SINGAPORE — An elderly patient at Ng Teng Fong General Hospital died last year after he choked on his dinner, a coroner’s court heard.

Simon Lee alias Lee Chwee Koon, 67, had three of his teeth removed the day before, and was eating with his remaining nine teeth.

His dentist had prescribed a soft diet, but this wasn’t adhered to. Instead, he was given three meals based on a regular diet plan.

Following resuscitation efforts, food residue had to be cleared from his airways and lungs.

At the State Courts on Thursday (18 April), State Coroner Marvin Bay found Lee’s death to be “a most unfortunate misadventure”.

The coroner said, “it will not be possible for this inquiry to conclusively attribute Lee’s choking to be from the failure to provide him with a soft diet, as Mr Lee had a number of known serious and chronic maladies including a previous stroke, past cardiac events and persistent coughing episodes”.

He noted that Lee had also eaten three “regular” meals on the evening of 16 January last year, when he had his teeth extracted, and the next day on 17 January, before he choked during dinner that day.

However, the coroner added that it was “deeply concerning” that the dietary advice given by the dentist, Dr Bertrand Chew, was not implemented by the hospital immediately. The dentist’s advice for a soft diet had been recorded in the hospital’s system. Food given to those on a soft diet would have a soft texture and be moist.

The reason for the non-compliance by the hospital with the dietary advice? It was pending a review by a dietician, and the short time lead was insufficient notice for the kitchen to change Lee’s meal from a regular meal to a soft diet.

Coroner Bay noted that Ng Teng Fong General Hospital has since used Lee’s case “as a teaching example to show the importance of precise and speedy implementation of specialist advice”.

At the department level, the hospital also improved its doctor-patient ratio to allow faster processing of notes and orders following the incident.

What happened at Ng Teng Fong General Hospital

Lee was admitted to Ng Teng Fong General Hospital on 11 January last year after having lower-back pains. He was found to have degeneration of the spine and bacteria in the blood, and had a dry cough, among other things.

He was also suffering from diabetes, hypertension, ischemic heart disease, and other conditions.

Investigations of his back pain revealed degenerative disc disease, and he was treated for the bacterial infection of the blood. The infection was suspected to have a dental cause as Lee had advanced tooth decay.

Dr Chew, a consultant dentist, saw Lee on 16 January and noted his poor oral health. He had multiple teeth caries and decayed tooth stumps. The dentist decided to immediately extract three teeth from the left upper jaw, in order to prevent possible infection.

Following the procedure, Dr Chew asked Lee to be put on a soft diet, to reduce trauma to the sockets of his gums and jaw. Although Lee could still chew on his right side of his mouth – he had four teeth left on the front upper jaw and five scattered on the lower jaw – the diet prescription was meant to make it easier for the patient.

Back in his ward, Lee called his wife, who was undergoing home dialysis, to tell her about his condition and that his gums were painful.

That evening, just after his procedure, he was given a regular diet dinner of rice noodles, seafood and chicken hor fun, green stir fried spinach with mock abalone, tofu and red dates soup, and fruit.

The next morning, he was given breakfast again on a regular diet – scrambled eggs, grilled tomato, wholemeal bread and tea.

Lee again complained to his wife that morning that his gums were painful. She advised him to tell his doctor if it was still painful. This was the last time that the couple spoke to each other.

For lunch, Lee was given chicken stew in brown sauce, sauteed potatoes, a bread roll, wholemeal bun, sauteed cabbage with thyme, minestrone soup and fruit.

Later that day, he was served mock meat, mock Sezchuan style chicken, steamed rice, stir fried bitter gourd with black bean, cabbage and wolfberry soup, and fruit.

But during dinner, a nurse heard Lee coughing vigorously. She went to ask if he was fine but didn’t receive a reply. She didn’t notice any signs of choking and tried to move him onto the bed but was unable to do so.