Decision Report 201906809

Summary

C complained that there was an error in carrying out their child (A)'s dental surgery at the Royal Hospital for Children. A had been referred by an orthodontist (medical professional dealing with the prevention and correction of irregular teeth) to have two teeth removed. C raised concerns that they had removed the wrong tooth (A's front tooth) and left in the two teeth they were supposed to remove.

The board said that their oral and maxillofacial surgery clinicians (OMFS, specialists in treating diseases and injuries of the mouth and face) had appropriately reviewed A's original treatment plan. The board explained that their OMFS clinicians had tried to contact the orthodontist to explain that A's original treatment plan was not clinically possible.

We took independent advice from a consultant OMFS. We found that A's treatment plan should not have been changed without consulting the referring orthodontist and agreeing the changes with them. We found that the clinical rationale for changing A's treatment plan was not clearly recorded. We also found that the changes were not communicated clearly enough to C and A in a manner that they could understand. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be given complex information in a way that they can understand and clinicians should check their understanding.
• The reasons for clinical decisions should be clearly recorded. This includes recording any discussions with senior staff that inform clinical decisions.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.