The investigation
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We telephoned Mrs D on 24 August 2010 to discuss the nature of her concerns and the way in which we would investigate her complaint. We confirmed our understanding of the complaint and the issues we would investigate in our letter to her dated 1 October.
During this investigation we have examined all the relevant documentation. This includes papers provided by Mrs D and Mr Nath and papers relating to the attempted resolution of the complaint both at local level and by the Healthcare Commission. We have taken account of the comments received from Mrs D as set out in her correspondence with this Office. We also met Mr Nath in January 2011 to discuss the complaint and his comments on our draft report.
We also obtained specialist advice from one of my clinical advisers, Adviser A BDS(Lond) LDSRCS(Eng) Dip HPM (the Adviser), a dentist. My clinical advisers are specialists in their field, and in their roles as advisers to me they are independent of any NHS body.
In this report I have not referred to all the information examined in the course of the investigation, but I am satisfied that nothing significant to the complaint or my findings has been omitted.
Mrs D and Mr Nath have both had the opportunity to comment on a draft of this report and their responses have been taken into account in coming to the decision.
Key events
Between July and September 2007 Mrs D attended the Practice complaining of a broken crown and toothache. She was seen on a number of occasions by Mr Nath, who took X-rays of her mouth but was unable to identify a cause of the pain. Mrs D says that during her final appointment on 7 September Mr Nath was rough and hurt her whilst trying to conduct further X-rays. She said that when she objected he said he could do nothing more for her, turned his back on her and demanded that she leave the surgery. Mrs D says that she was left ‘battered emotionally and in more pain’ from this appointment and she also says: ‘I was offended by his rude and unprofessional manner, I was shocked’.
The same day Mrs D made a verbal complaint to the Practice which included that Mr Nath had hurt her and was rude during a consultation when he was attempting to X-ray her teeth.
Mr Nath provided a written response to Mrs D and explained why he had needed to take X-rays. He also explained the procedure involved and that this can be uncomfortable. He said he felt that Mrs D had been rude to him and he could not offer her any further help. Mrs D then made a formal written complaint to the local primary care trust (PCT). This complaint included the following: that there was someone present during a consultation and Mrs D did not know who this was; the management of her dental pain; an attempt to take an X-ray was painful; Mr Nath’s attitude; and the response to her complaint. The PCT referred the complaint back to the Practice. Mr Nath responded to the PCT and said he had nothing more to add to his original response. The PCT then provided Mrs D with details of the Healthcare Commission.
In January 2008 Mrs D complained to the Healthcare Commission. In March 2008 Mr Nath wrote to the Healthcare Commission in response to its enquiries. Mr Nath said:
‘I am sorry that Mrs D felt that I had not treated her in a gentle manner … I can only apologise if the patient felt that I was uncaring … I can only apologise if Mrs D felt uneasy with the presence of my second nurse … I am sorry that the patient feels I have not handled this complaint appropriately but I believe I have carried out the complaint handling in an appropriate way.’
In response to the complaint regarding the management of Mrs D’s dental pain, Mr Nath wrote:
‘I am sure that any dental professional will confirm that if one is unable to identify the cause of the problem then one cannot carry out treatment. I believe that I looked carefully at the patient and considered the various options that I had. It would have been inappropriate for me to have advised on a diagnosis and treatment as I had not been able to take the appropriate X-rays.’
The Healthcare Commission upheld Mrs D’s complaint in April 2008 and made 13 recommendations to the Practice regarding the treatment Mr Nath had provided for her. Among other things, the Healthcare Commission recommended that the Practice should, by 16 May 2008, send a written response to Mrs D including:
- an apology for the pain and distress caused to Mrs D when Mr Nath attempted to insert an X-ray sensor during a consultation on 7 September 2007;
- an apology that Mrs D found Mr Nath’s attitude at this consultation uncaring;
- an apology for any concern caused to Mrs D by the unexpected presence of an additional dental nurse at a consultation on 3 July 2007;
- an apology for the fact that Mr Nath was not following professionally accepted guidelines when he chose to take X-rays on 16 July, and did not conduct appropriate investigations following this, and for the distress that this had caused Mrs D; and
- an apology for the Practice’s failure to adequately respond to Mrs D’s complaint, and for the additional inconvenience and distress this caused.
Mr Nath disputed the Healthcare Commission’s decision to uphold the complaint. On his behalf, the Dental Defence Union (DDU) forwarded his objections to the Healthcare Commission. Mr Nath considered that some aspects of Mrs D’s complaint had not been raised with him prior to her approaching the Healthcare Commission. He maintained his position that he could not add any more to his original response to resolve the complaint and questioned the clinical advice that the Healthcare Commission had received. The Healthcare Commission responded to the DDU and said that all of Mrs D’s complaint was laid out in her letter of 26 September 2007 and the Practice had acknowledged receipt of it on 1 October.
It also addressed Mr Nath’s concerns about the clinical advice referred to in its report and requested that he comply with the recommendations by 18 July 2008.
On 19 August 2008 Mr Nath wrote to Mrs D.
The letter simply said:
‘I reiterate the points made in all my previous correspondence to you and the [Healthcare Commission] in relation to your treatment. Our practice adheres to all the practice procedures seen as good practice by an acceptable body of general dental practitioners. I am still awaiting an apology from you for your rude and insulting behaviour.’
In September 2008 Mrs D wrote to the Healthcare Commission as Mr Nath had not provided her with any apologies. The Healthcare Commission subsequently asked Mr Nath to comply with the recommendations; informed the PCT that he had not complied with its recommendations; and asked the PCT to consider whether it was appropriate to refer him to the General Dental Council (GDC).4
In November 2008 Mrs D wrote to the GDC regarding her complaint about Mr Nath. In February 2009 the PCT wrote to Mrs D and explained that it had also contacted the GDC about him.
In April 2010 Mr Nath’s representative (now from the Medical Defence Union) wrote to the GDC. This letter set out Mr Nath’s position in relation to the GDC’s investigation into Mrs D’s complaint. It said that Mr Nath had addressed the issue regarding the management of Mrs D’s dental treatment in his letter to the Healthcare Commission in March 2008. It also said the letter to the Healthcare Commission included Mr Nath’s apologies for: his poor attitude; the unexpected presence of an additional dental nurse; pain caused while attempting to insert an X ray sensor; and poor complaint handling. Mr Nath’s representative said he reiterated these apologies in his letter to Mrs D in August 2008 and ‘Dr [Nath] repeats this apology’. A copy of the letter to the GDC was sent to Mrs D.
In May 2010 the GDC wrote to Mrs D and said it was extremely concerned to note that she had still not received a letter of apology and it had issued a warning to Mr Nath which included: ‘… Mr Nath is also warned in future to follow recommendations of professional bodies when issued with them’.
The complaint to the Ombudsman
Mrs D complains that Mr Nath has not provided her with the apologies that the Healthcare Commission recommended he make.
Specialist advice
We asked our Adviser to comment on the recommendations made by the Healthcare Commission in relation to Mrs D’s complaint. He said that the recommendations were appropriate and proportionate to the issues in the complaint.
Mr Nath’s comments on our draft report
Mr Nath told us he considered that Mrs D had had an apology and that his representative’s letter to the GDC (paragraph 34) constituted an apology. He said he had tried to address his shortcomings and he had sent more than one apology. He also said that he would not pay Mrs D any compensation.
4 The GDC is the regulatory body for dentists.
