NZ: Doctors lost man's false teeth during throat operation
New Zealand doctors lost an elderly man’s false teeth during surgery but found them four days later – stuck down his throat, a Health and Disability Commission report said today.
However, the commission found that doctors had taken all due care during the surgery.
The man had entered hospital for back surgery in February 2005 and his upper denture, which doctors noticed was loose, was removed before the operation, the report said.
Somehow the false teeth got back into his mouth, though no one admitted putting them there and, according to a nurse, there was “no way” the heavily sedated man could have put them back himself.
After the operation the patient said he was in “extreme pain” and was given painkillers.
Nurses noticed the elderly man was “very chesty,” spoke with a particularly husky voice, and couldn’t eat more than a couple of spoons of milky porridge at a time, the report said.
On the second day after the operation doctors recorded that his voice was down to a whisper and ordered chest X-rays. They found evidence of congestive heart failure.
The man was moved into his own room after suffering coughing fits.
His condition deteriorated as his coughing continued, his blood oxygen level plummeted and, while he was being washed, the 81-year-old stopped breathing, the report said.
Doctors put a laryngoscope down the man’s throat and found his missing denture plate.
They removed the teeth, resuscitated him and transferred him to a public hospital, the report said.
It noted the elderly patient recovered fully, but died within a couple of years from respiratory illness.
Experts reviewing the case said a serious underlying neurological condition had allowed the man to have his teeth stuck down his throat without gagging reflexively, as would have happened with a normal person.
The neurological impairment was caused by a cyst in the centre of the man’s spinal cord.
The fluid-filled sac pushed on his brain stem, damaging the parts responsible for swallowing and the feeling in the back of his mouth.
The names of all those involved were withheld by the commission.
