CLAIM IMPACTED WISDOM TOOTH


BACKGROUND A 33-year-old man – Mr T – has been referred for outpatient surgery at a local dental hospital for removal of an impacted wisdom tooth (LR8). The patient is warned of possible complications including pain, swelling, infection and possible nerve injury affecting the lip and tongue. The patient is content to proceed and the procedure is undertaken without incident. A discharge letter is sent to the referring dentist – Dr C – for ongoing care. Three weeks later Mr T attends the


dental surgery complaining of pain in the lower right jaw with trismus and paraesthesia. Dr C examines the socket and reassures the patient that such symptoms are not uncommon following removal of a deeply impacted wisdom tooth. Sometimes it can take months for sensation to return and symptoms to ease. He advises analgesia for the pain. Mr T is back in the surgery two weeks


later complaining of “shells” (sequestra) coming from a painful socket and lip paraesthesia. Dr C again reassures Mr T that such symptoms are not uncommon and he prescribes a course of amoxicillin. No note of an examination is recorded. Another three weeks later Mr T is still in


pain and while eating dinner hears a “crack” in his jaw. He attends the dental surgery the next morning and demands a referral. Dr C contacts the dental hospital by phone and requests that Mr T be seen in regard to


a non-healing extraction socket with associated swelling and obvious infection. Mr T attends the hospital and a radiograph


reveals a fracture of the right angle of the mandible. He is commenced on IV antibiotics and two days later undergoes surgery to reduce the fracture and internally fix with titanium plates. Five days later he is discharged but infection later recurs and further surgery is necessary. A letter of claim is received by the


practice alleging clinical negligence against Dr C in failing to refer Mr T for an unresolved infection associated with an iatrogenic fracture during the extraction of LR8. A separate claim is being pursued against the hospital trust.


ANALYSIS/OUTCOME MDDUS instructs a GDP expert who notes that in the first consultation post- extraction Mr T complained of pain with trismus and paraesthesia, and that such symptoms are common following surgical extraction of an impacted wisdom tooth. He states it would be unusual to initially suspect a mandibular fracture at this stage with no other apparent clinical signs. In regard to the second consultation the


expert again finds nothing inconsistent with expected side effects – but he is critical of the dentist’s record keeping. An antibiotic was prescribed but the notes provide no rationale for this or record of an examination/clinical findings.


Referral at the third consultation after


the reported “crack” was “entirely appropriate”, states the expert, and nothing from the available (albeit poor) clinical records suggests that Dr C failed to diagnose a fracture and treat the patient in an appropriate clinical manner. An expert report is also commissioned


from a consultant oral and maxillofacial surgeon. On considering the full patient records and radiographic evidence she contends the fracture was pathological rather than iatrogenic – the result of a post-operative low-grade infection which had been present from almost immediately after surgery, as evidenced by the ongoing pain, failure to heal and the presence of sequestra, and likely occurring when Mr T felt the “crack”. In regard to causation, she considers that had the infection been treated sooner, the fracture would, on the balance of probabilities, not have occurred; but that, nevertheless, Mr T would have still required surgical intervention. Given the vulnerabilities in the case,


primarily arising from the poor record keeping, MDDUS agrees to settle with agreement of the member.


KEY POINTS ●Make adequate notes justifying clinical decisions and detailing examinations and findings.


ADVICE AN ANGRY ENDING


BACKGROUND Mr B contacts his family medical practice asking to make an appointment for his wife that Friday, as her employer does not allow staff to make personal calls. He is told by the receptionist that the practice offer only “book-on-the -day” appointments and that Mrs B should phone back at 8.30am on Friday. Mr B explains that his wife will already be at work by then and asks why he can’t simply arrange an appointment. The conversation becomes heated and


the receptionist passes the call to the PM who offers an appointment on the Monday. Mr B shouts that this is too late and the PM eventually terminates the call due to his aggressive tone. The next day the practice receives a letter


from Mrs B complaining about her difficulty in booking an appointment and also about “unhelpful practice staff”. One of the GPs – Dr T – responds by calling Mrs B and offering to see her Friday afternoon. Later the PM phones Mr B who


apologises for losing his temper but Dr T is not satisfied and decides to remove him from the practice patient list. She informs


him of her decision by letter, stating that his behaviour was unacceptable and that he should look for another practice. She adds that his request for an appointment was not in line with policy, details of which could be found on the practice noticeboard. The next day Dr T receives a formal letter


of complaint from Mr B. He objects to being abruptly removed from the practice list and asks to be reinstated. His understanding was that practice policy allowed patients to book up to two days in advance and he was unaware of any posters stating otherwise. While he


KEY POINTS ●Ensure your booking system is flexible and does not disadvantage some patients. ●Practice policies should be advertised in multiple formats. ●Patients should not routinely be removed from the practice list without prior formal warning.


apologises for losing his temper, he accuses the practice staff of being obstructive and condescending and asks for a review of practice policy to make appointments easier to access.


ANALYSIS/OUTCOME Dr T contacts an MDDUS adviser for guidance on how to respond. She is advised to address each individual point raised and, where appropriate, offer an apology and an explanation of the circumstances that led to the complaints. In regard to the decision to deregister Mr


B, the adviser warns that the matter could be referred to the ombudsman or the GMC, and Dr T must be prepared to fully justify her decision. She is advised to review guidance from both the GMC and RCGP on ending your professional relationship with a patient. The GMC states that before ending a relationship, the doctor should warn the patient and do what they can to restore it. Dr T accepts she has not given Mr B due warning. She agrees to reinstate him to the practice list and offers to meet to discuss his complaints.


MDDUS INSIGHT / 19


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24