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Care of patient who suffered respiratory arrest secondary to upper airway obstruction from displaced dental plate (05HDC02988)

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(05HDC02988, 24 April 2007)

Anaesthetist ~ Orthopaedic surgeon ~ Private hospital ~ Spinal surgery ~ Standard of care ~ Patient prosthetic devices ~ Dentures ~ Ventilation by T bag ~ Right 4(1)

An 81-year-old man was admitted to a private hospital in February 2005 for elective spinal surgery. The patient's upper dental plate was removed prior to surgery.

The procedure and anaesthetic were thought to be uneventful and the patient was transferred to the recovery room. However, he experienced a slow recovery to breathing and consciousness, and his breathing was assisted by the anaesthetist with a T bag. The anaesthetist also left the recovery room for approximately five minutes to check on other patients, and then returned to extubate the patient. The recovery room nurse was not happy being left in charge of the patient.

On his return to the ward, the patient's upper denture was noticed to be missing, and attempts to locate it were unsuccessful. Over the next few days the patient experienced respiratory complications and deteriorated. He went into respiratory arrest and the missing upper dental plate was discovered lodged in his throat. The patient was successfully resuscitated and transferred to a public hospital. However, he did not fully recover his previous good health and was unable to return to independent living. He died several years later from a respiratory-related illness.

The investigation was not able to establish how the patient's denture was replaced into his mouth. It was found that the patient experienced a deterioration of a pre-existing, undiagnosed neurological condition during the surgery, and was able to tolerate the denture in his throat for three days because of the neurological deterioration.

It was held that the orthopaedic surgeon and anaesthetist took all due care in relation to the surgery. However, the anaesthetist was found to have breached Right 4(1) in relation to the recovery room care, in particular by using a T bag to ventilate the patient, and leaving the recovery room for a period.