NHS FIFE has apologised after a patient developed a brain infection following a wisdom tooth extraction.

The person, described as patient C, complained to the Scottish Public Services Ombudsman (SPSO), who upheld the complaint.

The decision report said C had developed the injection follow the tooth extraction which was not diagnosed and spread subsequently to their brain.

Having been reviewed in hospital on several occasions – including out-patient reviews by oral and maxillofacial surgeons who specialise in treating diseases and injuries of the mouth and face – and an in-patient admission to Victoria Hospital, the person asked how the infection was missed on so many different occasions by so many different people.

The ombudsman report stated: “The board indicated in their response that there were no clinical signs which led them to suspect bacterial infection, and jaw joint problems were being considered as the cause of C’s symptoms.

“C was then suspected, during their in-patient admission, to have viral encephalitis (inflammation of the brain). A plan to carry out an MRI wasn’t pursued due to noted improvement in C’s condition.

“The responsible consultant reflected that an MRI should have been performed during the admission, and that not doing so may have delayed the identification and treatment of the infection in C’s brain.”

The SPSO said it took independent medical advice and, while it was noted that C’s infection presented atypically and was difficult to diagnose, their C-reactive protein (CRP, inflammation marker) was raised when they presented initially and this wasn’t acted upon.

“A CT scan also showed subtle signs of infection but this wasn’t picked up at the time,” added the report. “An urgent out-patient MRI was requested to look for joint problems and not to exclude infection, otherwise it may have been carried out sooner.

“We also found that the subsequent in-patient assessment didn’t give due care and attention to C’s recent wisdom tooth extraction and hospital attendances.

"It was agreed that the failure to pursue an in-patient MRI contributed to the failure to correctly diagnose and appropriately treat C’s infection.

"We considered that the decision to discharge C with a persistent headache was unreasonable. Therefore, we upheld this complaint.”

The SPSO told NHS Fife to apologise to C for the failure to diagnose and treat their infection earlier. They also said the case should be reviewed and the findings of the investigation should be presented to ensure relevant learning for staff from the OMF service, radiology and medicine.

NHS Fife’s director of nursing, Janette Owens, said: “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 accept the findings of the Ombudsman and this individual will be provided with a sincere, formal apology. We are also reassessing the relevant processes and procedures to ensure similar outcomes are avoided in future.”