Consultant in Public Health, NHS Ayrshire and Arran

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2 An unusualpatientnotification notification exercise Hazel J Henderson Consultant in Public Health, NHS Ayrshire and Arran

3 Infection control breaches in two dental practices reported to NHS Board by whistleblower Why was this PNE unusual? Practice covered up the breaches when Board tried to investigate i making it difficult to assess risk ikto patients N hd b d ( i h diff d PNE had to be repeated (with a different message second time) due to unforeseen circumstances

4 What were the allegations? 1) Gloves re-used dbetween patients 2) Single use matrix bands autoclaved then re-used 3) Aspirator tips not being autoclaved

5 1) Convene PAG Initial response 2) Assess seriousness of alleged breaches 3) Investigate allegations: Voluntary practice inspection Staff interviews Request for invoices i 4) Assess risk/implement control measures

6 Cl Calculating lti BBV transmission risk Practicelist aligned withhps BBVdiagnosis databases Level of undiagnosed BBVinfection in Scotlandused to estimate total number of patients in the practice with BBVs This information i was combined with ihkey factors such as probability of blood on equipment being infected and viable Probability of infection from different instruments/procedures was estimated using current evidence

7 Response to investigation findings Evidence did not refute allegations: 1. Risk assessment of transmission likelihood 2. Patient notification exercise 3. BBV risk to patients extremely low purpose of notification was transparency testing not recommended

8 As a result of the notification exercise, new and more serious allegations emerged..

9 1) Reuse of: single use endodontic files single use stainless steel burs single use 3 in 1 tips single use impression trays gloves between patients matrix bands 2) Incomplete processing of aspirator tips 3) The following were not sterilized but surface wiped: amalgam carriers aspirator tips and ultrasonic scaler tips for single use

10 The repeat notification exercise 1) Further investigation of new allegations 2) Newrisk assessment undertaken. Concluded: Given the equipment involved, which usually comes into contact with blood during a procedure, and the number of Hep C infected patients within the practice, there was a higher risk of transmission for a small number of patients who received their dental treatment following a Hep C positive individual (diagnosed or undiagnosed).

11 Throughout h this incident id practice staff tff continually denied that any breaches had occurred

12 Second notification exercise 5100 Patients contacted 2250 patients tested (44%) No cases of Hep B, HIV <5 cases of Hep C No evidence of BBV transmission within the practice

13 Legal ramifications GDC Hearing investigated allegations of breaches and of cover up Dentist, Practice Manager struck off. Nurse placed on conditions patients suing dentist

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15 Why was this exercise unusual? Need for repeat notification exercise Dental practice dishonest in relation to allegations e a pac ceds o es ea o o aegaos hampered investigation (GDC Hearing findings)

16 Lessons learned 1) This incident raised concerns about the ability to assure infection control standards are being met withindental practices. 2) Patient notification exercises can have an adverse impact on patients. 3) The benefits of patient notification are unclear in instances such as this, where BBV risk to patients is estimated to be very low. 4) The financial cost (and opportunity cost) to the Health Board 4) The financial cost (and opportunity cost) to the Health Board was substantial.

17 Concerns highlighted hli ht Can we be confident that serious breaches are not occurring in other dental practices? Would current inspection and regulatory system pick them up?

18 We wrote to Chief Dental Officer (Scotland) outlining concerns

19 Progress? The new dental regulations for Scotland now give NHS Boards the right to undertake unannounced inspections of Dental Practices providing NHS General Dental Services, where concerns about patient t safety ft are raised dduring a previous routine inspection by the NHS Board; or information comes to light that necessitates further investigation by the NHS Board.

20 The rest of the team: Elvira Garcia, Consultant in Public Health Medicine Gill Hawkins, Consultant in Public Health Medicine Kate McDade, Health Protection Nurse Specialist Billy Cullinane, Health Protection Nurse Specialist

21 Thank You Hazel J Henderson Consultant in Public Health, NHS Ayrshire and Arran