Decision Report 201704288

Summary

Mr C complained about two consultations he attended at Edinburgh Dental Institute following a referral from his dental practice relating to temporomandibular disorder (a problem affecting the 'chewing' muscles and the joints between the lower jaw and the base of the skull). In particular, Mr C was unhappy with the assessments carried out and the lack of treatment provided.

We took independent advice from a consultant oral and maxillofacial surgeon (a specialist in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck). They considered that most aspects of the clinical management in the department were reasonable. However, they considered that Mr C's medication history was not recorded adequately at the first consultation. In relation to the second consultation, they were critical that an examination was not performed. We upheld these aspects of Mr C's complaint.

Mr C was also unhappy that a clinic letter relating to one of the consultations contained an error and was sent to the wrong address. We upheld this aspect of Mr C's complaint. However, we noted that the board had apologised to Mr C and identified appropriate action to help prevent the issue reoccurring.

Finally, Mr C was unhappy about the way the board handled his complaint. The board acknowledged that their response was delayed and apologised to Mr C for this. We considered that the board's communication about the delay was poor and upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to adequately record his medication history, failing to perform an examination, and the poor communication during the handling of his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients presenting with pain should have their medication history appropriately recorded within the documentation of the management plan. Consultations should include an examination where this is indicated clinically or because of the particular circumstances of the patient's situation.

In relation to complaints handling, we recommended:

• Where it is not possible to complete an investigation within 20 working days, the person making the complaint should be given an update about the delay and a revised timescale for completion. Communication about revised timescales should be accurate and further contact should be made if it emerges that the revised timescale is not achievable.