Inquest into the Death of Myosotis Julianna MORIARTY

68y · Female·acute gastrointestinal haemorrhage secondary to bilateral dental extraction

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.