Missed or delayed diagnoses feature prominently in complaints and claims, and although the example discussed in this article is fictitious, it is based on the types of cases commonly seen by the DDU.
Situations like these - and particularly those involving conditions such as oral cancer, where there can be a high risk of harm to the patient if not dealt with promptly - highlight the importance of following guidelines and procedures around processes such as referrals, record keeping and patient reviews.
Properly followed and undertaken, these can make the difference between a contented, well cared-for patient and a complaint or claim being made against a dental professional.
A member contacted the DDU advice line when a non-healing lesion was later identified as a squamous cell carcinoma. A number of difficulties were encountered from the first presentation of the lesion. The patient's solicitor alleged the member had failed to act appropriately, affecting the outcome for the patient.
The patient originally presented with an ulcer on the lateral border of the tongue, adjacent to a fractured tooth. The member diagnosed the likely cause of the lesion as traumatic ulceration, restored the tooth and asked the patient to return for a review appointment.
The patient returned after one week but the lesion had failed to heal. The member smoothed the tooth further, suspecting it was still a traumatic ulcer being exacerbated by a less than ideal restoration, and asked the patient to return for a further review appointment. However, this was not organised and the patient didn't return until six months later for a routine examination.
At this appointment the lesion was still present, so the member referred the patient to the local dental hospital for specialist advice under the two week rule for suspected oral cancer. The patient did not receive an appointment from the dental hospital and contacted the member to chase it up. The member organised for an urgent appointment in the next few days, and ultimately the patient was diagnosed with grade III squamous cell carcinoma.
The patient brought a legal claim for clinical negligence in which it was alleged that at the time of the review appointment, where the lesion had failed to heal, the member should have sought specialist advice. It was also alleged that the member had failed to take reasonable care to make sure the patient was followed-up appropriately at both the review stage and after the first referral was made.
This is obviously a very difficult situation to be in as ulcers are seen every day in practice. No-one sets out with the intention of either missing a suspicious lesion, not completing the clinical records fully, or failing to arrange appropriate follow-up care. However, deficiencies in any of these areas may lead to criticism during legal proceedings.
In this scenario the dentist took the correct action for the presenting ulceration and reviewed it appropriately. It could be argued that when the lesion failed to heal, but a further traumatic element was suspected, the member took the proper action by making further changes to the restoration and suggesting another review appointment was organised.
However, the member failed to record that an additional review appointment was recommended in the clinical notes. There was no record of a request for the appointment to be made by the member to the reception staff, or an appointment being organised by the reception team and subsequently cancelled/rearranged.
To add to the criticisms that were raised above, the member was also criticised for failing to follow up the referral appropriately because it was made under the two week rule for suspected oral cancer. It was suggested that the member should have followed up the status of the referral so that if it became apparent an error had occurred in the process, it could have been rectified and the patient seen without undue delay.
- Carefully record all details of suspicious lesions.
- Photographs can be a useful tool and form part of the clinical records. They can also be helpful to the accepting specialist - but make sure you follow your confidentiality protocol.
- Document any advice you give to patients, including returning to a review appointment.
- Make sure reception staff document their attempt to make appointments for a patient, eg if a patient refuses to make a review appointment, or cancels.
- Have follow-up procedures in place to make sure patients are not lost in the system. It can be difficult in a busy practice but can reduce the potential for scenarios of this type to occur.
- If in doubt, or if you suspect oral cancer, follow the referral guidance for your local area and follow up the referral. Referrals for potentially serious conditions warrant extra care and checks to make sure they have been processed.
- If you recommend a referral and the patient is aware that you suspect a potential carcinoma, but they refuse permission for you to refer/share their information with a third party, make sure the discussion is carefully documented in the clinical records. We are happy to advise members who face these situations.
- NICE's guidance Suspected cancer: recognition and referral offers specific advice on oral cancer.
- The BDA and Cancer Research UK have produced an oral cancer recognition toolkit, which contains a helpful referral decision guide.