HEARING HEARD IN PUBLIC

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1 HEARING HEARD IN PUBLIC DE FERREIRA GOMES, Marta Alexandra Registration No: PROFESSIONAL CONDUCT COMMITTEE JANUARY - JULY 2017 Outcome: Conditions imposed for 18 months with immediate conditions (with a review) Marta Alexandra De Ferreira Gomes, a dentist, LMD Lisbon 2007 was summoned to appear before the Professional Conduct Committee on 25 January 2017 for an inquiry into the following charge: Charge (as amended 25th and 31st January 2017) That, being a registered dentist you: Patient A 1. Between 24 January 2013 and 25 March 2013 you failed to provide an adequate standard of care to Patient A, in that you: (a) (b) (c) (d) (e) (f) (g) Patient B on or after 24 January 2013, failed adequately or at all to treat caries and/or to restore the upper right 5; on or after 24 January 2013, failed adequately or at all to treat caries and/or to restore the upper left 6; on or after 15 February 2013, fitted a crown to the lower left 6 which was of a poor standard with a large distal defect. 2. Between 17 July 2013 and 31 July 2013 you failed to provide an adequate standard of care to Patient B, in that you: (a) (b) on or after 17 July 2013, in respect of carious lesions on the lower right 5: i) failed to treat the carious lesions; ii) failed to make arrangements for someone else to treat the carious lesions; (c) on or after 17 July 2013, in respect of carious lesions on the lower left 5: DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -1/20-

2 i) failed to treat the carious lesions; ii) failed to make arrangements for someone else to treat the carious lesions; (d) on or after 17 July 2013, in respect of carious lesions on the upper left 6; i) failed to treat the carious lesions; ii) failed to make arrangements for someone else to treat the carious lesions; Patient C 3. Between 17 July 2013 and 31 July 2013 you failed to provide an adequate standard of care to Patient C, in that you: (a) (b) on or after 17 July 2013, in respect of the upper right 6: i) failed to restore the tooth; ii) failed to make arrangements for someone else to restore the tooth; (c) (d) Patient D 4. On 12 July 2013 you failed to provide an adequate standard of care to Patient D, in that you: (a) failed to drain the infection to the upper left 4 by removing the necrotic pulp tissue; (b) issued a prescription for an antibiotic when this was not warranted. 5. On 12 July 2013 you failed to maintain an adequate standard of record keeping in respect of Patient D s appointments, in that you failed to record the justification for prescribing antibiotics to Patient D. Patient E 6. Between 20 June 2013 and 2 July 2013 you failed to provide an adequate standard of care to Patient E, in that you: (a) on or after 2 July 2013, placed Patient E on a three monthly recall without treating, adequately or at all, her oral health problems, including:- i) retained roots in the upper right 6; ii) retained roots in the upper right 4; iii) retained roots in the upper left 6; iv) retained roots in the upper left 7; v) retained roots in the lower left 6; vi) caries on the lower right 7; DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -2/20-

3 (b) Patient F vii) caries on the lower left 8; viii) caries on the upper left 8; on or after 20 June 2013, failed to make arrangements for someone else to treat Patient E s oral health problems, including:- i) retained roots in the upper right 6; ii) retained roots in the upper right 4; iii) retained roots in the upper left 6; iv) retained roots in the upper left 7; v) retained roots in the lower left 6; vi) caries on the lower right 7; vii) caries on the lower left 8; viii) caries on the upper left 8; 7. Between 19 July 2013 and 31 July 2013 you failed to provide an adequate standard of care to Patient F, in that you: (a) (b) failed to take radiographs that showed, adequately or at all:- i) the upper right 8; ii) the lower right 8; failed to advise Patient F of the presence of intra-enamel lesions on:- i) the upper right 6; ii) the upper right 5; iii) the upper left 6; iv) the upper left Between 19 July 2013 and 31 July 2013 you failed to maintain an adequate standard of record keeping in respect of Patient F s appointments, in that you: (a) in breach of the Ionising Radiation (Medical Exposures) Regulations 2000 ( IR(ME)R ) Regulation 7(8), failed to record an evaluation of Patient F s radiographs; (b) (c) failed to record the presence of intra-enamel lesions on:- i) the upper right 6; ii) the upper right 5; iii) the upper left 6; iv) the upper left 5. DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -3/20-

4 (d) failed to give and/or failed to record having given any advice to Patient F regarding management of the intra-enamel lesions. Patient G 9. On 6 March 2013 you failed to provide an adequate standard of care to Patient G, in that you failed to take correct BPE measurements and/or failed to record having taken correct BPE measurements. Patient H 10. On 25 March 2013 you failed to provide an adequate standard of care to Patient H, in that you: Patient I (a) failed to diagnose the patient s pain as originating from the lower right 4; (b) failed adequately or at all to treat the lower right On or after 02 April 2013 you failed to provide an adequate standard of care to Patient I, in that you failed adequately or at all to complete root canal treatment on the lower left 6. And in light of the above, your fitness to practise is impaired by reason of your misconduct. On 3 February 2017 the Chairman made the following statement regarding the finding of facts: Ms De Ferreira Gomes, This is a Professional Conduct Committee hearing. You are represented by Mr Jenkins, Counsel. Mr Raudnitz, Counsel, represents the General Dental Council (GDC). The GDC received a complaint on 12 November 2013 from an Assistant Clinical Director of Denticare, where you were previously employed as a dentist for a period of approximately 6 months. You were dismissed from the practice on 31 July The allegations before the Committee concern your alleged failings in relation to your clinical practice in that you failed to provide an adequate standard of treatment in relation to 9 patients (Patients A-I) and there were alleged failures in your record keeping in relation to Patients D and F. Preliminary Matters At the outset of the hearing, Mr Raudnitz made an application to amend the charge under Rule 18 of the GDC (Fitness to Practise) Rules 2006 (the Rules). He applied to amend the wording as follows: Head of charge 1.c) replace right with left Head of charge 3.a) replace left with right Head of charge 5) replace 21 with 12 Head of charge 6.a) replace discharged with placed, and to insert the words on a threemonthly recall to read as follows: On or after 2 July 2013, placed Patient E on a three monthly recall without treating, adequately or at all, her oral health problems, including:- DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -4/20-

5 Head of charge 9) insert the words and/or failed to record having taken correct BPE measurements to read as follows: On 6 March 2013 you failed to provide an adequate standard of care to Patient G in that you failed to take correct BPE measurements and/or failed to record having taken correct BPE measurements He submitted that these amendments were typographical errors and did not alter the case brought against you. Mr Jenkins on your behalf, did not object to the amendments to the heads of charge as outlined. The Committee accepted the advice of the Legal Adviser. In granting the application, the Committee took into account that no objection was raised by Mr Jenkins. It was satisfied that these amendments could be made without injustice to you. It therefore acceded to the application to amend heads of charge 1.c), 3.a), 5), 6.a) and 9. Mr Raudnitz then informed the Committee that he was seeking to withdraw a number of heads of charge. He applied for heads of charge 1.a), 1.d), 1.e), 1.f), 2.a)i), 2.a)ii), 3.a)i), 3.a)ii), 3.c)i), 3.c)ii), 3.d)i), 3.d)ii) and 8.b) to be withdrawn. Mr Jenkins made no objection to the withdrawal of these heads of charge. The Committee accepted the advice of the Legal Adviser. The Committee considered the application to withdraw these heads of charge. It was satisfied that as it was the GDC s application and there were no objections from Mr Jenkins on your behalf. The Committee therefore agreed to the application. Further amendments to the charge On 31 January 2017, Mr Raudnitz made a further application, under Rule 18 to amend the wording in charge 11) to insert the words on or after and remove Between and 12 April 2013, to read as follows: On or after 02 April 2013 you failed to provide an adequate standard of care to Patient I, in that you failed adequately or at all to complete root canal treatment on the lower left 6. He submitted that the failure in this particular charge did not conclude on 12 April and that it goes beyond that date. He submitted that it would be appropriate for Mr Jenkins to ask you further questions, should the Committee allow the amendment. Mr Jenkins asked for a brief adjournment to seek instructions on this point alone, and after speaking to you he indicated that there was no objection to the application. The Committee considered the application and, on the basis that it was not opposed, acceded to it. Admissions Mr Jenkins on your behalf, made admissions to heads of charge: 1.c), 1.g), 2.b)i), 2.d)i), 2.d)ii), 5, 6a)i)-viii), 8.a), 8.c)ii), 8.d) as to failing to record the giving of dietary advice and 9 as to failing to record. DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -5/20-

6 During the course of your evidence you made a further admission to head of charge 3.b), although this was not formally admitted by you when you made your admissions at the start of the hearing. Findings In reaching its decisions the Committee has considered all the documentary and oral evidence before it, together with the submissions made by Mr Raudnitz and Mr Jenkins. The Committee accepted the advice of the Legal Adviser. The Committee considered each head of charge separately. It reminded itself that the burden of proof rests with the GDC and that the standard of proof is the civil standard, that is, whether the allegations are proved on the balance of probabilities. The Committee reminded itself that you are not required to prove or disprove anything. The Committee considered the facts alleged in the light of the formal admissions and the evidence and found those facts admitted to be proved. The Committee received copies of the clinical notes of Patients A-I, including radiographs and a chain of s sent between you and the members of Denticare. The Committee did not have sight of any witness statements from Patients A-I or hear any oral evidence from them. With regard to your evidence, the Committee took account of the fact that you were giving your evidence in a foreign country and in a foreign language. It accepted that this would make the experience of giving evidence more stressful for you. However, it did not find you to be a wholly credible witness. It noted that you did not always give a straightforward answer to the questions you were asked. Further, on occasion you appeared, in oral evidence, to change your explanation for the rationale for treatment. The Committee was also concerned at your claim to remember all the details of consultations where you had seen a patient for a short period of time on a single occasion. The Committee heard expert evidence from Mr Denis Toppin, called on behalf of the GDC, and from Ms Sharon Caro, on your behalf. The Committee found both experts to have done their best to assist it. The Committee considered their evidence to be balanced, fair, measured and clear. I will now announce the Committee s findings in relation to each head of charge. 1.(a) 1.(b) Patient A On or after 24 January 2013, failed adequately or at all to treat caries and/or to restore the upper right 5; Found Not Proved On 24 January 2013 it was recorded in the clinical notes that the relevant radiograph were taken of Patient A s teeth. It was Mr Toppin s evidence that the radiograph clearly showed signs of caries and it was his conclusion that treatment was required to the UR5. It was Ms Caro s evidence that she thought it was highly unlikely that caries was present in this tooth. However, both experts were in an agreement that this tooth required further investigation. The Committee accepted Ms Caro s evidence on this matter. It could not be DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -6/20-

7 1.(c) 1.(d) 1.(e) 1.(f) 1.(g) 2.(a)(i) 2.(a)(ii) satisfied on the evidence that the radiolucency shown on the radiograph of the UR5 was caries. The Committee noted your evidence that you had viewed the radiograph and that it was your clinical judgment at the time that there was no caries. It was your evidence that you considered it appropriate to review the tooth at the next appointment. On the basis of the evidence, the Committee was not satisfied on the balance of probabilities that caries was present. Further, on the basis of Ms Caro s evidence, the Committee accepted that as the crown of this tooth appears to have been in situ before 2007 and was asymptomatic, there was no need to restore the tooth at this stage but to keep it under review. On or after 24 January 2013, failed adequately or at all to treat caries and/or to restore the upper left 6; Admitted and Found Proved as Amended On or after 15 February 2013, fitted a crown to the lower left 6 which was of a poor standard with a large distal defect. Admitted and Found Proved Patient B 2.(b)(i) On or after 17 July 2013, in respect of carious lesions on the lower right 5: i) failed to treat the carious lesions; Admitted and Found Proved 2.(b)(ii) ii) failed to make arrangements for someone else to treat the carious lesions; Found Proved Mr Raudnitz submitted to the Committee that this head of charge was put on two alternative bases. Firstly, he submitted that on the 31 July 2013 at the time of your dismissal you should have made arrangements for another dentist to be able to treat this patient by means of a handover. Alternatively, he submitted that in failing to treat this tooth and failing to place in the records details of a treatment plan, you were failing to make arrangements for someone else to treat the carious lesions. You told the Committee that you had placed a watch on the tooth and that this was sufficient notice to any subsequent treating dentist. DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -7/20-

8 The Committee noted your admission to 2.(d)(ii) which you made on the basis that you had not placed watch on that tooth. The Committee concluded that this showed that you accepted that you should have provided information for any subsequent treating dentist. However, on the basis that the Committee has found 2(b)(i) proved and that you should have recorded a treatment plan for this tooth it was not sufficient to record watch on this tooth. The Committee concluded that in failing to identify that the caries required treatment and also failing to set out a treatment plan, you failed to make arrangements for another dentist to treat these lesions. The Committee was satisfied that this head of charge was proved on this basis but it did not find that you should have made further arrangements on the 31 July at the time of your dismissal. 2.(c)(i) On or after 17 July 2013, in respect of carious lesions on the lower left 5: (i) Found Proved failed to treat the carious lesions; The Committee had regard to the evidence of both Mr Toppin and Ms Caro. The Committee noted that both experts were in agreement that the tooth required immediate treatment. The Committee accepted their evidence and was satisfied that you had a duty to treat it and that you failed to do so. 2.(c)(ii) (ii) failed to make arrangements for someone else to treat the carious lesions; 2.(d)(i) 2.(d)(ii) 3.(a)(i) 3.(a)(ii) Found Proved The Committee found this charge proved for the same reasons as set out in head of charge 2(b)(ii) above. On or after 17 July 2013, in respect of carious lesions on the upper left 6; failed to treat the carious lesions; Admitted and Found Proved Failed to make arrangements for someone else to treat the carious lesions; Admitted and Found Proved The Committee accepted your evidence that you failed to put a watch on this tooth. Patient C 3.(b)(i) On or after 17 July 2013, in respect of the upper right 6; (i) Failed to restore the tooth; Found Proved Both experts were of the opinion that the UR6 required immediate treatment. The Committee noted that you did not formally admit this head of charge at the DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -8/20-

9 outset of the hearing but later accepted, under cross examination that you should have restored the UR6. 3.(b)(ii) (ii) Failed to make arrangements for someone else to restore the tooth; 3.(c)(i) 3.(c)(ii) 3.(d)(i) 3.(d)(i) 4.(a) 4.(b) Found Proved The Committee found this head of charge proved for the same reasons as set out in head of charge 2(b)(ii) above. Patient D On 12 July 2013 you failed to provide an adequate standard of care to Patient D, in that you: (a) Failed to drain the infection to the upper left 4 by removing the necrotic pulp tissue; Found Not Proved The Committee noted that the evidence of both experts was that the proper course of treatment would be to drain the infection. However, the Committee noted your evidence that this was a patient with dental fears and had regard to the clinical notes of a subsequent treating dentist who recorded on the 14 October 2013 that this patient had dental fears. The Committee accepted Ms Caro s evidence that, despite the guidelines, it would be reasonable for a dentist to treat a fearful patient by the prescription of antibiotics with an arrangement for the patient to return for further treatment. The Committee determined that it was reasonable to conclude that if a patient had dental fears on the 14 October 2013 that patient would also have dental fears on 12 July In reaching this conclusion it also had regard to the entry on the 14 October, which showed that the patient had not visited a dentist for many years. The Committee also had regard to the evidence in your statement that if you had proceeded to drain the infection by removal of the necrotic pulp you would have wished to give a local anaesthetic which may not have been successful given the presence of infection. The Committee accepted that this may well have been the position in this case. On the basis of the evidence the Committee could not be satisfied on the balance of probabilities that you were under a duty to drain the infection by the removal of the necrotic pulp tissue on that day. (b) Issued a prescription for an antibiotic when it was not warranted Found Not Proved The Committee was satisfied on the evidence that it was reasonable, if you did not drain the infection by removing the necrotic pulp tissue, to prescribe DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -9/20-

10 antibiotics was the appropriate alternative treatment. 5. On 12 July 2013, you failed to maintain an adequate standard of record keeping in respect of Patient D s appointments, in that you failed to record the justification for prescribing antibiotics to Patient D. 6.(a) 6.(b) Admitted and Found Proved as Amended Patient E Between 20 June 2013 and 2 July 2013, you failed to provide an adequate standard of care to Patient E, in that you: (c) on or after 2 July 2013, placed Patient E on a three monthly recall without treating, adequately or at all, her oral health problems, including: - ix) retained roots in the upper right 6; x) retained roots in the upper right 4; xi) retained roots in the upper left 6; xii) retained roots in the upper left 7; xiii) retained roots in the lower left 6; xiv) caries on the lower right 7; xv) caries on the lower left 8; xvi) caries on the upper left 8; Admitted and Found Proved in its Entirety as amended (b) on or after 20 June 2013, failed to make arrangements for someone else to treat Patient E s oral health problems, including:- xvii) retained roots in the upper right 6; xviii) retained roots in the upper right 4; xix) retained roots in the upper left 6; xx) retained roots in the upper left 7; xxi) retained roots in the lower left 6; xxii) caries on the lower right 7; xxiii) caries on the lower left 8; xxiv) caries on the upper left 8; Found Not Proved in its Entirety The Committee had regard to the way that this head of charge was drafted. It noted that the stem of head of charge 6 alleges a failure to provide an adequate standard of care between the 20 June and 2 July It also had regard to the sub-stem of this particular head of charge which alleges on or after 20 June The Committee determined that by reason of the dates set out in the main stem of head of charge 6, the relevant dates for its DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -10/20-

11 7.(a) consideration did not go beyond 2 July The Committee had regard to the clinical notes where you have recorded, as the treatment option on the 20 June, that the patient should return for a scale and polish. It further noted that on the 2 July 2013 the patient did return and you carried out a scale and polish. On the basis that you had made arrangements on 20 June for you to see the patient again, the Committee could not be satisfied that you had failed to make arrangements for someone else to treat Patient E s oral health between the 20 June and 2 July. The Committee therefore concluded that there was no requirement for you to make arrangements for anyone else to treat the patient because you had made such arrangements which you carried out on the 2 July. The Committee determined that this head of charge could not be found proved based upon the way it has been drafted. Patient F Between 19 July 2013 and 31 July 2013 you failed to provide an adequate standard of care to Patient F, in that you: (a) Failed to take radiographs that showed, adequately or at all:- (i) The upper right 8; (ii) The lower right 8; Found Not Proved in its Entirety The Committee noted Mr Toppin s evidence that the radiograph you had taken was not diagnostically acceptable as it did not fully show either the UR8 or the LR8. He said that as the radiographs form part of the pre-treatment assessment, it would be expected that the teeth would be observable, however, neither tooth is captured and his evidence was that the radiograph provided no assistance. You told the Committee that the patient had complained of pain on the right side in the area of the wisdom teeth and that you had clinically observed that the UR8 was fractured. You said that you made a decision to refer the patient to the hospital for the extraction of that tooth. On that basis, you felt it was unnecessary to take a further radiograph. The practice did not have the equipment to take orthopantomographs (OPG) whereas the hospital did. You described bitewing radiographs as being a mandatory part of your NHS examination of the patient and the requirement was that they should show the pre-molars and molars but not all aspect of the wisdom teeth. The Committee had regard to Ms Caro s evidence that it was unnecessary to take a further radiograph on the basis of your clinical observation and diagnostic conclusion. Consequently, any further radiograph could have potentially exposed the patient to an unnecessary dose of radiation. The Committee noted that there was no subsequent evidence before it that there was any problem with the LR8. On this basis, the Committee was not satisfied on the balance of probabilities DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -11/20-

12 that there was a failure on your part to take the appropriate radiographs. 7.(b) (b) failed to advise Patient F of the presence of intra-enamel lesions on:- 8.(a) 8.(b) 8.(c) 8.(d) v) the upper right 6; vi) the upper right 5; vii) the upper left 6; viii) the upper left 5. Found Proved The Committee had regard to your clinical notes in which there was no record that you had advised the patient as to the presence of intra-enamel lesions. The Committee also noted, that unlike in other similar cases where you had recorded what you had considered to be minor lesions, you had not arranged to put a watch on these teeth. Consequently, the Committee was satisfied on the balance of probabilities that you had failed to advise the patient of the presence of the lesions. Between 19 July 2013 and 31 July 2013 you failed to maintain an adequate standard of record keeping in respect of Patient F s appointments, in that you: (e) in breach of the Ionising Radiation (Medical Exposures) Regulations 2000 ( IR(ME)R ) Regulation 7(8), failed to record an evaluation of Patient F s radiographs; Admitted and Found Proved (c) failed to record the presence of intra-enamel lesions on:- v) the upper right 6; vi) the upper right 5; vii) the upper left 6; viii) the upper left 5. Admitted and Found Proved Failed to give and/or failed to record having given any advice to Patient F regarding management of the intra-enamel lesions. Admitted in respect of failing to record the giving of dietary advice and otherwise Found Proved The Committee noted that, in your clinical records you make reference to flossing and the use of interdental brushes. It was your evidence that this would have been part of the advice that you gave the patient. However, the Committee noted entries in your other records and concluded that references to flossing and interdental brushing were part of the template and were not specific to advice given on the management of intra-enamel lesions. The Committee noted that there was no record of you having given advice with DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -12/20-

13 regard to diet, fluoride toothpaste or other fluoride treatment. On this basis, the Committee determined that on a balance of probabilities you had failed to give advice to the patient regarding the intra-enamel lesions. Patient G 9. On 6 March 2013 you failed to provide an adequate standard of care to Patient G, in that you failed to take correct BPE measurements and/or failed to record having taken correct BPE measurements. 10.(a) Admitted as to failing to record and otherwise Found Proved as amended The Committee was satisfied on the evidence that the template on the computer for BPE scores was pre-populated with zeros until such time as the BPE measurements were entered. The Committee was satisfied that if you had taken measurements you would have recorded them. On the basis that you did not record them, the Committee was satisfied that you failed to take the BPE measurements. Patient H On 25 March 2013 you failed to provide an adequate standard of care to Patient H, in that you: (a) Failed to diagnose the patient s pain as originating from the lower right 4; Found Not Proved At the appointment, the records show that the patient complained of some jaw pain. The Committee did not accept that she merely felt discomfort as you later maintained in your oral evidence. The Committee had regard to Ms Caro s opinion that it can be very difficult to diagnosis which tooth is causing pain. The Committee noted that you had recorded an infiltration in the LR4 and you had carried out the appropriate tests which were both negative. It determined that you exercised your clinical judgement and decided it was appropriate for the patient to return for a follow up appointment for the tooth to be re-assessed. The Committee was not satisfied in this evidence that you had failed to diagnose the pain as coming from LR4. 10.(b) (b) Failed adequately or at all to treat the lower right 4 Found Proved The Committee considered the evidence before it. It determined that whilst you may not have been able to identify the LR4 as the source of pain, as you had identified infiltration in that tooth, you should have treated that tooth by applying a varnish or other treatment. The Committee was satisfied that the purpose of such treatment would be to relieve the pain or confirm or eliminate the LR4 as the cause of that pain. Patient I DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -13/20-

14 11. On or after 02 April 2013 you failed to provide an adequate standard of care to Patient I, in that you failed adequately or at all to complete root canal treatment on the lower left 6. Found Proved The Committee had regard to all the evidence it had received on this head of charge. It noted your evidence, supported by the evidence of Ms Caro, that another appointment had been made for this patient on 1 May However, the Committee also noted your entry in the clinical notes for 12 April 2013 which put the patient on a six-month recall lesion regression??? The Committee determined to take no account of the appointment of 1 May 2013 as it had received no evidence as to who had made the appointment, when it was made, why is was made and who cancelled it. The Committee also noted that the patient had being charged for the treatment as if it were completed on 12 April Consequently, the Committee was satisfied that you had failed to complete the root canal treatment. We move to Stage Two. On 3 February 2017 the hearing was adjourned and resumed on 10 July On 11 July 2017 the Chairman announced the determination as follows: Ms De Ferreira Gomes, The Committee s tasks at this stage of the hearing have been to consider whether the facts found proved amount to misconduct and if so, whether your fitness to practise is currently impaired by reason of that misconduct. If the Committee found current impairment, it must then go on to decide what sanction, if any, to impose on your registration. The Committee took into account all of the evidence presented to it, at both the fact-finding stage and this stage. This included a copy of your Remediation Bundle comprising evidence of your Continuing Professional Development (CPD) and a bundle of testimonials. The Committee also took into account the submissions made by Ms Daly on behalf of the General Dental Council (GDC) and those made by Mr Jenkins on your behalf. The Committee had regard to the fact that it received a set of proposed conditions which had been agreed by the parties. It accepted the advice of the Legal Adviser. Facts found proved The facts in this case concern your treatment of nine patients, Patients A-I, whilst you were practising as a dentist at Denticare, Lampeter ( the Practice ). There were a number of failings in your care of Patients A-I, some of which you admitted at the outset of the hearing and also during your oral evidence. The Committee found that over the material time you failed to provide an adequate standard of care to Patients A-I in a number of respects. Misconduct The Committee considered whether the facts found proved amount to misconduct. It took into account that a finding of misconduct in the regulatory context requires a serious falling short of the standards expected of a registered dental professional. It had regard to the DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -14/20-

15 GDC s publication Standards for Dental Professionals (May 2005), which contains the applicable standards at the time of the events in this case. In particular, the Committee noted the following paragraphs. The Principles of Practice in Dentistry as a dental professional, you are responsible for doing the following: 1 Putting patients interests first and act to protect them. 4 Co-operating with other members of the dental team and other healthcare colleagues in the interests of patients. 5 Maintaining your professional knowledge and competence. The Committee also had regard to the following paragraphs: 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. The Committee determined that you had breached these Standards. The Committee appreciated that any breach of a standard does not automatically result in a finding of misconduct. In considering the gravity of your departures from the GDC s Standards, the Committee took into account the opinions of the expert witnesses in this case, Mr Toppin for the GDC and Ms Caro on your behalf. The Committee noted the agreed evidence of the expert witnesses that many of the matters found proved in this case fall below the standards expected. Nevertheless, there were aspects of your clinical care of Patients A-C and E-I that were viewed as significantly below what was expected of you as a dental practitioner. In particular, your failure in not diagnosing and treating carious lesions in respect of two patients, was deemed to fall far below the standards. The experts were similarly critical of your failure in record keeping, radiography and overall clinical administration of dealing with treatment. The Committee determined that with regard to Patient D in head of charge 5, this finding did not cross the threshold of seriousness to support a finding of misconduct, but the Committee was satisfied that the remaining matters found proved did cross the threshold of seriousness both individually and collectively. The Committee was of the view that the breaches in this case were wide-ranging, related to multiple patients and occurred over several months. The Committee concluded that your conduct was a significant departure from the standards expected of a registered dentist. The Committee considered that failures in taking and recording radiographs, appropriate record keeping and the diagnosis and treatment of dental diseases were serious failures. The failures identified in this case caused significant risk of harm to your patients. The Committee considered that your treatment of Patients A-C and E-I lacked many of the features that would normally be expected in patient care and were a serious departure from DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -15/20-

16 the standards expected of a dentist. The Committee was therefore satisfied that misconduct is made out on the facts of this case. Impairment The Committee next considered whether your fitness to practise is currently impaired by reason of your misconduct. In reaching its decision, the Committee exercised its independent judgement. It had regard to the over-arching objectives of the GDC, which involves: the protection, promotion and maintenance of the health, safety and well-being of the public; the promotion and maintenance of public confidence in the dental profession; and the promotion and maintenance of proper professional standards and conduct for the members of the dental profession. The Committee took into account that your misconduct relates solely to failings of a clinical nature. It considered that such failings are capable of being remedied by way of further learning and professional development. In considering whether your identified failings have in fact been remedied, the Committee had regard to your Remediation Bundle. Whilst the Committee noted that your online CPD courses were extensive in the number of hours completed and the breadth of the areas covered some of which related to areas of deficiency in your clinical practice, it considered there to be little evidence of how you have actually used your learning to address the fundamental issues arising in this case or that you have reflected on what you have learned. The Committee took into account that you have undertaken further CPD courses in Portugal, where you presently reside. You told the Committee that you did not include evidence of this as the courses are not directly relevant to the issues identified in this case. The Committee acknowledged that, given your current circumstances, you may have faced some difficulties in accessing a full range of relevant CPD material in English. However, the Committee s primary concern is to safeguard the public and the fact remains that the evidence of your remediation to date is limited. Furthermore, given the range of your failings in relation to Patients A-C and E-I, the Committee considered that it would be impossible for you to fully address your clinical shortcomings by way of theoretical learning alone. In the circumstances, the Committee would have expected to receive evidence of how you have embedded your learning, albeit limited, into your clinical practice. It acknowledged that in your present circumstances you have not had the opportunity in the United Kingdom to put what you may have learned into practice. Therefore, there is no evidence of how you have changed your practice on the basis of what you have learned. The Committee has therefore been unable to assess adequately the current standard of your clinical practice. The Committee was satisfied from the evidence that you have shown some insight into your failings. It also took into account the admissions you made at the outset of the hearing and during your evidence. However, in its view, the Remediation Bundle you have provided demonstrates that the process of your remediation is still in its early stages. In the absence of sufficient remediation, including verifiable evidence of how your clinical practice has improved in the highlighted areas of concern, the Committee could not be satisfied that you would not repeat your misconduct. The Committee further had regard to the testimonials that were provided on your behalf and noted all but one pre-dated your practice in Lampeter and that there was no evidence to correlate what you have learnt and how it has been implemented into your practice. The Committee therefore concluded that there is a DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -16/20-

17 remaining risk to the safety of patients and that a finding of impairment is necessary in the circumstances. The Committee also considered the wider public interest. It accepted that your failings in clinical care alone were not so grave as to warrant action being taken in the wider public interest. However, in the light of your limited remediation and the level of your insight, the Committee decided that public confidence in the dental profession would be undermined if a finding of impairment were not made in the circumstances of this case. The Committee has determined that your fitness to practise is currently impaired. Sanction The Committee considered what sanction, if any, to impose on your registration. It noted 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. In reaching its decision, the Committee took into account the Guidance for the Practice Committees including Indicative Sanctions Guidance (effective from October 2016). It considered the range of sanctions available to it, starting with the least serious. The Committee applied the principle of proportionality, balancing the public interest with your own interests. Given your insufficient remediation and its concerns about patient safety and the wider public interest, the Committee decided that it would be wholly inappropriate to conclude this case without taking any action in respect of your registration. The Committee also concluded that the issue of a reprimand would be inadequate. It considered that the sanction of a reprimand would not afford the necessary public protection. Nor would it uphold public confidence, given the range of your clinical failings, which you have yet to fully address. The Committee next considered whether to impose conditions on your registration. It took into account that your clinical failings are capable of being remedied, that you have begun the remedial process and that you have demonstrated some insight. In the circumstances, the Committee concluded that it could formulate a set of workable and measurable conditions to address its outstanding concerns. It was satisfied that a period of conditional registration is an appropriate and proportionate response to the matters in this case. It was also satisfied that conditional registration would serve to protect members of the public adequately and would uphold the wider public interest. The Committee considered that a higher sanction would be disproportionate, in view of the fact that you have embarked on a process of remediation and you have engaged fully with the GDC s regulatory process. In all the circumstances, the Committee has determined to impose conditions on your registration for a period of 18 months. In deciding on this period, the Committee took into account your particular circumstances in that you are currently resident in Portugal. It considered an order for a period of 18-month would afford you adequate time to address all of the concerns that have been raised in this case, should you have the opportunity to return to the UK and find employment. The following conditions are set out as they will appear against your name in the Dentists Register: DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -17/20-

18 1) She must inform the GDC within 7 days of commencing employment in the UK as a dentist. The following conditions can only be fulfilled in the UK and compliance with these conditions will start from the date of her return to practise in the UK. 2) If employed in the UK she must inform the GDC within 7 days if she applies for dental employment outside the UK. 3) She must work with a Postgraduate Dental Dean/Director (or a nominated deputy) to formulate a Personal Development Plan to cover the identified deficiencies in her practice (diagnosing caries, treatment planning, record keeping, radiography). 4) She must forward a copy of her Personal Development Plan to the GDC within 3 months of the date of her return to practise in the UK. 5) She must meet with a Postgraduate Dental Dean/Director (or a nominated deputy) on a regular basis, to discuss progress towards achieving the aims set out in her Personal Development Plan. The frequency of her meetings is to be set by the Postgraduate Dental Dean/Director (or a nominated deputy). 6) She must place herself under the supervision of a workplace supervisor, nominated by her and approved by the GDC. The workplace supervisor shall be a GDC registrant in the same category of the Dentists Register as herself. 7) She must allow her workplace supervisor to provide reports to the GDC at intervals of 4 months, and the GDC will make these reports available to any Postgraduate Dean/Director referred to in these conditions. 8) (i) She must undertake audits in the areas of diagnosis of caries, treatment planning, record keeping and radiography. She must arrange for her workplace supervisor to sign off the audits at intervals of 4 months. (ii) She must provide a copy of each audit to the GDC on a 4-monthly basis. 9) She must provide to the GDC at intervals of 4 months a piece of reflective writing which will describe any learning she undertaken and how she has applied it to her practice. 10) She must notify the GDC promptly of any professional appointment she accepts and provide the contact details of her employer or any organisation for which she is contracted to provide dental services. 11) She must allow the GDC to exchange information with her employer or any organisation for which she is contracted to provide dental services, and any Postgraduate Dental Dean/Director, reporter or workplace supervisor referred to in these conditions. 12) At any time she is providing dental services, which require her to be registered with the GDC, she must agree to the appointment of a reporter nominated by her and approved by the GDC. The reporter shall be a GDC registrant in the same category of the Dentists Register as herself. 13) She must allow the reporter to provide reports to the GDC at intervals of not more than four months and the GDC will make these reports available to any Postgraduate Dental Dean/Director and workplace supervisor referred to in these conditions. DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -18/20-

19 14) She must inform the GDC of any formal disciplinary proceedings taken against her, from the date of this determination. 15) She must inform within 7 days the following parties that her registration is subject to the conditions, listed at (1) to (14), above: (i) (ii) (iii) (iv) Any organisation or person employing or contracting with her to undertake dental work Any locum agency or out-of-hours service she is registered with or applies to be registered with (at the time of application) Any prospective employer (at the time of application) The Commissioning Body on whose Dental Performers List she is included or seeking inclusion, or Local Health Board if in Wales, Scotland or Northern Ireland (at the time of application) 16) She must permit the GDC to disclose the above conditions, (1) to (15), to any person requesting information about her registration status. A Committee will review your case at a resumed hearing to be held shortly before the end of the period of conditional registration. That Committee will consider what further action, if any, to take in relation to your registration. You will be informed of the date and time of that resumed hearing, with which you will be expected to engage. Unless you exercise your right of appeal, your registration will become subject to the aforementioned conditions, 28 days from the date when notice is deemed to have been served upon you. The Committee now invites submissions from Ms Daly and then from Mr Jenkins, as to whether the conditions should be imposed on your registration immediately, pending its substantive determination coming into effect. In deciding whether to impose an immediate order of conditions on your registration, the Committee took into account the submissions of Ms Daly that such an order is necessary in the particular circumstances of this case. Mr Jenkins, on your behalf, made no objection to the application. The Committee accepted the advice of the Legal Adviser. The Committee has determined that it is necessary for the protection of the public to impose an immediate order of conditions on your registration. The Committee has found that you are yet to remedy the deficiencies in your clinical practice and it has imposed a substantive order of conditional registration to safeguard the public. Whilst the Committee took into account your present circumstances it considered that given the potential for risk to patients, it would be inconsistent not to impose an immediate order to ensure the public s protection and it would be in the public interest in the intervening appeal period. The effect of the foregoing determination and this order is that your registration is subject to the conditions immediately to cover the appeal period. If you do not appeal, the substantive direction for conditions will take effect 28 days from the date when notice is deemed to have been served upon you and will continue for a period of 18 months. DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -19/20-

20 Should you exercise your right of appeal, this immediate order for conditions will remain in place until the resolution of any appeal. That concludes this hearing. DE FERREIRA GOMES, M A Professional Conduct Committee January July 2017 Page -20/20-

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