Finding into death of Michael Anderson

36y · Male·Cardiorespiratory arrest complicating propofol administration for endodontic procedure in a man with borderline cardiomegaly

Michael Anderson, a 36-year-old obese man (BMI 38.5), suffered cardiorespiratory arrest during a root canal procedure under conscious sedation with propofol administered by Dr S. in a dental office setting. He had undiagnosed borderline cardiomegaly. Despite appropriate immediate resuscitation, he did not survive. The coroner found that while propofol administration was appropriate, blood pressure was not documented during or before drug administration, contrary to best practice. The confined dental treatment room and patient obesity complicated emergency response. The coroner could not establish that documented blood pressure would have changed the outcome; asystolic arrest has only 15% survival even in hospitals. The procedure in a dental office setting was considered acceptable practice, and no adverse findings were made against clinicians, though documentation of vital signs monitoring was criticised.