It took staff at a private plastic surgery clinic in Quebec too long to assist television producer Micheline Charest when she suffered complications after undergoing procedures in 2004, a coroner has concluded.

Charest, the co-founder of Cinar, died after six hours of surgery for a facelift and breast augmentation at the Clinique de chirurgie esthétique Notre-Dame in Montreal.

Micheline Charest, who died following plastic surgery in Montreal, was co-founder of an award-winning production company.
(CBC)

In a report released Wednesday, coroner Jacques Ramsay said her death, by cardiac arrest brought on by insufficient oxygen, could have been prevented — a conclusion that has prompted Quebec's health minister to call for tighter rule for private clinics.

Charest, 51, was in good health when she entered the clinic, but died of respiratory failure after she was left alone in a room, unconscious, without a breathing tube, the report revealed.

Ramsay's report highlighted several problems with Charest's medical treatment after her surgery.

• Her body temperature was not monitored correctly, and she was in a state of hypothermia.
• Her vital signs plunged after she was wheeled into the recovery room, either because the oximeter monitoring her oxygen levels was off, or wasn't set to alert mode. 
• A breathing tube inserted during surgery was removed while Charest was still unconscious. Once the breathing problems were noted, the anesthesiologist tried to reinsert it and revive her, but couldn't because her jaw was locked. Medication to relax her muscles should have been administered.
• The anesthesiologist called the plastic surgeon first, instead of calling 911.

Paramedics arrived on the scene 35 minutes after Charest stopped breathing, and were able to insert the breathing tube, but it was too late.

Ramsey is not blaming anyone in the case, but is recommending Quebec's Health Ministry monitor private clinics, and hold them to the same standards as public health services. 

He also said that anesthesiologists, no matter what their level, should receive training to update their skills in emergency situations. 

"When you have problems doing something, the unwritten rule is you call backup. And in this case, the best backup is Urgence Santé [ambulance service]."

Calls for safer plastic surgery

Ramsay's recommendation to clarify the status of private plastic surgery clinics was welcomed by Health Minister Philippe Couillard.

"I don't feel that all operations done in the domain of plastic surgery need the same level of scrutiny," said Couillard. "But certainly the cases that are done with general anesthesia obviously, probably need to be better looked after."

Couillard says new legislation (Bill 33) being finalized at the National Assembly will not only establish a greater role for private clinics in the health-care system, but will render plastic surgery safer.

"It's clear that a lot of activity now is done outside the hospital, and it's the normal evolution of technology in medicine. This also has to be better defined and regulated."

The clinic in question has already taken steps to train staff in resuscitation techniques, and introduced protocol that requires employees to call 911 in cases of emergency, an official said.

Charest co-founded the Cinar production company with her husband, Ronald Weinberg.

They created award-winning children's programming, including the popular Arthur and Caillou. The Quebec Security Commission later dismissed Charest and Weinberg from the company after financial irregularities were discovered.

With files from Presse Canadienne