DS sadly died following complications after a 19-minute operation to remove four teeth. Following general anaesthetic and a straightforward procedure, DS bit down on the endotracheal tube in recovery and stopped breathing. She was taken to intensive care, but passed away five days later.
At an inquest in August 2020, the senior registrar who performed the surgery told the coroner that while DS was considered to be high risk due to her clinical obesity, mild asthma and sleep apnoea (which was well controlled), he was not concerned about performing the operation and would not have done anything differently.
While writing his notes in the operating theatre he noticed there was a problem with DS and that she was turning blue. He alerted the consultant anaesthetist who was unable to maintain ventilation in DS airways and realised that she was biting on the endotracheal tube. Although not uncommon, the anaesthetist failed to recognise this for several minutes.
DS was given an anaesthetic drug to reverse the biting and a new endotracheal tube was inserted, but immediately flooded with a large volume of blood. She then suffered cardiac arrest and although her pulse was restored, due to several minutes of oxygen deprivation, DS suffered irreversible and fatal brain damage.
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