Ontario’s weak oversight of med spas puts patients at risk

She was pronounced dead at a nearby hospital. A coroner later determined she had died from lidocaine toxicity.

The cream was a prescription anesthetic that was only supposed to be used by or under the supervision of authorized medical staff. The clinic’s medical director, however, was not involved in the procedure.

He was not in the building. In fact, he did not even learn about the woman’s death until the next day.

The November 2020 death is the subject of a $3-million lawsuit, in which the woman’s family accuses the clinic, Beautox Bar & Wellness Lounge, its medical director and others of negligence. The defendants deny any wrongdoing.

The woman’s death also exposes glaring holes in Ontario’s oversight of medical spas and beauty clinics that may put customers unwittingly at risk, a Star investigation has found.

Esthetic injectables such as Botox or fillers carry a range of risks from common side effects to serious infections. In Ontario, they can either be done by authorized health-care professionals or delegated by a licensed physician or nurse practitioner who can act as a beauty clinic’s medical director. When delegating a procedure, the licensed professional remains responsible for assessing customers and making sure their treatments are performed safely.

Medical directors can delegate these treatments to staff, and there is currently no explicit requirement the directors be on site or even nearby when the treatments are performed.

These loose conditions have given rise to a troubling trend: beauty clinics will pay doctors or nurse practitioners for nothing more than to list them as a medical director. Their names may appear on the clinics’ websites, giving the consumers an illusion of assurance. But in reality, the medical directors may have little to no involvement in the clinic’s day-to-day operations.

Within the industry, it’s been referred to as “renting a licence” — and it can be lucrative. Doctors told the Star that clinics offer to pay thousands of dollars per month for a medical director on paper.

It has opened up a floodgate for unsupervised medical procedures performed by unqualified people, industry experts say.

“If something is going to go wrong, it can go wrong within seconds to minutes, and it can be devastating,” said Dr. Ihab Matta, who has run a cosmetic clinic for more than 30 years.

“If a medical director is not there, well, the patient is in limbo.”

Provincial regulators are reviewing the rules around the delegation of medical procedures that are otherwise reserved for physicians and nurse practitioners, with the College of Physicians and Surgeons of Ontario proposing a new policy that would require physicians to be physically on-site to supervise delegates in most cases.

Esthetician Rachel Wong was the only worker at the Beautox clinic that November 2020 evening when the customer arrived for her first-ever microneedling.

Wong opened a tub of cream, a mix of local anesthetics lidocaine and tetracaine, and applied it to the woman’s face, chin, neck, chest, back and legs.

Details of what happened are contained in police records, a coroner’s report and a lawsuit filed by the woman’s sister and mother. The lawsuit does not disclose the woman’s name in order to protect her privacy. Its allegations have not been proven and the case remains before the court.

The woman first felt dizzy and light-headed. Wong suspected it was due to hunger and ordered food. When Wong returned from picking up food at the door, she found the woman lying on the bed feeling unwell. The woman told Wong she felt like the room was spinning. Soon after that her legs began twitching, then her whole body began seizing and she started vomiting.

The coroner found the woman died of lidocaine toxicity, noting that the concentration was too high.

Wong first called Nga Luu, owner of Beautox and a registered nurse, before dialing 9-1-1, the lawsuit alleges. When paramedics arrived, they found the woman on the floor beside the treatment bed, in the midst of seizure.

The lawsuit alleges the medical director, Toronto doctor Anthony Chen, prescribed excessive quantities of the lidocaine cream for the clinic and did not monitor how it was used, failed to properly supervise the clinic and the employees, and was wilfully blind to the improper use of lidocaine cream by the clinic employees.

“Nobody was at the clinic but the esthetician,” the deceased woman’s sister said in an interview with the Star. “If you had somebody who was qualified, even someone who knows first aid CPR like any of those things, I think they would recognize the signs and know what to do.”

“The angering part really for me is the fact that like all of this happened it’s like nobody seems to be held accountable for it.”

Chen, Luu and Wong all denied that they had breached any duty of care in their respective statements of defence.

In his court filing, Chen said the prescribed cream was to be used during Botox treatments, not microneedling, and he had delegated the use of it only to Luu.

As the clinic’s medical director, Chen said his duties included reviewing medical questionnaires filled out on the patient’s behalf, as well as being available for in-person or video consultations.

Chen’s statement of defence states that microneedling did not fall under the scope of his agreement with Beautox, so he had no involvement with those treatments. He had no physician-patient relationship with the woman and could not have known the anesthetic cream would be “misused.”

For the woman’s sister, the explanation feels insufficient. “For someone to say ‘I didn’t know’ is an incredible lack of professionalism, a lack of judgment and a total cop out on your responsibility as a medical director,” she said.

Chen did not respond to questions from the Star, including what compensation he received for being medical director at the Beautox clinic.

Neither Luu, the clinic’s owner, nor Wong responded to the Star’s questions.

In their respective court filings, the clinic owner, esthetician and the medical director all pointed their fingers at each other.

Luu’s statement of defence alleged that Wong provided the treatment to the victim in her capacity as an independent contractor, and blamed the incident on negligence of the victim herself and other defendants.

She also alleged in a crossclaim that the medical director and the esthetician should be responsible for damages should any be paid.

Wong, meanwhile, denied any wrongdoing on her part and sued Beautox and its owner in a crossclaim. During the incident, she alleged that she had followed all guidelines and directions of Beautox Bar where she was an employee since 2019. She alleged that Luu instructed her to schedule the treatment with the victim after hours and directed Wong to start the treatment without her presence.

The lawsuit was filed after the College of Nurses of Ontario decided to caution Luu over her authorization of the use of the prescription cream for microneedling. For the victim’s family, it was a “slap on the wrist.” The family unsuccessfully appealed the decision.

The problem, says Dr. Ashwani Singh, lies in the regulation.

“There should be a medical director who is a physician, who is trained in the esthetics, who can manage complications, and who should be on site,” said Singh, an Alberta-based veteran in the esthetic medicine industry who has called for stricter regulations around how esthetic injectables should be administered to patients.

Physicians are regulated through their respective provincial colleges. In Ontario, when a physician delegates a cosmetic procedure such as Botox or fillers, the CPSO generally requires the physicians to first establish a physician-patient relationship by conducting a clinical assessment. These assessments can be done on-site or remotely depending on the circumstances of the delegation.

Over recent years, the regulator’s complaints committee became aware of “a number of cases involving physicians who are delegating inappropriately,” including incidents where the “delegates are essentially operating independently,” according to the minutes of the CPSO’s May 2025 board of directors meeting.

Concerned its delegation regulations “may be providing too much flexibility,” in September 2025, the CPSO amended its policy to require physicians to clinically assess new patients prior to delegating a controlled medical treatment. When that is not possible, the physician’s assessment must take place within two business days of a new patient’s first encounter with the delegated staff member.

In March, the CPSO will vote on even stricter changes to the policy, which would require physicians to be on-site to supervise delegated staff members performing treatments. This policy change would also expressly prohibit physicians from leaving delegates to manage their practice independently.

The College of Nurses of Ontario, whose members include nurse practitioners, is also considering changes. Margaret Barng, a spokesperson for the CNO, told the Star that the college is “actively reviewing” the regulatory framework to provide clarity for nurses and the public, with updates expected this year.

“The esthetic industry continues to evolve, and CNO supports measures that enhance patient safety. Our commitment remains focused on safe, ethical practice and collaboration with system partners,” she said.

Kate Mazzucco, a Toronto personal injury lawyer who represents the woman’s family in the lawsuit, said this is far from an isolated incident in the esthetic sector.

“Serious outcomes may be relatively rare, but near-misses and non-fatal injuries are far more common than the public realizes,” she said.

Most of the time, she noted, patients don’t realize how little medical supervision is actually involved until something goes wrong.

Mazzucco said the problem doesn’t lie in a lack of rules but how clearly those rules are defined and how consistently they’re enforced.

In December 2023, a CNO committee reprimanded a registered practical nurse Emilie Richard for performing medical esthetic procedures without authorization by a medical director. Richard’s registration was suspended for four months.

The committee found the suspension period was warranted in order to send “a strong message to the profession” in which this type of misconduct had become more frequent.

Richard was found to have done Botox, dermal fillers and dermal threads to 16 patients at her home-based Ambea Med Spa in Mississauga between September 2018 and November 2020. At the time of the incidents, the spa’s medical director was never on-site for patient consultations or assessments.

Richard was not allowed to administer cosmetic injections without the medical director’s tele-assessment, and repeatedly failed to document, and obtain informed consent, according to the college’s decision.

Richard told the Star that her “issue with the college arose from a documentation error related to the app I use.” She said the consultation was indeed conducted, and the medical director “received a fee for it” but did not disclose how much they were compensated.

Since the suspension, Richard said she had met a consultant to ensure compliance with the CNO guidelines and passed four audits by a new doctor.

“After investing over $50,000 in legal fees and recognizing that the college intended to make an example of me due to the unprecedented nature of these allegations, I chose to move forward with my life,” she said in a statement.

“If your intent is to present me or the nursing profession in a negative light, I do not consent to that portrayal. I take great pride in my work and the safety of my patients is always my top priority.”

The call itself wasn’t surprising for Dr. Singh. The person on the other end of the phone was offering $4,000 a month to act as a medical director for a beauty clinic with no requirement to be involved in the day-to-day work.

Singh, a doctor who specializes in advanced aesthetic treatments, had received similar offers before, including one pitching an equity ownership of 50 per cent of a beauty clinic if he just allowed them to use his name as a medical director. But as he did each of those previous offers, Singh quickly turned it down.

As commonplace as these offers have become, it was nevertheless unnerving for Singh, who has grown increasingly concerned about the trend of absent medical directors in Canada’s esthetic sector.

“At the end of the day, it’s the safety of the patient that is being compromised,” he said.

In the GTA, the going rate for a medical director “renting” their licence is around $2,000 per month, according to one physician in the industry who asked not be named for fear of professional backlash.

Since they are not required to be on site — or anywhere near the clinic — there is nothing stopping someone from being the medical director of numerous clinics.

The Star found a nurse practitioner was listed as a medical director for at least six different beauty clinics located as far as 250 km apart from each other.

For the sister of the deceased patron of the Beautox clinic, there is only one reason a doctor or nurse practitioner would accept being a medical director for a clinic without being part of the patients’ treatments:

“It’s just a money grab.”

Dr. Singh and dozens of physicians across Canada have penned a petition letter to the federal government for stronger regulations for the esthetic injection sector.

“While the esthetic industry has flourished and offers many the ability to enhance their appearance and confidence, the current regulatory framework does not sufficiently safeguard patient safety and warrants urgent attention,” reads the letter, dated September 2024.

It noted, in some countries, only physicians are allowed to perform these procedures.

In Quebec, the medical regulator made an effort to stamp out off-site physicians delegating staff to perform certain treatments unsupervised.

In its 2020 practice guide of the Quebec College of Physicians, it requires the prescribing physician at an esthetic clinic to be accessible and available within 15 mins of an injection procedure to manage and monitor complications.

The college said that it was deeply concerned that the proliferation of practices of medical esthetic treatments such as Botox and fillers performed outside a medical clinic at beauty clinics, salons and spas.

The changes in Quebec are a start, the letter notes, “but more needs to be done and be standardized for all Canadian provinces and territories.”

The letter urged the federal health minister to consider implementing stricter oversight measures for non-physicians performing injections in cosmetic medicine, as well as required supervision by qualified professionals.

“With the appropriate measures, we can prioritize patient safety and uphold high medical standards as this industry continues to thrive.”

Clarification: This article has been updated to make clearer which licensed professionals are allowed to delegate treatments such as Botox injections.