SINGAPORE - The coroner has expressed concern that advice given by a dentist for his patient to be given a soft meal diet was not heeded immediately.
Instead, 67-year-old Simon Lee, who was warded at Ng Teng Fong General Hospital (NTFGH) and in a vulnerable state, was given meals based on a regular diet after he had three of his teeth extracted on Jan 16 last year.
After a meal based on a regular diet a day later, a nurse heard him coughing vigorously before he became unconscious.
Mr Lee, alias Lee Chwee Koon, died on Feb 18 that year due to a lack of oxygen and blood flowing to the brain, and pneumonia.
At the inquiry on Thursday (April 18), Coroner Marvin Bay said that Mr Lee's death was an unfortunate misadventure.
But he added: "It is nevertheless deeply concerning that dietary advice given by the dentist, Dr Bertrand Chew, was not immediately implemented.
"It would be clear that a patient in a situation of having undergone extensive dental surgery would be in a compromised and vulnerable state, with the ever-present risk of choking needing to be appropriately anticipated and monitored."
Coroner Bay said the soft diet plan was not immediately implemented pending a review by the dietitian.
However, based on currently known facts, the coroner said it would not be possible to conclusively attribute Mr Lee's choking to be from the failure to provide him with a soft diet.
This was because he had a number of "known serious and chronic maladies" including "a previous stroke, past cardiac events and persistent coughing episodes".
He also noted that before falling unconscious, Mr Lee was able to eat regular meals on Jan 16 and 17 last year.
Mr Lee was treated for bacterial sepsis on Jan 11 last year at the hospital. It is a condition that arises when the body's response to an infection injures its tissues and organs.
On Jan 16, Dr Chew saw Mr Lee as the sepsis could have been caused by poor oral health.
Three decayed teeth from Mr Lee's left upper jaw were then extracted and Dr Chew submitted a recommendation to his colleagues for the patient to be placed on a soft diet.
The advice was recorded in their electronic medical report.
However, Mr Lee continued to receive meals based on a regular diet.
Coroner Bay noted that "NTFGH has taken positive steps following Mr Lee's demise".
"At the department level, there were efforts to improve the doctor to patient ratio to allow a speeding up of the processing of notes and orders," he added.
In a statement, a spokesman for the hospital said: "We wish to express our deepest condolences to the family of Mr Simon Lee.
"What happened was unexpected and the hospital has since taken positive steps to review and strengthen its processes to improve patient safety and prevent similar incidents from occurring."
Mr Lee's son, who was present in court on Thursday, declined to comment when approached.
This article was first published in The Straits Times. Permission required for reproduction.