TREATMENT: ONLY WHAT’S NECESSARY


BACKGROUND Mr Z has attended his regular dentist for three years, mainly for routine scale and polish. His dental health has always been judged as good, with satisfactory oral hygiene and only minor gingivitis. He phones the practice in early June to ask for a routine check-up as he is going on an extended holiday to visit family abroad. The practice is extremely busy and


cannot give him an appointment before his departure so Mr Z makes an appointment at another practice. Here he is seen by Mr H. The patient notes record that Mr Z complained of pain in the upper right side of his mouth and Mr H notes an exposed root on the upper right molar, UR7. An X-ray is taken covering three


teeth: UR5, UR6 and UR7. The dentist tells the patient that this has revealed “some holes” that he will fi x. No further explanation is given nor any indication of how many teeth are involved. Mr H carries out root treatment on UR5 and UR6 and submits a claim to Practitioner Services. Mr Z returns to the surgery two


days later aware that he cannot close his teeth properly, and the bite is adjusted in the fi llings. The patient expresses concern that Mr H has carried out unnecessary treatment on his teeth.


DIAGNOSIS: A RARE FEVER


BACKGROUND: GP, Dr Y, is called out to the home of a 61-year-old man, Mr J, who presents with a three-day history of fever and fatigue. He tells the doctor he has recently returned from a holiday in India. Dr Y examines Mr J,


measuring his temperature by hand, and diagnoses him with infl uenza, prescribing a course of antibiotics. Mr J takes the medication but his condition deteriorates over the next two days and he begins to have diffi culty breathing. His family call an ambulance and he is taken to hospital where he is diagnosed with falciparum malaria. He is immediately given the appropriate drug treatment but his condition does not


AUTUMN 2012


improve and Mr J dies a week later. Mr J’s family lodge a claim of clinical negligence against Dr Y, arguing that he would still be alive had he been referred to hospital for treatment during the home visit.


ANALYSIS/OUTCOME: Dr Y informs MDDUS of the claim and writes a detailed summary of the circumstances of Mr J’s case. He explains that he had carried out a full examination of Mr J but had not considered malaria as a potential diagnosis, despite being told the patient had recently been on holiday. He adds that he has written a letter of apology to the family, reassuring them that he has since undergone further training in malaria diagnosis. MDDUS, acting on behalf of Dr Y,


commissions expert reports from a GP and a consultant in infectious diseases. The reports are critical of Dr Y’s failure to consider malaria and did not support his diagnosis of infl uenza. An adviser discusses the reports with Dr Y and they agree that it would be in his best interests to settle the case.


KEY POINTS •


Tropical diseases should always be considered in all cases of fever in patients who have been abroad, whether to malaria regions or not.


•


Where fever is the main/only symptom, consider using a thermometer to achieve a more accurate temperature reading.


•


Prompt diagnosis and referral is a matter of urgency in malaria.


21 Three months later Mr Z


returns to his regular dentist for a check-up and discusses his worry about the treatment carried out by Mr H. The dentist expresses his surprise as he had noted no problems with the teeth in previous consultations with Mr Z. Six months later Mr H receives a


letter from solicitors acting on behalf of Mr Z requesting a copy of his patient records. This is later followed by a letter of claim alleging negligence in the dentist’s treatment of Mr Z, along with an impartial expert report.


ANALYSIS/OUTCOME Mr H sends copies of the letter and the report to an MDDUS adviser who reviews the material along with an in-house solicitor. Mr Z claims that he was subjected to unnecessary dental treatment, including the root fi lling of two teeth – and this conclusion is supported by the expert opinion. Among his criticisms of Mr H’s


treatment of the patient, the expert points out that the patient notes are “very sparse” and record no clinical/ radiological reasons why the treatment was necessary, no results or evaluation of the radiographs taken and no recording of the working lengths for


the root fi llings of UR5 and UR6. Examining the pre-


treatment radiograph he fi nds that it is “coned off ”, providing no useful view of UR5 and no evidence of decay or pathology present in UR6.


Working length radiographs of both teeth taken during treatment are poor, having missed most of the roots. Both should have been retaken. Later radiographs taken of the two


teeth show that Mr H has also failed to adequately obdurate all of the root canals of UR5 and UR6. The expert judges that both will need to be retreated. He concludes that the dentist has failed in his duty of care. MDDUS advisers and lawyers judge the allegations indefensible and in discussion with Mr H decide to settle the case for a modest amount.


KEY POINTS •


• • •


Provide justifi cation in the notes for all treatment undertaken.


Record discussions with the patient regarding informed consent and the treatment plan.


Record evaluation of radiographs including working lengths.


Consider retaking poor radiographs if used to justify decisions.


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