Decision Report 201800172

Summary

Mrs C complained that the dental treatment she received was unreasonable. Mrs  C had been a patient of the dentist for 20 years but received a second opinion from another dentist and was told that she had extensive gum disease. Mrs C was concerned that she was never informed of this and that the treatment she had received was inappropriate. Mrs C also complained that the dentist unreasonably communicated with her about the health of her mouth and that they provided an unreasonable response to her complaint.

We took independent dental advice. We found that the patient notes recorded were very limited, with little information about the ongoing overall health of Mrs C's mouth or the investigations or treatments that occurred over the 20 year period. We also found no record of a Basic Periodontal Examination (BPE - a check on gum health that is required to take place at every six month exam).

In relation to the dentist's communication with Mrs C, we found that there was little evidence in the dental records that the dentist adequately informed Mrs C about the health of her mouth over the 20 year period. We also found that the response to Mrs C's complaint included inaccuracies and comments that were not supported by the dental record and failed to signpost Mrs C to us at the end of the complaints process.

We upheld all of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in treatment and communication. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• The dentist should be fully aware of the requirements for good clinical record-keeping as stipulated in 4.1 of the General Dental Council Standards and the guidance for good note taking that is available in the Clinical Examination & Record Keeping Standards (FGDP RCS (Eng)).
• The dentist should be fully aware of the Scottish Dental Clinical Effectiveness Programme guidance contained within the Prevention and Treatment of Periodontal Disease in Primary Care.
• The dentist should be fully aware of the requirements of the Statement of Dental Remuneration.
• The dentist should be fully aware of the Selection Criteria for Dental Radiography (FGDP RCS (Eng)).
• The dentist should be fully aware of the Ionising Radiation (Medical Exposure) Regulations (2000) justification and reporting requirements, and the subsequent 2018 regulations.

In relation to complaints handling, we recommended:

• The dentist should ensure responses to complaints are accurate and supported by the dental records, and should also ensure that the complainant is advised of their right to come to the SPSO.