Regina girl, 5, survived '1-in-4 million' dental surgery mistake, expert says

A dental anesthesiologist at the University of Toronto who has studied the safety of sedation in dental clinics says mistakes such as the one that put a five-year-old Regina girl temporarily on life support are extremely rare.

Autumn Ferguson's lungs collapsed while receiving oxygen in the wrong way under general anesthesia in the recovery room, according to the Regina surgical centre's own admission. 

The girl had had some teeth pulled and got a couple of tooth caps installed at CDW Surgical Solutions on Aug. 19. The clinic has since admitted responsibility and apologized to Ferguson's parents. The incident is being reviewed by the College of Dental Surgeons of Saskatchewan. 

Dr. Carilynne Yarascavitch, a dental anesthesiologist at the Sunnybrook Health Sciences Centre and an assistant professor at the University of Toronto's faculty of dentistry, was part of an Ontario study that found the odds of serious injury during sedation in a dental clinic are low.

'Rare events'

"The incidence of a serious event like occurred in Regina was one in four million, so these are very rare events," Yarascavitch said. "The public should really be reassured that there is a lot of great care happening in out-of-hospital environments."

Yarascavitch says Canada has placed strict safety regulations on non-hospital clinics. Nevertheless, she says, human error can happen anywhere. 

"Access to care overall for dentistry, there is high demand and the access is poor, so being able to have care out of a hospital-based setting helps people to get the treatment that they need," Yarascavitch said. 

"It's actually quite safe to have dentistry done in an out-of-hospital environment with sedation." 

She says she hopes the results of any investigation will be shared with clinicians across Canada so they can make sure their teams don't make the same mistake. 

Dr Ken Ringaert, an anesthesiologist at CDW Surgical Clinic, told Ferguson's parents in a recorded conversation the incident happened when Autumn was hooked up to high-pressure oxygen without a relief valve.

Autumn was airlifted to Saskatoon and has spent most of the last seven weeks in hospital and seeing specialists. She no longer requires life support.

A brain scan did not detect damage but medical documents show the little girl has scarring between her vocal cords and trachea. She is still having trouble breathing while awaiting throat surgery in Edmonton to repair the damage. 

The Ministry of Health says private health clinics have to operate under the standards outlined in The Health Facilities Licensing Act. 

"These facilities are required to have a medical director in place to oversee the services provided," the ministry said in a statement.  It said the medical director is required to report any "critical incidents" to the College of Physicians and Surgeons of Saskatchewan. 

College reviewing incident

Brian Salte from the College of Physicians and Surgeons says his office did receive a report from CDW. 

"We're reviewing the information from the perspective of a root cause analysis to try to determine what went wrong here and what is necessary for that to be fixed," Salte said, adding the review will look at medical documents. 

He says the clinic has already made changes to avoid a repeat of the incident.

The college review is not the same as an investigation, he says, because the latter would look into whether an individual's conduct was unprofessional, which is not happening at this time. 

The College of Dental Surgeons of Saskatchewan is conducting a separate review of the incident. Once concluded it will decide whether to take the next step of launching an investigation.