A Quebec coroner has ruled that a woman’s death following cosmetic surgery at a private Westmount clinic in 2022 was preventable. The investigation revealed serious failures at the Espace MD clinic, including the use of unlicensed staff and the administration of a powerful opioid without proper oversight.
The 48-year-old patient from Mirabel underwent liposuction, fat transfer to the breasts, and scar revision on November 1, 2022. The procedure, performed by Dr. Sandra McGill, was intended to be done under local anesthesia with sedation.
About 40 minutes into the surgery, the respiratory therapist noticed the patient’s oxygen levels were abnormal. The patient’s hand became cold and pale, and her heart rate slowed. Emergency measures were taken, including inserting a laryngeal mask to assist breathing. Although her vitals briefly stabilized, she never regained consciousness.
An anesthesiologist was not present during the operation and was only called at 6:30 p.m., arriving at 7 p.m. By that time, the patient showed signs of brain injury, including dilated pupils and hyperventilation. The anesthesiologist advised immediate transfer to hospital.
A nurse called 911 at 7:35 p.m., reporting the patient was likely oversedated and struggling to breathe. She was rushed to Montreal General Hospital where scans confirmed severe oxygen deprivation. Despite treatment, she never recovered and died on November 13 after her family agreed to withdraw life support.
The coroner’s report found the patient was given sufentanil—a powerful opioid up to 10 times stronger than fentanyl—without proper authorization or informing the surgeon. Additionally, two individuals acting as nurses during the procedure were not licensed to practice in Quebec, though one had international experience.
Dr. McGill has pleaded guilty to two professional charges related to the case. A six-week suspension and a $7,500 fine have been recommended. Quebec’s medical college continues to investigate the matter.
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