A patient attended for an initial consultation last week and on examination I noted suspicious lesions on her tongue. But to my despair, she adamantly refused to consent to a referral. The patient is an ex-smoker and very anxious because her friend was diagnosed with oral cancer and had to have part of their tongue removed. I have another opportunity tomorrow when she returns for a scale and polish. What do I need to do to convince her?

The patient is probably expecting you to broach the subject again and so this is already likely to be a difficult encounter for her.

Improve your chances by approaching the conversation with the consideration you'd like to be shown to one of your friends or a family member in similar circumstances. Consider GDC guidance; be aware of your tone of voice and body language, avoid using jargon, and give the patient time to take in what you're saying. It's also advisable to have a nurse present who can provide reassurance and support.

Explain why it is important that you make a referral so the lesions on her tongue can be investigated and check she understands the potential seriousness of the situation. You could also provide written information or follow up your discussion in writing so she can think about it in her own time. In addition, you could explain that she can talk through options with the specialist if she agrees to a referral, and that she's under no obligation to have a particular treatment.  

If you can't persuade her to agree to a more detailed investigation, you must respect her wishes. Even then it's still important to leave the door open, so make it clear she can change her mind at any time.

Make sure you keep a record of the consultation and the outcome of your discussion with the patient. This will be a useful reminder if she returns at a later date and could be important if you are later asked to justify your approach.

I've just seen a patient for a check-up who is usually seen by one of my practice associates. I'm concerned because she has caries in several teeth which have been marked as 'watch' in the records and the radiographs also show lesions. I have advised the patient to make an appointment with my colleague but I don't want to undermine him, and so I've not yet told the patient about my findings. What's my next move?

The first job is to speak to you colleague about your findings and treatment recommendations. Talking to him in the first instance may give you an opportunity to discuss his approach and rationale. After all, he has more experience with this particular patient and may be able to tell you about her wishes and priorities which put his actions in context. Even if he allays your fears, it's still a good idea to put things in writing as well.

If the response to your approach is not positive and you're concerned about the patient's overall care, you would be justified in advising the patient directly. It would be advisable to warn your colleague of this in advance. 

When talking to the patient, avoid direct criticism of your colleague. While you may have concerns about her treatment, you're not in a position to pass comment or judge whether he is competent to practise. Other explanations could exist for the patient's oral health problems - she may have refused to accept his oral health advice. If the patient wants to make a complaint, you can explain your practice complaints procedure.

If you believe that the dentist's actions raise serious questions about his treatment of other patients, you will need to consider what to do next. Even if you are understandably reluctant to report a fellow professional, the GDC makes it clear that 'the duty to raise concerns overrides any personal and professional loyalties'.

If possible, you should first raise your concerns with your employer or manager, following your practice's procedures. If you can't, consider approaching someone from the Local Dental Committee (LDC). If you need to escalate matters you can consider raising your concerns with the Local Area Team or local Health Board. The most serious concerns might need to be reported to the Care Quality Commission or its equivalent, or even the GDC.  However, in circumstances like this it's likely that the concerns can be addressed at a local level without the need to escalate them. Make sure you keep a record of your concerns and the steps you've taken. 

I have received several requests for copies of a patient's records from her son and husband. The patient is elderly and her family insists she has dementia. Her GP says this is not the case and I have previously found her to be quite lucid. What can I do to resolve the situation?

Before a competent patient's record can be disclosed, you must get their expressed consent, preferably in writing. We recommend writing directly to the patient to explain the request from her husband and son and seek her consent.

If, as you believe, the patient has capacity, her reply may help to confirm this. If you are unsure, it's important not to make any assumptions based on what you have heard and to make your own assessment in person. The Mental Capacity Act 2005 (MCA) sets out the following two-stage test:

1. Does the person have an impairment of the mind or brain or is there some sort of disturbance affecting the way their mind or brain works, whether temporary or permanent?
2. If so, does that impairment or disturbance mean the person is unable to make the decision in question at the time it needs to be made?

In determining whether she is able to make this decision, the MCA Code of Practice says you should consider whether she is able to:

• understand what decision she needs to make and why
• understand the information relevant to the decision
• understand, retain, use and weigh up the information relevant to this decision
• communicate her decision (by talking, using sign language or any other means).

Bear in mind that assessing capacity is an extremely complex and sensitive legal area. If you're in any doubt, seek specific legal advice.

If you're convinced the patient does not have capacity in this instance, you can disclose her records as long as you believe it's in her best interest.

Whatever your eventual decision, make sure you document your decision-making in case you are later asked to justify your actions.