Swift Series Clinical Governance Book Edition 1

SWIFT
DENTISTRY SERIES
PROFESSIONALISM,
LEADERSHIP & MANAGEMENT
SCENARIOS
DR. PREYESH PATEL
INTRODUCTION
Dentistry is a complex art form. Whilst it is key to be competent in clinical techniques, it is

equally important to remember that the patient is more than just teeth. It is more likely that a patient
will be more critical of your communication skills rather than the neat crown margin you prepared on a
molar tooth. With this in mind, holistic patient care is critical in the long term success of you as a dentist
in achieving patient satisfaction and avoiding litigation.
Efficiency is key. Through my undergraduate training at Kings College London, I realised that efficiency of any dental
treatment can be maximised by following a well devised protocol. SWIFT series is a new movement of literature that can be
used by dental professionals and students alike, to aid in management of patients. This guide focuses particularly on professionalism, leadership and management scenarios in the dental setting.
A wide range of issues are explored within the 45 scenarios used in this guide. These issues range from consent, confidentiality, raising concerns, complaints, safeguarding, etc. Each scenario will include all the issues evident followed by the recommended course of management.
This guide can be used by current practitioners as well as students. In particular, final year dental students applying for a post
as a dental foundation trainee (DFT) can use this guide as a revision tool, to better equip themselves for the interview process which
includes a station dedicated to a professionalism, leadership and management scenario. Having successfully managed to secure my
first choice scheme in the 2013-2014 DFT interviews, I would now like to transfer all that I have prepared and learned to readers of this guide so that they too have a strong chance in securing their top choice scheme.
The lamps are different, but the light is the same.
(Rumi, Sufi poet)
What does this obscure quote mean in context to what weve been discussing so far? Overall, as dental professionals we
strive to provide the best quality care to our patients. This is the light. No matter where in the world you practice, you should
always do what is in the best interests of the patient. However there may be more than one route to achieve this. This is the
lamp. This guide has been compiled over many years using various different sources and opinions but keeping in line with current guidelines. There may be different opinions regarding management, but overall my aim is to ensure that patient safety/
interests are respected and I have ensured that this guide caters for this.
CONTENTS
1. A fathers influence
24. Playing with protocol
39
2. Left alone
25. An image problem
40
3. A difference in opinion
26. Switching sides
42
4. Parental guidance?
27. A curious case of insurance
43
5. A mothers influence
28. A question of comfort
44
6. Say cheese!
10
29. Positive practitioner
45
7. Dentist on call
11
30. Late again
46
8. Oops!
12
31. Nurse vs. Receptionist
47
9. Half-time!
13
32. Not in the right spirit
48
10. Nurse feeling worse?
15
33. Contaminated contents
49
11. A careless colleague
16
34. An abuse of power
51
12. Irritating injection
18
35. A teachers influence
52
13. Incompetent implantologist?
20
36. Hammering home
54
14. The root of the problem
22
37. Complicated conundrum
56
15. Naughty nurses
24
38. A daughters influence
58
16. A fractured file
25
39. The effect of neglect
59
17. The fractured file returns
27
40. A breach in confidentiality
60
18. Late-x
29
41. A probing partner
62
19. Scapegoat?
31
42. A sensitive issue
63
20. A prolonged perio problem
33
43. Duty of candour
65
21. A case of consent
35
44. Crossing the line
66
22. The cost of perfection
36
45. Problems, problems, problems
67
23. Scope of practice
37
3
SCENARIO
A fathers influence
A 22 year old female presents in pain. She doesnt speak English and is accompanied by her father who is the interpreter and dictates treatment.
Issues:__________________________________________________________________________
1.
Putting patient interests first-respecting their dignity and choices.
2.
Communicating effectively with patients in a way in which they can understand.
3.
Obtaining valid consent-informed, voluntary, patient is deemed competent.
Management:____________________________________________________________________
1.
Arrange for an interpreter- use an interpreter helpline to respect patients communication needs and ensure patient is
not discriminated against. Ideally encourage patient to bring relative or carer whom they are comfortable with.
2.
Obtain valid consent-informed, voluntary and patient deemed competent.
Informed-patient should be aware of the nature of treatment, alternative options, risks, benefits, success and costs.
(encourage patient to ask questions)
Voluntary-without coercion, some patients (particularly in some cultures) waver their autonomy-obtain written evidence if relinquishing autonomy.
Competent-can the patient understand the information, weigh up the risks and benefits, retain the information and
communicate it back to you.
3.
Document discussion in obtaining valid consent.

Offer patient leaflets in an appropriate language, followed by a cooling period (1-2 weeks) to consider treatment options.
4.
Refer for second opinion where appropriate -ensure patient is aware of any referral arrangements and that consent
has been sought prior.
SCENARIO
Left alone
A 15 year old child is being treated by you when the mother attending with the
child states that she must go and pick up another child from school. She tells you
to do whatever is necessary. You discover once she has gone that the permanent
tooth you are working on requires an extraction.
Issues:__________________________________________________________________________
1.
2.
3.
Obtaining valid consent-informed, voluntary, patient deemed competent.
Management:____________________________________________________________________
1.
Do you deem the child Gillick competent- do they have the capacity to understand the nature, risks, benefits and alternatives of the treatment options provided.
2.
Discuss treatment with child.
3.
Is treatment emergency?-are you safeguarding their life, do not delay emergency treatment if you cannot obtain consent.
4.
Gillick competency is not seen as first line for consent, ideally the patients mother needs to be made aware of the treatment. However where there is disagreement in treatment options, the child if deemed Gillick competent can consent for
their own treatment.
5.
Call supervisor/indemnity provider for advice.
6.
Where possible temporise tooth and inform the mother why you didnt proceed. If the tooth needed to be extracted, another appointment can be booked with more time to ensure the tooth is extracted safely with valid consent. If the tooth
can be saved it is important that the mother is made aware of specialist opinion and obtain consent for this process.
SCENARIO
A difference in opinion
A patient refuses to accept amalgam as a filling material in a posterior tooth, but
you feel it is best material for that situation. The patient also wants botox treatment.
Issues:__________________________________________________________________________
1.
2.
3.
4.
Maintain, develop and work within your professional knowledge/skills to provide patients with good quality care.
5.
Record keeping-provides picture of patient care and discussions held with patients.
6.
Advisable to register with CHKS to regulate quality assurance of adjunctive procedures.
7.
Make sure that any advertising complies with GDC guidance on ethical advertising. Seek advice from Committee of Advertising Practice (CAP).
8.
Compliance with HTM 07-01 in the safe management of healthcare waste- Amalgam waste should be placed in rigid
white receptacles with a mercury suppressant and the waste should be sent to permitted waste management facilities that
undergo a mercury recovery process.
9.
Dentist must be appropriately trained, indemnified, qualified, competent and confident to provide botox- ensuring you
are equipped to perform a task safely.
Management:____________________________________________________________________
1.
Ask why, listen to patient and give them an opportunity to have a discussion, treat patient with dignity and respect, taking
their preferences into account.
2.
If patient felt needs (their perceived need) are discrepant with normative need (professionally judged) ensure patient is
well informed to obtain valid consent-risks and benefits of all options, cost and prognosis (consider religious beliefs- alcohol based dental materials exist and patients should know of this fact-e.g. dentine bonding agent).
3.
Provide info in form of leaflets, i.e. about amalgam, and consider a cooling period before any treatment plan is finalised.
4.
Explain rationale before referring for second opinion.
5.
Keep clear, concise, contemporaneous notes of any discussions held with the patient.
6
SCENARIO
6.
Proactive measures- record audit card undertaken periodically to identify level of patient involvement by all clinicians
at the practice and whether consent is sought. This satisfies outcome 2 of CQC essential standard- seek consent to care
and treatment. An example of a typical audit cycle is shown below.
SCENARIO
Parental guidance?
Can I see a child under 16 for an examination and provide treatment if they attend with someone other than their parent or if they attend on their own?
Issues:__________________________________________________________________________
1.
Patient safety is paramount.
2.
Gillick competent-do they have the maturity to understand the nature, risks and benefits and alternatives of
the treatment options provided?
Management:____________________________________________________________________
1.
Examination requires consent if child not Gillick competent and under 16.
2.
Informed consent is ongoing, obtain consent at each visit-risks and benefits may change.
3.
Mother (check if it actually is mother, just because child calls her mother doesnt mean she is) has automatic parental responsibility, father if name on birth certificate for child born after 12/03 and married at time of birth
before 12/03 has parental responsibility. Parental responsibility can also be bestowed via court orderrequires written evidence.
4.
Extensive treatment-encourage discussing with parent as after care is usually required and thus needs support
from family members. The child can consent if Gillick competent, although should not be seen as first line. If
emergency can at least stabilise for patients best interest and safety.
SCENARIO
A mothers influence
A 35 year old female with a moderate learning disability attends your surgery for
the restoration of a lower molar. She is accompanied by a carer from the residential accommodation where she lives. The carer informs you that the patients
mother is unhappy with the treatment and will not give her consent for the restoration of the tooth.
Issues:__________________________________________________________________________
1.
Obtain valid consent-informed, voluntary and the patient is deemed capable to respect autonomy.
2.
Assess patient capacity-understand, weigh up, retain, communicate under the Mental Health Act (MCA) 05.
3.
Patient interests-respect their dignity and choices taking their preferences into account.
Management:____________________________________________________________________
1.
Assess patient to determine if they are competent-understand, weigh up, retain, communicate information.
2.
Emergency treatment can be provided to stabilise patient to act in their best interests.
3.
Arrange for a face to face meeting with mother- educate mother verbally as well as using visual aids and leaflets.
4.
Multidisciplinary approach-hold a best interests meeting involving relative, carer, lasting power of attorney, Independent
Mental Capacity Advocate (IMCA) in order to devise a treatment plan that is mutually agreed upon and is in the patients best interest. It is also important to consider patients past wishes.
5.
6.
Alternatively can refer to community dentistry in special care department.
7.
Keep complete, clear, concise and contemporaneous notes- on your methods of assessing capacity, seeking consent, and
all members involved in the holistic care of the patient.
8.
Record card audit-process of seeking consent.
SCENARIO
10
Say cheese!
A 75 year old female patient is accompanied by her daughter. The daughter explains the patients grandson is getting married in 3 months time. She wants her
mother to have teeth to smile at the wedding. The patient is adamant she does not
want dentures.
Issues:__________________________________________________________________________
1.
Obtain valid consent-informed, voluntary and the patient is deemed capable to respect autonomy.
2.
Assess patient capacity-understand, weigh up, retain, communicate under the MCA 05.
3.
Patient interests-respect their dignity and choices taking their preferences into account.
Management:____________________________________________________________________
1.
Discuss with patient ideally alone, determine competency. Obtain informed consent with patient to discuss issues with
daughter.
2.
Obtain valid consent-informed, capable and voluntary, not valid if under coercion-conform to equality act 2010 and
disability discrimination act 2005 - must not discriminate against the elderly.
3.
Patient can be provided with leaflets of all treatment options, and offered a cooling period (1-2 weeks) to consider what
treatment option is best for them, followed by a review appointment to discuss proposed course of action.
4.
Alternatively can refer for second opinion. Obtain informed consent, and make patient aware of referral pathway.
10
SCENARIO
11
Dentist on call
A patient rings and says that her 12 year old son has a toothache. Can they give
antibiotics?
Issues:__________________________________________________________________________
1.
2.
Work with colleagues in the best interest of patients- you must be appropriately supported when treating patients unless
treating patients in an out of hours emergency-assess risk of continuing treatment on that patient. Ensure there is at least one
other member, even if it is a carer or receptionist ,to deal with potential medical emergencies. There must be arrangements for
at least 2 members within the working environment to deal with medical emergencies.
3.
Antibiotic prescription refer to the British National Formulary (BNF) as well as Faculty of General Dental Practice
(FGDP) publication on antimicrobial prescription based on current evidence to provide good quality care.
Management:____________________________________________________________________
1.
Instruct mother not to give antibiotics, however can give simple advice over the phone.
2.
Can see patient yourself-emergency out of hours with another staff member, obtain consent for not having a full integrated team and potentially compromising patient safety.
3.
Contact supervisor/indemnity provider for advice.
4.
Alternatively can refer to Acute Dental Care (ADC) department in hospital.
5.
Keep clear, contemporaneous, concise and complete notes.
11
SCENARIO
12
Oops!
You make an operative error which causes the patient considerable pain.
Issues:__________________________________________________________________________
1.
2.
Competency to perform treatment-are you appropriately trained, indemnified and qualified?
3.
Complaints-ensure that there is a clear and effective complaints procedure for patient use.
Management:____________________________________________________________________
1.
Empathise with the patient and apologise to them (sorry glad you brought it to my attention).
2.
Reassure patient. Discuss what went wrong and what you will do to make it better.
3.
Call supervisor/indemnity provider (e.g. DDU/Dental Protection)-for advice.
4.
Can offer remedial treatment free of charge as good will gesture. Ensure you are appropriately indemnified to allow
patients to claim any compensation they may be entitled to. Pay for travel costs.
5.
Can refer to specialist-obtain consent and provide relevant contact details of professional, offer copy of referral letter to
patient. Follow up on referral.
6.
Refer to complaints procedures-deal with in house first, and then refer to other service if in house procedure not successful.
7.
Document clear, concise, contemporaneous and complete notes.
8.
Reflection-fill adverse incident form within 24 hours-an incident that has harmed patients or put patients at risk of harm,
separate to clinical notes. If it continues you may be prone to fitness to practice investigations.
9.
Arrange practice team meeting in view of discussing the issue and how to prevent it in the future. Any changes should be
made visible in the practice newsletter.
10.
Professional development-attend courses showing insight into failings and steps to address them. Can receive in house
CPD (keep log) or via externally accredited courses.
12
SCENARIO
13
Half-time!
You are halfway through root treatment on a patient who then suddenly decides
he no longer wants to continue with treatment and that he cant cope. He seems
very agitated and says he is going to just go home and forget the whole thing.
Issues:__________________________________________________________________________
1.
Informed consent -patient can stop treatment at any time and their wishes must be respected. Ensure patient aware of
risks of stopping treatment and future problems that may arise as a result. Document clearly.
2.
3.
Patient interests respect their dignity and choices.
4.
Management:____________________________________________________________________
1.
Empathise with the patient and apologise to them (sorry glad you brought it to my attention). Listen to patient regarding why cant they cope-and discuss.
2.
3.
Reassure patient.
What went wrong?
What you will do to make it better?
They maybe temporarily incompetent due to agitation, and thus may make irrational decisions and hence for patients
best interest encourage temporising, as otherwise tooth may flare up leading to an abscess and associated spread of
infection.
4.
5.
Keep clear, concise, complete and contemporaneous notes
6.
Arrange for definitive treatment
Continue treatment yourself
Refer to endodontic specialist-pay for consultation fee as a good will gesture, obtain valid consent.
13
SCENARIO
14
7.
8.
Reflection upon this uneventful situation-fill adverse incident form, separate to clinical notes.
9.
Arrange practice team meeting in view of discussing adverse incident in order to prevent it occurring in the future .
10.
Professional development-attend courses showing an insight into failings and steps to address them. Can receive in house
CPD (keep log) or via externally accredited courses.
14
SCENARIO
10
15
Nurse feeling worse?

You are halfway through the morning when suddenly your nurse starts to feel unwell.
Issues:__________________________________________________________________________
1.
Patient safety is paramount and to protect this if a member of the team is deemed not fit to practice they must not treat
patients.
2.
Strategic effectiveness-ensuring that a strategy is devised to ensure all patients are safely treated and ensuring that you
work with colleagues in the best interest of patients.
3.
Working with colleagues in the best interest of patients appropriately supported when treating other patients.
Management:____________________________________________________________________
1.
Empathise.
2.
Acknowledge illness, encourage nurse to see GP to get time off work.
3.
Call supervisor prior to sending nurse home-justify in terms of patient safety and team efficiency.
4.
Arrange transport for nurse to get home safely-this will improve team relationship.
5.
Arrange for replacement nurse-within practice or locum nurses via agency.
6.
If no nurse available, cant practice alone unless out of hours emergency according to GDC, hence may need to cancel
patients-apologise (written, verbally), rearrange appointments or refer patients to practice nearby in case of emergency
or hospital- contingency planning.
7.
Arrange practice team meeting in view of discussing how to manage this situation efficiently in the future.
15
SCENARIO
11
16
A careless colleague
A patient attends complaining of pain after previously being seen by a colleague.
You notice in the notes that the patient should have been given treatment for a
carious lower right molar, however the treatment was not completed and no follow
up was offered. Your nurse states that this is not the first time that this has happened.
Issues:__________________________________________________________________________
1.
2.
Raising concerns if patients are at risk-duty to patient safety overrides professional loyalty.
3.
Clinical effectiveness of clinician and thus their fitness to practice.
4.
Bolam risk assessment- to see if the dentist has reached standard of a responsible body of experts to determine negligence.
5.
Management:____________________________________________________________________
1.
Apologise for how patient feels.
2.
Listen to patient allowing them an opportunity to have a discussion.
3.
Reassure patient-pain relief.
4.
Call supervisor/indemnity provider for advice regarding fitness to practice, encourage previous colleague to contact defence organisation.
6.
Continue treatment yourself
Refer to specialist-pay for consultation fee as a good will gesture, obtain valid consent
7.
8.
Document complete, clear, concise and contemporaneous notes.

16
SCENARIO
11
17
9.
Raising concerns following is a flowchart highlighting the stages involved in raising concerns.
10.
Public interest disclosure act 1998 will protect employees who make genuine concerns.
11.
Identify whether nurse has gagging clause in her contract for raising concern and highlight issue with supervisor.
17
SCENARIO
12
18
Irritating injection
You are injecting a patient with anaesthetic when they cry out in pain and demand
to be seen by another dentist.
Issues:__________________________________________________________________________
1.
2.
Patient interests-must respect their dignity and choices.
3.
Maintain, develop and work within your professional knowledge/skills-are you appropriately trained to give local
anaesthesia (LA)?
4.
Management:____________________________________________________________________
1.
Apologise-not an admission of liability, can help defuse a situation.
2.
Reassure.
3.
Call supervisor-ask patient if they are comfortable with you continuing treatment under supervision- obtain consent. Alternatively make arrangements to refer to another dentist within the same practice, another practice or hospital.
4.
Document complete, clear, concise and contemporaneous notes.
5.
Notify indemnity provider.
6.
Refer to complaints procedures and complaints coordinator. Following is a flowchart highlighting the stages involved in the
complaints procedure.
18
SCENARIO
19
12
7.
Log complaint in complaint log book, separate from notes.
8.
Arrange practice team meeting in view of discussing complaints. Complaints are an opportunity to improve service, what
went wrong and how to improve. Produce a report of complaints quarterly to include key issues, improvements and ongoing developments.
9.
Reflection of uneventful situation-Fill an adverse incident form-record and report any adverse drug reaction using yellow
card scheme which is monitored by Medicines and Healthcare products Regulatory Agency (MHRA), separate to clinical notes.
10.
Professional developments-attend courses in view of improving LA technique, which can be taught in house or externally
accredited, keep a log book.
19
SCENARIO
13
20
Incompetent implantologist?
You have been qualified for 4 years and attend a weekend implant course. You
are keen to try out your new skills and when an edentulous patient attends asking for alternatives to conventional dentures, you decide to provide implants.
Complications occur a few weeks after placement and the patient complains.
Issues:__________________________________________________________________________
1.
2.
3.
Maintain, develop and work within your professional knowledge/skills-A weekend course is unlikely to be sufficient
enough to prepare you for all eventualities.
Management____________________________________________________________________
1.
What were the complications?-conduct a thorough history, listen to patient allow them to discuss. The history should also
take into consideration patient related factors that may contribute towards complications, i.e. smoking, poor oral hygiene,
etc.
2.
Reassure.
3.
4.
Is it a recognised risk-bolam risk standard appreciated by a regulatory body- British Society of Oral Implantology.
5.
Arrange for definitive treatment.
May need to offer remedial treatment free of charge or subsidised in accordance with indemnity provider.
Alternatively refer to specialist (implantologist) if outside your competency, make sure patient consent obtained
and patient aware of referral process.
6.
Document clear, complete, concise and contemporaneous notes.
7.
20
SCENARIO
21
13
8.
Reflection-fill out an adverse incident form and keep separate to clinical notes.
9.
Arrange for practice team meeting in view of discussing adverse treatment outcomes and methods to prevent this occurring in the future.
10.
Professional developments-attend courses to develop skills in implantology.
21
SCENARIO
14
22
The root of the problem

You recently extracted a molar and left a little bit of root behind. Patient has
complained to the surgery and wants access to their records.
Issues:__________________________________________________________________________
1.
2.
Maintain, develop and work within professional knowledge/skills-are you appropriately trained and competent?
3.
Bolam risk assessment to see if the dentist has reached standard of a responsible body of experts to determine negligence.
4.
5.
Data Protection Act (DPA) 1998-patient has rights to their records.
Management:____________________________________________________________________
1.
Apologise.
2.
Reassure patient.
What went wrong?
What you will do to make it better?
3.
4.
Is it a recognised risk-bolam risk standard appreciated by a regulatory body-British Association of Oral Surgeons.
5.
Arrange for definitive treatment.
Alternatively refer to specialist (oral surgeon) to deal with failed extraction within 24 hours, and pay consultation
fee as a good will gesture. The specialist oral surgeon would then determine whether the root should be extracted
and its associated risks and benefits.
6.
7.
22
SCENARIO
23
8.
14
If patient wants records, must address within 40 days as they have right to access them under DPA. If you want to charge
a fee, check latest guidelines from National Information Commissioners Office (NICO).
9.
Reflection- Fill an adverse incident form, separate to clinical notes in view to discussing at the next practice team meeting.
10.
Professional developments attend courses to develop skills in oral surgery, externally accredited or in house (record in
log book).
23
SCENARIO
15
24
Naughty nurses
You find that nurses are giving each other/patients scales.
Issues:__________________________________________________________________________
1.
2.
Scope of practice-you must only carry out treatment that is within your scope of practice and are appropriately trained,
qualified and indemnified for it.
3.
Working with colleagues in the best interest of patients.
4.
Raising concerns where patient safety is at risk.
Management:____________________________________________________________________
1.
Stop procedure and examine for potential damage to oral tissues- stabilise yourself if necessary.
2.
Apologise to patient and explain that they have received incomplete treatment. Ensure patient treatment is complete as a
goodwill gesture.
3.
Notify supervisor/indemnity provider for advice.
3.
Hold meeting with offending nurse, explain scope of practice (current guidelines-2013) and their duty to follow. Ask what
other patients have been affected and review their notes. A 1st stage warning to the nurse is in order.
4.
Raise concerns If problem persists and escalate appropriately (refer to flow chart on raising concerns-page 17).
24
SCENARIO
25
16
A fractured file
One of your colleagues patients attends with a broken maxillary first premolar
tooth. The patient is going on holiday the next day and your colleague is also
away on leave. The tooth is symptomless and you decide to take a radiograph to
assess its restorability. The tooth has been root-treated and you observe that the
tooth has 2 roots. The root filling in the palatal root appears to be short of the
apex by 2mm and there is evidence of a 1mm apical radiolucency. The buccal root
has what appears to be a fractured instrument near the apex but there doesnt appear to be any apical change. This is your last patient of the day and there appears to be some confusion as to where the patients original dental records have
gone. It may be that your colleague has taken them home to prepare a treatment
plan for the patient. The patient wishes to have a short-term fix to their appearance.
Issues:__________________________________________________________________________
1.
2.
3.
4.
Bolam risk assessment to see if the dentist has reached standard of a responsible body of experts to determine negligence-British Society of Endodontics (BSE).
5.
6.
7.
Record keeping-complete, clear, concise and contemporaneous notes.
8.
Confidentiality-maintain and protect patient information. It is the cornerstone of a good relationship between dentist and
patient.
Management:____________________________________________________________________
1.
Empathise and apologise.
2.
Listen to patient giving them an opportunity to discuss issues.
25
SCENARIO
26
3.
16
Explain situation-infected palatal root and instrument separation in buccal root. It is your duty of candour (volunteering
relevant information to the patient that has caused harm). It is also possible that the patient may have forgotten-ask patient. Show patient radiograph.
4.
Reassure-no pathology associated with fractured instrument.
5.
Discussion-how long holiday?
6.
Options:
No treatment-however can flare into an acute apical abscess.
Palatal root retreatment- dress infected canal with CaOH, temporise and review at a later date.
Extract tooth.
Temporary metal post and core retained crown.
7.
Obtain valid consent.
8.
9.
Alternatively refer to specialist (endodontist) if outside your competence, make sure patient consent obtained and
patient aware of referral process.
7.
8.
9.
Colleague Discuss case with colleague regarding procedure, recommend endodontic refresher courses and refer to National Clinical Assessment Service (NCAS). Highlight issue of clinical governance and duty of candour. Review previous
patients of colleague. Discuss clinical effectiveness of colleague with supervisor in view to raising concern.
10.
Practice team meeting in view to discussing:
clinical skills-revise BSE guidelines.
Storage of notes-DPA and raising concerns about patient notes safety. Can notes be digitalised? if paper records
used-can a tracking system if implemented? ( an audit for availability/tracking of notes can be undertaken). Patient notes can be stored on cloud storage systems although before implementing obtain advice from National Information Commissioners office (NICO).
26
SCENARIO
17
27
The fractured file returns

A patient returns following a recent endodontic procedure and complaints of pain
and swelling. The tooth contains a fractured instrument of which the patient is not
aware.
Issues:__________________________________________________________________________
1.
2.
Duty of candour-volunteering relevant info to a person who may have been harmed by provision of services.
3.
Bolam risk assessment to see if the dentist has reached standard of a responsible body of experts to determine negligence BSE.
4.
Maintain, develop and work within professional knowledge/skills.
5.
Record keeping-complete, clear, concise and contemporaneous notes.
6.
7.
Management:____________________________________________________________________
1.
Apologise.
2.
Listen to the patient to give them an opportunity to discuss any concerns.
3.
Explain situation regarding fractured instrumentation-duty of candour.
4.
Reassure-regarding management
5.
Options
6.
No treatment
Retreatment
Extraction
Treatment sequelae:
27
SCENARIO
28
17
7.
Obtain valid consent for procedures and referrals.
8.
Call supervisor /indemnity provider for advice regarding present management or future management.
9.
May decide to provide remedial treatment free of charge or at least pay for the consultation fee for specialist if referring out.
10.
11.
Reflection of an uneventful incident-Fill an adverse incident form, separate to clinical notes, audit on certain aspects of
endodontic procedures-(see the stages of a typical audit cycle on page 7).
12.
Arrange practice team meeting in view of discussing endodontic procedures. Did the file separate as it was used on more
than one patient? In 2007, the Chief Dental Officer (CDO) announced endo files are single use only due to difficulty in
decontamination. Fresh files used for each patient will also reduce the advent of file separation.
13.
Professional developments-attend courses in developing skills in endodontics, taught in house or externally accredited and
keep a log book.
28
SCENARIO
29
18
Late-x
A patient attends for an anterior restoration. After completing the treatment the
patient leaves the practice. When you are writing up the notes you discover that
the medical history includes latex allergy, which was noted 2 years ago, but not
recently. You used non-latex gloves but you discover that the anaesthetic cartridge
had a latex bung and the rubber dam used was latex.
Issues:__________________________________________________________________________
1.
2.
Communicating effectively with patients in a way in which they can understand- listen to patient.
3.
Record keeping- clear, concise, complete and contemporaneous notes.
4.
5.
Management:____________________________________________________________________
1.
Notify supervisor, phone patient-discuss severity of allergic reaction-i.e. have they experienced wheezing, loss of consciousness and pallor.
2.
Explain what has happened, apologise, and instruct patients on what symptoms to look out for- itchiness, swelling, flushing, shortness of breath. Explain that If they do notice any symptoms go to the hospital immediately or use adrenaline
(epipen).
3.
Call indemnity provider for advice.
3.
Invite patient back to practice for a review to hold a face to face meeting where a formal apology can be given and the
patient can be reassured.
4.
5.
Reflection-fill out a critical incident form-arrange for case to be put on agenda for next practice team meeting, separate
to clinical notes.
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6.
18
Arrange practice team meeting in view to discussing:
recording keeping standards comply to FGDP guidelines on record keeping.
Efficient management of medical emergencies:

1.
Preregister practice with ambulance to ensure you are recognised in GPS system.
2.
Hypoallergenic surgery-use non-latex products where possible.
3.
Detailed medical history form, allergy form, next of kin form-contact in case of emergency. Although patient
may feel that too many forms is bureaucratic the detail acquired may save someones life.
4.
Medical emergencies simulations-ensure all staff members know their role in the advent of a medical emergency. Conduct simulations at every 3 month interval to keep up to date and maintain skills.
5.
Update medical emergency drugs in accordance with the latest Resuscitation Council (UK) guidelines
(RESUS).
7.
Any changes to the practice affecting patients should be mentioned in the practice newsletter, website and leaflets.
8.
Professional developments- refer to Information Governance (IG) toolkit and Faculty of General Dental Practice- FGDP
(UK) guidelines for record keeping.
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19
Scapegoat?
You recently performed an extraction for Mrs Thomas due to progressive periodontitis. You now receive a letter from Mrs Thomas complaining that you did not
appropriately manage her periodontal condition over the years of her treatment
with you, and that the extraction may have been avoided if you had given her
adequate advice in the past. You believe you have always given appropriate advice and treatment to Mrs Thomas, and that she has not maintained healthy gums,
resulting in the loss of the tooth. You are due to take annual leave this evening
and will not return to work for 4 weeks. Mrs Thomas has asked for a response
within the next 3 weeks.
Issues:__________________________________________________________________________
1.
2.
Patients interest-respect patient dignity and choices.
3.
4.
Record keeping- keep clear, concise, complete and contemporaneous notes-diagnosis may have been recorded but not
told to patients.
Management:____________________________________________________________________
1.
Listen to patient-give opportunity to discuss.
2.
Review notes-to see if there is evidence of radiographs, discussions, continuous periodontal surveillance-plaque scores.
3.
Consult with complaints coordinator regarding complexity of situation.
4.
5.
Respond via a holding response in brief stating the reasons why you are unable to respond within the usual timescale to
the complaint, proposing a new timescale for a full response. (See flowchart on how to manage a complaint on page 19)
6.
Complaints response-apologise, reassure -what is the proposed course of action and what will be done to prevent communication breakdown in the future ?
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7.
8.
19
Continue treatment yourself.
Refer to specialist-pay for consultation fee as a good will gesture, obtain valid consent.
Record card audit-to determine level of involvement in consent seeking process to satisfy outcome 2 of CQC with respect
to seeking consent.
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33
A prolonged perio problem

A regular patient of the practice attends for a recall examination. As part of your
examination you undertake a routine periodontal assessment. You find that the
patient has advanced generalised chronic periodontitis with 5-6mm pocketing in
all quadrants. You review the notes and find that the patient has been attending
regularly every 6 months for a number of years with two other dentists and the
hygienist at the practice. The patient states that she has been told that she has
gingivitis and that is why her gums bleed on brushing.
Issues:__________________________________________________________________________
1.
2.
Communicating effectively with patients in a way in which they can understand- listen to patient.
3.
4.
Bolam risk assessment to see if the dentist has reached standard of a responsible body of experts to determine negligence British Society of Periodontology (BSP)
5.
6.
Clinical effectiveness
7.
Maintain, develop and work within your professional knowledge/skills.
8.
Management:____________________________________________________________________
1.
Read patient notes thoroughly to see if diagnosis of periodontitis mentioned earlier.
2.
Encourage dialogue between patient and colleagues in question.
3.
If in notes, tell patient that according to notes diagnosis written however there may have been a communication issue.
Support with evidence-radiographs, pocket charting score and plaque scores.
4.
If error in diagnosis, explain error in previous diagnosis, apologise and explain to patient about future course of treatment.
5.
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34
6.
20
Treatment plan yourself to deal with periodontitis, followed by appropriate recall interval. May need to offer remedial treatment free of charge or subsidised in accordance with defence organisation.
Refer to specialist (periodontologist)- pay for consultation fee as a good will gesture.
7.
Obtain valid consent for procedures and referrals.
8.
9.
Investigate other patients notes to see if problem is recurrent.
10.
Reflection-encourage practice team meeting with clinicians involved regarding patient management, encourage adverse
incident form to be filled, separate to clinical notes. An audit can be carried out to determine compliance with National
Institute of Health and Care Excellence (NICE) recall guidance 2004 in view to discussing at next practice team meeting.
11.
Professional developments-attend courses to develop skills in periodontology and diagnosis, via NCAS. Skills can be attained through in house training or externally accredited course.
12.
Raising concern- speak to supervisor/indemnity provider regarding negligence-supervised neglect/fitness to practice.

Seek advise from NHS whistleblowing helpline/ public concerns at work. If matters not dealt with escalate with practice
manager and subsequently Local Area Team (LAT)- to confirm whether they are happy with quality assurance procedures in the practice, CQC and finally GDC. (See flow chart on procedure for raising concerns on page 17).
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SCENARIO
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35
A case of consent
You see a patient in your clinic with learning difficulties. How do you ensure that
you have informed consent to treat the patient?
Issues:__________________________________________________________________________
1.
Obtaining valid consent-informed, voluntary and patient deemed competent. Assess capacity under the MCA.
2.
Communicate effectively with patients in a way they can understand.
Management:____________________________________________________________________
1.
Assess nature and severity of learning difficulties-mild, moderate, severe?
2.
Assess capacity under MCA-can patient understand, retain, weigh up, communicate information. (diagrammatically if necessary)
3.
If patient has fluctuant capacity, obtain consent at a later visit.
4.
If not deemed to have capacity consider speaking to relative, carer, IMCA (when no one close), lasting power of attorney
in a best interest meeting. Take into consideration the patients past wishes. If relative imposes a treatment in the best interest meeting that you feel is not the normative need (professionally judged need) of the patient, can obtain a second
opinion or apply to court to determine best interest of patient.
5.
6.
Alternatively can refer to community dentistry in special care department.
7.
Keep complete, clear, concise and contemporaneous notes- on your methods of assessing capacity, seeking consent, and
all members involved in the holistic care of the patient.
8.
Record card audit-process of seeking consent.
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22
The cost of perfection
You work in a large practice and a colleague is keen to discuss cases with the
other staff. They seem proud of their restorations and talk about re-doing them
until they are perfect. The problem is that they keep patients waiting and they
waste of lot of material.
Issues:__________________________________________________________________________
1.
Patient safety is paramount-risk of mercury vapour release.
2.
Patients interest before personal gain.
3.
4.
Resource effectiveness
5.
Strategic effectiveness
Management:____________________________________________________________________
1.
Discuss with colleague remind justification for restoration replacement and inform about patient waiting times-overall
compromise on quality of care. Patient safety overrides perfection.
2.
Encourage colleague to attend dental ethic seminars.
3.
4.
If matters not dealt with locally, escalate appropriately. (See flow chart on procedure for raising concerns on page 17).
5.
Proactive measures-arrange practice meeting in view to discussing effective use of materials, staff workload, dental ethics, audit on patient waiting times and longevity of restorations.
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SCENARIO
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37
Scope of practice
Your practice employs a visiting dentist from abroad. During the last visit he told
you that he really enjoys scaling and polishing, but he didnt really like the other
aspects of dentistry. After he has left the surgery you treat some of his patients
and you are concerned that he has left caries untreated and not referred the patient to another dentist to finish their care.
Issues:__________________________________________________________________________
1.
2.
3.
Raising concerns were patient safety at risk.
4.
Maintain, develop and work within professional knowledge/skills.
5.
Communicate effectively with patients in a way in which they can understand-is dentist fluent in spoken and written English to communicate effectively with patients?
6.
7.
Management:____________________________________________________________________
1.
Discuss concerns with dentist in question regarding untreated disease, completing care and reasons for avoiding certain
aspects of dentistry.
2.
Identify if there is an issue of supervised neglect.
3.
Notify supervisor in view for a discussion to be held with practice principal/ indemnity provider.
4.
Document any discussions held.
5.
Encourage offending dentist to apologise to patients/ apologise to patients on his behalf.
6.
Review patients seen under care of offending dentist and continue incomplete treatment where evident in partnership with
other dentists within the practice.
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38
23
7.
Proactive measures- encourage offending dentist to attend courses in restorative and other branches of dentistry.
8.
Escalate concerns with practice principal, LAT or CQC and finally GDC (if action at local level not practical, i.e. Due to
fear of victimisation). If you do nothing, you may be held vicariously liable and thus your registration could be at risk.
38
SCENARIO
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39
Playing with protocol

Your supervisor does something that goes against protocol.
Issues:__________________________________________________________________________
1.
2.
3.
Maintain, develop and work within profession knowledge/skills and provide good quality care based on current evidence.
Management:____________________________________________________________________
1.
Discuss with supervisor. There are often more than one way of doing things-if current practice deviates from established
practice, is there sufficient justification?
2.
Call indemnity provider for advice to avoid vicarious liability in case of uneventful situation.
3.
Speak to other colleagues regarding protocol and whether current practice diverges from conventional practice governed by guidelines and regulations. May conform to national guidelines- local protocol may be different to national
protocol.
4.
If supervisor goes against rules/regulations, important to educate and remind and escalate matters if not followed- practice manager, LAT, CQC, GDC.
5.
If supervisor forces you to do something that you are uncomfortable with-explain that you feel uncomfortable doing it
and if overlooked, escalate issue appropriately. (See flow chart on procedure for raising concerns on page 17)
6.
Arrange practice team meeting in view of discussing evidence based dentistry (EBD).
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SCENARIO
40
25
An image problem
You recently start work at a practice and notice that all of the radiographs you
take are too light. You find that no other dentist in the practice is justifying or
grading radiographs and that for various reasons very few fall into grade 1 category. The films are developed in automatic daylight which looks quite old.
Issues:__________________________________________________________________________
1.
2.
Health and safety-treat patients in a safe and hygienic environment.
3.
Maintain, develop and work within your professional knowledge/skills.
4.
Regulations- Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER)/Ionising Radiation Regulations 1999 (IRR)/
Health and Safety at work act 1974.
5.
FGDP guidelines on selection criteria for radiographs.
6.
Raising concerns where patient safety at risk.
7.
Risk management- identified fault, assessed frequency of risks-audit, remove risks that can be removed and reducing risks that cannot be eliminated, and evaluating.
Management:____________________________________________________________________
1.
Look at radiation protection policy in practice to determine patient safety measures.
2.
Speak to supervisor/Radiation Protection Advisor (RPA) for advice regarding compliance to IRMER (relating to patients and enforced by CQC) and IRR (relating to workers and enforced by HSE). Bring evidence, i.e. patient notes in view to discussing concerns
regarding patient safety.
3.
An error in equipment is best dealt with by Health Safety Executive (HSE), whereas operator errors are best dealt with by IRMER
inspectorates.
3.
Proactive measures conduct a quick radiograph audit evaluating justifications and grading. FGDP guidelines suggest performance
should conform to- 70% grade 1 , 20% grade 2, 10% grade 3.
4.
Keep records of what measures you have taken to address issues.
5.
Call indemnity provider for advice.
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41
6.
25
Arrange practice team meeting in view to discussing
Who in the practice is responsible for routine machine maintenance? Keep a log book.
Has x-ray machine gone through a risk assessment, may need to call HSE to obtain documentation of a critical examination
and acceptance test.
Appoint a Radiation Protection Supervisor (RPS)/RPA-regulates patient safety and equipment calibration if not already one
in place.
Consider wearing dose meters and discuss results with RPA.
Coin test annually for dark rooms to check for light tightness and film fogging.
Good practice can reduce risk of fatal malignancy due to radiation to 1 in 10 million.
All practitioners must have adequate training as required by IRMER and maintain knowledge via core CPD in radiography, for
which formal training is required every 5 years.
Regular clinical audits on justification and grading.
Keep a log book to record changes to practice. Mention in practice newsletter, leaflets and website.
May be able to develop radiographs at another practice-for emergency measures.
7.
If problem is overlooked escalate matters appropriately. Raise concerns to practice manager, LAT, CQC and then GDC.
8.
The principles of managing this scenario are based on risk management. Following is a flowchart illustrating the stages involved in
managing a risk.
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42
26
Switching sides
You have been working at a new practice for 3 months when you become aware
that a number of your patients you thought were under the NHS have been transferred to the private list.
Issues:__________________________________________________________________________
1.
Patient interest before financial gain.
2.
Obtaining valid consent-informed, voluntary, patient deemed competent. Patient should know what treatments are available privately and under the NHS.
3.
Management:____________________________________________________________________
1.
Review patient notes to see if there is evidence of discussions regarding transfer to private treatment with consent of patient.
2.
Discuss with dentist who is treating your patients under private care, to determine why they were moved , if reasons are
justified then can leave matter, however if it seems as though patients interest overridden by financial motives then raise
concern with dentist.
3.
Contact indemnity provider/NHS Protect (leads on work to safeguard NHS staff and resources from crime) for advice.
4.
Escalate appropriately if no action taken, i.e. practice manager, LAT & CQC and then GDC (can approach directly if
illegal practice being carried out, where you may fear that evidence may be concealed if you adopt the normal pathway for raising concerns).
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SCENARIO
27
43
A curious case of insurance

A patient attends for a final denture fit appointment. The patient asks you to sign
a form to claim costs of the treatment from their health insurance company. You
note that the patient is claiming for more treatment than you have provided. However you are unsure of what other treatment was provided for her by your predecessor. You check the notes and find discrepancies.
Issues:__________________________________________________________________________
1.
Record keeping-clear, complete, concise and contemporaneous records.
2.
Tax inspector can obtain financial documents under Finance Act 08- keep financial info separate form clinical info-still
attempt to gain valid consent for disclosure if required.
3.
Lab should be registered by MHRA thus conforming to medical devices directive.
Management:____________________________________________________________________
1.
Confirm discrepancies with predecessor and discuss case of patient, i.e. were some aspects of the treatment not noted
down? if not noted down speak to supervisor for advice and encourage predecessor to speak to their indemnity provider. Predecessor may need to see patient or establish some form of dialogue to discuss issue.
2.
If no error by dentist, explain to patient that perhaps they may made an error in their insurance claims whilst providing
hard evidence, i.e. FP17 form, statement of manufacture.
3.
If patient insistent-explain why you cannot sign the form as you abide by evidence-i.e. the treatment plan form, and if
diverging you would be committing insurance fraud which can lead to erasure from the GDC.
4.
If patient wishes to make a complaint deal with in house first, and then refer to other service if in house procedure not
successful.
5.
Arrange a practice team meeting in view to discussing recording keeping refer to FGDP guidelines on record keeping.
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44
A question of comfort
One of your colleagues refuses to see a patient as he is a reformed rapist.
Issues:__________________________________________________________________________
1.
Patient interest-treat patients fairly as individuals and without discrimination.
2.
Team dynamics- do not pressurise colleagues into accepting a task if they feel uncomfortable.
3.
Staff safety assessments colleague safety.
Management:____________________________________________________________________
1.
Discuss with colleague reason for not seeing patient, i.e. is the colleague scared? Would they would like another chaperone or enhanced security?
2.
If colleague is scared, cant force to treat as patient safety may be compromised. See if another dentist is willing to treat
patient.
3.
If patient behaviour is deemed suspicious in particular related to criminal thoughts, it may be necessary to breach patient
confidentiality by informing police in public interest. Seek advice from supervisor, indemnity provider and Caldicott
Guardian (a senior person responsible for protecting the confidentiality of a patient and enabling appropriate information sharing) prior to breaching confidentiality.
44
SCENARIO
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45
Positive practitioner
One of your patients is a maxillofacial surgeon. He had a HIV test as he suffered
a needle-stick injury a few months ago which has come back positive. However
you note that he still seems to be operating in the local hospital. You raise the
subject with him and he refuses to tell the hospital.
Issues:__________________________________________________________________________
1.
2.
Report HIV to comply with RIDDOR Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1995.
3.
The restriction on health care workers (HCWs) with HIV practising exposure prone procedures (EPPs) lifted as of 02/14.
4.
Management:____________________________________________________________________
1.
Patient safety is paramount and therefore a practitioner who doesn't conform to regulations, in this case RIDDOR, must be
put to attention.
2.
It is important to highlight to the patient in case he is unaware that the restriction on HCWs with HIV practising EPPs was
removed in February 2014.
3.
All HCWs with HIV who wish to perform EPPs must:
Be on effective combination antiretroviral drug therapy (cART).
Have a plasma viral load <200 copies/ml.
Be subject to plasma viral load monitoring every 12 weeks.
Be under joint supervision of a consultant occupational physician and their treating physician.
Be registered on a confidential national register, the UK Advisory Panel for Healthcare Workers Infected with
Blood-borne Viruses Occupational Health Monitoring Register for BBV Infected HCWs (UKAO-OHR).
4.
Does the patient satisfy the above criteria to carry out treatment? If not, discuss new regulations and encourage him to
have an occupational health check and not rely on his own assessment.
5.
It may be justified to breach confidentiality to protect patient interests/safety. Consult with supervisor, indemnity provider
and Caldicott Guardians prior to breaching confidentiality.
45
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46
30
Late again
Your nurse is consistently arriving late for work causing appointments to be delayed.
Issues:__________________________________________________________________________
1.
2.
Patient experience- diminished.
3.
Duty of professionalism -punctuality.
4.
Management:____________________________________________________________________
1.
Discuss with nurse to allow her to explain herself. This could be due to stress at work. Try to develop a strategy to help
nurse alleviate stress if within your capabilities.
2.
If matters not dealt with, discuss with supervisor regarding staffing issues- i.e. hiring a locum nurse for emergency treatment and practice manager as this is a staff management issue.
3.
If problem persistent, escalate matters with practice principal who would be in the best position to suspend nurse if that is
the best course of action, i.e. by giving a formal warning and suitable time period to rectify the issue.
4.
If matters not dealt with locally, inform LAT, CQC and finally GDC.
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SCENARIO
31
47
Nurse vs. Receptionist

You notice that the nurse and receptionist are not getting on with each other and
is starting to affect the atmosphere in the workplace.
Issues:__________________________________________________________________________
1.
2.
Patient interest members of the dental team must work with each other in the best interest of patients.
3.
Duty of professionalism- to maintain decorum at work.
4.
Team dynamics- do not make disparaging comments about another member in front of patients.
Management:____________________________________________________________________
1.
Stop situation as patient trust and confidence in profession is being diminished.
2.
Do not make disparaging comments towards staff in front of patients but raise issue through proper channel.
3.
Speak to other colleagues making enquiries whether this occurs frequently.
4.
Discuss with supervisor regarding break in team dynamics and whether a meeting can be arranged between nurse and
receptionist to deal with concerns, highlighting the importance of team work and patient interests.
5.
Discuss with supervisor, if it is possible to organise team building workshops to enhance team dynamics and give an opportunity for employees to relax and understand the importance of team work.
6.
Escalation appropriately if matters not dealt with, i.e. with practice manager, LAT, CQC and finally GDC.
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32
48
Not in the right spirit

You become aware that a colleague likes to go for a drink at lunch time and returns to the practice smelling of alcohol. One of the nurses tells you that he regularly runs late.
Issues:__________________________________________________________________________
1.
Patient safety is paramount-intoxication may affect clinical judgement of colleague.
2.
Professionalism-punctuality.
3.
Make sure that your personal behaviour maintains confidence in you/ dental profession.
4.
Staff development-help colleague to overcome problems.
5.
Raise concerns if patients are at risk.
Management:____________________________________________________________________
1.
Speak to colleague-he may feel as though moderate social drinking is acceptable while on duty, although that may be
futile if he is in denial. Avoid anonymous notes as this instils fear and affects colleagues performance.
2.
Speak to supervisor immediately as patient safety in question and follow advice on how to put interest first. Contact indemnity provider for advice.
3.
Send colleague home, arrange for taxi.
4.
Tell patient that colleague is unwell and arrange for emergency dentist- either from practice, locum dentist or refer patient to emergency care nearby in another practice/hospital. Alternatively patient can be rebooked at a later date.
5.
On the following day, discuss concerns with dentist regarding alcohol intake whilst treating patients and professionalism.
Ascertain whether colleague is stressed and develop a strategy together to deal with work related stress. Advise dentist
to seek support from local counselling groups, GP and Employee Assistance Programme (EAP).
6.
Escalate concerns with practice principal, LAT or CQC and finally GDC (if action at local level not practical, i.e. due to
Patient safety overrides professional loyalties.
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49
33
Contaminated contents
You have a patient due to arrive for a restoration and notice that the nurse is wiping down the high speed handpiece in between patients. On questioning, she justifies that is what the practice does as there arent enough high speed handpieces.
Issues:__________________________________________________________________________
1.
2.
Patient should be treated in clean and safe working environment- follow infection control procedures outlined in HTM 0105, Scottish Dental Clinical Effectiveness Programme (SDCEP) in cleaning instruments and National Patient Safety
Agency (NPSA).
3.
4.
Management:____________________________________________________________________
1.
Do not use handpiece if you feel uncomfortable using it, explaining your reasons why. May be able to adopt Atraumatic
Restorative Technique (ART) i.e. spoon excavators, enamel hatchets, until infection control issue dealt with. If not able to
see patient, refer to another practice/hospital for emergency care.
2.
Refer to practice infection control policy. Speak to supervisor, infection control lead and indemnity provider for advice.
3.
Speak to nurse. She may have a gagging clause in her contract preventing her from raising concerns. All members should
be able to raise concerns if patients at risk.
4.
Proactive measures-log issues in view to discussing at future practice team meeting. The following issues can be discussed:
Infection control policy.
Compliance with HTM 01-05 decontamination principles (best practice guidelines devised by department of
health). Requirements of HTM 01-05 ensures a safe and clean environment, minimising person to person transmission and thus healthcare associated infection (HCAI).
Determine why there arent enough handpieces- cost? Patient safety cannot be overridden for financially driven
motive.
Manual cleaning leads to human errors.
A clinical audit on infection control should be carried out every 6 months.

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SCENARIO
50
5.
keep patient surveys on cleanliness to identify previously unnoticed issues.
Follow British Dental Association (BDA) advice sheet on infection control.
Read SDCEP guidelines on clinical effectiveness in cleaning instruments.
In accordance with NPSA, keep note of cleaning mechanisms.
33
Escalate concerns with practice principal, LAT or CQC and finally GDC (if action at local level not practical, i.e. due to
Patient safety overrides professional loyalties.
50
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34
51
An abuse of power
A dentist is making inappropriate comments towards a nurse.
Issues:__________________________________________________________________________
1.
You must treat colleagues fairly and with respect. You must not bully, harass, or unfairly discriminate against them.
2.
Maintain professional conduct at work.
3.
Raising concerns due to indecent nature of dentist.
Management:____________________________________________________________________
1.
Listen to nurse-obtain a through history.
2.
Discuss nature of inappropriate comment with dentist, as well as highlighting GDC standards.
3.
Encourage dentist to apologise to nurse to boost team dynamics.
4.
Discuss with supervisor if it is possible to arrange for nurse to work with another dentist at the practice if uncomfortable.
5.
Speak to nurse to determine whether comfortable or not in raising concern, i.e. do they have a gagging clause in their
contract and whether or not nurse is aware of the process of raising concerns. Encourage nurse to contact their defence
union. Offer to go with the nurse to raise concern with practice manager.
6.
Contact supervisor/your indemnity provider for advice. May need to escalate if nothing done locally with practice principal, LAT, CQC and finally GDC.
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35
52
A teachers influence
A teacher brings in a young child into the surgery with 2 broken teeth.
Issues:__________________________________________________________________________
1.
Patient interest-must respect patients dignity and choices.
2.
3.
Obtaining valid consent-informed, voluntary and patient is deemed competent. Does teacher have statement of authority
to give consent to treatment?
4.
Must act promptly to safeguarding vulnerable children from abuse.
Management:____________________________________________________________________
1.
Determine age of child, if they are under 16 and Gillick competent they can consent for treatment as confirmed by the
Gillick judgement 1985, i.e. if they understand nature of treatment, appreciate the risks, benefits and alternative treatments. However Gillick competency is not seen as first line for obtaining consent, where ideally parents/guardians should
also agree to treatment.
2.
If they are under 16 and not Gillick competent, who can give consent? Parent-natural mother, father if named on birth
certificate for child born after 12/03 and father if married at time of birth for child born before 12/03 (parent can consent under Children Act 1989). Determine if teacher has been delegated parental responsibility-written statement of authority from parent. If teacher doesnt have consent, get in contact with parent to obtain consent. Consider best interest of
patient and act appropriately. If in pain provide treatment to alleviate pain otherwise arrange for another appointment
with someone who has parental responsibility.
3.
For safeguarding concern, follow the flowchart below:
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35
53
4.
If requested to keep a secret, you should not do so but should explain that you may have to share information, but will
explain with whom and when it will be shared.
5.
Cater for patient holistic care and manage concern appropriately. Do not be discouraged by barriers such as:
Fear of litigation-you will be protected by defence organisation if concern raised in good faith.
Lack of knowledge of local protection mechanisms-you can refer to practice, local or national policy.
Lack of knowledge of signs of abuse-you can receive training in house, CPD courses by child protection lead or
externally accredited courses. If receiving training in house, keep log, if ever you need to justify with GDC.
6.
Arrange practice team meeting in view of discussing case and ensuring all staff members equipped to deal with safeguarding issue- refer to BDA advice sheet and child protection and the dental team website.
53
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36
54
Hammering home
A patient comes in for treatment for a fractured incisor tooth with her husband,
who is interpreting for her. You can understand a little of their language enough
to have suspicion that the husband is not interpreting correctly when explaining
the injury.
Issues:__________________________________________________________________________
1.
Patient interest-must respect patients dignity and choices.
2.
3.
Obtain valid consent-informed, voluntary and patient is deemed capable.
4.
Must act promptly to safeguarding vulnerable adults from abuse.
5.
Management:____________________________________________________________________
1.
Communication deficit-does anyone speak language in practice? Arrange for an interpreter or use NHS interpreter service helpline.
2.
Follow the below flowchart for safeguarding vulnerable adults. It is important to note that each dental practice may have
a local policy which may be slightly different to the national policy, although the core steps will be the same.
54
SCENARIO
36
55
3.
If requested to keep a secret, you should not do so but should explain that you may have to share information, but will
explain with whom and when it will be shared.
4.
Cater for patient holistic care and manage concern appropriately. Do not be discouraged by barriers such as:
Fear of litigation-you will be protected by defence organisation if concern raised in good faith.
Lack of knowledge of local protection mechanisms-you can refer to practice, local or national policy.
Lack of knowledge of signs of abuse-you can receive training in house, CPD courses by safeguarding lead or
externally accredited courses. If receiving training in house, keep log, if ever you need to justify with GDC.
5.
Arrange practice team meeting in view of discussing case and ensuring all staff members equipped to deal with safeguarding issue- refer to BDA advice sheet.
55
SCENARIO
37
56
Complicated conundrum
A 17 year old with mild learning difficulties attends your dental surgery with a
broken incisor as well as facial bruising and what appears to be a small burn just
under his left ear. He is accompanied by his partner who says she will translate
for him as he doesnt speak much English. One of your colleagues, who you suspect could be drunk, refuses to treat the patient because he doesnt like him and
says he will swap patients with you. The patient is in the waiting room and is in
a lot of pain, but is saying that he doesnt want to see a dentist in case they give
him an injection. Meanwhile the partner is swearing at the receptionist because
she left the patients notes lying in the waiting room where another patient was
reading them.
Issues:__________________________________________________________________________
1.
2.
Patient interest-treat patients fairly as individuals and without discrimination. Manage pain and anxiety appropriately.
3.
Obtain valid consent- informed, voluntary and patient is deemed capable under MCA 05.
4.
Safeguarding vulnerable adults from abuse.
5.
Maintain professional conduct at work.
6.
Patient experience/satisfaction-diminished.
7.
8.
9.
Maintain and protect patient information-you must not leave records in frank view of other patients.
10.
Staff safeguarding-security measures employed in the practice.
Management:____________________________________________________________________
1.
Speak to supervisor regarding complex nature of situation to see if other members of the team can provide assistance.
2.
Carry out an initial pain history to ascertain whether patient requires urgent medical care if so, call for an ambulance
for an immediate referral to A & E services. Do they have signs of drowsiness, double vision or loss consciousness? May
need to initiate BLS by checking airway, breathing and circulation.
56
SCENARIO
57
3.
37
Calm the partner, offer a drink and apologise for breach in patient confidentiality. Place patients notes in an appropriate location. If partner continues to be aggressive, give warning that their actions will result in expulsion from building, to
cater for a safe and secure environment, unless it is a result of illness where they may not be competent. The police/
security may even need to be called.
4.
Send home colleague, arrange for taxi. Arrange emergency dentist for patients under care- either from practice, locum
dentist or refer patient to emergency care nearby in another practice/hospital.
5.
Communication deficit-arrange for an interpreter/use NHS interpretation service to obtain consent.
6.
If there is evidence to suggest incapacity under mental capacity act, may need to arrange for a best interests meeting,
with carer, relative, IMCA or lasting power of attorney to decide definitive treatment for patient in their best interest.
7.
Discuss anxiety issue with patient, reassure, explain that appropriate measures will be taken to ensure that needle administration is as comfortable as possible (sedation is also an option) and written consent for it. Make reasonable adjustments to treat patient safely however if not possible refer to hospital/community dental services.
8.
Follow flow chart for safeguarding vulnerable adults as shown on page 55.
9.
Discuss concerns with dentist regarding alcohol intake and discrimination whilst treating patients, ascertain whether colleague is stressed and develop a strategy to deal with work related stressed. Encourage dentist seek advice from EAP.
Remind dentist of professionalism. Speak to supervisor regarding behaviour. Seek advice from Public concern at work/
NHS whistleblowing helpline. Escalate concerns if matter not dealt with locally- practice manager, LAT, CQC and finally
GDC.
10.
Arrange practice team meeting in view to discussing storage of notes, data protection act and patient confidentiality.
Audit on note storage. Devise strategy for safe storage of notes, i.e. keep out of sight of other patients and paper notes
locked. Record card audit on seeking patient consent which can be provided to CQC to satisfy outcome 2 of essential
standards-consent to care and treatment.
57
SCENARIO
38
58
A daughters influence
You are treating an elderly patient who suffers from the early stages of dementia.
They are accompanied by their daughter. The patient becomes agitated whilst you
are examining them, meanwhile the daughter gets annoyed and slaps the patients legs, telling them to behave. The patient immediately cowers back in the
chair and seems frightened.
Issues:__________________________________________________________________________
1.
2.
Patient interest-treat patients fairly as individuals and without discrimination. Manage pain and anxiety appropriately.
3.
Obtain valid consent- informed, voluntary and patient is deemed capable under MCA 05.
4.
Safeguarding vulnerable adults from abuse.
Management:____________________________________________________________________
1.
Assess capacity of patient. Does daughter have patients best interest?
2.
Attempt to get daughter away from situation-offer drink and ask to wait in the waiting room until you finish examination.
3.
Manage patient anxiety.
4.
If patient in pain provide urgent dental treatment and carry out full oral health assessment after carrying out a best interests meeting.
5.
Contact supervisor/indemnity provider for advice. May need to flag up a safeguarding issue and act accordingly.
6.
Engage daughter rather than maligning her, i.e. offer resources to help take care of mother-leaflets, useful contacts.
7.
May need to refer to community or special care dentistry.
58
SCENARIO
39
59
The effect of neglect

A mother brings in a child with gross carious lesions in most teeth.
Issues:__________________________________________________________________________
1.
2.
Safeguarding vulnerable children from abuse-dental neglect.
3.
Patient interests-respect patient dignity and choices.
4.
Management:____________________________________________________________________
1.
Conduct a thorough history- Is it causing toothache, disturbed sleep, difficulty eating or change in food preferences, absence from school and interference with play and socialisation?
2.
Consider holistic care- Is child at risk of being teased, taking repeated antibiotics and is systemically ill due to a preventable disease. (Dental caries has a multifactorial origin and thus various factors including medical and social factors also
need to be considered)
3.
Assess whether parent has access to treatment, yet child still presents with disease. Take into consideration missed appointments, treatment plan not completed and returning in pain at repeated intervals.
4.
If concerned about safeguarding and neglect, refer to practice policy on safeguarding or follow the flow chart on page
53. Consult with supervisor, defence organisation, and safeguarding lead with respect to escalating the matter.
5.
In this case it is important to identify unmet need so that the family can receive the support they need, rather than on apportioning blame. The parent can be educated on:
Fluoride a regular source, usually supplied by twice daily use of fluoride toothpaste.
Diet limit frequency of sugary snacks and drinks.
Oral hygiene facilities, supervision and assistance.
Dental visits to benefit from preventive care and treatment when needed.
Medical exam-if there is an underlying systemic illness may need to refer to medical professionals.
59
SCENARIO
40
60
A breach in confidentiality
You go out for a social drink with the staff from the dental surgery. Your nurse,
the receptionist and another dentist from the surgery are talking carelessly about
some of the patients. You can tell that other people at the pub are listening. When
you mention this to your supervisor, who is also present, he tells you not to
worry about it and that the staff are just letting off steam.
Issues:__________________________________________________________________________
1.
Patient privacy and confidentiality-maintain and protect patient information under the DPA. Non GDC members must be
aware of the importance of confidentiality and abide by legislation.
2.
Raise concerns where patients at risk.
3.
Team dynamics.
Management:____________________________________________________________________
1.
Change topic of conversation.
2.
Discuss with supervisor on the matter of professionalism, patient confidentiality and the seriousness of breaching GDC
standards to maintain and protect patient information.
3.
If despite your warning the conversation still continues, try to get out of the situation otherwise you will also be held vicariously liable.
4.
Seek advice from indemnity provider and Caldicott guardians.
5.
Investigate if confidentiality is being breached elsewhere in the practice, i.e. social media.
6.
Arrange for a practice team meeting in view to discussing confidentiality, GDC standards, duty of professionalism as well
as appointing, if not already existing, an information governance lead to handle matters regarding confidentiality. Even
non-GDC members should follow GDC guidelines, as vicarious liability will rest with GDC members i.e. practice manager
or dentist.
60
SCENARIO
61
7.
40
Methods to prevent breach in confidentiality include:
Staff training on confidentiality information governance toolkit training courses online.
Have a confidentiality clause in contract of employees both GDC and non GDC registered.
Do not keep handheld devices containing patient information where it may be stolen or lock using a Kensington
lock.
8.
Attach USB devices containing patient information to key rings.
Ensure robust password protection and encryption if storing patient data electronically.
Escalates matters if not dealt with locally with practice manager, LAT, CQC and finally GDC.
61
SCENARIO
62
41
A probing partner
A lady calls your practice asking for the appointment time for her husband the
following day.
Issues:__________________________________________________________________________
1.
2.
Patient privacy and confidentiality-maintain and protect patient information under the DPA. Non GDC members must be
aware of the importance of confidentiality and abide by legislation.
Management:____________________________________________________________________
1.
Arrange to speak to her husband directly, remind wife of policy of speaking directly to patient to protect confidentiality.
2.
Alternative the lady can find out this information from her husband.
3.
Does lady have statement of authority that is signed by husband to give authority to collect info on behalf of person?
4.
Arrange practice team meeting in view to discussing patient confidentiality. Can implement a password system to ensure
that patients can be identified even when not face to face. Ensure staff trained in confidentiality and that even non GDC
members are trained in dealing with confidentiality cases as you may not be there to deal with them and appreciate the
need to maintain and protect patient information.
62
SCENARIO
42
63
A sensitive issue
You see a 14 year old female patient for an examination. You find that she has
severe erosion on the palatal surface from canine to canine. You enquire about her
diet and she denies excessive carbonated drink intake or other items that may
cause erosion. The medical history doesn't indicates acid reflux problems. You
come to the conclusion that she has an eating disorder and suggest to her that diagnosis. She breaks down in tears and admits that she does binge eat and purge
herself by vomiting. She begs you not to inform her parents or the GP.
Issues:__________________________________________________________________________
1.
2.
Patient interest-respect their dignity and choices.
3.
Obtain valid consent-informed, voluntary and patient deemed capable. Assess for Gillick competency.
4.
Maintain and protect patient information-is it in the patients best interest to breach confidentiality?
5.
Working with colleagues to act in the best interests of patients-refer and delegate appropriately to cater for patients
holistic care.
Management:____________________________________________________________________
1.
Address competency. Is the patient deemed Gillick competent?
2.
Encourage her to tell GP, and parent-this is a significant psychological and physical disease where she is going to need
help from both family and professional agencies.
3.
Ask supervisor to examine patient for second opinion. Contact indemnity provider for advice.
4.
Provide immediate treatment to deal with acute dental pain dentine hypersensitivity.
5.
Give a cooling period of 1 week to allow patient to take on board your findings, and see if she has followed your recommendations.
6.
If patient has not yet disclosed information to anyone else for support, weigh up breach in confidentiality vs. best interest,
i.e. will telling her parents result in further harm?
63
SCENARIO
64
7.
42
If decided to raise concern, inform patient about intention to do so, unless you feel this may result in further harm. Before
referring to GP, discuss with supervisor, indemnity provider and Caldicott guardian.
64
SCENARIO
43
65
Duty of candour
You have referred an elderly patient to hospital with a persistent mouth ulcer
suspicious of oral cancer. The family ask you not to inform the patient of the results of any investigations confirming diagnosis of oral cancer.
Issues:__________________________________________________________________________
1.
2.
Patient interest-must be honest with patients.
3.
Duty of candour- volunteering relevant information to a person who may have been harmed by provision of services.
4.
5.
Management:____________________________________________________________________
1.
Assess patient competency-can they understand, retain, weigh up and communicate information?
2.
Speak to family regarding concern about not telling patient whilst empathising with their viewpoint. Remind family of
duty of candour, a professional duty to inform patient of condition. This is important to obtain valid consent from the patient. The treatment plan would involve a multidisciplinary team approach and thus it is important the patient knows of
their condition and the members involved in provision of treatment.
3.
Stress importance of early diagnosis and improving 5 year survival rates.
4.
65
SCENARIO
44
66
Crossing the line

A patient starts to make inappropriate sexual comments towards your nurse.
Issues:__________________________________________________________________________
1.
Staff safety assessment.
2.
Strategic effectiveness.
Management:____________________________________________________________________
1.
Explain to patient inappropriate nature of comments. Provide warning of consequences of not obeying initial concern.
2.
If patient continues , change nurse. This will ensure that patient treatment can be completed after which a definitive solution can be decided upon.
3.
Call supervisor/ indemnity provider for advice.
4.
Refer to practice policy on patient tolerance.
5.
If inappropriate behaviour continues, justified to expel patient from building.
6.
If there is a relationship breakdown between dentist-patient, write to them to tell them of your decision and reasons for
deregistering them from practice whilst making arrangements for them to be seen in another practice to ensure continuity
of treatment. This could involve providing them with a leaflet of nearby practices to register with instead.
7.
Document any discussions held with the patient.
8.
Ensure that all patients in the practice are aware of their duties to behave appropriately when being treated by a dental
professional. Some practices may implement a zero-tolerance policy, which should be clearly evident on patient notice
boards.
66
SCENARIO
45
67
Problems, problems, problems

You go to the waiting room and find that the receptionist has accidently triple
booked the following patients:
1. Man complaining loudly that he has taken a day of work for his 6 month
check up.
2. Mother who says her filling came out and has 2 screaming children in the reception area.
3. Elderly lady who is sitting quietly but appears to be in a lot of pain.
Issues:__________________________________________________________________________
1.
2.
Patient interest-treat patients fairly as individuals and without discrimination.
3.
Patient experience-diminished
4.
Strategic effectiveness
5.
Work with colleagues in the best interest of patients
Management:____________________________________________________________________
1.
Empathise with the patient and apologise to them (sorry glad you brought it to my attention).
2.
Reassure patient.
What went wrong?-technical administrative error.
What you will do to make it better?-all patients will be seen at some point today.
3.
Call supervisor with view to arrange for help from other colleagues, i.e. to distribute load and help diffuse the situation.
4.
Patient specific:
Loud man Offer beverage and try to calm down. Reassure.
Mother with screaming children Offer beverage. Direct children towards play area in practice to keep them
occupied. Reassure.
Elderly lady Ascertain for signs of medical emergency, which may require urgent attention.
67
SCENARIO
68
5.
45
If all patients cannot be seen today by either yourself or another dentist at the practice, can refer to dentist in another
practice, hospital or can rearrange appointment.
6.
7.
Record adverse incident in log book in view to discussing issue at future practice meeting.
8.
Arrange for practice team meeting in view to discussing the following:
IT issues-software checked by IT consultant.
Verification of appointments to ensure that there isnt an issue which has to be resolved in short notice but rather
can be dealt with much earlier.
Set up a practice organisational chart so that each member of the team are aware of their responsibilities in certain situations.
68
SWIFT
69
DENTISTRY SERIES
PROFESSIONALISM,
LEADERSHIP & MANAGEMENT
SCENARIOS
This guide provides a summary of the
management and issues raised in a variety
of dental scenarios with particular reference to professionalism and leadership. It
can serve as a useful reference tool to all
dental professionals, both qualified and
currently under training.
The layout used in this guide assists
readers in:
Rapidly identifying key issues involved

in each scenario
Managing each scenario using the
recommended pathway
Disclaimer
Dentistry is an ever-changing field where knowledge and best practice are constantly changing. Readers are advised to check the
most current information provided on the management of scenarios. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to determine the most suitable pathway of management. To the fullest extent of the law, neither the Publisher nor the Editor assumes any liability for any injury and/or damage to persons or property arising out of or related
to any use of the material contained in this book.
69
DR. PREYESH PATEL

Swift Series Clinical Governance Book Edition 1

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SWIFT

DR. PREYESH PATEL

Dentistry is a complex art form. Whilst it is key to be competent in clinical techniques, it is

24. Playing with protocol

25. An image problem

26. Switching sides

27. A curious case of insurance

28. A question of comfort

29. Positive practitioner

30. Late again

31. Nurse vs. Receptionist

32. Not in the right spirit

10. Nurse feeling worse?

33. Contaminated contents

11. A careless colleague

34. An abuse of power

12. Irritating injection

35. A teachers influence

13. Incompetent implantologist?

36. Hammering home

14. The root of the problem

37. Complicated conundrum

15. Naughty nurses

38. A daughters influence

16. A fractured file

39. The effect of neglect

17. The fractured file returns

40. A breach in confidentiality

41. A probing partner

42. A sensitive issue

20. A prolonged perio problem

43. Duty of candour

21. A case of consent

44. Crossing the line

22. The cost of perfection

45. Problems, problems, problems

23. Scope of practice

Putting patient interests first-respecting their dignity and choices.

Communicating effectively with patients in a way in which they can understand.

Obtaining valid consent-informed, voluntary, patient is deemed competent.

Obtain valid consent-informed, voluntary and patient deemed competent.

Document discussion in obtaining valid consent.

Putting patient interests first-respecting their dignity and choices.

Communicating effectively with patients in a way in which they can understand.

Obtaining valid consent-informed, voluntary, patient deemed competent.

Discuss treatment with child.

Call supervisor/indemnity provider for advice.

Putting patient interests first-respecting their dignity and choices.

Communicating effectively with patients in a way in which they can understand.

Obtaining valid consent-informed, voluntary, patient deemed competent.

Advisable to register with CHKS to regulate quality assurance of adjunctive procedures.

Explain rationale before referring for second opinion.

Patient safety is paramount.

Call supervisor/indemnity provider for advice.

Alternatively can refer to community dentistry in special care department.

Record card audit-process of seeking consent.

Patient safety is paramount.

Contact supervisor/indemnity provider for advice.

Alternatively can refer to Acute Dental Care (ADC) department in hospital.

Keep clear, contemporaneous, concise and complete notes.

Patient safety is paramount.

Competency to perform treatment-are you appropriately trained, indemnified and qualified?

Call supervisor/indemnity provider (e.g. DDU/Dental Protection)-for advice.

Document clear, concise, contemporaneous and complete notes.