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I told the patient….but I didn’t write it down

24 October 2019

Mr L visited his dentist complaining of pain in the posterior maxilla area under his existing partial denture. Clinical examination revealed an area of redness and tenderness over the area of his left upper second molar.

A radiograph taken at the time of the examination revealed a buried root, which was clearly being irritated by the denture. As a temporary measure, the denture was adjusted and Mr L was advised that the retained root should be removed.

The radiograph also showed the floor of the maxillary sinus was very close to the root; however, the root was extracted without too much difficulty. Unfortunately Mr L developed problems associated with the creation of an OAC, but never returned to the practice and obtained further treatment elsewhere. This denied the dentist the opportunity to discuss with Mr L what had happened and to resolve the patient’s concerns.

Mr L later rang to complain that his new dentist said that the extraction should have been carried out by an oral surgeon and he has been poorly treated. To the dentist’s frustration, Mr L then made a complaint to the Dental Council. 

The records and radiographs were examined by one of Dental Protection’s experts and, despite all efforts to assist the dentist in robustly defending the case; any defence was compromised by the lack of record keeping. The dentist suggested that it was his normal practice to tell patients of such risks and to offer specialist referrals, however neither he nor his nurse could specifically remember if a discussion had taken place on this specific occasion and he had not recorded any warnings in the records.

As with any regulatory investigation, the registrant’s actions are measured against the current guidance and, unfortunately, the dentist was criticised in relation to his record keeping. The Council were more accepting of the treatment issues and determined that, despite Mr L’s comments, there was little criticism of the procedure itself. The new dentist had been asked to provide his records and comments and, as is so often the case, these told a very different story to that of the patient. It is very common for dissatisfied patients to interpret what they hear from others differently in an attempt to benefit their cause.

Whilst there was little in the way of sanction, the member was very distressed about the whole process, which was the first time he had experienced such matters. He felt angry that Mr L had made such a complaint and was very frustrated that he had not made a more detailed record of his discussions with the patient.

Learning points:

  • If there is a lack of documentation that warnings had been given to the patient, in a dispute it becomes the patient’s word against the dentist’s and, as the onus is on keeping comprehensive records, criticism may follow when there is an investigation. It is therefore imperative to record the details of the specific warnings given.
  • We have a legal and ethical obligation to disclose risks to patients and keep comprehensive records. Without adequate records being made of patients being warned about possible treatment outcomes, it is very difficult to provide a robust defence against a Dental Council investigation, as this case illustrates.
  • A dentist could be tempted to alter or add to a patient’s record should they become aware that the record is to be scrutinised. With modern technology such changes are easily recognised, and the courts and dental registration bodies take an extremely serious view of non-contemporaneous records being submitted as originals in evidence.

These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits Dental Protection members enjoy as part of their subscription. 
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