July 14, 2026

“Talk Amongst Yourselves!” — The Need for Effective Patient Care Coordination and an Illustrative Dental Case Study

Repurposed from The Scope, Second Quarter, 2026

Addressing patient needs is a complex endeavor that can often require the effective coordination of multiple providers who may be practicing in very different care environments. It is crucial that medical centers, health systems, and office practices have an effective care coordination system to optimize patient outcomes and thereby reduce the risk of professional liability claims.

Coordination failures made while transitioning a patient’s care across the healthcare continuum can occur at any stage. For example, #9 of ECRI’s 2025 Top Ten Patient Safety Concerns was Inadequate Communication and Coordination During Discharge.1 Care coordination failures also have numerous possible origins, and most prevalent today are issues relating to technology. Data “siloing” and poor interoperability over varying electronic health record (EHR) platforms can prevent the patient’s full story and vital health information from being shared between the healthcare team, leading to delays in diagnosis and treatment.

The following case illustrates failures of provider-to-provider care coordination that, in the context of multi-specialist treatment, led to the orthodontist being successfully sued for malpractice by the patient, who was awarded a large monetary settlement.

CASE STUDY: Poor Care Coordination, Inconvenient Travel, and Tragic Results

Initial Diagnosis and Treatment

A one-year-old infant was diagnosed with a mild case of Pierre Robin syndrome associated with temporomandibular joint (TMJ) ankylosis. Between the ages of one and three, he underwent several surgeries and procedures to correct this condition, which, while initially successful, ultimately failed when the child was five years old, as his jaw bones had re-ankylosed and his mouth opening had decreased. The patient’s surgeon referred him to a plastic and reconstructive surgeon for an evaluation.

The family, who resided in another state, brought the child to New York City, where he was evaluated by a plastic and reconstructive surgeon as well as a surgeon who specialized in cleft lip and palate surgery. Various options were discussed and, ultimately, the plan was to remove a small portion of the condyle, use a Matthews device to hold the jaw in place, and use an orthodontic device immediately following the removal of the Matthews device.

The MLMIC-insured orthodontist was consulted and agreed to fabricate the orthodontic device. He was to take impressions during the initial surgery so the mouthpiece would be ready for use immediately following the removal of the Matthews device. The mother later testified that the surgeon emphatically stressed the importance of using the mouthpiece immediately after removing the Matthews device.

Matthews Device Implemented

The surgeons successfully performed their respective parts of the surgery, including inserting the Matthews device. The device was connected to the child’s skull with a rod coming out above his ear and rods that spanned his lower jaw. The device was to remain in place for three months so the body could build up cartilage and scar tissue to fill in the gap between the bones, after which it would be removed, and the child would immediately start using the orthodontic device.

The surgeons never called the MLMIC-insured orthodontist into the operating room to take impressions for the mouthpiece. The orthodontist was later told that the new plan was to take the impressions during the removal procedure.

Following discharge, the family returned to their home state with no postoperative visit having been scheduled. Initially, the child was able to eat soft food and sleep well.

One month following discharge, one of the rods from the Matthews device became loose on one side. The cleft surgeon advised the family that as long as the other rod on that side was tight, there was no problem.

One month later, another rod became loose, and the child began to complain of pain and developed redness and an infection. The cleft surgeon placed the child on antibiotics. The surgeon also contacted the child’s prior surgeon in his home state to remove the loose rods, but attempts at removal were unsuccessful.

The child developed a second infection, and arrangements were made for the Matthews device to be removed the following month. The plan was for the impressions to be made at the same time so the MLMIC-insured orthodontist could fabricate the orthodontic device.

Surgeon “Fills In” for Orthodontist

The office of the orthodontist sent an email to the reconstructive surgeon advising that the orthodontist would be unavailable to take the impressions on the planned surgery date because he would be out of the country. The insured orthodontist asked the surgeon if he would take the impressions for him, and the surgeon agreed.

The family returned to New York, and the reconstructive surgeon removed the Matthews device and took intraoperative impressions for the fabrication of the orthodontic device. The parents later testified that they asked the reconstructive surgeon about the device at that time because they were told that the child would need to use it immediately following the removal procedure. They also testified that the reconstructive surgeon assured them that the device was being fabricated and would be shipped to their home.

After the removal of the Matthews device, the surgeon sent the impressions to the lab of the insured orthodontist, who was out of the country. The surgeon never told the orthodontist that fabrication was urgent or that the family was waiting for the device.

The Orthodontist Returns

The orthodontist returned to his office approximately 10 days after the removal procedure and began fabricating the device.

Two weeks later, the orthodontist became aware that the family was waiting for the device, and three days after that, he spoke with the patient’s mother for the first time and advised her that the orthodontic device needed to be inserted by a local orthodontist.

Ten days later, the mother notified the reconstructive surgeon via email that her local orthodontist was unable to insert the device because her son’s jaw had regressed. The surgeon forwarded the email to the orthodontist, who responded to the mother the following day by letting her know that he had spoken with the local orthodontist and recommended that he cut the oral appliance in the back in the molar region. The mother indicated that she would make another appointment with the local orthodontist. The MLMIC-insured orthodontist had no further contact with the family.

Poor Results Confirmed

Shortly thereafter, the local orthodontist referred the child to an oral maxillofacial surgeon, who confirmed that the child’s condition reverted to where it had been prior to the surgery performed in New York City. At that point, the child could barely open his mouth or chew food.

The patient was then seen by other specialists in different states, one of whom criticized the reconstructive surgeon’s approach. Evaluation by an ENT specialist revealed the child had severe sleep apnea and low oxygen levels. Therefore, an emergency tracheostomy was performed within 48 hours. Following insertion of the tracheostomy, the child was able to sleep and receive nutrition, and he began to gain weight.

In the fall of the following year, the child was evaluated by multiple physicians in other states, all of whom opined that the Matthews device was antiquated, that the mouthpiece should have been placed when the device was removed, and that a rib graft should have been done at the outset.

Several months later, at the age of seven, the child underwent additional surgery. Silicone optical balls were inserted to keep the gap open until an artificial joint could be placed, likely within one to one and a half years, depending on the child’s growth and jaw condition.

The child had a tracheostomy for two years. During this time, he needed assistance with clothing that went over his head, washing his hair, neck, and face, and brushing his teeth, as the stoma could not get wet. Ultimately, the tracheostomy was reversed, but the child needed extensive orthodontic and dental work.

Lawsuit Filed

The family filed a lawsuit against the MLMIC-insured orthodontist and both surgeons alleging that the defendants were negligent in the treatment of the child’s TMJ ankylosis, including the delay in fabricating and providing the orthodontic device to use immediately after removal of the Matthews device. They alleged that this negligence resulted in harm to the child, including an inability to open his jaw, restriction of his airway necessitating a tracheostomy for two years, and the need for extensive revision surgery.

MLMIC’s consulting experts reviewed the case. They opined that this syndrome in an infant is notoriously difficult to treat with a high incidence of failure due to the continued growth of the child. Further, they opined that the codefendant’s surgery was ineffective and criticized the surgeon for failing to ensure that the child was receiving the appropriate postoperative therapy because the orthodontic device had not been placed when the Matthews apparatus was removed.

The consulting experts opined that the risk of reankylosis of the joint would have been dramatically reduced had the orthodontic device been inserted immediately upon removal of the Matthews device. They also criticized the surgeon for failing to take alternative measures to have the orthodontic device fabricated when he discovered that the insured orthodontist was out of the country. Ultimately, the parents agreed to a significant global settlement with the codefendants

A Legal and Risk Management Analysis

The plaintiff in this case took issue with both the type of surgery performed and the failure to timely provide the orthodontic device, which contributed to the delay in treatment and the worsening of the child’s condition.

After the surgeon failed to bring the orthodontist into the surgery to take intraoperative impressions during the insertion of the Matthews device, the surgeon later took the impressions himself during the removal surgery and never told the orthodontist that the subsequent fabrication was urgent or that the family was waiting. It was this failure of communication between providers that resulted in allegations of damage that included the need for a seven-year-old to have a tracheostomy for two years and undergo extensive dental surgery, both of which may have been avoided.

CARE COORDINATION

Risk Mananagement Takeaways:

Having a Care Coordination System is Essential

Given the tremendous amount of information that may be involved in patient care coordination, practices must have a system(s) in place to track diagnostic testing and confirm that results are reviewed, communicated to the patient, and acted upon. Physicians and dentists should always consider whether the severity of the condition being treated requires phone calls between providers in addition to written reports.

Explicit Accountability Must Be Addressed

Care coordination processes should clearly identify who is responsible for the ongoing management of the patient, including following up with other providers to track and communicate a patient’s response to treatment. Avoiding assumptions avoids gaps in patient care.

Avoid Working in Silos

Effective management of a patient’s care includes ensuring that all care providers and staff share a common understanding of the care plan, including any adjustments made to the plan as circumstances warrant, and have access to the reports of the other providers.

For more complex or severe cases, treating physicians and dentists should consider implementing an “interprofessional huddle.” A better outcome may have been possible had the surgeon and orthodontist spoken by phone rather than communicating through office personnel and emails.

A patient’s social determinants of health (e.g., income, education, housing, transportation, and food security challenges), which can help identify risk factors, are examples of the types of information that should be clearly communicated to and documented for all care providers.

Engage the Patient

Empowering your patients to be active members of their healthcare team is a crucial step to providing coordinated care. Engaged patients are more likely to adhere to treatment from multiple providers.

Recognize Patient Transitions as High-Risk

Patient discharge, specialist referrals, shift changes, and changes in care settings can lead to communication lapses. Practices should use established handoff processes to ensure care continuity, including the SBAR and IPASS protocols for transfers and handoffs, and the IDEAL model (AHRQ) for transitions back to home.

Documentation Should Reflect Coordination

As always, EHR documentation of what was communicated and when, and what follow-up is expected, is essential. Clear documentation supports continuity of care and enhances the defensibility of malpractice lawsuits.

Should you have any questions regarding the legal or risk management implications of, or requirements for successful care coordination, please do not hesitate to contact MLMIC Insurance Company for assistance and guidance at any time.

MLMIC policyholders can reach out to our healthcare attorneys for questions about litigation, claims, legal papers, or other healthcare law inquiries by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here.

Our 24/7 hotline is also available for urgent matters after hours at (877) 426-9555 or by emailing hotline@tmglawny.com.

If you are not already a MLMIC insured, learn more about us here.

This document is for general purposes only and should not be construed as medical, dental or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, dental, medical or professional obligations, the applicable state or federal laws or other professional questions.