Report Date


Case Against

A Dental Practice in the area of Cardiff and Vale University Health Board


Clinical treatment outside hospital

Case Reference Number



Upheld in whole or in part

On 16 September 2019 Mrs X attended the Practice and complained of pain to her tooth and that it smelt. On 18 September a porcelain crown was fitted to the left second premolar tooth (“the UL5”). Mrs X said that the “wrong tooth” was treated, she said that the left second premolar tooth (“the UL4”) should have been treated. Mrs X said that the Dentist had not explained the procedure. Mrs X said that a few days later the UL5 fell out. Mrs X complained that she has been left with a gap in her teeth, she now speaks with a lisp and is unable to smile or have photographs taken. Mrs X sought quotations for private dental work for restoration to the UL5 by an implant.

The Ombudsman found that comparison of X-rays taken on 1 April 2020 and 16 April to those taken on 3 March 2021 corroborated that there was no problem with UL4. He found that UL5 was appropriately treated with a crown, the “wrong tooth” was not treated. The Ombudsman found that the uncertainty of treatment with Mrs X and UL5’s limited prognosis should have been discussed. He also found that Mrs X should have been presented with options – removal of the tooth, restoration with either a crown or a large filling, but a crown was preferable. He found that an implant is not provided by the NHS that only offers dentures. The Ombudsman upheld the complaint on the basis that options were not given to Mrs X.
The Practice agreed to implement the Ombudsman’s recommendations within 1 month to apologise to Mrs X for the failings, ensure its dentists are reminded to discuss and consider treatment options, and to make a redress payment of £367 as a reasonable contribution towards a denture for UL5 (reflective of a percentage for treatment to the UL5 by denture only).