Quebec coroner cites serious failings in woman’s death after cosmetic surgery

A Quebec coroner has found that the death of a 48-year-old woman who underwent cosmetic surgery at a private clinic in Westmount was avoidable.

In a recently released report, Coroner Karine Spénard identified several egregious failures by the surgeon and medical staff present during the Nov. 1, 2022, plastic surgery and issued recommendations.

During her investigation, Spénard found that the woman was supposed to be put under local anesthesia but was put under general anesthesia, which requires the presence of an anesthesiologist. However, there was no anesthesiologist present.

The surgery was performed by Dr. Sandra McGill, the owner of the clinic, with the assistance of a respiratory therapist, an operating room nurse, an outpatient nurse, and a scrub nurse.

Additionally, the report also states the respiratory therapist administered sufentanil, a synthetic opioid considered to be seven to 10 times more potent than fentanyl, breaking protocol and without informing McGill.

The coroner noted that since the death, the respiratory therapist has not been registered with the Professional Order of Respiratory Therapists (Ordre professionnel des inhalothérapeutes du Québec).

“In this case, the syndic was indeed notified of the situation, and a disciplinary hearing was held in 2024, at the end of which the respiratory therapist pleaded guilty to the offenses with which he was charged,” Spénard wrote.

The report also states that the outpatient nurse was not registered with the Quebec Order of Nurses (Ordre des infirmières et infirmiers du Québec).

“She has extensive experience working as a nurse in another country with clinical care similar to Canada’s but is not authorized to work as a nurse in Quebec or to use the title,” the report states.

“However, she presented herself to patients as a nurse and was hired as such by the medical clinic. She attended X’s surgery and was the one who informed the anesthesiologist of the situation around 7 p.m., in addition to administering intravenous medication.”

A second individual who was also acting as a nurse during the surgery was not registered with the order, the coroner said.

Moreover, the coroner said the professionals involved in the case were blaming each other regarding their respective responsibilities.

According to the report, the Mirabel woman’s cause of death was severe cerebral anoxia, which occurs when the brain is completely deprived of oxygen.

“Out of respect for the ongoing disciplinary process, and while the Disciplinary Council of the Collège des médecins du Québec is deliberating, Dr. McGill will not be making any comments at this time,” the clinic said in a statement to CTV News.

The Quebec College of Physicians is currently conducting its own investigations and has accused McGill of allowing employees to identify themselves as nurses when they were not, noncompliance in maintaining medical records, and failure to adequately inform a patient or obtain consent for treatment.

The coroner has recommended the College of Physicians review the quality of professional acts provided during the surgery and, when put in place, appropriate measures to improve the quality of patient care.

She also recommended that the Quebec Order of Nurses take appropriate measures to ensure the protection of the public in light of the death.