Report Date


Case Against

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


Clinical treatment outside hospital; Dentist

Case Reference Number



Upheld in whole or in part

Ms A complained about the care she received from 2016 onwards from a dentist (“the First Dentist”) based at the Dental Practice and questioned whether it was of an adequate standard. She also remained unhappy with the First Dentist’s handling of her complaint.

The Ombudsman’s investigation concluded that the care provided to Ms A by the First Dentist was broadly reasonable and appropriate. However, he identified that there was a failure by the First Dentist to carry out X-rays to monitor Ms A’s teeth between 2018 and 2020 in accordance with the Faculty of General Dental Practice (“the FGDP”) guidance. Whilst this was a failing, he was satisfied that the X-rays taken in March 2020 showed that with clinical intervention, Ms A’s periodontal disease progression might have been prevented. Unfortunately, the delay in treatment due to the COVID-19 pandemic led to a rapid progression of Ms A’s disease to the point that it was untreatable. The Ombudsman concluded that whilst the failings amounted to service failing, they had not caused an injustice to Ms A and this aspect of Ms A’s complaint was not upheld. However, the First Dentist was reminded of the importance of adhering to the FGDP guidance in such cases.

The Ombudsman was concerned about the way in which Ms A’s complaint was handled by the Dental Practice, as it did not appear to be in accordance with the NHS complaints procedure Putting Things Right (“PTR”) or its own complaints policy. The Ombudsman was of the view that the matter should have been treated as a complaint against the Dental Practice. This would have enabled better management of the complaint process and meant the Dental Practice was not acting as a “post box” by passing Ms A’s complaint to the First Dentist. The hands-off approach adopted by the Dental Practice and the lack of senior oversight and review of Ms A’s complaint by a senior partner meant the opportunity to learn lessons, an important component of the PTR process, was lost. The Ombudsman found that the shortcomings in the Dental Practice’s handling of Ms A’s complaint not only amounted to maladministration but also caused Ms A an injustice as she had to complain to the Ombudsman’s office to get answers. It was to that extent only that the Ombudsman upheld this aspect of Ms A’s complaint.

The Ombudsman recommended that the Dental Practice should review its handling of NHS complaints, discuss the Ombudsman’s report at the Dental Practice meeting and consider the wider organisational learning to be gained from Ms A’s case.