A man's false teeth were stuck in his throat for eight days after he 'inhaled' them during a routine operation, it has emerged.
The 72-year-old retired electrician underwent surgery to remove a harmless lump in his abdominal wall at Gorleston's James Paget University Hospital when the dentures got stuck according to a British Medical Journal case report.
Aside from experiencing considerable pain, bleeding, and swallowing difficulties, the oversight led to repeated hospital visits, additional invasive tests, blood transfusions, and eventually more surgery.
The report reveals how six days after surgery, the man turned up at A&E complaining of blood in the mouth, swallowing difficulties, and pain, which had prevented him from eating solid food.
The man, who lived with his wife, also had a hoarse voice and was short of breath, particularly when lying down.
Nothing in his test results prompted doctors to consider anything other than a respiratory infection and the side effects of having had a tube down his throat during his operation.
He was prescribed mouthwash, antibiotics and steroids, and sent home.
Two days later he returned with worsening symptoms.
He had been unable to swallow any of the medicine and was admitted to hospital with a severe chest infection.
During this hospital stay, a closer look at his throat and voice box revealed a semi-circular object lying across his vocal cords causing internal swelling and blistering.
When this was explained to him, the man revealed that his dentures, which consisted of a metal roof plate and three false teeth, had been lost during his previous hospital stay.
He then had emergency surgery to remove them and was discharged after six days.
But six days later a bout of bleeding prompted his return.
As tests revealed the bleeding had stopped, he was sent home, only to reappear 10 days later with the same problem.
After a couple of days he was again discharged, but returned six days later because of further bleeding.
Tests revealed he had internal wound tissue around the site of the blistering which was cauterised to prevent further bleeding.
Because he had lost so much blood, he also required a blood transfusion.
He was discharged after two days, but returned again nine days later with further bleeding, which required emergency surgery as the source of the bleed was a torn artery in the wound.
A check-up a week after this procedure showed that the tissue was healing well, and six weeks later he had not needed further emergency care and his blood count was back to normal.
It has lead to calls for the presence of any false teeth or dental plates to be clearly documented before and after any surgical procedure, with all members of the surgical team made aware of what is to be done with them, they add.
Hazel Stuart, James Paget University Hospital Medical Director, said: "We had an incident in 2018 and as soon as it was identified the patient was advised and an apology provided by the clinical lead.
"The case was subject to a full Trust investigation, as we take the learning from any incident extremely seriously to ensure we continuously improve our services to patients.
"As a result of this, processes have been reviewed, amended as necessary, and the lessons learnt have been shared with staff."
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