13. This complaint involved two conflicting accounts for us to consider. This meant we have had to consider on a ‘balance of probabilities’ the most likely version of events.
14. We consider Mr E’s account of his experience with the Practice has been consistent. He has given the same account in writing, and verbally, on the complaint given to us, as well as the complaint he made to the Practice.
15. We have also found the Practice’s view does not support what Mr E has told us in either its clinical records, or its complaint response.
16. We have considered each perspective, but do not feel we can reach a view on what occurred during the September 2024 appointment. This is because we cannot see evidence which would allow us to form a view on what the Practice communicated to Mr E about the specialist referral for the root canal treatment.
Mr E’s view
17. Mr E says the emergency dentist told him to talk to reception staff before he left the Practice to arrange the referral to a specialist. Mr E complains that when he followed the dentist’s instructions, reception staff told him they do not make referrals, so he was left to find treatment for himself.
18. For Mr E this was very difficult as there were no spaces for NHS dentistry in his local dental practices. He explains he felt time pressured to find a resolution because the temporary dressing would only last two to three months and he did not want to lose his tooth.
19. Mr E says these factors forced him to pay to see a private dentist. The private dentist confirmed he needed specialist treatment, and the referral was made privately. As a result, Mr E incurred costs of nearly £2500 for the root canal treatment and the crown replacement.
20. We considered the impact of Mr E seeking private treatment for the RCT and crown. The payment Mr E made for his treatment was significant and we appreciate that this decision will not have been made lightly. Mr E said that he felt worried that if he did not find a specialist to treat him, he would lose his tooth. He was also feeling anxious there was no other availability for NHS dental treatment in his area, so he sought out the private care believing the Practice did not make specialist referrals for their patients. We understand this will have been a time-pressured and worrying time for Mr E.
21. We do not consider that Mr E is likely to have left the Practice and willingly gone to a private specialist knowing how expensive it would be, if he didn’t feel he had to.
22. The General Dental Council guidance (2013) states:
‘You should refer patients on if the treatment required is outside your scope of practice or competence. You should be clear about the procedure for doing this’
23. This indicates the Practice had a duty of care towards Mr E to make a specialist referral, which we know the Practice is aware of because of the evidence shown by the Practice Manager and the accounts from dentists mentioned earlier in this statement.
24. It is possible the emergency dentist was not clear enough about the procedure for referrals when speaking to Mr E, but we have no way to prove this.
The Practice’s view
25. We can see the dentist who treated Mr E in August 2024 responded to his complaint stating that when Mr E subsequently returned to the Practice in September 2024 he saw another clinician who discussed his treatment options. The response states Mr E was advised an RCT would be required and it was ‘in line with established guidelines and the clinical complexities’ that he should seek care from a specialist, stating this was in his best interests.
26. In November 2025, the practice manager provided us with information regarding Mr E’s dental treatment, including context behind the clinical notes written at the time of his appointments at the Practice. When we consider this account we can see she later told Mr E that the emergency dentist seen in September 2024:
‘…explained that at the time he would dress the tooth, to allow you more time to decide if you wanted to opt for a root filling on that tooth, as you were undecided’.
27. We consider this account from the Practice to be reliable as it is taken directly from the clinical notes filled in at the time of the examination in September 2024 which we have reviewed. The Practice manager also went further on our request and asked the emergency dentist what he had told Mr E to do if he decided to go ahead with the RCT. The dentist in question said, ‘I don’t remember advising him on that’.
28. These accounts highlight that staff at the Practice are unsure about what was specifically said to Mr E regarding the timing of when it considered the specialist referral should be made in September 2024. This does not mean that we can automatically state that the Practice committed an error.
29. It is difficult for us to be critical of the dentist’s lack of recollection regarding Mr E’s appointment, given 15 months has now passed. As such, we do not consider we can make a fair decision on what was said in the appointment regarding Mr E’s referral.
30. We have considered the Practice’s processes and its understanding of how to make a specialist referral. When questioned, the practice manager said if Mr E’s case met the referral criteria, he would have been referred to the appropriate dental hospital for specialist treatment. She said this referral was not made as he did not return to see a dentist following the temporary filling in September 2024 and instead sought private treatment, meaning the ‘opportunity to discuss NHS referral options may not have arisen’.
31. When we questioned the practice manager about this complaint, she said:
‘In respect to the enquiry regarding the referral to a specialist I can confirm that I did not suggest a specialist, nor did I make a referral. I only advised the patient to rebook if any issue occurs. The patient was made aware that…at a later date, a root canal treatment/crown may be necessary’.
32. This view contradicts Mr E’s view that he was told the reception team would make the referral, only to be turned away by the team and is supported by the clinical notes we have reviewed as part of our investigation.
Our view
33. Taking all evidence from both Mr E and the Practice into account, we do not consider we can reach a view on exactly what happened or what went wrong in the appointment which took place in September 2024. As such, we cannot reach a clear decision about whether the Practice failed to complete a specialist referral for Mr E.
34. We have considered whether we needed the advice of a clinician to make a decision on this case. We have been unable to find any clinical guidelines stating the Practice has a duty to follow up on Mr E’s decisions or contact him to support him in his thinking about his treatment after he has left the appointment.
35. Given the limited amount of evidence the clinical advisor could review and the differing accounts in this case, we cannot justify moving forward to clinical advice as it would not be beneficial nor a good use of resources.
36. On balance, it seems likely that if Mr E had arranged a follow up appointment with the Practice, he would have been able to get a referral as staff would have then followed the Practice’s local policies regarding referrals (outlined by the practice manager) and the NHS guidelines above, too.
37. In reviewing this case we came to the view that, in continuing our investigation, we would have to make assumptions not based on factual evidence. This would be unfair to both Mr E and the Practice. We have no evidence which can be weighed more heavily than any other to prove what was stated around the timing of the referral or what Mr E’s understanding was when he finished speaking with the dentist.
38. Therefore, we have decided we cannot consider this matter further as we cannot reach a robust, fair conclusion. The complaint is so equally balanced that, even on the balance of probability, we cannot come to a view.
39. Given Mr E brought this complaint to us hoping that we could help him resolve his complaint and receive compensation in line with what he spent on the private treatment, we understand that this decision will be disappointing for him.
40. We hope this has clearly explained why we cannot consider his complaint further. We also help this statement helps assure him we only came to this decision after carefully considering every aspect of his complaint.