Gaps in NHS dental services and confusion over responsibility of care left patients in pain and without appropriate treatment, the Parliamentary and Health Service Ombudsman (PHSO) has found.
In one case, a woman waited eight years for treatment for broken teeth after falling into a gap between local dental and hospital services. In another, a patient remained in severe pain for over a year after a dental practice failed to arrange appropriate follow-up treatment after faulty NHS root canal work.
The Ombudsman said the cases highlight wider concerns about how NHS dental care is commissioned and delivered, and confusion about who is responsible for patients receiving the treatment they need.
Issues in the commissioning and delivery of services beyond dentistry and across the NHS are a recurring theme in complaints to the Ombudsman. In its new strategy, the Ombudsman has committed to using its evidence to support systemic improvements in the design and delivery of public services.
Anne, 58, from South Devon, broke a front tooth and damaged another in an accident in 2017 but did not receive effective treatment until 2025.
She said the damage made it difficult to eat, affected her confidence and her employment. She worked as a teacher and says she was told her appearance was not professional enough to teach face-to-face.
Anne’s dental practice told her they couldn’t provide the treatment she needed and she was referred to hospital services. However, the Trust she was referred to said she ‘fell into a gap between primary and secondary care’ and advised her to pursue the issue with NHS England (NHSE).
NHSE noted there was a lack of resources in the area which meant it was challenging to provide the care she needed.
In 2019, Anne was fitted with a denture after funding was approved through an Individual Funding Request (IFR) to NHSE. However, Anne explained the denture type had been identified as clinically unsuitable for her overbite and gag reflex.
Anne, said,
Following the provision of this inappropriate treatment the NHS hospital consultants and I chased NHSE for the treatment I needed. I feel that NHSE, despite knowing that I met the criteria for treatment, found ways to delay. I explicitly told them I did not want more opinions or appointments about treatment planning, but that was all I received for a long time. My patient journey was marred by NHSE not completing actions within promised timescales, not responding to emails and phone calls, and supplying inaccurate or incomplete information.
“Importantly, against my wishes, NHSE sent me for another five consultant treatment planning appointments. The first hospital consultant had already identified the treatment I needed; the only problem was how NHSE was going to deliver it. I did not need eight treatment planning appointments with multiple consultants.”
Parliamentary and Health Service Ombudsman, Paula Sussex, said,
Patients should be able to access the right treatment at the right time. Anne was unable to get the treatment she needed for eight years. That is an unacceptable delay.
“This is not an isolated issue and there may be systemic problems in the commissioning of services across multiple areas in the NHS. We have concerns that the system is confusing for patients, as well as those responsible for managing and delivering NHS services, is not consistently meeting people’s needs, and is letting patients down.
“We are reviewing our evidence around NHS commissioning and working to better understand how these problems affect patients. This will help support improvements so that patients receive consistently high standards of care.
“NHSE has committed to sharing learning from our investigation with all Integrated Care Boards. This is a powerful example of the impact of our investigations and how just one complaint can improve public services for everyone.”
Anne complained to NHSE, who should respond within 40 days. It took over two years to reply and did not address the issues raised or give comprehensive answers to specific questions. It also did not signpost her to the Ombudsman until 18 months after she raised a complaint.
Anne, said,
Leaving a patient in limbo by constantly promising action but not delivering is worse than refusing treatment at the outset. Had I known that NHSE would not deliver the care I needed for eight years, or if they had refused to provide the treatment, I could have changed my career to one where my appearance did not matter and saved up to pay privately for the treatment I needed. I could have solved my dental issues much earlier.
“I hope that NHSE learns from this case that treatment planning by hospital consultants for primary care dentists needs to be realistic in terms of treatment options that can be carried out within the primary care budget and expertise. I’ve estimated that over 20 hours of NHS hospital consultant time has been spent on ‘treatment planning’ to deliver the two hours of treatment I actually needed. I seriously question whether that is an effective use of NHS resources.
“My experience shows that the commissioning team for the South West is not doing what it is supposed to, which is to deliver timely, standard secondary care that is accessible to all. There needs to be greater transparency about which treatments are available, timescales, and funding.”
In a separate investigation, the Ombudsman found a dental practice had misunderstood its responsibilities under the NHS dental contract, leaving a woman in pain for over a year after a faulty root canal treatment.
The Ombudsman found that, as the contracted NHS provider, the practice — not the individual dentist who carried out the treatment — was responsible for ensuring appropriate NHS follow-up care was arranged. The Ombudsman said misunderstandings about this responsibility may be more widespread across dental services.
Claire, from North Somerset developed an infection after receiving inadequate root canal treatment on the NHS. When she returned to the practice, she was told it could not provide restorative treatment because the original dentist had left.
The practice referred Claire to a local NHS hospital, despite knowing she was not eligible for treatment there under local commissioning arrangements and later directed her towards private care.
Claire did not want to pay privately for treatment to correct NHS care that had failed. The practice later attempted to contact the original dentist, but Claire did not receive a response for several months.
The failings meant Claire remained in pain for longer than necessary and faced an increased risk of losing her tooth.
Claire said:
My experience with the dental practice was extremely disappointing. The treatment process was drawn out unnecessarily and left me dealing with side effects that lasted for years. It could have been resolved much sooner with more care, attention, and follow-up support. I felt dismissed and fobbed off when raising concerns, and there was a real lack of personal care throughout and after the treatment, despite the issues it caused.
“Even now, I remain unsure whether the practice has truly taken accountability for the issues caused by their dentist. The apology I received felt more like sympathy that I felt there was a problem, rather than sincere remorse for the impact the treatment had on me.”
In both cases, the Ombudsman asked the organisations to apologise to the women, make payments to them to recognise the impact of their failings, and detail what actions they will take to make sure similar failings don’t happen again. Both organisations complied with the recommendations.
For more information about Anne’s case, read the final investigation report.
For more information about Claire’s case, read the final investigation report.