Dr. Sandra McGill

By Dan Laxer
The Suburban

The death of a woman who had gone into a private Westmount clinic for elective cosmetic surgery was “preventable,” says a Quebec coroner.

“Actions were performed by unauthorized personnel,” the coroner’s report said. “Some alarms were deactivated or not heard.”

The woman, whose identity is protected throughout the coroner’s report, was from Mirabel. She went into surgery on November 1, 2022. She died 12 days later of severe cerebral anoxia, meaning her brain had been deprived of oxygen. According to the Bureau du coroner, the procedure was supposed to have been done under local anesthesia with minimal sedation, but the woman was put into “deeper sedation.”

The surgeon, Dr. Sandra McGill, is also the owner of the clinic where the surgery took place, Espace MD. Her assisting team included a respiratory therapist and three nurses.

Coroner Karine Spénard noted in her report that sufentanil, a synthetic opioid seven to 10 times stronger than fentanyl, had been administered. “I questioned the protocol applicable to the cosmetic surgery clinic regarding the use of this substance,” Spénard wrote in her report. “According to the surgeon, she did not authorize the use of sufentanil and was not informed of it.”

The surgery – liposuction, fat transfer, and scar revision – began 5:10 p.m. on November 1. Half an hour later, toward the end of the procedure, the respiratory therapist told McGill he could not get a reading on the oximeter. The patient’s hands were pale and cold. McGill, noting that the patient’s heart rate had slowed, instructed that she be intubated and put on medication.

The clinic’s anesthesiologist, who had already left for the day, was called to come back around 6:30 p.m. He returned at 7:00 and was told that the patient had suffered “a hypoxic and bradycardic event while under local anesthesia and sedation.”

The patient was transferred to the Montreal General Hospital where she was admitted to intensive care where she was diagnosed with “bilateral and symmetrical cerebral edema, consistent with hypoxic-ischemic encephalopathy.” Her condition deteriorated over the following days. Her family agreed that it was time to take her off life support. She died on November 13.

Spénard noted in her report that the respiratory therapist was not registered with the Ordre professionnel des inhalothérapeutes du Québec at the time. “A disciplinary hearing was held in 2024, at the end of which the respiratory therapist pleaded guilty to the offences with which she was charged.”

McGill pleaded guilty to two professional charges. The Collège des médecins du Québec is still investigating. n