Coroner's Finding: SALMON Daniel Brindley

Contributing factors

• Delayed transfer from Queen Elizabeth Hospital to Royal Adelaide Hospital
• Transfer by private vehicle instead of ambulance resulting in no medical records accompanying the patient
• Failure to clearly communicate diagnosis of Ludwig's angina to the Royal Adelaide Hospital surgical and anaesthetic teams
• No pre-operative consultation between anaesthetist and surgeon
• Lack of awareness by anaesthetist of serious diagnosis at time of decision to extubate
• Premature extubation post-operatively in a patient with bilateral Ludwig's angina
• No discussion with surgeon about nature and severity of the condition before surgery
• Inadequate post-operative monitoring and failure to escalate when respiratory distress noted
• Delayed seeking of definitive dental treatment by patient over several months

Coroner's recommendations

1. Queen Elizabeth Hospital should review processes and guidelines to ensure that in all cases of transfer, whether by ambulance or private vehicle, appropriate medical notes accompany the patient to the receiving hospital
2. Minister for Health should remind the public of the importance of seeking timely treatment for signs of dental infection, as delayed treatment can allow infective processes to progress to life-threatening conditions such as Ludwig's angina