The coronavirus pandemic has caused pressures on society and individuals unprecedented in recent times, and has brought into sharp focus the need to protect anyone who is vulnerable. There is no universally applicable definition of a 'vulnerable patient', and we can all be vulnerable at times, depending on our circumstances.
Dental professionals can be well placed to pick up on patient abuse or neglect and to take appropriate action, or help the patient to take appropriate action. In a recent letter to NHS dental practitioners, the Chief Dental Officer for England, Sara Hurley, drew attention to domestic abuse and the role of dental teams in helping victims.
One of the definitions of a profession is that it is a body of people that submits itself to a code of conduct over and above that required of the ordinary citizen by law.
In dentistry, that code of conduct is defined by the GDC, as the regulator of dentistry, and is set out in its guidance Standards for the Dental Team, as well as its accessory guidance documents. This has a whole section (Section 8) on raising concerns.
The GDC's Standards for the Dental Team places a general professional obligation on all dental professionals to put patients' safety first, to act promptly if patients are at risk, to take measures to protect them, and to take appropriate action if they have concerns about the possible abuse of children or vulnerable adults. That is in addition to the general common law duty of care owed to all patients, a breach of which can result in a negligence claim.
Dental professionals are also subject to the law - the common law that has grown up over many years as a result of decisions by the UK courts, which includes the law surrounding negligence claims, as well as statute law passed by parliament.
As a result of the Health and Social Care Act passed in 2008, all dental practices in England are required to register with the Care Quality Commission and to comply with the CQC's requirements for safeguarding patients. Similar statutory bodies and requirements exist in Wales, Scotland and Northern Ireland, and failure to comply with any of these bodies' requirements on safeguarding could result in loss of registration and resultant closure of a dental practice.
If you are concerned that a patient may be abused or neglected, your first and foremost duty is to that patient and that patient alone.
Policies and procedures
Every dental practice should have a written safeguarding policy and a safeguarding lead, and every dental professional should know who to contact for further advice and how to refer concerns to an appropriate authority, such as the local social services department.
Furthermore, every registrant should know about local procedures for the protection of children and vulnerable adults, and should follow those procedures if they suspect that a child or vulnerable adult might be at risk because of abuse or neglect.
Dental professionals may have limited training in safeguarding before qualification. The GDC recommends that registrants should take part in regular CPD to keep their knowledge up to date on safeguarding children, young people and vulnerable adults.
Members of the dental team may suspect abuse or neglect from the patient's behaviours, from their general appearance, and from their physical signs and symptoms on presentation. A considerable amount of guidance is available from the NHS and elsewhere on how to recognise abuse or neglect, and how to address it. If abuse or neglect is suspected full clinical records will, as always, be invaluable.
During the COVID-19 pandemic, particular issues may have arisen in relation to remote triaging and consultations. It is important to be alert to the risk that the more limited information available during remote consultations may make it more difficult to pick up on abuse and neglect, so a full history is important and a face-to-face consultation may be necessary to confirm or allay a concern, subject to an individual COVID-19 risk assessment of the patient.
If you are concerned that a patient may be abused or neglected, your first and foremost duty is to that patient and that patient alone. The fact that the patient's parent or carer may also be a patient is irrelevant.
Issues of confidentiality may arise, but should not get in the way of taking the action needed to protect the patient from further harm. The GDC and the law recognise that a breach of confidentiality may be justified to protect a patient from harm. However, patients with capacity to consent should generally be informed of any concern you may have and the action you propose.
In the case of minors or vulnerable adults without capacity, it would be usual to discuss your concerns with the parent/person with parental responsibility or carer, and explain what action you propose taking - unless you believe that to do so might put the patient at additional risk.
The following case study is fictitious, but based on the issues discussed above and on the types of cases members can face.
The mother of a seven-year old boy called a dental practice requesting antibiotics for her son to treat dental pain lasting several days. The dentist spoke to the mother and obtained a history, noting that the child had attended once before, some two years previously, when nothing abnormal had been detected. The dentist was concerned and asked the mother to bring in the child for an examination later that morning.
On examination the dentist found all the deciduous teeth to be carious, with the lower left second deciduous molar (LLE) grossly carious and abcessed, with an associated gingival and facial swelling. The member also noted that the child was very unkempt - he was unwashed, his hair was wild and his clothes were dirty.
The mother seemed to be totally unaware of the extent of the tooth decay and the facial swelling, and this, combined with the child's general physical appearance and withdrawn demeanor, caused the dentist to be seriously concerned that the child was neglected.
The dentist prescribed a course of antibiotics for the child and made an urgent referral for removal of the abcessed tooth under a general anaesthetic via the community dental service, advising the mother to return immediately if the facial swelling failed to resolve, or to attend A&E if it worsened in the meantime.
The dentist then discussed her concerns with the mother and explained that in the child's best interest she felt compelled to make a referral to social services to support the family. The dentist found this a very uncomfortable conversation but realised she had to have it.
The mother became upset, and she left the surgery abruptly with the child, taking the prescription with her. On leaving the practice she told he receptionist that the dentist "had no right to be poking her nose into things that did not concern her" and that she would complain if the dentist passed details of the visit to social services.
The dentist consulted with the practice safeguarding lead and they both agreed that a referral was warranted in the child's best interest, notwithstanding the mother's objection and the breach of confidentiality involved.
Social services were duly informed using the established local procedure, and it turned out they were already aware of the family's problems in coping with the care of their several children, but were unaware of the child's dental problems and neglect. Social services thanked the practice for the additional information, which helped them to take appropriate action to safeguard all the children in the family.
The dentist also made a note to follow up to check the child had attended for the emergency treatment. Restoration of oral health is integral to improving overall health for this and every child or young person, so if this was not the case, it would have to be escalated.
Tips and checklist
The following section has been kindly contributed by Adele Rees Johnson, consultant in paediatric dentistry and Safeguarding Children co-lead at Royal National ENT & Eastman Dental Hospitals, UCLH, and Hana Cho, consultant in special care dentistry, UCLH.
Here they offer a checklist of tips and reminders that dental professionals can refer to when considering potential safeguarding issues, divided into four key categories: Recognise, Respond, Report and Record.
- Identify potential signs of abuse and neglect.
- Awareness of the broad spectrum of issues - historic types emotional, physical, and sexual abuse.
- More recent challenges of bullying, female genital mutilation (FGM), grooming, radicalisation, and the overlap with domestic violence.
- Remember patients may present with more than one type of abuse
- Adverse Childhood Experiences (ACEs) and stressful childhood events.
- Familiarise yourself with terminology around safeguarding children, eg looked after child, child protection plan and interim care order.
- The patient (child or young person, or adults with care and support needs) who Was Not Brought (WNB), or repeatedly cancels (disguised non-compliance) may represent a safeguarding issue.
- It is good practice to telephone patients when they do not attend, and you should have a WNB policy.
- Importance of good governance and essential information for telephone and video consultations.
- The safeguarding/dental issue relationship, eg dental trauma and physical abuse, tooth aesthetics, and bullying where there is a dental anomaly or a severe malocclusion.
- Is presence of dental caries neglect?
- A grey area, but a definite concern is where dental disease has been identified which is impacting on the child or young person's quality of life and care organised is not accepted by the family. Also, is dental neglect part of a bigger picture of neglect or abuse?
- Be curious - questions/information are key in understanding more about the child or young person's situation, which has particular relevance to contextual safeguarding.
- Who is the child or young person accompanied by?
- Determine who has parental responsibility for the child.
- Is the child in school? Note the school name and year.
- Who does the child live with?
- Anyone else involved in their care from both medical and social perspectives?
- This includes if the family receives any support from social care eg social or support worker.
- Remember to ask about the patient's social history, including:
- Who they live with.
- Type of accommodation
- Any dependents (children or adults).
- Any carers.
- Communication needs.
- Mental capacity (undertake a mental capacity assessment as appropriate)
- Transport requirements
- When an adult at risk is identified, always check if there are children at risk. Follow safeguarding children protocols as required
Issues of confidentiality may arise, but should not get in the way of taking the action needed to protect the patient from further harm.
- Gather information and discuss/share concerns with colleagues.
- If approaching other agencies for information, it is good practice to share this with the patients and/or family.
- Assess the level of risk to the patient, and follow local safeguarding procedures.
- Refer to social care where appropriate following the safeguarding policy with contacts identified to ask if queries around the process.
- By providing any dental treatment needed (for example, for caries, trauma, infection, etc.)
- Share information with other agencies if requested - social care, police, health, etc.
- Attend regular and appropriate safeguarding training, which grows confidence in the team and increases awareness.
- When referring a family for additional support (section 17 referral), consent is needed from the family.
- If the referral is for a child or young person where they have suffered or are at risk of harm (section 47 referral), then consent does not need to be obtained.
- Have posters displaying NSPCC contact details, as these are useful for children and their families as a great resource for help and information.
- Assess and record patient's mental capacity where appropriate
- Ask for patients consent, but always remember you are likely to need to report due to your duty of care.
For domestic violence, signpost patients to local helplines and contacts. If there are children at risk of domestic violence, follow safeguarding children procedures.
- Follow local safeguarding procedures.
- Inform the local safeguarding lead.
- Ensure policy and procedures are easily accessible and kept up to date.
- Information sharing where appropriate with other health and social care professionals.
- Write detailed notes with factual information
- Use clinical photographs, diagrams, and/or drawings as needed with the patient's consent
- Local safeguarding lead to ensure safeguarding is on the regular meeting agenda
- Record kept of safeguarding concerns and referrals.