A dentist reports another dentist after a proper handover was not conducted, leading to the distress of a patient.
Mrs D had been attending Dr L’s practice for many years, seeing Dr L as her treating practitioner. Dr L expanded her practice to employ some OHTs and hygienists to undertake appropriate examinations and treatment within their respective scopes of practice, while she performed high value treatments.
Mrs D had been handed over to Ms W, a registered hygienist, by Dr L some years previously, although Dr L always popped into Mrs D’s examination appointments – initially to run a second pair of eyes over her dentition, but in later years purely as a social visit. The issue here arose largely because neither Ms W nor Mrs D fully understood that a handover had occurred, both believing that Dr L was assessing Mrs D, and, that Dr L retained final responsibility for Mrs D’s care.
Dr L took some extended annual leave, and in her absence Mrs D sought advice from a local dentist, Dr V, regarding her bleeding gums and bad breath. Examination revealed multiple teeth with 7 to 9mm pockets, many of which were bleeding and some of which were suppurative. Dr V took an OPG which painted a dim picture, with over 50% bone loss on most of the teeth, and some teeth having 70% clinical attachment loss. Dr V broke the bad news to Mrs D and referred her to a specialist periodontist for assessment and treatment.
A specialist treatment plan was developed, with a guarded prognosis for some teeth, and ultimately 47, 46 and 45 were lost as they did not respond to the treatment. Mrs D contacted the practice seeking answers and, in Dr L’s absence, her letter was passed to her treating hygienist, Ms W, for response.
Ms W was of the view that she had acted appropriately through her examination and cleaning of Mrs D’s teeth, and that any failure to refer lay with Dr L alone, as Dr L was responsible for Mrs D’s care, not Ms W. Dr L was not told of the complaint, and feedback was provided to the patient that there was no error on the part of the practice, and it was just ‘one of those things’. Mrs D was devastated but resolved to do no more. Dr V, however, was deeply troubled by what he had seen, and how it had been handled. He reviewed the guidelines on mandatory notifications and believed that this matter required he make a mandatory notification about both Dr L and Ms W, which he promptly did.
AHPRA assessed the matter by reviewing all documentation from Drs V and L and Ms W, from the specialist periodontists and an independent expert. They made the following findings:
Dr L was issued with a caution on the grounds that she had or may have fallen below the standard reasonably expected of a professional of an equivalent level of training.
Ms W was directed to attend a performance interview to assess her theoretical understanding of, but not limited to, periodontal treatment, diagnosis, treatment planning and referral. This could have a potentially serious outcome for her registration, if she was found to be lacking at this performance interview.
The difference in outcome arose because AHPRA formed the view that the care of Mrs D, in the form of regular examinations, was handed over by Dr L to Ms W, and by definition from the regulatory guidance, this meant that all responsibility for this aspect of her care was held by Ms W. If, however, Ms W had identified an issue that fell outside her scope of practice, then it would have been appropriate for her to hand back over to Dr L or refer to another colleague as appropriate.
Dental Protection assisted Ms W in preparing for the performance interview and attended with her. Pleasingly, Ms W had a good outcome, only receiving a caution.
Dental Protection supported Dr L and Ms W in contacting Mrs D to apologise and assist with her future treatment costs, as neither practitioner felt it appropriate to ignore what had happened.
Learning points
In a handover/delegation/referral it is important to have clarity about who is managing which aspects of the patient care, for all involved parties.
Ms W’s view that Dr L retained responsibility for Mrs D was flawed.
Periodontal disease is a commonly overlooked condition, and it does not serve anyone well to monitor the progression of this condition without notifying the patient and without considering an appropriate referral.
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