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A dental practice in the Bury area

P-002582 · Statement · Decision date: 27 May 2024
Hospital acquired infection / healthcare-associated infection Clinical negligence harms learning
Complaint (AI summary)
Mrs M complained a dentist improperly extracted teeth, causing a sepsis infection requiring hospitalisation, ongoing jaw issues, and a poorly fitting denture, making her unable to eat.
Outcome (AI summary)
The complaint was closed. The Ombudsman found no indication the dentist failed to carry out the extraction procedure properly or acted wrongly in subsequent calls.

Full decision details

The Complaint

3. Mrs M complains the dentist did not carry out the procedure properly in July 2023, when extracting the teeth from her lower jaw.

4. Mrs M says as a result she developed a dental-related sepsis infection and was hospitalised for several days. She says the left side of her lower jaw has never fully healed. Mrs M says the denture provided when her teeth were extracted no longer fits, and she is left unable to eat. She says she has no faith in any dentist at the Dental Practice because of what happened and cannot access another NHS dentist in the area to get the denture she needs.

5. Mrs M would like a financial payment to resolve her complaint.

Background

6. Mrs M went to the Dental Practice on 5 July 2023 requesting extraction of all nine remaining teeth from her bottom jaw. She says having had all her top teeth extracted previously and using a denture with success, she wanted the same for her bottom jaw.

7. Mrs M told us she wasn't aware of anything untoward at the time of the procedure but in the days that followed she felt things were not quite right. She called the Dental Practice on 11 July and spoke with the dentist who advised she had a dry socket (where a blood clot either fails to develop in the tooth socket after extraction or becomes dislodged). The dentist prescribed a course of antibiotics.

8. Mrs M says these antibiotics caused her to have loose bowels. She called the Dental Practice again on 13 July and the dentist prescribed a different antibiotic. Mrs M told us she only managed to take three of these tablets before she became delirious, her husband called for an ambulance, and she was admitted to hospital.

9. Mrs M provided us with her hospital discharge records, which state she was diagnosed with metabolic acidosis secondary to ketosis, secondary to starvation related to the dental extraction. This means Mrs M had a build-up of acid in the body, caused by a state where the body was burning fat as fuel because she had not eaten sufficiently after the extraction. Hospital records note a second, questioned working diagnosis of dental-related infection.

10. Mrs M complained to the Dental Practice. Remaining unhappy with the responses she received, she asked us to consider her complaint.

Findings

14. Before we decide if we should conduct a detailed investigation, we look at whether there are signs the organisation has got something wrong. We do this by comparing what happened with what should have happened. We have done this, and we have not found any indications that anything went wrong with the procedure carried out on Mrs M.

15. Records of the procedure clearly document Mrs M’s wish for extraction of all her lower teeth and to have a lower acrylic denture. Records note the dentist advised Mrs M to reconsider, as this procedure was not advised nor recommended by him. The dentist noted his recommendation, to maintain the remaining teeth and to wear a lower partial denture and offered two alternative options: to leave and do nothing or consider fixed options such as implants or a bridge.

16. Records note Mrs M was aware of all options available to her, after discussion of the advantages and disadvantages, the risks, benefit and suitability of each, and she continued to want to proceed with full extraction. The dentist noted: ‘All risks and side effects explained: Pain, bleeding, bruising and swelling – Post Operative Pain, Infection, Paraesthesia [pins and needles] or fracture. Patient understands risks and consents to Tx [treatment]’.

17. The dentist documented the actions taken to complete the procedure, including the anaesthetic and equipment used, the checks undertaken and that there were no complications. Our adviser confirms this is all in line with the appropriate approach to an extraction procedure.

18. The dentist documented the work he completed to ensure the denture’s fit, noting this was well-fitting and Mrs M was happy with the aesthetics (looks) and fit. The dentist advised Mrs M she may experience a difference in speech and eating, that it may feel strange and tricky to tolerate and may be slightly loose or tight. He informed her about after care, to wear the denture as much as possible, to take it out at night and place in cold water, to clean with a soft toothbrush and warm soapy water and advised that any symptoms should resolve in a few weeks.

19. Our adviser says the recorded evidence shows the dentist acted in line with GDC Standards Principle 1, ‘Put patients’ interests first’, specifically: ‘1.1.1You 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.

1.2.2You should take patients’ preferences into account and be sensitive to their individual needs and values.

1.4.2You must provide patients with treatment that is in their best interests, providing appropriate oral health advice and following clinical guidelines relevant to their situation. You may need to balance their oral health needs with their desired outcomes. If their desired outcome is not achievable or is not in the best interests of their oral health, you must explain the risks, benefits and likely outcomes to help them to make a decision.’

20. Our adviser says the recorded evidence shows the dentist acted in line with GDC Standards Principle 2, ‘Communicate effectively with patients’, specifically:

‘2.2.1You must listen to patients and communicate effectively with them at a level they can understand. Before treatment starts you must: • explain the options (including those of delaying treatment or doing nothing) with the risks and benefits of each; and • give full information on the treatment you propose and the possible costs

2.3.5You should make sure that patients have enough information and enough time to ask questions and make a decision’

21. Our adviser says the recorded evidence shows the dentist acted in line with GDC Standards Principle 3, ‘Obtain valid consent’, specifically:

‘3.1.1You must make sure you have valid consent before starting any treatment or investigation.

3.1.3You should find out what your patients want to know as well as what you think they need to know. Things that patients might want to know include: • options for treatment, the risks and the potential benefits; • why you think a particular treatment is necessary and appropriate for them; • the consequences, risks and benefits of the treatment you propose; • the likely prognosis; • your recommended option’

22. In addition, records show the dentist acted in line with NHS England’s oral surgery guidance, specifically:

•‘Clinicians providing oral surgery care should be competent to manage complications that may arise.

•The clinician should ensure that the cooperation, motivation, aspirations, and general health of the patient are consistent with the provision of oral surgery.

•Prior to the provision of oral surgery, a comprehensive oral health assessment should be undertaken; the information collected and the risks identified should be reviewed before oral surgery procedures are undertaken.

•Patient has received sufficient information about procedure to enable them to provide informed consent.

•Patient has information with respect to appropriate selfcare after oral surgery procedure has been completed.’

23. Considering all the above, we do not see any indication of failings in relation to the procedure carried out. Whilst this is Mrs M’s primary complaint, we know she is also concerned about the dentist’s actions when she called twice afterwards. We hope the following information can further assure her, as we again see no indication of failings.

24. Records note Mrs M called to report pain since the extraction, and our adviser confirms the symptoms documented, that she described, are consistent with dry socket. Our adviser explains Mrs M’s risk of having dry socket was increased, as explained on the NHS website, considering her age (over 25 years old), smoking status (an active smoker) and the extraction being difficult or complicated (having nine extractions at once would apply here). This was a reasonable conclusion for the dentist to have made, and reasonable this was done by phone.

25. Our adviser confirms telephone consultation on this matter was appropriate. Telephone triage is common in medical and dental practice, more so after COVID-19. This is considered established good practice and in line NHS England urgent dental care guidance, specifically:

‘The care patients receive should be timely, safe and effective while being tailored to meet the needs of the individual. Care decisions should be reached via a process of shared decision making. Care needs will range from remote triage and advice, to delivery of face-to-face care…

The triage service should be able to: • Consider remote prescribing’

26. The first time Mrs M called, the dentist documented giving advice for continued home after care, hot salt mouth washes, to take pain relief as required and he prescribed a course of antibiotic treatment. Our adviser confirms this is appropriate treatment and prophylaxis (to prevent) for infection.

27. When Mrs M called two days later, it is recorded she explained having sickness and diarrhoea after taking the previous antibiotics. The dentist prescribed an alternative drug, which our adviser again confirms was appropriate to the circumstances and in line with the above extract from NHS England urgent dental care guidance.

28. We are sorry to have learned Mrs M later became unwell and needed a short admission in hospital. We acknowledge that she feels something must have gone wrong during the extraction procedure to have led to that need. We hope we can assure her we do not find any indication of service failure in the extraction procedure or in the actions of the dentist thereafter.

Our Decision

1. We have considered the evidence carefully and do not see any indication the dentist failed to carry out the extraction procedure properly in July 2023. We know Mrs M is also concerned about the dentist’s actions when she called twice afterwards, and we again find no indication of failing on either occasion.

2. As we have seen no indication that anything went wrong, we have decided not to investigate further. We appreciate the details Mrs M kindly shared with us and we recognise how important this complaint is to her.