HEARING HEARD IN PUBLIC

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1 HEARING HEARD IN PUBLIC MEW, John Roland Chandley Registration No: PROFESSIONAL CONDUCT COMMITTEE APRIL AUGUST 2017** Most recent outcome: Suspension extended for a period of six months (with a review) ** The latest determination can be found on page 35 John Roland Chandley MEW, a dentist, DGDP(UK) 1992,LDS RCS Eng 1956, MOrth RCS Edin 1999, BDS Lond 1953, was summoned to appear before the Professional Conduct Committee on 4 April 2016 for an inquiry into the following charge: Charge (as amended on 4 April and 30 August 2016) That, being a registered dentist: 1. At all material times you were a United Kingdom registered Dental Practitioner practising at Warwick Park Dental Practice, 22 Warwick Park, Tunbridge Wells, Kent TN2 STB ( the Practice ). 2. Between 5 December 2012 to 18 July 2014, you provided care and treatment to Patient A. Treatment Planning & Provision of Information 3. You failed to carry out sufficient treatment planning, including:- a) failing to make any, or any accurate, diagnosis, b) failing to take any radiographs, c) failing to make any Cephalometric analysis, d) failing to provide a treatment plan, specific to the needs of Patient A. 4. You recommended treatment for Patient A for which there was:- a) No evidence based diagnosis, b) No clinical indication. 5. You recommended treatment that was inconsistent with Patient A's presenting condition, namely that she presented with a space between her upper front teeth and yet you recommended treatment for a patient with a crowded dentition. 6. You provided generic information to Patient A's parents describing treatment options for a patient with a crowded dentition when in fact Patient A presented with a spaced dentition. MEW, J R C Professional Conduct Committee April August 2017 Page -1/39-

2 7. The changes which you claimed would result to the spatial position of the maxilla of Patient A through the proposed methods of orthotropics were in fact the normal growth increments that would be expressed in a girl from 7 to 8 years old without any clinical intervention. 8. You failed to provide an accurate diagnosis of the patient s treatment needs. 9. You failed to provide accurate information about the treatment options, including the option of no treatment. 10. You failed to provide accurate information about the effects of different treatment options. 11. Your conduct as set out in relation to Head of Charge 7 and/or 8 and/or 9 and/or 10 was a) Misleading, b) Deliberately misleading. Treatment & Informed Consent 12. You provided treatment to Patient A for which there was;- a) No evidence based diagnosis, b) No clinical indication. 13. You provided treatment that was inconsistent with Patient A's presenting condition. 14. The matters set out in Head of Charge 13 resulted in exacerbating the condition with which the patient presented. 15. You unacceptably withdrew treatment because fees had not been paid. 16. You left the patient without continuity of care. 17. You did not obtain informed consent for the treatment provided to Patient A. 18. Following Patient A s mother withdrawing consent for the fitting of buttons on Patient A s front teeth, you continued to fit buttons and thereby:- a) Ignored Patient A's mother's withdrawal of consent, b) Acted without Patient A's mother's consent. 19. You failed to maintain adequate standards of cross-infection control by not wearing gloves during treatment. Record Keeping & Communication 20. You did not maintain an adequate standard of record keeping in respect of Patient A s appointments from 5 December 2012 to 18 July 2014, in that you:- a) failed to adequately record: i. Any diagnosis, ii. iii. Any measurements taken, Any patient specific treatment plan, MEW, J R C Professional Conduct Committee April August 2017 Page -2/39-

3 iv. Sufficiently clear and detailed clinical notes of your appointments with the patient, v. Any methodology used to determine the diagnosis and/or treatment needs, b) Failed to include laboratory receipts on file, c) Failed to include a consent form on file relating to the treatment to be provided. 21. In or around December 2012, you told Patient A's mother that:- a) Treatment with train tracks would ruin Patient A's face, require long term retention and that without orthotropic treatment the patient would have an "ugly face", or words to that effect, b) Patient A would be very ugly unless her jaw was realigned, or words to that effect, c) Orthodontic treatment can noticeably damage the face and a brace would need to be worn for the rest of the patient s life, or words to that effect. 22. The statements set out at Head of Charge 21, or words to the effect of those statements, were:- a) Unprofessional, b) Inaccurate, c) Misleading, Patient Confidentiality d) Deliberately misleading. 23. You failed to protect patient confidentiality, including by discussing Patient A s treatment with her school friends and/or their parents. Inadequate Standard of Care 24. As a result of the matters set out from Head of Charge 3 to Head of Charge 23 you failed to provide an adequate standard of care to Patient A. Statements in an advertisement 25. In or around May 2014 you published an advert in the Holmewood Advertiser which stated:- a) Orthodontics usually requires the extraction of 4 to 8 sound teeth although this is frequently denied, b) Research shows Orthotropics gets significantly better results than Train Tracks, c) Nine years old may be too late to start corrective treatment. 26. The statements as set out at Head of Charge 25 above are:- a) Inaccurate, MEW, J R C Professional Conduct Committee April August 2017 Page -3/39-

4 b) Without scientific basis, c) Not evidence based, d) Misleading, e) Deliberately misleading. 27. In or around July/August 2015 you published an advert in 'Parents News' which stated:- a) Orthodontics usually requires the extraction of 4 to 8 sound teeth although this is frequently denied, b) Research shows Orthotropics gets significantly better results than Train Tracks, c) Nine years old may be too late to start corrective treatment. d) 'Blowing the Whistle on GDC Scam. Orthodontists and the General Dental Council are operating an illegal scam to withhold information from the public about new methods which can avoid almost all extractions and even major jaw surgery. This is being done partly to protect traditional methods and partly to preserve the high incomes of orthodontists and surgeons As a result hundreds of children and young adults have extractions and jaw surgery, unaware that they may be unnecessary. Some orthodontists mislead patients, saying that extractions can be avoided although the traditional methods they use leave too little room, risking severe damage to the face..' 28. The statements as set out at Head of Charge 27 above are:- a) Inaccurate, b) Without scientific basis, c) Not evidence based, d) Misleading, e) Deliberately misleading. 29. You published an advert in the February 2016 edition of 'Parents News' which stated:- a) Orthodontics usually requires the extraction of 4 to 8 sound teeth although this is frequently denied, b) Research shows Orthotropics gets significantly better results than Train Tracks, c) Nine years old may be too late to start corrective treatment. d) 'Blowing the Whistle on GDC Scam. Orthodontists and the General Dental Council are operating an illegal scam to withhold information from the public about new methods which can avoid almost all extractions and even major jaw surgery. This is being done partly to protect traditional methods and partly to preserve the high incomes of orthodontists and surgeons As a result hundreds of children and young adults have extractions and jaw MEW, J R C Professional Conduct Committee April August 2017 Page -4/39-

5 surgery, unaware that they may be unnecessary. Some orthodontists mislead patients, saying that extractions can be avoided although the traditional methods they use leave too little room, risking severe damage to the face..' 30. The statements as set out at Head of Charge 29 above are:- a) Inaccurate, b) Without scientific basis, c) Not evidence based, d) Misleading, e) Deliberately misleading. 31. You published an advert in the March 2016 edition of 'Parents News' which stated:- a) Orthodontics usually requires the extraction of 4 to 8 sound teeth although this is frequently denied, b) Research shows Orthotropics gets significantly better results than Train Tracks, c) Nine years old may be too late to start corrective treatment. d) 'Blowing the Whistle on GDC Scam. Orthodontists and the General Dental Council are operating an illegal scam to withhold information from the public about new methods which can avoid almost all extractions and even major jaw surgery. This is being done partly to protect traditional methods and partly to preserve the high incomes of orthodontists and surgeons As a result hundreds of children and young adults have extractions and jaw surgery, unaware that they may be unnecessary. Some orthodontists mislead patients, saying that extractions can be avoided although the traditional methods they use leave too little room, risking severe damage to the face..'. 32. The statements as set out at Head of Charge 31 above are:- a) Inaccurate, b) Without scientific basis, c) Not evidence based, d) Misleading, e) Deliberately misleading. 33. You published an advert in the April 2016 edition of 'Parents News' which stated:- a) "Orthodontics usually requires the extraction of 4 to 8 sound teeth although this is frequently denied, b) Research shows Orthotropics can get much better results than Train Tracks, MEW, J R C Professional Conduct Committee April August 2017 Page -5/39-

6 c) Nine years old may be too late to start corrective treatment. d) "Blowing the Whistle on GDC Scam. Orthodontists and the General Dental Council are operating an illegal scam to withhold information from the public about new methods which can avoid almost all extractions and even major jaw surgery. This is being done partly to protect traditional methods and partly to preserve the high incomes of orthodontists and surgeons As a result hundreds of children and young adults have extractions and jaw surgery, unaware that they may be unnecessary. Some orthodontists mislead patients, saying that extractions can be avoided although the traditional methods they use leave too little room, risking severe damage to the face..'. 34. The statements as set out at Head of Charge 33 above are:- a) Inaccurate b) Without scientific basis c) Not evidence based d) Misleading e) Deliberately misleading. AND by reason of the facts alleged your fitness to practise as a dentist is impaired by reason of misconduct. On 20 December 2016 the Chairman made the following statement regarding the finding of facts: Mr Mew You are present at this hearing and are represented by Mr Philip Newman of Counsel. Mr Richard Milne of Counsel appears for the General Dental Council (GDC). Preliminary matters At the start of the hearing Mr Milne made an application to amend the charge by way of adding further charges, referred to as heads of charge 27 to 32, in accordance with Rule 18 of the General Dental Council (Fitness to Practise) Rules 2006 ( the Rules ). Mr Newman on your behalf made no objection to the amendments. The Committee, having accepted the advice of the Legal Adviser, was content to accede to the application. The schedule of charge was duly amended. Mr Milne made a further application to add heads of charge 33 and 34 at the resumption of the hearing on 30 August Mr Newman made no objection to those further additions. The Committee again accepted the advice of the Legal Adviser and acceded to the application. The schedule of charge was duly amended. Mr Newman on your behalf made a number of admissions to the allegations that you face. The Committee noted those admissions. Background to the case and summary of allegations The allegations relate to the standard of care and treatment that you provided to a patient, referred to for the purposes of these proceedings as Patient A, in the period 5 December 2012 to 18 July Patient A was seven years of age at the time of her first appointment with you. The incidents giving rise to the allegations are said to have taken place whilst you MEW, J R C Professional Conduct Committee April August 2017 Page -6/39-

7 were practising at the Warwick Road Dental Practice in Tunbridge Wells, Kent. The GDC has also raised a further series of allegations against you in respect of statements about orthodontics and orthotropics that you are alleged to have made in two local publications. You first saw Patient A on 5 December She was accompanied by her mother, who is referred to for the purposes of these proceedings as Witness 1. Witness 1 was concerned about the spacing of her daughter s upper incisors and took Patient A to see you following an advertisement that you had placed in her daughter s school magazine which advocated early clinical intervention. It is contended that, at that first appointment on 5 December 2012, you advised Witness 1 that the best way to deal with the problem was through orthotropics, which would correct the position of the jaw and would allow the teeth to grow through straight. It is alleged that you stated that Patient A would be very ugly unless her jaw was realigned, although it is contended that in fact she did not present with an overjet or recessive jaw. Witness 1 decided to proceed with the treatment that you proposed to provide to her daughter and signed a generalised consent form to that effect. It is alleged that, as the treatment progressed, the gaps between Patient A s teeth became wider and an overjet developed. Although it is contended that you were initially dismissive of these concerns, in around April 2013 you are said to have agreed that the gaps between Patient A s two front teeth were becoming much wider. You placed buttons fixed together with elastic bands in an effort to correct these increased gaps. Although this remedial action appeared to have some effect initially, wider gaps at the side appeared, and once the buttons were removed the teeth relapsed. By June 2013 Witness 1 describes that Patient A had a large overjet and receding jawline, and although distressed by your treatment of her daughter she felt that she had no choice but to continue with that treatment. The patient s brace was adjusted by a colleague of yours in September 2013, and following a review appointment that you had with the patient after that adjustment it is alleged that Patient A s front teeth began to cross over each other and the brace caused bleeding, with one tooth almost rotated in its socket. Patient A was apparently unable to close her mouth. You saw the patient at an emergency appointment and are said to have proposed placing further buttons on the patient s bottom teeth, which Witness 1 refused, and that you further wanted to push the top teeth forward in an attempt to uncross the front four teeth, which had by this stage crossed over. Witness 1 declined this option on the basis that it would lead to a more prominent overjet, larger gaps at the front teeth and a lengthier treatment period. It is alleged that you later wrote to Witness 1 and suggested that she no longer accompany Patient A in the treatment room at future appointments. Witness 1 felt that she had no alternative than to comply so that treatment could continue. At the next appointment, it is alleged that you placed buttons on Patient A s bottom teeth, despite Witness 1 having expressly refused permission for such treatment at the previous appointment. Your last appointment with Patient A took place in December Witness 1 alleges that her daughter s front four teeth were beginning to protrude alarmingly and, contrary to her instructions, the front wires of the patient s brace had been pushed forward in an attempt to straighten out the crossing of the top front four teeth. Although she wished to speak to you, Witness 1 alleges that you again fitted new buttons to Patient A s teeth, again contrary to her wishes. The relationship with the patient and her mother then broke down. MEW, J R C Professional Conduct Committee April August 2017 Page -7/39-

8 The patient s mother complained to the GDC in July The GDC has raised a number of specific allegations against you in respect of the standard of care and treatment that you provided to Patient A over the period in question. The first series of allegations that you face relates to the standard of treatment planning and the provision of information that you provided in respect of Patient A. It is specifically alleged that you failed to carry out sufficient treatment planning, including the failure to make any, or any accurate, diagnosis of the patient s treatment needs, take radiographs, make a Cephalometric analysis and provide a specific treatment plan. It is alleged that the treatment that you recommended was not clinically indicated and was not predicated on an evidencebased diagnosis; further, that your proposal was inconsistent with the patient s presenting condition, in that she presented with a space between her upper front teeth, but you recommended treatment suitable for a patient with a crowded dentition. It is similarly alleged that the information that you provided to the parents of Patient A was generic and described treatment options for patients with a crowded dentition. The GDC also contends that the changes which you claimed would result to the spatial position of the maxilla through the method of orthotropics that you proposed were, in fact, the normal growth increments that would be expected in a girl of seven to eight years of age without any clinical intervention. It is also alleged that you failed to provide accurate information about the different treatment options available to Patient A, including the effects of those alternatives. The GDC alleges that these matters constitute conduct that was misleading, and deliberately misleading. The next series of allegations that the GDC has raised against you concerns the treatment that you provided to Patient A, and the informed consent relating to that treatment. The GDC alleges that there was no clinical indication or evidence-based diagnosis for that treatment, and that the treatment was not only inconsistent with Patient A s presenting condition but also exacerbated the condition with which she had in fact presented. It is also contended that you unacceptably withdrew treatment because fees had not been paid and that you left the patient without continuity of care. It is further alleged that you failed to obtain informed consent for the treatment that you provided to Patient A, and indeed that, having had Witness 1 s consent withdrawn for the fitting of buttons on the patient s front teeth, you nonetheless continued to fit buttons. The GDC also alleges that you failed to maintain adequate standards of cross-infection control by not wearing gloves during the treatment sessions that you had with Patient A. The next series of allegations that the GDC has raised against you relate to your standards of record-keeping and communication. It is contended that in particular you failed to make adequate records of your appointments with the patient, including diagnoses, measurements taken and a treatment plan. It is further alleged that you stated in terms to Patient A s mother that her daughter would be very ugly unless you realigned her jaw using orthotropic methods, that orthodontic treatment can noticeably damage the face and that a brace would need to be worn for the rest of the patient s life, and that orthodontic treatment would ruin Patient A s face. The GDC alleges that such statements were unprofessional, inaccurate, misleading and deliberately misleading. The GDC also alleges that you discussed Patient A s treatment with her school friends and their parents, and thereby failed to protect the patient s confidentiality. In this respect, and in relation to the other aspects of the care and treatment that you provided to Patient A as set MEW, J R C Professional Conduct Committee April August 2017 Page -8/39-

9 out above, the GDC alleges that you failed to provide an adequate standard of care to Patient A. You also face a series of allegations relating to the accuracy and basis of a number of statements that you made in advertisements that you placed in publications to promote your use of orthotropic methods. It is alleged that you published an advertisement in a local newspaper which made claims about the relative merits of orthotropics and orthodontics which were inaccurate, without scientific basis, not evidence-based, misleading and deliberately misleading. These statements you then allowed to be republished in other publications on three subsequent occasions, together with a further statement which alleged that orthodontists and the General Dental Council are operating an illegal scam to withhold information from the public about new methods which can avoid almost all extractions and even major jaw surgery. This is being done partly to protect traditional methods and partly to preserve the high incomes of orthodontists and surgeons [ ]. Some orthodontists mislead patients, saying that extractions can be avoided although the traditional methods they use leave too little room, risking severe damage to the face. The GDC also contends that this statement, which you published on three occasions, was inaccurate, without scientific basis, not evidence-based, misleading and deliberately misleading. Evidence The Committee has heard oral evidence from Witness 1; from a dentist who treated Patient A following the course of treatment that you provided to her, referred to for the purposes of these proceedings as Dentist 2; from the expert witness instructed by the GDC, namely Mr Stephen Powell; from a dental nurse employed at your practice, referred to as Defence Witness (DW)1; from the parents of two children to whom you have provided treatment, referred to for the purposes of these proceedings as Defence Witness (DW)2 and Defence Witness (DW)3; and from you. The Committee was also provided with a number of documents. These include copies of a series of witness statements and documentary exhibits. These have been provided by Patient A s mother, who is referred to for the purposes of these proceedings as Witness 1; by two of Patient A s subsequent treating dentists, referred to for the purposes of these proceedings as Dentist 1 and Dentist 2; and by an investigator for the GDC, referred to for the purposes of these proceedings as Witness 2. The Committee has also been provided with copies of the patient records of Patient A, the reports of the expert witness instructed by the GDC, namely Mr Powell, and a witness statement and documentary exhibits provided by you and introduced on your behalf. Committee s findings of fact The Committee has taken into account all of the evidence presented to it, both oral and written. It has also considered the submissions made by Mr Milne on behalf of the GDC and those made by Mr Newman on your behalf. The Committee has accepted the advice of the Legal Adviser. In accordance with that advice it has considered each head of charge separately, although in respect of those heads of charge to which you have made admissions the Committee s reasons will be announced collectively. Its findings at heads of charge 18 (a) and 18 (b), heads of charge 26 (a), 26 (b) and 26 (c), heads of charge 28 (a), 28 (b) and 28 (c), heads of charge 30 (a), 30 (b) and 30 (c), heads of charge 32 (a), 32 (b) and 32 (c), and heads of charge 34 (a), 34 (b) and 34 (c) will also be given together. The Committee has been reminded that the burden of proof rests MEW, J R C Professional Conduct Committee April August 2017 Page -9/39-

10 with the GDC, and has considered the heads of charge against the civil standard of proof, that is to say, the balance of probabilities. I will now announce the Committee s findings in relation to each head of charge: 1. Admitted and proved 2. Proved 3. a) Proved The Committee finds the facts alleged at head of charge 1 proved on the basis of your admission. The Committee also finds the facts alleged at the other heads of charge to which you have made admissions proved on the basis of those respective admissions. The Committee finds the facts alleged at head of charge 2 proved. It notes that you recorded that you conducted a first consultation with Patient A on 5 December 2012 in the patient s clinical notes. The clinical notes record that your last appointment with the patient took place on 11 December You subsequently wrote to Patient A s mother on 14 February 2014 to request a further appointment with the patient, and you then ed her parents on 19 March 2014 to notify them that treatment was being withdrawn. You sent a further letter to Patient A s mother dated 18 July Having been presented with evidence of this chronology the Committee is satisfied that the treatment that you provided to Patient A fell within the period set out at head of charge 2, namely 5 December 2012 to 18 July 2014, and the Committee therefore finds the facts alleged at this head of charge proved. The Committee finds the facts alleged at head of charge 3 (a) proved. It notes that you took measurements using an indicator line in your first consultation with Patient A on 5 December You considered that the patient presented with severe discrepancies in the spatial relationship between her upper jaw and her lower jaw. You stated that the patient s lower teeth were tilted up too high, more particularly some 11mms relative to the position of her jaw. You determined that her upper jaw was back some 10mm from its correct position, and had grown downwards rather than forwards as it should. In the letter dated 7 December 2012 which you wrote to Patient A s parents shortly after that initial consultation you stated that these measurements represented severe discrepancies and that they accounted for why the patient s lower teeth were tilted up too high relative to the position of her upper teeth, and why she had a space between her two upper front teeth. In your evidence to this Committee you stated that, in conclusion, the patient had a class two occlusion, although you did not record that information in the patient s clinical notes. The Committee accepts that you therefore made a diagnosis of the patient s condition at the start of her course of treatment. It does not however consider that your diagnosis was accurate. In reaching this conclusion the Committee accepts the expert evidence of Mr Powell, who states that although he agrees with you that the patient presented with a slight malocclusion, your diagnosis of the patient s maxilla being in the MEW, J R C Professional Conduct Committee April August 2017 Page -10/39-

11 wrong position is incorrect and that in fact there was not evidence to support your diagnosis of severe discrepancies. Mr Powell gave evidence of his subsequent Cephalometric analysis which revealed that there were in fact no severe problems apparent. A Cephalometric analysis was also conducted in February 2014, which did not support your initial contention that Patient A s face had the potential for severe deformity. The Committee also accepts his evidence that the contemporaneous photographs of Patient A suggest a balanced face with only a mild mandibular retrusion, and that the problems that you diagnosed were illusory. The Committee finds, then, that your diagnosis of the patient s mandible dropping downwards was not accurate. Having found that you did not make an accurate diagnosis of the patient s condition, the Committee then went on to consider whether you were under a duty to do so. The Committee is satisfied that you were required to form an accurate diagnosis and that by not having done so you failed in this duty. The Committee accepts the expert evidence of Mr Powell, who in his evidence to this Committee stated that a formal diagnosis is required before any therapeutic intervention is proposed, planned and provided. It further considers that this failure to make an accurate diagnosis meant that your treatment planning for Patient A was insufficient. For the reasons set out above, the Committee finds the facts alleged at head of charge 3 (a) proved. 3. b) Admitted as a fact and culpability denied; proved The Committee finds the facts alleged at head of charge 3 (b) proved. It notes that you accept that you did not take any radiographs of Patient A at the treatment planning stage, and it finds this element of the head of charge proved on the basis of your admission. The Committee then went on to consider whether this was a culpable failure on your part. In your evidence to this Committee you stated that you did not need to take any radiographs as you had no need for such evidence. The Committee considers that you were under a duty to take radiographs, and that having failed to do so you failed to carry out sufficient treatment planning for Patient A in this further respect. In arriving at this finding the Committee accepts the expert evidence of Mr Powell. In his evidence to this Committee Mr Powell stated that radiographs are required at the treatment planning stage for the purposes of providing a baseline against which the treatment that is subsequently provided can be assessed, for instance in relation to the movement of the teeth, primarily by means of a Cephalometric analysis. Patient A was also in the mixed dentition at the time of her treatment with you, and the Committee accepts Mr Powell s evidence that radiographs should have been taken so that the presence and progress of her teeth could have been identified. Mr Powell stated that as you proposed to move bone, a baseline was required so that the movement of bone could be identified. The Committee received evidence from Patient A s subsequent treating dentist, namely Dentist 2, who stated that he had not been able to establish what changes had occurred given the absence of an initial radiograph. The Committee also MEW, J R C Professional Conduct Committee April August 2017 Page -11/39-

12 accepts Mr Powell s evidence that a radiograph, and more particularly an orthopantomograph (OPG) radiograph, should have been taken so that any underlying pathology could be identified. The Committee finds that your admitted omission of radiographs was a culpable failure on your part to carry out sufficient treatment planning for Patient A, and that accordingly the facts alleged at head of charge 3 (b) are proved. 3. c) Admitted as a fact and culpability denied; proved 3. d) Proved The Committee finds the facts alleged at head of charge 3 (c) proved. You admit, and the Committee finds proved, that you did not make any Cephalometric analysis as part of your treatment planning for Patient A. The Committee also finds that this was a culpable failure which constituted insufficient treatment planning. The Committee accepts the expert evidence of Mr Powell that a Cephalometric analysis of a patient s bones can only be derived from a lateral skull radiograph which, as found above at head of charge 3 (b), you did not take. The Committee accepts the evidence of Mr Powell that the absence of a Cephalometric analysis meant that you were not in a position to judge reliably and accurately the patient s treatment needs. In your evidence to this Committee you stated that your indicator line is only a rough guide. The Committee considers that this imprecision meant that the treatment planning for Patient A was insufficient and that instead a Cephalometric analysis was required so that accurate measurements of the relative spatial relationships could be obtained, following which appropriately tailored treatment could be planned, provided and monitored. The Committee therefore finds that you were under a duty to undertake a Cephalometric analysis, and that having not done so you failed to carry out sufficient treatment planning for Patient A in this further respect. Accordingly, it finds the facts alleged at head of charge 3 (c) proved. The Committee finds the facts alleged at head of charge 3 (d) proved. The Committee heard and read evidence from the mother of Patient A, who is referred to as Witness 1. She provided a clear and consistent account of the reasons for her contacting you with a view to you examining Patient A, namely that she was concerned about the space between the patient s two upper front teeth. Following your initial consultation with Patient A on 5 December 2012 you wrote to Patient A s parents on 7 December In that letter you set out your treatment plan for Patient A, namely to expand the patient s maxilla. The Committee accepts the expert evidence of Mr Powell that such a course of treatment would exacerbate rather than resolve the concerns that had been expressed to you. The treatment plan that you presented to Patient A s parents in your letter dated 7 December 2012 focussed on encouraging and guiding the growth of the patient s jaws. The Committee accepts Mr Powell s evidence that the most appropriate form of treatment would have been to provide no treatment, and that as the spacing was normal, reassurance should have been MEW, J R C Professional Conduct Committee April August 2017 Page -12/39-

13 4. a) Not proved 4. b) Proved 5. Proved provided to the patient s parents about spacing being normal in a noncrowded dentition. Instead, as your plan for treatment involved the expansion of the patient s jaws, the Committee finds that this treatment plan was not specific to the needs of the patient. The Committee considers that this failure represents insufficient treatment planning and that accordingly the facts alleged at head of charge 3 (d) are proved. The Committee finds the facts alleged at head of charge 4 (a) not proved. The treatment that you recommended for Patient A was expansion of the arches, and the Committee finds that, although the evidence base for this recommendation was poor, the GDC has not demonstrated to the standard required that there was no evidence at all for this proposal. As noted above you used an indicator line to arrive at your diagnosis, and recorded measurements of the patient s presenting dentition and spatial relationships. The Committee accepts that you made these measurements and that these measurements constitute evidence for your diagnosis. As set out above the Committee considers that this evidence was insufficient and that your diagnosis was wrong, but it accepts that you did obtain some evidence for your recommendation. Accordingly, the Committee finds the facts alleged at head of charge 4 (a) not proved. The Committee finds the facts alleged at head of charge 4 (b) proved. As set out in relation to its findings at heads of charge 3 (a), 3 (b), 3 (c) and 3 (d), your recommendation of arch expansion was not consistent with the presentation of Patient A. You recommended treatment for a patient with a crowded dentition, whereas Patient A presented with a spaced dentition. The Committee accepts the expert evidence of Mr Powell that your proposal therefore lacked a clinical indication, and the Committee accordingly finds the facts alleged at head of charge 4 (b) proved. The Committee finds the facts alleged at head of charge 5 proved. As set out in relation to the Committee s findings at head of charge 4 (b) above, your treatment plan was to expand the patient s upper jaw with the use of screw appliances, whereas in fact the patient presented with spacing in her upper jaw. The Committee finds that you were effectively proposing to treat a problem that did not in fact exist, namely crowding. Patient A s parents expressed concerns about the spacing in the upper front dentition were not addressed. Instead, you stated that you would correct the jaw so that the teeth have room. Mr Powell stated that the recommended treatment that was subsequently provided resulted in the further gross expansion of the maxillary dentition. In your oral evidence to this Committee, you stated that, I really don t have much concern about initial spacing. You were asked whether that suggested that the same treatment would be provided to a patient regardless of their presenting condition, to which you responded, I think that s probably true. MEW, J R C Professional Conduct Committee April August 2017 Page -13/39-

14 6. Proved 7. Not proved 8. Proved The Committee therefore finds that the treatment that you advocated was not consistent with Patient A s specific presentation, and accordingly the facts alleged at head of charge 5 are proved. The Committee finds the facts alleged at head of charge 6 proved. At your first consultation with Patient A on 5 December 2012 you provided an information leaflet to the patient s parents which contained general information about orthotropics. The patient s parents then signed that leaflet. You wrote to the patient s parents two days later on 7 December 2012 to set out your findings and treatment plan. In your oral evidence to this Committee you stated that a number of the paragraphs that appear in your letter to Patient A s parents dated 7 December 2012 were copied and pasted and that they are standard, generic paragraphs which appear in the letters that you typically write to the parents of patients. The letter describes treatment associated with patients who appear with a crowded, rather than a spaced, dentition, and as set out above you stated in your oral evidence to this Committee that, regardless of the issue with which a patient presents, they will receive the same treatment. In her evidence to the Committee Witness 1 further stated that the orthotropics website to which the letter dated 7 December 2012 refers contained information which did not appear to her to be relevant to her daughter s presenting condition. For these reasons, the Committee considers that the information that you provided to Patient A s parents was generic and not relevant to her specific presenting condition, and accordingly it finds the facts alleged at head of charge 6 proved. The Committee finds the facts alleged at head of charge 7 not proved. It considers that the GDC has not demonstrated to the standard required that the changes that you proposed to make to the spatial position of Patient A s maxilla were similar to the changes that would normally occur in a patient of her age. The Committee accepts that, as you admit, you were proposing to make changes to the position of the maxilla, both laterally and anteroposteriorly, but the Committee is not able to rely on the expert evidence of Mr Powell in relation to this head of charge. The Committee was not provided with sufficient evidence to demonstrate that the normal growth increments would return the same result in both planes as your proposed orthotropic intervention, and the Committee considered that Mr Powell did not demonstrate that the research to which he referred suggested that the intervention would return a different result. The Committee therefore finds the facts alleged at head of charge 7 not proved. The Committee finds the facts alleged at head of charge 8 proved. As set out at heads of charge 3 (a) and 3 (d) above, the Committee has found that you did not make an accurate diagnosis of the patient s presenting MEW, J R C Professional Conduct Committee April August 2017 Page -14/39-

15 9. Proved 10. Proved condition, and that you did not provide a treatment plan that was specific to her needs. It therefore follows that you did not as alleged provide an accurate diagnosis of the patient s treatment needs, and for the reasons set out at heads of charge 3 (a) and 3 (d) above the Committee again considers that this was a culpable failure on your part. Therefore, the facts alleged at head of charge 8 are found proved. The Committee finds the facts alleged at head of charge 9 proved. It considers that the alternative options to the orthotropic treatment that you advocated in your letter to Patient A s parents dated 7 December 2012 were expressed in pejorative terms, in that you stated that orthodontics can noticeably damage the face, will require a retainer for the rest of a patient s life to avoid orthodontically-treated teeth from being crooked, and may require the extraction of some teeth. The Committee accepts the expert evidence of Mr Powell that it is not axiomatic that a patient s face will be damaged or that teeth tend to become crooked. The Committee also finds that you did not provide accurate information, or any information at all, about the possibility of providing no treatment, and it accepts the evidence of Mr Powell that this in itself constitutes a treatment option which should have been explained to Patient A s parents. Although you did state that the patient s parents could decide to have orthodontic treatment later, the Committee considers that this does not mean that you specifically suggested that providing no treatment at that stage was an option. The Committee considers that you therefore did not provide accurate information about the treatment options open to Patient A, and that accordingly the facts alleged at head of charge 9 are proved. The Committee finds the facts alleged at head of charge 10 proved. As set out at head of charge 9, the Committee has found that you failed to provide accurate information about the treatment options that were open to Patient A. It further finds that you failed to provide accurate information about the effects of those different treatment options. The Committee accepts the expert evidence of Mr Powell of you not providing accurate and objective information about orthodontic treatment, as a removable rather than a fixed appliance could have been used, and further that the enamel damage and root damage to which you referred in your letter to the patient s parents is rare and unlikely. The Committee again notes that you did not provide any information about the option of no treatment. In his evidence Mr Powell stated, and the Committee accepts, that orthotropics is a treatment option, but the Committee finds that you overstated the relative disadvantages of orthodontic treatment in advocating orthotropic treatment. The Committee is not satisfied that the GDC has discharged its burden of proof in respect of the allegation that you did not provide accurate information on the option of orthotropics, but it nonetheless finds that, given your failure to provide accurate information about the effects of the other options available to Patient A, including the option of no treatment, the facts alleged at head of charge 10 are proved. MEW, J R C Professional Conduct Committee April August 2017 Page -15/39-

16 11. a) Proved in relation to the proven conduct at heads of charge 8, 9 and b) Not proved The Committee finds the facts alleged at head of charge 11 (a) proved in respect of heads of charge 8, 9 and 10. It finds the facts alleged at head of charge 11 (a) not proved in relation to the facts that it has previously found not proved at head of charge 7 above. The Committee has found above that you failed to provide an accurate diagnosis of Patient A s treatment needs and accurate information about the possible treatment options, including the effects of such options. The Committee finds that this inaccurate information was capable of, and indeed had the effect of, misleading the parents of Patient A. The information that you provided caused the patient s parents to follow a particular course of action, namely the orthotropic intervention that you advocated. This was despite their initial reasons for attending with their daughter, namely their concern at the gap between her two upper front teeth. As a result of the information that you provided, and did not provide, Patient A s parents acquired the idea that there were severe discrepancies that required orthotropic intervention. The Committee has found that this was not the case. As a result of their consultation with you, the parents of Patient A placed their trust in you and were misled by the information that you provided. The Committee therefore finds the facts alleged at head of charge 11 (a) proved in respect of your proven conduct at heads of charge 8, 9 and 10. The Committee finds the facts alleged at head of charge 11 (b) not proved. The Committee found above at head of charge 11 (a) that the information that you provided the Patient A s parents about her diagnosis and treatment options was not accurate, and that this had the effect of misleading her parents. However, the Committee does not consider that this was deliberate, or that you intended to misdirect Patient A s parents. The Committee has heard and received a considerable amount of evidence from you about your advocacy of orthotropic treatment. The Committee is in no doubt that your belief in the relative merits of orthotropics is sincere, longstanding and deeply held. The consultation that you conducted, the information that you provided and the treatment that you planned were defined by this belief. The Committee finds head of charge 11 (b) not proved in relation to the conduct alleged at head of charge 7 on the basis that it has previously found head of charge 7 not proved. In relation to head of charge 8, the Committee is not satisfied that the GDC has demonstrated to the required standard that you knew that you were making an inaccurate diagnosis of Patient A s treatment needs. In relation to the conduct found proved at heads of charge 9 and 10, the Committee is again not satisfied that you knew that you were, respectively, minimising the disadvantages of orthotropics and at the same time exaggerating the risks and shortcomings of orthodontics. You considered that Patient A presented with severe problems, and although the Committee has found that the orthotropic treatment that you advocated and then provided was not consistent with MEW, J R C Professional Conduct Committee April August 2017 Page -16/39-

17 12. a) Not proved 12. b) Proved 13. Proved 14. Proved the patient s presenting condition, the Committee does not conclude that you knew that the information that you provided, and did not provide, was wrong and would mislead. The Committee therefore finds the facts alleged at head of charge 11 (b) not proved. The Committee finds the facts alleged at head of charge 12 (a) not proved. The Committee previously determined in respect of head of charge 4 (a) that the GDC has not demonstrated to the standard required that the treatment that you recommended for Patient A lacked an evidence based diagnosis. As you then went on to provide the same treatment that you had planned, namely Biobloc stage one appliances in the upper and lower arches, it follows that such treatment has not been demonstrated to have been without an evidence based diagnosis. The Committee therefore finds the facts alleged at head of charge 12 (a) not proved. The Committee finds the facts alleged at head of charge 12 (b) proved. The Committee previously determined in respect of head of charge 4 (b) that you recommended treatment for Patient A for which there was no clinical indication. The Committee accepts the expert evidence of Mr Powell that no treatment was required because of the normal spacing with which the patient presented. Instead you recommended treatment that involved the expansion of the maxilla, and as this treatment was the treatment that you went on to provide to Patient A, it follows that such treatment lacked a clinical indication. The Committee therefore finds the facts alleged at head of charge 12 (b) proved. The Committee finds the facts alleged at head of charge 13 proved. The Committee previously found at head of charge 5 that you recommended treatment that was inconsistent with Patient A s presenting condition, more particularly that you recommended treatment for crowding when in fact the patient presented with spacing. As this was the treatment that you then went on to provide to the patient, it follows that the course of treatment was inconsistent with the patient s presenting condition. Accordingly the Committee finds the facts alleged at head of charge 13 proved. The Committee finds the facts alleged at head of charge 14 proved. The Committee has been provided with evidence of the increased spacing that occurred in the patient s maxilla as a result of the treatment that you provided to her. It accepts the evidence of Patient A s mother, who provided evidence of increased spacing. She in particular gave evidence of marked gaps at an appointment that you had with her daughter in April The Committee further notes the photographic evidence which demonstrates this change. Indeed, you yourself noted that this would be the likely effect of your treatment as set out in the treatment information form that you provided to Patient A s parents at your initial consultation on MEW, J R C Professional Conduct Committee April August 2017 Page -17/39-

18 15. Not proved 16. Not proved 17. Proved 5 December In your letter to Patient A s mother dated 14 October 2013, you also referred to you having deviated from this course as a result of her concerns about the increased spacing that had arisen. As the gaps with which the patient had initially presented increased as a result of your treatment, the Committee finds the facts alleged at head of charge 14 proved. The Committee finds the facts alleged at head of charge 15 not proved. It considers that the GDC has not demonstrated to the standard required that your withdrawal of treatment was unacceptable on account of the treatment fees not having been paid. The Committee notes that you wrote to Patient A s parents on 19 March 2014 to withdraw treatment. Your correspondence followed an appointment that the patient had missed, in relation to which you had written to the patient s parents for clarification of their intentions. You received no response, and in the circumstances the Committee considers that the GDC has not demonstrated that you acted unreasonably in notifying them that treatment was being withdrawn. Further the Committee does not find that the GDC has proved that treatment was being withdrawn because fees had not been paid, and instead it accepts your evidence that you were making reasonable efforts to ensure that Patient A continued to receive treatment. For these reasons the Committee finds the facts alleged at head of charge 15 not proved. The Committee finds the facts alleged at head of charge 16 not proved. The Committee notes the evidence that Patient A s subsequent treating dentist, referred to as Dentist 2, first saw the patient on 20 February 2014, and once more on 15 March In his written evidence to this Committee Dentist 2 stated that his intention was to clinically examine the patient to facilitate treatment planning. These sessions predate your withdrawal of treatment which followed on 19 March The Committee considers that in the circumstances the patient was not left without continuity of care, and that accordingly the facts alleged at head of charge 16 are not proved. The Committee finds the facts alleged at head of charge 17 proved. The Committee has previously found that you provided an incorrect diagnosis to Patient A s parents, and provided them with inaccurate and misleading information about the treatment options that were available to them, and it follows that informed consent could not have been given on the basis of defective information. The Committee accepts the expert evidence of Mr Powell that the treatment information form that the parents signed on 5 December 2012 was generic, and does not constitute a consent form, particularly as their receipt of this form predated the treatment plan letter dated 7 December 2012 in which you set out the options for treatment and your recommendation of orthotropic intervention. The Committee also accepts the evidence of Witness 1 of her continually asking questions MEW, J R C Professional Conduct Committee April August 2017 Page -18/39-