Treatment
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. Mr A says the Practice did not complete his RCT and passed all blame to the treating dentist. He says the Practice told him to seek alternative treatment options privately or start a new treatment plan.
15. The Practice passed the complaint to the original dentist who contacted Mr A and offered to continue the treatment at their new Practice. However, Mr A had an NHS exemption due to his Universal Credit status for the treatment plan to be paid for at the Practice.
16. The NHS defines a RCT as:
‘Root canal treatment (endodontics) is a dental procedure used to treat infection at the centre of a tooth. Root canal treatment is not painful and can save a tooth that might otherwise have to be removed completely.’
17. The dentist originally started the RCT on LL6 (lower left first adult molar tooth) on 16 October 2023. The dentist found the treatment was challenging and advised Mr A that either specialist treatment would be needed, or they could fill the root canal to the accessible length but this would not be the full length of the root.
18. From the notes dated 16 October 2023, Mr A opted for specialist treatment, and said he ‘will check with his own dentist and then get back to us if he wants specialist referral through [Practice]’. It is not clear who Mr A’s ‘own dentist’ was.
19. It appears Mr A then chose to return to the dentist at the Practice for treatment instead. The records show the dentist completed Mr A’s LL6 RCT on 6 November 2023, with a plan to crown this tooth.
20. The records show the dentist made Mr A aware that failure of RCT can happen at any time in the future (days to many years after the procedure). Also, further treatment may be required such as re-RCT or extraction and replacement of the tooth which the dentist explained would be at Mr A’s expense. The records show Mr A understood the risks and was happy to continue. The plan was for Mr A to return for a full coverage crown but the dentist left the Practice before this could be arranged.
21. Having reviewed the records, it appears the dentist’s communication was in line with GDC Standards Principle 2 ‘Communicate effectively with patients’ which says:
‘You must communicate effectively with patients – listen to them, give them time to consider information and take their individual views and communication needs into account.
You must give patients the information they need, in a way they can understand, so that they can make informed decisions.’
22. Mr A saw a different dentist at the Practice on 16 February 2024 who declined to place a crown based on their clinical judgement that the RCT was sub-optimal (not at the best possible level). Our adviser says the dentist was justified in saying they did not feel comfortable placing the crown.
23. The NHS website for ‘Root canal treatment’ says:
‘A crown is a cap that completely covers a real tooth. It might be necessary to use a crown after root canal treatment to prevent the tooth fracturing. Root-filled teeth are more likely to break than healthy unrestored teeth, so your dentist may suggest placing a crown on the tooth to protect it.’
24. The dentist then wrote a clinical note to say they advised Mr A they could refer him to an NHS hospital for a re-RCT but there would be a risk of rejection due to capacity or they could submit a private referral which would cost around £600-700. The records show Mr A did not attend or make any further appointments at the Practice after this date.
25. The additional evidence Mr A has provided shows he chose to pay for treatment privately at another practice for re-RCT of LL6. This did not include provision of a crown.
26. The records show there were three months between the original RCT and the follow up appointment in February to consider a crown being fitted. Our adviser says the original RCT did not reach the bottom of the root so it was sensible to monitor for any symptoms and three months is a reasonable timeframe for this.
27. Our adviser explained patients are ‘patients of the practice’. Although patients often see the same dentist who has a duty of care while they work at the practice, once the dentist has left, it is the practice’s responsibility to provide continued care if there is an open course of treatment (COT), or if further treatment is indicated as part of the previous COT.
28. Our adviser says a dentist will examine the patient and decide what treatment is needed. A treatment course is opened, and the course should stay open until treatment is completed. There is no set timeframe for the work to be completed in, the treatment course would remain open regardless of time taken to complete the work.
29. However, it is reasonable to close a course of treatment if (for whatever reason) the patient has not been seen within two months of their last attendance. This is usually because a COT cannot be kept open indefinitely, and many changes can occur over this time period, which may then alter/add to the initial treatment plan.
30. If Mr A’s original dentist had not left the Practice and he attended the crown appointment after two to three months of monitoring the RCT, our adviser said this would more than likely have been considered a new COT and if he was no longer exempt, he would have had to pay for this.
31. We recognise the dentist leaving the Practice and being unable to complete the treatment was inconvenient for Mr A.
32. We have not found any indication anything went wrong with Mr A’s treatment. The original dentist gave Mr A all of the relevant information and risks of having the RCT so he could make an informed decision, acting in line with GDC standards. The dentist also offered a specialist referral but Mr A chose to return to the dentist for the treatment.
33. The second dentist also offered an NHS hospital referral, or a private referral and informed Mr A of the potential costs involved but he did not follow up on this. We are pleased to see the Practice offered Mr A alternative treatment options and shared all of the relevant information with him.
Cancellations
34. Mr A says his RCT was delayed due to a number of cancelled appointments and this left sensitivity in his tooth due to the incomplete procedure.
35. The Practice passed Mr A’s complaint to his treating dentist who had, by this point, left the Practice. The dentist apologised for the delays and explained these were related to illness or equipment malfunctions.
36. Mr A attended an appointment on 1 September 2023 following an emergency dental appointment. The notes indicate the RCT had been started but needed completing and Mr A was to book the necessary appointment.
37. It appears Mr A had an appointment booked for 21 September but the dentist’s patient list was cancelled due to ill health. The Practice rebooked Mr A’s appointment for 28 September but, unfortunately, the dentist’s patient list was cancelled again due to ill health.
38. The records show a further appointment was booked for 16 October 2023, the dentist could not reach the full canal length but offered to complete the work to this length or for Mr A to have a specialist referral. Mr A said he would contact the Practice about this, so the work was not completed on this day.
39. The records show Mr A had a further appointment booked for 24 October 2023 but the dentist’s patient list was cancelled again due to ill health. The Practice rearranged his appointment for 27 October 2023 to have the RCT done, however, this had to be rescheduled due to the machinery not working.
40. The Practice booked another appointment for Mr A for 6 November 2023 which he attended and the RCT was completed.
41. The records do not indicate Mr A was in any pain or discomfort prior to the RCT being completed as there were no emergency appointments between 1 September 2023 and 6 November 2023.
42. We spoke to the Practice manager who explained:
‘As a practice we believe in providing exceptional patient care, and whilst cancelling a patient’s appointment should only happen as a last resort, unfortunately sometimes it is completely out of our control. If a dentist cancels their day due to sickness or an emergency, we will try to accommodate the patient’s re-scheduled appointment as a priority. If we are unable to accommodate the appointment, we will offer the most suitable day and time and add the patient to our cancellation list.’
43. Mr A had four appointments cancelled from 21 September to 27 October 2023 and we understand this was very frustrating. We also recognise this impacted his personal commitments, work schedule and earnings. The cancellations also delayed his root canal treatment.
44. The Practice did offer Mr A a new appointment when it had to cancel and these appointments were re-booked promptly.
45. This was in line with Our Principles of Good Administration for ‘Being customer focused’ which says:
‘Dealing with people helpfully, promptly and sensitively, bearing in mind their individual circumstances.
Ensuring people can access services easily.’
46. We recognise that staff members can be unexpectedly unwell and may not be able to work or other factors can cause cancellations out of the Practice’s control. These cancellations are often provided on short notice and we recognise this is inconvenient for patients. However, we cannot say this is a failing. We are pleased to see the Practice re-booked Mr A’s appointments whenever there was a cancellation and this was typically within eight days of the original appointment.