Complaint One - The complaint handler at NHS England-Cheshire and Merseyside (NHSCM) (was formerly Cheshire and Merseyside Integrated care Board (CMICB) was ill prepared when speaking to her, failed to comprehend her complaint and therefore did not investigate adequately, and did not provide an adequate response to her complaint.
13. Before we decide if we should conduct a detailed investigation of 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. We have done this and have not found any indications that something has gone wrong.
14. Although Miss A has supplied a copy of her complaint letter to My Dentist (the Practice), dated 16 May 2023, and addressed to both the Practice and NHS England, she states she complained to NHSCM on 5 June 2023 and spoke to the named complaint handler on the same date. NHSCM records show the initial complaint being received on 5 June 2023, and a copy of the formal complaint form, dated 5 June 2023, is included in the records.
15. Miss A states the complaint handler appeared ill prepared for the call, asking what she wanted to complaint about, and advising her of how to make a complaint.
16. Miss A states the complaint handler’s lack of preparation caused delays in her complaint being handled and that they did not handle the complaint properly. Miss A states she advised the complaint handler she had made a formal complaint and wanted an investigation but states the complaint handler instead tried to obtain an appointment for her with the Primary Care Dental team (PCDT).
17. She further states the complaint she made about the Practice was misunderstood by the complaint handler, and therefore was not investigated correctly.
18. NHSCM’s response letter of 19 October 2023 states the complaint handler spoke to Miss A on 5 June 2023, to discuss her complaint. Following this, on the same date, she contacted the PCDT to ask for advice regarding how to obtain an alternative appointment for Miss A, that was not with the Practice.
19. The response also states the PCDT advised it would investigate and get back to Miss A and the complaint handler contacted it for an update on 14 June 2023. The PCDT advised the complaint handler that, as there was no clinical need for an appointment, the procedure being sought not being deemed necessary. PCDT told the complaints handler it was unable to assist in obtaining an appointment for Miss A. The complaint handler contacted Miss A to advise of this on the same date.
20. NHSCM records indicate the complaint handler also contacted the Practice on 6 July 2023 advising of the complaint received from Miss A and asking them to investigate the complaint and respond to her directly. The records indicate numerous communications between NHSCM and the Practice. They also include records from other practices and communications between NHSCM and Miss A between 5 June 2023 and the date of the final response on 19 October 2023.
21. The response provided by NHSCM on 19 October 2023 included a response from the Practice.
22. On review both elements of this response were in line with the Ombudsman’s Principles of Good Complaint Handling, in that they addressed all the concerns raised by Miss A, were clear and unambiguous in both language and actions taken as a result of the complaint, such as feedback about processes and hold music.
23. It is our opinion the evidence does not indicate any failings on behalf of NHSCM with regard to the investigation undertaken or the response provided. As no record of the call of 5 June 2023 is available, we are unable to make any comment on the preparedness of the complaint handler named. The response of 19 October 2023 offers an apology for any upset caused.
24. It is therefore our decision that there are no indications of failings on behalf of NHSCM, it is not proportionate to take this element of the complaint forward for any further investigation.
Complaint Two – Miss A states the MyDentist (the Practice): • unnecessarily delayed/refused to provide her with an appointment for the Scale and Polish required, which delayed/prevented her having a (private) implant fitted at the other practice • staff failed to respond to emails and calls, make contact when they said they would and were dismissive and aggressive in their manner with her • fabricated a reason to remove her from the patient list and did so without notice.
• failed to maintain appropriate records of contact or falsely claimed they did not have such records.
25. Before we decide if we should conduct a detailed investigation of 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. We have done this and have not found any indications that something has gone wrong.
26. Miss A states, following an unrelated assault, she attended the Practice on 27 January 2020 and was referred to another practice to receive a tooth extraction, and dental implant treatment. This was because the Practice did not offer this type of treatment. Miss A was therefore referred privately to another practice that is a specialist dental implant practice.
27. Miss A had the dental implant on 14 April 2022. Sadly in January 2023 the crown on top of the dental implant broke. Miss A contacted the practice to have this addressed. She was informed the crown needed to be mended and refitted.
28. Miss A states she was told she needed a scale and polish procedure before the crown could be refitted. As the practice did not offer this procedure under the NHS, Miss A contacted the Practice to arrange the scale and polish under the NHS.
29. Miss A states she contacted the Practice in the week commencing 23 March 2023 to arrange an NHS appointment. She informed the Practice the appointment needed to take place before 10 May 2023. She was assured by the Practice there was plenty of time and that there were plenty of NHS appointment spaces/slots to accommodate this. She states the receptionist advised that she would communicate with the practice themselves and provide her with a date that would coincide with her crown refitting appointment. Miss A states she was told the manager of the Practice would call her back, but that this did not happen.
30. Miss A states she telephoned the Practice on 3 and 4 April 2023, and following an extended time on hold on each occasion, she ended the calls as she was unable to tolerate the hold music. On 4 April 2023 Miss A states she sent an email to the Practice asking for someone to contact her with regard to the appointment she needed.
31. She further states she received a response from the Practice, via email on 5 April 2023, which was flippant and unprofessional. Miss A also states she telephoned the Practice on 7 April 2023 and asked to speak to the manager. She states she was informed that she would receive a call that day or at the latest the following day. She also stated she queried the appointments and was reassured that there were still plenty of NHS appointment slots available to be made before 10 May 2023, and that the practice manager would schedule this with her when they called. She states no contact was received and no appointment given.
32. Miss A states she then contacted the Practice, on 20 April 2023, and advised it she was considering either legal action or approaching the Ombudsman as it had not communicated with her. She further states the practice manager then contacted her, on the same date. The practice manager stated there was no record of Miss A contacting the Practice. Miss A complains the Practice failed to maintain appropriate records of contact or falsely claimed it did not have such records.
33. Miss A states she telephoned the Practice again in the week commencing 10 April 2023, and requested again to speak to the practice manager. She says her call was directed to a new appointment co-ordinator. Miss A stated the call was chaotic, with the coordinator stating that the Practice offered all of the treatment Miss A needed, and not just the scale and polish. Miss A said the co-ordinator proceeded to try to organise for Miss A to have the crown refitting procedure done at the Practice.
34. Miss A said she was somewhat bemused about why the co-ordinator was trying to organise the crown refit to be done at the Practice, as she called to arrange a scale and polish, having already paid the practice for the dental implant and crown procedure. She further states that due to this confusion the co-ordinator stated she would get back to her but did not.
35. Miss A states she received a letter from the Practice on 20 April 2024, offering her an NHS appointment for the scale and polish on 1 June 2023. She states she immediately emailed the Practice to request a telephone call as she had been told she would be given an appointment before 10 May 2023.
36. Miss A states, not receiving a response within the hour, she called the Practice again and once more requested to speak to the practice manager. She states she was again, assured by the Practice she would receive a call back within the hour. Miss A also queried the email content with the receptionist, regarding the appointment booked for 1 June 2023. Miss A states she was informed by the receptionist there were no NHS appointment slots remaining pre 10 May 2023, however, there were plenty of private ones if Miss A wanted to pay.
37. Miss A states this angered her as she had been actively communicating with the Practice for four weeks regarding the issue. Miss A further states she emailed the Practice at 3.21pm on the same date, as she had not had the return call she had been promised. She states she received a missed call from the Practice soon after sending her email. When Miss A called the Practice back, she states the manager was aggressive and unsympathetic, and indirectly accused Miss A of lying by stating she had not been promised callbacks previously.
38. Miss A states the practice manager’s attitude triggered her PTSD. She further states she advised the practice manager she would be seeking legal advice and considering the treatment as discriminatory against her condition.
39. The manager of the practice, in the call of 26 June 2023, confirmed the scale and polish was not necessary before the crown was refitted. This was because the implant surgeon confirmed the area could be cleaned by them and the scale and polish of other teeth could be done at a later date. They also stated, as a specialist implant centre, it had the different tools needed for a scale and polish of a dental implant. Miss A advised it she wanted to access the scale and polish as an NHS treatment at the Practice.
40. Miss A states she then received another letter from the Practice stating that due to her unreasonable behaviour she had been removed from the patient listing for the Practice.
41. The copy of the letter provided by Miss A shows the letter refers to her behaviour in a call on 15 May 2023. It states her aggressive behaviour was not able to be tolerated, as the Practice felt the professional relationship with her had been irrevocably broken. This meant treatment could no longer be offered. Miss A denies being aggressive or unreasonable on any occasion.
42. Miss A states she has paid for the implant procedure, a sum of £3,000, and the unnecessary refusal or delays by the Practice to perform the scale and polish has meant she has not been able to have this procedure done. She further states she has had to access private care as her teeth continued to deteriorate due to her not being able to have the implant procedure done.
43. We can see from the records Miss A is mistaken on this point. She had had a dental implant on 14 April 2022. The appointment in question was for a refitting of a crown at the practice.
44. Miss A also states the practice manager of the Practice was dismissive, aggressive, and not sympathetic to her mental health needs. Miss A has been diagnosed with Post Traumatic Stress Disorder (PTSD) following an unrelated assault she suffered, as well as her losing six members of her family in a small period of time.
45. We have seen a statement dated 20 April 2023 by the acting practice manager at the Practice. This is in response to an email and a call from Miss A expressing dissatisfaction and requesting a call back. The statement notes the acting manager telephoned the practice prior to calling Miss A back. The acting manager states they were told the practce had had a lot of conversations with Miss A about appointments. The practice stated it had offered a hygienist appointment, but this was refused by Miss A as it was a private appointment and cost £53.
46. The statement further states the acting manager telephoned Miss A on 20 April 2023, but was unsuccessful in reaching her and left a voicemail. The statement says Miss A called the Practice back 20 minutes later.
47. The statement goes on to say the acting manager advised Miss A they had booked her an appointment with her dentist for 15 May 2023, as they had no availability for NHS appointments before then. It continues to say it had placed Miss A on the cancellation list in case an appointment became free sooner.
48. The statement says Miss A stated the lack of an appointment was discrimination against her, as a disabled person, and she would be consulting a solicitor. It is noted Miss A complained she had tried repeatedly to get through by telephone and had not received any callbacks in response to her emails requesting this.
49. The statement goes on to say Miss A was advised by the Practice that it was a very busy Practice and NHS appointments did go quickly. It went on to ask her to send copies of her emails so an investigation could be done of this.
50. It is recorded in the statement that Miss A is then noted as saying the staff she dealt with before were “stupid and thick and could not do their job” and the acting manager asked her not to call the staff names. It is noted the acting manager again confirmed they would investigate Miss A’s concerns. They also offered an appointment with the (private) hygienist before 10 May 2023 (it is noted this was a repeat offer).
51. The statement also says Miss A is noted as raising her voice at this point, saying she was exempt because she was disabled and should be given an NHS appointment. The acting manager again confirmed she was on the cancellation list. It is noted Miss A ended the call by calling the acting manager a rude name and included some swear words with it.
52. The records provided by the Practice include a record of an email trail of communications between Miss A and the practices which indicates unhappiness on behalf of various staff at the Practice, as well as Whiston (also known as Prescot) who were also contacted on 20 April 2023 by Miss A to try to arrange on appointment. The email dated 4 May 2023, from the Practice to the patient support staff at MyDentist head office references Miss A swearing at staff on more than one occasion when telephoning the Practice.
53. The practice manager’s email to patient support, dated 12 May 2023, states ‘none of the clinicians are willing to see this patient at the practice due to her behaviour, not only at [the Practice] but also with the team at the [other] practice, given the verbal abuse I received as well as the receptionist I don’t feel a warning letter is acceptable.’ The manager of the practice advised in their call to PHSO on 26 June 2024 that abuse had been received from Miss A also on several occasions, and this had escalated since 2020.
54. This email goes on to state the abuse experienced from Miss A is the worst experienced during her time at the Practice, staff feel the relationship has broken down to the point it would not be advisable for Miss A to attend the Practice moving forward.
55. The response to the practice manager from patient support at MyDentist head office on 15 May 2023, makes it clear the NHS expects a warning letter to be issued before refusal to treat and the response on 19 May 2023 states no dentists are prepared to see Miss A.
56. The Practice response of 23 September 2023 apologises to Miss A for the difficulty getting through on the telephone. It also apologised for the directness of the manager in her email reply of 5 April 2023, which Miss A felt was inappropriate, explaining the manager was trying to be clear in her communications and was working alone on that occasion.
57. The response goes on to state the manager felt Miss A’s communication with MyDentist staff, across more than one practice, was inappropriate and accordingly issued a warning letter, in line with the Practice zero tolerance policy. It further states, as Miss A communications with staff continued to be unacceptable the decision was taken to remove her from the list.
58. MyDentist’s equality and diversity policy and failure to attend/late cancellation guidelines do not address removal from the list due to patient unacceptable behaviour. The National Health Service (General Dental Services Contracts) Regulations 2005, Schedule three, part 1.5 states, in the case of the reasonable opinion of the contractor (dental practice) an irrevocable breakdown in the relationship between a patient and their dental practice has taken place, the practice should inform the patient and the Primary care Trust it will no longer provide services to that patient.
59. Part 1.4 also states services shall not be refused to a person if the grounds for doing so relate to ‘(a) a person’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical or dental condition; or (b) a person’s decision or intended decision to accept or refuse private services in respect of himself or a family member’.
60. Sections 2.1.1 and 2.2.1 also states practices must treat patients as individuals, taking into account their specific communication needs and preferences where possible, listening to them and communicating effectively at a level they can understand, about treatment and possible costs. Sections 2.3.3. and 2.3.4 further states they should recognise patients’ communication difficulties and try to meet the patients’ particular communication needs, and satisfy themselves patients have understood the information given to them.
61. A review of the evidence provided by the Practice shows no indication Miss A advised any of the MyDentist practices of her preexisting anxiety and PTSD. The records indicate staff listened to Miss A and tried to assist her to the best of their ability. They communicated clearly the fact telephone lines were busy and NHS appointments were limited and taken fast. They offered Miss A private hygienist appointments and were clear as to the costs of these.
62. Section 9.1.1. of the NHS (General Dental Services Contracts) Regulations 2005, states you must treat all team members, other colleagues and members of the public fairly, with dignity and in line with the law.
63. The records, including emails between Miss A and the Practice manager and the Practice and MyDentist patient support, as well as statements from reception staff at the practices, indicate the language used by Miss A both verbally and by email was, on many occasions, not of the expected level, being perceived as rude or confrontational by the staff involved. Emails between the Practice Manager and MyDentist patient support and indicate the practice manager raised this behaviour with Miss A on several of the calls.
64. Miss A denies being rude or unreasonable in any of her communications and audio records of the telephone calls are not available. The (undated) statement from the receptionist at Whiston, and the statement by the acting manager at the Practice, dated 20 April 2023, reference statements by Miss A that involve personal attacks on staff previously spoken to. Miss A has made it clear in her complaint form to the Ombudsman, and during the telephone call of 28 February 2024, her anxiety can increase when she is frustrated or upset, and her PTSD can be triggered.
65. The copy of her GP letter, dated 14 February 2024, states Miss A struggles with communication, can be triggered by people who do not offer her the patience and understanding of her circumstances and has difficulty trusting strangers. Taking into account the emails from the Practice to MyDentist patient support, statements from members of staff, information provided by Miss A and the GP letter, our view, based on a balance of probabilities, although Miss A may not have intended to behave in a way that aggressive or due, this is how her communications came across to the staff involved.
66. The email of 16 May 2023 from patient support states Miss A’s behaviour on several occasions was ‘in serious breach of zero tolerance policy’. No zero tolerance policy has been provided to PHSO by the Practice and no NHS wide policy is able to be located.
67. However, the NHS England publication ‘Violence prevention and reduction standard’ indicates aggression by patients, both verbal and physical, is not something to be tolerated. This is supported by other publications, such as the NHS Constitution which states patients should treat NHS staff and other patients with respect.
68. UK Government Standard General Dental Services Contracts, does not specifically reference unreasonable behaviour such as language but paragraph 33.1.and 33.2 does state where a patient has committed an act of violence against, or behaved in such a way against any clinicians or dental practice staff, as a consequence of which that person has feared for his safety; and the Contractor has reported the incident to the police, the Contractor may notify the Board that it will no longer provide services to that patient under the Contract.
69. Paragraph 35 states notification of the decision not to provide services may be given by any means including telephone, email, or fax but if not given in writing shall subsequently be confirmed in writing within seven days.
70. The Practice response of 23 September 2023 states both a warning letter and final letter were issued to Miss A regarding her behaviour. The records provided include one letter which was undated. This letter advised Miss A she had been removed from the Practice list due to her unacceptable behaviour. We therefore cannot say with any certainty whether a warning letter was issued.
71. It is therefore our view, taking into account the referenced guidance, and the fact Practice records state clinicians refused to see Miss A, the decision to remove her from the Practice list immediately was reasonable.
72. It is therefore our view there are no failings on behalf of the Practice with regard to this aspect of the complaint.
73. We understand the frustration Miss A expressed about not being able to obtain an NHS appointment. We understand how this may have been heightened for her, due to her preexisting anxiety and PTSD symptoms. We understand this may have made her symptoms of anxiety and PTSD worse and acknowledge how difficult this may have been for her.
74. It is our view the Practice, as well as the other practices, tried their best to assist Miss A in accessing the procedure she wanted. The records provided indicating telephone calls and emails were responded to in a reasonable time frame. It is unfortunate an NHS appointment was not able to be found, due to the demand on the Practice for NHS appointments.
75. As the records from the practices indicate the procedure was not clinically necessary for her refitting of a crown appointment to go ahead, it is our view there are no indications of failings on behalf of the Practice with regard to this aspect of the complaint.
76. With regard to Miss A’s statement that she believes the Practice has not kept accurate or up to date records. This issue is more suitable to investigation by the Information Commissioner’s Office (ICO) because it more to do with falsified or incorrect recording of data. The ICO is the UK’s independent authority for data protection and information rights.
77. It is therefore our decision that this aspect of the complaint should not be investigated by the Ombudsman, and if Miss A wishes to take this issue further she should contact the ICO directly. We have shared ways of doing this with Miss A in our accompanying letter.
78. It is our overall decision that there are no indications of failings on behalf of the Practice or NHSCM.
79. We thank Miss A for being willing to bring her concerns to us and understand how difficult this may have been for her. We hope this detailed explanation helps her understand how and why we have reached our decisions.