rimmer - General Dental Council

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					                                    GENERAL DENTAL COUNCIL
                          PROFESSIONAL CONDUCT COMMITTEE
                                            July 2010
                                      Rimmer, Barry Anthony
                                      Registration No: 61491

Charge
Barry Anthony Rimmer registered as of 19 Wigan Road, Ashton in Makerfield, Lancs, WN4 9AR;
BDS Lpool 1986, was summoned to appear before the Professional Conduct Committee on 13
July 2010 for inquiry into the following charge:
Amended with the agreement of both parties

That, being a registered dentist:

1.     At all material times you were the owner and principal dentist at a dental practice at 19
       Wigan Road, Ashton in Makerfield, Wigan, WN4 9AR.

2.     During the period 2003 to 2006, you provided dental treatment to children under sedation.
       You provided treatment under sedation to Patients 1 to 15 (who are identified in the first
       Schedule hereto).

3.     In providing the treatment described at paragraph 2 above, you did not comply with then
       current guidelines applicable to the sedation of minor patients in that: -

       (a)     child patients you treated under sedation were routinely sedated intravenously with
               multiple sedative/anaesthetic agents;

       (b)     the anesthetic agents administered to minor patients at the Practice included
               general anaesthetic agents and potent opiods which ought to have been
               administered to minor patients either by an anaesthetist with appropriate post
               graduate training or in a hospital setting.

4.     Prior to providing the treatment referred to at paragraph 2 above, neither you nor the
       medical practitioner you employed to conduct the sedation: -

       (a)     took a medical history from the parents or guardians of the patients;

       (b)     provided the parents or guardians of the patient with an explanation of alternative
               methods of pain and anxiety control, in particular inhalation sedation (the medical
               history was taken by a dental nurse);

       (c)     provide the parents or guardians of the patient with an explanation that intravenous
               conscious sedation with multiple agents was not the standard method providing
               sedation to children.

5.     In the circumstances described at paragraph 4(b) and/or (c) above, you carried out
       treatment under conscious sedation without the informed consent of the parents or
       guardians of the patients.

6.     You failed to ensure that patients 1-15 were adequately monitored, in that: -



RIMMER, B A             Professional Conduct Committee – July 2010              Page -1/8-
       (a)     in the cases of Patients 2, 4 and 13 pulse oximetry and heart rate were not
               measured or recorded;

       (b)     in the cases of Patient 5, 6, 7, 10, 11 and 15 pulse oximetry and heart rate were
               measured and recorded on one occasion;

       (c)     in the case of Patient 9 oxygen saturation was measured and recorded on two
               occasions but the pulse was not measured and recorded;

       (d)     in the cases of Patients 1, 3 and 8 pulse oximetry and heart rate were measured
               and recorded on two occasions.

7.     You failed to ensure that adequate sedation records were maintained in respect of patients
       1 to 15.

And that, in relation to the facts alleged, your fitness to practice as a dentist is impaired by reason
of misconduct.

Findings of fact

Mr Rimmer,

The Committee has taken into account all the evidence presented to it. It has accepted the advice
of the Legal Adviser. In accordance with that advice it has considered each head of charge
separately.

I will now announce the Committee‟s findings in relation to each head of charge:


1.     Admitted and Proved.


2.     Proved as amended to read: „During the period 2003 to 2006, you provided dental
treatment to children under sedation. You provided treatment under sedation to Patients 1 to 15
(who are identified in the first Schedule hereto).‟

Mr Bradly, on behalf of the GDC, presented this head of charge on the basis that the patients cited
in the first schedule are typical examples of children to whom you provided dental treatment under
sedation. However, the Committee finds that the evidence concerning how the samples were
chosen does not show that this small sample was representative of your practice of sedation.

The Committee therefore amended this head of charge to delete „By way of examples of this
practice‟.


3.(a) Not proved.

The Committee had regard to all the published recommendations and guidelines that were put
before it, but considers that the appropriate guidelines applicable at the time for dentists were
“Maintaining Standards” and “Standards for Dental Professionals” which replaced Maintaining




RIMMER, B A             Professional Conduct Committee – July 2010                Page -2/8-
Standards in May 2005. These were and are the regulatory guidelines with which dentists must
comply.

In light of the amendment it made to head of charge 2, the Committee found there was insufficient
evidence upon which it could make a finding of a routine of treating your child patients with
multiple sedative/anaesthetic agents.

In particular the Committee noted that not all children were treated with the same intravenous drug
or combination of drugs, that some children received other kinds of sedation, and some were
referred elsewhere.


3.(b) Not proved.

The Committee was satisfied that the anaesthetic agents administered to minor patients at the
Practice included general anaesthetic agents and potent opioids.

In the Committee‟s opinion, Dr van Vuuren had the appropriate training and experience in dental
sedation. The Committee did not hear any evidence suggesting that the Practice was an
inappropriate setting for the provision of such sedation.


4.(a) Not proved

Medical histories were taken on your behalf by your qualified dental nurse, Alex Bradley. The
Committee accepts her evidence and your own evidence that you checked and updated the
medical history when you saw each patient.


4.(b) Not proved

The Committee accepts your evidence that you, or the other dentists in the practice, discussed the
options for treatment with the parents or guardians of the patients. This was confirmed by Ms
Bradley, who told the Committee that at an assessment appointment she would confirm with
patients and their parents the treatment that had been offered to them.


4.(c) Proved

You acknowledged in evidence that you did not give an explanation that intravenous conscious
sedation with multiple agents was not the standard method of providing sedation to children.


5. Proved

Despite the fact that you said in evidence that you were aware that multiple agent sedation was a
contentious issue at the relevant time, you did not explain that to parents and guardians.
Therefore, there was no informed consent.


6.(a), (b) and (c) Not proved


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Mr Bradly conceded that there was insufficient evidence to support this head of charge.

7.     Proved as amended to read: „You failed to ensure that adequate sedation records were
maintained in respect of patients 1 to 15.‟ The Committee has added the word „sedation‟ and
deleted „in the respects identified in the second schedule hereto‟.

A qualified admission was made by you that you failed to take reasonable steps to ensure that
adequate sedation records were maintained in respect of patients 1 to 15.

The Committee finds that the guidance referred to above makes it an absolute obligation on the
dental practitioner providing the oral health care to ensure that records relating to that care are
clear and accurate.

Mr Bradly on behalf of the GDC and Mr Cridland on your behalf asked the Committee to consider
this head of charge, not by reference to each individual allegation in the second schedule, but by
reference to the themes appearing in that schedule. The Committee has considered the head of
charge in this way, and, having regard to the guidelines as they were at the relevant time, has
found as follows:

-          There was inadequate identification of the drugs administered (including in one patient,
local anaesthetic);
-          Recovery records were not completed;
-          There was a lack of completed timescales.

The Committee found there was evidence of one instance of an absence of a dated consent form
and one instance of the absence of a signed medical history form, but did not consider either
amounted to a theme.

We move to Stage Two.


Determination
Mr Rimmer,

The Committee has heard from Mr Bradly on behalf of the General Dental Council (GDC) and Mr
Cridland on your behalf. The Committee has heard and accepted the advice of the Legal Adviser.

Between January 2003 and August 2006 you provided treatment under sedation to Patients 1 to
15 at specially arranged sessions for child patients who it was thought would not co-operate with
treatment under local anaesthesia alone. At these sessions you employed a registered medical
practitioner Dr van Vuuren to provide intravenous conscious sedation. You were aware that he
frequently used multiple sedation/anaesthetic agents. The provision of intravenous conscious
sedation with the use of multiple agents was not the standard method of providing sedation to
children and you were aware that it was at that time a contentious technique.

You told the Committee that you did not explain the contentious nature of this form of conscious
sedation to the parents or guardians of your child patients. The Committee therefore determined
that there was no informed consent given for this type of sedation. The Committee also found that
the records relating to the conscious sedation of these patients were inadequate in that drugs were



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not clearly identified, recovery records were not complete and there was a lack of completed
timescales.

On 26th November 2009, you appeared before the Professional Conduct Committee in relation to a
different matter, regarding your treatment of one patient in 1997 to 1998 and 2000 to 2002. It was
found that there was no informed consent. That Committee made a finding of impairment by
reason of deficient professional performance. You were reprimanded and recommendations were
made.

Whilst that complaint was being investigated, the Ashton, Leigh and Wigan Primary Care Trust
complained of the matters dealt with by this Committee. The Committee has been told that the
hearings were separated for administrative reasons and that this is not an instance of subsequent
infraction.

Misconduct

In deciding whether the findings against you amount to misconduct, the Committee had regard to
the test as laid down in Roylance v GMC. It considered first the failure to obtain informed consent.
In light of all the evidence presented, the Committee was uncertain whether other practitioners in
the field of conscious sedation would, at the relevant time, have warned parents and guardians
that multi-drug intravenous sedation was not a standard method of treatment for children. It
received no evidence that a failure to do so would be considered deplorable by fellow
professionals. Therefore, the Committee might not have held that this alone amounted to
misconduct.

The Committee saw evidence that you took steps to educate yourself on conscious sedation and
placed reliance for the provision of sedation on Dr van Vuuren, who had additional training in
dental sedation. However, the Committee has held that a dentist has an absolute duty to maintain
proper records and that you wholly failed to check or even look at the sedation records compiled
by Dr van Vuuren. These records were in fact woefully inadequate and fellow professionals would
have regarded them as deplorable. The Committee is therefore satisfied that your failings taken
together amounted to misconduct.

The standards applicable for dentists during this period were “Maintaining Standards” until May
2005 and “Standards for Dental Professionals” since then. The Annex to Standards for Dental
Professionals „Statement on providing dental treatment under general anaesthesia and conscious
sedation‟ specifically says: ‘We also support the guidance set out in ‘Conscious sedation in the
provision of dental care’ (November 2003)‟.

The particular sections of these that are appropriate to this case are:

Maintaining Standards:
2.4 Protecting Patients
3.1 Acting in The Best Interest of Patients
3.2 Providing a High Standard of Care
3.7 Consent
4.3 Contemporaneous Records
4.6 Misleading Claims in relation to the following quote: „A dentist should take particular care when
employing techniques and forms of therapy which are unproven‟,
4.12 Assessment, Consent and Instructions



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4.13 Record Keeping, in relation to the following quote: „An explanation of the conscious sedation
technique proposed and of appropriate alternative methods of pain and anxiety control must be
given‟.
6.1 Professional Responsibility

Standards for Dental Professionals:
1.4, 2.2, 2.4, 5.2 and 5.3.

Additionally, for those providing dental sedation, a number of relevant guidance documents and
reports were available during the period and the Committee noted in particular the following:

   A Conscious Decision (2000)
   UK National Clinical Guidelines in Paediatric Dentistry (2002)
   Conscious Sedation in the Provision of Dental Care (SDAC 2003)
   Scottish Intercollegiate Guidelines Network 58 (2004)
   Conscious Sedation in Dentistry (SDCEP Guidance May 2006)

Impairment of Fitness to Practise

Informed consent and adequate record keeping are basic and fundamental requirements of
dentistry. They arise in all contexts of practice. The PCC finding in 2009 also involved a lack of
informed consent. The principle of patient autonomy was infringed by the failure to obtain informed
consent. There are potential risks of inadequate record keeping, including the risk of serious harm
to patients should there be an adverse reaction or untoward event during or after treatment under
conscious sedation. Another dentist or doctor trying to help the patient in these circumstances
might be seriously hindered by not knowing what drugs have been administered, in what quantities
or over what period of time. You showed a lack of responsibility for, and a failure in duty of care to
your patients.

The Committee considered the bundle of Continuing Professional Development documents you
provided. In the period since deficiencies were first identified by the PCT in December 2006 you
have undertaken a large number of CPD hours. However, there appears to the Committee to be a
pattern in your behaviour of pursuing an interest in types of treatment and dental procedures that
are not categorised as having a high level of evidence base. The Committee also noted that the
previous PCC in November 2009 suggested to you that „your future CPD would be better focused
by contact with your local Deanery who may assist you by advising you to develop an appropriate
and well-grounded Personal Development Plan (PDP) that continues to address the matters raised
in this determination.‟ This Committee noted that you did not meet with the Deanery until June
2010 and a PDP has not yet begun to be developed.

The Committee also noted that you are continuing to provide sedation to your adult patients.
However, it was not presented with any evidence in relation to sedation records, which could have
provided it with information about your own commitment to good record keeping.

The Committee is therefore not satisfied that the two issues of the lack of informed consent and
poor record keeping have been addressed and remedied.

The Committee noted your numerous supportive references and the evidence of your testimonial
witnesses. It has heard that you no longer practise alternative sedation techniques or child
intravenous sedation. These matters are now four years old or more, and you have not performed



RIMMER, B A             Professional Conduct Committee – July 2010               Page -6/8-
treatment on children under intravenous sedation since August of 2006. Mr Cridland submitted that
there is thus is no risk of repetition.

However, the Committee is concerned that you were, and remain, a risk to patients. Problems
could have occurred during or immediately following the sedation treatments and the records
would not have been of assistance. Your failings brought the profession into disrepute. Record
keeping is a basic requirement of all dentistry and the Committee notes that it was not until the
eighth day of this hearing that you accepted your responsibility for the inadequacy of the records
compiled by Dr van Vuuren.

The Committee has concluded that you have a lack of insight into the potential significance of your
failings. It was left unconvinced that you realise the gravity of this situation and therefore finds your
fitness to practise to be still impaired by reason of your misconduct.

Sanction

In deciding upon sanction, the Committee has been mindful of its obligation to protect patients,
maintain public confidence in the dental profession and to act in the wider public interest. The
Committee has also borne in mind the principle of proportionality. The Committee has recognised
that the prime purpose of sanctions is not punitive, although some sanctions may have that effect.

The Committee first considered whether to conclude this case with or without a reprimand. The
Committee is concerned that you do not appear to have reflected upon your professional practice.
Your failure to act promptly on the recommendations of the previous PCC hearing and the
seriousness of your misconduct in this case led the Committee to conclude that your failures could
not be met by concluding the case, with or without a reprimand.

The Committee next considered conditions upon your registration, and bore in mind that conditions
must be measurable, workable, appropriate and proportionate. It decided that the following
conditions would be appropriate.

The conditions will be imposed for a period of 12 months. This appears to the Committee to be an
appropriate period to allow you to demonstrate a commitment to personal development.

The conditions will appear on the GDC website as follows:

1.     He must notify the GDC promptly of any professional appointment he accepts and provide
the contact details of his employer and PCT on whose Dental Performers List he is included.

2.      He must advise the Council of the full contact details of a professional colleague who is
involved in the delivery of postgraduate education of a non-specialised nature, agreed with the
GDC, who would act as his adviser and would be prepared to assist him to formulate a Personal
Development Plan, specifically designed to address the deficiencies in his practice of dentistry;
keep his conditions under review; and to report every three months to the Council on his fitness to
practise. He must advise the Council of the name of any new professional colleague if the current
nominated professional colleague changes, within 2 weeks of the change.

3.      He must forward a copy of his Personal Development Plan to the GDC within three months
of the date on which these conditions become effective.




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4.     He must meet with the Postgraduate Dental Dean (or a nominated deputy), on a regular
basis to discuss his progress towards achieving the aims set out in his Personal Development
Plan. The frequency of his meetings is to be set by the Postgraduate Dean.

5.    He must allow the GDC to exchange information about his progress towards achieving the
aims set out in his Personal Development Plan with the Postgraduate Dental Dean (or a
nominated deputy), and his adviser referred to at condition 2 above.

6.     He must refrain from treating patients under 12 years of age under conscious sedation,
except when using inhalation sedation.

7.      He must inform the GDC of any formal disciplinary proceedings taken against him, from the
date of this determination.

 8.     Within one week of the date of this determination he must inform the following parties that
his registration is subject to the conditions, listed at 1 to 7, above:

              Any organisation or person employing or contracting with him to undertake dental
work
              Any locum agency or out-of-hours service he is registered with or applies to be
registered with (at the time of application)
              Any prospective employer (at the time of application)
              The PCT in whose Dental Performers List he is included, or seeking inclusion (at
the time of application).

9.      He must inform the Regional Director of Public Health that he has been subject to
investigation by the GDC and of the conditions, 1 to 8 above.

10. He must permit the GDC to disclose the above conditions, 1 to 9, to any person requesting
information about his registration status.

The Committee is satisfied that the imposition of the above conditions is a sufficient sanction to
protect the public interest. The Committee finds that it would be disproportionate to impose a
period of suspension.

The effect of this direction is that, unless you exercise your right of appeal, these conditions will be
imposed on your registration for a period of 12 months, 28 days from today. Before the end of the
12 months period there will be a review hearing, at which the Committee will expect to see
evidence of your personal development, which must include steps towards improving your
knowledge in particular (but not exclusively) in the areas of consent, record keeping and evidence
based dentistry. At the review hearing a range of sanctions, including suspension, will be
available.
That concludes the case.




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