Godden,george 2011 08 31 14 50 44 877
Deceased
George Godden
Demographics
unknown
Date of death
2007-02-22
Finding date
2011-08-12
Cause of death
Lignocaine toxicity following dental surgery with atherosclerotic and valvular heart disease
AI-generated summary
George Godden died at Prince of Wales Hospital on 22 February 2007 from lignocaine toxicity following dental surgery. His post-extraction gingival bleeding was treated with gauze soaked in co-phenylcaine spray, a medication indicated for nasal and pharyngeal use only. Lignocaine was systemically absorbed through the compromised gingival tissue, causing toxicity in a patient with pre-existing atherosclerotic and valvular heart disease. The coroner found the medication application inappropriate and recommended distribution of a standardized post-dental extraction bleeding protocol to all NSW hospitals and referral of the treating dentist (Dr T.) and nurse to the Health Care Complaints Commission for professional conduct review. This death was preventable with proper medication selection and protocol adherence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Inappropriate use of co-phenylcaine spray (indicated for nasal and pharyngeal use, not oral/gingival application)
- Systemic absorption of lignocaine through compromised gingival tissue and post-extraction bleeding site
- Application of topical anaesthetic to area of broken skin (gingival bleeding) contrary to product precautions
- Pre-existing atherosclerotic heart disease
- Pre-existing valvular heart disease
- Absence of standardized protocol for post-dental extraction bleeding management
Coroner's recommendations
- Provide the Prince of Wales Hospital protocol relating to management of post-dental extraction bleeding to all hospitals within NSW with a view to publication amongst clinical staff
- Provide the bulletin 'Co-phenylcaine Forte spray' to all hospitals within NSW with a view to publication amongst clinical staff
- The Health Care Complaints Commission to consider the professional conduct of Dr T. and Registered Nurse Shores for appropriateness
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