A dental practice in the Kingston upon Thames area

6. Mr R complains that in September 2021 the Practice cemented a crown in place without letting him review it first. He also complains that, after fitting a crown which looks too large, the Practice has told him it cannot be removed as it may cause him further problems in future.

7. As a result of the large crown being cemented in place before he could see it, Mr R says he is continually embarrassed when he speaks. He says he must cover his mouth with his hand when he is in conversation with others or when he laughs, and this makes him feel less confident and is impacting his emotional well-being and self-confidence. He says he is also having trouble eating.

8. Mr R wants the Practice to give him a refund of the money he paid for the crown, and financial compensation in recognition of the impact of him now having to get the crown removed and replaced, and the embarrassment he has been made to feel.

9. Mr R attended an appointment at the Practice in August 2021 as he believed he may have needed a filling. The Practice conducted an assessment and advised him it needed to remove the current filling, remove decay, and if enough tooth structure remained, fit a crown. A crown is a dental cap that typically encircles a tooth or dental implant.

10. Mr R had a crown fitted at the Practice in mid-September 2021. Mr R complained to the Practice in early October 2021 about the way the crown looked. The Practice responded five weeks later. Mr R also raised a complaint to NHS England, and it provided a response in December 2021.

15. Mr R had a crown fitted at the Practice in September 2021. Mr R says the crown is too large, and the way it looks causes him embarrassment. He also says before the dentist cemented the crown in place, they did not give him the chance to see it to agree he was happy with it. Mr R says when he is in conversation with others or when he laughs, he has to cover his mouth with his hand, and this makes him feel less confident and is impacting his emotional well-being and self-confidence.

16. In order to make a finding, we consider what should have happened to provide care in line with national guidance, and if there are any signs the care fell below the standard expected.

17. GDC standard 1.1.1 says, ‘You must discuss treatment options with patients and listen carefully to what they say. Give them the opportunity to have a discussion and to ask questions.’ GDC standard 1.7.1 says, ‘You must always put your patients’ interests before any financial, personal or other gain.’

18. NHS England’s response to Mr R’s complaint says it is considered common clinical practice for a dentist to ask the patient’s consent to fitting a crown before it is permanently cemented in place. Our adviser agrees with this. They say this is so the dentist and the patient can discuss how it looks and the patient can ask any questions before it is permanently cemented in place. We are satisfied this explanation is in line with the above guidelines about discussion with the patient.

19. The Practice does accept the dentist did not give Mr R the option to review the crown before cementing it in place. It says it normally does this and was unsure why on this occasion it did not.

20. The Practice also says in its final response that in order to provide a smaller crown it would have needed to remove more of Mr R’s natural tooth tissue, which was already compromised due to heavy decay. It explains the dentist did not believe this would be in Mr R’s best interest as it would have increased the risk of tooth fracture and further problems in future.

21. Based on the evidence we saw, the Practice did not discuss the crown with Mr R before cementing it into place and it should have done. This denied Mr R the opportunity to see it before it was cemented in place. Mr R told the dentist, when he saw the crown for the first time, he was unhappy as it looked too large. He has explained to us, had he seen it before it was cemented in place, he may have chosen not to go ahead with this treatment.

22. We asked our adviser what could have been offered as alternative treatment had Mr R been given the opportunity to see the crown before it was cemented. Our adviser explained the whole process of finding an alternative would have been less complex at that stage. They explained the Practice could have discussed the options with the laboratory, possibly re-prepared the tooth explaining that further work would then have been needed and made a new crown.

23. Our adviser also explained that as the crown has now been fitted, it is possible within the NHS contract to remove it, re-prepare it and create a new crown. If the underlying structure is compromised, the tooth could be root-filled, and the crown could be positioned more acceptably with a support post. This would still fall within the band 3 charge Mr R has already paid.

24. Our adviser explained, although there are no specific guidelines, it is considered common practice when a crown is prepared, to place it into the patient’s mouth, and allow them to inspect the colour and size to make sure it matches their other teeth.

25. Mr R’s records show in August 2021, the Practice discussed crown options with Mr R and the dentist explained that NHS crowns are not aesthetically driven, and they could make a crown on a private basis from a different material which would be thinner. The records show Mr R then decided aesthetics was not a driver for him so he would have the NHS-funded crown.

26. Our adviser explained that while NHS restorations are not cosmetically driven, efforts should be taken to make sure the crown provided is suitable. Mr R’s crown seems to affect his ability to carry out daily tasks. Our adviser says his comment that he now has to ‘hide’ his mouth while smiling is significant, and in line with the GDC guidelines above, dentists should consider the patient as a whole person when delivering care. This includes mental well-being. If the patient is worse off for any reason after treatment, then treatment can be said to have failed.

27. Based on the images Mr R supplied of his crown, we asked our adviser if the crown was suitable. Our adviser explained the shade match is not correct and the shade of the crown is distinctly lighter than Mr R’s surrounding natural teeth. Regarding the size, our adviser said the tooth is positioned slightly more towards the lip than the adjacent teeth, but the size is probably due to the dentist trying to retain as much of the natural underlying structure as possible. Then on top of that the thickness of the material used in the crown construction. Our adviser explained overall, the crown is ‘less than optimal’.

28. Our adviser explained that although aesthetics was not a driver for Mr R, the Practice should have taken reasonable steps to shade match the crown to his other natural teeth. From the images we have seen, the crown supplied was not suitable for Mr R and this again is not in line with the GDC guidelines above which say the patient should be involved and asked about the treatment being provided.

29. Overall, the Practice has not followed GDC guidelines, as it did not give Mr R the option to see the crown before it was cemented in place and the crown is not suitable for him. The Practice has apologised for the failings and said it would ‘redouble its efforts’ in the future.

30. Our ‘Principles for Remedy’ (our Principles) say organisations should seek continuous improvement and use lessons learned from complaints to make sure maladministration (fault) or poor service is not repeated. Our Principles also say organisations should put things right and, if possible, return the affected person to the position they would have been in if the poor service had not happened.

31. As a result of the Practice not gaining consent correctly and using a mismatched crown, it has led to the impact Mr R has told us about. Although we understand the Practice says it has learned from its error and will redouble its efforts in future to ask for consent, we are not satisfied the action taken by the Practice has fully addressed the complaint or the impact it had on Mr R in line with our Principles. We think the Practice needs to do more to address the complaint and the impact it has caused.

32. We therefore uphold this complaint and make recommendations below in our report.

1. The Parliamentary and Health Service Ombudsman is sorry to hear from Mr R of his sad and distressing experience at a dental practice in the Kingston upon Thames area (the Practice). We hope our report helps to explain what happened and whether this was in line with what should have happened.

2. In relation to Mr R’s complaint about the Practice not asking for his consent before cementing the crown into place, we found the Practice’s actions were not in line with relevant guidelines. Based on what we saw, something went wrong, which led to the distress and embarrassment Mr R describes.

3. In relation to his complaint about the crown’s size and aesthetic quality, we have found the Practice has not acted in line with relevant guidelines, which led to distress and embarrassment for Mr R.

4. The Practice has not done enough to accept these failings. While we cannot say this might have changed the outcome, it has clearly caused distress and embarrassment for Mr R.

5. We recommend the Practice accept the failings we found and apologise to Mr R for the impact of those failings. We also recommend the Practice take steps to improve its service to help prevent such an issue happening again, and refund Mr R the NHS Band 3 charge of £282.80 and pay him £250 in recognition of the distress and embarrassment the failings have caused.

33. In considering our recommendations, we have referred to our Principles. These state where maladministration (fault) or poor service has led to an injustice or hardship, the organisation responsible should take steps to provide an appropriate and proportionate remedy.

34. We recommend, within one month of the date of our final report, the Practice should write to Mr R to acknowledge the impact of the mistakes it made during the fitting of his crown in September 2022. It should apologise for this impact.

35. Our Principles say organisations should seek continuous improvement and use lessons learned from complaints to make sure maladministration (fault) or poor service is not repeated.

36. In line with this, within three months of the date of our final report, the Practice should create an action plan to explain to Mr R what it will do to address the failings in it not requesting consent before cementing a crown and using a crown which was not optimal. It should detail how it will take steps to prevent this happening again, including who is responsible for the actions, the timeframe and how the Practice will monitor the improvements.

37. The Practice should send a copy of the action plan to Mr R and to this office. It should also send a copy, along with an anonymised version of the final report, to NHS England.

38. Our Principles also say organisations should put things right and, if possible, return the affected person to the position they would have been in if the poor service had not happened. If that is not possible, they should compensate them appropriately.

39. To work out a level of financial remedy, we have reviewed similar cases where similar issues have arisen. We have also looked at our Guidance on Financial Remedy which includes a severity of injustice scale.

40. We recommend, within one month of the date of our final report, the Practice should refund the Band 3 NHS charge Mr R paid of £282.80.

41. We recommend the Practice should also pay Mr R, within one month of the date of our final report, £250 in recognition of the pain, distress and embarrassment he experienced because of its poor treatment in September 2021.

42. The Practice should send us evidence it has complied with all our recommendations.