HPARB Decision Holds Valuable Lessons for Dentists

HPARB Decision Holds Valuable Lessons for Dentists

A recent decision of the Health Professions Appeal and Review Board (the “Board”) confirming a decision by the Inquiries, Complaints and Reports Committee (the “Committee”) of the Royal College of Dental Surgeons of Ontario (the “College”) provides valuable lessons for all dentists.

After investigating a complaint regarding a dentist’s treatment of an elderly woman, the Committee decided not only to advise the dentist and require him to complete a specified continuing education and remediation program (a “SCERP”), they also decided to issue a caution to the dentist as well.

Background

The complaint arose from the treatment of an elderly woman who fell, hit her head and knocked out some of her teeth. With the assistance of her daughter, the elderly woman was seen by a general dentist on an emergency basis that same day.

The dentist, his office staff, and the daughter had highly divergent recollections as to what transpired during the visit.

The daughter recalled waiting for over an hour in the waiting room before seeing the dentist, only to be with the dentist for less than five minutes. The daughter also recalled that the dentist did not assess or examine her mother or provide any diagnosis of any kind. Nor did he take any x-rays. The dentist had simply briefly peered into her mother’s mouth. He then wrote a referral to a dental surgeon, advising that her mother would have to wait 2-3 weeks for an appointment. The dentist did not advise them to go to an emergency room for the mother’s head trauma. If he did, the daughter said she would have taken her mother.

The dentist recalled starting the examination at 1:05 pm and that the patient checked out of his clinic at 1:38 pm (according to the office computer tracking system). He advised that he reviewed the medical and dental history of the patient, followed by both an extra-oral and intra-oral examination and that both he and his assistant attempted to take x-rays, but the patient could not tolerate the x-ray sensors. He recalled diagnosing the patient with “severe facial and head trauma” and advised her to go to the nearest hospital and he explained the possible risks of the trauma. He also wrote a referral to a dental surgeon to have two teeth extracted. He estimated he spent between 15-20 minutes with the patient.

The dental assistant explained that she tried approximately 3-5 times to take x-rays but was unsuccessful. She recalled the dentist advising the patient to go to the nearest emergency room but does not recall whether he warned her of potential internal bleeding or brain damage.

The office receptionist explained that the computer system confirmed that the patient was seated in the examination room by 1:20 pm and the invoice was paid at 1:32 pm.

Committee and Board Decisions

The Committee concluded that the dentist failed to diagnose and treat the patient appropriately, including that he failed to triage the patient and he provided no rationale for referring the patient to an oral surgeon for the extraction of two of her teeth without undertaking a comprehensive examination with radiographs. Also, the Committee noted that the computer system indicated that the patient was in the room for no more than twelve minutes and that it was not possible for the dentist to have undertaken an appropriately thorough examination of the patient and arrive at a diagnosis in that time. The Committee was also of the opinion that the dentist was not “forthright in his response to the complaint”.

The Committee decided to advise the dentist that when a patient presents with head and neck trauma that is of great concern, he should make a formal referral to a hospital and not just verbally advise the patient to attend for medical attention. The Committee also decided to direct the dentist to complete a SCERP in emergency diagnosis and treatment, including appropriate pain relief, and have his practice monitored by the College. In addition, the Committee required the dentist to appear before the Committee to be cautioned that he must be honest and forthright in all of his communications with the College and must represent the treatment he provided accurately and in a manner supported by his clinical records.

The dentist requested a review before the Board. Specifically, the dentist argued, among other things, that the caution was “unduly harsh”.

Two members of the three-member panel of the Board confirmed the Committee’s decision. The two members found the Committee’s disposition to be reasonable as a whole, as it made the dentist aware of the Committee’s specific concerns and serves to protect the public interest by guiding the dentist’s practice in the future.

One member agreed that the Committee’s decision to advise the dentist and require him to complete a SCERP was reasonable but disagreed with her colleagues’ decision to confirm the decision to issue a caution.  In her view, this decision was unreasonable. The Committee’s rationale for requiring the dentist to undertake a SCERP to protect the public was clear, however, the Committee did not explain how cautioning the dentist on his communication enhanced the ability of the public to make informed decisions or how it protected the public. The dissenting member also concluded that the Committee overstepped its limited ability to weigh facts in making wide-ranging credibility findings that the dentist was dishonest.

Takeaway

This case provides guidance to dentists when a patient presents head and neck trauma, including the importance of conducting a thorough examination and making a formal referral to a hospital regarding the trauma. It also confirms the importance of being forthright and honest in all communications with the College.

If you have any questions about this particular case or health professionals regulatory proceedings in general please contact us.

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