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Case ref:201104811
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Date:May 2013
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Body:A Dental Practice in the Lothian NHS Board area
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mrs C's dentist extracted her bottom left molar. Eleven days later, the dentist extracted Mrs C's upper right molar and prescribed antibiotics because of pain at the site of the previous extraction. Several days after that, Mrs C was treated by another dentist for infected sockets. They gave her an antiseptic mouthwash and a dressing to promote healing. Mrs C was also given advice about giving up smoking and pain relief. Mrs C said that shards of tooth came out of her gum at the extraction sites. A radiograph was taken and showed no retained roots. She returned to the dental practice a month later and another dressing was put in place. At the end of the following month, Mrs C returned to the practice saying that another back tooth was causing discomfort and that she felt unwell. She was prescribed antibiotics and had further extractions a couple of months later. She was then referred to the dental hospital. Mrs C complained that the extraction sites have not healed, she has loose teeth and she takes antidepressants due to the poor cosmetic appearance of her teeth. Mrs C also complained that there were delays by the practice in responding to her complaint.
We found that the clinical care and treatment provided was reasonable, but that there were failings in relation to record-keeping, about which we made a number of recommendations. In relation to complaints handling, the practice delayed in sending a written response, but did take other action. They arranged a meeting between Mrs C and a dental practitioner to discuss her complaint and referred Mrs C to hospital. We were satisfied that, on the whole, the practice dealt with Mrs C's complaint in line with the NHS complaints procedure as they took action to respond to and resolve it within a reasonable time.
Recommendations
We recommended that the practice:
- ensure that a copy of a signed treatment plan for scheduled appointments is retained in patient records;
- ensure that dentists record information about medication provided;
- ensure that dentists record it when they provide a post extraction information sheet to patients following extractions;
- ensure that dentists report on all radiographic findings in patients' records; and
- ensure that there is written evidence of a British periodontal (gum) examination in patients' records for all scheduled appointments.