A patient’s false teeth became stuck in his throat in a routine operation, and were not found for eight days.
The 72-year-old complained of swallowing difficulties and was coughing up blood before doctors discovered the dentures.
He underwent repeated hospital visits, more surgery and blood transfusions to correct the complications from the routine abdominal surgery.
The James Paget University Hospital in Norfolk said it had amended processes.
Details of the man’s case emerged in the journal BMJ Case Reports, in which authors recommend that false teeth be taken out before general anaesthetic.
Six days after surgery to remove a harmless lump from his abdominal wall in 2018, the man went to A&E, telling doctors he had been unable to eat solid food.
Doctors at the Great Yarmouth hospital believed it was a respiratory infection and side effects from having a tube in his throat during surgery, and prescribed antibiotics and steroids.
When the man again returned two days later, medical staff looked at his throat and voice box – and found a semi-circular object lying across his vocal cords.
He then told doctors he had lost his dentures – three false teeth and a roof plate – during his time in hospital for his operation.
After the operation to remove the dentures, he was discharged but returned four more times suffering from bleeding.
By the time surgeons cauterised the wound in his throat, he had lost so much blood he needed a blood transfusion.
The report’s authors said there had been other documented cases of dentures being inhaled during anaesthetic.
The presence of any false teeth or dental plates should be recorded before and after surgery, they added.
Hazel Stuart, medical director at the James Paget University Hospital, said a full investigation had taken place.
“As a result of this, processes have been reviewed, amended as necessary, and the lessons learnt have been shared with staff,” she said.