18. Miss E says the Practice did not drill far enough during her root canal treatment. She says this mistake caused her to get an infection.
19. The Practice reviewed Miss E on 4 July 2021, as she had pain in her lower right front tooth (LR1). The dentist diagnosed Miss E with irreversible pulpitis (inflammation of the tooth’s pulp) and said she may need to have a root canal treatment.
20. BES guidelines give clinical steps on how to improve the outcome of a root canal treatment. These include the ‘root filling extending within 2mm of the radiographic apex’ (the highest point or tip of the root as seen on an X-ray).
21. The Practice performed Miss E’s root canal treatment on 6 July 2021. During the procedure the dentist took an X-ray. The dentist noted that the preparation ‘appeared short at the radiograph but checked with the apex locater [a physical measurement tool] multiple times for the canal length prior to obturation [filling and sealing]’.
22. BES guidelines say ‘To help with diagnosis, prognosis and treatment planning of the root filled tooth, a thorough radiographic assessment [an X-ray] is required’. It goes on to say ‘this is to check the quality of the obturation - extent of the root canal filling, presence or absence of voids and root filling material’.
23. Our adviser confirmed the X-ray showed the completed root canal filling was more than 2mm short of the apex and that the X-ray is more accurate than an apex locator which has the potential to malfunction.
24. We find the decision to prefer the apex locator finding was a failing and led to a root canal treatment that was too short.
Initial impact - infection
25. Miss E says the Practice’s failings in the original root canal treatment caused her to have an avoidable infection. BES guidelines say ‘The aim of obturation is to establish a fluidtight barrier to protect the periradicular tissues [tissues around the root] from microorganisms that reside in the oral cavity’.
26. Our adviser said an incomplete obturation (preparation) increases the risk of infection. Our adviser said the Practice’s failure to fully prepare Miss E’s tooth likely caused the infection as bacteria would have been able to enter the short root canal. Our adviser went on to explain this likely caused Miss E to be in avoidable pain from the infection that developed.
27. The Practice told us Miss E had an infection before the treatment. The records do not support that view. On 4 June 2021 it noted she had ‘irreversible pulpitis’ (inflammation of the pulp). The dentist took a radiograph and noted in the records they ‘explained to pt that can't see anything on the radiograph’. On 9 June when it assessed Miss E again, the dentist documented ‘explained to pt that nerve has died and is favourable to have RCT to prevent secondary infections’. There is no mention in Miss E’s dental records that the cause of her irreversible pulpitis was an infection. The first mention of an infection was in August 2021 which was after the Practice did the root canal.
28. The medical records recorded at the time are a contemporaneous piece of evidence, whereas the Practice’s current view is based on events years later. On the balance of probabilities, we are persuaded that the records at the time are a more accurate account of events, over the Practice’s current view.
29. We find that, on the balance of probabilities, the Practice’s root canal treatment failings led to her developing an infection.
30. The Practice had opportunities to put that right. The next sections of our report will consider what the Practice did next.
Referral
31. Miss E says that following her infection the Practice should have referred her to hospital sooner for treatment, and this delay caused her to be in pain longer than necessary.
32. Miss E returned to the Practice on 18 August 2021, as she had an infection. She was also actively complaining about problems with her root canal treatment from September 2021. When the Practice saw Miss E on 13 January 2022, she said she was still having pain, and the dentist again noted the root canal treatment was ‘short’.
33. The dentist noted Miss E wanted to have NHS treatment to resolve her problems. The dentist referred her to the local hospital because they were unable to do the root canal themselves due to complexity. The hospital rejected the referral.
34. The hospital’s referral guidelines say it will provide dental treatment for patients:
• with special or social care needs • with moderate or severe learning disabilities • with severe physical disabilities for whom access to a local dentist is impossible • with severe management, behavioural, or psychological difficulties • who are house bound • with severe cognitive impairment.
35. The dentist ticked ‘re rct’ on the referral form. But that tick-box was a simple means of selecting the type of treatment needed, with further sections on the form available to describe the reasons for the referral to the hospital. Miss E would have needed to also meet one of the above criteria for the hospital to accept the referral. She did not meet any of those criteria.
36. We find the Practice did not take account of the referral guidelines above when completing the referral. We cannot say the Practice should have referred Miss E to hospital sooner. As the hospital was not commissioned for this service the Practice should not have referred her there at all. The mistake certainly did not set her expectations correctly.
37. GDC guidance says that when referring a patient, it should be in their best interests and should be appropriate and effective. GDC guidance also says dentists should ‘provide good quality care based on current evidence and authoritative guidance and delegate and refer appropriately and effectively’. Miss E attended the Practice with an infection and short root canal, the Practice referred Miss E to the hospital. Referring Miss E to the hospital when she did not meet the referral criteria was not effective, this is because it was not appropriate or in her best interests as she did not meet the criteria for acceptance. This was a failing.
38. That failing added to the delay in fixing Miss E’s failed root canal treatment which we consider in the next section of the report.
Completion of root canal treatment
39. Miss E says there were avoidable delays in the Practice completing her root canal treatment. She says this left her experiencing shockwave pains and increased the chance of her tooth going black.
40. The Practice reviewed Miss E on 27 August and diagnosed her with a failed root canal treatment and an infection. It prescribed antibiotics. The dentist noted the ‘rct slightly short’. The dentist noted Miss E would likely need specialist treatment. They noted Miss E understood this and asked to be referred internally to an endodontist. During an appointment in September 2021 Miss E said she did not think she should need to pay for private treatment to fix her failed root canal.
41. Miss E sent the Practice a statement in September 2021, explaining that she was still in pain. The Practice offered her a referral to an internal specialist on a private basis. But it is also clear Miss E was saying she wanted her treatment on the NHS. The Practice did not see Miss E again until January 2022.
42. During that consultation the dentist noted her only options were specialist treatment on the NHS at hospital (which we have discussed above) or via a private referral. The Practice told us it could not do the treatment on the NHS as she now needed specialist treatment, and it did not have a clinician who was able to do it on the NHS. The records do not show it explained to Miss E clearly why it could not do the treatment at the Practice.
43. We asked our adviser if Miss E could have had her treatment sooner than August 2022, a year after she reported problems with the root canal treatment. Our adviser explained Miss E could have had her root canal treatment at the local Practice sooner. BES guidelines say non-surgical retreatment can be started because of ‘Procedural errors including separating instruments and perforations’. The dentist appears to have made a procedural error during Miss E’s first root canal treatment because they did not prepare the tooth correctly and the root canal was short. Our adviser said they could see nothing in the records to explain why the Practice could not follow the BES non-surgical retreatment guidance above.
44. When Miss E complained about the Practice not fixing her failed root canal on the NHS it referred her complaint to the dentist who originally did the treatment. That dentist had since left the Practice. There was a delay in that dentist responding. In July 2022 the original dentist offered to pay for the treatment. In the meantime, the Practice took no action to resolve the problem itself.
45. The Practice holds a Standard General Dental Services contract with the NHS.
46. Clause 61 of that contract says ‘where a restoration specified in clause 62 needs to be repaired or replaced, the Contractor shall repair or replace the restoration at no charge to the patient’. It goes on to say that ‘The restorations referred to in clause 61 are […] root filling’. In this case, the Practice is the contractor, not the dentist who carried out the original root canal treatment.
47. The NHS website also confirms that ‘If you have had restorative treatment on the NHS, and something goes wrong, requiring repair or retreatment, within 12 months of the original treatment, then your dentist should do the necessary work free of charge’. Restorative treatment includes root fillings.
48. In response to an earlier version of this report the Practice said ‘It was not the practice which completed the root canal treatment for the patient, but rather, the dentist’. It also said ‘The practice has no control over the outcome of treatment provided by a GDC mandated dentist. Contractually, every GDC registered and mandated dentist has full clinical freedom and the practice owner cannot control the treatment discussion and outcomes in case of 1000s of patients seen by each dentist in the privacy of their surgery’.
49. We approached NHS England to ask it if our understanding of the NHS Dental Services Contract was right. NHS England confirmed to us that our understanding, that the ‘Contractor’ who is named on the contract (which in this case is the Practice) retains overall responsibility for the NHS care its clinicians provide, is correct. Furthermore, the NHS contract says the name of the Contractor and not the Performer should be entered onto the treatment plan. Miss E’s treatment plan shows the Practice’s name and not the individual dentist.
50. We find, as confirmed by NHS England (above), that it was the Practice’s responsibility to fix Miss E’s failed root canal in line with its NHS contract. This was to be at no expense to her. The Practice failed to do this. It delayed fixing the problem by first making an incorrect referral to the local hospital and then chasing the dentist for a solution to the problem the Practice was responsible for. Not fixing the failed treatment its dentist caused, even if this was at its own expense, was not in line with GDC guidelines or the NHS General Dental Services contract.
51. Miss E had her treatment at the Practice in August 2022, carried out by a dentist in the Practice who had the specialist training required to complete the treatment. This option was available to the Practice sooner. It should have taken responsibility rather than wait for the individual dentist to agree to pay. It did not act in line with GDC guidance. This was a failing.
Extended Impact
52. Miss E says that, having developed an infection, the Practice’s failure to resolve the problem for over a year meant she was in pain for longer than she needed to be.
53. Miss E began complaining about pain in August 2021, one month after her treatment. The dentist recommended referring her internally to an endodontist in August but Miss E wanted her treatment completed on the NHS. When she was seen again in January 2022, it incorrectly referred her to the hospital. This referral should not have been made, as Miss E did not meet the criteria. This caused a period of avoidable pain for Miss E as when she was seen again she still had an infection. Miss E was also actively complaining to the Practice manager who knew she was still in pain.
54. Miss E developed an infection first in August 2021 one month after the Practice did the original root canal. Miss E had no further dental treatment on that tooth until August 2022 when the Practice redid it privately at the expense of the original dentist who did the treatment. We find the Practice caused Miss E to be in avoidable pain for a year.
55. Finally, found the Practice should have taken responsibility to redo Miss E’s root canal treatment sooner, as set out in the BES guidance, but instead continued to liaise with the dentist who had left to pay for the treatment. Our adviser explained that if the Practice was unable to complete it under the NHS, it could have referred Miss E to another NHS dentist in the area. Alternatively it could have contacted the NHS local area team to see if there was another NHS dentist in the area with the skills to treat Miss E. Not doing this caused another preventable delay in fixing the failed root canal treatment.
56. Overall, we find that because The Practice delayed fixing the problem Miss E was in pain for a year longer than she needed to be.
57. As for the other impacts Miss E told us about, our adviser explained that as front teeth are used for a lot of biting down, this would have impacted Miss E’s ability to carry out basic daily tasks such as eating. Our adviser said that although there was a chance her tooth could go black regardless of any failings, this risk would have increased because of the delay to fix the failed root canal treatment. And the shockwave pains she experienced up until the root canal was redone were likely caused by the poor treatment provided in July 2021.
58. Our adviser also explained there was a risk Miss E’s tooth could fall out in two years even without the poor treatment that was provided, but this risk will likely have increased because of the Practice’s delay fixing the poor treatment. Although we are unable to say for certain her tooth will fall out, this will have led to an impact of a missed opportunity for a better clinical outcome.
The Practice’s comments
59. We discussed an earlier draft of this report with the Practice. It commented that there is no guarantee dental treatment will be successful, and that where that is the case it might not be appropriate to provide further NHS care to fix any problems that arise. The Practice also highlighted the problems with NHS dental provision in England, and that access to NHS services can vary from area to area.
60. The Practice explained that when NHS dental treatment was not successful in resolving problems, or where complications occurred, their local area might not have NHS pathways or services to provide ongoing or more specialist treatment. It was concerned that our report implies Practices should be responsible for shouldering the burden of providing treatment, and paying for that treatment, where NHS pathways do not exist in their area. The Practice said there were no appropriate pathways on the NHS to treat Miss E’s complication. It said it had offered private treatment to her, but she insisted on NHS treatment.
61. We are grateful to the Practice for taking the time to consider our provisional views. It has clearly thought carefully about our report and we were happy to reflect on those points.
62. Without going into further detail here, we agree there are significant challenges in the provision of NHS dental services in England. Those challenges are well-publicised, and we know the issues facing NHS dentistry will vary from area to area.
63. We also agree with the point the Practice makes about NHS treatment that does not deliver the outcomes hoped for. There are no guarantees that any sort of NHS treatment will work. Treatments might fail to resolve the underlying problem, or complications, both common and rare, might cause additional issues. The Practice also noted that where there is fault in care in the NHS then remedial action is picked up in the NHS, whereas where there is fault in care in NHS dental work the commissioning arrangements do not allow for that. The effect is that remedial care in such cases, as here, falls on the dental practice to provide out of its own resources. The Practice made the point forcibly that this represented an inequity around dental care provision and incentivised dentists to avoid providing NHS care.
64. That said, we are of the view that in this individual case the Practice was responsible for what happened with Miss E’s root canal treatment. That is because we consider this was not an unfortunate complication of good care. As we explain in paragraphs REF _Ref219963374 \r \h 18 to REF _Ref219963384 \r \h 24, the treating dentist did not act in line with relevant guidance in the initial root canal treatment. The root canal treatment was too short and that was the cause of Miss E’s subsequent problems. As such, in this case, the onus was on the Practice to put things right.
Conclusion
65. Overall, the failings we have found stemmed from the dentist not preparing Miss E’s tooth fully at her first root canal appointment. We find it is more likely than not that had the dentist prepared the tooth fully this would have reduced or prevented the chance of her developing an infection. Miss E went on the develop an infection which lasted almost a year. The Practice should have resolved the problem much sooner. Delays in treatment were caused by the Practice erroneously referring her to hospital and then waiting for the original dentist to pay for her to have private treatment.