Report Date


Case Against

A Dental Practice in the area of Betsi Cadwaladr University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

Mrs C complained that the Practice failed to undertake adequate and appropriate monitoring of the condition of her teeth following root canal treatment (“RCT”) in April 2016. She also complained that she did not receive prompt and appropriate treatment when complications arose following that RCT. The Dentist who carried out the treatment has since left the Practice.

The investigation found that a degree of dental decay would have occurred in any event due to Mrs C’s approach to oral hygiene. However, the Practice did not follow the relevant guidance regarding the frequency of intervals between X-rays of Mrs C’s teeth. This meant Mrs C suffered an injustice because her decay could have been identified and treated earlier, with smaller fillings. Consequently, the first complaint was partially upheld. However, Mrs C’s second complaint was not upheld because she consented to the RCT treatment, having received a warning that complications could arise. In addition, the Dentist’s overall care and monitoring of the tooth following the RCT reflected good clinical practice.

The Ombudsman recommended that the Practice should write to Mrs C to apologise for the fact her teeth were not X-rayed as often as they should have been for her recorded risk level. The Practice accepted the Ombudsman’s recommendation. The Ombudsman further invited the Dentist to reflect on the findings of the investigation and to review the appropriate guidance as part of her continuing professional development. The Dentist agreed to do so.