The Commissioner received a complaint from a mother about the care her daughter received from the provider, a dentist, in mid-April 1997. The consumer, who is aged three, had suffered a laceration to the back of her mouth, which required suturing. The provider chose to carry out the procedure without placing an anaesthetic. The procedure was traumatic for the child. The essence of the complaint is that the provider should have placed an anaesthetic before suturing the affected area, and the suture should have been a dissolving stitch rather than a silk stitch.
The complaint was received on 15 April 1997 and an investigation was carried out. Information was obtained from:
The Consumer's mother and father
The Provider, a Dentist
The Practice Nurse
The Complainant's family GP
Dental records from the Emergency Department at a Hospital were obtained and viewed. Dental records from the Dental Care Unit where the provider works were obtained and viewed. Dental advice was obtained from a dental surgeon.
Details of Investigation
The consumer and her mother attended the Dental Care Unit in mid-April 1997. The consumer, aged 3 years and 5 months, had suffered a laceration to the back of her mouth which required suturing. The provider, who was the attending dentist, estimated that it was a "very large laceration, greater than 1 cm .... extending from the retromolar region to the soft palate" The provider decided to suture the wound without placing a local anaesthetic, believing that to do so would have caused such distress that the child would not have let him into her mouth again.
The complainant held her daughter while the provider carried out the procedure with the assistance of his nurse. The procedure was particularly upsetting for the child who kicked and screamed, and consequently the provider was able to get only one stitch in.
The complainant still had concerns after she left the unit so she took her daughter to the Hospital Accident and Emergency for further assessment. The consumer's medical notes show that she was given a saline mouthwash, pain relief, and amoxycillin for her injury and the following comments were also made: "Given today's experience suggest GA if surgical/dental intervention needed in this injury's care"
Four days later the complainant took her daughter to the family GP who referred her to the Hospital Dental Department for removal of the suture. In his referral letter the GP stated: "she will need these removed but I suspect under a general anaesthetic as she was very traumatised during the insertion of the stitches"
The next day the complainant and the consumer presented at the Hospital Dental Department to have the stitch removed. Given the consumer's traumatic experience and her reluctance to have the suture removed the decision was made (after consultation with the consumer's parents) to leave the stitch "in situ" and allow it to exfoliate with time.
Code of Health and Disability Services Consumers' Rights
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
Right to be fully Informed
1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including -
a) An explanation of his or her condition; and
b) An explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option; ....
In my opinion the provider has breached Right 4(2) and Right 6(1) of the Code of Rights as follows:
The provider's decision to suture the consumer's injury without administering an anaesthetic was incorrect given that he was dealing with a 3-year-old child who was already in a state of some distress as the result of the injury. The provider failed to take into account the emotional and physical effect the procedure would have on the child. Hospital records and the GP's notes confirm how traumatised the child was as the result of the experience. From the information available it appears that the provider considered the possibility of placing a local anaesthetic and then dismissed it. There was no thought given to the option of a referral for a general anaesthetic which in the circumstances would have been more appropriate. I accept my dental advisor's view on this point:
"To attempt to suture the wound without anaesthetic was inappropriate, and given the child's age and the trauma she had suffered, the use of a general anaesthetic should have been the treatment of choice"
The dental adviser also indicated that it would have been more appropriate to use a dissolving suture rather than a silk one given that the wound was reasonably difficult to access and also the fact that the experience had been quite traumatic for the child up to that point.
The provider had several options available to him in relation to the course of action he was going to follow when treating the consumer. Specifically, these were whether or not he was going to use a local anaesthetic, general anaesthetic or no anaesthetic at all. Also, the provider had a choice between using dissolving sutures or silk sutures. Thirdly, the option of referring the consumer to the Hospital Accident and Emergency Department should have been considered by the provider.
Although the situation required the provider to act with some urgency it did not excuse the provider from his responsibilities under Right 6 of the Code to provide such information to the complainant. The provider did not attempt to explain to the complainant the various options available to her.
In my opinion the provider's failure to advise the complainant of the treatment options available was a breach of Right 6(1).
I recommend that the provider take the following actions:
- Apologise in writing to the complainant for his breaches of the Code. This apology is to be sent to the Commissioner who will forward it to the complainant. A copy of the apology will be retained on the Commissioner's file.
- Pay $200.00 towards the treatment costs incurred by the complainant for her daughter. Such payment includes a contribution to the costs incurred with the provider, the general practitioner, and hospital visits. This payment is to be sent to the Commissioner who will forward it to the complainant.
- Read the Code of Health and Disability Services Consumers' Rights and view the video Code of Health and Disability Services Consumers' Rights - A General Introduction. The provider is to confirm in writing to the Commissioner that he has read the Code, viewed that video and understands his obligations.
A copy of this opinion will be sent to the Dental Council of New Zealand for their information.