** See page 15 for the latest determination.

Transcription

1 HEARING HEARD IN PUBLIC MINEVA, Pavlina Stefanova Registration No: PROFESSIONAL CONDUCT COMMITTEE NOVEMBER 2017 AUGUST 2018 Most recent outcome: Suspension revoked and conditions imposed for 9 months (with a review) immediately** ** See page 15 for the latest determination. Pavlina Stefanova MINEVA, a dentist, DDM Sofia 2003, was summoned to appear before the Professional Conduct Committee on 6 November 2017 for an inquiry into the following charge: Charge That being a registered dentist: 1. You failed to provide an adequate standard of care in respect of Patient A between 20 January and 10 May 2016 in that: a. Prior to commencing treatment to provide fixed bridges you did not: i. Adequately assess his occlusion; ii. iii. iv. Take study models; Sufficiently investigate and/or diagnose the causes of Patient A s presenting tooth wear; Adequately assess the abutment teeth; v. Take a radiograph of the abutment teeth vi. Adequately assess the edentulous spaces in respect of the bridges; vii. Take a radiograph of the edentulous space; viii. Adequately assess the support offered by adjacent teeth; b. You provided a poor standard of treatment in respect of bridgework between LR4 and LR7; c. In respect of LL7 you: i. Did not adequately investigate and/or diagnose Patient A s symptoms; ii. iii. iv. Prescribed antibiotics without sufficient clinical justification; Provided a poor standard of root canal treatment; Did not carry out a post operative radiograph after a root canal obturation. 2. You failed to obtain informed consent for the fixed bridge treatment provided to Patient A between 20 January and 10 May 2016 in that you did not: MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -1/20-

2 a. Adequately communicate alternative treatment options to him prior to commencement of treatment; b. Adequately communicate the treatment plan to him; c. Adequately discuss the risks and benefits of the proposed treatment. 3. You retrospectively amended the records of the treatment of Patient A carried out on: a. 29th February 2016; b. 3rd May Your conduct in relation to allegation 3 was: a. Misleading; b. Dishonest. And that by reason of the facts alleged, your fitness to practise as a dentist is impaired by reason of your misconduct. On 9 November 2017 the Chairman made the following statement regarding the finding of facts: Ms Mineva, At the start of this hearing, the General Dental Council s Case Presenter, Mr Coke-Smyth, submitted that the Council would not be inviting a finding on paragraphs 1(a)(vi) and 1(a)(viii). He submitted that the criticism made in 1(a)(vi) was already captured in paragraph 1(a)(vii) and as such this was a duplicate charge. In relation to paragraph 1(a)viii) he submitted that the criticism made within that allegation was captured in paragraph 1(a)(iv) and as such this was also a duplicate allegation. Mr Holl-Allen, Counsel on your behalf did not oppose the submissions. The Committee accepted the advice of the Legal Adviser. It accepted Mr Coke-Smyth s submissions and crossed out paragraphs 1(a)(vi) and 1(a)(viii) from the charge. On your behalf Mr Holl-Allen entered admissions to paragraphs 1(a)(i), 1(a)(ii), 1(a)(v), 1(a)(vii) in relation to the bridges in LL and UL only, 1(c)(ii), 1(c)(iii) and 3. The Committee suspended making a final finding on your admissions until all the evidence had been adduced. Background This case concerns the treatment you provided to Patient A between 20 th January 2016 and 10 th May Patient A first attended your practice on 20 th January 2016 for an examination. He wanted all his teeth to be extracted and replaced with dentures. Patient A complained that his teeth were breaking up and jagged, and that he was finding it painful to eat. Patient A also complained of tooth ache in his lower left jaw and pain to his lower right teeth. The LR5 was subsequently extracted on 28 th January You advised Patient A against a full clearance of his teeth and you recommended a treatment plan which would involve three fixed bridges, one bridge on the upper left to replace the UL2, one bridge on the lower left posterior region and one bridge on the lower right posterior region. A number of restorations of existing teeth were also proposed. Patient A attended an appointment on 29 th February 2016 in order to have restorations carried out on his UL1 and UL3. Further treatment planning in relation to the bridgework was carried out on this appointment. The bridges on the upper left and lower right were fitted in April MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -2/20-

3 After you prepared the teeth on the lower left for a bridge, you identified that Patient A had a partially erupted lower left wisdom tooth and you postponed fitting the bridge until the tooth had been extracted by an Oral Surgeon. Patient A also complained of pain from his LL7. You carried out root canal treatment on that tooth which was unsuccessful, and the tooth was subsequently extracted. Patient A complained that his lower right bridge collected food debris underneath and moved when he chewed sticky items. Patient A was unhappy with the treatment he had received from you and did not return after the extraction of his lower left wisdom tooth to have the bridge on the lower left fitted. Patient A made a complaint to the practice about his treatment on 23 rd May Witnesses The Committee received a statement dated 19 April 2017 and heard oral evidence from Patient A. He was honest in his recollection of events. The Committee was of the view that he did not appear to have a full understanding of the treatment he would be receiving. He attended requesting a full clearance of his teeth and subsequent provision of full dentures. He was clear in his oral evidence that his intention was not to retain his own teeth despite being advised that some of his teeth were healthy. The Committee found Patient A to be an honest and credible witness, but concluded that, not surprisingly in view of other evidence before it, his precise recollection of the content of conversations and when they took place contained in accuracies. He himself accepted in evidence that his recollection was unclear about the precise nature of certain matters. The Committee also heard oral evidence from you. It also had a copy of your witness statement dated 21 September The Committee accepted your evidence in so far as it related to your usual practice. It did not accept your account as to missing entries in the dental records. The Committee received expert reports from Ms Glass and Ms Firestone. It also received a joint expert report dated 29 th October The Committee heard oral evidence from both experts. It accepted their experience and expertise. The Committee carefully considered all the evidence before it. It took account of the submissions made by Mr Coke-Smyth, Counsel on behalf of the General Dental Council (GDC) and those made by Mr Holl-Allen, Counsel on your behalf. It accepted the advice of the Legal Adviser. In accordance with that advice it considered each head of charge separately. In relation to the allegation on dishonesty the Committee was referred to the recent Supreme Court judgment in the case of Ivey Genting Casinos (UK) Ltd t/a Crockfords [2017] UKSC 67 where the test for dishonesty was revisited. "The test of dishonesty is as set out by Lord Nicholls in Royal Brunei Airlines Sdn Bhd v Tan and by Lord Hoffmann in Barlow Clowes: When dishonesty is in question the fact-finding tribunal must first ascertain (subjectively) the actual state of the individual's knowledge or belief as to the facts. The reasonableness or otherwise of his belief is a matter of evidence (often in practice determinative) going to whether he held the belief, but it is not an additional requirement that his belief must be reasonable; the question is whether it is genuinely held. When once his actual state of mind as to knowledge or belief as to facts is established by the fact-finder by applying the (objective) standards of ordinary decent people there is no requirement that the defendant must appreciate that what he has done is, by those standards, dishonest." MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -3/20-

4 The Committee s findings in relation to each head of charge are as follows: 1. You failed to provide an adequate standard of care in respect of Patient A between 20 January and 10 May 2016 in that: 1.(a) 1.(a)(i) 1.(a)(ii) 1.(a)(iii) 1.(a)(iv) Prior to commencing treatment to provide fixed bridges you did not: Adequately assess his occlusion; Admitted and found proved The Committee accepted your admission and the joint opinion of the experts. Take study models; Admitted and found proved The Committee accepted your admission and the joint opinion of the experts. Sufficiently investigate and/or diagnose the causes of Patient A s presenting tooth wear; Not admitted and found not proved Ms Glass opinion is that further investigation should have been carried out to determine whether the tooth wear was as a result of bruxism as diagnosed, or erosion due to either dietary or medical reasons, or a combination. Ms Firestone s opinion is that the evidence available suggests that the tooth wear was due to bruxism, however it is possible that other factors played an aetiological role in the wear and so taking an appropriate history as to diet, reflux, intestinal disorders would have been helpful. In their joint report both experts agreed that there was a failure which was below the standard. In her oral evidence Ms Firestone told the Committee that there was no evidence to suggest that there was any other reason for the tooth wear other than bruxism which you had diagnosed, which went further than her written report where she expressed her view that other tests could have been helpful. Ms Glass opinion was based on a reference to a medication taken by Patient A which might be for prophylactic reasons. The Committee found your evidence clear on this point. You described clearly your examination of Patient A s mouth and the condition of his teeth. Your notes of your examination were clear as to your diagnosis. There was no evidence within the records to suggest any other cause of tooth wear. The Committee preferred the oral evidence of Ms Firestone. Adequately assess the abutment teeth; Not admitted and found not proved The parties agreed that this charge related to a failure to take a vitality test of the abutment teeth. Ms Firestone agrees that you assessed the vitality of the abutment teeth. Your evidence is that it is your usual practice to assess the vitality of abutment teeth using the cold air from the triple syringe. The Committee accepted your MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -4/20-

5 1.(a)(v) 1.(a)(vi) 1.(a)(vii) 1.(a)(viii) 1.(b) 1.(c) 1.(c)(i) evidence. Take a radiograph of the abutment teeth Admitted and found proved The Committee accepted your admission and the joint opinion of the experts. Adequately assess the edentulous spaces in respect of the bridges; The Committee was invited not to make a finding on this allegation. Mr Coke- Smyth submitted that the criticism made is already captured in 1(a)(vii). Take a radiograph of the edentulous space; Admitted and found proved in relation to bridges in LL and UL only. The parties agreed that this charge related to the lower left and upper left bridges only. The Committee accepted your admission and found this charge proved on the basis of your admission and the joint opinion of the experts. Adequately assess the support offered by adjacent teeth; The Committee was invited not to make a finding on this allegation. Mr Coke- Smyth submitted that the criticism made is already captured in 1(a)(iv). You provided a poor standard of treatment in respect of bridgework between LR4 and LR7; Not admitted but found proved This allegation related to a finding that there was a large mass of cement which extends underneath the gum and behind the tooth which was described as a blob. The Committee heard from Ms Firestone that this is the type of mistake that students often make. Ms Glass opinion is that it is more likely to be difficult to remove the blob as it would be difficult to access, direct visions would be impossible and it is an adhesive cement, designed to adhere permanently to tooth structure and direct restorations. Ms Glass was also of the opinion that the radiographic evidence of the marginal fit together with the blob of cement suggests that the bridge was of a poor standard. Ms Firestone s opinion is that the fit of the retainers LR4 and LR7 can only accurately be assessed by clinical examination. In your oral evidence you said that you could not detect any problems at the time the bridge was provided however you accepted that the treatment you provided was of a poor standard based on the radiographic evidence. On your own admission and based on the opinion of Ms Glass, the Committee found this charge proved. In respect of LL7 you: Did not adequately investigate and/or diagnose Patient A s symptoms; Not admitted and found not proved The Committee accepted Ms Firestone s opinion that there would be a range MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -5/20-

6 1.(c)(ii) 1.(c)(iii) 1.(c)(iv) of opinion in respect of whether it was appropriate to commence root canal treatment on 20 th April The Committee accepted your evidence that you carried out adequate clinical investigations prior to commencing root canal treatment. Prescribed antibiotics without sufficient clinical justification; Admitted and found proved The Committee accepted your admission and the joint opinion of the experts. Provided a poor standard of root canal treatment; Admitted and found proved The Committee accepted your admission and the joint opinion of the experts. Did not carry out a post operative radiograph after a root canal obturation. Not admitted but found proved The Committee noted that this head of charge alleges a failure to provide an adequate standard of care. You have admitted to not adequately assessing occlusion, taking study models and taking radiographs of the abutment teeth and the edentulous space. The Committee therefore first considered whether or not you were under a duty to take a post-operative radiograph. Ms Glass opinion is that you are under a duty to take a radiograph at the conclusion of treatment. The Committee concluded that best practice was to take a radiograph either at the conclusion of the treatment or within a short time thereafter. As you failed to take a radiograph when Patient A returned six days later, the Committee decided that this charge was proved. 2. You failed to obtain informed consent for the fixed bridge treatment provided to Patient A between 20 January and 10 May 2016 in that you did not: 2.(a) Adequately communicate alternative treatment options to him prior to commencement of treatment; Not admitted but found proved Patient A s evidence demonstrated that some alternative treatment options were discussed with him. He accepted that he resisted the suggestion of preserving any natural teeth and wanted full mouth clearance instead. The Committee accepted the opinion of Ms Glass that there were several treatment options available which should have been discussed with Patient A, these included: a. Restoring teeth affected by caries or pathology as required, then restoring spaces upper and/or lower with removeable partial dentures; b. Restoring teeth affected by caries or pathology as required, then accepting spaces upper and/or lower; c. A combination of. restoring teeth affected by caries or pathology MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -6/20-

7 2.(b) 2.(c) as required, then restoring the single tooth upper space with a bridge to restore the single upper tooth space and restoring the lower space with a removable partial denture; d. Options of acrylic or chrome dentures should have been discussed and offered in the partial denture options; e. Restoring teeth affected by caries or pathology as required then restoring spaces upper and/or lower spaces with implant retained crowns. The only documentary evidence of the treatment options discussed is the retrospective entry you made in the dental records. This entry did not reflect all the alternative treatment options available to Patient A. The Committee found this proved. Adequately communicate the treatment plan to him; Not admitted but found proved Patient A was under the impression that he was getting a 5-unit bridge in the lower when he was getting a 4-unit bridge. He clearly did not understand what was going on and what treatment he was actually receiving. The treatment plan states that a fixed-fixed bridge was to be provided to replace the UL2 but the dental notes indicate a cantilever bridge without any indication that this change was explained to the patient. The Committee found that you did not adequately communicate the treatment plan to Patient A. Adequately discuss the risks and benefits of the proposed treatment. Not admitted but found proved You admitted that you did not adequately assess the occlusion, you did not take radiographs and you did not take study models as a result you did not have sufficient information to be able to adequately discuss the risks and benefits of the treatment you were proposing. The risks and benefits you listed as discussed in your retrospective entry are also not adequate. 3. You retrospectively amended the records of the treatment of Patient A carried out on: 3.(a) 29th February 2016; Admitted and found proved The Committee accepted your admission and the joint opinion of the experts. 3.(b) 3rd May Admitted and found proved The Committee accepted your admission and the joint opinion of the experts. 4. Your conduct in relation to allegation 3 was: 4.(a) Misleading; MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -7/20-

8 4.(b) Not admitted but found proved In relation to the retrospective entry regarding the appointment of 3 rd May 2016, the Committee concluded from the evidence that this was done immediately after the following appointment when you realised that information relevant to previous appointment had been omitted. In relation to the retrospective entry regarding the appointment of 29 th February 2016, this was more substantial in nature, made three months after the appointment in question and as a result of receiving a complaint from Patient A. The Committee found that the entries were misleading because of the use of the word Today as they gave the impression that they were made on the date of the relevant appointments. Dishonest. Not admitted but found proved In relation to the retrospective entry regarding the 3 rd May 2016 appointment, the Committee accepted that it was a late entry which was made with the intention of correcting gaps in the record which were identified at a subsequent appointment. It found that your conduct in this respect was not dishonest. In relation to the retrospective entry regarding the 29 th February 2016 appointment, the Committee was of the view that this was a deliberate act. The entry was made three months after the appointment with Patient A, following the receipt of a complaint from the patient and without any indication that it was a retrospective entry. In addition, in your oral evidence you claimed that your original records of that appointment may have been accidentally deleted. However, there was no evidence before the Committee to demonstrate that such an error had occurred in the past in relation to your records. The Committee did not accept your explanation for making the retrospective entry. It concluded that it was more likely than not that, having received the complaint letter and realising that you had no records of that appointment, you sought to fill in the gaps in the dental records based on your recollection and the complaint letter. We move to Stage Two. On 10 November 2017 the Chairman announced the determination as follows: Ms Mineva, Having announced its decision on the facts the Committee was provided with a remediation bundle which contained your Personal Development Plan (PDP); certificates of Continuing Professional Development (CPD) courses; written reflections on record keeping and clinical examination, antimicrobial prescribing, radiography, crown and bridgework; audits on radiography, record keeping and antimicrobial prescribing; curriculum vitae; testimonials and correspondence with the Postgraduate Dental Team. MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -8/20-

9 The Committee took account of the submissions made by Mr Coke-Smyth on behalf of the GDC and those made by Mr Holl-Allen on your behalf. It accepted the advice of the Legal Adviser. Mr Coke-Smyth submitted that prior to this case, you have no previous fitness to practise findings against you. The Committee acknowledged that its decisions on misconduct and impairment are matters for its own independent judgement. There is no burden or standard of proof at this stage of the proceedings. Misconduct The Committee found proved serious failings in basic aspects of dentistry. You failed to provide an adequate standard of care to Patient A, you failed to obtain informed consent and you retrospectively amended dental records of two appointments attended by Patient A. It was found that the retrospective entry made about the appointment of 29 th February 2016, 3 months after Patient A attended the appointment and, following the receipt of a complaint from him, was done dishonestly. Your conduct breached a number of the standards of the profession as set out in Standards for the Dental Team (September 2013) and in particular: 1.3 Be honest and act with integrity. 2.1 Communicate effectively with patients listen to them, give them time to consider information and take their individual views and communication needs into account. 2.2 Recognise and promote patients rights to and responsibilities for making decisions about their health priorities and care. 2.3 Give patients the information they need, in a way they can understand, so that they can make informed decisions. 7.1 Provide good quality care based on current evidence and authoritative guidance. Both experts, Ms Glass and Ms Firestone were of the opinion that a number of the failings found proved, some of which you admitted, fell far below the standard of conduct expected of a reasonable general dental practitioner. The Committee accepted their opinion. It was of the view that although this case relates to one patient, the clinical failings are serious. In addition, your dishonest conduct as well as your clinical failings are a serious departure from the standards of conduct expected from a dental practitioner. The Committee was in no doubt that the facts found proved are serious and amount to misconduct. Impairment The Committee next considered whether your fitness to practise is currently impaired by reason of your misconduct. It is of the view that the clinical failings are remediable. It took account of the remediation bundle produced on your behalf. The remediation bundle includes reflective statements of variable quality often giving a commentary on the course content. Some of the reflective statements note changes you have made in your clincial practice that the Committee feels are work in progress. Your PDP is being actioned as confirmed by the Deanery. The Committee notes from your of 3 November 2017 that you are taking steps to engage further with your local Deanery. The Committee notes that you have undertaken audits covering aspects of your practice which are the subject of the findings made in this case. Whilst they demonstrate your attempts to remedy your failings, an independent review of the audits which confirm your MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -9/20-

10 findings would assure the Committee and give the audits more weight. The Committee was not satisfied that you had remedied your clinical failings to the extent that there was no longer a risk of repetition. The Committee acknowledged that you made some admissions at the start of the hearing which demonstrates that you have some insight. However, the Committee identified from your oral evidence that you had not developed a full understanding of your actions particularly in relation to making retrospective entries. You accepted that a retrospective entry should be clearly marked as such, however the Committee would have liked to see your personal reflection demonstrating your understanding of why retrospective entries should not be made or should be clearly marked and the effect of inaccurate records on the safety of patients. The Committee concluded that your insight was yet to crystallise into a full acknowledgement of the implications of your dishonest conduct. With respect to the public interest, the Committee adopted the approach set out by Dame Janet Smith in her fifth report from the Shipman case. You placed Patient A at an unwarranted risk of harm by failing to provide an adequate standard of care, you acted dishonestly which was a breach of the standards of the profession and brought the profession into disrepute. The Committee concluded that a member of the public would be shocked, astonished and dismayed, and public confidence in the profession would be undermined if a finding of impairment was not made in a case where dishonest conduct was found proved. The Committee therefore concluded that your fitness to practise is currently impaired by reason of your misconduct relating to both your dishonest conduct and your clinical failings. Disposal The Committee next considered what action, if any, to take in relation to your registration. It reminded itself that the purpose of a sanction was not to be punitive although it may have that effect. The Committee bore in mind the principle of proportionality. It also had regard to the Guidance for the Practice Committees including Indicative Sanctions Guidance, October 2016, ( PCC Guidance ). The Committee first considered the mitigating factors in this case. It took account of the evidence of the circumstances leading up to the complaint, you have undertaken remedial action to avoid repetition, you have no previous fitness to practise history, you were previously of good character and you have shown some insight and remorse. The aggravating factors are that there was some harm to Patient A and you acted dishonestly. The Committee noted the testimonials written on your behalf. It was particularly encouraged by the letter dated 15 th October 2017 from a patient who had not attended a dental practice for eight years due to her fear of dental treatment. She explained in detail how you were able to provide her with care and treatment and that she now attends 6 monthly check up appointments with you. The Committee however was of the view that to conclude this case with no further action would be wholly disproportionate and would not protect patients or maintain public confidence in the profession. The Committee considered the available sanctions in ascending order starting with the least serious. It determined that a reprimand would be insufficient because your clinical failings were yet to be addressed in full and the dishonest conduct found proved required a more serious sanction. MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -10/20-

11 The Committee then considered whether a conditions of practice order would be appropriate in this case. It acknowledged that conditions must be workable, measurable and proportionate to the impairment. It was of the view that your clinical failings could be addressed by the imposition of conditions on your registration. It is difficult to design practical conditions to address dishonest conduct, which is attitudinal in nature. Furthermore, imposing conditions would send the wrong message to the profession and the public. The Committee next considered whether suspension would be sufficient to mark the serious misconduct in this case. It was of the view that withdrawal of registration was necessary to mark the serious nature of the dishonest conduct found proved. The Committee concluded that the essence of the dishonesty finding was that you had failed to make it clear that your records were not contemporaneous. The Committee went on to consider whether erasure was required but concluded that such a step would be disproportionate as the notes were substantially accurate. As you had accepted at an early stage that you had made retrospective entries to the dental records of Patient A, a period of suspension was the appropriate and proportionate sanction to impose. The Committee therefore determined, pursuant to Section 27B(6)(b) of the Dentists Act 1984, as amended, to direct that your registration be suspended for a period of 6 months with a review prior to the expiry of the order. Decision on immediate order of suspension No immediate order The Committee took account of the submissions made by Mr Coke-Smyth, Counsel on behalf of the GDC that an immediate order should be imposed on your registration on the basis of the Committee s determination that you placed Patient A at risk through poor clinical care and your failings were yet to be remedied. Further he submitted that an immediate order is otherwise in the public interest given the serious dishonesty found proved and the sanction of six months suspension directed by the Committee. Mr Holl-Allen, Counsel on your behalf submitted that this is not a case for an immediate order of suspension. He submitted that the sanction of suspension was imposed in the public interest to maintain standards in the profession and not because you pose a risk to patients. He informed the Committee that you have been working for a period of 18 months since the complaint was made. The Committee accepted the advice of the Legal Adviser. The Committee made a determination that it was not satisfied that you had remedied your clinical failings to the extent that there was no longer a risk of repetition, it found that your fitness to practise is impaired and directed that your registration be suspended for a period of six months. However, it acknowledged that no other concerns have arisen since Patient A s complaint and as submitted by Mr Holl-Allen you have been practising for 18 months. The Committee was satisfied that an immediate order is not necessary for the protection of the public. In relation to the public interest the Committee was of the view that the substantive order is sufficient to address the public interest in this case. The Committee therefore concluded that an immediate order is not necessary for the protection of the public, otherwise in the public interest or in your own interest. MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -11/20-

12 The effect of the foregoing direction and this decision of no immediate order is that your registration will remain unrestricted and the substantive direction of suspension for 6 months will take effect 28 days from when notice is deemed served on you. That concludes the case. On 18 May 2018, at the review hearing the Chairman announced the determination as follows: Mrs Mineva, This is a resumed hearing pursuant to Section 27C of the Dentists Act 1984 (as amended) ( the Act ) to review the order of suspension for 6 months which was imposed on your registration by the Professional Conduct Committee (PCC) on 10 November Findings at the Initial Hearing This case concerns the treatment you provided to Patient A between 20 th January 2016 and 10 th May Patient A first attended your practice on 20 th January 2016 for an examination. He wanted all his teeth to be extracted and replaced with dentures. Patient A complained that his teeth were breaking up and jagged, and that he was finding it painful to eat. Patient A also complained of tooth ache in his lower left jaw and pain to his lower right teeth. The LR5 was subsequently extracted on 28 th January You advised Patient A against a full clearance of his teeth and you recommended a treatment plan which would involve three fixed bridges, one bridge on the upper left to replace the UL2, one bridge on the lower left posterior region and one bridge on the lower right posterior region. A number of restorations of existing teeth were also proposed. Patient A attended an appointment on 29 th February 2016 in order to have restorations carried out on his UL1 and UL3. Further treatment planning in relation to the bridgework was carried out on this appointment. The bridges on the upper left and lower right were fitted in April After you prepared the teeth on the lower left for a bridge, you identified that Patient A had a partially erupted lower left wisdom tooth and you postponed fitting the bridge until the tooth had been extracted by an Oral Surgeon. Patient A also complained of pain from his LL7. You carried out root canal treatment on that tooth which was unsuccessful, and the tooth was subsequently extracted. Patient A complained that his lower right bridge collected food debris underneath and moved when he chewed sticky items. Patient A was unhappy with the treatment he had received from you and did not return after the extraction of his lower left wisdom tooth to have the bridge on the lower left fitted. Patient A made a complaint to the practice about his treatment on 23 rd May The initial Committee found proved that you failed to provide an adequate standard of care to Patient A, you failed to obtain informed consent and you retrospectively amended dental records of two appointments attended by Patient A. It was found that the retrospective entry made about the appointment of 29 th February 2016, 3 months after Patient A attended the appointment and following the receipt of a complaint from him was done dishonestly. That Committee found that the proven facts amounted to misconduct. In relation to impairment, the initial PCC was not satisfied with the extent of the remediation you had undertaken. It stated in its determination that The Committee was not satisfied that MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -12/20-

13 you had remedied your clinical failings to the extent that there was no longer a risk of repetition. That Committee was also not assured that you had developed a full understanding of your actions particularly in relation to retrospective entries. It determined that your fitness to practise was impaired by reason of your misconduct relating to both your dishonest conduct and your clinical failings. Your registration was suspended for a period of 6 months with a review prior to the expiry of the order. First PCC Review Today this Committee has comprehensively reviewed your case taking account of all the evidence presented. It has also taken account of the submissions made by Ms Headley on behalf of the GDC and those made by Mr Holl-Allen QC on your behalf. The Committee accepted the advice of the Legal Adviser. Current Impairment In considering whether your fitness to practise is currently impaired the Committee bore in mind that this is a matter for its own independent judgement. It also had regard to its duty to protect the public, declare and uphold proper standards of conduct and competence and maintain public confidence in the profession. The Committee was referred to the cases of Cohen v GMC; Ibrahim v GMC; Kimmance v GMC and CHRE v NMC and Paula Grant. The Committee received your most recent Personal Development Plan (PDP) dated 4 January 2018 and certificates from the Continuing Professional Development (CPD) courses you have undertaken in the period of your suspension. The courses cover a wide range of topics in dentistry. The Committee noted in particular that you attended deanery courses on record keeping on 9 January 2018, medical history update on 25 April 2018, pharmacology (anti-microbial prescribing) on 20 March 2018, Identifying Faults and Grading of X-Rays on 8 May 2018, a hands-on rubber dam in endodontic practice on 7 February 2018, Crown Lengthening and Pocket Reduction on 12 April and 3 May 2018, Consent and Mental Health Capacity on 24 April 2018, Managing Patients on Anti-Coagulant on 26 April 2018, and Treating Medically Compromised Patients in General Dental Practice on 10 May The Committee noted from your PDP that you plan to attend courses on drugs within dentistry on 14 June 2018 and Treatment Planning A Practical Guide on 11 July and 12 July The Committee noted the CPD certificates and your reflections on these courses. You have undertaken self-reflection including working with your Deanery approved mentor on the importance of contemporaneous recording of clinical findings, treatment planning and events relating to patients. You have also carried out audits of your practice in record keeping, antimicrobial prescribing, radiography and radiology, and there has been an independent review of your audits. The Committee noted your dedication and resilience in remedying your clinical failings. Your personal reflections on the courses you attended were very helpful to the Committee in showing your understanding of the topics. You worked with the postgraduate dental dean and your mentor and have undertaken audits. The Committee was of the view that you had demonstrated good insight and reflection into your clinical failings. However, the Committee noted that you had not practised dentistry since December 2017 and as such you had been unable to apply your learning in your practice and thereby demonstrate that your learning has been embedded. The Committee concluded that your clinical failings had not been fully remedied and could not be until you were able to apply the remediation learning you had undertaken in your day to day practice of dentistry. It decided that for these reasons your MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -13/20-

14 fitness to practise remained impaired by reason of misconduct relating to your clinical failings. In relation to the dishonesty finding, the Committee noted from Kimmance v GMC [2016] EWHC 1808 (Admin) per Kerr J at paragraph 66 that a doctor or other professional who has done wrong has to look at his or her conduct with a self-critical eye, acknowledge fault, say sorry and convince a panel that there is real reason to believe he or she has learned a lesson from the experience. The Committee was of the view that you had not demonstrated within your reflective statement an understanding and acknowledgement that your actions in not indicating that your retrospective entry on 29 February 2016 was dishonest, why it was dishonest and the impact of a finding of dishonesty on the reputation of the dental profession. Your reflective statement did not include any apology for your actions, or an indication that such conduct would not be repeated in the future. The Committee noted from your remediation in relation to your clinical failings that you have a practical understanding of the record keeping issues and the need to make a note to indicate an entry was made retrospectively. However, your remediation did not address the finding of dishonesty. The Committee noted your mentor s report dated 20 April 2018 in which she states: The process is on-going, however I have been impressed by the degree of selfawareness she has shown and the eagerness with which she has engaged in the mentoring relationship. Mrs Mineva shows a commendable degree of insight into the circumstances of the complaint and a strong determination to learn lessons from the experience. This has been evidence in our conversations and the reflections she has undertaken It is my opinion that Mrs Mineva has developed a full appreciation of why her actions at the time were not correct. She understands that on the rare occasion when a retrospective entry may be required, full justification must be given and the record dated and signed. She also understands why her actions were viewed as dishonest conduct. The Committee noted that this suggested that you understood why others would perceive your conduct as dishonest however there was no evidence that you yourself accepted that your conduct was dishonest. It did not hear oral evidence from you in this hearing which demonstrated any insight or understanding of the dishonest finding made against you saved from the documentary evidence before it. The Committee expected to see evidence of insight showing a full acknowledgement of the implications of your dishonest conduct as recommended by the previous Committee. It was of the view that without an understanding of dishonesty, it would be difficult to acknowledge and demonstrate remediation and insight into dishonest behaviour. The Committee concluded that you had not provided evidence that your dishonest conduct had been remedied and that you had not demonstrated full insight. It determined that your fitness to practise remained impaired by reason of your misconduct relating to your dishonest conduct. In coming to this conclusion, the Committee noted that you had not apologised for your conduct nor reflected on the impact of your conduct on the reputation of the profession. Therefore, the Committee determined that your fitness to practise remained currently impaired. Sanction The Committee next considered what sanction to impose on your registration under Section 27C of the Dentists Act, 1984 as amended. It reminded itself that the purpose of any sanction is not to be punitive although it may have that effect. The Committee bore in mind MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -14/20-

15 the principle of proportionality. It carefully considered the GDC s Guidance for the Practice Committees, including Indicative Sanctions Guidance (October 2016). The Committee considered whether to revoke the suspension order currently on your registration. Having found that your fitness to practise remains currently impaired, the Committee decided that it would be inappropriate to revoke the order on your registration and allow you to practice unrestricted. The Committee then considered whether to replace the order of suspension with an order for conditional registration. It noted that the previous Committee had clearly given you signposts on the types of remedial information it expected to receive from you including insight showing a full acknowledgement of the implications of your dishonest conduct. In its determination that Committee concluded that: your insight was yet to crystallise into a full acknowledgement of the implications of your dishonest conduct. Regrettably this Committee did not have this evidence before it which led to a finding of current impairment. It was of the view that for conditions to be workable, a registrant must have full insight into all the findings made about their practice. The Committee noted that you had carried out extensive remediation in relation to your clinical failings and that conditions would have been sufficient to address the remedial issues relating to embedding your learning in your practice. However, given the absence of a demonstration of insight and remediation in relation to the dishonest conduct, the Committee decided that conditions would not be appropriate at this stage. The Committee determined that the appropriate order to make was one of suspension. In considering the duration of the suspension order, the Committee was of the view that a short period to enable you reflect on the meaning of dishonesty, demonstrate an understanding and acknowledgement of why your actions were found to be dishonest and demonstrate remorse would be sufficient in this case. It was also of the view that evidence of discussions with your mentor regarding dishonesty and evidence of your personal reflection on the issues set out above may assist the reviewing Committee. The Committee therefore determined to extend the suspension of your registration for a further period of 3 months pursuant to section 27C (1)(b) of the Dentists Act 1984, as amended, with a review prior to the expiry of the order. On 29 August 2018 at a second review hearing, the Chairman announced the determination as follows: Mrs Mineva, This is a resumed hearing pursuant to Section 27C of the Dentists Act 1984 (as amended) ( the Act ) to review the order of suspension which was imposed for 6 months on your registration by the Professional Conduct Committee (PCC) on 10 November 2017, and extended for 3 months on 18 May Findings at the Initial Hearing This case concerns the treatment you provided to Patient A between 20 th January 2016 and 10 th May Patient A first attended your practice on 20 th January 2016 for an MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -15/20-

16 examination. He wanted all his teeth to be extracted and replaced with dentures. Patient A complained that his teeth were breaking up and jagged, and that he was finding it painful to eat. Patient A also complained of tooth ache in his lower left jaw and pain to his lower right teeth. The LR5 was extracted on 28 th January You advised Patient A against a full clearance of his teeth and you recommended a treatment plan which would involve three fixed bridges, one bridge on the upper left to replace the UL2, one bridge on the lower left posterior region and one bridge on the lower right posterior region. A number of restorations of existing teeth were also proposed. Patient A attended an appointment on 29 th February 2016 in order to have restorations carried out on his UL1 and UL3. Further treatment planning in relation to the bridgework was carried out on this appointment. The bridges on the upper left and lower right were fitted in April After you prepared the teeth on the lower left for a bridge, you identified that Patient A had a partially erupted lower left wisdom tooth and you postponed fitting the bridge until the tooth had been extracted by an Oral Surgeon. Patient A also complained of pain from his LL7. You carried out root canal treatment on that tooth which was unsuccessful, and the tooth was subsequently extracted. Patient A complained that his lower right bridge collected food debris underneath and moved when he chewed sticky items. Patient A was unhappy with the treatment he had received from you and did not return after the extraction of his lower left wisdom tooth to have the bridge on the lower left fitted. Patient A made a complaint to the practice about his treatment on 23 rd May The initial Committee found proved that you failed to provide an adequate standard of care to Patient A, you failed to obtain informed consent and you retrospectively amended dental records of two appointments attended by Patient A. It was found that the retrospective entry made about the appointment of 29 th February 2016, 3 months after Patient A attended the appointment and following the receipt of a complaint from him was done dishonestly. That Committee found that the proven facts amounted to misconduct. In relation to impairment, the initial PCC was not satisfied with the extent of the remediation you had undertaken. It stated in its determination that The Committee was not satisfied that you had remedied your clinical failings to the extent that there was no longer a risk of repetition. That Committee was also not assured that you had developed a full understanding of your actions particularly in relation to retrospective entries. It determined that your fitness to practise was impaired by reason of your misconduct relating to both your dishonest conduct and your clinical failings. Your registration was suspended for a period of 6 months with a review prior to the expiry of the order. First PPC Review The matter was reviewed on 18 May 2018, where that Committee determined that your fitness to practise remained impaired and for your registration to be continued for a further period of 3 months. The Committee was of the view that a short period to enable you reflect on the meaning of dishonesty, demonstrate an understanding and acknowledgement of why your actions were found to be dishonest and demonstrate remorse would be sufficient in this case. It was also of the view that evidence of discussions with your mentor regarding dishonesty and evidence of your personal reflection on the issues set out above may assist the reviewing Committee. MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -16/20-

17 Second PCC Review Today this Committee has comprehensively reviewed your case taking account of all the evidence presented. It has also taken account of the submissions made by Mr Middleton on behalf of the GDC and those made by Mr Holl-Allen QC on your behalf. The Committee accepted the advice of the Legal Adviser. Current Impairment In considering whether your fitness to practise is currently impaired the Committee bore in mind that this is a matter for its own independent judgement. It also had regard to its duty to protect the public, declare and uphold proper standards of conduct and competence and maintain public confidence in the profession. The Committee was referred to the cases of Cohen v GMC; Ibrahim v GMC; Kimmance v GMC and CHRE v NMC and Paula Grant. The Committee received your most recent Personal Development Plan (PDP) dated 8 August 2018 and certificates from the Continuing Professional Development (CPD) courses you have undertaken in the period of your suspension. The Committee noted the CPD certificates and your reflections on these courses. You provided an updated reflective statement dated 8 August You have also provided a report from your mentor dated 6 August 2018, and undertaken self-reflection including working with your Deanery approved mentor on the importance of contemporaneous recording of clinical findings, treatment planning, antimicrobial prescribing, patient consent, effective communication, crown and bridgework and endodontics. With regards to the dishonesty finding, the Committee took into account the relevant case law. It notes that you have fully accepted that your actions in respect of retrospective entries made in patient records were dishonest. Your mentor has stated that it is not easy to address your dishonesty in a reflective statement, however, in your most recent reflective statement dated 8 August 2018, you have shown remorse and regret for your past dishonest behaviour. You have taken into account the findings of the last PCC review hearing and acknowledge and appreciate the seriousness and implications of your wrong-doing. The Committee notes you have liaised with your Postgraduate Deanery in attending a further three mentor sessions to demonstrate self-awareness and insight into your dishonest behaviour. The Committee concluded that you have demonstrated insight into your dishonest behaviour and provided evidence that your dishonest conduct had been remedied. The Committee considered that the past 3 months had given you an opportunity to realise the errors of your dishonest actions. Your reflective statement showed that you had learnt a salutary lesson from these proceedings and you have demonstrated clear measures to avoid repetition. It was satisfied that the likelihood of repetition was low. The Committee determined that your fitness to practise is not impaired by reason of your misconduct relating to your dishonest conduct. In coming to this conclusion, the Committee noted that you have shown insight, remorse for your conduct and have reflected on the impact of your conduct on the reputation of the profession. With regards to the clinical failings in this case, the Committee noted you have continued to work with the postgraduate dental dean, and provided personal reflections on the courses you attended. The Committee is of the view that you have demonstrated good insight and reflection into your clinical failings. However, it does note that you have not practised dentistry for over 9 months and as such you have been unable to apply your learning in your MINEVA, P S Professional Conduct Committee Nov 2017 Aug 2018 Page -17/20-