Excellent record keeping is the best defence against unforeseen consequences of treatment, as this case demonstrates...
A recently qualified dentist decided to remove a maxillary first molar under local anaesthetic and, having explained the procedure to the patient, obtained her consent to proceed with the extraction. The case turned out to be more difficult than had been anticipated, even having the benefit of a good pre-operative radiograph.
Unfortunately the dentist displaced the mesio-buccal root into the maxillary antrum after the tooth had been sectioned, creating an oro-antral fistula. As soon as the dentist realised what had happened, he explained the situation to the patient and, while she was still in the chair, sought advice from the local maxillofacial surgeon on the telephone.
The surgeon advised a primary closure for the socket and the prescription of an appropriate antibiotic, along with the usual antral regime. All these discussions were recorded in the notes.
The dentist asked a senior dentist in the practice to close the socket. The patient was then discharged with the appropriate prescriptions and instructions. A referral letter including the radiograph was immediately written and sent to the maxillofacial surgeon.
Complaint after follow-up
The patient was followed up, in due course, at the local hospital and after several weeks of continued symptoms, she eventually recovered. The dentist was shocked to receive a complaint from the patient, alleging that she would not have embarked on the treatment if she had been warned that this complication might have occurred.
She further complained that the young dentist should not have attempted the extraction given the possible complications and she held the dentist responsible for her pain, suffering and loss of earnings while away from work.
The dentist’s protection organisation drafted letters for him to send in response to this complaint and ultimately the patient accepted that he had acted properly and promptly following this rare and unpredictable complication during a routine procedure.
Assisting the clinician in this case was made easy because his record keeping was excellent and he was given support by the maxillofacial surgeon as soon as he requested it. A prompt, accurate referral helped to resolve this complaint satisfactorily without lawyers becoming involved.
The case demonstrates the value of keeping good notes and of retaining copies of all correspondence in the file. The more information that is stored in the records, the easier it is to defend a clinician against an allegation of negligence arising out of a referral.
- A prompt, accurate referral (to a maxillofacial surgeon) helped to resolve this complaint satisfactorily without lawyers becoming involved.
- Providing assistance (to the clinician) in this case was made easy (for the dento-legal team) because his record keeping was excellent, and he was given support by the maxillofacial surgeon, as soon as it was requested. (Sending an x-ray as a JPEG within an e-mail is very easy).
- The case demonstrates the value of keeping good notes, and of retaining copies of all correspondence in the file. The more information that is stored in the records, the easier it is to defend a clinician against an allegation of negligence arising (had it arisen) out of a referral. (It is also important to know when and to whom you can refer a case on an expedited manner if an emergency.)