PSOW Individual Decisions

Mrs C complained about the care and treatment she received from a Dental Practice in the area of Betsi Cadwaladr University Health Board. Mrs C complained that the Practice did not perform dental work to an appropriate standard when it carried out 2 fillings on 27 February and 2 extractions on 20 March 2025. She also complained that the Practice did not provide appropriate aftercare following the extractions of 20 March. The investigation found that the dental work carried out by the Practice on 27 February and 20 March reached an appropriate standard, so this point of Mrs C’s complaint was not upheld. However, it found that, although the Dentist’s own aftercare was appropriate following the extractions of 20 March, there was a lapse in the Practice’s internal communication. The second point of Mrs C’s complaint was therefore upheld. The Ombudsman recommended that the Practice apologise to Mrs C for this lapse, and remind reception staff of its process regarding notifying dentists of contact from patients. The Practice agreed to implement the Ombudsman’s recommendations.

The investigation considered whether the dentures provided to Mr A were clinically appropriate, including the advice provided about their longevity. By way of an outcome Mr A wanted the cost of the dentures reimbursed. The Dental Practice agreed as part of a settlement to reimburse Mr A the sum of £260 for the dental treatment it provided in 2025, which included the cost of the dentures. It also said that as part of wider learning the Dental Practice will feed back any points of learning to the Dentist.

Mrs C complained that the Practice failed to provide a response to her complaint about her ill-fitting denture. The Ombudsman found that the Practice had failed to provide a response to Mrs C’s complaint. She said that this caused frustration and uncertainty to Mrs C. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to write to Mrs C with an apology and explanation for the delay in issuing a complaint response and for the failure to provide regular and meaningful updates, offer to pay Mrs C £50 in recognition of her time and trouble in making a complaint to the Ombudsman and issue a complaint response within 2 weeks.

Mr C complained on behalf of his wife, Mrs C, about the care and treatment she received from a dental practice in the area of the Health Board. Mr C complained that dental treatment for Mrs C’s fractured front tooth and crown was urgent and should not have been dealt with on a private care basis. Specifically, the investigation considered whether the decision not to offer a timely NHS appointment was made appropriately on 5 February 2024. It also considered whether the decision to decline Mr and Mrs C any further dental care on an NHS basis was appropriate. The Ombudsman found that the decision not to offer an urgent NHS appointment on 5 February 2024 was made appropriately owing to the presenting symptoms not requiring urgent care or treatment. The offer of a routine NHS appointment in April was acceptable. It was also found that there was no maladministration in relation to the decision by the Practice to decline Mr and Mrs C any further dental care, based on a breakdown in the relationship. The Ombudsman did not uphold either complaint.

Ms A complained that the Practice had not fully responded to her complaints regarding care and treatment supplied over a number of years. Following assessment of the complaint, the Ombudsman decided that some of Ms A’s complaints were out of time for consideration. Ms A had, however, approached the Practice with more recent complaints which had not been addressed. The Ombudsman sought and gained the Practice’s agreement to respond to Ms A’s more recent complaints, provide an apology and an update on her current care and treatment. The Practice agreed to do so within 30 working days.

Mr A complained that the dental practice did not fully respond to his formal complaint submitted to it in October 2024. The Ombudsman decided that the dental practice had failed to respond to a second letter of complaint from Mr A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the dental practice to respond to Mr A’s second letter of complaint and apologise for the delay in responding fully. The dental practice agreed to do this within one month of the Ombudsman’s decision.

Miss A complained about the care and treatment provided to her by a Dental Practice in the area of Cardiff & Vale University Health Board (“the Practice”), and she raised concerns about her discharge. Miss A said the Practice’s response to her complaint was inadequate, vague, and failed to address all of the issues raised. The Ombudsman decided that the Practice had not provided an adequate response to Miss A’s concerns. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement that, within one month, it would provide a full written response to Miss A, to address the points raised in her letters.

Miss B complained that a Dental Practice in the area of Betsi Cadwaladr University Health Board had removed her from its patient list after she raised concerns with it about dental charges. The Ombudsman found that the dental charges were for private treatment, so fell outside of her remit. Miss B was signposted to the Dental Complaints Service for this element of her complaint. The Ombudsman also found that the Practice had not issued a full complaint response to Miss B about its decision to remove her from its patient list, and its complaints procedure for NHS patients contained incorrect and outdated information. The Ombudsman said this caused frustration to Miss B and decided to settle the complaint without a formal investigation. The Ombudsman sought and gained the Practice’s agreement to issue a complaint response to Miss B about its decision to remove her from its patient list and to update and correct its complaints procedure within 6 weeks.

Mr M complained that the Practice had failed to respond to his complaints about the poor care and treatment provided to him. The Ombudsman found that the Practice had responded to one complaint but that there had been a failure to respond to the second complaint and this had caused frustration and uncertainty for Mr M. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Practice to apologise to Mr M and provide him with a complaint response within 3 weeks.

Mr C who had complained to the Dental Practice about the poor fitting dentures that he had paid for, was unhappy that in a telephone conversation the Dental Practice had informed him that he had been “struck off their register” due to a breakdown of trust. Mr C, who had been refunded the cost of his treatment, said that he was now having to find a new NHS Dentist. He wanted an apology for the way he had been treated. The Ombudsman found no evidence that the decision itself to remove Mr C from the Dental Practice’s register was improperly taken. However, the Dental Practice accepted that there was a shortcoming in its complaint handling process and how it how it had applied its removal policy (“the Policy”) in Mr C’s case. In particular, it had not written to him setting out the reasons for its decision to remove him from its dental list. In reviewing the Policy, the Ombudsman concluded that there was a degree of ambiguity about the circumstances when a letter would be written to a patient. The Dental Practice agreed as part of a settlement that it would apologise to Mr C for the shortcomings identified in the way that it followed the Policy. In addition, it would amend the Policy so that it was clear that a letter would be sent in all cases about a patient’s removal and relevant information provided in relation to NHS patients.

Mr A complained that a dental practice had not provided treatment for an issue with his front tooth. He said that he had made a complaint regarding this but had not received a response as the dental practice had closed and contact was unable to be made with the dentist that had treated him. The Ombudsman found that Bupa Dental Care could have investigated and responded to Mr A’s complaint, despite not being able to contact the dentist that treated him. Bupa Dental Care agreed to apologise to Mr A, offer him a payment of £100 to reflect the time and trouble taken for him to pursue his complaint and provide a full and final response to his complaint.

Mr D complained about the care and treatment his wife had received from the Practice. He complained about communication including that she had attended an appointment which was cancelled without prior warning. He also complained that he had requested copies of his wife’s records on 13 March 2024, in order to inform a formal complaint about her care, and these were not provided despite him supplying the required consent from his wife. Mr D complained that his wife had not received permanent fillings despite multiple appointments and instead said she had been lectured on dental hygiene. The Ombudsman found that Mr D had provided the required consent for his wife’s records to be released to him but the Practice had not actioned this. Mr D had therefore been unable to submit a formal complaint of his concerns. The Ombudsman also found Mr D had informed the Practice that his preferred method of communication was email. The Practice agreed to, within 4 weeks, issue Mr D with an apology and explanation about why he was not provided with his wife’s dental records. It also agreed to provide a copy of the records to enable him to submit a formal complaint. The Practice also agreed to confirm to Mr D that the system had been updated with his preferred method of communication. The Ombudsman considered these actions were reasonable and the complaint was closed on this basis.

Miss X complained about the care she received from the Practice during and following root canal treatment. Miss X said she had complained to the Practice but no formal response had been provided to her. The Ombudsman found that the Practice had not considered Miss X’s email as a formal complaint and it had not therefore addressed Miss X’s complaint fully. The Ombudsman said this caused inconvenience and frustration for Miss X. The Ombudsman decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the Practice to provide Miss X with a written apology for its failure to log her complaint and to provide her with a formal complaint response within 3 weeks.

Mr C complained about the treatment he received from a Dental Practice within the Betsi Cadwaladr University Health Board area from November 2022 to May 2023. The Ombudsman investigated whether it was appropriate to refuse Mr C treatment due to him having dental work overseas, whether delaying Mr C’s filling by 6 months caused his tooth further damage, and whether it was appropriate to de-register Mr C from the Practice. The Ombudsman’s investigation found that the treatment Mr C received from the Practice was appropriate. Given the dental work Mr C had undergone abroad, we found that it was appropriate for the Dentist to refuse treatment. We also found that the delay in carrying out a filling did not cause the tooth further damage and that it was appropriate to de-register Mr C from the Practice when the relationship broke down. The Ombudsman did not uphold Mr C’s complaints.

Mr C complained about the care he received from the Practice. Mr C said that the Practice failed to discuss his treatment with him in detail or tell him that the person who would carry out the treatment would be a dental therapist, rather than a dentist. Mr C also complained that the Dental Therapist used amalgam (a mixture of metals) in the filling, to which he did not consent, and that he was unhappy with the quality of the work she performed. The Ombudsman found that Mr C had received a response to his complaint from the Dental Therapist who carried out his treatment. However, he had not received a formal response from the Practice. As a result, the Practice had not addressed Mr C’s complaint fully. The Practice agreed to provide a formal and final complaint response to Mr C, addressing his concern that treatment was performed without his informed consent. This would include whether it was the responsibility of the Dentist who prescribed his treatment or the Dental Therapist who carried it out, and whether appropriate informed consent was documented. It also agreed to offer Mr C an appointment for him to have his tooth reviewed. The Practice agreed to do this within 1 month of the Ombudsman’s decision.

Ms A complained about the treatment she received from the Practice after she attended an emergency appointment due to a crown falling out. The investigation considered whether Mrs A’s dental treatment from December 2022 was appropriate; and whether the Practice’s response to Ms A’s complaint (including the decision to refuse her further treatment) was appropriate and in line with relevant guidance. The investigation found that it was unlikely that the Practice’s treatment (specifically a dentist making small adjustments to a tooth by ‘easing’ or filing it) caused the occlusion (‘bite’) issues Ms A complained about and this element of the complaint was therefore not upheld. However, it found that the complaint responses provided to Ms A when she raised concerns about this were very brief and did not answer any of her specific questions. It also found that although relationship breakdown was given as the reason for refusing to further treat Ms A after she had made a complaint, it was never explained why this applied to all the dentists in the Practice when she had only complained about the treatment provided by 1 named dentist. Both of these failings contradicted relevant guidance. The investigation concluded that while the relationship between the Practice and Ms A eventually deteriorated to the point where the Practice’s decision to refuse Ms A further treatment and remove her as a patient was justifiable, opportunities were missed to avoid the relationship deteriorating to this extent. This element of the complaint was therefore upheld. The investigation recommended that the Practice should write to Ms A offering a formal apology for the issues identified and offer her a payment of £500 in acknowledgement of the substandard responses to her complaint.

Mr B complained about the service he received from a dental practice (“the Practice”) in the area of Aneurin Bevan University Health Board. He complained that the Practice did not have a complaints policy displayed or provide him with a copy. He said that they did not provide him with a copy of its policy regarding payments or its unreasonable behaviour policy. Mr B was also unhappy with the Practice’s response to his complaint and that it issued him with a formal warning following his complaint. The assessment of Mr B’s complaint identified that the Practice had apologised to him for the distress and inconvenience he experienced during his visit. The assessment also identified that Mr B was not reminded of the payment policy before his dental treatment was undertaken and that he did not receive a copy of its unreasonable behaviour and complaint policies. The Practice agreed to confirm to Mr B in writing that the formal warning has been removed from his record and supply him with a copy of its policy that includes payment terms, its unreasonable behaviour policy and its complaints policy. The Ombudsman considered this was a reasonable way to resolve Mr B’s complaint and it was closed on this basis.

Mr X complained that the dental practice did not fully respond to all aspects of his complaint, submitted to it in August 2023. The Ombudsman decided that the dental practice had failed to respond fully to the complaint. She said this caused frustration and uncertainty to Mr X. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the agreement of the dental practice to issue a further written response to Mr X to address all the issues raised within his original complaint.

We investigated complaints made by Mr A about his treatment by his Dental Practice. These consisted of whether the decision to remove a tooth was appropriate given the information known at the time, if Mr A should have been referred to a consultant earlier, and if the decision made not to treat Mr A owing to him being a high-risk patient, was appropriate and in line with relevant guidance. After the investigation had started, Mr A contacted the Ombudsman to state that he had since gone back to the Practice to ask for treatment but was refused because he had made a complaint. The Ombudsman therefore used her own initiative powers to expand the investigation and include 2 further heads of complaint. These considered whether it was reasonable for the Practice to refuse Mr A treatment because of the complaint he had referred to the Ombudsman, and, whether, in determining that future treatment be refused to Mr A, the Practice had failed to inform him appropriately of its decision. The investigation found that although some communication around Mr A’s treatment and changes to dental contracts could perhaps, have been explained better, ultimately Mr A’s dental treatment was appropriate for his presenting symptoms and in-line with relevant guidance. Therefore, these elements of his complaint were not upheld. However, the investigation found that the subsequent decision to refuse to see Mr A as a patient after he had made a complaint, and the way this was communicated to him was not in-line with relevant complaint handling standards, which was an injustice to him. These aspects of the complaint were therefore upheld. The Ombudsman therefore recommended that the Practice should apologise to Mr A for the failings identified and offer him £500 in recognition of the injustice caused to him. She also recommended that it should review its complaint handling practices to ensure that they are in-line with relevant Regulations and “Putting Things Right”, and invite the Health Board t

We investigated complaints made by Mr A about his treatment by his Dental Practice. These consisted of whether the decision to remove a tooth was appropriate given the information known at the time, if Mr A should have been referred to a consultant earlier, and if the decision made not to treat Mr A owing to him being a high-risk patient, was appropriate and in line with relevant guidance. After the investigation had started, Mr A contacted the Ombudsman to state that he had since gone back to the Practice to ask for treatment but was refused because he had made a complaint. The Ombudsman therefore used her own initiative powers to expand the investigation and include 2 further heads of complaint. These considered whether it was reasonable for the Practice to refuse Mr A treatment because of the complaint he had referred to the Ombudsman, and, whether, in determining that future treatment be refused to Mr A, the Practice had failed to inform him appropriately of its decision. The investigation found that although some communication around Mr A’s treatment and changes to dental contracts could perhaps, have been explained better, ultimately Mr A’s dental treatment was appropriate for his presenting symptoms and in-line with relevant guidance. Therefore, these elements of his complaint were not upheld. However, the investigation found that the subsequent decision to refuse to see Mr A as a patient after he had made a complaint, and the way this was communicated to him was not in-line with relevant complaint handling standards, which was an injustice to him. These aspects of the complaint were therefore upheld. The Ombudsman therefore recommended that the Practice should apologise to Mr A for the failings identified and offer him £500 in recognition of the injustice caused to him. She also recommended that it should review its complaint handling practices to ensure that they are in-line with relevant Regulations and “Putting Things Right”, and invite the Health Board t

Miss X complained that a Dental Practice in the area of Swansea Bay University Health Board had failed to respond to her complaint about being deregistered from the Practice. Miss X had made her complaint in September 2023. The Ombudsman found that the Practice had failed to respond to Miss X’s complaint and had not properly updated her during the delay. The Ombudsman said this caused frustration for Miss X and decided to settle the complaint without an investigation. The Ombudsman sought and gained the Practice’s agreement to apologise and explain the reasons for the delay to Miss X, to offer her £50 in recognition of the complaint handling delay and failure to update Miss X, and to issue its complaint response within 4 weeks.

Mr A complained about whether the treatment he received from a Dental Practice (“the Practice”) within the Hywel Dda University Health Board area between May 2019 and September 2021 was appropriate. The Ombudsman’s investigation found that Mr A was seen at the Practice on several occasions between May 2019 and September 2021 when he presented with significant wear to his teeth and associated dental issues. Treatment was proposed and carried out, along with advice on how Mr A could maintain his oral health. Due to the complexity of the wear to Mr A’s teeth, he was referred to an NHS dental hospital. It was found that Mr A’s treatment was appropriate. The Ombudsman did not uphold the complaint.

Ms P complained that the Practice failed to formally respond to a complaint she raised in February 2023. The Ombudsman found that the Practice had met with Ms P to discuss her complaint but it failed to issue a response in writing. This caused additional frustration for Ms P. The Ombudsman decided to settle the complaint without an investigation. She sought and gained the agreement of the Practice to write to Ms P within 2 weeks to apologise and issue its formal complaint response.

Ms A complained about the Dental Practice’s care and management provided to her mother, Dr A, since October 2020. Ms A said that the Practice unreasonably withdrew services because she complained. Ms A also complained about the Dental Practice’s handling of her complaint. The Ombudsman found that aspects of the Dental Practices’ care and management were reasonable and appropriate. However, the Ombudsman found that X-rays were not carried out, or that the reasons for not doing so were not documented. This aspect of Ms A’s complaint was upheld. The Ombudsman upheld Ms A’s complaint about the Dental Practice’s complaint handling. The Ombudsman was satisfied that dental services were not withdrawn because Dr A complained. This aspect of the complaint was not upheld. The Dental Practice agreed to implement the Ombudsman’s recommendations and apologise to Ms A and Dr A for the identified shortcomings, to review its complaints handling to ensure compliance with the accepted complaints handling process and to review guidance relating to the frequency of X-rays for patients with differing levels of risk as part of the dentists continuing professional development.

Mrs A complained that a Dental Practice in the area of the Cwm Taf Morgannwg University Health Board had failed to issue a complaint response to her in accordance with an agreement it had previously reached with the Ombudsman’s office (ref: 202204027). The Ombudsman contacted the Practice and it agreed to provide a full apology to Mrs A for failing to respond to her complaint and failing to meet the Ombudsman’s deadline, pay Mrs A £50 redress, and provide its complaint response within 6 weeks. The Ombudsman accepted the actions set out above as an alternative to issuing a Special Report.