The Quebec coroner’s report concludes that a 48-year-old woman’s death after cosmetic surgery at a Westmount private clinic on November 1, 2022, was avoidable. Coroner Karine Spénard identified multiple mistakes by the surgeon and medical staff.
The patient was meant to receive local anesthesia. Instead, she was given general anesthesia—a procedure that legally requires an on-site anesthesiologist. No anesthesiologist was present during the operation.
Unlicensed Staff and Unauthorized Drug Administration
Dr. Sandra McGill, the clinic’s owner and operating surgeon, was assisted by respiratory therapists and nurses. The report states that a respiratory therapist injected the patient with sufentanil, a powerful synthetic opioid, without notifying Dr. McGill. Sufentanil is seven to ten times more potent than fentanyl.
Investigators found that this respiratory therapist was not registered with the Professional Association of Respiratory Therapists of Quebec at the time of the incident. A disciplinary hearing in 2024 resulted in a guilty plea for the therapist’s professional offences.
The report also revealed that two women who acted as nurses during the surgery held no valid nursing registration with the Ordre des infirmières et infirmiers du Québec. One provided clinical care, administered an IV, and briefed the (absent) anesthesiologist, all while presenting herself as a registered nurse.
Blame Shifting and Cause of Death
According to the coroner, the clinic staff members blamed each other over their roles and responsibilities. The patient’s death was caused by severe cerebral hypoxia—a total lack of oxygen to the brain.
Dr. McGill’s clinic released a statement to CTV News, saying she will not comment while the Faculty of Medicine of Quebec’s Disciplinary Committee is deliberating.
Ongoing Investigations and Recommendations
The Faculty of Medicine of Quebec is conducting an internal review. It alleges that Dr. McGill allowed unlicensed staff to call themselves nurses, failed to follow medical record-keeping regulations, and did not properly inform patients or obtain consent.
Coroner Spénard made several key recommendations:
The Faculty of Medicine should review surgical conduct standards and take measures to improve patient care.
The Quebec Nurses’ Association should enforce public safety measures for nursing practice.
These steps aim to prevent similar tragedies and ensure that only qualified professionals perform and assist in surgical procedures.
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