Godden,george 2011 08 31 14 50 44 877

Unknown·Lignocaine toxicity following dental surgery with atherosclerotic and valvular heart disease

George Godden died at Prince of Wales Hospital on 22 February 2007 from lignocaine toxicity following dental surgery. His post-extraction gingival bleeding was treated with gauze soaked in co-phenylcaine spray, a medication indicated for nasal and pharyngeal use only. Lignocaine was systemically absorbed through the compromised gingival tissue, causing toxicity in a patient with pre-existing atherosclerotic and valvular heart disease. The coroner found the medication application inappropriate and recommended distribution of a standardized post-dental extraction bleeding protocol to all NSW hospitals and referral of the treating dentist (Dr T.) and nurse to the Health Care Complaints Commission for professional conduct review. This death was preventable with proper medication selection and protocol adherence.