Failure to diagnose an abscess in December 2021
17. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We have seen the Practice accepted it missed the abscess on the X-ray and delayed the treatment Mrs R needed. We discussed this with the Practice and it has agreed to take steps to put things right. We explain this in more detail below.
18. The FGDP guidelines explain the treatment for a dental emergency:
‘The emergency examination and related treatment should focus on the identification of the cause of the patient’s complaint, and appropriate management, with a view to resolution of the symptoms.’
19. The FGDP guidelines say toothache, swelling and abscesses are dental emergencies.
20. Mrs R’s dental records identify her appointments in 2021 as dental emergencies. The dentist recorded the cause of Mrs R’s problems and the management plan. The dentist prescribed antibiotics each time Mrs R attended the Practice.
21. On 15 April 2021, Mrs R’s dental records show she had an emergency appointment for pain and swelling in her mouth that had got worse in the last 24 hours. The dentist diagnosed pericoronitis (inflammation or swelling of the gum around a wisdom tooth), completed a ‘peripheral radiograph’ (an X-ray designed to show individual teeth) and prescribed a course of antibiotics.
22. The Practice’s complaint response confirms there were no issues with the LL6 or LL7 teeth at the time, but there was obvious inflammation and infection with the partly grown wisdom tooth (LL8).
23. Our adviser confirmed the X-ray taken on 15 April 2021, clearly shows no issues with the LL6 or LL7 teeth and there was no evidence of an abscess. We can see why the dentist thought LL8 was the cause of the problems.
24. Mrs R attended the Practice again on 8 September 2021 with the same issue, pain and swelling in the lower left quadrant of her mouth.
25. NICE guidance says at the first episode of pericoronitis, surgical extraction should not be considered unless it is particularly severe. The guidance also says surgery should be considered for the second or further episodes of pericoronitis.
26. The dental records do not show the dentist discussed referring Mrs R for surgical extraction before November 2021. Mrs R did not mention any treatment discussions in her detailed notes of her experiences. The dentist did not refer to any discussions in their complaint response. We think it is likely that the Practice did not discuss treatment options with Mrs R before November 2021. It seems likely the Practice missed opportunities to refer Mrs R for the treatment she needed on LL8 on 8 September and 29 October 2021.
27. Mrs R’s dental records confirm the Practice referred her to hospital on 4 November 2021. This was Mrs R’s fourth appointment for pain and swelling.
28. The dentist prescribed antibiotics at each of the four urgent appointments in 2021. These are the same antibiotics they would have prescribed if they had diagnosed Mrs R with an apical abscess (the most common type of abscess, caused by infection of the root canal of the tooth).
29. The Good Practice Guidelines) confirm the treatment for repeated infection is extraction or root canal treatment of the tooth.
30. Prescribing antibiotics would have given temporary relief of any swelling, but the correct treatment is root canal treatment or extraction.
31. Mrs R went to hospital on 25 November 2021 for a whole head X-ray. Mrs R says the dentist reviewed this X-ray during her appointment on 8 December and did not identify the abscess.
32. The Practice says the hospital X-ray was not complete enough to correctly diagnose an abscess and it did not know there was an abscess.
33. The later complaint response from the Practice says it is now aware there were issues it could have noted from the hospital X-ray.
34. Our adviser confirmed that on the whole mouth X-ray taken at the hospital in November 2021, two abscesses can be clearly seen on LL6 and LL7. Mrs R’s dental records on 8 December 2021 just say ‘review LL8’. There is no information of what the dentist discussed with Mrs R at this appointment and no evidence that the dentist reviewed the X-rays from the hospital.
35. The abscesses were also noted by a different dentist at the Practice when Mrs R attended on 9 February 2022.
36. A specialist’s letter dated 21 March 2022 says they do not think LL8 is the cause of the problems and there is evidence of a possible fracture on the LL7 tooth.
37. We think if the dentist reviewed the X-ray correctly during Mrs R’s appointment on 8 December 2021, they would have identified the abscesses.
38. Treatment for the abscess should have started on 8 December 2021, when the dentist reviewed the X-ray. The dentist should have given Mrs R options for either a root canal treatment or extraction of the tooth. The treatment was delayed until another dentist saw Mrs R on 9 February 2022 and told her about the abscesses on her X-ray.
39. There was also a delay in the referral for the wisdom tooth extraction. As the NICE guidance says after two episodes of pericoronitis a patient can be referred for surgical extraction of the tooth.
40. Extraction of the wisdom tooth should have been offered in September after the second episode of pericoronitis.
41. From the evidence available, we have seen signs that the dentist failed to refer Mrs R for the extraction of her LL8 wisdom tooth in September 2021. There are also signs the dentist failed to diagnose the abscess from Mrs R’s hospital X-rays in December 2021.
42. We appreciate the delays prolonged Mrs R’s pain and suffering. Had the delays not happened, the Good Practice Guidelines say the outcome for the teeth would have been the same, as the only options are root canal treatment or extraction. We know from the information Mrs R has provided that both teeth had to be extracted due to the condition of the teeth and were unsuitable for root canal treatment.
43. Where we find that poor service has led to an injustice, we look to see what the organisation has done to put things right. We refer to our ‘Principles for Remedy’ for this.
44. These Principles say an organisation should try and put a person back to the position they would have been in before the event happened. If this is not possible, they should be compensated appropriately.
45. Our Principles say an appropriate range of remedies may include an apology and an explanation or remedial action to prevent the same thing happening again. In some cases, financial compensation may be appropriate for financial loss, inconvenience, distress or a combination of these.
46. In this case, we think the Practice should do more than apologise to Mrs R as she has experienced a degree of distress and prolonged pain.
47. When someone has been negatively affected because an organisation had not acted correctly, we use our severity of injustice scale to identify what an organisation should do to put things right.
48. A level one injustice is defined as ‘annoyance, frustration, worry or inconvenience, typically arising from a single incident’.
49. A level two injustice is described as having a relatively low impact on the person affected, resulting in ‘a degree of distress, inconvenience or minor pain.’ We say a level two injustice will not usually have a significant lasting impact. We say in these cases, an apology is not enough by itself.
50. Mrs R suffered a degree of distress as a result of the delays to her dental treatment. The delay to Mrs R’s treatment resulted in more pain until the true cause of the problem was identified. Mrs R would still have had to have her teeth extracted as this was the correct treatment, but this may have happened sooner.
51. We would expect Mrs R to recover quickly once the correct treatment was received and there would not be a significant lasting impact. We think Mrs R’s injustice is level two on our scale.
52. We discussed this with the Practice and it agreed to pay £100 to Mrs R in recognition of how Mrs R was affected. We discussed this with Mrs R and she accepts the amount offered. The Practice has also agreed to provide a written apology to Mrs R.
53. The dentist has also identified additional training needs that they have added to their individual performance plan.
54. We do not consider it would be reasonable to expect the Practice to compensate Mrs R for the cost of the later treatment she had, as she would have had these costs regardless of when the abscess was identified.
55. With the actions it has agreed to take, the Practice has now done enough to put things right. We will not investigate this further. We appreciate how difficult this experience has been and were very sorry to hear of how this has affected Mrs R.
Failure to complete a regular check-up in December 2021 and to diagnose gum disease
56. The dentist’s complaint response says there was no evidence of gum disease on 7 February 2020 when Mrs R had her last routine check-up, before the emergency treatment in April 2021.
57. Mrs R’s dental records confirm the Practice completed a Basic Periodontal Examination (BPE, the tool used to diagnose gum disease) on 7 February 2020.
58. There is no evidence available to assess Mrs R’s gum disease in 2021 as she only had four emergency urgent appointments and these focused on her wisdom tooth pain and swelling.
59. The FGDP guidelines tell dentists to consider soft tissue screening and BPE if appropriate. It further says it is not necessary to do a BPE unless the patient’s symptoms indicate that it is appropriate.
60. As explained above, under FGDP guidelines dentists are only required to assess and treat the cause of the immediate problem at emergency appointments. They are not required to provide routine dentistry at the same time.
61. The Practice did not complete a full dental examination for Mrs R in 2021, because she attended for emergency appointments and therefore no BPE was completed.
62. Mrs R says she understood her appointment on 8 December 2021 was for a regular check-up. Her dental records show the reason for this appointment was a review of the LL8 tooth. The dentist’s complaint response confirms the appointment had been about an urgent problem and this is why the dentist did not do a comprehensive examination. The dentist said that had they seen signs of periodontitis, they would have told Mrs R and planned treatment.
63. The first mention of gum disease was at the emergency appointment on 2 February 2022, which shows Mrs R’s gums had deteriorated since her last full examination in February 2020.
64. We conclude that as Mrs R attended for emergency appointments in 2021, there was no requirement to complete a BPE. We can see no sign that the dentist did anything wrong. We will not investigate this further. We appreciate this is not what Mrs R was hoping for and we hope we have clearly explained the reason for our decision.
Failing to respond to the complaint in good time
65. Mrs R complained to the Practice on 10 February 2022. It acknowledged receipt on 14 February and the dentist responded on 25 March. This is six weeks from Mrs R’s complaint.
66. Mrs R raised more concerns on 28 March 2022 and the Practice acknowledged these on 30 March. The dentist responded to the concerns in an undated letter. Mrs R’s record of events confirm she got this response in August. This is five months after she raised more concerns and six months after Mrs R made her first complaint.
67. The Regulations say organisations must investigate the complaint in a manner appropriate to resolve it quickly and efficiently. It also says they should keep the complainant informed about the progress of the investigation.
68. The Regulations also say if organisations are unable to respond within six months, they should write to the complainant to explain.
69. Our ‘Principles of Good Complaints Handling’ tell organisations to ‘acknowledge the complaint and tell the complainant how long they can expect to wait to receive a reply.’ We say organisations ‘should keep the complainant regularly informed about the progress and the reasons for any delays.’
70. The Practice updated Mrs R on 20 April and 4 May 2022, confirming it was still looking into her complaint.
71. In an email dated 10 June 2022, the Practice confirmed it had received some comments from the dentist that needed further clarification. On 5 July the Practice responded to Mrs R’s request for an update sent on30 June 2022, saying it was waiting for detailed comments from the dentist.
72. Mrs R emailed the Practice again on 26 July to explain her frustrations about the lack of a response. The Practice emailed the dentist’s final response to Mrs R on 5 August.
73. The Practice sent regular emails to Mrs R to explain the reasons for the delay.
74. The Practice sent three emails to keep Mrs R up to date, advising the dentist was working on providing a response.
75. The Practice’s response to the complaint also falls within the six-month timeframe for responding to NHS complaints.
76. The Practice responded to the complaint in line with the Regulations and followed our ‘Principles of Good Complaint Handling’ by keeping Mrs R updated.
77. Making a complaint is not easy and waiting for a response and navigating the complaint process can be stressful for people, so we understand Mrs R’s point of view. Investigating and responding to complaints properly takes time. In this case, we think the Practice responded in a reasonable time frame. We will not investigate this further.