A dental practice in the West Northamptonshire area

6. Mr O complains about aspects of care and treatment the Practice provided to him between March 2022 and March 2024. Specifically, he says:

• his dental check-ups were too short. The dentist did not look at his teeth properly and refused to take X-rays despite him requesting them at each appointment • He was incorrectly removed from the Practice patient list. He says the Practice informed him he was rude in a social media post about it, but he was not.

7. Since the Practice removed Mr O from its list, he has been under the care of a private practice. The new practice took X-rays and discovered decay which he was informed should have been spotted sooner, and a crown needed replacing.

8. Mr O feels his tooth removal and several fillings could have been avoided if he had been provided with adequate care. He has also suffered a financial impact, so far, he has had to pay over £1100 for work on his teeth at his new Practice.

9. In March 2024, Mr O attended an appointment at the Practice. He states he asked for X-rays to be completed and the Practice refused. He saw a different dentist around this time who informed him he required urgent work on his teeth. He says this made him realise there had been issues with his teeth for the two years prior.

10. On 10 March 2024, Mr O put a post in his local community Facebook group, asking for people to share their experiences at the Practice because he was considering changing practices due to a high quote he had been given for treatment.

11. In March 2024, the Practice removed Mr O from its patient list. It explained this was due to his rude behaviour.

12. In April 2024, Mr O joined a new, private dental practice. He attended an appointment and said the dentist informed him he had decay which should have been spotted sooner, and a crown needed replacing.

Evidence we have considered

13. We considered evidence from Mr O, including a telephone call in which we talked through his account of what happened. We also considered the relevant parts of Mr O’s dental records and his complaints (to us and to the Practice).

14. We also got advice from a dentist (our adviser) who is familiar with the issues raised in this case.

15. We use relevant law, policy, guidance and standards to inform our thinking. This allows us to consider what should have happened. We have referred to the following standards:

• Department of Health and Social Care, Delivering better oral health: an evidence based toolkit for prevention, June 2014.

• College of General Dentistry, Selection criteria for dental radiography, 2018.

• National Health Service, NHS rules and regulations, NHS Dental Agreements, 2005.

Dental check-ups

16. Mr O states his dental check-ups between March 2022 and March 2024 were too short. He says the dentist did not look at his teeth properly and refused to take X-rays despite him requesting them at each appointment.

17. Since the Practice removed Mr O from its list, he has been under the care of a private practice. The new practice took X-rays and discovered decay, he says the new practice informed him this should have been spotted sooner, and a crown needed replacing.

18. In its response, the Practice explained it conducted a thorough clinical examination at each visit and took X-rays when necessary.

19. Our adviser explained the Practice did not do enough to carry out adequate assessment and treatment of Mr O’s teeth, and there were many lost opportunities for treatment to be carried out. They explained the records are not clear as it appears a template has been used, meaning some of the records are copies of previous appointments. This makes it difficult to see what has been assessed.

20. The medical records show in 2019, the dentist informed Mr O he had decay under his crown, he was advised to have the old crown removed, decay removed, and a new crown put in. The records say Mr O was going to go away and think about it. Since this point, our adviser explained this decay was not reviewed properly. Each appointment since this date did not re-address the issue.

21. Our adviser explained the clinical notes are contradictory. There is very clear decay on many of Mr O’s teeth. The X-rays show clear decay on his UR8 (upper right) and UR6, which is not in the records.

22. The Practice failed to recognise decay and monitor Mr O appropriately. He was a high-risk patient as he repeatedly attended the Practice with problems, and the Practice did not manage this properly. The Practice focused on monitoring the top left teeth, ignoring the right side and decay there. An example of the contradiction is where the radiographic report initially states no abnormality detected but then goes on to say the ‘lr7 mo decay’, which suggests there was in fact decay.

23. Delivering better oral care guidance states that dentists can prescribe high fluoride toothpaste and refer patients to a hygienist when decay is present. Our adviser explained this could have been done in Mr O’s case.

24. The Practice carried out temporary fillings on Mr O’s back teeth and the occlusal surface (chewing surface) of the UR5. Our adviser explained this should not be carried out without good reasoning. Temporary fillings work well on the side of teeth, but do not last long on the top and biting surfaces of back teeth or pre-molar teeth. A good reason for temporary fillings on a back tooth would be situations such as a patient not being able to tolerate drilling.

25. We cannot say there was a good reason for this to be carried out, as it is not documented in the notes why it was done. Our adviser said a normal permanent filling, crown or onlay should have been provided instead.

26. There are three X-ray entries between February 2022 and March 2024.

27. Whilst the X-ray images are not dated, our adviser explained it is clear they were not taken at the correct intervals. Our adviser explained it is difficult to monitor decay in a tooth if regular X-rays are not taken. In line with guidance on selection criteria for dental radiology, patients with active decay should be monitored by X-ray every six months to one year. There are big gaps in Mr O’s X-rays, suggesting they were not carried out frequently enough.

28. The X-rays taken also contradict the written dental notes. The X-rays supplied show obvious decay, but this is not in the records.

29. This evidence suggests the Practice did not carry out thorough assessment of Mr O’s teeth. It did not carry out adequate X-rays, address his decay, or record this appropriately within the medical records. This is a failing in the care and treatment the Practice provided to Mr O.

Removal from Practice list

30. Mr O says the Practice incorrectly removed him from the patient list. He says the Practice informed him this was because he was rude in a social media post about it, but he was not. Mr O explained he was shocked and upset to be suddenly dismissed and was unsure of what to do as there were no dental Practices accepting NHS patients. We appreciate the Practice’s decision to remove Mr O from the patient list would have been disappointing for him.

31. The Practice wrote to Mr O on 20 March to explain the relationship between him and staff had broken down, and as a result it would be removing him from the Practice. It did not send any correspondence or written warnings before this.

32. In its response, the Practice explained the reason for the removal was the content of a Facebook post which was felt by members of the team to be of an inappropriate and threatening nature. In line with the wider NHS and guidance around the provision of dental care, it explained it has a zero-tolerance policy for this type of behaviour.

33. Mr O has provided us with evidence of the social media post. This was a post on a local Facebook community page, where he explained he was thinking of moving to a different Practice as he felt his check-ups at the current Practice were too short. Mr O named a Practice staff member on this post and explained he was unhappy with the treatment he was receiving.

34. The Practice sent us a copy of its zero tolerance on violence and aggression policy. This policy defines harassment as:

• ‘can range from minor cases of disrespect to more serious acts. It can be defined as any conduct which is unwanted by the recipient, and causes humiliation, offence and upset’

35. It then goes on to say:

• ‘A Practice is entitled, as part of their NHS Contract, to no longer see patients if they have shown threatening or aggressive behaviour. You will need to write to the patient and within that letter you will need to explain you have a zero tolerance policy. Within the letter it must detail clear instructions for that patient to be able to source another NHS dentist, i.e visit the NHS website’

36. Within the letter the Practice sent to Mr O on 20 March, it acted in accordance with the above policy by providing instructions of how to find another dentist.

37. We appreciate Mr O did not mean any malicious intent from his comments and was not trying to undermine the Practice’s and the individual staff member’s reputation. We consider the comments he made to fall under the ‘minor cases’ of the zero tolerance policy.

38. As the Practice’s zero tolerance policy is wide and sets out occasions where it can remove a patient from the Practice, we cannot say it acted incorrectly by removing Mr O as a patient. We do consider the Practice could have provided Mr O with more information about why it felt he had been threatening.

39. In considering the above, we do not see evidence of wrongdoing by the Practice when it removed Mr O from its patient list.

Impact

40. We then considered whether the failing we identified had an impact.

41. We find the Practice did not carry out thorough assessments of Mr O’s teeth. It did not carry out adequate X-rays or address his decay.

42. Mr O states he has suffered a financial impact because of the Practice not carrying out a thorough assessment of his teeth, as he feels his tooth removal and several fillings could have been avoided if he had had proper care. So far, he has had to pay over £1100 for work on his teeth at his new practice.

43. Mr O joined the Practice as a patient in 2019. Our adviser explained his problems are historic, so a lot of the damage to his teeth would have already existed when he first joined the Practice. We know that the Practice failed Mr O in terms of not spotting or reporting decay in his teeth sooner and not recording adequate notes at appointments.

44. Mr O was also reluctant to have treatment at certain points, for example at one point he was offered a crown but decided as the tooth did not hurt to not go ahead with it at that point.

45. Our adviser explained that whilst the X-rays at the NHS practice are not dated, there is not a huge amount of change in Mr O’s teeth when he was under the NHS practice, to the private practice. The condition of his teeth had not deteriorated significantly between him being a patient under the NHS practice, to the private practice, for example the decay is not significantly worse since Mr O moved to the private practice.

46. Overall, the dentist should have done more work on Mr O’s teeth, but regardless of what they did or did not do, Mr O still needed the work to be carried out on his teeth. Our adviser explained the treatment plan he had under the private practice is what he should have had carried out at the NHS practice, the tooth still needed filling. The extraction was required as everything that could have been done to save the tooth had been done, so this was the only option.

47. The private dental Practice has not found a huge number of new problems on many more of Mr O’s teeth, for example where the NHS practice put a temporary filling on Mr O’s back tooth, the private dentist put a crown on.

48. This work could not have been avoided. The Practice could have done this work sooner, but at times Mr O also refused the work to be carried out.

49. In considering the above, we can partly link the financial impact to the failing we have identified.

50. Mr O has paid around £1100 under the private practice. This is for a crown, two hygienist appointments, and a filling.

51. Overall, at the time the events happened, if Mr O had this treatment under the NHS practice, it would have cost around £306.80 for the crown, £70.30 for the filling, and a hygienist appointment is usually around £100 a session as this is usually private treatment. Our adviser also explained this treatment would have been phased, so overall could have cost him around £700 (costs calculated using NHS Rules and Regulations, NHS Dental Agreements guidance).

52. Mr O did not go back to the Practice before he complained, and before he was removed from the patient list. If he had done so, we cannot say for certain, but the Practice may have given him the opportunity to see a different clinician to attempt to put things right. Due to pressures on NHS dentistry, we do not know if this could have been an option or not.

53. Mr O feels his tooth removal and several fillings could have been avoided if he had had proper care. In considering the above, we cannot link this impact. Whilst the Practice could have identified the problems sooner, this work could not have been avoided. We can say Mr O paid an extra £400 for the work to be carried out. This is the difference between the £1100 he has paid for private dental treatment, and the £700 he would have paid for this same treatment at the NHS Practice.