Coronial
VICother

Finding into death of Angela Cuthbert

Deceased

Angela Cuthbert

Demographics

59y, female

Coroner

Coroner Simon McGregor

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.

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Specialties

oral and maxillofacial surgerydentistryintensive caregeneral practicedisability medicine

Error types

communicationsystem

Clinical conditions

cerebral palsydysphagiaaspiration pneumoniaoral abscessintellectual disability

Procedures

dental extractiongeneral anaesthesiasurgical drainage of abscesses

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

  1. Develop post-operative care instructions specific to patients who have undergone removal of all teeth
  2. Modify post-operative instructions to accommodate patients with dysphagia and aspiration risk
  3. Improve record-keeping for persons in disability accommodation, particularly during critical post-operative periods
  4. Reduce reliance on oral handovers between support staff and implement written documentation protocols
Full text

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