On Dec. 24, 2013, four patients at a Kitchener colonoscopy clinic became infected with hepatitis C.

It was several months before any of them realized it – and nearly a year before a second diagnosis allowed public health officials to link the cases to Tri-City Colonoscopy Clinic.

While nobody knows what happened to transmit the virus with complete certainty, it’s believed shared equipment is to blame.

A report prepared by Region of Waterloo Public Health says an undiagnosed patient likely brought the infection to the clinic that day.

After that, the report says, anesthesia vials that were improperly reused likely transmitted hepatitis C from patient to patient.

A malpractice lawyer representing one of the infected patients claims the incident speaks to a “fundamental concern” for patients’ safety.

“No one expects to go in for a colonoscopy and walk out with hepatitis C,” Rose Leto told CTV News.

Since the outbreak, Public Health Ontario has created new standards around vial use.

“The best thing to do is use single-dose vials,” Dr. Liana Nolan, Waterloo Region’s medical officer of health, said Wednesday.

The health unit has also asked the College of Physicians and Surgeons of Ontario to further assess the doctor involved, who no longer works at Tri-City Colonoscopy Clinic.