A person in Scotland had wisdom teeth removed that resulted in an infection. This lead to a persistent headache that was later diagnosed as viral encephalitis but initially missed. The person who had wisdom teeth removed did not have the proper diagnosis made by both oral and maxillofacial surgeons and when admitted to a hopsital, medics from NHS Fife at the Victoria Hospital in Kirkcaldy, Scotland. None of the people who treated the person suspected an infection and the person was not given an MRI scan. This lead to encephalitis which is an inflammation of the brain typically caused by an infection.
A complaint was submitted to the Scottish Public Services Ombudsman for this case and they came out with a decison report that contained a summary of the case and recommendations. The board of NHS Fife where the person was treated said that there were no clinical signs which led them to suspect bacterial infection, and they believed that jaw joint problems were causing the persistent headache. The board of NHS Fife said that medics at the hospital did not perform an MRI scan because the persons condition improved.
A consultant physician and oral surgeon presented the Scottish Public Services Ombudsman their review of the case. The consultant physician said that an MRI should have been conducted when the person was in the hopsital and that not doing so delayed treating the persons brain infection. These consultants also said that while the persons infection presented atypically and was difficult to diagnose, the person had n elevated C-reactive protein. Further, a CT scan that was performed did show subtle signs of infection but somehow this was missed by the radiologist. These consultants also found that the in-patient assessment didn’t give due care and attention to the recent wisdom tooth surgery and hospital visits. These consultants said and the Scottish Public Services Ombudsman said
“[we] agreed that the failure to pursue an in-patient MRI contributed to the failure to correctly diagnose and appropriately treat [the person’s] infection. We considered that the decision to discharge… with a persistent headache was unreasonable.”
In the recommendations found by the Scottish Public Services Ombudsman, they said that NHS Fife needs to appologize for the person who suffered from the infection for failing to timely diagnose and treat the infection. The Ombudsman also said that the case should be reviewed by Mortality & Morbidity and the findings of this investigation presented to oral surgeons, doctors, and radiologists to ensure they learn from it going forward. The director of Nursing of NHS Fife is quoted as saying:
“We strive to provide all of our patients with the highest standard of care. However, in this instance it is clear that we have fallen short of our standards….We are…reassessing the relevant processes and procedures to ensure similar outcomes are avoided in future.”
As discussed through some case reports on the wisdom teeth complications page having MRIs performed shortly after wisdom teeth removal due to infection is not unheard of. One one think that given the symptoms experienced by the patient and the elevated C-reactive protein an MRI would have been performed sooner in this case. It is not clear whose idea it was that jaw joint problems were causing the persistent headache after wisdom teeth removal. It is also not clear why the oral surgeons who treated the patient and removed the wisdom teeth went along with this idea and not did suspect infection. Hopefully all involved with treating the patient and other physicians and doctors can learn from this case.
Sources:
- Sarah Vesty, “Scot suffered brain swelling after wisdom tooth removal infection went unnoticed,” Daily Record, December 28, 2021.
- SPSO decision report. Case 201906320, Fife NHS Board. December 2021.