Names have been removed (except Dr Natu Rama) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The Commissioner received a complaint from Mrs T about the services provided by Dr Natu Rama. The complaint is that:
- Dr Rama quoted $1700 for implantation of Mrs T's front teeth. Prior to the treatment Mrs T asked Dr Rama for an explanation of the procedure. Dr Rama did not return any of Mrs T's calls and did not give an explanation as requested.
- On 3 August 1998 Dr Rama drilled large holes in Mrs T's three front teeth to make way for a bridge. When Mrs T complained Dr Rama stopped the treatment, did not install temporary dressings and has not completed the treatment.
- Despite repeated attempts to resolve the issue Dr Rama will not discuss the differences in the treatment or why he changed the treatment. All appointments Mrs T has made to complete the treatment have been cancelled by Dr Rama.
- Dr Rama accepted payment in advance and has not refunded the money for the treatment which was not completed.
The Commissioner received the complaint on 14 September 1998 and an investigation commenced on 10 November 1998. Information was received from:
Mrs T Consumer / Complainant
Dr Natu Rama Provider / Dental Surgeon
Dr W Dental Surgeon
Mr T Consumer's ex Husband
Mrs T's dental records were obtained from Dr Rama and the Commissioner obtained advice from an independent dentist. Information was also supplied by Health Advocates Trust and Dr Rama's receptionist.
Information Gathered During Investigation
On 20 July 1998 Mrs T consulted Dr Rama about having a tooth implant. She had previously worn a stainless steel partial plate but it broke. She decided to have an implant rather than another partial plate.
Mrs T advised that Dr Rama examined her mouth and said that he could do an implant. He quoted $1700 for the complete job. He explained that Mrs T would have to pay in advance by cash or bank cheque.
Dr Rama's dental notes for 20 July state:
" ... Patient states that she would like something more permanent as she was not happy with the old acrylic partial denture.
(1) Partial upper acrylic denture with two clasps. Explain that this would also include teeth on the other edentulous areas as well. The few extra teeth does not add to the price as the price includes 1 to 6 teeth on the denture.
(2) The unit bridge - retainer teeth 21 and 23 Pontic 22, VMK A bridge will improve the appearance of the 21 and 23 as well.
On quoting $1700-00 for the bridge the patient reacted by stating quote:
"Too much - that is too much - I don't know if I can afford that."
Patient asked if this was permanently fixed in the mouth.
Answer: yes, the three unit bridge will be retained by the two adjacent teeth.
Patient asked if there were any other options.
Answer: No as anything else will cost far more than $1700-00 possibly around 3 times more.
Patient state that she can't afford the $1700-00 as it is.
Advised: In that case the bridge or partial upper acrylic denture was her best option.
Mrs T advised the Commissioner that she did not have this conversation with Dr Rama.
Dr Rama advised that Mrs T asked him if he would be able to do some dental treatment for her husband. Dr Rama said that he could but would need to see her husband and that it could cost as much as $2000.00. Dr Rama's notes state:
" ... Patient states that she will need to discuss costs with her husband and now that she knows that her husbands treatment will cost less than $2000-00, they may just be able to afford the dental treatment that they need."
Mrs T advised the Commissioner that she is no longer married. She has been divorced for about twelve years and she only ever refers to Mr T as her ex-husband. Furthermore she would not discuss her finances with her ex-husband. They are financially independent and have been since their separation. The only time she ever sees her ex-husband is if she drives him to a doctor's appointment. Dr Rama advised the Commissioner that he assumed they were still married because she still calls herself "Mrs T".
Dr Rama advised the Commissioner that:
... There are adequate records to show that Mr T was referred by [Mrs] T and that he attended the surgery on 31st July 1998 ... .
Mr T advised the Commissioner that he only attended one appointment with Dr Rama and that was for an estimate of the dental work needed. He did not return for treatment. He did not want the option Dr Rama suggested.
Dr Rama continued:
... "Mrs T claims that I originally quoted for an implant for the edentulous area 22. An implant takes 12 to 15 months to complete and costs around $5,000-00. The overhead materials and laboratory costs would come to a figure greater than $1,700-00. I would not under any circumstances quote $1,700-00 for an implant. Mrs T was at all times aware that the quote of $1,700.00 was for a 3-unit-Bridge."
Mrs T told the Commissioner she did not ask for a bridge because she did not know anything about a bridge. She knew about the implant because her neighbour and friends have told her about it and an implant sounded like the answer to her problems. Mrs T thought an implant was a simple matter of drilling a hole in her bone and screwing in a new tooth. It was not until after Dr Rama had damaged her teeth that she sought more advice about implants. It was also the reason that she continued to ask Dr Rama what technique he would use to do the implant. Dr Rama never responded to these requests for information. She has since found out from another dentist about the differences between a bridge and an implant.
On 28 July 1998 (the day after the initial consultation with Dr Rama) Mrs T rang his surgery and confirmed with the receptionist that she would proceed with the implant. She also asked the receptionist to tell Dr Rama that she would like an explanation of the technique he proposed to use. Dr Rama did not return her call. The following day Mrs T made an appointment for 3 August 1998 at 2:00pm. She again asked for an explanation of the procedure and continued to ring each day until her appointment but Dr Rama did not ring her back.
On 3 August 1998 at 2:00pm Mrs T kept her appointment with Dr Rama. Before treatment commenced she was asked to pay $1700.00.
Dr Rama's notes state:
Patient asked as she walked into the treatment room "what are you going to do today"
Patient did not sit down.
Answer: My dental nurse had phoned her a few days ago and left a detailed message on the answer phone and that I understand that you had telephoned back to surgery stating that you had received the answerphone message. My dental nurse then read out the same answer phone message to you.
Patient states that she knows but she wants to know what is going to be done today."
Mrs T advised the Commissioner she does not, and has never had, an answer phone. She said that on one occasion she left a friend's telephone number who has an answer phone but no messages were left on this answer phone for her. Furthermore she did not tell Dr Rama that she had received the answer phone message.
Dr Rama did not give an explanation about the preparation for an implant but commenced the dental treatment. He gave Mrs T two injections to numb the area and commenced drilling her teeth. At a break in the drilling, when the suction was removed, Mrs T could feel the results of his drilling. Dr Rama had drilled into her teeth on either side of the gap where the implant would be placed. This was not Mrs T's understanding of the preparation for an implant. Mrs T was upset and asked Dr Rama for an explanation. He said that he was going to give her the treatment that he would recommend for himself. Mrs T protested that this was not the treatment that she had discussed with him nor was it the treatment that she had paid for. Dr Rama was not prepared to discuss the matter any further. He applied temporary dressings to her teeth and Mrs T left his surgery.
Dr Rama's notes for 3 August 1998 state:
" ... Treatment carried out:
(1) Local anaesthetic
(2) Shade selection Lumin Vac A2
(3) Upper alginate impression x 2, one protemp temporary crowns and the other for a study model for lab
(4) Prepare two teeth 21 and 23 for crowns
(5) Upper impregum impression
(6) Bite registration
(7) Alginate lower for antagonist model
(8) Protemp temporary crowns construct splinting to two teeth to maintain the edentulous space
(9) Maintenance instructions
Advised to make appointment for two weeks but practice will confirm this appointment closer to the time depending on whether the crown and bridge laboratory has completed fabricating the bridge." Mrs T's complaint about her dental treatment is not recorded in the notes.
Mrs T left the surgery after Dr Rama fitted the temporary dressing. It is difficult to know at what point in the above plan Mrs T's treatment concluded. On arriving home Mrs T rang the Dental Association who advised her to give Dr Rama the opportunity to complete the treatment. In addition they referred her to Health Advocates Trust, the local advocacy service provided under the Health and Disability Commissioner Act. Mrs T also rang Mr T to advise him that he may wish to re-consider whether to proceed with his appointment with Dr Rama. Mr T confirmed this conversation.
On the advice of the Health Advocates Trust Mrs T wrote to Dr Rama asking why he had changed the treatment without discussing it with her. This letter was sent by registered post dated 11 August 1998. She received no reply. Mrs T made appointments with Dr Rama for follow up treatment on 17 August, 20 August, 27 August and 3 September 1998, all of which were cancelled by Dr Rama. By this time her teeth and gums were so painful that she had difficulty eating and drinking.
On 10 September 1998 Mrs T made another appointment and arrived at the surgery at 9:00am. Dr Rama's receptionist told her that Dr Rama was sick and would not be coming in until later. However, there was another lady in the waiting room who had an appointment with Dr Rama that morning. When Mrs T asked the receptionist why Dr Rama was keeping an appointment with the other woman the receptionist did not reply. The Commissioner requested Dr Rama's appointment book for 10 September 1998 but Dr Rama advised the Commissioner, through his receptionist, that it had been destroyed.
Mrs T then concluded that Dr Rama was not going to do any further work on her teeth. He has not refunded the $1700 payment made in advance.
In response to a provisional opinion Dr Rama advised the Commissioner:
"... At no point was Mrs T informed that treatment would not be continued. She also did not seek assistance from another dentist nor approach Dr Rama at this point. From notes kept by the Receptionist Dr Rama continued to contact Mrs T regarding continuing this treatment but was informed that Mrs T was not going to accept Dr Rama's offer to complete the work.
Even though Mrs T had reached that conclusion and was so distraught over the state of her teeth at that time she did not consult with another dentist until her teeth had become infected. Her negligence therefore contributed the amount of remedial treatment required ... ."
Mrs T advised the Commissioner that she had the original treatment on 3 August 1998 and did not seek treatment from Dr W until 20 October 1998. Health Advocates Trust confirmed that they rang twice on Mrs T's behalf but Dr Rama did not return the calls. Mrs T informed them that she had found another dentist willing to continue her dental treatment and she would not return to Dr Rama.
Mrs T was advised by the Dental Association that Dr Rama should be given an opportunity to complete the work. However given the repeated cancellations from Dr Rama she reached the conclusion that he no longer intended to complete the treatment. Furthermore Dr Rama had not made any other provisions for continuing her dental treatment. Each time Dr Rama cancelled an appointment Mrs T informed his receptionist about her painful gums and teeth but this seemed to be ignored.
On 20 October 1998 Mrs T's teeth and gums became so painful that she had to consult another dentist, Dr W, who agreed to perform the remedial treatment to her teeth. Dr W supplied the Commissioner with photographs showing the progress of Mrs T's remedial treatment. On 13 April 1999 Dr W advised the Commissioner that he has still to assess whether or not the teeth cut away before Mrs T came to him can be saved. He would remove the temporary bridge (he put in place) and if the teeth under the crowns are healthy he will then place a ceramic metal crown on each of the teeth to form the basis of a three unit bridge.
Independent Advice to Commissioner
The Commissioner's dental advisor reported:
"It is my opinion that Mrs T did not receive an appropriate standard of dental care from Dr Rama. I do not believe that Dr Rama's cutting of Mrs T's adjoining teeth in preparation for a bridge was within appropriate professional standards. I do not believe Dr Rama's follow-up care of Mrs T was within acceptable professional standards ...
- Mrs T believes that she was to have an implant to replace her missing upper left lateral incisor. She accepted that she would need to pay in advance. She does not appear to have understood the procedure that would be involved ... . Although Dr Rama did not call and explain the procedure to her she still appeared for treatment prepaying as she had agreed ...
- A bridge and an implant are two very different procedures. Dr Rama believed he was preparing for a bridge for Mrs T and consequently cut the two teeth adjacent to the space. This is normal accepted procedure for the preparation of a bridge in this area. An implant is a stand alone treatment, the first stage the implanting of a fixture to the jaw bone where the tooth is missing. This procedure is carried out by a specialist e.g. oral surgeon or periodontist. Implants are a team job and are complex treatments that require a lot of planning and a lot of commitment including the patient. It is a very costly procedure and is likely to cost around $4000. Had Mrs T had a vague understanding of implants she would have realised nothing Dr Rama was doing was consistent with the procedures involved with implants.
- The photographic evidence supplied by Dr W (1a, 1b and 1c) show grossly inflamed gingival tissues associated with very poor tooth preparation of the two teeth adjacent to the space. This is not the standard of care that would be reasonable expected of a dental surgeon. In contrast photograph 2a shows these same teeth prepared in a more acceptable manner - there are no rough edges and crown margins can be seen. In series 3a, 3b and 3c taken with Dr W's temporary bridge in place the improvement in gingival health is very apparent. It may well be that Mrs T's teeth have been cut in such a way that "damaged the nerves" but I can not confirm this with the evidence before me.
- Dr Rama and his receptionist do not have the same view as Mrs T of the telephone support provided. It is difficult to know where the truth lies. However Mrs T has paid for the work that she has not received and there is agreement that Mrs T phoned on a number of occasions.
- Mrs T will incur additional financial costs to restore her upper left anterior teeth. She may well require root treatments to the two teeth adjacent to the space or indeed these teeth may need to be removed. While the evidence before me does not allow me to give a prognosis for these teeth there is no doubt of the additional time and money needed to correct Dr Rama's treatment. Because the teeth adjacent to the space have been cut the provision of an implant would now not be the most appropriate treatment for Mrs T.
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.
4) Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer.
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.
2) Before making a choice or giving consent, every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, needs to make an informed choice or give informed consent.
3) Every consumer has the right to honest and accurate answers to questions relating to services.
Right to Make an Informed Choice and Give Informed Consent
1) Services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent, except where any enactment, or the common law, or any other provision of this Code provides otherwise.
Right to Complain
6) Every provider, unless an employee of a provider, must have a complaints procedure.
7) Within 10 working days of giving written acknowledgement of a complaint, the provider must, -
a) Decide whether the provider -
i. Accepts that the complaint is justified; or
ii. Does not accept that the complaint is justified; or
b) If it decides that more time is needed to investigate the complaint, -
i. Determine how much additional time is needed; and
ii. If that additional time is more than 20 working days, inform the consumer of that determination and of the reasons for it.
8) As soon as practicable after a provider decides whether or not it accepts that a complaint is justified, the provider must inform the consumer.
In my opinion Dr Rama breached Right 4(2), Right 4(4), Right 6, Right 7(1) and Right 10 as follows:
Rights 6(1)(b), 6(2) and 6(3)
When Mrs T asked Dr Rama for an explanation of the technique he would use, the information should have been supplied readily and in time for her to consider all her options before she consented to the treatment. The onus is on Dr Rama to ensure that Mrs T received a satisfactory explanation of his technique in keeping with her request. Mrs T made repeated requests but was not supplied with the information which was in breach of Right 6(3).
If Dr Rama explained the difference between a bridge and an implant it would have become obvious that Dr Rama's intended treatment was not what Mrs T was seeking. Dr Rama had an obligation to provide all the options and the associated risks, side effects, benefits and costs to ensure Mrs T understood. In failing to provide this information Dr Rama breached Right 6(1)(b) of the Code.
Mrs T firmly understood that she was to have an implant and would not have agreed to any other treatment unless she was convinced that an alternative treatment was better for her. Even if Dr Rama had left a message on an answer phone or relied on a receptionist to give an explanation, these are inappropriate means of ensuring that Mrs T had the full information she required to make an informed choice. In my opinion Dr Rama's failure was in breach of Right 6(2).
Services may only be provided to a consumer if the consumer gives informed consent. In terms of the Code, informed consent is not a single event, but a process involving effective communication, provision of all necessary information and the consumers freely given competent consent. Each of these elements reflects a fundamental component of the informed consent process and may all work together to ensure valid consent.
As discussed above, Mrs T was given insufficient information on which to base her decision about treatment on her teeth. As consent is not valid unless it is given with complete understanding of what it is being consented to, in my opinion, Dr Rama failed to obtain informed consent from Mrs T in accordance with Right 7(1) of the Code.
Standard and Timeliness of Treatment
Mrs T was entitled to dental services that comply with professional standards. On 3 August 1998 Dr Rama cut into Mrs T's teeth in preparation for a bridge. As stated above, in my opinion he undertook this procedure without informed consent. Mrs T became upset at the treatment and Dr Rama placed a temporary dressing to the drilled teeth.
I do not accept that Dr Rama tried to make arrangements to continue treatment but was unable to contact Mrs T in the weeks between 3 August and 20 October when Mrs T made alternative arrangements. Furthermore I do not accept Dr Rama's statement that Mrs T contributed to her own misfortune by waiting so long to consult another dentist. Dr Rama accepted Mrs T as a client, accepted payment of $1700 and commenced preparatory dental work by drilling her teeth extensively. He therefore had a duty to complete the dental treatment and to do so within a reasonable timeframe. These services should have included early intervention to prevent infection of the gums. In my opinion Dr Rama failed to meet these obligations and breached the Code.
When Mrs T made further appointments Dr Rama cancelled them. Dr Rama made no attempt to see or talk with Mrs T personally when it was apparent that her treatment was not completed. Mrs T eventually consulted another dentist but by this time she had severe infection of her gums.
I do not accept Dr Rama's statement to me that he could not complete Mrs T's treatment because of matters beyond his control. If Dr Rama was ill he should have made arrangement with another dentist to complete the treatment especially as he was or should have been aware of the pain Mrs T was experiencing. Further Dr Rama must have appointment times available for emergency dental treatment and in my opinion Dr Rama should have treated Mrs T's case with urgency.
The dental records Dr Rama provided me with set out a very different version of the consultations than Mrs T described. These notes are at best inaccurate as they bear little resemblance to Mrs T's actual life circumstances. For example Mrs T has been divorced for a number of years and does not have to consult with her ex-husband about the costs of her dental treatment and she is clear she did not tell Dr Rama this. Nor does Mrs T have an answer phone.
I accept Mrs T's version of events as I have been able to verify these matters with other sources. Further, in attempting to check matters (such as whether Dr Rama was available on 10 September 1998) I was unable to obtain independent verification as I was advised the appointment book had been destroyed. In the circumstances it is my opinion that Dr Rama's record keeping does not accurately record events that occurred and in this is a breach of Right 4(2).
When Dr Rama drilled Mrs T's teeth it is likely he damaged the nerves creating a risk that these teeth may have to be removed. Additionally as a result of Dr Rama's treatment it is impossible for Mrs T to have the implant she originally requested. Dr Rama failed to follow up the treatment which he knew to be temporary and incomplete, his drilling cut too close to the nerves and as a result placed Mrs T at risk of losing her two adjacent teeth. In my opinion Dr Rama's treatment did not minimise potential harm to Mrs T, nor did it optimise her quality of life and therefore he breached Right 4(4) of the Code.
Mrs T has the right to complain and did so directly to Dr Rama about the treatment she received. Dr Rama did not respond despite repeated opportunities for him to do so. Dr Rama did not take steps to facilitate a speedy resolution of Mrs T's complaint nor did he deal with the complaint in accordance with Rights 10(4), 10(6), 10(7) and 10(8). Dr Rama did not have a complaint procedure that complied with the Code as follows:
- Dr Rama did not keep Mrs T informed about how he would resolve the complaint;
- Dr Rama did not acknowledge Mrs T's verbal complaint in writing within 5 working days;
- Dr Rama did not inform Mrs T of any internal or external complaints procedures;
- Dr Rama did not consider the complaint and failed to attend any appointments or explain or correct the problems;
- Dr Rama did not advise the reasons for his failure to respond to complaints.
Dr Rama's inappropriate standard of treatment, inaccurate record-keeping and lack of response to complaints have been the source of several complaints to me and to advocates operating under the Health and Disability Commissioner Act.
Dr Rama practises in South Auckland and advertises his service extensively. Despite a number of investigations and advocacy referrals Dr Rama has not improved his communication with consumers. He also continues to fail to respond appropriately to complaints. In the interests of warning the public seeking treatment from him to ask about treatment options and risks and to ensure his standard is appropriate by not making payment in advance, I have decided to make this investigation and Commissioner's Report a matter of public record.
I recommend that Dr Rama takes the following actions:
- Provides a written apology to Mrs T for breaching the Code of Health and Disability Services Consumers' Rights. This letter is to be forwarded to the Commissioner who will send it to Mrs T.
- Refunds Mrs T the $1700 she paid for treatment before the treatment began. His cheque made payable to Mrs T is to be forwarded to my office and I will send it to Mrs T.
- Pays for the costs of Mrs T's remedial treatment.
- Informs all future consumers of their rights in accordance with the Code and stops taking payment in advance of treatment.
- Introduces immediately a procedure for dealing with consumers' complaints which complies with the Code.
- Displays the Commissioner's Rights poster in his waiting room.
A copy of this opinion will be sent to the Dental Council of New Zealand, the New Zealand Dental Association, Accident Compensation and Rehabilitation Insurance Corporation, the Director General of Health and the Minister of Health.
I recommend that Mrs T submit a claim under ACC legislation.
In accordance with Section 45 of the Health and Disability Commissioner Act 1994 I will refer this matter to the Director of Proceedings for her consideration.
Response to Provisional Opinion
Dr Rama responded to my opinion on 24 January. I have summarised, or included in this report, a fair and accurate summary:
"[Mrs] T still refers to herself as "Mrs" T therefore one could easily assume that she still had a husband and not an ex-husband and that Mr T's treatment could be used by Mrs T as a bargaining tool in order to reduce the price of treatment for not only her but for them both. I dispute the allegation that my records are inaccurate therefore.
It is also stated that Mrs T sees her ex-husband when she drives him to doctor's appointments - evidencing her involvement in Mr T's medical treatments. It seems odd that Mrs T would refer Mr T to me if at her initial appointment she was not informed properly as to the treatments she had available to her and treated in a less than competent manner.
You also state that dental records have been falsified to the extent that a message was left on an answer phone for Mrs T. Mrs T admits that she left a number for an answer phone and while the leaving of a message on an answer phone alone would not be acceptable communication there is no evidence to suggest that records have been falsified nor that a message was not left on this answer phone. It may well be that the message was erased in error or that the machine malfunctioned. The accusation of falsifying records made with no evidence to substantiate that amounts to slander - as this opinion is to become a matter of public record.
In your opinion regarding a possible breach of Right 4(4) you state that "When Dr Rama drilled Mrs T's teeth he damaged the nerves creating a risk that these teeth may have to be removed." According to the independent advice sought by HDC there is insufficient evidence to confirm this. In addition as Mrs T left abruptly at the first treatment the tooth preparation would not necessarily be up to the normal standard and given the delays in further treatment being sought damage could have been sustained to these teeth in the interim. If nerve damage had occurred as outlined surely it would have been appropriate for Dr W to have discussed root canal therapy. The visibility of crown margins indicates further cutting by drilling. Further preparation would have exacerbated nerve damage.
Further to this the independent advice obtained by HDC states that "Had Mrs T a vague understanding of implants she would have realised nothing Dr Rama was doing was consistent with the procedures involved with implants." In your notes you state that Mrs T "knew about the implant because her neighbour and friends have told her about it and an implant sounded like the answer to her problems." This demonstrates a better than "vague understanding" of implants. One assumes that as Mrs T was price conscious she would have discussed price with her neighbour and friends and would have had more than a "vague understanding" as to the likely cost of such a procedure and would have been aware to some degree as to the fact that for $1700 she would not be receiving an implant ... .
... Regarding Rights 6(1)(b), 6(2) and 6(3) Mrs T was made fully aware as to the costs of various treatments and the risks, benefits and possible side effects of those different options. The conclusion reached, given all the factors available to me, was that the most appropriate treatment was a bridge.
Regarding Right 7(1) Mrs T demonstrated to me complete understanding of the treatment proposed and therefore gave me "informed consent". At not time has it been practice policy to proceed with treatment that a patient has not authorised.
In conclusion therefore I agree with your independent advice that Mrs T has paid for work that she has not received and given that I am willing to enable the treatment as first advised to Mrs T to be completed. Whether that be at my practice or by way of supplying the necessary bridge to enable another dental surgeon to fit it to Mrs T is up to her.
I will also offer an apology to Mrs T for the misunderstanding and contribute to the remedial work as undertaken by Dr W."