A CORONER is to write to the country’s chief medical officer over the case of a West Cumbrian man who suffered a fatal allergic reaction to a mouthwash he was given by his dentist.

The tragedy happened as Graham Dalby, 63, of Keswick, visited Penrith’s Ghyllmount dental practice in September 2009 because he was still suffering from toothache after having a tooth extracted weeks before. He quickly became ill after the dentist treating him, Rachael Gibson, washed out his tooth socket with a standard antibacterial solution called chlorhexidine.

Despite the staff making determined efforts to treat Mr Dalby, he suffered a cardiac arrest and died in hospital four weeks later.

After a five-hour hearing in Carlisle last week, north Cumbria coroner David Roberts said he would write to country’s chief medical officer to highlight the dangers of possible allergic reactions.

He expressed concern that not enough had been done to investigate an allergic reaction that Mr Dalby suffered during a visit to the Cumberland Infirmary in 2002.

The inquest heard several medical experts praise staff at the dental practice for their handling of the incident, saying their actions had been beyond reproach.

The case was investigated for the coroner by retired consultant immunologist Richard Pumphrey, who said he was “95 per cent certain” that the cause of Mr Dalby’s allergic reaction – known as an anaphylaxis – was the mouthwash used to wash out his tooth socket.

He ruled out earlier suspicions that Mr Dalby, from Castlehead Close, Keswick, who was left paraplegic after falling from a roof in his 20s, suffered a reaction to the latex gloves used by his dentist.

The inquest heard detailed evidence of how staff at the practice had observed all the proper procedures, checking with the patient to see whether he had any allergies. He told them he had an allergy to rubber, but not to latex, the inquest heard.

After hearing how the senior dentist at the practice recognised that the patient was suffering an anaphylactic reaction while in the chair, Mr Pumphrey said he and his colleagues at the practice had administered the best possible treatment to Mr Dalby.

Asked about the possibility that the reaction may have been caused by something other than the mouthwash, Mr Pumphrey said: “I am convinced it was chlorhexidine. My personal point of view is that it is more than 95 per cent certain, and if it was chlorhexidine, there have been other ones [fatalities] due to this substance.”

He said the substance was commonly used as an anti-bacterial in substances such as mouthwashes.

In earlier evidence, Miss Gibson told how she routinely checked the medical history of all patients as they arrived for treatment.

Home Office pathologist Dr Alison Armour commended the actions of the staff who treated him on the day.

After recording a verdict of accidental death, Mr Roberts said he shared medical experts’ concerns that this initial episode, in 2002, should have been explored further and may have given Mr Dalby enough information to prevent a further allergic attack.

He said: “I am going to write to the government’s chief officer and bring his attention to the main issues that have been explored today.

“This might extend awareness and raise knowledge of anaphylaxis, so that nationally it gets more attention.

“There are lessons to be learned in this case and this letter is a way of trying to ensure that.”