Delayed response to postoperative complications

Mr S complained to the Trust and asked for £300 to replace the damaged crown. The Trust replied that it had got his consent for the operation and that his records noted that he had fixed crowns on his teeth. The Trust said it gave patients a standard information sheet that noted the risks of anaesthetic, one of which was dental damage, and Mr S should have received one. Because dental damage was rare, it would not be routinely discussed with patients unless there were particular risk factors that made it more likely to occur (such as difficult airway management or poor dentition). The Trust had not identified any particular risks in Mr S's case and said that having a crown did not significantly increase the risk of damage. Furthermore, it said that had he been specifically consented for this, it would not have reduced the possibility of dental damage.

The Trust said that Mr S's laryngeal mask was inserted by a trainee but overseen by a consultant anaesthetist and that there was no damage during insertion or when staff removed the mask. The Trust apologised that there was no record that staff told Mr S about dental damage before the operation. However, if he had been told about this, dental damage would not have been avoided. Overall, it said that the damage was an unavoidable and non‑negligent complication of anaesthesia.

What we found

The Trust's comments that dental damage is a rare complication were reasonable. But its comments that Mr S was not at a higher level of risk were unreasonable: patients with crowns, bridges, veneers, or implants on a front tooth are at greater risk of dental damage.

There was no evidence that the Trust gave Mr S any information before the operation to fully explain the risks, and the preoperative paperwork was not properly completed. That meant we could not confirm if staff discussed risks. This poor record keeping, along with a lack of clarity about which anaesthetist or anaesthetists were present, meant we could not say if Mr S's dental injury was unavoidable. Overall, the Trust's response to Mr S's concerns was unreasonable and there were problems in its record keeping.

Putting it right

The Trust paid Mr S £250 compensation and agreed to tell us how it will maintain the quality of its written records.