HEARING PARTLY HEARD IN PRIVATE The Committee has made a determination in this case that includes some private information. That information has been omitted from this text. O BRIEN, Natasia Registration No: 114852 PROFESSIONAL CONDUCT COMMITTEE September 2017 Outcome: Erased with immediate suspension Natasia O BRIEN, a dentist, BDS Lond 2007 was summoned to appear before the Professional Conduct Committee on 11 September 2017 for an inquiry into the following charge: Charge (as amended 11,13,14 and 15 September 2017) That, being a registered dentist: 1. You were practising in general dentistry, between: (a) March 2011 and September 2011 at the Barn Clinic in Salisbury; 21 May 2012 and 18 October 2012 at the Integrated Dental Holdings ( IDH ) practice in Banbury; 2. You provided care and treatment to the patients set out in Schedule A. 1 Barn Clinic Patients 3. You failed to provide an adequate standard of care to Patient 1, on 25 July 2011, in that: (a) (c) (d) (e) you crowned the LL6 rather than restoring it with a filling or inlay; and/or in preparing LL6 for a crown you caused unnecessary drilling of the tooth; and/or you failed to correct the occlusion of the crown, which was too high; and/or you failed to ensure an adequate marginal fit of the crown; and/or you failed to ensure that the contact point between the crown you fitted and LL5 was adequate. 4. You failed to provide an adequate standard of care to Patient 2, on 8 September 2011, in that you carried out a composite restoration to the LL4, which was unnecessary. 1 Please note Schedule A is a private document which may not be disclosed. O BRIEN, N Professional Conduct Committee September 2017 Page -1/26-
IDH Patients 5. You failed to provide an adequate standard of care to Patient 3 in that you failed to diagnose caries at LL5, detectable radiographically on 20 June 2012. 6. You failed to provide an adequate standard of care to Patient 4 on 18 July 2012, in that, following a perforation of the root of the LL6 on 13 July 2012, you left the roots of the LL6 untreated and filled the cavity in the tooth. 7. You failed to provide an adequate standard of care to Patient 5 between 18 July 2012 and 24 July 2012, in that you: (a) failed to report on the radiograph of the UR8, taken on 18 July 2012; and/or completed fillings at the LR7 on 24 July 2012 without the use of a matrix band. 8. You failed to provide an adequate standard of care to Patient 6 between 2 July 2012 and 11 September 2012, in that you: (a) (c) (d) (e) (f) (g) prepared a crown for the UL4/5 on 2 July 2012, without providing root canal treatment, or, alternatively; (ii) allowing a probationary monitoring period after removing the caries; and/or made a core for the UL4/5 on 2 July 2012, that was: structurally inadequate to support a crown; and/or (ii) had voids beneath; and/or inadequately assessed the periapical radiograph taken on 17 July 2012 in that you reported that all appears sound when it showed: (ii) that the core was structurally inadequate to support a crown; and/or voids beneath the core; and/or fitted a permanent crown onto the UL4/5 on 17 July 2012, despite the radiograph showing that the core: was structurally inadequate to support a crown; and/or (ii) had voids beneath; and/or repaired a defect at the buccal margin with filling material, rather than ensuring that the crown you fitted onto the UL4/5 on 17 July 2012 had correctly adapted margins; and/or prepared the UL4/5 for a further permanent crown on 30 August 2012, when the tooth had been giving symptoms of sensitivity following the first crown, without: providing root canal treatment, or, alternatively; (ii) providing a provisional crown to seal all margins and monitoring the response; and/or [withdrawn]: O BRIEN, N Professional Conduct Committee September 2017 Page -2/26-
(h) [withdrawn] (ii) [withdrawn] [withdrawn]: [withdrawn] (ii) [withdrawn] (iii) [withdrawn]; [withdrawn]: [withdrawn] (ii) [withdrawn]. 9. You failed to make adequate records on 21 September 2012 in respect of Patient 7, in that you: (a) failed to make adequate notes about the treatment options; and/or failed to report on the radiograph. PCT and First Tier Tribunal proceedings 10. On the 27 August 2010, following concerns about your clinical practice, the Hampshire Primary Care Trust ( the PCT ) wrote to you to inform you that they had made the decision to contingently remove you from their Dental Performer s List ( the List ) on grounds of efficiency, and to inform you of the twelve conditions that they had resolved to impose on your practice. 11. Following an oral hearing of the Contractor s Performance Panel on 1 st October 2012, the PCT resolved to remove you from the List. 12. In October 2012, an appeal against your removal from the List, was lodged to the First Tier Tribunal. This appeal was heard in March and June 2013, and on 12 July 2013 the First Tier Tribunal issued a determination dismissing your appeal. Statements in the First Tier Tribunal proceedings relating to your employment at Barn Clinic 13. During the proceedings in the First Tier Tribunal, you signed a witness statement, dated 9 May 2012, which contained a declaration of truth, in which you stated, at paragraph 41: In February 2012, I received a letter from [Witness 1] at my former employing practice, the Barn, raising concerns about treatment and care I provided to patients there between March and April 2011. This was the first time any concerns about my practice there had been raised, despite me having had regular meetings there with [Witness 1] to discuss any issues. 14. Your statement at paragraph 13 above was: (a) misleading; O BRIEN, N Professional Conduct Committee September 2017 Page -3/26-
dishonest; in that you knew that Witness 1, your supervisor at the Barn Clinic, had raised concerns about your practice with you prior to February 2012; and (ii) your intention was to mislead the First Tier Tribunal. Statements to the PCT and in the First Tier Tribunal proceedings relating to Condition 11 15. From 27 August 2010, or shortly thereafter, you were subject to conditions of practise imposed by the PCT. Condition 11 stated: You will develop with the PCT and undertake a Patient Satisfaction Survey of 50 patients designed to gain insight into the patients treatment experience when visiting the practice; produce a summary of learning arising from the survey; develop an action plan from the results and satisfactorily conclude any actions arising. The survey should include questions on patient waiting times in the practice and the time spent with the practitioner. 16. You sent an email to Witness 2 of the PCT, dated 26 July 2012, in which you stated: Condition 11 of my contingent removal requires me to develop with the PCT a Patient Satisfaction Survey. To that end would you please examine the enclosed patient questionnaire which we have at ADP Banbury, which I can implement on my own merits, request my patients complete (if they are agreeable), collect the data from and analyse to see where improvements are required and can be made. If you agree this questionnaire is suitable, I can complete the patient satisfaction questionnaire survey and forward you all the results obtained for your perusal. Please let me know as soon as possible whether this would satisfy condition 11. 17. The email you sent to Witness 2, of the PCT, dated 26 July 2012, in relation to Condition 11, gave the impression that: (a) you had not yet used the attached questionnaire to conduct a patient satisfaction survey; you were requesting the approval of the PCT to use that questionnaire to fulfil Condition 11 of your contingent removal conditions; (c) you would, after receiving that approval, ask your patients to complete the attached questionnaire. 18. Your statement at paragraph 16 above was: (a) misleading; dishonest; in that you knew that the patient questionnaires had already been completed by the time you sent the email of 26 July 2012; (ii) your intention was to mislead the PCT. O BRIEN, N Professional Conduct Committee September 2017 Page -4/26-
19. During the proceedings for your appeal to the First Tier Tribunal you signed a witness statement, dated 19 April 2013, which contained a declaration of truth, in which you stated, at paragraph 64 (iii): Condition 11 and the patient satisfaction questionnaire I did not understand develop to mean requiring approval or consent or given permission from the PCT, which it appears is the PCT s interpretation. 20. Your statement at paragraph 19 above was: (a) misleading; dishonest; in that you understood the wording of Condition 11 to require the approval or consent of the PCT; and (ii) your intention was to mislead the First Tier Tribunal. Statements to IDH and in the First Tier Tribunal proceedings relating to your employment at IDH 21. During your employment at IDH, you failed to inform your supervisor, Witness 3, that: (a) you were dismissed from the Barn Clinic following concerns about your clinical practice; you had been dismissed from more than one practice prior to your employment at IDH. 22. Your conduct at paragraph 21 above was: (a) misleading; dishonest; in that you knew that you had been dismissed from the Barn Clinic following concerns about your clinical practice; and/or (ii) you knew that you had been dismissed from more than one practice prior to your employment at IDH; and (iii) your intention was to prevent your employer knowing your full employment history. 23. The PCT held an oral hearing on 1 October 2012 regarding your removal from the Dental Performer s list ( the list ). The outcome of that hearing was to remove you from the list, and a letter dated 4 October 2012 was sent to you informing you of that decision. 24. You failed to inform: (a) your supervisor, Witness 3; your employer, IDH Ltd; O BRIEN, N Professional Conduct Committee September 2017 Page -5/26-
of the decision of the PCT to remove you from the Dental Performer s List, until at least 18 October 2012. 25. At a meeting convened by IDH to terminate your contract on 18 October 2012, you stated that: (a) you had only been notified of the outcome of the hearing in paragraph 23, on 17 October 2012; and/or you were going to inform the practice manager of that outcome that day. 26. Your conduct at paragraphs 24 and/or 25, was: (a) misleading; dishonest; in that you knew of the outcome of the hearing in paragraph 23 by, or shortly after, 5 October 2012; and (ii) your intention was to mislead your employer. 27. During the proceedings for your appeal to the First Tier Tribunal you prepared a witness statement, that was received by the PCT on 22 February 2013, in which you stated at paragraph 17: When I obtained the verdict of the CPP held on 1 st October by email from [Witness 2] on behalf of Hampshire PCT in the late evening of 5 th October 2012, I discussed this openly with my clinical supervisor [Witness 3] at the earliest opportunity on Tuesday 9 th October 2012 when I saw him next. 28. Your statement at paragraph 27 above was: (a) misleading; dishonest; in that you knew that you did not discuss the verdict with Witness 3 on 9 October 2012; and (ii) your intention was to mislead the First Tier Tribunal. 29. During the proceedings for your appeal to the First Tier Tribunal you prepared a witness statement, that was received by the PCT on 22 February 2013, in which you stated at paragraph 9, that: IDH had a policy to temporise crowns using composite material which I was unaccustomed to so asked for advice whether this was the best method to dress a tooth until the definitive crown was made by the lab.although the implementation of the advice was not well received by my nurse. 30. Your statement at paragraph 29 above was: (a) misleading; dishonest; O BRIEN, N Professional Conduct Committee September 2017 Page -6/26-
in that you knew that IDH did not have a policy to temporise crowns using composite material; and (ii) your intention was to mislead the First Tier Tribunal. Statements to Witness 4 31. PRIVATE (a) (c) (d) (e) (f) PRIVATE PRIVATE PRIVATE PRIVATE PRIVATE PRIVATE 32. Your statements at paragraphs 31 (a),, (c), (d), (e) and/or (f) above were: (a) misleading; dishonest; in that you knew that your statements in paragraphs 31 (a),, (c), (d), (e) and /or (f) were not true; (ii) and your intention was to mislead Witness 4, and thereby the First Tier Tribunal. And that, by reason of the facts alleged, your fitness to practise is impaired by reason of your misconduct. On 21 September 2017, the Chairman made the following statement regarding the finding of facts: Mrs O Brien You are present at this hearing of the Professional Conduct Committee (PCC). You are represented by Mr Stephen Brassington of Counsel, instructed by Gordons Partnership solicitors. Ms Natasha Tahta, instructed by Capsticks solicitors, appears for the General Dental Council (GDC). Preliminary matters and amendments to the charge At the outset of the hearing Ms Tahta applied to amend head of charge 32 pursuant to Rule 18 of the General Dental Council (Fitness to Practise) Rules 2006 ( the Rules ). Mr Brassington made no objection on your behalf. The Committee was content to accede to the application, and the schedule of charge was amended accordingly. The Committee then heard an application made by Ms Tahta, which was supported by Mr Brassington, for parts of the hearing to take place in private in accordance with Rule 53 of the Rules. Ms Tahta submitted that head of charge 31 relates to your health and private life, and that accordingly the parts of the hearing which deal with those matters should be heard O BRIEN, N Professional Conduct Committee September 2017 Page -7/26-
in private. The Committee again acceded to the application, and further directed that head of charge 31 be redacted so that the particulars of that charge are kept private. Mr Brassington made a number of admissions to the heads of charge that you face. The admissions were noted by the Committee and are set out below. An admission to head of charge 31 (c) was subsequently withdrawn, and this withdrawal was similarly noted by the Committee. Ms Tahta subsequently made an application to amend head of charge 31 (c) in accordance with Rule 18 of the Rules. Mr Brassington made no objection to the amendment. Having accepted the advice of the Legal Adviser the Committee determined to accede to the application on the basis that the amendment sought could be made without prejudice being caused to you. The schedule of charge was again amended accordingly. Ms Tahta also made a further application to amend head of charge 31 (e) in accordance with Rule 18. Mr Brassington did not consent to the amendment. Having accepted the advice of the Legal Adviser the Committee decided that it was fair and appropriate for the amendment to be made. The schedule of charge was once more amended accordingly. The Committee also made amendments to heads of charge 8 (g) (ii) and 8 (h) (ii) following an application made by Ms Tahta which was not opposed by Mr Brassington. The Committee accepted the advice of the Legal Adviser, and determined that the heads of charge could be amended without prejudice being caused to you. The schedule of charge was then amended. The Committee also made a minor amendment to head of charge 8 (c) to correct a typographical error. Ms Tahta and Mr Brassington made no objection to the amendment. Following the conclusion of the GDC s case Ms Tahta sought to further amend the charge by way of withdrawing heads of charge 8 (g), 8 (h) and 8, and amending head of charge 8 (f) (ii). Mr Brassington made no objection to the application. The Committee accepted the amendments, and the schedule of charge was duly amended. Application under Rule 57 During the course of the factual inquiry Ms Tahta applied to have the oral evidence of a witness, namely Witness 1, to be given by Skype pursuant to the provisions of Rule 57 (1). Ms Tahta submitted that Witness 1 partly resides in Barcelona, that he is in Spain for the duration of the hearing, and that it is not possible for him to attend this hearing in person to give his evidence. Ms Tahta submitted that your defence team has previously been notified of the GDC s intention to make such an application, and that it would be fair and just for Witness 1 s evidence to be heard by Skype. Mr Brassington on your behalf opposed the application on the basis that it is possible for Witness 1 to give evidence in person at this hearing, that the giving of his evidence by Skype has not been agreed in advance, and that the Committee would not hear best evidence from a witness whose evidence is contentious if that evidence were to be given by Skype. The Committee also received documentary evidence in relation to the application, including copies of correspondence with Witness 1, as well as correspondence between the GDC, those who act for it in these proceedings, and your defence team. O BRIEN, N Professional Conduct Committee September 2017 Page -8/26-
The Committee accepted the advice of the Legal Adviser. Having given careful consideration to the matter the Committee determined that it was fair and appropriate for Witness 1 to give his evidence by Skype. The Committee also considered that the giving of Witness 1 s evidence by Skype would not prejudice your defence case, and would secure the most expeditious disposal of this case. The Committee was mindful of the deficiencies inherent in the giving of evidence by Skype and took every care to ensure that appropriate weight is given to that evidence. The Committee was similarly mindful that technical difficulties can unexpectedly arise with Skype and that it may need to reassess the appropriateness of hearing evidence via Skype should the need arise. Background to the case and summary of allegations These proceedings arise from concerns about the standard of your care and treatment that you provided to seven patients, as well as from concerns about a number of statements that you made in relation to appeal proceedings that you brought against Hampshire NHS Primary Care Trust (PCT), now known as NHS England, following its decisions to contingently, and then fully, remove you from its Dental Performers List. The GDC has raised a number of allegations against you in respect of your care and treatment of the seven patients referred to above, who are referred to for the purposes of these proceedings as Patient 1 to Patient 7. You provided care and treatment to the first of these patients, namely Patient 1, on 25 July 2011. You were in practice at the time at the Barn Clinic in Salisbury, Wiltshire. The practice is a wholly private practice. You started work at that practice in March 2011 and ceased working at the practice in September 2011. It is specifically alleged that you failed to provide an adequate standard of care to Patient 1, in that you crowned the patient s LL6 rather than restoring it, that in preparing the same tooth for a crown you caused unnecessary drilling to be performed on the tooth, that you failed to correct the crown s occlusion, that you failed to ensure an adequate marginal fit for the crown, and that you failed to ensure a correct contact point between the crown and the adjacent LL5. The standard of care and treatment that you provided to a second patient, namely Patient 2, whilst at the Barn Clinic has also given rise to an allegation. It is alleged that you failed to provide an adequate standard of care to Patient 2 on 8 September 2011, more particularly in that you carried out an unnecessary composite restoration to the patient s LL4. The remaining patients about whom you face allegations relating to your standard of care and treatment, namely Patient 3 to Patient 7, received treatment from you during the course of your subsequent employment with Integrated Dental Holdings (IDH) at its practice in Banbury, Oxfordshire. It is specifically alleged that you failed to provide an adequate standard of care to Patient 3, in that you failed to diagnose caries at the patient s LL5 which was detectable radiographically on 20 June 2012. In relation to Patient 4, the GDC contends that you failed to provide an adequate standard of care to the patient, in that on 18 July 2012 you left the perforated roots of the patient s LL6 untreated and filled the cavity following a perforation of the root five days earlier. The GDC also alleges that the standard of care that you provided to Patient 5 in the period of 18 to 24 July 2012 was inadequate, in that you failed to report on O BRIEN, N Professional Conduct Committee September 2017 Page -9/26-
a radiograph that was taken of the patient s UR8 and completed fillings on the LR7 without using a matrix band. You face a number of allegations in relation to your care of Patient 6 in the period of 2 July 2012 and 11 September 2012, with particular regard to your crown work and associated record-keeping. It is alleged that you prepared a crown for the patient s UL4/5 on 2 July 2012 either without providing root canal treatment (RCT) or instead without allowing a probationary monitoring period after removing caries. The GDC also alleges that the core for the crown was structurally inadequate and had voids beneath it. It is also alleged that your report on a periapical radiograph that was taken on 17 July 2012 was inadequate, in that you did not take account of these specific deficiencies and instead recorded that all appears sound. You are also criticised for having fitted a permanent crown at UL4/5 on 17 July 2012 in spite of these two deficiencies, and for having repaired a defect at the buccal margin with filling material rather than ensuring that the crown had correctly adapted margins. You provided further treatment to the UL4/5 on 30 August 2012 in the form of preparation for a further permanent crown. It is alleged that you prepared the tooth for a further permanent crown on that date, despite there being symptoms of sensitivity following the first crown, and that you did not provide RCT or, instead, provide a provisional crown to seal all margins and monitor the response to such treatment. The standard of your record-keeping in relation to your care and treatment of the final patient, namely Patient 7, has also given rise to a number of heads of charge. The remaining heads of charge that have been raised against you relate to the appeal proceedings that you brought against Hampshire NHS PCT following its decisions to contingently, and then fully, remove you from its Dental Performers List. On 27 August 2010, the then Hampshire NHS PCT wrote to you to inform you that they had decided to remove you on a contingent basis from its Dental Performers List on the grounds of efficiency following concerns about your clinical practice. Your entry on that list was made contingent upon and subject to 12 conditions, and some time later in February 2012 you lodged an appeal with the First Tier Tribunal regarding those conditions. A decision was taken by the PCT s Contractor s Performance Panel to remove you from the Dental Performers List on 1 October 2012, with written confirmation of that decision contained in a letter dated 4 October 2012. You appealed against that decision to a First Tier Tribunal. Your appeal was heard before the tribunal in March to July 2013, with your appeal being dismissed on 12 July 2013. You face a number of allegations about statements that you are said to have made in relation to your appeals, in relation to the PCT s management of the concerns that had been raised, and in relation to your disclosure of relevant information to your employer. Pursuant to your appeal to the First Tier Tribunal against the conditions to which your NHS practice was then subject, you signed a witness statement on 9 May 2012 which referred to concerns being raised with you about the care and treatment that you provided to patients in the period of March to April 2011. You stated that the first time that any such concerns had been raised with you by the practice owner of the Barn Dental Clinic, namely Witness 1, was in February 2012. The GDC contends that this statement was misleading and dishonest, in O BRIEN, N Professional Conduct Committee September 2017 Page -10/26-
that you knew that Witness 1 had raised concerns about your practice with you before February 2012. Some weeks later on 26 July 2012, at which time your entry in the NHS Performers List remained subject to conditions, you sent an email to the PCT s case manager, who is referred to for the purposes of these proceedings as Witness 2. Your email related to condition 11 and the requirement that you undertake patient satisfaction surveys. The GDC alleges that your email to Witness 2 conveyed the impression that you had not yet used a questionnaire to conduct surveys, and that this impression was misleading and dishonest, in that you knew that you had in fact already completed the patient questionnaires by the time that you sent the email to Witness 2. The GDC further alleges that, in a witness statement subsequently made in relation to your appeal to the First Tier Tribunal, you stated that you did not understand condition 11 to mean that the PCT needed to give approval, permission or consent for your patient satisfaction survey. The GDC contends that this statement was misleading and dishonest, in that you understood that condition to require the approval or consent of the PCT. The GDC has also raised a number of allegations against you in relation to your disclosure of information to your later employer, namely IDH in Banbury, and about that period of employment in the First Tier Tribunal proceedings. It is specifically alleged that, during your employment with IDH, you failed to inform your clinical supervisor, who is referred to for the purposes of these proceedings as Witness 3, that you were dismissed from your previous employment at the Barn Clinic following concerns about your clinical practice, or that you had been dismissed by more than one employer. The GDC contends that such conduct was misleading and dishonest. The Council also alleges that you failed to inform Witness 3 and IDH of the decision taken to remove you from the Dental Performers List in a timely manner, that you incorrectly stated to IDH at a contract termination meeting on 18 October 2012 that you had only been notified of the PCT s decision to remove you from the Dental Performers List on the day prior to that meeting, and that you had intended to inform the practice manager of the decision on 18 October 2012. The GDC again alleges that such conduct was misleading and dishonest. You also face an allegation that you misleadingly and dishonestly stated in a witness statement produced for the purposes of the First Tier Tribunal proceedings that you discussed your removal from the Dental Performers List with Witness 3 on 9 October 2012, after having received notice of that decision on 5 October 2012. It is also alleged that, in or around February 2013, you made a misleading and dishonest statement in a witness statement prepared in relation to your appeal to the First Tier Tribunal, in that you stated that IDH had a policy to temporise crowns using composite material when you knew that IDH had no such policy. IN PRIVATE [text omitted] IN PUBLIC Evidence The Committee has heard oral evidence from each of the five witnesses referred to above, namely Witness 1 to Witness 5; from the expert witness instructed by the GDC, namely Mr O BRIEN, N Professional Conduct Committee September 2017 Page -11/26-
Jeremy Woodcock; and from the expert witness instructed by your defence team, namely Mr David Kramer; and from you. The Committee has also been provided with documentary material in relation to the heads of charge that you face, including the witness statements and documentary exhibits of the witnesses referred to above; the clinical records of Patient 1 to Patient 7; and the reports of the expert witnesses, namely Mr Woodcock and Mr Kramer. Committee s findings of fact The Committee has taken into account all the evidence presented to it, both written and oral. It has also considered the submissions made by Ms Tahta on behalf of the GDC and by Mr Brassington on your behalf. The Committee has accepted the advice of the Legal Adviser. The Committee has been reminded that the burden of proof lies with the GDC, and has considered the heads of charge against the civil standard of proof, that is to say, the balance of probabilities. The Committee has considered each head of charge separately. However, in respect of those heads of charge which have been found proved on the basis of your admissions, as well as its findings at certain other heads of charge, the Committee s findings will be announced collectively. I will now announce the Committee s findings in relation to each head of charge: 1.(a) 1. The Committee finds the facts alleged at head of charge 1 (a) proved on the basis of your admission. The Committee also finds the facts alleged at the other heads of charge to which you have made admissions proved on the basis of those respective admissions. In reaching these findings the Committee has also had regard to the other documentary and oral evidence presented to it. 2. 3.(a) The Committee finds the facts alleged at head of charge 3 (a) not proved. In his oral and written evidence to the Committee Mr Woodcock was critical of you for having crowned Patient 1 s LL6 rather than restoring it with a filling or an inlay. Mr Kramer disagreed with that criticism on the basis that, given the extensive filling already present at LL6, a crown was not inappropriate. The Committee prefers the expert evidence of Mr Kramer on this point. It accepts his evidence that the bitewing radiograph that you took of the LL6 on 11 July 2011 is a twodimensional representation of a three-dimensional tooth, and that it is therefore not possible to state definitively that LL6 was not suitable for crowning. The Committee also notes that the radiograph in question is now of poor quality and is therefore of limited diagnostic value. The Committee accepts Mr Kramer s expert evidence that a crown may have been appropriate, and that your clinical judgement is not undermined by the radiograph. Accordingly the Committee O BRIEN, N Professional Conduct Committee September 2017 Page -12/26-
3. 3.(c) 3.(d) 3.(e) finds the facts alleged at head of charge 3 (a) not proved. As the Committee has found head of charge 3 (a) above not proved, it follows that you did not cause unnecessary drilling of Patient 1 s LL6 during the course of crownwork which has not been found to have been inappropriate treatment. The Committee therefore finds the facts alleged at head of charge 3 not proved. The Committee finds the facts alleged at head of charge 3 (c) not proved. The Committee has heard that the effect of the local anaesthetic that you administered to Patient 1 at the appointment on 25 July 2011 was running out and that Patient 1 stated that she wished to return to check the bite at a later appointment. You recorded in the patient s clinical notes that the patient withdrew consent. Although Mr Woodcock is critical of you for not having corrected, or at least checked, the occlusion of the crown at LL6, the Committee prefers the evidence of Mr Kramer, who in his evidence stated that it would not have been appropriate for you to correct the occlusion in circumstances where the patient expressed a desire to leave and had withdrawn consent. The Committee notes that the occlusion was later adjusted by the patient s subsequent treating dentist. For these reasons the Committee finds the facts alleged at head of charge 3 (c) not proved. The Committee finds the facts alleged at head of charge 3 (d) not proved. Following your fitting of the crown to Patient 1 s LL6 on 25 July 2011, the patient left your care and attended an appointment with a subsequent treating dentist one week later on 2 August 2011. The patient is recorded as having reported a complaint of sensitivity. The dentist who treated her applied a resin. The Committee accepts the expert evidence of Mr Kramer, who in his evidence to the Committee stated that there is no mention in Patient 1 s clinical records to suggest that the marginal fit of the crown was inadequate. The Committee notes that the subsequent treating dentist who treated Patient 1 on 2 August 2011 made no mention or criticism of the marginal fit of the crown. The Committee also notes that the crown did not require any further treatment for a period of some four years. This is further suggestive of the absence of a problem concerning the marginal fit, given that if the marginal fit had been inadequate it is likely that there would have been continual problems for some time. For these reasons the Committee finds the facts alleged at head of charge 3 (d) not proved. 4. The Committee finds the facts alleged at head of charge 4 not proved. Mr Woodcock is critical of your composite restoration to Patient 2 s LL4 on the basis O BRIEN, N Professional Conduct Committee September 2017 Page -13/26-
that such treatment was unnecessary, and that the radiograph that is available does not support your recorded clinical observation of the presence of caries. Mr Kramer suggested in his evidence that there may have been caries present which would represent a reason for the restorative work that you provided. The Committee accepts that a radiograph can support a clinical observation of caries, but that the apparent absence of caries on a radiograph does not mean that caries is not detectable on clinical examination. The Committee therefore accepts your account of caries being present on clinical examination and your recording of removing slight caries when providing the filling. Therefore the Committee finds that the GDC has not demonstrated to the standard required that the composite restoration to the LL4 was unnecessary. The Committee therefore finds the facts alleged at head of charge 4 not proved. 5. 6. 7.(a) 7. 8.(a) 8.(a)(ii) The Committee finds the facts alleged at head of charge 8 (a) not proved. In his written report to the Committee Mr Woodcock stated that RCT should have been provided at Patient 6 s UL4/5. Mr Woodcock subsequently stated in his oral evidence that RCT could have been provided on an elective basis, and did not maintain his earlier view that RCT should have been provided. In his evidence to the Committee Mr Kramer stated that there is no evidence available to show that RCT was required or indicated. In your clinical notes you recorded that you discussed the possibility of RCT and subsequently that you made a reasoned decision not to provide such treatment as the patient had no symptoms upon her return on 17 July 2012. The Committee has taken note of the concession made by Mr Woodcock and considers that the GDC has not proved to the standard required that you should have provided RCT when preparing the UL4/5 for crowning. Accordingly the Committee finds the facts alleged at head of charge 8 (a) not proved. The Committee finds the facts alleged at head of charge 8 (a) (ii) not proved. Although initially critical of you for not having allowed a probationary monitoring period of unspecified duration after the removal of caries, Mr Woodcock conceded that a monitoring period would represent best practice but was not mandatory, and that you could provide crownwork without a probationary period. The Committee notes that, in any event, a period of two weeks passed before Patient 6 returned for the fitting of the permanent crown on 17 July 2012, after which symptoms were absent. The Committee therefore finds that the GDC has not demonstrated to the standard required that you should have, and did not, allow a probationary monitoring period following the removal of caries. O BRIEN, N Professional Conduct Committee September 2017 Page -14/26-
8. 8.(ii) 8.(c) 8.(c)(ii) 8.(d) 8.(d)(ii) 8.(e) 8.(f) 8.(f)(ii) 8.(g) 8.(g)(ii) 8.(h) 8.(h)(ii) 8.(h)(iii) 8. 8.(ii) 9.(a) 9. Accordingly the Committee finds the facts alleged at head of charge 8 (a) (ii) not proved. The Committee finds the facts alleged at head of charge 8 (f) nor proved. The Committee accepts the expert evidence of Mr Kramer, who stated that, although there is some evidence in the clinical notes for Patient 6 of sensitivity, there is no evidence of irreversible pulpitis which would require the provision of RCT. The Committee further accepts his evidence that a reasonable explanation for the reported sensitivity would be the poorly fitting crown at UL4/5. The Committee finds that the GDC has not proved that you should have provided RCT, and it therefore finds the facts alleged at head of charge 8 (f) not proved. The Committee finds the facts alleged at head of charge 8 (f) (ii) nor proved. The Committee has heard that you provided a temporary crown at Patient 6 s UL4/5. The Committee does not accept the GDC s criticism that you should have instead used a provisional crown, as it considers that there is little practical difference between the two, and that your use of a temporary crown did not amount to an inadequate standard of care. The Committee therefore finds the facts alleged at this head of charge not proved. Withdrawn Withdrawn Withdrawn Withdrawn Withdrawn Withdrawn Withdrawn O BRIEN, N Professional Conduct Committee September 2017 Page -15/26-
10. 11. 12. 13. 14.(a) 14. 14.(ii) Proved Proved The Committee finds the facts alleged at heads of charge 14 and 14 (ii) proved. In your written and oral evidence to this Committee you stated that you did not interpret the discussions that you had with Witness 1 to relate to any concerns that he may have had about your practice, and more particularly that he had not raised any such concerns with you before he wrote to you to raise concerns in February 2012. Witness 1 disputes your account. In his evidence to this Committee he stated that he frequently raised his concerns about your care and treatment of patients at regular monthly meetings that he held with you. The Committee was taken to the written agenda for one such meeting that was scheduled to take place on 28 July 2011 which clearly refers to clinical concerns, but in cross-referencing this agenda it notes that the meeting was recorded by you as having been cancelled. In any event, in attempting to resolve the dispute in the evidence presented to it, the Committee on balance prefers the evidence of Witness 1. The Committee considers that it is more likely than not that Witness 1 did, as he maintains, report his concerns to you, given that as its owner he had a vested financial interest in the running of The Barn. The Committee is also satisfied that you did in fact properly understand at the time that concerns were being raised with you. This is demonstrated by the content of an exchange of emails that you had with had with the Practice Manager of The Barn i on 3 and 4 October 2011 in which you acknowledge your understanding of the concerns that had been expressed. The Committee considers that the reasonable and honest observer would consider your false representation to the First Tier Tribunal to be dishonest. It further considers that, cognisant as you were that concerns about your care and treatment of patients had been raised with you quite some time before February 2012, you deliberately attempted to deceive the First Tier Tribunal into believing that no such concerns had been expressed to you prior to Witness 3 s letter of February 2012. The Committee therefore finds that you knew at the time that your actions would be viewed as being dishonest by the standards of a reasonable and honest observer. The Committee is satisfied that the GDC has demonstrated to the standard required that you were deliberately and dishonestly attempting to mislead the First Tier Tribunal so as to influence its treatment of you in a manner that would be more favourable to you. O BRIEN, N Professional Conduct Committee September 2017 Page -16/26-
For the reasons set out above, the Committee finds the facts alleged at heads of charge 14 and 14 (ii) proved. 15. 16. 17.(a) 17. 17.(c) 18.(a) 18. 18.(ii) Proved Proved The Committee finds the facts alleged at heads of charge 18 and 18 (ii) proved. The Committee finds that you knew that you had already obtained completed patient satisfaction surveys by the time that you contacted the PCT on 26 July 2012. Your email to the PCT of that date sought their approval of a patient satisfaction survey. Your email conveyed the misleading impression that you had yet to implement that survey and that you would await the PCT s comments before so doing. However, the surveys which you subsequently produced to the PCT were each dated June 2012, with the exception of one survey on which it appears the patient had mistakenly entered their own date of birth rather than the date of completion. The Committee considers that a reasonable and honest observer would consider your email to the PCT to be dishonest, conveying as it did the clear impression that you had yet to implement the survey and obtain the results, when in fact you had already done so. The Committee also considers that you knew that you were acting dishonesty by the standards of a reasonable and honest observer, and that in attempting to obtain retrospective approval for a patient satisfaction survey that you had already incorporated in to your practice you were dishonestly attempting to mislead the PCT. The Committee therefore finds the facts alleged at heads of charge 18 and 18 (ii) proved. 19. 20.(a) 20. 20.(ii) Proved Proved Proved The Committee finds the facts alleged at heads of charge 20 (a), 20 and 20 (ii) proved. The Committee considers that your statement in the First Tier Tribunal proceedings dated 19 April 2013 was false, misleading and dishonest. In your O BRIEN, N Professional Conduct Committee September 2017 Page -17/26-
21.(a) 21. 22.(a) 22. 22.(ii) email to the PCT of 26 July 2012, which is referred to at heads of charge 18 and 18 (ii) above, you stated that you were asking the PCT to review your proposed patient satisfaction survey, that you would implement the survey if they were to agree to its contents, and that you would wait to hear from them in that regard. Your earlier email therefore conveys a clear sequence of events which you considered you needed to follow, and in particular demonstrates that you considered that the PCT s approval was an important part of that process. This is particularly apparent because of your subsequent follow-up email to the PCT of 5 August 2012 in which you again asked for the PCT s approval. Your later statement in relation to the First Tier Tribunal proceedings sought to persuade the tribunal that you had in fact a quite different understanding in which the PCT s approval or agreement was not necessary. The Committee is in no doubt that this later statement of 19 April 2013 was false and misleading in light of your different characterisation of your understanding of the need for the PCT s approval as expressed in your statement of 26 July 2012. The Committee considers that a reasonable and honest observer would consider your conduct to be dishonest. It also finds that you knew that your statement in the First Tier Tribunal proceedings would be viewed as dishonest by those standards. The Committee finds that you intended to mislead the First Tier Tribunal so that you would not face criticism for submitting the results of a patient satisfaction survey which had not been approved by the PCT. For these reasons the Committee finds the facts alleged at heads of charge 20 (a), 20 and 20 (ii) proved The Committee finds the facts alleged at heads of charge 21 (a) and 21 not proved. The Committee considers that the GDC has not demonstrated to the standard required that you were under a duty to either inform Witness 3 of your earlier dismissal from the Barn Clinic following concerns about your clinical practice or that you had been dismissed by more than one previous employer before starting work at IDH. The Committee notes in particular that the conditions to which your NHS practice was subject at the time set out no such requirement, and the Committee has not been provided with any other evidence sufficient to demonstrate that you were under such a duty. Accordingly the Committee finds the facts alleged at heads of charge 21 (a) and 21 not proved. 22.(iii) As the Committee has found the facts alleged at heads of charge 21 (a) and 21 O BRIEN, N Professional Conduct Committee September 2017 Page -18/26-
not proved, the facts alleged at heads of charge 22 (a), 22, 22 (ii) and 22 (iii) are found not proved, given that they are founded on allegations which have been found not proved. 23. 24.(a) 24. 25.(a) 25. The Committee finds the facts alleged at head of charge 24 (a) not proved. The Committee has not been presented with evidence sufficient to demonstrate that you were under a duty to inform Witness 3 of the decision taken to remove you from the Dental Performers List. Accordingly the Committee finds the facts alleged at this head of charge not proved. The Committee finds the facts alleged at head of charge 24 not proved. Although the Committee notes from a copy of the letter of termination dated 18 October 2012 that IDH stated to you that you did not keep them informed of the PCT s proceedings and its decision, the Committee has not been presented with evidence sufficient to demonstrate that you were under a duty to inform them prior to 18 October 2012. The Committee therefore finds the facts alleged at this head of charge not proved. The Committee finds the facts alleged at head of charge 25 (a) not proved. The Committee considers that the notes that were made of the meeting on 18 October 2012 are not sufficiently reliable for it to conclude that you, as alleged, stated that you had only been notified of the outcome of the hearing on the previous day, namely 17 October 2012. The Committee finds that, as you accept, you received an email of 5 October 2012 from the PCT later on that same day which conveyed the decision that had been taken to remove you from the Dental Performers List, and in particular contained a copy of the letter setting out that decision. Your evidence to the Committee is that you considered that you would receive further documentation in relation to that decision in the post. In the event that hard copy letter proved to simply be the original letter that was copied to you by email on 5 October 2012. The Committee finds that you were aware of the outcome on 5 October 2012, and that it is more likely than not that you did not, as alleged, state at your termination meeting on 18 October 2012 that you had only been notified of the outcome on the previous day. The Committee considers that your comments may not have been fully recorded at the meeting and that it is conceivable that you stated that you had collected the postal letter on the previous day, but that you did not in fact state that you had not been aware of the PCT s decision until receiving that letter. The Committee therefore finds the facts alleged at head of charge 25 (a) not proved. O BRIEN, N Professional Conduct Committee September 2017 Page -19/26-
26.(a) 26. 26.(ii) As the Committee has found the facts alleged at heads of charge 24 (a), 24 and 25 (a) not proved, the Committee finds the facts alleged at heads of charge 26 (a), 26 and 26 (ii) not proved in relation to those heads of charge, founded as they are on the same unproven facts. The Committee also finds the facts alleged at heads of charge 26 (a), 26 and 26 (ii) not proved in relation to the proven conduct referred to at head of charge 25. The Committee again accepts that you may have been referring to your receipt of the postal letter when stating that you would inform the practice manager of the outcome on 18 October 2012. In the circumstances the Committee is not satisfied that the GDC has demonstrated to the required standard that it was not your intention to inform the practice manager of that letter at the meeting that took place on 18 October 2012. Accordingly, the Committee finds that the allegation of misleading conduct at head of charge 26 (a), and with it the allegations of dishonest conduct at heads of charge 26 and 26 (ii), are not proved. 27. 28.(a) 28. 28.(ii) Proved Proved Proved The Committee finds the facts alleged at heads of charge 28 (a), 28 and 28 (ii) proved. Although you have stated in evidence that you informed Witness 3 of the outcome of the PCT hearing on 9 October 2012, the Committee prefers the evidence of Witness 3 on this point. Witness 3 stated in his workplace supervisor report that you did not inform him of the decision that had been taken to remove you from the Dental Performers List on 9 October 2012. This report is contemporaneous and was made pursuant to important and formal proceedings in accordance with the requirements of the PCT. The Committee accepts the veracity and accuracy of this contemporaneous statement, supported as it is by Witness 3 s clear and consistent oral evidence. The Committee was not able to rely on the varying accounts that you provided of your conversations with Witness 3. The Committee finds that your conduct was misleading, in that you stated that you had informed Witness 3 of your removal from the Dental Performers List on 9 October 2012 when you had not in fact done so. The Committee also considers that a reasonable and honest observer would consider your conduct to be dishonest. The Committee further finds that you knew that your statement in the First Tier Tribunal proceedings would be viewed as dishonest by those O BRIEN, N Professional Conduct Committee September 2017 Page -20/26-
standards, and that you intended to mislead the tribunal and secure more favourable treatment. 29. 30.(a) 30. 30.(ii) 31.(a) 31. 31.(c) 31.(d) 31.(e) 31.(f) 32.(a) 32. 32.(ii) IN PUBLIC The Committee finds the facts alleged at heads of charge 30 and 20 (ii) not proved. The Committee accepts your evidence that you were under a genuine belief that IDH had a policy to temporise crowns using composite material. The Committee finds that the evidence presented to it demonstrates that there was no such policy in place, and indeed that you had used temporary crown material for such purposes. However, the Committee finds that the GDC has not demonstrated to the standard required that you knew that there was not a policy in place concerning the use of composite material, or that you were intending to deceive the First Tier Tribunal into believing that there was such a policy. The Committee therefore finds the facts alleged at heads of charge 30 and 20 (ii) not proved. Proved IN PRIVATE [text omitted] Proved in relation to the conduct at heads of charge 31 (a), 31, 31 (c), 31 (d) and 31 (f); not proved in relation to the conduct at head of charge 31 (e) IN PRIVATE [text omitted] Proved in respect of the conduct at heads of charge 31, 31 (c) and 31 (f); not proved in respect of the conduct at heads of charge 31 (a), 31 (d) and 31 (e) Proved in respect of the conduct at heads of charge 31, 31 (c) and 31 (f); not proved in respect of the conduct at heads of charge 31 (a), 31 (d) and 31 (e) IN PRIVATE [text omitted] O BRIEN, N Professional Conduct Committee September 2017 Page -21/26-