HEARING HEARD IN PUBLIC

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1 HEARING HEARD IN PUBLIC RADCLIFFE, Nicholas Henry Registration No: PROFESSIONAL CONDUCT COMMITTEE NOVEMBER DECEMBER 2017 Outcome: Erased with Immediate Suspension Nicholas Henry RADCLIFFE, a dentist, BDS Brist 1989; was summoned to appear before the Professional Conduct Committee on 27 November 2017 for an inquiry into the following charge: Charge (as amended on 27 November 2017) That being a registered dentist: 1. At all material times you practiced as a dentist at [address redacted]. Patient 1 2. Between 30 January 2003 and 11 February 2015 you were consulted by Patient 1 in relation to dental treatment. 3. On a date or dates set out in Schedule A 1 your care in relation to Patient 1 was inadequate in that: a. You did not carry out sufficient diagnostic assessments. b. You did not carry out a full assessment of Patient 1 s presenting dental condition. c. You did not provide a diagnosis. d. You did not carry out sufficient treatment planning. e. You did not provide a treatment plan. f. You did not obtain informed consent. g. You did not provide any or any adequate advice into oral health. h. You did not take sufficient radiographs. i. You did not take radiographs when clinically indicated. j. You did not record adequate justification for taking a radiograph. k. You did not record an adequate report on the radiograph. l. You provided a poor standard of treatment in relation to UR5: i. You provided repeated amalgam fillings; and ii. You did not advise Patient 1 that a crown would need to be fitted. 1 Schedule A E are private documents and cannot be disclosed. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -1/58-

2 Patient 2 m. You provided a poor standard of treatment in relation to LL7 in that: i. You did not adequately treat caries; and ii. You restored LL7 with a marked overhang in the amalgam. n. You did not record accurate BPE scores. o. You did not carry out any adequate periodontal examinations. p. You did not diagnose Patient 1 s worsening periodontal condition. q. You did not treat Patient 1 s periodontal disease. 4. Between 31 July 2003 and 11 February 2015 you were consulted by Patient 2 in relation to dental treatment. 5. On a date or dates set out in Schedule B your care in relation to Patient 2 was inadequate in that: a. You did not carry out sufficient diagnostic assessments. b. You did not carry out a full assessment of Patient 2 s presenting dental condition. c. You did not provide a diagnosis. d. You did not provide a treatment plan. e. You did not obtain informed consent. f. You did not provide any or any adequate preventative treatment. g. You did not take sufficient radiographs. h. You did not take radiographs when clinically indicated. i. You did not record any justification for taking a radiograph. j. You did not record a report on the radiograph. k. You did not diagnose caries at: i. UL5; ii. iii. iv. UL6; UL7; UR6; v. LL6; vi. vii. LR6; and LR7; l. You did not treat caries at: i. UL5; ii. iii. UL6; UL7; RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -2/58-

3 Patient 3 iv. UR6; v. LL6; vi. vii. LR6; and LR7. m. You provided a poor standard of filling at: i. UL6; ii. iii. UR6; and LR6. n. You provided a poor standard of orthodontic treatment in that: i. You did not carry out an adequate orthodontic consultation; ii. iii. iv. You did not carry out sufficient pre-treatment investigations; You did not carry out sufficient treatment planning; You did not provide Patient 2 with all of the treatment options; v. You did not discuss the risks and benefits of orthodontic treatment with Patient 2; and vi. You provided orthodontic treatment despite the presence of untreated primary disease. 6. Between 21 July 2000 and 11 and/or 12 May 2015 you were consulted by Patient 3 in relation to dental treatment. 7. On a date or dates set out in Schedule C your care in relation to Patient 3 was inadequate in that: a. You did not carry out sufficient diagnostic assessments. b. You did not carry out a full assessment of Patient 3 s presenting dental condition. c. You did not provide a diagnosis. d. You did not carry out sufficient treatment planning. e. You did not provide a treatment plan. f. You did not obtain informed consent. g. You did not provide any or any adequate advice into oral health. h. You did not take sufficient radiographs. i. You did not take radiographs when clinically indicated. j. You did not record adequate justification for taking a radiograph. k. You did not record an adequate report on the radiograph. l. You did not record BPE scores. m. You did not carry out any adequate periodontal examinations. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -3/58-

4 Patient 4 n. You did not diagnose Patient 3 s worsening periodontal condition. o. You did not treat Patient 3 s periodontal disease. p. You did not diagnose caries at: i. UL5; ii. iii. iv. UL6; UR4; UR5; v. LR5; and vi. LR7. q. You did not diagnose poor fillings at: i. LL6; ii. iii. LL4; and UR6. r. You did not treat: i. UL5; ii. iii. iv. UL6; UR4; UR5; v. LR5; vi. vii. viii. ix. LR7; LL6; LL4; and UR6. 8. Between 26 September 2000 and 11 March 2015 you were consulted by Patient 4 in relation to dental treatment. 9. On a date or dates set out in Schedule D your care in relation to Patient 4 was inadequate in that: a. You did not carry out sufficient diagnostic assessments. b. You did not carry out a full assessment of Patient 4 s presenting dental condition. c. You did not provide a diagnosis. d. You did not provide a treatment plan. e. You did not obtain informed consent. f. You did not provide any or any adequate advice into oral health. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -4/58-

5 Patient 5 g. You did not take sufficient radiographs. h. You did not take radiographs when clinically indicated. i. You did not diagnose caries at: i. UR5; and ii. LL6. j. You did not treat caries at: i. UR5; and ii. LL6. k. You did not record accurate BPE scores. l. You did not carry out any adequate periodontal examinations. m. You did not diagnose Patient 4 s worsening periodontal condition. n. You did not treat Patient 4 s periodontal disease. 10. Between 27 October 2000 and 11 March 2015 you were consulted by Patient 5 in relation to dental treatment. 11. On a date or dates set out in Schedule E your care in relation to Patient 5 was inadequate in that: a. You did not carry out sufficient diagnostic assessments. b. You did not carry out a full assessment of Patient 5 s presenting dental condition. c. You did not provide a diagnosis. d. You did not provide a treatment plan. e. You did not obtain informed consent. f. You did not provide any or any adequate advice into oral health. g. You did not take sufficient radiographs. h. You did not take radiographs when clinically indicated. i. You did not record adequate justification for taking a radiograph. j. You did not record an adequate report on the radiograph. k. You did not diagnose caries at: i. UL7; ii. iii. UL8; and UR5. l. You did not treat caries at: i. UL7; ii. UL8; and RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -5/58-

6 Patient 7 iii. UR5. m. You did not record accurate BPE scores. n. You did not carry out any adequate periodontal examinations. o. You did not diagnose Patient 5 s worsening periodontal condition. p. You did not treat Patient 5 s periodontal disease. 12. Between 19 February 2004 and 29 October 2014 you were consulted by Patient 7 in relation to dental treatment. 13. Your care in relation to Patient 7 was inadequate in that between 19 February 2004 and 29 October 2014: Patient 8 a. You did not carry out sufficient diagnostic assessments. b. You did not carry out a full assessment of Patient 7 s presenting dental condition. c. You did not provide a diagnosis. d. You did not provide a treatment plan. e. You did not provide any or any adequate oral health advice. f. You did not provide any or any adequate preventative treatment. g. You did not take any routine radiographs. h. On 29 October 2014 you failed to diagnose caries at: i. UR6; ii. iii. UL6; and LL7. i. On 29 October 2014 you failed to treat caries at: i. UR6; ii. iii. UL6; and LL Between 11 September 2012 and 8 June 2015 you were consulted by Patient 8 in relation to dental treatment. 15. Your care in relation to Patient 8 was inadequate in that between 11 September 2012 and 8 June 2015: a. You did not carry out an adequate orthodontic consultation. b. You did not carry out sufficient pre-treatment investigations. c. You did not provide a diagnosis. d. You did not carry out sufficient treatment planning. e. You did not provide a treatment plan. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -6/58-

7 f. You did not provide Patient 8 with all of the treatment options. g. You did not discuss the risks and benefits of orthodontic treatment with Patient 8. h. You did not obtain informed consent. i. You did not take radiographs when clinically indicated. Record Keeping 16. You failed to maintain an adequate standard of record keeping in respect of: a. Patient 1 s appointments between 30 January 2003 and 11 February 2015; b. Patient 2 s appointments between 31 July 2003 and 11 February 2015; c. Patient 3 s appointments between 21 July 2000 and 12 May 2015; d. Patient 4 s appointments between 26 September 2000 and 11 March 2015; e. Patient 5 s appointments between 27 October 2000 and 11 March 2015; f. Patient 7 s appointments between 19 February 2004 and 29 October 2014; and g. Patient 8 s appointments between 11 September 2012 and 8 June Complaint Handling 17. You failed to respond to complaints about your provision of dental treatment from: a. Patient 1 on 19 August 2015 and 1 October 2015; b. Patient 2 on 27 August 2015; c. Patient 3 on 13 November 2015; d. Patient 4 on 5 October 2015; e. Patient 5 on 5 October 2015; f. Patient 6 in respect of Patient 7 on 28 October 2015; and g. Patient 8 on 9 October Failure to Cooperate 18. You failed to cooperate with an investigation by the GDC into your treatment of: a. Patients 1 and 2 from 4 December 2015; b. Patient 3 from January 2016 onwards; c. Patient 4 from 4 March 2016 onwards; d. Patient 5 from 3 March 2016 onwards; e. Patient 7 from 10 February 2016 onwards; and f. Patient 8 from 27 June 2016 onwards. AND that by reason of the matters alleged, your fitness to practice is impaired by reason of your misconduct. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -7/58-

8 Mr RADCLIFFE was not present and was not represented. On 7 December 2017 the Chairman announced the findings of fact to the Counsel for the GDC: Mr Radcliffe is not present and is not represented at this Professional Conduct Committee hearing. Ms Broome, Counsel, is the Case Presenter for the General Dental Council (GDC). At the outset, Ms Broome made an application under Rule 54 of the GDC (Fitness to Practise) Rules Order of Council 2006 (the Rules), to proceed with the hearing notwithstanding Mr Radcliffe s absence. The Committee took account of Ms Broome s submissions in respect of the application and had regard to the supporting documentation provided. It accepted the advice of the Legal Adviser. Decision on service of the Notification of Hearing The Committee first considered whether notice of the hearing had been served on Mr Radcliffe in accordance with Rules 13 and 65 of the Rules and section 50A of the Dentists Act 1984 (as amended) (the Act). It received a bundle of documents containing a copy of the Notification of Hearing letter, dated 20 October 2017, which was sent by the GDC to Mr Radcliffe s registered address, as required by the Rules. In addition, having received information indicating that Mr Radcliffe was no longer practising at his registered address, the GDC sent a further copy of the letter to his home address. The Committee had regard to the Royal Mail Track and Trace receipts confirming that both letters were sent by Special Delivery. It also noted that a copy of the letter was sent to Mr Radcliffe by , to an address previously used by him to correspond with the Council. The Committee was satisfied that the Notification of Hearing letter of 20 October 2017 contained proper notification of the hearing, including its start date, time and venue, as well as notification that the Committee could proceed with the hearing in Mr Radcliffe s absence. On the basis of the information provided to it, the Committee was of the view that the GDC had made comprehensive efforts to notify Mr Radcliffe of the hearing. Accordingly, it was satisfied that service had been effected in accordance with the Rules and the Act. Decision on whether to proceed with the hearing in the absence of Mr Radcliffe and/or any representative on his behalf The Committee next considered whether to exercise its discretion under Rule 54 of the Rules to proceed with the hearing in the absence of Mr Radcliffe and/or any representative on his behalf. It approached the issue with the utmost care and caution. The Committee took into account the factors to be considered in reaching its decision as set out in the case of R v Jones [2003] 1 AC 1HL. It remained mindful of the need to be fair to both Mr Radcliffe and the GDC, and it also had regard to the public interest in dealing with the case expeditiously. The Committee was satisfied, on the information before it, that Mr Radcliffe s absence was deliberate. It considered that he had voluntarily waived his right to attend the hearing and/or be represented. In reaching its conclusion, the Committee took into account the evidence of Mr Radcliffe s history of non-engagement with the GDC. It noted that almost all of the letters sent to him by the Council regarding his fitness to practise proceedings went unanswered. Mr Radcliffe s last contact with the GDC was over a year ago, when in an , dated 24 November 2016, he confirmed that he would not be attending an Interim Orders Committee hearing of his case. Mr Radcliffe also stated that he did not wish to continue to be included in the Dentists Register. There has been no contact by Mr Radcliffe with the Council since that time. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -8/58-

9 In all the circumstances, the Committee considered that an adjournment would serve no useful purpose. It noted that Mr Radcliffe had not requested an adjournment, and given the lack of any meaningful engagement on his part, the Committee considered that an adjournment was highly unlikely to secure his attendance on a future occasion. It therefore determined that it was fair and in the public interest to proceed with the hearing notwithstanding the absence of Mr Radcliffe or any representative on his behalf. Summary of the charge At all material times Mr Radcliffe was practising as a dentist. The charge against him is divided into four separate categories. The first category includes allegations of inadequate clinical practice in respect of the care and treatment he provided to seven patients. For the purposes of this hearing, the patients are referred to as Patients 1, 2, 3, 4, 5, 7 and 8. Patient 2 and Patient 7 were minors at the time of starting their treatment with Mr Radcliffe. The second category of the charge sets out Mr Radcliffe s alleged failings in record keeping in respect of the patients appointments with him. The clinical and record keeping allegations in this case cover the period from 21 July 2000 to 8 June 2015, which is a total period of almost 15 years. Although it is noted by the GDC that the range of appointment dates vary from patient to patient. The third and fourth category within the charge relate respectively to Mr Radcliffe s alleged failings in complaints handling and his alleged failure to cooperate with an investigation by the GDC into his treatment of the patients concerned. In relation to the complaints handling aspect, there is reference in the charge to a further patient, Patient 6, who is the mother of Patient 7. As Patient 7 was a minor at the time of treatment, it was Patient 6 who made the complaint on Patient 7 s behalf. There are no allegations in this case concerning Patient 6 herself. Amendments to the charge and to Schedules B and C to the charge During the course of opening the case for the GDC, Ms Broome made an application under Rule 18 of the Rules to amend the charge. She highlighted to the Committee a number of administrative errors which she wished to correct. Firstly, the reference to UL5 at head of charge 3(l) which, Ms Broome stated, had been incorrectly transposed and should, according to the evidence, read UR5. Ms Broome also applied to amend an incorrect date that had been included at heads of charge 12, 13 and 16(f). She requested that the date 9 February 2004 as wrongly stated in these heads, be corrected to read 19 February There were also some typographical issues with the paragraph numbering in Schedule B to the charge. This schedule relates to Patient 2 s appointments with Mr Radcliffe. In respect of the date 3 July 2009, Ms Broome asked the Committee to substitute the references to heads of charge 5(i) and 5(j), which had been incorrectly included, with heads of charge 5(h) and 5(n)(ii). In addition, Ms Broome applied to amend the stem at head of charge 6, which relates to Patient 3. She asked that the date range Between 21 July 2000 and 12 May 2015 be changed to Between 21 July 2000 and 11 and/or 12 May Ms Broome also asked that 11 and/or 12 May 2015 be included in Schedule C to the charge; this schedule relates to Patient 3 s appointments with Mr Radcliffe. Ms Broome explained that the basis for these amendments was that there was some uncertainty in the evidence, as to the precise date of Patient 3 s last appointment with Mr Radcliffe. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -9/58-

10 Following advice from the Legal Adviser, the Committee acceded to Ms Broome s application in its entirety. It was satisfied, having considered the merits of the case and the fairness of the proceedings, that all of the proposed amendments could be made without causing any injustice. The charge and relevant schedules were amended accordingly. The factual evidence of the GDC In relation to the clinical matters in this case, the Committee was provided with a significant amount of documentary evidence. This evidence included Mr Radcliffe s clinical records in respect of each of the patients. The Committee also received witness statements from: Patient 1, dated 2 June 2017, Patient 3, dated 2 May 2017, Patients 4, 5 and 6, each dated 10 June 2017 and Patient 8, dated 27 June The patients also provided documents in support of their statements, including copies of letters and/or s of complaint sent to Mr Radcliffe. Additionally, the Committee had before it, a witness statement, dated 28 June 2017, from Dr Katherine Leeming, the dentist who treated subsequently Patients 1, 2, 3, 4, 5 and 7. Exhibited with Dr Leeming s witness statement were her clinical records in respect of these patients. Also provided was a witness statement, dated 14 June 2017, from Dr Steven Neal, the dentist who treated subsequently Patients 3 and 8. Dr Neal also exhibited his clinical records in respect of these patients. Further witness statements were received from Dr Clifford Nissen, dentist, and Mr James Dickson, Consultant Orthodontist, dated 2 May 2017 and 21 June 2017 respectively. Dr Nissen saw Patient 3 in November 2015 following a referral. Mr Dickson saw Patient 8 in August 2015, the patient having been referred to him by Dr Neal. With regard to Mr Radcliffe s alleged failure to cooperate with the GDC s investigation, the Committee was provided with a witness statement, dated 2 November 2016 and associated exhibits, from Mr Matt Biggins, Case Manager at the GDC. The Committee also noted a letter to Mr Radcliffe by the GDC on 29 September It was made clear to Mr Radcliffe that the GDC intended to read the witness statements at this hearing, so as to avoid the need for the witnesses attendance. It was also made clear that the witnesses would be made available by phone for any supplemental questions the Committee may have. It was put in this way unless we hear from you to the contrary, by 9 October 2017, we will assume that you accept this proposal. The Committee was told by Ms Broome that there had been no response from Mr Radcliffe to that letter. The Committee accepted the Legal Adviser s advice and has treated the evidence from the patients, the treating dentists, and Mr Biggins, as if it had come from the witness chair. The expert evidence of the GDC The Committee received a report dated 11 July 2017, prepared by Dr Stephen Powell, Consultant in Orthodontics, the expert witness called by the GDC. Dr Powell also gave oral evidence to the Committee. The Committee found him to be very knowledgeable in his specialist field of orthodontics and noted that he has considerable current experience in general dental practice. It noted that when he gave his evidence he was mindful to make clear his area of expertise, although he was able to assist the Committee with a number of the clinical matters in this case. The Committee found that Dr Powell was well acquainted with the evidence in this case. Further, in the absence of Mr Radcliffe, the Committee considered that Dr Powell was very measured in giving his opinions. In particular, it noted that when challenged, he readily acknowledged the likely realities of some of the situations RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -10/58-

11 faced by the registrant and he expanded on his conclusions accordingly. The Committee considered Dr Powell to be a fair, balanced and compelling expert witness. The absence of any documentary material/submissions from the registrant The Committee took into account that, in the absence of Mr Radcliffe or any representative on his behalf, the evidence provided by the GDC was not challenged. However, it also took into account that all of the evidence upon which the Council relied, was sent to Mr Radcliffe and no defence material or submissions were forthcoming. The Committee noted that in the interest of fairness to the registrant, where possible, Ms Broome put alternative possibilities for Mr Radcliffe s alleged shortcomings to Dr Powell in her questioning. The Committee s Findings of Fact The Committee considered all the evidence presented to it and accepted the advice of the Legal Adviser. In accordance with that advice, it considered each head of charge separately, bearing in mind that the burden of proof rests with the GDC and that the standard of proof is the civil standard, that is, whether the alleged facts are proved on the balance of probabilities. The Committee drew no adverse inferences from the absence of Mr Radcliffe. The Committee s findings in relation to each head of charge are as follows: 1. At all material times you practiced as a dentist at [address redacted]. Patient 1 The Committee was satisfied on the evidence provided to it, that this head of charge is proved. It received a number of documents, including Mr Radcliffe s clinical records for the patients in this case, which confirmed where he had been practising as a dentist. 2. Between 30 January 2003 and 11 February 2015 you were consulted by Patient 1 in relation to dental treatment. The Committee had regard to Mr Radcliffe s clinical notes for Patient 1, which cover the period 30 January 2003 to 11 February On a date or dates set out in Schedule A your care in relation to Patient 1 was inadequate in that: 3. a) You did not carry out sufficient diagnostic assessments. In relation to what constitutes sufficient diagnostic assessments, the Committee had regard to, and accepted, the evidence of Dr Powell. He set out in his report the information that he would have expected to see in Mr Radcliffe s clinical notes for Patient 1, had sufficient diagnostic assessments been carried out. According to Dr Powell, such information would have included: a history of the patient s presenting symptoms, a medical history, extra oral and intra oral examinations and special investigations, including the taking of radiographs. The Committee reviewed Mr Radcliffe s clinical notes, taking into account the RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -11/58-

12 relevant dates indicated in Schedule A. It noted that on occasions, Mr Radcliffe recorded having undertaken certain diagnostic aspects, such as clinical examinations of the patient s mouth. However, it found no evidence that he carried out diagnostic assessments to the level of sufficiency explained by Dr Powell. In reaching its decision, the Committee also took into account the evidence of Dr Leeming, who saw Patient 1 in August Dr Leeming stated in her witness statement that she carried out a full assessment of Patient 1, which included the taking of radiographs. Dr Leeming diagnosed the patient with a number of dental problems, including the following: the UR5, which had been root-filled, had heavily broken down; there was caries present under a large restoration at LL7; and there were areas of poor gum health and subgingival calculus. Patient 1 stated in her witness statement that she had been extremely surprised by the diagnoses of Dr Leeming. Patient 1 said that Mr Radcliffe had told her and her family that we had no problems with our teeth. The Committee considered Dr Leeming s account together with the very limited information it found in Mr Radcliffe s clinical notes and it concluded, on the balance of probabilities, that Mr Radcliffe did not carry out sufficient diagnostic assessments in relation to Patient 1 on any of the dates specified in Schedule A. The Committee was of the view that had Mr Radcliffe carried out sufficient diagnostic assessments at the relevant appointments, the extent of Patient 1 s dental problems would have been apparent. The evidence before the Committee is that these were longstanding and ongoing dental problems, which could not have developed in the six-month interval between February 2015, when the patient last saw Mr Radcliffe, and August 2015, when she saw Dr Leeming. There is a marked difference between the information recorded by Mr Radcliffe in his notes and what he told Patient 1, compared to the evidence of Dr Leeming. The Committee accepted her evidence, which is supported by radiographic evidence and the opinion of Dr Powell. 3. b) You did not carry out a full assessment of Patient 1 s presenting dental condition. The Committee found no information in Mr Radcliffe s clinical notes for Patient 1 to indicate that he had carried out a full assessment of the patient s presenting dental condition on the dates set out in Schedule A. In the absence of such information, it was satisfied that he did not carry out full assessments at the relevant appointments. It was the view of the Committee that Mr Radcliffe could not have carried out what would be considered a comprehensive assessment of the patient s presenting condition in any event, given its finding that he never carried out sufficient diagnostic assessments in respect of the patient. 3. c) You did not provide a diagnosis. Dr Powell s evidence, based on the information contained in Mr Radcliffe s RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -12/58-

13 clinical notes, was that there was insufficient diagnosis at each assessment of Patient 1 to be certain of her dental disease problems. The Committee had regard to the clinical information recorded by Mr Radcliffe and noted the lack of a recorded diagnosis for any of the appointments in question. Taking the evidence into account, the Committee found on the balance of probabilities, that Mr Radcliffe did not make a diagnosis on any of the relevant dates in Schedule A. Accordingly, he could not have provided one to the patient. This is consistent with the evidence of Patient 1, who stated that she had never been made aware of any problems with her teeth. 3. d) You did not carry out sufficient treatment planning. The evidence of Dr Powell was that once a diagnosis has been made, a treatment plan is then formulated. He provided in his report a non-exhaustive list of what a treatment plan would include. He explained that a treatment plan would essentially include all the information and treatment required for the patient s dental fitness. In deciding whether Mr Radcliffe carried out sufficient treatment planning, the Committee took into account its finding that he had neither made nor provided a diagnosis in Patient 1 s case. It considered that in the absence of a diagnosis, it would not have been possible for Mr Radcliffe to formulate a sufficient treatment plan. In its view, he did not have the relevant information on which to base such a plan. Indeed, when the Committee considered Mr Radcliffe s clinical notes, it did not find any evidence of sufficient treatment planning. Instead, his notes indicated that he had carried out ad hoc and reactive treatment to cope with Patient 1 s dental concerns, as and when she presented with them. 3. e) You did not provide a treatment plan. The Committee considered and accepted the evidence of Patient 1. She indicated in her witness statement that she had no idea about the extent of her dental problems, whilst she was under the care of Mr Radcliffe. Patient 1 reiterated this in her letter of 19 August 2015, in which she complained about the dental treatment Mr Radcliffe had provided to her. Having had regard to the surprise expressed by Patient 1 in relation to the actual status of her dental health, the Committee concluded that Mr Radcliffe did not provide her with any plan for treatment. Furthermore, it saw no evidence of a treatment plan or the provision of a treatment plan in Mr Radcliffe s clinical notes. 3. f) You did not obtain informed consent. The Committee found nothing in Mr Radcliffe s clinical notes to support him having obtained informed consent from Patient 1 for any of the treatment he provided. Dr Powell s opinion was that, as no formal overall diagnosis was ever made in respect of the patient, it was not even possible for her to have given her informed consent. The Committee found it clear from Patient 1 s RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -13/58-

14 evidence, including her letter of complaint, dated 19 August 2015, that she had never been involved in any discussions regarding her treatment with Mr Radcliffe to the extent that she could have been considered as being informed. In all the circumstances, the Committee found proved that Mr Radcliffe did not obtain informed consent. 3. g) You did not provide any or any adequate advice into oral health. Found proved on the basis that no adequate advice into oral health was given. The Committee noted from Mr Radcliffe s clinical notes that in relation to an appointment on 21 May 2009, he recorded discuss OH slipped slightly over the last few yrs. In the Committee s view, this suggested some discussion with Patient 1 on that date regarding her oral hygiene (OH). It also noted that under 9 July 2009 in the clinical notes, there is reference to Patient 1 being referred to the hygienist. The Committee decided, on balance, that oral health advice would have been given to the patient as part of that referral, albeit not by Mr Radcliffe. However, these instances of oral health advice occurred some six years into Mr Radcliffe s care of the patient. The Committee found no other instances, on the relevant dates in Schedule A, of recorded advice in respect of oral health, nor were there any other referrals to the hygienist on those dates. The Committee considered that, in the circumstances, there should have been such advice to Patient 1, given the nature of her dental health. It was therefore satisfied that on a date or dates set out in Schedule A, Mr Radcliffe s care in relation to the patient was inadequate. 3. h) You did not take sufficient radiographs. In making its finding on this head of charge, the Committee accepted the evidence of Dr Powell. He stated in his report that, the interval for the use of radiographs in routine general dental practice generally is recommended to be every two years. Dr Powell explained that with more acute dental disease the radiograph interval is decreased, sometimes to every six months. In relation to Mr Radcliffe s care of Patient 1, which spanned a period of 12 years, Dr Powell s conclusion was that at least six sets of bitewing radiographs should have been taken. He noted, however, that only two radiographs had been recorded as having been taken by Mr Radcliffe with only one disclosed as part of this case. Having noted the evidence of the number of radiographs taken by Mr Radcliffe in relation Patient 1, the Committee accepted the conclusion of Dr Powell that this was insufficient. The Committee accepted Dr Powell s evidence that Mr Radcliffe s lack of, and poor quality, radiographic practice had been part of the reason he had not diagnosed the patient s dental caries and periodontal disease. 3. i) You did not take radiographs when clinically indicated. The Committee saw from the clinical notes that on occasions when Patient 1 RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -14/58-

15 had presented with symptoms that would have required radiographic investigation, no radiographs were taken. For instance, on 12 May 2005, it is noted that the patient attended complaining of pain on biting. According to the notes, Mr Radcliffe only dressed the tooth. The patient returned on 16 May 2005, when again no radiograph was taken. Whilst the Committee has highlighted these two instances, it considered that the overall picture of the evidence before it is of Patient 1 having reported symptoms to Mr Radcliffe over a long period of time with no radiographs being taken. The Committee accepted Dr Powell s opinion that the lack of diagnosis by Mr Radcliffe, and particularly his lack of investigation using radiographs, had led to no significant periodontal treatment being carried out on Patient 1 from July 2009 to August The Committee was satisfied on the basis of the evidence that on dates included in Schedule A, Mr Radcliffe did not take radiographs when clinically indicated. 3. j) You did not record adequate justification for taking a radiograph. Found not proved. The Committee noted from Mr Radcliffe s clinical notes that in respect of the radiographs he took in relation to Patient 1, he recorded as justifications to investigate pathology. It was Dr Powell s opinion that such a record was not adequate. He considered that a recorded justification should detail the type of pathology suspected of being present. In the Committee s view, a more extensive description by Mr Radcliffe would have been helpful and would have indicated that he had been more methodological in his approach. However, the Committee considered that what he recorded as his justification was adequate in the circumstances. The Committee decided that it was clear from the clinical notes that Mr Radcliffe had taken the radiographs because he had wanted to find out more. It considered that it was not necessary for him to have detailed exactly what it was he wanted to identify. 3. k) You did not record an adequate report on the radiograph. Having recorded taking the radiographs to investigate pathology, the Committee could not find in the clinical notes any report made by Mr Radcliffe of his findings. It noted that the absence of a report was also commented on by Dr Powell. In the circumstances, the Committee found this allegation proved. 3. l) You provided a poor standard of treatment in relation to UR5: (as amended) 3. l) i) You provided repeated amalgam fillings; and Mr Radcliffe s clinical notes for this patient indicate that he provided an amalgam filling to the UR5, six times over a period of two years. Dr Powell explained to the Committee in evidence that the UR5, which was a tooth that had been root-filled, would have become brittle on account of the root canal RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -15/58-

16 treatment and therefore was liable to fracture. Dr Powell s evidence was that, after a reasonable period of time following the root canal treatment, a crown should have been placed on the tooth. His opinion was after a period of six months. In the light of Dr Powell s evidence, which the Committee accepted, it decided that it was improper of Mr Radcliffe to have continued to replace the filling, particularly on the evidence that the demise of the tooth would have been obvious. This was, in the Committee s view, a poor standard of treatment. 3. l) ii) You did not advise Patient 1 that a crown would need to be fitted. The Committee saw from the clinical notes that at an appointment on 12 May 2014, Mr Radcliffe recorded advising Patient 1 that her UR5 needed a post and crown. However, given the history of this tooth, the Committee considered that Mr Radcliffe should have given the patient this advice before May 2014, by which time the patient had already experienced significant problems with the UR5. It is on this basis that the Committee found this head of charge proved. In its view, Mr Radcliffe did not advise the patient of the need for a crown at the appropriate time. Indeed it noted the evidence that Patient 1 s UR5 was eventually extracted by Dr Leeming on 19 August m) You provided a poor standard of treatment in relation to LL7 in that: 3. m) i) You did not adequately treat caries; and In her witness statement, Dr Leeming, who saw Patient 1 in August 2015, reported secondary caries on the LL7. The Committee noted that Dr Leeming made this diagnosis, after assessing the radiograph that she took. The identified caries was situated underneath an amalgam filling that had been placed by Mr Radcliffe. Dr Leeming stated that she advised Patient 1 that the tooth would need refilling, however, due to the size of the restoration work and the size of the caries, she also advised that the tooth may require root canal treatment. Dr Leeming stated that she was unable to say how long the caries had been present. She noted that the last radiograph taken in respect of the patient was on 30 January 2012 which, she said, did not show the caries. She highlighted that the tooth had not been restored at that time. It was Dr Powell s opinion, however, that the radiograph of 30 January 2012 did show caries present mesially in the LL7. According to the relevant clinical notes, this tooth was first filled by Mr Radcliffe on 10 April 2014 and then replaced on 12 August 2014 with no further radiographs taken. Dr Powell s view was that Mr Radcliffe had not adequately treated the caries present when he initially restored the tooth. The Committee accepted Dr Powell s conclusion and the evidence of Dr Leeming regarding the location and size of the caries. It decided, on the balance of probabilities, that the caries had been present whilst Patient 1 was under the care of Mr Radcliffe and that he had failed adequately to treat it. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -16/58-

17 3. m) ii) You restored LL7 with a marked overhang in the amalgam. As noted at 3. m) i) above, the amalgam filling at Patient 1 s LL7 was first placed by Mr Radcliffe on 10 April He re-filled the tooth on 12 August The Committee saw the radiograph taken by Dr Leeming when she saw the patient on 19 August 2015, which showed a marked overhang on the filling at the LL7. 3. n) You did not record accurate BPE scores. The Committee considered Mr Radcliffe s clinical notes for Patient 1, in which he had consistently recorded low Basic Periodontal Examination (BPE) scores. The patient s BPE scores are then shown to have increased dramatically when she was seen by Dr Leeming in August The higher scores recorded by Dr Leeming indicated that the patient had significant periodontal disease. The Committee took into account that Dr Leeming s scoring is supported by radiographic evidence, as well as the conclusions of Dr Powell regarding Patient 1 s dental status. Dr Powell notes in his report the disjunction between Mr Radcliffe s BPE scores and the radiograph taken of the patient some six months later. Having accepted the evidence that Patient 1 s periodontal disease would have been present whilst she was under the care of Mr Radcliffe, the Committee was satisfied that the consistently low BPE scores he recorded were inaccurate. 3. o) You did not carry out any adequate periodontal examinations. The BPE scores recorded by Dr Leeming indicated that Patient 1 s periodontal disease was more severe that Mr Radcliffe s clinical notes suggested. The Committee, taking into account this evidence and the conclusions of Dr Powell, considered that Mr Radcliffe should have done more to ascertain the true state of the patient s dental health. In the Committee s view, Mr Radcliffe s failure to undertake sufficient diagnostic assessments, including radiographic investigation, meant that he did not carry out any adequate periodontal examinations on the patient. 3. p) You did not diagnose Patient 1 s worsening periodontal condition. The Committee was satisfied on the basis of the evidence before it, that Patient 1 s periodontal condition had worsened during the time she was under the care of Mr Radcliffe. As it has already found that Mr Radcliffe did not formally diagnose the condition, it concluded that he could not have diagnosed that it was worsening. It considered the clinical notes in any event, but found no information to support that any such diagnosis was made by Mr Radcliffe. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -17/58-

18 3. q) You did not treat Patient 1 s periodontal disease. Patient 2 The Committee s finding is that Mr Radcliffe did not diagnose that Patient 1 had periodontal disease. In its view, the evidence indicates that he was unaware of the existence of the disease. The Committee therefore decided that he could not have treated the condition. 4. Between 31 July 2003 and 11 February 2015 you were consulted by Patient 2 in relation to dental treatment. The Committee had regard to Mr Radcliffe s clinical notes for Patient 2, who is the child of Patient 1, which cover the period 31 July 2003 to 11 February On a date or dates set out in Schedule B your care in relation to Patient 2 was inadequate in that: 5. a) You did not carry out sufficient diagnostic assessments. The Committee reviewed Mr Radcliffe s clinical notes, taking into account the relevant dates indicated in Schedule B. It noted that on occasions, Mr Radcliffe recorded having undertaken certain diagnostic aspects. However, it found no evidence that he carried diagnostic assessments to the level of sufficiency explained by Dr Powell. The Committee also took into account the evidence of Dr Leeming, who stated that she saw Patient 2 for a routine appointment on 12 August Dr Leeming stated that as part of an initial examination she took bitewing radiographs, as no recent ones were available. From the radiographs, Dr Leeming diagnosed multiple carious cavities, stating that the most notable was at the LR6, which had a sub-optimal filling. Her evidence was that there was also a cavity on the distal part of this tooth. Dr Powell told the Committee that Patient 2 s caries had been present whilst he was under the care of Mr Radcliffe. Dr Powell based his opinion on an OPG radiograph taken by the registrant in June 2009 in respect of the patient s orthodontic treatment. Whilst Dr Powell noted that an OPG is not the best type of radiograph for the detection of caries, he stated Caries is however certainly significantly present and untreated. In answer to questions from the Committee on whether what he saw on the radiographs were artefacts, as opposed to caries, Dr Powell confirmed his opinion that it was caries. He considered that the extensive nature of the patient s caries meant that it could be seen, despite the type of radiograph. Dr Powell said that Patient 2 s caries was not addressed prior to Mr Radcliffe commencing orthodontic treatment. On the basis of the evidence provided, the Committee was satisfied that Mr Radcliffe did not carry out sufficient diagnostic assessments in relation to RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -18/58-

19 Patient 2 on any of the relevant dates specified in Schedule B. It accepted the evidence of Dr Powell that the patient s caries was extensive as far back as 2009, long before the patient saw Dr Leeming. The Committee considered Dr Powell s conclusions to be consistent with the overall picture provided by the clinical evidence in Patient 2 s case. The Committee was of the view that had Mr Radcliffe carried out sufficient diagnostic assessments at the relevant appointments, Patient 2 s caries would have been obvious. 5. b) You did not carry out a full assessment of Patient 2 s presenting dental condition. The Committee found no information in Mr Radcliffe s clinical notes for Patient 2 to indicate that he had carried out a full assessment of the patient s presenting dental condition on the relevant dates set out in Schedule B. In the absence of such information, it was satisfied that he did not carry out full assessments at the relevant appointments. It was the view of the Committee that Mr Radcliffe could not have carried out what would be considered a comprehensive assessment of the patient s presenting condition in any event, given its finding that he never carried out sufficient diagnostic assessments in respect of the patient. Furthermore, the Committee concluded that Mr Radcliffe provided orthodontic treatment whilst caries remained present in the patient s mouth. The caries should have been treated before orthodontic treatment commenced. 5. c) You did not provide a diagnosis. The Committee had regard to the clinical notes of Mr Radcliffe and found no evidence to indicate that he made a formal diagnosis in Patient 2 s case. It also took into account the evidence of Patient 1, who stated that she had never been made aware of any problems with her or her familiy s teeth. In all the circumstances, the Committee was satisfied that Mr Radcliffe neither made a diagnosis in respect of Patient 2, nor did her provide one to the patient s mother. 5. d) You did not provide a treatment plan. Patient 1 stated in her witness statement in relation to the treatment of Patient 2 that At no point did we receive a treatment plan. Patient 1 also stated that it was Mr Radcliffe who had suggested that Patient 2 undergo orthodontic treatment. Taking Patient 1 s evidence into account, the Committee further considered the opinion of Dr Powell, who stated that there should have been a treatment plan for Patient 2. Dr Powell s evidence was that the treatment plan should have included all of the alternative treatment options, including the option of no treatment considering that orthodontics is an inherited variation and not a disease. Dr Powell also stated that a risk/benefit assessment should also have been included in the treatment plan. The Committee had regard to Mr Radcliffe s clinical notes for Patient 2 and RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -19/58-

20 found no evidence of a treatment plan. In the absence of such evidence, it decided that Mr Radcliffe did not formulate one and it accepted the evidence of Patient 1 that a plan was not provided. 5. e) You did not obtain informed consent. Having determined that Mr Radcliffe did not formulate a treatment plan, which should have included reference to alternative treatment options and a risk/benefit assessment, the Committee was satisfied this head of charge is proved. There was no indication in the relevant clinical notes to indicate that there had been any discussion of any kind regarding a treatment plan and the necessary information required for the obtaining of informed consent. The Committee further had regard to Patient 1 s evidence, which indicated to it, that Patient 2 s orthodontic treatment had been driven by Mr Radcliffe. It considered from Patient 1 s account that she did not know why Patient 2 was having the treatment at all. Therefore, she was never in a position to give her informed consent for the course of treatment Patient 2 underwent. 5. f) You did not provide any or any adequate preventative treatment. Found proved on the basis that no adequate preventative treatment was provided. The Committee saw from the clinical notes that on 11 February 2015, Mr Radcliffe made records in relation to dietary discussion. This indicated to the Committee that there was some discussion at that appointment about these matters. However, this is the only reference to preventative treatment that the Committee could identify over the entire duration of Patient 2 s care with the registrant. The Committee accepted Dr Powell s evidence that for preventative treatment to have been adequate for this patient, it should have included: scale and polish on a regular basis, instruction on oral hygiene, diet analysis, application of topical fluoride, maintenance monitoring every four to six months with reinforcement. In view of the very limited information contained within the clinical notes, the Committee found that the treatment that Mr Radcliffe did provide was not adequate. 5. g) You did not take sufficient radiographs. The only radiograph taken in relation to Patient 2 during the period in question, was the OPG radiograph Mr Radcliffe took in June 2009 for orthodontic purposes. The Committee concluded this was not sufficient in the circumstances, having accepted Dr Powell s opinion that the patient had a high caries risk and that OPGs are not the most appropriate radiographs for diagnosing caries. Furthermore, the Committee accepted Dr Powell s evidence that bitewing radiographs should be taken at least every two years. In the absence of any evidence that Mr Radcliffe took bitewing radiographs, the Committee was satisfied that this head of charge is proved. RADCLIFFE, N H Professional Conduct Committee November December 2017 Page -20/58-

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