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.

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.

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its decision to remove her from its patient list, and its complaints procedure for NHS patients contained incorrect and outdated information.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 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 A complained to the Health Board about the service provided at his local branch of Dental Practice after experiencing multiple appointment cancellations at short or no notice. Mr A said that the Health Board failed to ensure that the Dental Practice addressed the issues raised in his complaint about access to services. He was then unreasonably removed as a patient from the Dental Practice list, along with his wife, because he had complained. The investigation identified that the Health Board failed to ensure that the Dental Practice responded to Mr A’s concerns about access to services in accordance with the NHS Complaints Procedure. Although the Health Board tried to resolve the complaint by arranging check-ups for Mr & Mrs A, it did not hand the complaint to the Dental Practice to investigate and respond when those appointments were subsequently cancelled. Consequently, there was a missed opportunity for the Dental Practice to learn from Mr A’s complaint and his family’s poor experience of waiting for care. The Health Board also gave a false expectation that it would help Mr & Mrs A to find a new dentist when they were removed from the Dental Practice list, although this was not a service it provided. The Dental Practice failed to follow professional guidelines and its own policy when making the decision to remove Mr & Mrs A from the patient list at the Dental Practice. There was a lack of evidence to support the reasons given for the decision to remove Mr & Mrs A and a failure to warn them before services were withdrawn. To settle the complaint, the Dental Practice and the Health Board agreed to apologise and each pay financial redress of £250 to Mr & Mrs A in recognition of the failings and the unnecessary time, trouble and upset caused. Both organisations also agreed to share the findings with the appropriate staff to ensure the learning from the complaint. In addition, the Dental Practice agreed to offer the family the opportunity to register as patients at

Mrs C complained that the Practice failed to undertake adequate and appropriate monitoring of the condition of her teeth following root canal treatment (“RCT”) in April 2016. She also complained that she did not receive prompt and appropriate treatment when complications arose following that RCT. The Dentist who carried out the treatment has since left the Practice. The investigation found that a degree of dental decay would have occurred in any event due to Mrs C’s approach to oral hygiene. However, the Practice did not follow the relevant guidance regarding the frequency of intervals between X-rays of Mrs C’s teeth. This meant Mrs C suffered an injustice because her decay could have been identified and treated earlier, with smaller fillings. Consequently, the first complaint was partially upheld. However, Mrs C’s second complaint was not upheld because she consented to the RCT treatment, having received a warning that complications could arise. In addition, the Dentist’s overall care and monitoring of the tooth following the RCT reflected good clinical practice. The Ombudsman recommended that the Practice should write to Mrs C to apologise for the fact her teeth were not X-rayed as often as they should have been for her recorded risk level. The Practice accepted the Ombudsman’s recommendation. The Ombudsman further invited the Dentist to reflect on the findings of the investigation and to review the appropriate guidance as part of her continuing professional development. The Dentist agreed to do so.

Ms X complained to the Practice on behalf of Ms Y on 14 December 2021. Ms X complained to the Ombudsman on 6 April 2022 as the Practice had failed to respond to the complaint. The Ombudsman contacted the Practice as she was concerned about the length of time it has taken to conclude its investigation. The Practice agreed to issue its apology and response no later than 31 May 2022 as an alternative to an investigation by the Ombudsman .

Ms A complained about the care she received from 2016 onwards from a dentist (“the First Dentist”) based at the Dental Practice and questioned whether it was of an adequate standard. She also remained unhappy with the First Dentist’s handling of her complaint. The Ombudsman’s investigation concluded that the care provided to Ms A by the First Dentist was broadly reasonable and appropriate. However, he identified that there was a failure by the First Dentist to carry out X-rays to monitor Ms A’s teeth between 2018 and 2020 in accordance with the Faculty of General Dental Practice (“the FGDP”) guidance. Whilst this was a failing, he was satisfied that the X-rays taken in March 2020 showed that with clinical intervention, Ms A’s periodontal disease progression might have been prevented. Unfortunately, the delay in treatment due to the COVID-19 pandemic led to a rapid progression of Ms A’s disease to the point that it was untreatable. The Ombudsman concluded that whilst the failings amounted to service failing, they had not caused an injustice to Ms A and this aspect of Ms A’s complaint was not upheld. However, the First Dentist was reminded of the importance of adhering to the FGDP guidance in such cases. The Ombudsman was concerned about the way in which Ms A’s complaint was handled by the Dental Practice, as it did not appear to be in accordance with the NHS complaints procedure Putting Things Right (“PTR”) or its own complaints policy. The Ombudsman was of the view that the matter should have been treated as a complaint against the Dental Practice. This would have enabled better management of the complaint process and meant the Dental Practice was not acting as a “post box” by passing Ms A’s complaint to the First Dentist. The hands-off approach adopted by the Dental Practice and the lack of senior oversight and review of Ms A’s complaint by a senior partner meant the opportunity to learn lessons, an important component of the PTR process, was lost. The Ombudsman fo