Finding into death of Angela Cuthbert

59y · Female·complications of abscesses following dental extraction, in a woman with cerebral palsy

Angela Cuthbert, a 59-year-old woman with severe cerebral palsy and dysphagia, died from complications of abscesses following extraction of all 14 teeth under general anaesthetic. Surgery occurred 20 June 2022; she developed laboured breathing on 5 July; presented with jaw swelling and distress on 13 July; and underwent drainage of extensive oral abscesses on 14 July. She subsequently developed aspiration pneumonia and died 24 July 2022. The coroner found the death was from natural causes and not preventable. Key clinical lessons include: patients with dysphagia require modified post-operative instructions specific to their swallowing impairment; careful post-operative monitoring is essential after oral surgery in vulnerable populations; and prompt escalation of respiratory symptoms and new fever is critical. The inadequate record-keeping between 22 June and 5 July delayed recognition of deterioration.