A case of neglect?

Earlier this week, a mother brought her three-year-old son in for emergency dental treatment. He was in pain, his teeth were in a very poor state, and he was very distressed. His mother was shocked when I explained the extent of the decay and the treatment needed, but she agreed an appointment date and seemed committed to following my dietary and oral health advice. Now a health visitor has requested details of my diagnosis and treatment plan to support a safeguarding referral to children's services because she is concerned the child is being neglected. How should I respond?

While the health visitor may view this as a potential case of neglect, it may not be that straightforward. You need to carefully consider what action you should take and respond sensitively, putting the interests of the patient first at all times.

I suggest you should consider the potential impact of untreated dental disease on the patient's health and quality of life and the risk that his poor dental health could be a symptom of general neglect and mistreatment. However, if the mother attends with the child for treatment as arranged this may indicate she has accepted your advice and is determined to do what is necessary to remedy the situation. Passing on confidential information in these circumstances could alienate her and jeopardise the child's chance of receiving the treatment he needs.

Child protection and the dental team has useful guidance on how to recognise and assess possible neglect. It suggests the factors you should take into account and causes of particular concern, such as irregular attendance and failure to complete planned treatment. You could also seek specialist advice from an experienced colleague, a paediatric dentist or the person responsible at your place of work for the protection of children and vulnerable adults.

If you remain concerned the child is at risk of abuse or neglect, you have a duty to follow local procedures for notifying the child protection team in partnership with the health visitor. However, you should still inform the mother that you intend to disclose information to a third party, unless this would potentially be counter-productive and put the child at additional risk. The GDC ordinarily expects you to inform a patient (or the patient's parent in the case of minors) if you intend breaching confidentiality by passing information to a third party without their consent.

Before making a final decision, you could talk to the health visitor and find out whether she is willing to wait until after the child's next appointment. If the mother does not return, you may then have good reason to believe the child is at risk, in which case you would be justified in sharing the information with the health visitor.

Whether or not you decide to disclose the information, you must be able to justify your decision if called upon to do so, and you should therefore keep a careful record of your concerns and your decision-making process.

Photo fallout

I am a dental hygienist. The other week a colleague who has just joined my practice asked to be my friend on Facebook. I accepted his request but now he has told the practice owner that the photos which show me drinking alcohol were inappropriate and could damage the practice's reputation. I can't believe he is trying to undermine me like this but I'm also worried about the implications for my career. What should I do?

It is unfortunate that your colleague is making life uncomfortable although it might be better to let others make up their mind about his behaviour.

From your perspective it's probably more important to consider whether the images could damage public confidence in you or the dental profession. The GDC's guidance on social media warns: 'As a registrant you have a responsibility to behave professionally and responsibly both online and offline. Your online image can impact on your professional life and you should not post any information, including photographs and videos, which can bring the profession into disrepute.'

A few pictures showing a party or celebration are unlikely to do any harm but if you feel embarrassed at the prospect of a patient or the practice owner seeing a particular image it may be better to take it down or ask the person who uploaded it to do so.

However, bear in mind that everything you post on social media is in the public domain, and no matter how many security options you use, images can be accessed by others in your network and may be distributed without your knowledge.

Wrong tooth extracted

I made an awful mistake and extracted the wrong tooth after misreading instructions from the patient's orthodontist. I only realised what had happened after the patient and her mother had left the practice when I noticed a discrepancy between the dental chart and the orthodontist's letter. I feel terrible, but what should I do?

Now you have realised your error, you must act straight away.

If possible, call the orthodontist first and ask him about the implications of the error for the patient's orthodontic treatment. That way you will be better informed and able to answer questions. You might also consider asking him whether he can review the patient as an emergency to see what needs to be done to remedy the situation.

Whether or not you are able to contact the orthodontist, you should not delay informing the patient and her mother. The GDC recently joined forces with seven other healthcare regulators to remind dental professionals that they have an ethical duty of candour in this situation. In practice, this means telling the patient (or, where appropriate, the patient's advocate, carer or family) when something has gone wrong; explain the short- and long-term effects of what has happened; say sorry; and offer an appropriate remedy or support to put matters right (if possible). Bear in mind that an apology, offer of treatment or other redress does not itself amount to an admission of negligence so there is no reason to avoid saying sorry for something that has happened to the patient.

Since April 2015, CQC-registered dental practices in England have also been subject to a statutory duty of candour, which requires that they inform the patient, or their representative, as soon as possible and in person when a notifiable patient safety incident occurs. A notifiable patient safety incident has a specific statutory meaning: it applies to incidents where something unintended or unexpected has occurred in the care of a patient resulting in death or serious injury and includes changes to the structure of the body (for example, erroneous extraction). Dental professionals must also inform the CQC about the incident without delay.

As well as being open and honest with your patient, the GDC expects you to reflect on mistakes and to learn lessons to prevent history repeating itself (remediation). For example, you could carry out a significant event audit within the practice to see if the incident was entirely human error or if systems could also be improved. It's worth telling the patient about any improvements you have made to your practice as a result. It might help them to know that their experience has not been in vain.

Finally, it's also important to notify the DDU, because this kind of incident could easily result in a claim. The DDU has seen an increasing number of erroneous extraction cases in recent years and if the worst does happen, it will help if we have a statement from you while the incident is fresh in your mind.