Issue: failing to book an appointment
13. Mr A complains the Practice failed to book an appointment with a doctor, or a dentist when he complained of dental pain.
14. By examining the medical records we can see on the record entry of 23 August 2021 at 9.46am it was noted ‘wing officer called – pt (patient) stating he has toothache. paracetamol not working. added onto nurse list for pain relief and spoke to dental staff who will book him an appointment for next week’.
15. Our adviser suggested this was the correct course of action by arranging a same day nurse triage as per section 5.6 of Dental service for prisons in England, 2020 where Mr A had quality and access to healthcare.
16. The data entry on the same day at 3.31pm was written by a registered nurse, who recorded ‘History: Seen in healthcare for acute toothache which started last friday. Pain located lower aspect of mouth. Nil broken teeth, nil inflammation. No signs of current infection. Nil current facial swelling. Has been bathing mouth in salty water. Struggling to eat and drink but able too. Been px (prescribed) simple analgesia NSAID (non-steroidal anti-inflammatory drugs) today - issued.’
17. The history recorded suggests that the dental pain started on 20 August 2023.
18. Our adviser suggested Mr A’s issue is a common presentation in prison and he did not have any inflammation or facial swelling. There were no signs of infection or broken teeth and although it was difficult for Mr A, he was able to eat and drink. Therefore, he did not need to be seen urgently the same day by a doctor.
19. On 27 August 2021, at the dental appointment that was arranged the previous week, Mr A’s vital signs, pulse, blood pressure, temperature, peripheral oxygen saturation, respiratory rate etc in line with a NEWS2 score were recorded. Mr A was then seen by GP later the same day as he had a swollen gland under his chin, was feeling sick and was struggling to eat.
20. Mr A was also referred to the emergency department by the GP the same day on 27 August 2021 as there was an abscess in his jaw, which needed to be drained and the possible need for intravenous antibiotics.
21. It is clear the Practice triaged and booked an appointment for Mr A with a doctor when needed. He was referred to the emergency department subsequently when his condition worsened. We have therefore not found any indications of failings for this aspect of the complaint.
Issue 2: failing to provide adequate pain relief whilst he was waiting to see a dentist
22. Mr A complains the Practice did not provide adequate pain relief whilst he was waiting to see a dentist.
23. The SystmOne (clinical computer records) provided by the Practice indicate that Mr A was already prescribed paracetamol (a mild painkiller) on a regular basis.
24. The SystmOne ‘tasks’ indicate that a doctor was requested to prescribe ibuprofen (an anti-inflammatory painkiller) for dental pain on 23 August 2021 at 10.52am and that the doctor marked this ‘task’ as complete on 23 August 2021 at 1.02pm.
25. From the records, it appears that Mr A specifically requested ibuprofen and as such there does not appear to have been any request for ‘stronger’ analgesia (painkillers), such as co-codamol (codeine and paracetamol) requested of the GP(s) on duty.
26. Our adviser stated that it should be noted that ‘stronger’ pain relief, even if it had been prescribed at this stage would not have altered the subsequent abscess formation.
27. The actions of the Practice adhere to section 4 of Pain Management Formulary for Prisons: Implementation Guide, December 2015.
28. There is no evidence that the complainant did in fact present between Monday 23 August 2021 and Friday 27 August 2021 with increasing dental pain, facial swelling or any other symptom (or sign) suggestive of an increasing dental infection. The Practice therefore did not have an opportunity to prescribe any stronger painkillers until 27 August 2021, when Mr A was seen again. On this date codeine (a stronger pain killer) was used on its own and was prescribed by a doctor.
29. Therefore, we have seen no indications the Practice failed to provide adequate pain relief to Mr A.
Issue: failing to provide adequate pain relief, or antibiotics following dental surgery
30. According to the Nottingham University Hospital Queens Medical Centre medical discharge summary, Mr A was admitted on Friday 27 August and discharged on Sunday 29 August 2021.
31. On admission, it was noted that Mr A reported a ‘10 day’ history of facial pain and swelling, suggesting that symptoms may have started earlier than previously reported or recorded by the triaging nursing staff at the Practice.
32. The discharge summary stated: ‘Dear Doctor, Mr A was admitted under the Oral and Maxillofacial Surgery team on 27/08/21 due to a significant right sided dental abscess with involvement of the submental, sublingual and submandibular spaces. He reported a 10 day history of dental pain as well as difficulty eating and swallowing. We note his medical history to include anxiety, depression and high cholesterol. He was taken to theatre on 28/08/21 for extra-oral incision and drainage of the abscess as well as extraction of 3 teeth (including a dental bridge on the lower right hand side). One corrugated drain was placed in the neck and has since been removed. He has been well in the post-operative period and therefore we have discharged him from our care with oral antibiotics and analgesia.’
33. According to the discharge summary, the ‘new’ [N] medications to be continued in the prison on discharge were: • Co-amoxiclav 625 mg, taken three times daily,5-day duration, complete course on 01 September 2021 (ten doses supplied)
• Chlorhexidine mouthwash 0.2%, 10 ml, four times a day, 14 days duration (300 mL supplied)
• Codeine 30 mg, four times a day, 7 days duration (28 tablets supplied)
34. The SystmOne records do not provide the precise time of the return of Mr A from Queens Medical Centre on 29 August 2021.
35. The entry on 30 August 2021 at 2.37pm by a nurse stated: ‘Follow up (Xaljm) - Patient had a extra-oral incision and drainage of abcess and extraction of 3 teeth (including a dental bridge on the lower right side) Seen in department (XaBKN) - max fax Emergency appointment (9N58.) Discharge summary (XaFqz) Follow up (Xaljm) - oral abx and oral analgesia’.
36. As outlined above, the discharge summary indicates that a number of medications ought to have been continued by the Practice following Mr A’s return to prison.
37. Our adviser stated accepting that Mr A returned to the prison on Sunday 29 August 2021 and there may not have been a GP or non-medical prescriber on duty in order to prescribe the medications advised by the hospital, at the very least, these should have been prescribed/continued on Monday 30 August 2021.
38. The discharge summary indicates that supplies of these medications were provided for the discharge back to prison.
39. Our adviser stated it is usual practice for the escorting officers to hold these and then hand them over to Practice nursing staff on return to the prison. The nurses will usually store these medications until they can be authorised by a Practice GP or non-medical prescriber and an ongoing prescription be issued.
• Antibiotics, such as co-amoxiclav are usually given on an ‘in-possession’ (IP) basis to people in prison as they pose very little risk in terms of overdose or currency and diversion value.
• Chlorhexidine mouthwash would need to be given to the patient to hold in their possession (IP) and poses no risk in terms of misuse or diversion.
• Codeine tablets would need to be prescribed on a ‘not in-possession’ (NIP) basis as they are highly liable to misuse and diversion.
40. It is possible that the short supply of antibiotics (ten tablets) provided by the hospital to the nursing staff at HMP Whatton was simply given to Mr A without a formal prescription. Similarly, the chlorhexidine mouthwash was recorded following Mr A’s return to HMP Whatton. Again, it is possible that the 300 mL bottle provided by the hospital was simply given to Mr A without a formal prescription.
41. Ibuprofen was also given for pain relief.
42. The SystmOne records indicate that the dentist had intended to see Mr A on 2 September 2021 for a follow up but that he was ‘isolating’ and could not be seen on that occasion. This was presumably in response to COVID-19. Mr A was then seen by the dentist 9 September 2021.
43. The records indicate that codeine was not prescribed until 7 September 2021 at 11.11am when Mr A saw a doctor to prescribe medicine, following discharge from the hospital. At this appointment Mr A requested codeine which was prescribed on an ‘as required’ basis. This again adheres to the principles in section 4 of Pain Management Formulary for Prisons: Implementation Guide, December 2015.
44. Upon review of the medical records, there is no suggestion Mr A complained of further pain to staff between his hospital discharge to his GP appointment on 7 September 2021.
45. We have considered the pain relief Mr A was already taking (paracetamol and ibuprofen) and what he was prescribed when he left the hospital, along with an increase in strength of analgesia (given codeine). We are of the opinion the Practice did provide adequate pain relief post dental surgery and have seen no indication it did anything wrong.
Conclusion
46. As we have seen the medical records and associated SystemOne records, we have not seen any indication the Practice failed in its care towards Mr A. He was seen promptly after he stated he was suffering from dental pain. An appropriate appointment was made after he complained of pain and he was given adequate medication after his dental surgery as he was already in possession of pain relief. He was seen by a GP and provided codeine to further help him and when he was seen by a dentist on 9 September 2021, it was noted the pain and swelling was improving.
47. We understand Mr A suffered with dental pain and we were very sorry to hear this. We are pleased to hear he is feeling much better now.
48. As we have seen no indications of failings in how the Practice has acted, we will not consider this complaint further.