It could happen to you

Dr T has worked as a GDP for 15 years. He talks to us about an unusual complaint he received and the lessons he has learned from it.

I love my job and take enormous pride in it. I work in a great central London practice where we’ve won many awards for the standard of our patient care.

I read journals avidly, do lots of hands-on courses and have a particular interest in restorative dentistry. I take my responsibilities to my patients very seriously and always see my own patients in emergencies, even when I am extremely busy. I often frustrate my dental nurses by talking endlessly and showing photos and diagrams until I am satisfied that my patients understand everything about their treatment options, benefits, risks, costs, etc.

A DIFFICULT PATIENT

In June 2017, my practice principal received a formal complaint about me from a patient.

The patient was a retired health professional who had registered with me initially because he was unhappy with his existing dentist. He had seen me several times over a few years for routine exams and some very minor treatments. At every appointment he would initially refuse to take a seat until he had first stood in front of me and given me his own diagnosis, using what he believed was appropriate dental terminology (which it never was).

He had 20-year-old veneers on his upper central incisors, both of which had been repaired over the years by his previous dentists. He came to see me one day as an emergency when one chipped.

I fitted him in on the same day. Having checked the damage I advised him it could be easily repaired straight away as he had done before. The repair was completed with composite; he approved the result in the mirror and got up to leave. I mentioned that it might be time to start thinking about replacing both veneers because of the history of repeated repairs and I suggested that we could discuss this in detail at his next scheduled exam.

RISK MANAGEMENT MESSAGE– a complaint can arise from an unexpected source

THE COMPLAINT

Months later he sent a lengthy complaint about me to the practice. The basis of the complaint seemed to be that all definitive treatment options had not been discussed before the emergency treatment was carried out. The complaint included references to the Health and Social Care Act 2008,our own practice policy and complaints procedure, and the GDC’s Focus on Standards.

Possibly alarm bells should have been ringing at this stage. This person appeared to know exactly how to complain, even if there appeared, in my view, to be very little substance to the complaint.

An initial investigation by the practice management concluded that there had simply been some misunderstanding. The practice manager also attached a letter from me, providing my explanation of events.

The complainant refused to accept this and there was a further exchange of correspondence. At this point I sought advice from Dental Protection. Despite further efforts to conciliate the patient, he remained dissatisfied and made a formal complaint to the GDC.

RISK MANAGEMENT MESSAGE– a complaint can easily pick up momentum so it is never too early to seek advice

INVOLVING THE GDC

His complaint to the GDC included references to a long list of standards,subsections and paragraphs from the GDC’s own Standards, giving examples of how I had breached each one.

One example was the inclusion of an information leaflet that I had prepared for a nearby health centre within a list of “published articles” on our practice website. This inclusion was apparently “misleading”,as even though it was clearly an information leaflet, it was not technically a “published article” and therefore the patient alleged I had not acted with honesty and integrity.

The GDC requested a copy of the patient’s records. Although the majority of the points on the long list raised by the patient were rejected, the matter was nonetheless passed to case examiners to decide whether my fitness to practise was impaired due to failures on my part related to this one emergency appointment.

The GDC allegations included stating that I had failed to:

• provide an adequate standard of care (which included six separate allegations)
• maintain adequate records
• obtain consent for treatment.

The GDC commissioned a clinical report from a clinical advisor based on the patient’s records. This concluded that I had clearly been motivated by the best interests of the patient and had in fact provided appropriate treatment in the circumstances.

However, my records did not live up to GDC/FGDP standards, and in particular there should have been more written about the discussions that took place, verbal consent for the repair and anything else that was discussed in relation to his treatment.

RISK MANAGEMENT MESSAGE– cases before the GDC often focus on the quality of records, and on the nature of the consent process

THE DECISION

The case examiners concluded that although there was a real prospect that several of the allegations could be proved if the case proceeded to a hearing, it was felt that taken together these would not constitute misconduct.

The decision was therefore made to issue me with formal advice. The advice was that I should always offer alternative treatment options, including that of doing nothing (which dentists know can elicit interesting reactions from emergency patients) and clearly record consent.

Although the most lenient sanction, it has resulted in a permanent mark on my fitness to practise history.

Many months have now passed and I have had time to reflect on the experience. Before this incident, I had never feared a GDC investigation, despite all the stories I’d heard, because I believed I worked very much in accordance with the GDC’s guidelines.

From the time of receiving the initial complaint I had a feeling that it could end up going to the GDC based on what I knew about the complainant. However, as I felt I had done nothing wrong and because, in my opinion, the complaint seemed groundless, inconsistent and simply based upon a demand to cover the cost of new veneers, I believed that I had nothing to fear and that a sensible reading of the evidence would result in the case being thrown out.

What I totally failed to appreciate was that when the GDC receives a complaint about a registrant their focus is on the actions of the clinician; what was or was not done, what records have been kept, and whether any of their standards have been breached.The GDC has little interest in the motivation of the complaint or the complainant.

RISK MANAGEMENT MESSAGE– bear in mind that when a complaint is received by the GDC the records will be subject to close scrutiny. Record keeping failings can form the basis of allegations that have little relevance to the original complaint

MOVING ON

I had previously thought that I kept good records. After each appointment I wrote detailed notes of all relevant clinical information. I learnt the hard way that they were not sufficiently detailed to protect me from the spotlight of the GDC. The case centered on what was said at the appointment. My notes were my only evidence and did not contain enough to counter the patient’s claims.

I have changed little about the way I treat patients and communicate with them. I talk as much as I always did. I aim to provide the highest standard of care I can offer.

But my records have changed entirely. I now write my notes as though these maybe requested by the GDC at any time. Even the shortest, simplest appointments require thorough record keeping, including stating the obvious.

I had never anticipated that a minor appointment could have resulted in such a major process that lasted months and ultimately left me with a fitness to practise record.In conclusion, I have learnt that clinical prowess counts for little if there is a weakness in the clinical record. Given the opportunity to start over, I would make sure I had paid as much attention to the notes as I did to getting a good result with the restoration.

LEARNING POINTS

• It could be you. Remember you are not the only one who may read your records.
• Ensure you record all discussions/warnings and advice given as well as the clinical care provided.
• In this case Dr T's clinical care was not criticised by the GDC.
• The case centred on what was said – or rather on the patient’s recollection of what was said. An absence of a clear record of advice or discussion can leave a clinician vulnerable to a patient’s selective memory.
• When 'squeezing in' emergency patients make sure you allow enough time to write up the notes as well as doing the treatment.
• Do not rely solely upon clinical excellence to avoid risk. Good communication with the patient is essential; communicating with the future (via your records) should never be forgotten.