A dental practice in the City of Wolverhampton area

4. Mr X, represented by Mrs X, complains about the care the Practice provided to him on 8 October 2024. He says:

• The Practice did not consult his wife regarding his treatment, despite her being his main carer, before extracting four teeth.

• The Practice should not have extracted any teeth from him knowing he was taking the medication apixaban.

5. Mr X says he has suffered as consequence of the treatment provided by the Practice on 8 October as he now struggles with eating and has needed an increase in medication for Anaemia. Mr X says he and his wife have both suffered stress and upset because of the Practice’s actions.

6. As an outcome to the complaint, Mr X would like an acknowledgment that the Practice made mistakes, as well as a financial remedy for the discomfort and distress caused.

7. On 8 October 2024, Mr X attended the Practice due to two loose teeth. Mrs X did not go into the examination room with Mr X initially but did take him into the Practice to check-in. Whilst there, Mrs X informed Practice staff that Mr X had been taken off his previous blood-thinning medication, warfarin, and instead been put on apixaban, a different blood-thinning medication.

8. Mr X attended the Practice for what he tells us he believed was an initial examination. He and his wife did not believe any teeth would be removed at this time, nor until Mr X had come off his blood-thinning medication. Mr X had not been to the Practice in two years, but previously a dentist at the same Practice had refused to remove Mr X’s teeth until he had come off his blood-thinning medication.

9. After approximately forty-five minutes, Mrs X, curious about the length of time her husband had been gone, was told by Practice staff she could enter the examination room. Mrs X was informed that the dentist had removed four of Mr X’s teeth and Mr X had been given stitches. Mrs X says she was never consulted regarding Mr X’s treatment.

10. In the early hours of 9 October, Mr X’s bleeding became worse. He was taken to hospital by paramedics where he required further stitches and a blood transfusion.

11. On 11 October, Mr X’s bleeding began again, and Mrs X rang 111. Paramedics took Mr X to hospital where he required further stitches.

12. Mr X says he still struggles to eat because of the treatment, due to having so many teeth removed, and has needed an increase in medication for anaemia as a result. This was discovered after a doctor suggested Mr X seek medical attention due to significant weight loss, as he was unable to eat properly due to the removal of so many teeth. After seeing a doctor about the weight loss, Mr X was sent for blood tests which confirmed anaemia.

13. Mr X was unhappy with these developments and so he and his wife complained to the Practice, and then to our Office.

17. When we consider 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. We explain why below.

Consent

18. Mr X complains that the Practice did not consult his wife regarding his treatment, despite her being his main carer.

19. Mrs X kindly gave us a copy of her carer’s card from the local council, and it is clear to us that she is her husband’s carer. We therefore reviewed the Practice’s records and considered whether it should have done anything differently in managing communication with Mr X and his wife.

20. We have not seen anything within the patient file from the Practice that indicated Mrs X was officially listed as her husband’s carer. We also found no record within the file that Mr X lacked capacity or was unable to give consent to the treatment himself. There is an entry within the patient file confirming that Mr X was of sound mind at the time of the procedure. The Practice also told us that Mr X showed full mental capacity to understand the treatment options and possible risks and complications, and to provide consent to that treatment. Because of this, the Practice advised it was not required to get Mrs X’s consent before going ahead with the procedure.

21. Since there was no evidence that Mr X lacked capacity or had given Mrs X the authority to make decisions for him, we have not seen any guidelines or standards that indicate the Practice should have declined to accept Mr X’s own consent. It explains the consent process was discussed with Mr X, and he made the decision to proceed. This appears in line with the GDC guidance, section 3.1.1, which says, ‘you must make sure you have valid consent before starting any treatment or investigation’ and section 3.2.4, which says ‘you must always consider whether patients are able to make decisions about their care themselves’. As such, we have not seen any indications of service failure here.

22. The patient file does contain a consent document, signed by Mrs X, and treatment plan. This indicates Mrs X should have been aware of what treatment was planned for her husband.

23. Mrs X says she was forced to sign the consent document, and did so only after the procedure had taken place, before being allowed to leave the Practice. This is something the Practice disputes. We have considered this complaint that the Practice handled signing of the consent document poorly.

24. The Practice told us that the dentist explained the treatment options and potential risks and complications to Mr and Mrs X. Mr X provided verbal consent for the treatment to proceed. The dentist then asked Mr X to sign the consent forms before starting the treatment but, as Mr X was experiencing pain in his tooth, Mrs X offered to sign on his behalf. The Practice says Mr X gave verbal consent for his wife to do so, and she signed the consent forms on his behalf.

25. We have carefully considered whether we could reach any independent and impartial view here as to what happened, based on the evidence available to us. Having reviewed the evidence provided by both Mr and Mrs X and the Practice, we are not able to give a view on the balance of probabilities as to what took place. As such, we are not able to reach a view on this matter and so will take no further action.

26. We acknowledge Mrs X’s concerns and appreciate the important role she plays in supporting her husband’s care, and we hope we have clearly explained why we will take no further action here regarding the signing of the consent document. As explained previously, where the Practice’s obtaining of consent from Mr X directly is concerned, we have not seen any indications of mistakes.

Removal of teeth

27. Mr and Mrs X also complain the Practice should not have extracted any teeth from Mr X knowing he was taking the blood-thinning medication apixaban.

28. We considered this issue with the help of our Adviser. They told us that the guidance from the SDCEP (paragraph 16) grades dental procedures from ‘low risk’ to ‘higher risk’ for bleeding. They told us ‘higher risk’ does not imply a procedure is dangerous, just that it carries a greater risk of bleeding than a low-risk procedure. However, the risk of the procedure itself is still relatively low. A low-risk procedure would not need the patient to change their dose of apixaban and would include the removal of up to three teeth in a single visit, where the removal of the teeth was considered a simple extraction.

29. The guidance recommends that for a higher risk procedure the patient misses one dose of their medication before the procedure takes place and advises they may require stitching of wounds as a secondary precaution. This type of procedure would include:

• More complex surgical dental extractions.

• The removal of more than three teeth in a single visit.

• The removal of adjacent teeth.

30. Based on the SDCEP guidance, we explored whether the Practice followed that guidance correctly, as Mr X had four teeth removed.

31. After looking at the patient file and speaking with our Adviser, we can see the four teeth removed from Mr X were very loose and likely easy to take out. Our Adviser told us the extractions would have been relatively simple. Although two of the teeth were next to each other, our Adviser explained it would not have made sense to leave one behind, and the guidance provides recommendations that dentists must consider in addition to using their clinical judgement.

32. The clinical notes show the dentist packed and stitched the sockets after the extractions, which is in line with the guidance for reducing the risk of bleeding in patients on apixaban. Our Adviser also said that, based on the notes, Mr X was likely in pain from these teeth. As such, it would have been generally in keeping with the guidance and in Mr X’s best interests clinically for the dentist to offer treatment on the same day, especially if Mr X agreed to it.

33. Our Adviser explained that there is always a chance of bleeding after any tooth removal. Whilst the risk is higher for patients on blood-thinning medications, bleeding can still happen and is sometimes unfortunate but not a sign of a mistake by the dentist.

34. With the above in mind, it appears the care given to Mr X was appropriate, and generally in line with the provisions of the SDCEP guidance. Because the teeth were very loose this would have mitigated the risk, and it would likely have been more important to relieve Mr X’s pain. Our Adviser said this was a case of clinical judgement by the dentist, and they told us the judgement used in Mr X’s case was appropriate.

35. Therefore, we have not seen any indication of failings. Clinicians need to be able to use their judgement to balance the risks and make decisions that are in the best interests of the patient. We consider the dentist who treated Mr X acted appropriately and, for that reason, we have decided to take no further action.

36. From speaking to Mrs X, we understand how upsetting and stressful this experience has been for her and her husband, and we appreciate them taking the time to raise their concerns and speak with us. We hope our review and explanations have been helpful and provide some clarity.

1. We have carefully considered the complaint Mr X, represented by his wife, Mrs X, has brought about the Practice. We are sorry to learn of Mr X’s experiences with the Practice, and we know that he and his wife have been upset and distressed by the events of the complaint.

2. We have considered the evidence available to us carefully, including obtaining independent clinical advice, and we do not see any indication of failings by the Practice in the treatment provided to Mr X. Where the signing of the consent form is concerned, we are not able to give any view on this matter, based on the evidence available to us. Therefore, we have decided to take no further action.

3. We explain the reasons for our decision below and hope they provide Mr and Mrs X with reassurance that we have given full consideration to their concerns.