Mr A, a 48-year-old salesman, was admitted to hospital for an elective cholecystectomy. Dr B assessed him for anaesthesia on the night before his operation. He was noted to be in good general health. Dr B observed that Mr A had several crowns on his front teeth and noted this finding.
Mr A had had several anaesthetics in the past. He had experienced postoperative nausea and vomiting (PONV) after some of the operations. Mr A expressed concern about this and appeared somewhat anxious about his operation. Dr B made a note that he had explained the general anaesthetic procedure, the plan for postoperative pain relief, and what steps he would take to minimise the risk of him experiencing PONV.
There was no specific record of the risk of dental damage despite the presence of several crowns on the patient’s front teeth. Dr B prescribed a “premed” of an anxiolytic and an antiemetic. Dr B used a “total intravenous” type of anaesthetic technique. The record showed that he had intubated the trachea to secure the airway. There was no note of any difficulties with the airway nor laryngoscopy. The operation proceeded smoothly. Mr A was pleased that he had not experienced any PONV on this occasion. However, he did complain of dental pain.
Mr A visited his dentist a few weeks later. The dentist found a damaged crown and associated fracture of the underlying root. He concluded that this was consistent with an injury associated with instrumentation of the airway. Mr A required several appointments with the dentist and experienced discomfort for some time. Mr A made a claim against Dr B.
Scrutiny of the notes and anaesthetic records confirmed that Dr B had assessed the airway and noted the presence of the crowns. Crucially, there was no mention that he had warned Mr A of the risk of dental trauma. Furthermore, Mr A stated that he had not received any verbal warning at any time about the risk. The case was settled for a low sum to cover the costs of dental work and pain and suffering.
Further reading The Royal College of Anaesthetists (www.rcoa.ac.uk ) has a series of downloadable “risk information” leaflets for patients, one of which is entitled Damage to the Teeth, Lips or Tongue.
Consent for Anaesthesia, a guideline published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI), can be downloaded from www.aagbi.org/publications/guidelines.htm
Consent: Patients and Doctors Making Decisions Together published by the General Medical Council (GMC), can be downloaded from www.gmc-uk.org/guidance/ethical_guidance
Dental trauma occurs in about 1 in 4,500 operations. It is more common in those who have poor teeth. Two thirds of the injuries occur in those with poor teeth and gums. Damage to the teeth (or gums and lips) does not necessarily imply negligence but patients should be warned of the risk of dental trauma, particularly where specific risk factors have been identified. Examples include the presence of loose teeth, crowns, veneers and a “difficult” airway.
Consent is a process rather than a “one-off” exercise. It consists of discussion, explanations, answering questions and a clear note of what was discussed.
Whilst the presence of good records and notes might not necessarily help to defend every claim, they will demonstrate evidence of a discussion and reflect good care. Conversely, the absence of any written record may make a successful defence less likely.