Finding into death of Danielle Cadan

Contributing factors

• Administration of lignocaine 2% during tooth extraction
• Smoking history increasing oxidative stress
• Obesity as risk factor for oxidative stress
• Prolonged and difficult tooth extraction with fragmentation
• Inadequate discharge advice regarding warning signs of drug reactions and sepsis
• Lack of safety-netting instructions for when to seek emergency medical review

Coroner's recommendations

1. Written discharge advice following dental treatment should include explicit warning: 'All medications can cause side effects, and the medications you have received today as part of your dental treatment are no different, even if you've had them before'
2. Discharge advice should explicitly state warning signs: 'While most may be mild and pass quickly, if you feel very tired, weak, dizzy and this is concerning for you, please present to the Emergency Department for review. These could be signs of nothing at all or something serious, so it's best to get checked out.'
3. Patients should be counselled that even after previous uneventful exposures to medications, rare drug reactions can occur with standard therapeutic doses
4. Enhanced safety-netting on discharge should cover both rare drug reactions and rare complications such as sepsis following dental procedures
5. Medical records should include time stamps and clear identification of procedure performers and record authors