Inquest into the Death of Myosotis Julianna MORIARTY
Deceased
Myosotis Julianna MORIARTY
Demographics
68y, female
Date of death
2010-12-18
Finding date
2015-02-09
Cause of death
acute gastrointestinal haemorrhage secondary to bilateral dental extraction
AI-generated summary
A 68-year-old woman on long-term warfarin therapy for a prosthetic aortic valve died from acute gastrointestinal haemorrhage following dental extraction. The dentist failed to obtain an INR test within 24 hours of the procedure and did not use the tranexamic acid protocol recommended by Therapeutic Guidelines for patients on warfarin undergoing extractions. While causation could not be established with certainty, the coroner found the management deficient. The dentist provided only verbal post-operative instructions to an anxious patient in a high-risk category, without written instructions emphasizing bleeding risks or emergency contact procedures. The coroner emphasised that written instructions should accompany verbal instructions, particularly for high-risk patients, and that dentists should view guideline-recommended precautions as integral rather than backup measures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to obtain INR test within 24 hours of procedure
- failure to use tranexamic acid protocol as recommended by Therapeutic Guidelines
- provision of verbal-only post-operative instructions without written documentation
- failure to emphasise need for emergency treatment in event of ongoing bleeding
- lack of written emergency contact procedures
Coroner's recommendations
- Refer evidence of Dr C.'s conduct to the Dental Board of Australia under section 50 of the Coroners Act 1996
- Provide written post-operative instructions to all patients undergoing extractions, especially those on warfarin, addressing possible complications and actions to avoid (such as rinsing or brushing)
- Ensure written instructions include information about the tranexamic acid protocol if applicable
- Accompany oral instructions with written instructions to emphasise the need to seek treatment for ongoing bleeding
- Include emergency contact numbers and after-hours contact procedures in written instructions
- Advise patients and their accompanying persons of the most critical aspects of post-operative care
- Dentists should use checklists such as the Therapeutic Guidelines during procedures to ensure protocols are followed
- Dentists should view tranexamic acid protocol as intrinsic to the process for patients on anticoagulants, not as backup measures
- Advise the Australian Dental Association to encourage members to provide written post-operative instructions to patients undergoing extractions
Further listening
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