A dental practice in the Shropshire area

3. Mrs E is complaining about the treatment she received from the Practice between April and December 2019. Specifically, she complains that:

· the Practice should have offered dental implants as she is unable to tolerate dentures due to sensory issues she experiences because of her Asperger’s Syndrome · the Practice has not acknowledged her diagnosis of Asperger’s Syndrome as the reason she requires sedation before a tooth extraction, and has dismissed her as having a ‘dental phobia’ · she had to wait eight months for an appointment.

4. Mrs E says because the Practice refused to give her dental implants, she is unable to eat solid foods and needs to take dietary supplement drinks. She says her mental and physical health have been badly impacted as a result.

5. She says she was also left with a hole in her gum while she was waiting to be referred for surgery. Regarding the ‘dental phobia’ comment, she feels the apology issued to her by the Practice was inadequate.

6. She would like to know whether the Practice followed the correct process in denying her the implants, and for the Practice to acknowledge her diagnosis of Asperger’s Syndrome as the reason she has requested the implants.

7. She would also like the Practice to acknowledge her diagnosis of Asperger’s Syndrome as the reason she requires sedation during dental treatment and offer an apology for the long delays she has experienced in between dental appointments.

8. Mrs E has had dental issues for many years and had her first tooth extraction in 2014. By August 2019, she had already had a total of seven extractions and had ongoing issues with another two teeth. Due to the number of teeth she has had removed, she is now unable to eat solid foods, and takes dietary supplement drinks.

9. Mrs E states she needs sedation while undergoing tooth extractions as she has sensory issues related to her diagnosis of Asperger’s Syndrome. She is also unable to travel long distances for appointments as she has agoraphobia. Mrs E was referred to the Practice in April 2019 but did not get her first appointment for an extraction until October 2019.

10. The Practice booked Mrs E to have another tooth extraction on 21 October 2019. She was unable to attend as she was ill. The Practice told her it would book another appointment for her, but this did not happen. After her advocate called on the 29 October, the Practice gave her an appointment for 6 December.

11. Mrs E put her request for dental implants in a complaint, written by her advocate, in August 2019. During the complaints process with the Practice in October 2019, it made comments referring to Mrs E as requesting sedation during tooth extraction due to her having a ‘dental phobia’. In March 2020 she received her final response stating the Practice does not offer dental implants.

The refusal to provide Mrs E with dental implants

14. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.

15. Mrs E told us the Practice was wrong to decline dental implants. She says the Practice should have offered implants because she is unable to tolerate dentures. She says this is because of sensory issues she experiences due to her Asperger’s Syndrome.

16. In consideration of Mrs E’s complaint, we looked at the Chief Dental Officer interim guidance: Dental Implants, and the Royal College of Surgeons Guidelines for Selecting Appropriate Patients to Receive Treatment with Dental Implants. These are the two guidelines used by the Practice when it decided Mrs E did not meet the criteria for dental implants.

17. In the Practice’s response to Mrs E in March 2020, it stated implant provision is not recommended for people who smoke, which is clearly stated in both guidelines. The guidelines produced by the Royal College of Surgeons states patients ‘should be counselled to quit or reduce their smoking habits or refused treatment, especially where other factors could contribute to failure’.

18. The guidance from the Chief Dental Officer states funding requests for dental implants must demonstrate there are no contraindications for treatment, including smoking. It is clear throughout Mrs E’s dental records that she is a smoker, and her dentist has advised her to stop smoking.

19. As both guidelines are clear that smoking is a contraindication for dental implants, it appears the Practice was entitled to apply this part of the guidelines to Mrs E’s situation. The evidence indicates there were no failings in how the Practice reached its decision. For that reason, we have decided to take no further action on this issue.

20. Despite this, we think the Practice could have been clearer in the responses to Mrs E. So far, it has not explained whether she could be considered for dental implants in the future should she quit smoking. It is not clear whether the Practice has given a total refusal, or whether, with lifestyle changes, it would consider implants.

21. We discussed this with the Practice directly, and it has agreed to issue another letter to Mrs E. The Practice will tell her it is prepared to re-refer her for another opinion in the knowledge that she has recently stopped smoking. It will also state it has considered her sensory issues as part of her request for implants.

The long wait time for an appointment between April 2019 and December 2019

22. The Practice has responded to Mrs E’s complaint about the long wait time, stating that it appears there was a breakdown in its internal referral process which meant it did not book an appointment for Mrs E.

23. Mrs E told us the delay left her with a hole in her gum while waiting for surgery. We recognise this caused Mrs E discomfort and distress.

24. The Practice offered its ‘sincerest apologies for this mistake’ and explained that it was in the process of writing a Standard Operating Procedure for the Intravenous Sedation Service.

25. It said part of this would cover a pathway for internal referrals. It also stated that its clinical team had already been informed, through Mrs E’s feedback, that they had been told to ensure to book appointments at the start of the pathway, and to write the appropriate referral letters.

26. Our Principles of Good Complaint Handling state in the section on ‘putting things right’ that where a public body has failed to get it right and this has led to injustice or hardship, it should take steps to put things right. In many cases, a prompt explanation and an apology will be a sufficient and appropriate response.

27. With these principles in mind, it appears the Practice has acknowledged an internal failure in this instance. It has issued an apology and explained to Mrs E the steps it has taken in response to her complaint. As the apology given meets our principles, we consider the Practice has done enough to put things right. We have decided not to take any further action on this issue.

The Practice referring to ‘dental phobia’ and not acknowledging Mrs E’s Asperger’s Syndrome

28. This complaint relates to comments made during the complaint process, and in a letter issued to Mrs E from the Practice, dated 1 October 2019. The Practice said in this letter Mrs E’s requirement for sedation prior to a tooth extraction is caused by a dental phobia.

29. It also stated part of the long-term plan of the service is to provide a CBT pathway for patients with dental phobias to increase their chances of being able to access primary care dentistry without sedation. Mrs E refutes she needs sedation due to a phobia. She told us she has Asperger’s Syndrome and needs sedation for sensory issues related to that.

30. The Practice has addressed this complaint in its letter dated 10 March 2020. It stated it, ‘apologises that Mrs E feels that consideration has not been given to the impact her Asperger’s has on her ability to have dental care under local anaesthetic’. It continued by stating that the dental team have a great deal of experience with patients on the autism spectrum, and as a service it would like to do more work to help those with sensory issues around the mouth. It also stated that it had arranged a date for an initial meeting with occupational therapy to look at other strategies to assist patients with sensory issues.

31. We have considered our Principles of Good Complaint Handling in considering whether this is a sufficient and appropriate response to Mrs E’s complaint. The Practice has issued an apology and has indicated it is revising its strategies in assisting patients with sensory issues. However, it has not directly apologised for stating that Mrs E has a dental phobia, or for suggesting that she could be assisted by a course of CBT.

32. We consider the Practice’s letter did not meet our principles in terms of giving a full explanation and apology. We discussed this with the Practice, and it has agreed to provide a further response to Mrs E to do this. We consider this action we have agreed with the Practice is appropriate to resolve this part of Mrs E’s complaint.

1. We have carefully considered Mrs E’s complaint about a dental practice in the Shropshire area (the Practice). We acknowledge the decision to refuse Mrs E dental implants has caused her distress. We were sorry to hear her mental health has consequently been affected. Mrs E articulated clearly to us her feelings of being left behind by the system, as a person on the autistic spectrum. We are sorry to hear about this and we appreciate she has had a difficult experience.

2. We have come to multiple decisions regarding the complaint Mrs E has brought to us. We have seen no indications anything went wrong with the Practice’s decision not to offer implants to Mrs E. We have agreed the Practice should take some further action to put right the impact Mrs E suffered when it did not fully acknowledge her Asperger’s Syndrome. We have seen the Practice has already done enough to put right the impact of delays with an appointment for Mrs E.