Dr. Luc Magne is registered with the College of Dental Surgeons (CDSBC) as a specialist in pediatric dentistry. He also owns and operates a dental facility located in Prince George (the facility).
Background
In December 2019, CDSBC received notice that a child had been admitted to hospital following an incident at the facility. At the time, the child was being treated under sedation by Dr. Magne, who was authorized to provide moderate sedation level 2. CDSBC also received a complaint from the patient’s mother about this incident.
CDSBC conducted an investigation including a site inspection of the facility by a team from the College of Physicians and Surgeons of BC. The inspection revealed significant issues including concerns about patients entering a deeper level of sedation than Dr. Magne was approved to provide. CDSBC accepted Dr. Magne’s undertaking that he would not provide any level of sedation and none would be provided in the facility until the matter was resolved.
A pediatric anaesthesiologist provided a review of 15 patient files, which identified further serious concerns relating to the sedation provided to those patients and the emergency preparedness of the facility.
The Inquiry Committee that oversees and directs complaint investigations directed the Registrar to issue a citation against Dr. Magne. A discipline hearing in Vancouver was scheduled for June 2022 but was cancelled when Dr. Magne made admissions and proposed a resolution under section 37.1 of the Health Professions Act.
Admissions
Dr. Magne has admitted to professional misconduct with respect to the child patient by failing to:
- perform and/or record required assessments prior to providing sedation
- ensure he had the necessary training, skills and/or equipment for pediatric airway management to allow rescue of the patient
Dr. Magne has admitted to professional misconduct with respect to multiple patients, in that he:
- provided sedation at the facility when it was not operating in compliance with CDSBC’s standards and guidelines for sedation
- continued dental procedures while allowing his patients to enter deeper levels of sedation than he was approved to provide
- failed to perform and/or record levels of consciousness during procedures or recoveries to pre-sedation consciousness prior to discharges and failed to conduct adequate monitoring
- failed to undertake and/or record diagnostic testing necessary to support a proper diagnosis and treatment plan
- administered oral ketamine without permission
- provided sedation to pediatric patients without a current certification in pediatric advanced life support or basic life support/CPR healthcare provider course
- allowed a [health professional other than a dentist or registered nurse] to administer oral sedation medication
Dr. Magne has admitted to professional misconduct with respect to the facility, in that he failed to:
- adequately maintain medication and equipment in the emergency mobile cart
- ensure staff were appropriately qualified and/or trained to assist with sedation and/or manage medical emergencies
- conduct mock emergency drills as required
- ensure required equipment was available during sedation
- adequately store restricted drugs
Resolution
The Inquiry Committee accepted Dr. Magne’s proposal and considered the issued an order (PDF) effective March 30, 2022. The order states that Dr. Magne:
- is permanently prohibited from:
- providing any level of sedation in any dental facility in BC; this practice limitation will appear on CDSBC’s online public register
- acting as the operator or director of the facility, or any other non-hospital facility that provides sedation
- being involved in management/directorship of the facility relating to sedation services or standards
- provide a list of all facility staff to CDSBC, and update CDSBC when changes occur
- pay a fine of $40,000
- pay $2,000 to CDSBC towards the costs of the investigation
- is reprimanded
In accordance with the order, Dr. Magne may continue to act as operator or director of the facility but only in relation to non-sedation issues. The facility may only provide sedation services if it is maintained in compliance with sedation standards, and a qualified dentist or medical practitioner acts as facility director and performs clinical directorship responsibilities. In this case, Dr. Magne must also include a statement on the facility’s website, and on informed consent documents given to patients, providing the name of the dentist or medical practitioner who is acting as the facility director and/or clinical director.
This resolves the disciplinary proceeding.
This notice is a summary of the consent order approved by the Inquiry Committee on March 30, 2022. Full details are available in the consent order package (PDF).