Finding into death of Michael Anderson
Deceased
Michael Peter Anderson
Demographics
36y, male
Date of death
2017-04-18
Finding date
2021-11-12
Cause of death
Cardiorespiratory arrest complicating propofol administration for endodontic procedure in a man with borderline cardiomegaly
AI-generated summary
Michael Anderson, a 36-year-old obese man (BMI 38.5), suffered cardiorespiratory arrest during a root canal procedure under conscious sedation with propofol administered by Dr S. in a dental office setting. He had undiagnosed borderline cardiomegaly. Despite appropriate immediate resuscitation, he did not survive. The coroner found that while propofol administration was appropriate, blood pressure was not documented during or before drug administration, contrary to best practice. The confined dental treatment room and patient obesity complicated emergency response. The coroner could not establish that documented blood pressure would have changed the outcome; asystolic arrest has only 15% survival even in hospitals. The procedure in a dental office setting was considered acceptable practice, and no adverse findings were made against clinicians, though documentation of vital signs monitoring was criticised.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Propofol administration
- Obesity (BMI 38.5)
- Borderline cardiomegaly with left ventricular hypertrophy
- Lack of documented blood pressure monitoring before and during propofol administration
- Confined dental treatment room limiting emergency response space
- Anaesthetic management in office-based dental setting
Coroner's recommendations
- The Australian and New Zealand College of Anaesthetists should develop guidelines around the use of conscious sedation/anaesthesia, including but not limited to Propofol, in the dental practice setting on patients within WHO Class II and Class III obesity
- The Australian and New Zealand College of Anaesthetists should use the circumstances surrounding Michael Peter Anderson's death as an educational tool for emphasising the importance of documenting vital signs following the administration of anaesthetic
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