According to the report, George Godden, who was 74-years-old and a heart patient, died from an overdose of a local anesthesia, after he was given a wrong and extremely dangerous dose of cophenylcaine by an ‘on-call registrar’ to treat his bleeding gums, as his teeth were removed in preparation for his heart surgery.

Also, the registrar, Tani Brown, is said to have had no experience treating post-operative dental patients and was unaware of the hospital having a dentist on call.

The counsel assisting the coroner, Kristina Stern, stated: “Dr. Brown had used cophenylcaine to treat nose bleeds in the emergency department. However, the medication is not indicated for use in the mouth where the skin is broken”.

However, Mr. Godden was said to have fallen on the floor of his hospital room on the 22nd February 2007, as he was having a seizure and his airway was partly blocked by a’ piece of gauze’ that had been put in his mouth, then Dr. Brown instructed a nurse to spray the gauze with cophenylcaine.

Moreover, an analysis of Mr. Godden's blood revealed the level of ‘lignocaine’ was 25.6mg, which is one of the major ingredients in cophenylcaine and above the considered toxic level, 10mg per liter.