Denture care and treatment
21. Mr C told us his mother went to the Practice six to eight times because of problems with her dentures. He is unhappy that the Practice continued to charge for treatment but then decided his mother needed to be referred. He says when his mother managed to get an appointment at the Practice in March 2021. The dentist did not look at his mother’s teeth but said the Practice could not do anything.
22. He wants to know why the Practice did not do more sooner, and he questions if it had a treatment plan. He wonders why the Practice did not stop treatment if the work needed was too complex for it. He feels the Practice blamed the pandemic and says the Trust told him the pandemic is not the reason why the referral was rejected. He also says the Practice failed to send a referral to a dental service after it asked his mother to register elsewhere.
23. The Practice says it saw Mrs K in March 2021 for an adjustment to her denture. It says her issues were complex and needed to be dealt with by a dental hospital. It says it tried to make a denture previously but this was uncomfortable for her. The Practice explained that when the Trust rejected the referral, it called the Trust numerous times to discuss the case and try and make progress. It says the Trust telephoned in April confirming it cannot accept the referral but once the restrictions are lifted, it would be happy to accept.
24. 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.
25. We have seen the Practice referred Mrs K to the Trust in 2018. At this time the reason for referral and circumstances were different to the events of 2021. We will explore this in more detail below. Mr C is correct as in 2018 there was no need for referral as the Practice could provide the needed treatment. The Practice followed the Trust’s instructions and treated Mrs K. We will not comment further on what happened in 2018 as the complaint is about the Practice’s management of issues since then.
26. We have considered if the Practice did the right thing when referring Mrs K in March 2021. There is no specific list as to what treatment a dentist can or cannot do in Practice. A dentist should offer care and treatment until they can no longer meet the patient’s needs, such as when these become too complex. At this point a referral should be made. The GDC standard explains, ‘You should refer patients on if the treatment required is outside your scope of practice or competence. You should be clear about the procedure for doing this’ (6.3.3). Referral is therefore based on whether the Practice can meet the needs of the patient.
27. Mr C wants to know why the Practice continued treatment and charged for this, instead of referring his mother sooner. We have seen her dental records from August 2015. We can see Mrs K had a full dental examination in June 2017 and it noted there were issues with her denture. The Practice treated these issues. Because of our organisation’s time limit, we can only look at issues that were complained about and brought to us within one year of realising there was a problem. We have included this information to show that we are aware of Mrs K’s history. We understand Mr C is complaining about the denture fitted in October 2018 which he says was causing his mother pain in 2021.
28. Our adviser explains that generally it would be expected for a patient to return within a few weeks if they were in discomfort or unable to use the denture. The records show Mrs K next went to the Practice on 21 March 2019 for a routine examination, where she complained of problems with her dentures. There is no indication that she returned soon after the denture fitting.
29. We appreciate Mrs K may have been in discomfort before she went back to the Practice. We are not critical of the Practice for not addressing issues that it was not aware of. We can see that Mrs K went to the Practice a number of times from March 2019 to March 2021. According to the GDC guidance, a Practice should continue to treat a patient until it becomes clear that it cannot meet their needs. Therefore, we do not think the Practice did anything wrong in continuing to try to resolve the problem.
30. NHS BSA guidance says, ‘If it is not long after the denture or bridge has been fitted, this should be considered as part of the aftercare and therefore, part of the original Course of Treatment (CoT). The patient should not be charged’. Mrs K did not return to the Practice soon after the denture was fitted. Therefore, further treatment could not be considered as part of aftercare or as part of the original course of treatment. Although we understand Mr C’s concern, in line with the NHS BSA guidance, the Practice were right to charge for further treatment.
31. Mr C feels if the Practice had managed things better, it would have known the care was too complex and would have stopped treatment sooner. As we were not there at the time, it is difficult for us to know what was discussed during appointments. The only other evidence we can look at is the medical records. From March 2019 the records show the Practice gave Mrs K advice and discussed treatment options with her. It is documented that she agreed to the treatment plan. We cannot see that Mr C or Mrs K raised concerns or complaints about this at the time. We do not dispute what Mr C says and we have considered his account. However, the records give strong evidence of the Practice having a treatment plan and deciding referral was needed when it had exhausted treatment options.
32. The records show that in July 2020, the Practice adjusted Mrs K’s denture and advised her to return in a few weeks, or sooner, if pain or problems persisted. Mrs K returned in March 2021 and reported her denture was causing soreness. Mr C told me that during this appointment the dentist did not look at his mother’s teeth but just said there was nothing the Practice could do.
33. This appointment was booked as an emergency. The records show the dentist did an examination and the findings are noted. The dentist advised a new denture was needed and a referral could be made to the Trust. Mrs K saw a different dentist on 19 March 2021 for a second opinion. It is noted that this dentist also recommended referral. We are sorry Mrs K felt dismissed. The evidence we have seen tells us the Practice did examine her teeth on 17 and 19 March and it advised on the best course of action.
34. Taking the evidence into account, we do not think the Practice failed to manage the issues or that it charged Mrs K unnecessarily instead of making an earlier referral. Mrs K had many appointments, but these were to try and solve the ongoing problem. In line with the GDC standard, the Practice was correct to continue treatment until it was no longer within its scope of practice to do so. We have not seen anything to suggest the Practice should have referred Mrs K sooner.
35. Our adviser explains it is not unusual for a denture to need adjusting, and this need alone would not indicate an automatic referral for specialist opinion. We asked our adviser to consider if the Practice followed the correct process when it made or fitted the denture. Our adviser says the Practice made appointments for each stage of denture production and no steps were missed or skipped. The evidence in the dental records shows the Practice met the BSSPD standards for denture work. We have not seen anything to suggest the problems were caused by the Practice not following the guidelines correctly in performing denture treatment.
36. Mr C told us about his concerns with the referral process and the reason why the referral was rejected. He feels the Practice has used the pandemic as an excuse, and the Trust told him it did not reject the referral for this reason. We have already commented on how it was appropriate for the Practice to complete the treatment itself in 2018. The Practice had tried to provide treatment in 2021 but this had been unsuccessful. As the work had become too complex to manage, a referral was appropriate. Our adviser explains that this is because specialist prosthodontists (dentists who specialise in complex matters) are often based in hospital settings.
37. The Practice provided us with a screenshot of the referral it sent to the Trust on 19 March 2021. The complaint file documents how the Practice called the Trust asking the consultant to call back so the referral could be discussed. It is noted that the Practice called the Trust again on 22 March. A receptionist told the Practice on 30 March that the Trust was only accepting high priority cases. The Practice again asked for a consultant to call to discuss.
38. On 6 April 2021 the Trust rejected the referral as it did not meet the high priority criteria. The Practice emailed the Trust asking the consultant to call and it received a response referring to only high priority cases being accepted. We have seen the Practice asked the Trust if treatment could be provided anywhere else, and it suggested another service. The Practice called this service but it said it only accepts referrals for specialist care patients. It suggested referral to the Trust. The Practice also asked the Head of the local Dental Committee for advice but they did not know of any other suitable places for referral.
39. The Practice did make the referral and it was rejected because of the acceptance criteria at the time. The NHS SOP says the acceptance criteria had changed from the norm because of the pandemic. It gives guidance for all dental care providers in recognition of the reduced capacity for treatment. The SOP says the priority was urgent dental care, patients with the greatest clinical need, and those who are vulnerable.
40. The Practice has no control over the acceptance criteria and whether the referral was accepted. From what we have seen, it did all it could to try to ensure the reason for referral was understood. We have seen the email from the Trust dated 7 April 2021 confirming the referral was rejected because of only taking high priority patients at the time. It says there is a very long waiting list within prosthodontics and the acceptance criteria have changed. Unfortunately, Mrs K did not meet the criteria as she was not regarded as clinically vulnerable, on a high-risk pathway, or an emergency case needing urgent care. This does not mean that she did not need treatment. It means the Trust were not accepting this type of referral at the time, because of what work was being prioritised.
41. We realise Mr C says he spoke to the Trust who said no referral was made. We do not dispute what he says. The weight of evidence tells us the referral was made and it was rejected for the reasons discussed.
42. The complaint file further documents how the Practice made repeated calls to the Trust on 12 and 13 April 2021 to try to discuss the rejected referral. The Practice called the British Dental Association for advice. It advised not to start a new course of treatment or to make a denture in Practice, considering the previous attempts. We appreciate what Mr C says and how strongly he feels about this. We have not seen indications that the Practice failed to refer or that it used the pandemic as an excuse. We think the Practice did all it could in the circumstances and approached different organisations to try to help Mrs K.
43. We have considered what Mr C says about the Practice failing to send a referral to the dentist he found who could care for his mother’s needs. The complaint file shows he telephoned the Practice later in April 2021 to ask for it to refer his mother on. We have seen the email Mr C sent to the Practice Manager (PM) confirming what he needed.
44. We have also seen screenshots of the PM’s reply that same day in April 2021. They ask Mr C for their contact details so the referral can be sent to the dental service. The complaint file shows the PM emailed the dental service to ask what information it needed and how to send it to them. The Practice says it did not get a reply and we have not seen evidence to suggest otherwise.
45. There is evidence of the Practice contacting the dental service on the same day that Mr C contacted it. We do not think the Practice has tried to prevent Mrs K from getting dental care elsewhere, or that it failed to process the request. We cannot comment on why the dental service did not reply. We are not critical of the Practice for not doing more in this situation. We are sorry if this issue is still outstanding for Mr C and Mrs K. It seems the Practice will help if the service provider gets in contact with it.
De-registration
46. Mr C says the Practice failed to identify the alleged comments he made leading to the ‘breakdown in trust’. He recalls one conversation with the PM and he says she became very aggressive and rude. He says the only comments he made were about poor communication, lack of ‘bedside manner’, and a staff member’s arrogant manner towards his mother. He explains he told the PM he would report her to the regulators and the media, and she hung up. He disputes the Practice’s reasons for making this decision. He is concerned it has taken advice from the NHS to act, without his account being considered.
47. The Practice’s de-registration letter is not dated but information from the complaint file confirms the letter was sent on 22 April 2021. The letter says the Practice has reflected on comments Mrs K made about a dentist’s character, comments Mr C made to staff, and it has taken advice from its NHS Local Authority. The Practice says all future correspondence should be in writing.
48. We have considered if the Practice were able to take this action without warning, without explaining what behaviour it felt was unacceptable, and without asking Mr C to give his version of events.
49. The GDS contract states that where there is an irrevocable breakdown in the dentist-patient relationship, the dentist may decide to no longer provide treatment to that patient. They must inform the patient and NHS England of this decision.
50. The Practice’s ‘Refusing Access to Patients Policy’ explains what actions the Practice should take in cases of unacceptable behaviour, including but not limited to verbal abuse. It says incidents will be discussed at a management meeting and if a majority agreement is reached, the PM will tell the patient verbally or in writing of the decision to de-register them, including details of the reason.
51. The policy further says where there is a relationship breakdown and the dentist no longer feels able to provide quality care, the problem should be reported to the PM who will consult with the indemnity provider. The PM will meet with the patient to discuss the situation, then a management meeting will be held to try to solve the problem. It says that the PM will write to the patient to explain the de-registration, and regional contact details will be given for finding an alternative dentist.
52. The GDS contract and Practice policy explains what a Practice can do and the steps it needs to take. The Practice says its reasons for asking Mrs K to register elsewhere is because of a ‘significant and irrevocable breakdown in trust’. Based on the GDS contract, a Practice can decide to stop providing a patient with treatment if this happens.
53. The Practice told Mr C it had reached this decision after consulting with its NHS Local Authority. We have seen from the complaint file that the Practice did this on 13 April 2021. Therefore, we consider the Practice met the expectations of the GDS contract in telling Mrs K and NHS England about its decision.
54. We are aware Mr C disputes the reason why the Practice reached this decision, and he feels he has not been given proof. It is important to note that any healthcare professional has the right to feel safe and respected in the workplace. If they feel behaviour towards them has been unacceptable, this is their right. But unacceptable behaviour has to be defined. We can see that the Practice’s policy does this, particularly it lists verbal abuse as unacceptable behaviour.
55. In the Practice’s complaint file are records of what the Practice has deemed as unacceptable behaviour. These include times where Mr C or Mrs K have shouted at staff over the telephone or made unacceptable comments. This is recorded as happening more than once. We will not attempt to list the incidents concerned. This is verbal abuse. The information we have seen shows this contact was directed at the PM or to staff.
56. Based on the Practice’s policy there should have been a management meeting to consider if a patient should be de-registered. We have not seen evidence to tell us this happened and this is a shortcoming. Yet, we think it is more than likely that the PM would have met with the staff concerned to discuss what happened, so the incidents could be reported and logged.
57. It is clear from the information we have seen that there was a progressive breakdown in relationship. The PM attempted to resolve this more than once by telephone. In line with the Practice’s policy, the PM did consult the indemnity provider and also NHS England, who advised them to de-register Mrs K. Because of this and the history of previous contact with Mr C and Mrs K, we understand why the PM did not make further attempts to contact them before sending the de-registration letter.
58. The GDS contract and Practice policy does not say that a warning has to be given. The Practice needs to give the reason for de-registration but there is no guidance to say this has to be exhaustive.
59. We realise that because Mr C was not given specific information about what exact behaviour the Practice felt was inappropriate, he was not able to give his version of events. However, we do not think the Practice de-registered Mrs K without having good reason. Its reasons are well supported by the record it has kept of the behaviour it has experienced. We think there was a breakdown in relationship and this had not improved despite the Practice’s efforts.
SAR
60. Mr C says he submitted a SAR because he wanted to see what information the Practice had to support its de-registration letter. He says the Practice did not reply within a month. He explains when he chased this up, the Practice only sent the dental records.
61. He told us if some information is confidential and cannot be disclosed, the Practice should explain or send redacted documents. He says the PM said they had spoken to the ICO who told them it did not need to send third party information. He says if this is true the Practice should still have sent correspondence between himself and the Practice.
62. The ICO guidance says, ‘Individuals have the right to access and receive a copy of their personal data, and other supplementary information…You should respond without delay and within one month of receipt of the request’. It says a SAR helps individuals understand how organisations are using their data, and to check they are doing it lawfully. The ICO says if the request involves other individuals the organisation should consider if complying with the request would identify another person. If the organisation decides not to disclose third party information, it should justify this decision and keep a record of its decision.
63. We understand why Mr C requested information this way. He has a right to make this reasonable request. He asked the Practice for his medical records, his mother’s medical records and any correspondence relating to them (either written, recorded, or sent by the Practice).
64. The ICO also says there are exemptions to what an organisation has to provide, and if it withholds some information, it should explain this to the requestee and keep a record of its rationale. This agrees with what Mr C says about the Practice giving an explanation if not all information is disclosed.
65. We have seen the ICO response of 8 June 2021 in reply to the Practice’s query about what it can/has to provide. This includes the above guidance and that the organisation should balance the right of the individual to request this information, with the third party’s rights in respect of their own data. When the Practice received the SAR, it needed to decide what personal information it held, what it could disclose, and whether any exemptions in the relevant Data Protection Act (DPA) allowed it to withhold information.
66. We considered whether there is an exemption permitting the Practice giving Mr C the information he asked for. On balance, we do not have enough information to reach a decision on this. We do not have evidence of the Practice’s rationale (what exemption it relied upon) other than that it consulted the ICO. It does not seem that the Practice explained its reason for not giving full disclosure to Mr C. The Practice should have actioned the SAR within one month and told Mr C if it could not meet this timescale.
67. ICO guidance says if an organisation refuses to comply with a request, as well as informing the individual, they should be told of their right to complain to the ICO or another supervisory authority, as well as their ability to seek to enforce this right through the Courts.
68. We are sorry if Mr C was not made aware of this. We have decided the ICO is best suited to pursue this part of the complaint. It is the expert organisation in looking into compliance with the DPA, in responding to an SAR. ICO can look into the matter, give advice to the Practice and ask it to solve the problem if necessary. ICO set the exemption rules and is best placed to consider if an exemption applied here. If Mr C remains dissatisfied with the outcome, he can take the matter to Court.
Communication
69. Mr C complains the Practice did not tell him how he could escalate his complaint.
70. His letter of complaint dated 1 May 2021 is addressed to several public organisations including the GDC, CQC, ourselves, as well as the Practice. In this he refers to the Practice’s letter asking his mother to register elsewhere.
71. Before May 2021, he complained about his own dental care and treatment. We have not seen evidence of him raising a formal complaint about his mother’s care before then. We can see he contacted the Practice about his mother’s care and the plan for this, but these were enquiries and not formal complaints.
72. It is clear from Mr C’s letter that the Practice wrote to his mother about its efforts to care for her dental health, and its decision to remove her as a patient, before he wrote this complaint letter. The Practice’s complaint file confirms the de-registration letter and summary letter, although undated, were sent on 22 April 2021.
73. From earlier email correspondence between Mr C and the Practice, we can see he was aware of the role of the GDC, CQC, and ourselves. When making enquiries from as early as March 2020 (about his own healthcare), he refers to these organisations and states his intentions to escalate matters if things are not dealt with as he would like.
74. Our Principles of Good Complaint Handling say, ‘public bodies should provide clear and accurate information about the next stage of the complaint process so the complainant is clear about what to do next if they remain dissatisfied’. In this case, when writing his letter of complaint Mr C included the appropriate organisations to escalate his complaint to. The letter was not sent to the Practice to address first. Because of this, we do not think the Practice had the opportunity to respond and tell him how to escalate his complaint. As he had already contacted the other organisations, our decision is he was not prevented from escalating matters.