Decision Report 201802678

Summary

Mr C complained that the care and treatment he received from the dentist was unreasonable. Mr C had a lump on his tongue and was concerned that he was not referred to oral health or a dental hospital which he said resulted in there being a delay in him being diagnosed with oral cancer.

We took independent advice from a dental adviser. We found that the clinical examination carried out by the dentist was reasonable and, given that the dentist suspected that the lump on Mr C's tongue was a result of trauma, it was reasonable that a topical anaesthetic mouthwash was prescribed and an appointment was made to review Mr C. However, we also found that the dentist had not recorded in Mr C's medical record anything about:

• the history of Mr C's complaint, his past dental history, past medical history and social history.

• the diagnosis considered at the time.

As good record-keeping is an important part of a patient's care and treatment, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to take a full history of his symptoms and record the diagnosis considered. 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:

• Good record-keeping should include a full history of a patient's symptoms and a record of the diagnosis considered.