DISCLOSURE: OUT OF DATE CONSENT


BACKGROUND: A 15-year-old patient with a history of mental health problems lives in a residential care home. Her social worker contacts her GP, Dr A, and asks for access to the girl’s medical records so that her file can be updated. Dr A asks the social worker to put the request in writing and to also provide evidence that the patient has consented to the release of her medical records. The next day the practice receives a


faxed request for copies of referral letters to psychiatric services. This is accompanied by a consent form, signed by the patient but dated almost two years ago. Dr A is concerned about the length of time that has passed since the form was signed and contacts MDDUS for advice.


treatment to be reviewed where “significant time has passed since the initial decision was made”. The guidance also clearly states that patients have the right to “change their mind about a decision at any time”. As the consent in this case is out-of-


OUTCOME/ANALYSIS: An MDDUS adviser discusses the issue with Dr A and agrees that the consent is now so old as to be no longer valid. While there is no specific or official time limit on consent taken in advance of treatment or for other purposes such as third party disclosure of confidential information, it would be advisable to review it in this case. The adviser highlights GMC guidance on consent which encourages decisions about


date, there is no good reason for the GP to grant access to the patient’s records. Dr A is advised to request an up-to-date signed consent form.


KEY POINTS • Ensure consent is up-to-date. • When sharing patient information with a third party, ensure the consent given is sufficient and relevant to the request being made.


TREATMENT: INSTRUMENT FAILURE


BACKGROUND: Mr Z attends his dental surgery with a history of pain in a lower right tooth (LR6), especially on biting and chewing. The dentist – Ms J – takes X-rays and notes irreversible pulpitis due to infection. She discusses options with the patient: root treatment or extraction. Mr Z opts for root canal treatment. Two weeks later Mr Z attends the


surgery. Pre-treatment X-rays are taken and Ms J proceeds to remove the MOD restoration and then the pulp using a barbed broach. Next she employs a lentulo spiral filler to spin Ledermix into the canal but the instrument fractures and part of it is retained in the canal. Ms J attempts to use another spiral


filler to remove the fragment but this is unsuccessful. She abandons the procedure and the tooth is dressed with sedanol. A second radiograph is taken confirming the presence of the fractured instrument and Ms J informs the patient (though this is later disputed). An appointment is made for a week’s time. The second attempt to remove the


fractured instrument is also unsuccessful. The patient later alleges that Ms J told her that there should be no problem leaving the broken instrument in the tooth as it is sterile. The dentist places an MOD amalgam


SUMMER 2014


restoration in the tooth and tells Mr Z she will refer him to the dental hospital if there is persistent pain. A few weeks later Mr Z returns to the


surgery complaining of discomfort though not severe pain in the tooth. Ms J makes a routine, nonurgent referral which is sent by post but not received at the dental hospital. Two months on Mr Z phones the dental surgery to say he has not heard from the dental hospital. He is now suffering persistent pain in LR6 so an urgent appointment is arranged. Mr Z attends the dental hospital and


is treated by Mr K who removes the amalgam filling and locates the fractured instrument but fails to remove it. A second attempt is made one month later but also fails. The only remaining option is extraction of the tooth. Six months later Ms J receives a letter of claim from solicitors acting on behalf of Mr Z alleging clinical negligence.


ANALYSIS/OUTCOME: A report has been produced by a restorative dentist that is critical of Ms J’s treatment of the patient. MDDUS advisers and solicitors review the report along with the records. It transpires that Ms J’s record keeping


is very poor. There are no written treatment plans or references in the notes


to the radiographs taken. No note can be found to refute Mr Z’s claim that he was not informed of the instrument failure until a follow-up appointment. The expert is also critical of the dentist’s suggestion that the tooth would be okay because the instrument had been sterile. Further discussion with Ms J regarding the paucity of notes also reveals that she did not use an apex locator to estimate working length. There is no record of use of rubber dam or any instrumentation or irrigation prior to the use of the spiral filler. This casts doubt on the actual standard of root canal treatment. Considering these weaknesses a settlement is negotiated based on the cost of a single implant.


KEY POINTS • Ensure full records are kept of treatment plans and discussions with the patient.


• Be open and up-front with patients when complications occur.


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