HEARING PARTLY HEARD IN PRIVATE*

Transcription

1 HEARING PARTLY HEARD IN PRIVATE* *The Committee has made a determination in this case that includes some private information. That information has been omitted from this text. HERMANN, Hari Cristofor Registration No: PROFESSIONAL CONDUCT COMMITTEE FEBRUARY 2017 Outcome: Suspended for 12 months with immediate suspension (with a review) Hari Cristofor HERMANN, a dentist, DMD Arad 2003 was summoned to appear before the Professional Conduct Committee on 6 February 2017 for an inquiry into the following charge: Charge (as amended 9 February 2017) That being a Registered Dentist: 1. You provided care and treatment to the patients identified in Schedule 1. Patient A: 2. Patient A, consulted you variously between 31 st October 2012 and 1 st December 2012 initially seeking options for the cosmetic replacement of veneers present on UR1, UL1 and UL2. 3. On 31 October 2012 you failed to carry out: a) an adequate diagnostic assessment of Patient A s dental condition; b) adequate pre-treatment investigations including radiographic examination and vitality testing. 4. On 31 October 2012 you provided root canal treatment to teeth that was not clinically justified, namely: a) UR1; b) UL1; c) UL2. 5. On 31 October 2012 you failed to provide an adequate standard of root canal treatment, including by: a) causing a perforation in the UR1 which you failed to recognise; b) failing to repair the perforation in UR1 and/or failing to advise that the perforation in UR1 be repaired; c) providing a canal filling short of the apex on UR1, UL1 and UL2. 6. On 31 October 2012 you failed to maintain an adequate standard of record keeping, including by failing to record: HERMANN, H C Professional Conduct Committee February 2017 Page -1/17-

2 a) the evaluation of any radiographs taken of Patient A; b) the diagnosis and justification for the root canal treatment provided on UR1, UL1 and UL2; c) the details of the root canal treatment stages, including data of diagnostic and working lengths of the respective canals of the UR1, UL1 and UL2; d) the detail of the procedure followed for the root canal filling on UR1, UL1 and UL2; e) the detail of the procedure used to achieve an optimum adequate root canal seal; f) details of the type and the amount of local anaesthetic used; g) the stages of crown preparation; h) a full dental chart. 7. You prescribed antibiotics to Patient A at some point between 31 October 2012 and 1 December 2012 without recording: Patient B: a) the appointment at which you did so; b) the justification for the prescription. 8. Patient B, consulted you variously between December 2013 and June 2014, initially on the 6 December On 6 December 2013 you failed to carry out: a) an adequate diagnostic assessment of Patient B s dental condition by taking a set of bitewing radiographs; b) adequate pre-treatment investigations assessing the suitability of abutment teeth by the use of periapical radiographs. 10. On 6 December 2013 you failed to obtain informed consent for treatment of the conventional bridge proposed, including; a) by not informing Patient B that complications might occur, such as: i) the teeth becoming non-vital after preparation; ii) the need for root canal treatment. 11. On 13 December 2013 you failed to provide an adequate standard of care to Patient B by using excessive force in order to fit a bridge to his upper left quadrant. 12. Between 17 January 2014 and 13 June 2014 you failed to provide an adequate standard of root canal treatment to UL4, including by; i) not establishing the diagnostic length and the working length of the canal; ii) providing a short, poorly condensed root canal filling. 13. Between 17 January 2014 and 11 February 2014 you failed to maintain an adequate standard of record keeping, including by failing to record: HERMANN, H C Professional Conduct Committee February 2017 Page -2/17-

3 i) the diagnosis and clinical justification for the root canal treatment provided on UL4; ii) details of the root canal treatment stages, including data on diagnostic and working length of the canals; iii) the details of any difficulties and possible complications that occurred; iv) the detail of the procedure used to achieve an optimum adequate root canal seal; v) the obstruction created during the process of root canal treatment; vi) details of the type and the amount of local anaesthetic used; vii) a full dental chart. 14. You prescribed antibiotics on 13 June 2014 without clinical justification. 15. You failed to refer Patient B for further treatment on UL4 at an earlier opportunity than 26 June And that by reason of the facts alleged, your fitness to practise is impaired by reason of your misconduct. As Mr HERMANN did not attend and was not represented at the hearing, the Chairman made the following statement regarding proof of service. He addressed this to the Counsel for the GDC. Decision on service of notification of hearing Mr Hermann was neither present nor represented at this hearing. At the commencement of the hearing the Committee heard applications from Mr Raudnitz, Counsel, on behalf of the General Dental Council (GDC). He first made an application under Rule 13 of the General Dental Council (Fitness to Practise) Rules 2006 that the notification of hearing had been sent to the Registrant in accordance with the Rules. The Committee had sight of a copy of the notification of hearing letter dated 3 January 2017 which was sent to Mr Hermann s registered address in Romania. It noted that the letter contained all the components necessary for notice to be valid as set out in the Rules. The Committee also had sight of the Royal Mail track and trace proof of delivery which showed that the notification of hearing letter was delivered on 11 January The notice of hearing was sent to Mr Hermann s then legal representatives, RadcliffesLeBrasseur (RLB) but in a letter dated 11 January 2017, RLB informed the GDC that they were no longer representing Mr Hermann in these proceedings. The notice of hearing was then sent on 12 January 2017 to Mr Hermann via to an address with which he had previously corresponded with the GDC. The Committee was satisfied that the notification of hearing had been served in accordance with Rules 13 and 65. Decision on proceeding in the Registrant s absence Mr Raudnitz then made an application under Rule 54 that the hearing should proceed in Mr Hermann s absence. The Committee bore in mind that its discretion to proceed with a hearing in these circumstances should be exercised with the utmost care and caution. The Committee was referred to the cases of R v Jones [2003]; R v Hayward [2001] QB 862; R v Jones [2001] EWCA Crim 168 and GMC v Adeogba & Visvardis [2016] EWCA Civ 162. It also took account of Mr Raudnitz s submissions and it accepted the advice of the Legal Adviser. HERMANN, H C Professional Conduct Committee February 2017 Page -3/17-

4 The Committee noted the dated 5 February 2017 from Mr Hermann to the GDC in which he stated With respect, I can t be present in the hearing. I am back in Romania for unknown period due to personal problems. This was in response to a chasing from the GDC s legal representatives asking the Registrant to confirm whether he would be attending today s hearing. The also offered the Registrant the opportunity to participate at this hearing via Skype or telephone. The Committee noted that the Registrant did not indicate the nature of the personal problems neither had he requested an adjournment of this hearing. The Committee concluded that the Registrant had waived his right to attend these proceedings and an adjournment would be unlikely to secure his attendance at a future date. The Committee noted Mr Raudnitz s submissions that this hearing was adjourned in 2016 due to issues of service. Given the time that matters have been waiting to be resolved, the serious nature of the allegations against the Registrant, the effect of any further delay on the memory of the witnesses, fairness to the GDC and the public interest in the expeditious disposal of this case, the Committee determined, in the circumstances, to proceed with this hearing notwithstanding the absence of the Registrant. Mr HERMANN was not present and was not represented. On 10 February 2017 the Chairman announced the findings of fact to the Counsel for the GDC: The General Dental Council s (GDC) case The GDC s case concerns allegations against Mr Hermann in respect of his treatment of Patient A at the Lichfield Family Dental Practice (the Practice) between 31 October 2012 and 1 December 2012 and his treatment of Patient B between December 2013 and June 2014 at Elite Dental Clinic (the Clinic) and Smiles Dental Practice, Birmingham. In brief, the allegations against Mr Hermann fall into three categories: His investigation and pre-treatment work The treatment provided His record keeping Patient A s complaint surrounds the provision of root canal treatment (RCT) and crowns. Patient A complained that from the completion of the temporary crowns by Mr Hermann she suffered pain and discomfort. She sought a second opinion in January 2013 where she was advised that the root canals had not been filled to the apex. She subsequently received remedial work. Patient B s complaint surrounds the provision of a four-unit bridge on 13 December 2013 and the pain he suffered following the fitting of the bridge. Patient B subsequently received treatment at Broadway Dental Centre to alleviate his pain. Application to amend the charge Prior to closing your case, you made an application under Rule 18(1) to amend charge 5(b) by inserting the following text after the word UR1 : and/or failing to advise that the perforation in UR1 be repaired. You made this application in the light of Ms Karpeta s oral evidence (expert witness called on behalf of the GDC) following a question put to her by a panellist that she would not expect a general dental practitioner to repair the perforation in UR1. However, she considered that in HERMANN, H C Professional Conduct Committee February 2017 Page -4/17-

5 those circumstances there would be a duty on the dentist to advise the patient that the perforation should be repaired by a practitioner who could carry out the procedure. The Committee has accepted the advice of the Legal Adviser. It has borne in mind that the proposed amendment has been made at a late stage in the proceedings, namely at the close of the GDC s case. Mr Hermann has not been placed on notice of this proposed amendment. Mr Hermann has not prepared a defence to his case and is not participating in the hearing. In the circumstances the Committee considers that the proposed amendment allows it to consider the full range of options open to the dentist. Accordingly, the Committee is satisfied that the amendment to charge 5(b) can be made without injustice to Mr Hermann and has determined to amend charge 5(b) in the terms set out above. The evidence The Committee has had regard to all the evidence before it, both documentary and oral. This includes the GDC s hearing bundle which contained the signed witness statements of VH (a dentist and the current owner of the Practice), Patient B and PH (an associate dentist at Patient B s regular treating dental practice). In addition, the Committee has had regard to copies of Patient A s dental records provided by the Practice and from other dental practices as well as copies of Patient B s dental records from the Clinic and from other dental practices. Patient A was not a witness in this case and therefore the Committee received no direct evidence from her. VH gave evidence by Skype and she was able to give evidence in relation to the dental records of Patient A. VH confirmed in her evidence that two searches had been completed on two separate occasions by different individuals which established that no x-rays were available for Patient A at the Practice. The Committee found VH to be an honest and credible witness. Patient B did not attend the hearing and the Committee agreed to receive his witness statement as hearsay evidence. It also had regard to Patient B s dental records, which were consistent with his written statement, in view of which the Committee was able to give weight to his evidence. The Committee also heard evidence from PH by way of telephone. It found her to be an honest and credible witness. The Committee considered carefully the expert evidence of Ms Karpeta. She produced a report on Patient A dated 13 January 2016 and a report on Patient B, also dated 13 January 2016, in which she set out her opinion as to the shortcomings in Mr Hermann s treatment of these patients. In coming to her view, Ms Karpeta referred to a number of publications, including the Faculty of General Dental Practice s Standards in Dentistry (2007), the GDC s Standards for Dental Professionals (2005) for Patient A and the GDC s Standards for the Dental Team (2013) for Patient B. The Committee considered that Ms Karpeta gave a fair and balanced opinion in respect of the allegations against Mr Hermann. In general, the Committee has accepted her evidence and where it differs from her opinion, the Committee has set out its reasons for doing so. The Committee has considered carefully the submissions you have made. It has accepted the advice of the Legal Adviser. It has borne in mind that the burden of proof is on the GDC to prove the facts as alleged and that it must decide the facts according to the civil standard of proof, namely on the balance of probabilities. Mr Hermann does not have to prove anything. In accordance with that advice it has considered each head of charge separately. I will now announce the Committee s findings as follows: 1. Found proved The clinical records show that Mr Hermann provided care and treatment to HERMANN, H C Professional Conduct Committee February 2017 Page -5/17-

6 Patients A and B at the times alleged. 2. Found proved The clinical records show that Mr Hermann saw Patient A on 31 October 2012 when Patient A attended for an examination. Discussions took place concerning cosmetic treatment of the UR1, UL1 and UL2. The clinical records confirm that RCT was provided to UR1, UL1 and UL2 at this same appointment. On 13 November 2012 crowns were fitted. Thereafter Mr Hermann saw Patient A at an appointment on 1 December a) Found proved The clinical records for 31 October 2012 record an examination, including medical history, extra-oral and intra-oral examination. During this same session, the UR1, UL1 and UL2 were root filled and prepared for cosmetic crowns. Ms Karpeta s evidence was that she could find no evidence of an assessment and diagnosis made prior to treatment. She was critical of Mr Hermann s failure to perform any diagnostic assessments, particularly given that the treatment proposed (RCT) is irreversible. Ms Karpeta explained that not performing any diagnostic assessments and pre-treatment investigations could lead to a wrongful diagnosis and subsequently to unjustifiable/unnecessary treatment. The Committee accepts Ms Karpeta s evidence on this matter. 3. b) Found proved 4. a), 4.b) & 4.c) VH confirmed that there were no x-rays available for Patient A at the Practice. Ms Karpeta considered that as part of the assessment and diagnosis process, radiographic examination and vitality testing should have been carried out. She was unable to find any evidence of such testing having been carried out on 31 October The Committee agrees. Found proved The Committee has had regard to the letter dated 11 February 2013 from AV, an endodontist to whom Patient A had been referred by RM, a dentist from Whitehouse dental practice. The letter from AV contains information reported to her by Patient A. The Committee was mindful that this was hearsay evidence but the account given by Patient A appeared detailed and credible and the Committee felt able to give some weight to it. The Committee agrees with Ms Karpeta that there was no evidence of any symptoms from these three teeth to lead to their RCT. She explained that as the purpose of the treatment was to improve the cosmetic aspect of the teeth previously treated with veneers, treatment planning should have been limited to that aspect, preserving the teeth s vitality. The Committee agrees with Ms Karpeta s opinion. 5. a) Found proved RM saw Patient A on 18 January 2013 where he took a radiograph. He records: Showed pt and showed pa. Radiolucency in this area suggest prob perforation prior to today s tmt. Advised poor prognosis but suggest endo opinion. RM referred Patient A to AV. The referral letter to AV explains that as I stepped down it became evident that there was perforation labially as the file protruded through the labial attached gingiva! I believe that this must have been present HERMANN, H C Professional Conduct Committee February 2017 Page -6/17-

7 previous to my treatment and probably is associated with the distal radiolucency under the crown. RM confirmed this position in his referral letter to AV dated 11 February Ms Karpeta referred to the radiographic image of the UR1 which showed that it had been perforated. Accordingly, the Committee finds this charge proved. 5. b) Found not proved insofar as it relates a failure to repair the perforation in UR1. Found proved in relation to a failure to advise that the perforation in UR1 needed to be repaired. Ms Karpeta accepted that there was no culpable failure in not repairing the perforation in the UR1 if the dentist did not think that he was qualified or able to do so. The Committee agrees with Ms Karpeta s opinion that in the event that the dentist could not carry out the repair himself, it was incumbent upon him to advise the patient that the perforation should be repaired. There is no evidence that he took any remedial action and the canal remained perforated until May 2013, when AV repaired the perforation. 5. c) Found proved The Committee has accepted Ms Karpeta s evidence that the radiographic images of the three teeth concerned showed the canal fillings were short of the apex. This position was confirmed in the correspondence between AV and RM. 6. a) Found not proved The Committee has found that in charge 3(b) radiographs were not taken on 31 October 2012 and therefore this charge falls away because radiographs cannot be evaluated if they were not taken. 6. b) Found proved The Committee, having seen the clinical records for 31 October 2012, can find no record of the diagnosis and justification for the RCT provided on UR1, UL1 and UL2. It accepts Ms Karpeta s evidence that this information should have been recorded in the clinical notes. 6. c) Found proved The Committee, having seen the clinical records for 31 October 2012, can find no record of the details of the RCT stages for UR1, UL1 and UL2, including data on diagnostic and working lengths of the respective canals. It accepts Ms Karpeta s evidence that this information should have been recorded in the clinical notes. 6. d) Found proved The Committee, having seen the clinical records for 31 October 2012, can find no record of the details of the procedure followed for the RCT at UR1, UL1 and UL2. It accepts Ms Karpeta s evidence that this information should have been recorded in the clinical notes. 6. e) Found proved The Committee, having seen the clinical records for 31 October 2012, can find no record of the details of the procedure used to achieve an optimum adequate HERMANN, H C Professional Conduct Committee February 2017 Page -7/17-

8 root canal seal. It accepts Ms Karpeta s evidence that this information should have been recorded in the clinical notes. 6. f) Found proved The Committee, having seen the clinical records for 31 October 2012, can find no record of the details of the local anaesthetic used. It accepts Ms Karpeta s evidence that this information should have been recorded in the clinical notes. 6. g) Found proved The Committee, having seen the clinical records for 31 October 2012, can find no record of the stages of crown preparation. It accepts Ms Karpeta s evidence that this information should have been recorded in the clinical notes. 6. h) Found proved The Committee, having seen the clinical records for 31 October 2012, can find no record of a full dental chart. It accepts Ms Karpeta s evidence that this information should have been recorded in the clinical notes. 7. a) Found proved In support of its case, the GDC relies on the evidence of Ms Karpeta. In her report, Ms Karpeta quotes a letter dated 18 January 2013 from Patient A, which states that after having the temporary crowns fitted she experienced pain and discomfort. She was then given a course of amoxicillin. She describes feeling uncomfortable at meeting Mr Hermann at his house to pick up antibiotics from his wife. The Committee has not been provided with a copy of Patient A s letter and has received no evidence from her. However, the Committee considers that Patient A s account referred to in Ms Karpeta s report is consistent with the account set out by AV in her letter to Dr M dated 11 February In AV s letter she states that Patient A waited until after Christmas when she was given another course of antibiotics via the dentist s wife. The Committee considers that the circumstances in which Patient A described receiving antibiotics from Mr Hermann are unusual and it is something that she is likely to have remembered. Furthermore, this account is supported by the entry made by RM on 11 January 2013 (when he first saw Patient A) in which he records Had crs fitted upper ants 2/12 ago at dentist in Lichfield Pt has had 2 x courses amoxicillin which settled for a while but pain now returned. The evidence before the Committee satisfies it that Mr Hermann prescribed antibiotics to Patient A between 31 October 2012 and 1 December b) Found proved There is no record in the clinical notes of the justification for the prescribing of amoxicillin to Patient A sometime between 31 October 2012 and 1 December Ms Karpeta was critical of Mr Hermann s failure to record the justification for this prescription and the Committee agrees. 8. Found proved It is clear from the clinical records that Patient B consulted Mr Hermann variously between 6 December 2013 and June Furthermore, Patient B, in his letter of complaint to Mr Hermann dated 14 July 2014 referred to Mr Hermann having HERMANN, H C Professional Conduct Committee February 2017 Page -8/17-

9 9. a) & 9.b) 10. a) i) & 10. a) ii) provided him with a bridge at around the end of November and the fact that he had returned to see Mr Hermann many times due to the problems he had experienced. Found proved Patient B s first appointment with Mr Hermann took place on 6 December The notes of that consultation record discussions of the different options being offered to Patient B and a note that Patient B was happy with option 2 (remove the existing bridge and place bridge at UL4-UL7) and to proceed with treatment that day. During that same appointment, the existing bridge was removed and the UL4 and UL7 were prepared as future bridge retainers. Patient B s evidence was that no x-rays were taken at the first appointment and there is no reference to radiographs having been taken in the clinical records for 6 December Ms Karpeta s opinion was that given that this was a new patient examination, Mr Hermann should have taken a set of bitewing radiographs to assess possible carious lesions and bone levels of the patient s teeth in view of the lack of a previous dental history. She also opined that as part of the assessment and diagnostic process, Mr Hermann should have taken periapical radiographs of the abutment teeth (UL4 and UL7). Ms Karpeta referred to the Faculty of General Dental Practice 2013 Selection Criteria for Dental Radiography regarding the requirement to take radiographs. The Committee has accepted Ms Karpeta s evidence on this matter. Found proved Patient B s evidence was that at the initial appointment on 6 December 2013 Mr Hermann told him that he could do a 4-unit bridge instead of implants and that he had time to do the bridge straight away. Patient B s evidence was that Mr Hermann only told him about the reasons why he should not have implants Mr Hermann did not tell him about the risks or benefits of having the bridge. However, the Committee has borne in mind that Patient B s evidence on this matter is fairly general and does not go to the issues raised by Ms Karpeta. Ms Karpeta considered that the patient should have been informed of possible risks and complications, such as the teeth becoming non-vital after the preparation and the need for RCT. The Committee has seen the clinical records for 6 December 2013 which sets out the treatment options proposed. However, the only disadvantage being recorded is disadvantage is teeth have to reduced in size slightly due to filing the enamel, teeth aren t damaged this way but will be sensitive to hot/col if exposed. There is no mention of the teeth becoming nonvital and the possibility of RCT being required, should this occur. The Committee therefore finds this charge proved. 11. Found not proved Patient B s evidence was that when Mr Hermann fitted the bridge he really had to force it and hold Patient B s head still at the same time. Patient B describes the procedure as being unbearable. However, the Committee has borne in mind that it has not had an opportunity to explore Patient B s evidence further by way of oral testimony. It considers that a patient s perception of feeling that excessive force was used could be considered to be quite subjective. There is no evidence, either from other dental professionals who may have been HERMANN, H C Professional Conduct Committee February 2017 Page -9/17-

10 assisting Mr Hermann at that appointment, or from subsequent treating dental professionals who saw Patient B, to corroborate Patient B s account. In the absence of any supporting evidence, the Committee is not satisfied that this charge is proved to the requisite standard. 12. i) Found not proved Patient B attended for further stages of RCT on 22 January 2014, 3 February 2014, 11 February 2014 and on 13 June During that time the UL4 was irrigated. Ms Karpeta s evidence was that she could find nothing from the clinical records providing evidence of the RCT stages and data of diagnostic and working lengths of the respective canal(s) of the UL4. However, the Committee has had regard to the clinical notes between 17 January 2014 and 13 June 2014 which records on several occasions a working length of 21mm as well as the use of an apex locator. The Committee is satisfied, on the balance of probabilities, that these entries indicate that Mr Hermann had established the diagnostic length and working length of the canal. 12. ii) Found proved PH s evidence was that she saw Patient B for an urgent appointment on 21 July She explained that Patient B had brought with him some x-rays taken by another dentist who had been treating him regarding his bridge. PH s evidence was that the x-rays showed that the RCT at UL4 was very short. She told the Committee that it was apparent from the x-ray that the root canal was roughly halfway up the root, and not close to the apex. The Committee has seen a copy of the x-rays from which it is evident that there is a short poorly condensed root canal filling. Ms Karpeta s evidence was that Mr Hermann failed to provide an adequate standard of RCT by providing a short, poorly condensed RCT at UL4 and the Committee agrees. 13. i) Found not proved Ms Karpeta considered that the clinical notes were lacking in detail in respect of the diagnosis and clinical justification for the RCT provided on UL4 on 17 January The Committee, having seen the clinical notes for 17 January 2014 and using its own professional judgement, considers that they contain sufficient information such that another dentist taking over the care of Patient B would understand Mr Hermann s rationale for the clinical justification of RCT at UL4. It is satisfied that the record is adequate and therefore disagrees with Ms Karpeta s evidence on this matter. 13. ii) Found proved in respect of details of the root canal treatment stages Found not proved in respect of data on diagnostic and working lengths of the canals. The Committee notes that there is nothing in the clinical notes for the times alleged regarding details of the root canal treatment stages and therefore the Committee finds this part of the charge proved. However, as set out in its reasons at finding charge 12(i) above not proved, the Committee has seen evidence of a record of the diagnostic and working length of the canals. HERMANN, H C Professional Conduct Committee February 2017 Page -10/17-

11 13. iii) Found proved The Committee notes that there is nothing in the clinical notes to say that Mr Hermann had finished the RCT. There are no details of any difficulties and possible complications that may have occurred, such as difficulties in access due to blocked or sclerosed canals. The Committee agrees with Ms Karpeta s evidence on this matter. 13. iv) Found proved There is no record of the details of the procedure used to achieve an optimum adequate root canal seal whereas it notes that a full note of this has been recorded in the patient notes dated 18 August 2014 for the Broadway Dental Centre. The Committee agrees with Ms Karpeta s evidence on this matter. 13. v) Found proved There is no record of the obstruction created during the process of RCT. The Committee agrees with Ms Karpeta s evidence on this matter. 13. vi) Found not proved The clinical notes dated 17 January 2014 states la espestesin 4% x 1 cart infiltrations and therefore Mr Hermann has made a record of the local anaesthetic used on that occasion. In respect of the further appointments on 22 January 2014, 3 February 2014 and 11 February 2014, the Committee notes that the GDC has adduced no evidence to demonstrate that Mr Hermann had used anaesthetic on these occasions. There is no record in the clinical notes of anaesthetic being used. Given that Mr Hermann has recorded the use of anaesthetic elsewhere in the notes, and at the previous appointment, the Committee is not satisfied that this charge is made out to the requisite standard. 13. vii) Found proved There is no evidence of a full dental chart. 14. Found proved The clinical records state that on 13 June 2016 Patient B was still having pain when biting something hard and to hot/cold. Pt concerned as going away in x 2 weeks for 3 weeks. Mr Hermann prescribed a course of antibiotics ( co-amoxi 625mg x 7 days x 12 hours ). Ms Karpeta referred to the Antimicrobial Prescribing for General Dental Practitioners by the Faculty of General Dental Practice (May 2012) which sets out the circumstances where antimicrobial prescribing in primary care is indicated. Ms Karpeta could find nothing in the clinical records to indicate that Patient B had signs of a systemic illness or that there was a severe and spreading infection. She considered that, based on current practice and the above guidelines, Mr Hermann should not have prescribed antibiotics. The Committee has accepted Ms Karpeta s evidence on this matter. 15. Found proved The Committee has seen a copy of Mr Hermann s letter dated 26 June 2014 in which he refers Patient B for further investigation following the painful symptoms from the upper left quadrant. There is no evidence elsewhere in the clinical HERMANN, H C Professional Conduct Committee February 2017 Page -11/17-

12 notes that Mr Hermann referred Patient B for further treatment prior to this date. The Committee notes that there is reference in the clinical notes of pain being recorded on 7 occasions within a period of about six months: 16 December 2013, 3 January 2014, 17 January 2014, 22 January 2014, 3 February 2014, 11 February 2014 and 13 June Patient B, in his statement, describes being in daily pain with his tooth for a year and having to take regular painkillers to help with the pain. In these circumstances, given that Patient B had been experiencing pain for some six months following the fitting of the bridge on 6 December 2013, the Committee considers that Mr Hermann should have referred Patient B for further treatment before 26 June We move to Stage Two. On 10 February 2017 the Chairman announced the determination as follows: At this hearing the Committee made a determination that includes some private information. That information shall be omitted from any public version of this determination and the document marked to show where private material is removed. Mr Raudnitz: The Committee has considered the submissions you have made under Rule 20 of the General Dental Council (GDC) (Fitness to Practise) Rules 2006 (the Rules) following the Committee s announcement of the facts found proved. During the course of your submissions you referred the Committee to your document dated 7 February 2017 in which you set out the law in relation to the issues under consideration by the Committee at this stage of the proceedings. The Committee has accepted the advice of the Legal Adviser. Misconduct The Committee considered whether the facts found proved amount to misconduct. In so doing, it has had regard to all of the evidence before it, including the expert evidence of Ms Karpeta. The Committee has also had regard to the GDC s Standards for Dental Professionals (2005) for Patient A and the GDC s Standards for the Dental Team (2013) for Patient B. You submitted that the findings against Mr Hermann, which relate to the care and treatment he provided to Patients A and B, are serious and amount to misconduct. You referred to Ms Karpeta s opinion that she was critical of the matters set out in the charges (those charges which have been found proved by this Committee) and she considered that each of them amounted to a falling far below the standards expected of a reasonable competent dentist. The Committee has exercised its own professional judgement. It is aware that a finding of misconduct in this regulatory context requires a serious falling short of the standards to be expected of a registered dentist. The Committee has had regard to its findings in relation to Mr Hermann s treatment of Patient A between 31 October 2012 and 1 December In summary, the findings in respect of Patient A are: Failing to carry out an adequate diagnostic assessment of Patient A s dental condition and pre-treatment investigations, including radiographic examination Providing root canal treatment to three teeth that was not clinically justified Failing to provide an adequate standard of root canal treatment on 31 October 2012 HERMANN, H C Professional Conduct Committee February 2017 Page -12/17-

13 Failing to maintain an adequate standard of record keeping on 31 October 2012 Prescribing antibiotics on one occasion without recording the appointment at which he did so and the justification for that prescription. The findings in relation to Patient B include: Failing to carry out adequate diagnostic assessment of Patient B s dental condition by not taking appropriate radiographs Failing to obtain informed consent for the treatment of the conventional bridge proposed Failing to provide an adequate standard of root canal treatment to UL4 in providing a short, poorly condensed root canal filling Failing to maintain an adequate standard of record keeping between 17 January 2014 and 11 February 2014 Prescribing antibiotics on 13 June 2014 without clinical justification Failing to refer Patient B for further treatment on UL4 until 26 June 2014, where the Patient had been experiencing pain for some six months following the fitting of the bridge on 6 December The Committee considers that Mr Hermann s clinical failings, which concern two patients, were basic and wide ranging and amounted to a clear departure from the standards expected of a registered dentist. In relation to Patient A, the Committee considers that Mr Hermann has breached the following paragraphs of the GDC s Standards for Dental Professionals (May 2005): 1.1 Put patients interests before your own or those of any colleague, organisation or business. 1.4 Make and keep accurate and complete patient records, including a medical history, at the time you treat them. Make sure that patients have easy access to their records. 5.2 Continuously review your knowledge, skills and professional performance. Reflect on them, and identify and understand your limits as well as your strengths. 5.3 Find out about current best practice in the fields in which you work. Provide a good standard of care based on available up-to-date evidence and reliable guidance. In relation to Patient B, the Committee considers that Mr Hermann has breached the following paragraphs of the GDC s Standards for the Dental Team (September 2013): 1. Put patients interests first 2. Communicate effectively with patients 3. Obtain valid consent 4.1 You must make and keep complete and accurate patient records, including an up-to date medical history, each time that you treat patients. 6.3 Delegate and refer appropriately and effectively. HERMANN, H C Professional Conduct Committee February 2017 Page -13/17-

14 7.1 You must provide good quality care based on current evidence and authoritative guidance. Ms Karpeta (the GDC s expert witness) was critical of Mr Hermann s failures in his treatment of Patients A and B. Overall, Ms Karpeta graded Mr Hermann s treatment of both patients under category C (unacceptable) as set out in the Standards in Dentistry from the Faculty of General Dental Practice, UK, Category C describes a situation in which as a result of the care and treatment provided, the patient concerned has either been damaged or there is a potential for them to be damaged. The Committee agrees with Ms Karpeta s opinion. It has concluded that Mr Hermann s failures were serious, would be considered deplorable by fellow professionals and serve to bring the profession into disrepute. It is satisfied that the facts found proved amount to misconduct. Previous fitness to practise history You provided the Committee with details concerning Mr Hermann s fitness to practise history prior to the events in question. Mr Hermann first appeared before a Professional Conduct Committee (PCC) hearing in July He was present at the hearing and he was represented. The PCC reached a substantial number of findings against Mr Hermann concerning his treatment of Patient CB between May 2013 and December These included a failure to carry out sufficient diagnostic assessments; a failure to treat her periodontal disease; a failure to carry out sufficient pre-treatment investigations; providing treatment that was not indicated, and a failure to keep or maintain adequate dental records. The PCC in that case was satisfied that the findings against Mr Hermann amounted to a clear departure from the relevant GDC standards and were serious. They concluded that the findings amounted to misconduct. The PCC in July 2015 was not satisfied that the failings in respect of his treatment of Patient CB had been remedied. It also considered that Mr Hermann had made serious errors of judgement relating to basic and fundamental aspects of dentistry. The PCC determined that Mr Hermann s fitness to practise was impaired by reason of misconduct and imposed a suspension order for 12 months with a review. The PCC reviewed the order at a hearing on 15 July Mr Hermann attended that hearing and he was represented. At that hearing the PCC had regard to the material submitted in relation to his remediation. It acknowledged that Mr Hermann had taken some steps towards remediation since the last hearing. The PCC determined that Mr Hermann s fitness to practise was impaired. It concluded that a conditions of practice order was the appropriate sanction to allow Mr Hermann to return to work and to take further steps to remedy his failings. The PCC directed that conditions be imposed on Mr Hermann s registration for a period of 12 months, with an immediate order of conditions. [Private material removed] Current impairment The Committee next considered whether Mr Hermann s fitness to practise is currently impaired as a result of the misconduct proved in this case. You submitted that Mr Hermann s fitness to practise is currently impaired. You referred to the failings identified in this case in respect of two patients and the absence of evidence of remediation. Further, you say that there is no evidence of any insight, or any admissions made by Mr Hermann. In short, you say that Mr Hermann has failed to engage in relation to this hearing. You also invited the Committee to have regard to Mr Hermann s fitness to HERMANN, H C Professional Conduct Committee February 2017 Page -14/17-

15 practise history. You say that there has been a repeated pattern of clinical shortcomings in Mr Hermann s practice concerning other patients and spanning a considerable period of time. You therefore submit that the risk of repetition of the failings identified in this case remain. You also invited the Committee to reach a finding of current impairment in the wider public interest, which includes upholding the reputation of the profession and the declaring and upholding of proper standards of conduct. The Committee has carefully considered the submissions made. It has received no submissions or evidence from Mr Hermann, noting that he has chosen not to engage in these proceedings. The Committee is aware from correspondence contained in the documents before it that Mr Hermann is currently living in Romania. The Committee first considered whether the deficiencies in Mr Hermann s clinical practice are capable of being remedied, whether they have in fact been remedied, and whether they are likely to be repeated. The Committee is satisfied that Mr Hermann s clinical deficiencies are potentially remediable. However, it has received no evidence of Mr Hermann s attempts to remediate the deficiencies in his practice nor of his insight into the shortcomings of his treatment of Patients A and B. In these circumstances the Committee is not satisfied that Mr Hermann has addressed the concerns identified in this case. In the Committee s view, there is a risk of Mr Hermann repeating his behaviour, should he seek to return to dental practice in the United Kingdom, and therefore he poses a real risk to patients. The Committee has regard to Mr Hermann s fitness to practise history which demonstrates similar clinical failings relating to other patients at around the same time. The Committee has concluded that a finding of current impairment is necessary for the protection of patients. The Committee has also borne in mind the wider public interest, including the need to declare and uphold proper standards of conduct and behaviour, in order to maintain public confidence in the profession. The Committee has found proved that Mr Hermann has breached the GDC s standards. He failed to provide an appropriate standard of care to Patients A and B. In these circumstances, the Committee considers that public confidence in the profession would be undermined if a finding of impairment were not made. Having regard to all of these matters, the Committee has determined that Mr Hermann s fitness to practise is currently impaired by reason of his misconduct. Sanction The Committee has considered what sanction, if any, to impose on Mr Hermann s registration. It is mindful that the purpose of a sanction is not to be punitive, although it may have that effect, but is to protect patients and the wider public interest. The Committee has taken into account the GDC s Guidance for the Practice Committees including Indicative Sanctions Guidance (October 2016). It has applied the principle of proportionality, balancing the public interest with Mr Hermann s own interests. You submitted that the sanction of suspension for a period of 12 months would be appropriate and proportionate. The Committee has taken into account the mitigating and aggravating features of this case. No mitigation has been advanced by Mr Hermann or on his behalf. The aggravating factors include the serious errors of clinical judgement which resulted in Patients A and B suffering harm; the absence of any evidence of remediation, remorse or insight and his fitness to practise history [Private material removed] in respect of clinical concerns of a similar nature. HERMANN, H C Professional Conduct Committee February 2017 Page -15/17-

16 The Committee first considered whether to conclude this case with no further action but it determined that this would be wholly inadequate in view of the serious nature of Mr Hermann s misconduct and the ongoing risk to patient safety. Furthermore, taking no further action would not satisfy the public interest. It then considered whether issue a reprimand. The Committee concluded that a reprimand would not be sufficient to protect patients or safeguard public confidence in the profession. The Committee next considered the imposition of conditions on Mr Hermann s registration, bearing in mind that any conditions must be proportionate, measurable and workable. The Committee considers that the clinical failings in this case are potentially remediable and that on the face of it, Mr Hermann s deficiencies could be addressed by conditions on his registration. However, the Committee is aware that Mr Hermann s registration is currently subject to conditions following a direction made by the PCC in July It notes from the documents that Mr Hermann is currently in Romania and that he is not practising dentistry in the United Kingdom. The Committee has borne in mind the absence of any evidence of any insight or corrective steps taken by Mr Hermann, as well as his lack of engagement with the GDC in relation to these proceedings. It therefore has concerns about his capacity to comply with conditional registration. Accordingly, the Committee is not satisfied that conditions will adequately protect the public and the public interest. The Committee next considered whether to impose a period of suspension on Mr Hermann s registration. The Committee takes a serious view of Mr Hermann s failings when treating Patient A and Patient B. Ms Karpeta considered that Mr Hermann had breached relevant standards and guidelines and concluded that the failings in respect of both patients fell below the standard expected of a general dental practitioner. Furthermore, the Committee has had regard to Mr Hermann s fitness to practise history, which suggests a pattern of sustained, unacceptable practice. The Committee considered that although the misconduct was serious, it was not so serious as to merit the sanction of erasure. The Committee is of the view that the clinical shortcomings in this case are potentially remediable if Mr Hermann were to engage positively in remedial steps. The Committee is therefore satisfied that suspending Mr Hermann s registration will be sufficient and proportionate for the protection of the public and to main public confidence in the profession. The Committee directs that Mr Hermann s registration be suspended for a period of 12 months. It considers that Mr Hermann will need sufficient time to develop insight into his failings and for him to provide evidence of remediation. It is satisfied that a period of 12 months is appropriate and proportionate. A Committee will review Mr Hermann s case at a resumed hearing to be held shortly before the end of the period of suspension. That Committee will consider what action it should take in relation to Mr Hermann s registration. It may be assisted by evidence of sustained and targeted CPD specifically designed to address the deficiencies in his practice identified in this case. Mr Hermann will be informed of the date and time of that resumed hearing. Immediate order The Committee has considered whether to make an order for the immediate suspension of Mr Hermann s registration. In so doing, it has had regard to the submissions made by you as well as the advice of the Legal Adviser. HERMANN, H C Professional Conduct Committee February 2017 Page -16/17-

17 In accordance with Section 30 of the Dentists Act 1984 (as amended) the Committee has determined that it is necessary for the protection of the public and is otherwise in the public interest to order that Mr Hermann s registration be suspended forthwith. In reaching its decision, the Committee has concluded, for the reasons set out above, that Mr Hermann currently poses a risk to the public and that immediate action is necessary for the protection of the public and to maintain public confidence in the profession. It is satisfied that it would be inconsistent to allow Mr Hermann to practise during the 28 day appeal period, should he return to the United Kingdom, or, if an appeal is lodged, until it has been disposed of. The effect of this direction is that Mr Herman s registration will be suspended immediately. Unless Mr Hermann exercises his right of appeal, the substantive order of suspension will come into effect 28 days from the date on which notice of this decision is deemed to have been served on him. Should Mr Hermann exercise his right of appeal, this immediate order for suspension will remain in place until the resolution of any appeal. That concludes the hearing of Mr Hermann s case. HERMANN, H C Professional Conduct Committee February 2017 Page -17/17-