Finding into death of Angela Cuthbert
Deceased
Angela Cuthbert
Demographics
59y, female
Date of death
2022-07-24
Finding date
2023-07-19
Cause of death
complications of abscesses following dental extraction, in a woman with cerebral palsy
AI-generated summary
Angela Cuthbert, a 59-year-old woman with severe cerebral palsy and dysphagia, died from complications of abscesses following extraction of all 14 teeth under general anaesthetic. Surgery occurred 20 June 2022; she developed laboured breathing on 5 July; presented with jaw swelling and distress on 13 July; and underwent drainage of extensive oral abscesses on 14 July. She subsequently developed aspiration pneumonia and died 24 July 2022. The coroner found the death was from natural causes and not preventable. Key clinical lessons include: patients with dysphagia require modified post-operative instructions specific to their swallowing impairment; careful post-operative monitoring is essential after oral surgery in vulnerable populations; and prompt escalation of respiratory symptoms and new fever is critical. The inadequate record-keeping between 22 June and 5 July delayed recognition of deterioration.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- oral abscesses with extensive fluid collections on floor of mouth post-extraction
- aspiration pneumonia secondary to dysphagia and dental surgery
- inadequate post-operative care instructions not tailored to patient's dysphagia
- inadequate record-keeping during post-operative period (22 June to 5 July 2022)
- delayed recognition of clinical deterioration due to poor documentation
- reliance on oral handovers between support staff
Coroner's recommendations
- Develop post-operative care instructions specific to patients who have undergone removal of all teeth
- Modify post-operative instructions to accommodate patients with dysphagia and aspiration risk
- Improve record-keeping for persons in disability accommodation, particularly during critical post-operative periods
- Reduce reliance on oral handovers between support staff and implement written documentation protocols
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