Canada's Medical Assistance in Dying (MAiD) regime — cases waved off as fake or isolated, arguments dismissed as histrionic. Yet even practitioners know better. As one practitioner mentioned in a recent Medical Law Review study on MAiD oversight: "There are stupid clinicians. We need to make sure it’s done well and oversight’s mandatory."

It’s time for Parliament to legislate real oversight.

As a former member of Ontario's MAiD Death Review Committee, I reviewed cases with substandard capacity assessments, influences from caregiver burnout or family pressure, and requests driven by fear of future decline, often occurring in the context of inadequate palliative and home-care supports that might have alleviated suffering. Investigative reporting by journalist Alexander Raikin found that Ontario's Chief Coroner flagged 428 compliance issues in MAiD cases since 2018, with not a single case referred to police.

Now an internal 2024 British Columbia MAiD Oversight Unit report, obtained through a freedom-of-information request by reporter Terry O'Neill, adds an independent signal from the other side of the country, and points in the same direction.

An earlier FOI investigation, also reported by O'Neill, already found how thin MAiD oversight was in B.C. The Ministry of Health confirmed that its MAiD Oversight Unit does not investigate wrongdoing; it only reviews the documentation practitioners submit, and its referrals to a regulatory college or to police "do not represent allegations of misconduct." A briefing note prepared for the deputy health minister argued the unit should not be too strict about reporting infractions, warning that doing so could discourage practitioners from providing MAiD given high demand.

The new report reflects this. In 2024, 51.9 per cent of the reportable MAiD case outcomes — 2,126 cases — required follow-up by the unit, with 2,807 total errors, meaning some cases contained multiple errors. Many were classified as "missing or incomplete non-critical reportable information.” That does not mean half of MAiD cases failed to meet the Criminal Code, but neither is this just paperwork. Among the errors, 353 cases were serious enough to require formal education of practitioners or pharmacists on legal requirements and professional standards. And a significant share of the required follow-up was flagged administratively, related to the very sections of the reporting forms meant to protect patients: decision-making capability, eligibility conclusions, the right to withdraw, safeguards for patients whose deaths are not reasonably foreseeable, informed consent. Up to a quarter of provincial cases involved these types of reporting issues.

The report is also candid about the system’s limits. High caseloads left little room for policy work or for acting on the lessons its own reviews surfaced. An oversight body without the capacity to notice problematic trends, educate practitioners, and ensure safeguards are applied consistently cannot do its job.

British Columbia's report examines its oversight system. Ontario's MAiD Death Review Committee publishes statistics on both MAiD recipients and deidentified individual cases. Yet the provinces' conclusions converge: compliance is failing, eligibility is not being properly assessed, and safeguards are not being enforced.

When Parliament acts on the recommendation to halt the planned expansion of MAiD to mental illness as a sole underlying condition, it should go further. It should mandate independent oversight bodies with the obligation, resources, and teeth to enforce compliance. It should also legislate a real-time pause mechanism, so a family's or clinician's concerns trigger independent review by qualified medical and legal authorities before a death, not after.

In every other area of medicine, when something goes wrong, we investigate, we learn, and we change our practice. MAiD is a life-ending intervention and wrongful deaths can never be corrected — and yet we have chosen to police it the least. A death cannot be appealed. The oversight has to come first.

Ramona Coelho, MDCM, CCFP, is a senior fellow at the Macdonald-Laurier Institute, an adjunct research professor of family medicine at the University of Western Ontario’s Schulich School of Medicine and Dentistry and co-editor of “Unravelling MAiD in Canada: Euthanasia and Assisted Suicide as Medical Care.”