The scene
During a routine examination, the patient discussed with her dentist the pain she had been experiencing in the lower left posterior region of her mouth. The pain was not specific to one tooth. The dentist carried out a thorough examination and found that the gums were inflamed between the last two teeth in this area of the mouth. This inflammation was associated with food packing so the dentist provided oral hygiene instruction as well as scaling and polishing of the associated periodontal pocket. The dentist advised the patient to return if her symptoms did not subside.
The patient alleged that two days later she rang the practice and spoke to the practice manager to complain that the dentist had not treated the tooth and she was still in pain. In her complaint to the PCT the patient went on to say she did not receive a response following her call and so she took the matter to the Trust.
The PCT requested further information from the dentist, including a copy of the patient's records.
Following receipt of the records, the PCT asked the dentist to attend an interview to discuss the issues raised in the patient's complaint. The PCT was concerned about the quality of the records and how the complaint had been handled. The member contacted the DDU for advice.
DDU advice
The dento-legal adviser (DLA) advised the member to reply to the PCT's request and ask whether the PCT would be happy for a DDU adviser to accompany him to the meeting. Before the meeting, the DLA discussed the records, and the nature of the complaint and how it was handled, with the member. The member explained that he had not sent a full set of the computer records to the PCT. Due to difficulties with the software package used at the practice, it was not possible to print all of the computer notes.
The member also informed the DLA that he had not known about the patient's complaint, and lack of response from the practice, until he received the letter from the PCT. He said that on investigating the matter he had discovered that there had been various performance issues with the practice manager, which had been addressed. The DLA advised him to explain this to the PCT.
The meeting went well. The PCT panel was happy that the DDU member had examined the patient properly and formulated an appropriate treatment plan. They were also happy that he would act on their advice regarding how to respond to complaints and how to improve his recordkeeping in light of the incomplete computer records presented before the interview.
In addressing the fact that the practice had not responded to the patient's complaint, the DDU adviser explained that under the NHS complaints procedure, an oral complaint that is resolved within one working day does not require a formal written response. The practice should note the complaint in a record separate from the patient's clinical records. If an oral complaint cannot be resolved within that time, then it needs to be treated in the same way as other complaints and should be acknowledged within three working days. The practice should offer the complainant the opportunity to discuss an agreed approach to the complaint and give expected timescales for a response. It should investigate the complaint thoroughly and provide a detailed response as soon as possible. If the response cannot be provided within six months the practice must inform the complainant and explain why.
The DDU advises that clear, contemporaneous records of each consultation are essential. If records do need to be disclosed, for example to the PCT, ensure that a full set of records is disclosed.
This page was correct at publication on 21/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.