Problem Patients come with greater risks
MDDUS Case study
Mr D, a young male adult patient, has a history of poor dental care. He had a permanent molar extracted at the age of 14 and three years later another permanent tooth removed. He attends his regular dentist – Miss L – and is advised that two additional teeth, LL5 and LR5, are badly decayed with the only option being extraction. Mr D is needle phobic so Miss L discusses with the patient the option of sedation. She also discusses the risk of complications inherent in the procedure including incomplete extraction of the teeth. Mr D is appropriately consented and advised to attend the arranged appointment with his escort.
Mr D attends for the extractions accompanied by his escort. Miss L reinforces the consenting process and Mr D is appropriately sedated, complying with available guidance. Miss L finds the teeth are brittle and during the extraction there are root fractures in both. Mr D becomes uncooperative at this stage and Miss L is unable to extract the roots. Miss L has to administer a reversal agent due to the behaviour of Mr D. While the patient recovers from sedation the dentist explains to Mr D’s escort that the roots have been left in situ. An appointment is made for Mr D to re-attend the surgery in a week’s time for review and to discuss further treatment options. Miss L neglects to make a record of the retained roots in the patient’s notes or of her detailed discussions with Mr D’s escort.
Mr D does not attend his appointment and fails to arrange an alternative appointment. Unfortunately, Mr D is lost to follow up by the practice.
11 MONTHS LATER
Mr D makes an appointment at the surgery and sees a different dentist – Mr N. The dentist carries out an extensive examination along with an OPG radiograph due to the presence of the retained roots. He notes the retained roots and discusses treatment options for removal of the roots. Mr D expresses his preference for surgical removal of the roots under general anaesthetic even if this means a trip to the hospital. Mr N makes no reference in the notes to an abscess or infection associated with the retained roots and no antibiotics are prescribed. A referral letter is sent to the oral surgery department of the local general hospital and an appointment scheduled, which Mr D later cancels.
ONE YEAR LATER
The patient arranges an emergency appointment at the surgery for a painful abscess in UR7. This time he sees Miss L and they discuss both the need to extract UR7 and the retained roots from LL5 and LR5. Mr D is adamant that the treatment must be carried out under a general anaesthetic in hospital. Again there is no mention of pain, infection or abscess associated with the retained roots. Another referral letter is sent to the oral surgery department and two months later the roots are removed along with UR7 under a general anaesthetic.
A letter from solicitors representing Mr D arrives at the dental surgery six months later alleging breach of duty against Miss L. It is claimed that the dentist failed to record and inform the patient that the teeth had fractured during the extraction. It is also alleged that she failed to arrange an appointment in order to discuss treatment options for removal of the roots.
The patient also claims that within days of the failed extractions he was in considerable pain and that the extraction sockets were open and infected. Pain and infection were then intermittent from the date of the procedure until the roots were finally removed nearly two years later.
Miss L contacts MDDUS and an expert report is commissioned. The dental expert finds no breach of duty in regard to the fractured roots as such complications are sometimes unavoidable. He also accepts there could be valid reasons for not prolonging a procedure in order to extract retained roots. But he does find fault with Miss L’s clinical notes. The dentist should have recorded the fact that she failed to complete the extractions along with a note of what action was to be taken as a consequence. In addition she should have recorded her detailed discussions with Mr D’s escort.
The expert also points out that it is normal practice to inform a patient post-procedure of any unforeseen event, such as root fracture. But he accepts that in this case that Mr D was still under sedation and in no fit position to discuss any information given at that time. In this situation it was reasonable for Miss L to arrange a follow-up appointment. Examination of the appointment book verifies a follow-up visit was scheduled despite claims by the patient to the contrary.
Had Mr D attended the follow-up the dentist would have informed the patient of the retained roots and treatment options would have been discussed along with recommended referral to the local hospital. In regard to the pain and infection claimed by the patient, the expert can find no evidence that this was associated with the retained roots.
MDDUS lawyers and advisers give the case some further consideration – most notably how it hinges on the disputed facts regarding the patient being given an appointment for follow-up review. Given the poor record-keeping by the dentist this is considered a risk should the case come to court. There is also no written evidence in the patient notes that the follow-up appointment was confirmed in writing nor any record of the patient being contacted when he did not attend.
Given these weaknesses in defending the case the decision is made to settle for a modest sum.
- Ensure dental records comply with available guidance
- Ensure the practice appointment system details interaction with patients
- Be aware of available sedation guidance.
Aubrey Craig is head of dental division at MDDUS.