What is Expected?
According to the General Dental Council, every healthcare professional must be open and honest with patients when a treatment does not go to plan and this leads to, or may lead to, harm or further problems occurring in the future. This means that healthcare professionals must;-
- Inform the patient (or the patient’s representative, carer or family member if appropriate) when something has gone wrong, being clear and transparent about the matter.
- Apologise to the patient regarding the mistake or what went wrong and explain its reasoning, avoiding talking around the subject. An apology is not an admission of liability but simply good practice. This is set out in legislation in parts of the United Kingdom and in addition, the NHS Litigation Authority also advises that saying sorry is the right thing to do.
- The clinician should offer an appropriate solution to the problem where practical and should advise the patient on their options.
- The clinician should also explain fully to the patient the short and long term effects of what has happened and what this means for their future prospects regarding the tooth/teeth or other tissues affected.
All healthcare professionals must be open and honest with their colleagues and employers as well as their patients. If relevant, they must also inform any organisations such as local area teams and must be open and honest with their regulators such as Care Quality Commission, raising concerns where appropriate. They must support and encourage each other to be open and honest and not stop someone from raising concerns.
The issues surrounding patient safety, quality of care and leadership are always at the forefront especially since Robert Francis’s report into the failings at the Mid Staffordshire Foundation Trust. The GDC was one of eight organisations to sign a joint statement in October 2014 which outlined the professional duty of candour. Healthcare organisations including dental practices are expected to demonstrate a duty of candour by being open and honest with patients when something goes wrong with the treatment or care being provided. This is also in line with Principle 8 of the Standards set by the General Dental Council which relates to raising concerns if patients are at risk.
Where is Candour important?
Recently a colleague of mine was carrying out a particularly difficult root canal treatment on an upper molar when the hand file fractured and was retained deep in the root. He followed good practice guidelines and informed the patient and managed the case accordingly. We both discussed the importance of telling the patient not only as a risk factor before the treatment but also if something went wrong during the treatment. It is best to be honest from the outset and so long as the risk was explained at the outset and the patient had understood then there should not be any challenges. It is equally important not to try to steer away from the issue by using jargon such as ‘the instrument separated’ instead of informing the patient that the instrument has broken. One can understand the temptation of using the former as the latter implies the clinician is at fault. In reality, it is an acceptable risk and not malpractice unless of course a single use instrument has been re-used.
Another common incident which can occur during routine extractions is fracture and retention of the root. Again informed consent would be in place however the patient must always be informed of the fracture and its subsequent management. The patient records must demonstrate the details given to the patient after the event including pre-extraction radiographs and appropriate assessment which are part of the records.
Mishaps occur in all areas of healthcare so systems to help prevention or reduction of incidents are very important. As an example, orthodontic treatment often requires space creation by extraction of premolar teeth. Understandably the young patient and accompanying parent are extremely anxious in most cases and the dental team needs to stay calm and focused and not let the anxiety influence their treatment. The tooth or teeth needing to be extracted should not only have associated radiographs and assessment but the clinician and nurse should both identify and match the tooth to that requested by the orthodontist. There are several recorded cases of the wrong tooth being extracted. In cases where the serious error of taking a radiograph on the wrong side again may be prevented by rehearsed communication with support staff in double checking specific views. Regulations not only require that the patient is informed but that these records are kept in the radiation protection file for fifty years.
How to follow your Duty of Candour
Maintaining an open and honest culture in the workplace should be standard and adopted by all team members and also in the absence of a complaint. It is important that patients have all the information regarding the treatment including longevity, complications and consequences and that they have the capacity to understand this information. A full range of options should be offered and patients should have time to assimilate and not be rushed into decision making which must be their own.
Dental practices should have policies in place that are updated annually and which should clearly demonstrate a culture of candour and openness. The Care Quality Commission will expect dental practices to have a Duty of Candour Statement which all staff members have understood and adopted. This requirement comes under Health & Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20: Duty of Candour.