A pensioner spent eight days with his dentures - made up of a metal plate and three front teeth - stuck in his throat after he had surgery, it has emerged.
The 72-year-old anonymous man had an operation at an unnamed hospital to remove a harmless lump in his abdominal wall, but six days later he returned after finding blood in his mouth and finding it painful and difficult to swallow food.
According to a report in the BMJ Case Reports medical journal, he was sent home and prescribed mouthwash, antibiotics and steroids to treat what doctors thought were the effects of having a tube down his throat during surgery - and a respiratory infection.
But, two days later, the retired electrician went back to A&E with worsening symptoms - unable to swallow any of the medicine he was admitted with suspected pneumonia.
Doctors then found he had a semi-circular object lying across his vocal chords, which had caused internal swelling and blistering.
The report said the man revealed that his dentures "had been lost during general surgery admission" eight days earlier.
X-rays confirmed this was the foreign body lodged in his throat and he was taken for emergency surgery to remove them - and he was discharged six days later.
The report added that this was not the first case of dentures being inhaled while anaesthetic was administered.
It said: "There are no set national guidelines on how dentures should be managed during anaesthesia.
"But it is known that leaving dentures in during bag-mask ventilation allows for a better seal during induction, and therefore, many hospitals allow dentures to be removed immediately before intubation, as long as this is clearly documented."
According to the authors, lessons learned from what happened, included clearly documenting before and after any procedure the presence of any dentures or false teeth - and ensuring all members of the surgical team are made aware of what is to be done with them.
© Sky News 2019