Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

 

Introduction. 

Events leading up to complaint 

Opinion: Dr B — breach. 

Changes made since events.

Recommendations. 

Follow-up actions. 

Appendix A: Independent clinical advice to Commissioner. 

 

Introduction

1. On 8 March 2022 the Dental Council of New Zealand contacted the Office of the Health and Disability Commissioner (HDC) about a complaint the Council had received from Ms A. The complaint was referred to HDC under section 64(1) of the Health Practitioners Competence Assurance Act 2003.
   
   
2. This report is the opinion of Deborah James, Deputy Health and Disability Commissioner, and is made in accordance with the power delegated to her by the Commissioner.
   
   
3. The report concerns the identification of the correct tooth for dental treatment. The tooth was to be crowned following a root canal undertaken previously at another dental practice. The tooth that was crowned was situated next to the tooth intended for treatment.
   
   
4. The following issue was identified for investigation:

• • Whether Dr B provided Ms A with an appropriate standard of care in 2020.

5. The parties directly involved in the investigation were:

Ms A                                                          Complainant/consumer

Dr B                                                           Dentist

6. Further information was received from dentist Dr C.
   
   
7. Independent clinical advice was obtained from Dr Brett Hawkins (Appendix A).

Events leading up to complaint

8. In September of 2019 Ms A underwent root canal treatment[1] at her usual dental practice, on a tooth identified in the clinical records as tooth 15. The treatment was completed on 25 September 2019 and Ms A was advised by her dentist that tooth 15 should be crowned[2] in approximately six months’ time.
   
   
9. Ms A told HDC that she had been given a quote for $1,850 for her dentist to crown the tooth, and this was a lot of money for her. She said that she went past Dr B’s dental practice on her way home one day and noticed a sign advertising crowns. She went into Dr B’s practice and booked an appointment for her tooth to be crowned.
   
   
10. Dr B denied advertising using a sign outside his practice. However, he did confirm that at the time of these events he was performing crowns for a reduced price, and this information was available on his website.
    
    
11. The clinical record shows that Ms A attended four appointments with Dr B in 2020. Ms A told HDC that she had an initial consultation, and the crown was completed in two parts. The additional appointment occurred between treatments and was because Ms A was experiencing severe pain, which Dr B put down to infection and prescribed antibiotics.
    
    
12. Although the record of these four appointments is handwritten and difficult to read, the number 16 (referring to tooth 16) is recorded clearly at two of the appointments. There is no reference to tooth 15 in Dr B’s dental records.
    
    
13. In April 2021 Ms A returned to her usual dentist who had performed the root canal treatment to tooth 15 in 2019. Dental records from this appointment confirm that a crown had been placed on tooth 16, but not tooth 15.

First treatment

14. Dr B’s clinical record notes that the first crown treatment procedure occurred in 2020. Ms A stated that at this appointment she was alarmed as Dr B was not sure which tooth was to be crowned and asked her to indicate the tooth, which she pointed to. She said that she was reassured when Dr B went to the computer as she thought he was checking her previous clinical records to clarify which tooth required treatment.
    
    
15. Dr B provided HDC with an outline of his usual practice when consumers who are not regular patients attend appointments for a crown procedure. Dr B stated that usually he would explain the procedure of making a crown and review clinical notes and radiographs prior to proceeding. Dr B said that his usual process for identifying the correct tooth to be treated is as follows:

‘Check the patient’s card identifying the tooth to be treated and confirm with a review of the x-ray and discussion with the patient to ensure that the patient is aware of what the procedure is and what the treatment is entailing for that appointment.’

16. Ms A told HDC that she requested a copy of her past clinical record from her usual dental practice and provided this to Dr B. However, previous dental provider notes were not part of the dental record provided by Dr B to HDC, and there is no evidence to confirm Ms A’s request or to indicate that any information was passed on to Dr B. 
    
    
17. Ms A does not recall any X-ray images being taken by Dr B prior to the crown procedure commencing. Dr B told HDC that he does not recall Ms A, or the treatment provided, in any detail. He provided a copy of notes he recorded at the time and advised that there were no X-ray images, as ‘they appear to be lost’. 
    
    
18. The notes provided by Dr B consist of one page of handwritten notes. There is no card identifying the tooth that required treatment, nor is there any documentation of a discussion with Ms A, nor of an X-ray being taken.
    
    
19. Dr B outlined his usual consent process for a crown, which is verbal consent including a discussion on the options for the situation the patient has presented with and advantages and disadvantages of the requested treatment. He said that in this situation the discussion would include the following:

‘[T]he possibility of the tooth becoming nonvital requiring root therapy or extraction, what alternative treatments are available and suitable, the possibility of porcelain fracture, what types of material we [he] may use in that situation and also, possible referral to a specialist for treatment.’

20. Ms A told HDC that following the first treatment she was in a great deal of pain and at the time thought that ‘this [was not] right’. She went back to see Dr B due to the pain, which she described as so severe that she was crying and finding it hard to cope several days after the procedure. Ms A stated that Dr B ‘was not fazed’ and said that the pain would settle. He prescribed antibiotics as he thought her pain was due to an infection. The clinical record notes that a prescription for antibiotics was provided.
    
    
21. Two weeks later, Ms A went back to Dr B for the crown cap to be completed. This was the last appointment she had with Dr B. In her complaint to the Dental Council (passed on to HDC), Ms A said that she was still in ‘terrible pain and yet [Dr B] proceeded to complete the crown treatment without hesitation, noting that it would fix the pain’.

Identification of error and subsequent events

22. It was not until Ms A went back to her usual dentist on 12 April 2021, for treatment on other teeth, that the error was discovered. Ms A said that she realised that a mistake had been made when, after having an X-ray, her usual dentist asked why there was a crown on tooth 16. The clinical record notes:

‘Clinically 16 is now crowned. [Patient] said she had it crowned last year and it is the one that had the [root canal]. Advised [patient] that the [root canal] one is the 15 not the 16 and the crowned the one behind the [root canal] one. Clinically 16 slight [tender to percussion], air sensitive B ++ others not.’

23. When the error was identified, Ms A sought advice from Citizens Advice Bureau, who recommended that she contact her general practitioner for assistance with filing a treatment injury claim with ACC. The claim was filed and approved by ACC, allowing any treatment resulting from the crown to tooth 16 to be covered. Ms A went on to require a root canal on tooth 16 on 9 March 2022.
    
    
24. Ms A said that tooth 16 had been a ‘perfectly healthy tooth’ prior to being crowned. There was no indication in the clinical record that prior to the crown being placed, tooth 16 was showing concerning features that would require treatment in the immediate future.
    
    
25. Dr B has accepted that he made a mistake and expressed that he was ‘truly sorry that this situation [had] arisen’ and that he felt very sorry for the position Ms A had been put in. He expressed his willingness to apologise but said that he has been unable to do so, as he has had no direct contact with Ms A since these events.

Relevant standards

26. The Dental Council of New Zealand’s informed consent practice standard (2018)[3] states that dentists ‘must ensure patients are fully informed during the informed consent process’ and ‘give honest and accurate answers to questions relating to their care’.
27. Guidance under this section of the standards includes the following:

‘…

·     Provide the information the patient requests or needs to make an informed choice, including:

• • an explanation of their condition and the purpose of care.
  • an explanation of the possible options for care, including their likelihood of achieving the purpose of care; the associated risks, side effects, and benefits — and their likelihood; and the costs of each option.

• • Do not make assumptions about the information the patient might want or need — encourage questions and engage in discussion with your patients to ensure they have all of the information they feel they need to make an informed decision.

4.    You must obtain the informed consent of the patient before providing care, unless there is some other clear authority to treat.

5.    You must ensure informed consent remains valid throughout the period of care.

• • In the event that a change of practitioner is necessary during a period of care, obtain the patient’s consent for this change and confirm their consent for the planned care before proceeding.
    
    
  • Recognise that for informed consent to be valid throughout the period of care, an ongoing process of communication is required between yourself and your patient that keeps them fully informed regarding their condition and the progress of care. This provides them with multiple opportunities to review and re-assess their choice, and to affirm or withdraw their consent for care. This is particularly relevant for treatment with long timeframes, such as orthodontic care.
    
    
  • Respect the patient’s right to decide about the return or disposal of any body parts or bodily substances removed or obtained during care; offer to return a patient’s extracted teeth to them.
    
    
  • Keep an accurate and contemporaneous written record of the discussions held in the informed consent process; and document the patient’s oral consent when this is given.’

28. The Dental Council of New Zealand’s Patient records and privacy of health information practice standard includes the following:[4]

‘1.   You must create and maintain patient records that are comprehensive, time-bound and up-to-date; and that represent an accurate and complete record of the care you have provided.’

29. This section of the standards includes the following guidance:

‘·     Write clearly and only use standard abbreviations and acronyms, so the information can be easily understood by the patient or authorised third parties who may access the record.

• • Record the following information in the patient record:

…

• • • Reason for attendance, including details of any presenting complaint.
    • Relevant history, clinical observations and findings, and diagnosis.
    • Treatment options given, information given to the patient on associated benefits, likely outcomes of care, and potential risks, and final care plan for which consent is obtained’

Responses to provisional decision

Ms A

30. Ms A was given an opportunity to comment on the ‘information gathered’ section of my provisional report and advised HDC that she had no further comments.

Dr B

31. Dr B was given an opportunity to comment on my provisional report. His comments have been incorporated into this report where relevant.  

Opinion: Dr B — breach

32. To assist with determining whether the care provided to Ms A was appropriate, I sought independent clinical advice from dentist Dr Brett Hawkins.

Assessment, history-taking, planning of treatment

33. Dr Hawkins outlined the accepted process for identifying a tooth that requires treatment. This includes taking a history from the patient, including questioning when the root canal was done, a clinical examination, X-ray imaging, diagnosis, and a discussion on the options available. Dr Hawkins advised that the clinician providing treatment needs to establish their own clinical justification for treatment and not rely on another clinician’s assessment and treatment plan.
    
    
34. Although Dr B provided HDC with a detailed description of his usual practice, there is no evidence in the clinical record to support that Dr B assessed Ms A appropriately prior to proceeding with treatment, and Dr B does not actually recall having treated Ms A. Ms A indicated that the tooth she wanted to be crowned and the reason for this was that previously it had had a root canal. Adequate history-taking and clinical assessment would have assisted with identification. Of particular relevance is the absence of any X-ray image, as Dr Hawkins advised that this would have identified the tooth that had been root filled.
    
    
35. Dr B stated that his usual process is to review an X-ray, but no images were available to HDC, there is no indication in the clinical record that an X-ray was taken, and Ms A does not recall an X-ray having been taken. On balance, I find it more likely than not that Dr B did not take or review an X-ray prior to proceeding with the crown on tooth 16. Dr Hawkins advised that it appears that the expected process was not followed in Ms A’s case and, had it been followed, treatment on the wrong tooth could have been avoided. I agree, and I consider it is more likely than not that Dr B did not assess Ms A adequately or obtain an adequate history prior to treating her.
    
    
36. I accept Dr Hawkins’ advice that the treating clinician has a responsibility to establish their own clinical justification for treatment (in this case proceeding with a crown to tooth 16), and I can find no evidence to support that this occurred or was discussed with Ms A.
    
    
37. I note Dr Hawkins’ advice that it is not uncommon for a dentist to treat patients without the benefit of having their previous clinical record, and I am therefore not critical that Dr B did not ensure that he had Ms A’s previous records from her other dentist. However, even without the historical clinical records, the process of assessment, history-taking, planning, and consent to treatment is expected. In addition, prior to any treatment occurring, the clinical justification for that treatment needs to be established by the treating clinician.
    
    
38. Dr Hawkins advised that the NZ Dental Association and the Dental Council have codes of practice and standards that were in place at the time of these events, and that failure to follow these standards in this case is a severe departure in relation to assessment, history-taking, and planning of treatment. I accept this advice.

Consent to treatment

39. Ms A specifically made an appointment with Dr B for the purpose of having a crown on a tooth that had previously had a root canal. I appreciate that a crown was recommended by Ms A’s usual dentist and that this may have been the only option available for her tooth. I have given some weight to the information Dr B has provided on his usual practice for obtaining consent for a procedure. However, there is no clinical documentation to support that a consent discussion occurred outlining the options, risks, and benefits. I acknowledge Dr Hawkins’ opinion that Dr B’s consent process was a severe departure from the acceptable standard of care. However, due to the lack of documentation, I am unable to determine whether the consent process was completed appropriately, although the lack of record of any discussions with Ms A at all is very concerning.

Documentation

40. Dr B’s clinical notes are brief, difficult to read, and include no information on history-taking, assessment, planning, or consent discussion that took place, which I consider reflects poor documentation practices as well as an inadequate assessment.
    
    
41. Dr Hawkins advised that the quality of Dr B’s documentation is inadequate and represents a severe departure from the expected standard. There is no detailed information in the clinical record to indicate that the expected process outlined by Dr Hawkins occurred. Similarly, the documentation does not include any patient card or notes to support that Dr B undertook his usual process as he described to HDC. 
    
    
42. Overall, it is clear that Dr B’s documentation does not meet the expected standard for his profession as outlined in the Dental Council’s Patient records and privacy of health information practice standard, and I accept Dr Hawkins’ advice that this represents a severe departure from accepted practice.  

Conclusion

43. The care provided by Dr B to Ms A fell well below the standard expected of a competent dentist. Dr B did not obtain Ms A’s history adequately or conduct an appropriate clinical examination, including taking or reviewing X-ray imaging. Consequently, he failed to identify the correct tooth to be crowned. Accordingly, I consider that Dr B did not provide dental services to Ms A with reasonable care and skill, and therefore breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code).[5]
    
    
44. Dr B also failed to maintain adequate records, and so did not comply with the professional standards set by the Dental Council of New Zealand. Accordingly, I find Dr B in breach of Right 4(2) of the Code.[6]

Changes made since events

45. Dr B is no longer practising as a dentist. He retired and sold his dental practice to another provider. Dr B has not held a practising certificate with the Dental Council since 2021.

Recommendations

46. Recommendations are designed to improve practice and systems with the aim of preventing similar situations occurring to other people. Although this investigation has identified areas for improvement, Dr B’s retirement from clinical practice makes recommendations targeted at quality and practice improvement impractical.
    
    
47. I recommend that:

1. 1. Dr B provide a formal written apology to Ms A for the deficiencies identified within this report. The apology is to be sent to HDC within three weeks of the date of this report, for forwarding to Ms A.
   2. Should Dr B return to practice, the Dental Council of New Zealand consider whether a review of his competence is necessary.

Follow-up actions

48. A copy of this report with details identifying the parties removed, except the independent advisor on this case, will be sent to the Dental Council of New Zealand, and it will be advised of Dr B’s name.
49. A copy of this report with details identifying the parties removed, except the independent advisor on this case, will be placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

 

 

Question 1: The accepted process for a dentist to identify whether a new patient requires a dental crown, including whether an x-ray is required.
List any sources information	Dentist Peers
reviewed other than the	Lectures & webinars over many years
documents provided by HDC:	NZ Dental Association Code of Practice: Informed consent 25 March 2017
	NZ Dental Council Informed consent practice standard
Advisor’s opinion:	The process of assessment and treatment planning is the same for any dental treatment including crowns.
	This process is taught by the New Zealand Dental
	School as standard practice.
	The basic steps are
	Establish the patient’s reason for their visit
	Questions about dental history
	Clinical examination
	X-rays
	Special test
	Diagnosis
	7.     Develop a treatment plan, consider other options, identify benefits, risks and limitations
	Patient informed consent
	Deliver treatment
	The steps to identify if a tooth needs a crown are as follows:
	1.  Why has the patient come to see me. In this case [Ms A] came to have a crown on a root filled tooth 15 2. Question the patient about any problems they are experiencing such as symptoms from the tooth. 3. Questions about history of this tooth. In [Ms A’s] case I would want to know when the root filling was done. If the root canal treatment was difficult or complex often there is pause before crowning to ensure the infection fully resolves 4. Refer to previous notes and records if available. The majority of patients present without their previous notes. 5. Perform clinical examination where some of the following things are checked If the tooth is restored or not Any current restorations and size Any dental decay Any cracks If the tooth is opposed by another tooth 6. Clinical tests Percussion test to see if a tooth sensitive to pressure Cold test to see if tooth is still vital 7. Radiographs are taken to check for any problems around the root or top of tooth. For new patients I would always take a radiograph 8. Diagnosis Based on the dental findings above a diagnosis is made if the tooth needs a crown or not A crown is commonly recommended for these situations To protect a tooth that has become weakened (for example by decay) or cracked, by holding it together and preventing it from breaking To cover and support a tooth that has a large filling if there isn’t much natural tooth structure left. A common criterion is if the filling is greater than 1/3rd the width of the tooth then a crown is indicated. Some clinicians use a percentage of the tooth that is restored as a criteria

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