A teenage girl died while undergoing routine dental surgery so she could have a brace fitted, an inquest has heard.
Denisa Alexandra Stefanoaia, known as Alex, died at Great Ormond Street Hospital (GOSH) in London after complications during an operation to have four teeth removed.
The 15-year-old was told the surgery would take no more than an hour, was put under general anaesthetic, and was said to be pleased that it would eventually result in fixing her smile.
St Pancras Coroner’s Court heard Alex, from Watford in Hertfordshire, was “severely obese”, with mild asthma and sleep apnoea.
Experts told coroner Mary Hassell that the chance of Alex dying during the procedure, on February 14 2020, was “less than one in 100,000”, and that the risk was therefore deemed so low that Alex and her family were not warned about this.
The procedure lasted 19 minutes, and was deemed by the surgeon to have been “very straightforward”, the inquest heard.
But medics discovered Alex had bitten down on the endotracheal tube and had stopped breathing.
She was taken to intensive care but was pronounced dead five days later, her brain having been starved of oxygen.
Giving evidence remotely on Thursday, Dr Atheer Ujam, a senior registrar at GOSH who carried out the surgery, told the coroner that while the patient was a higher risk, he had no qualms about proceeding with the surgery.
He told the inquest: “I remember looking at her and her dad (before the operation) and there was a sense that although she was having an operation, it was something that was going to be associated with a good outcome – she was going to have her teeth straight.”
Dr Ujam described the procedure as “uncomplicated”, but said he later noticed there was a problem with the patient.
He said: “I stayed in the theatre to make sure the patient was stable.
“I finished my notes … I went (back to the operating table) to see what was going on, that’s when I saw Alex – she was blue.”
Dr Ujam said a colleague told him it was a problem with Alex’s lungs, but that a short time later he could see blood coming from her mouth.
He said: “I began to feel for a pulse and we couldn’t find one.
“At that point (a colleague) said we have to start CPR … within 10 or 15 seconds there were many people coming into theatre.”
Dr Ujam said he would not do anything differently were he to be faced with a patient similar to Alex.
Dr Akane Iguchi, consultant anaesthetist at GOSH, was also in the operating theatre at the time and said she began to become concerned when she was unable to ventilate Alex’s lungs after the procedure.
She said: “We were trying to improve her lung capacity.
“I looked over at Alex’s face and she was biting the ET (endotracheal) tube and she was becoming blue.”
Dr Iguchi told the coroner that Alex’s obesity meant she may have been deprived of oxygen for only “a matter of seconds” before turning blue.
She said: “Less than one minute – much, much less than healthy children.
“In her case, because of her severe obesity, her oxygen consumption is very high.
“All the factors combined make her very risky.”
Alex’s mother Angelica Stefanoaia described how the death of her daughter – her “best friend” – had an impact on her life.
“I have cried every day since she died, desperate to bring her back,” she said.
“I begged them on my knees to do everything they could for her and save her and they simply said she wouldn’t wake up.