HEARING HEARD IN PUBLIC. HOLLIDAY, Andrew Registration No: PROFESSIONAL CONDUCT COMMITTEE April 2019 Outcome: Erased with immediate suspension

Transcription

1 HEARING HEARD IN PUBLIC HOLLIDAY, Andrew Registration No: PROFESSIONAL CONDUCT COMMITTEE April 2019 Outcome: Erased with immediate suspension Andrew HOLLIDAY, a dentist, BDS University of Bristol 2003, was summoned to appear before the Professional Conduct Committee on 1 April 2019 for an inquiry into the following charge: Charge (as amended) That being registered as a dentist Andrew Holliday s (82112) fitness to practise is impaired by reason of misconduct. In that: 1. You failed to provide an adequate standard of care to Patient A, from 25 September 2013 to 6 March 2015 in that: a) In the days after 26 December 2014 you were told by Patient A that she was suffering excruciating pain in her mouth and/or jaw in the upper right quadrant, and in response you advised that the cause was gingivitis and suggested she contact her GP. b) You were not clinically justified when you informed Patient A that she had gingivitis. c) You failed to conduct appropriate tests to determine the cause of Patient A s presenting complaint of pain in the upper right quadrant in December 2014 and January d) You failed to identify that the cause of Patient A s pain was an endodontic issue and may require root canal treatment. 2. You did not act professionally in that you sought to overrule witness 1 s diagnosis in front of Patient A. 3. Your attempt to overrule witness 1 s diagnosis was not clinically justified. 4. You failed to maintain an adequate standard of record keeping in respect of Patient A s appointments from 25 September 2013 to 6 March 2015 including: a) You failed to record a prescription for metronidazole in December b) You failed to record a justification for prescribing metronidazole in December c) You failed to record adequate details of Patient A s presenting complaint and/or any special tests carried out to investigate it. 5. You failed to follow appropriate employment practice by not ensuring/recording Witness 3 was: HOLLIDAY, A Professional Conduct Committee April 2019 Page -1/40-

2 a) A suitable individual to be employed as a nurse in a dental practice, b) Up to date with the required vaccinations including evidence of Hepatitis B seroconversion blood test results, c) Provided with an adequate induction to allow her to perform her duties safely, d) Either enrolled on a recognised training course or intending to enroll on such a course. 6. Your actions with respect to allegation 5 put patient safety at risk. In relation to treatment provided to Patient B, from 19 July 2012 to 16 September 2016: 7. You failed to maintain an adequate standard of record keeping in respect of Patient B s appointments from 19 July 2012 to 16 September 2016 including: a. You failed to make any records in relation to appointments on: i. 3 November 2014 ii. 25 November 2014 iii. 3 March 2016 iv. 24 March 2016 v. 7 May 2016 vi. 24 August 2016 vii. 15 September 2016 viii. 16 September 2016 b. You failed to make adequate records in relation appointments on: i. 3 August 2012, including: ii. iii. A. No record of medical history update. B. No record of haemostasis having been achieved. C. No record of post-operative instructions given. 3 September 2012, including: A. No record of medical history update. B. No details of the surgical protocol used. C. No record of whether primary stability was achieved. D. No record of whether the implants were submerged following surgery or left exposed through the soft tissues. E. No details as to temporization. 17 October 2012, including A. Incomplete details in relation to the nature of the impression taken. B. No details of any jaw registration records. C. No details of any laboratory prescriptions. HOLLIDAY, A Professional Conduct Committee April 2019 Page -2/40-

3 iv. 9 November 2012, including A. Details of a four unit implant supported bridge (replacing UR1 UR4), which was fitted on or around 9 November B. No record as to why the bridge was cemented when a screw retained bridge had been proposed. C. No record/copy of a statement of manufacture. v. 28 July 2014 A. No record of medical history update B. No record of surgical protocol including: surgical flap design, and/or whether primary stability was achieved C. No record of any consent having been obtained. D. No record of radiographs taken during and/or after the surgery. E. No record of medication provided pre-operation or post-operation. F. No record of any post-operative instructions given vi. 1 December 2014 A. No record of medical history update. B. No record of any consent having been obtained. C. Inadequate record of the surgical protocol used including no record of whether primary stability was achieved. D. No record of the removal of the UL4 root apex. E. No record of radiographs taken before or after the surgery. vii. 25 June 2015 A. No record of medical history update. B. No record of any consent having been obtained. C. No record of whether primary stability was achieved. viii. 11 February 2016 A. Details as to whether a laboratory fabricated bridge replacing UL1 - UL5 was fabricated and/or tried in' and/or fitted. B. Details of the temporary bridge fitted on around 11 February c. You failed to make adequate records in relation to: i. Details of what action was taken with a temporary denture (fitted on or around 27 June 2014) after a colleague had recorded that the fit was poor and a reline was required. ii. iii. Whether a second temporary denture was made and/or fitted after an impression was taken on or around 1 December 2014; The provision of a nightguard to the patient; HOLLIDAY, A Professional Conduct Committee April 2019 Page -3/40-

4 iv. Details of what action was taken in relation to an upper hard splint (impression taken on or around 11 March 2016); v. Details of actions involved in the fabrication and fitting of overdenture (fitted on or around 15 September 2016). 8. In relation to Treatment Plan 1 ( TP1 ) which concerned an implant supported bridge in the Upper Right Quadrant commenced on or around 24 July 2012: a. You failed to carry out sufficient pre-treatment investigations in that you failed to undertake a comprehensive evaluation of the patient s dental health. b. You failed to identify that the prognosis for the bridgework in the upper left quadrant was severely compromised. c. You failed to adequately consider and/or explain the implications of the compromised prognosis for the bridgework in the upper left quadrant for the proposed treatment plan. d. You failed to obtain informed consent in that the patient was not adequately informed of the risks and/or benefits of the proposed treatment. e. You failed to obtain an up to date medical history before undertaking surgical procedures. 9. In relation to Treatment Plan 2 ( TP2 ) which concerned an implant supported bridge in the Upper Left Quadrant commenced on or around 12 May 2014 a. You failed to carry out sufficient pre-treatment investigations in that you failed to undertake a comprehensive evaluation of the patient s dental health. b. You failed to obtain informed consent, including: i. Failing to adequately inform the patient of the risks and/or benefits of the proposed treatment; ii. Failing to adequately communicate the treatment plan and/or changes in the treatment plan, including: A. Not identifying whether the surgery was to be executed in a single stage or multiple stages. B. Not updating the patient that the original plan had been to place three implants but had been altered to involve the placement of two implants. C. Not updating the patient and/or adequately explaining the change from a fixed to a removable prosthesis on or around 11 February 2016 D. Not providing the patient with a revised treatment plan in writing. c. Provided a poor standard of treatment in relation to dentures in that you: i. Failed to remedy deficiencies in temporary denture worn during the duration of TP2. ii. Failed to remedy the deficiencies in the final denture provided to Patient B HOLLIDAY, A Professional Conduct Committee April 2019 Page -4/40-

5 d. Provided a poor standard of implant treatment on or around 28 July 2014 in that: i. The UL3 fixture approximated to an area of pathology associated with the root of UL4. ii. You failed to take appropriate measures to seek to ensure that the temporary denture did not overload the implants. e. Failed to maintain an adequate level of professionalism in that: i. You did not maintain reasonable communication with the patient; ii. You did not respond, adequately or at all, to requests for information from the patient in relation to the progress of his treatment. 10. You provided information, on 12 May 2014, regarding the proposed implant treatment, to Patient B that was: a. Inaccurate in that it suggested that implants would either fail in the first few weeks or last a lifetime when in fact implants can fail at any time owing to numerous factors, b. Misleading. 11. You failed to provide an adequate standard of care and/or maintain an adequate standard of record keeping in respect of Patient C from 25 February 2016 to 26 April 2016 in that: a. On 25 February 2016 you failed to identify, cause to investigate further and/or conduct further investigations into: i. UL7; and/or ii. iii. iv. UR6; and/or UR7; and/or LL7; and/or v. LL6; and/or vi. vii. viii. LR3; and/or LR5; and/or Possible signs of early bone loss; and/or b. Having identified caries in relation to the UL4 and/or UL5 you failed to communicate that to Patient C; and/or c. Having identified the matters in allegation 11(a) you failed to communicate that Patient C; and/or d. You failed to provide Patient C a treatment plan to address the matters referred to in allegation 11(a); and/or e. You failed to maintain an adequate standard of record keeping in respect of Patient C's consultation on or around 5 March 2016 in that there is no record at all of the consultation. HOLLIDAY, A Professional Conduct Committee April 2019 Page -5/40-

6 12. You failed to inform patient C of the need for treatment and/or the risks of not proceeding with treatment on 25 February For some or all of the period between 12 May 2014 and January 2018 you were practising as a general dental practitioner and were practice principal at St James Square Dental Surgery, 6 St James Square, Cheltenham ( St James Square ) and/or Hewlett Road Dental Surgery, Hewlett Road, GL52 6AH ( Hewlett Road ). 14. During an announced inspection at Hewlett Road on 05 October 2017 you failed to ensure that the legal requirements in the Health and Social Care Act 2008 and associated regulations were met in that: a) The equipment being used to care for and treat service users was not safe for use. In particular there was no regular servicing or regulation testing of the autoclave, compressor, or X-ray equipment. b) You did not have effective governance systems in place which assessed, monitored and improved quality and safety of services provided. c) You did not have fully effective systems in place to assess, monitor and mitigate the risk relating to the health, safety and welfare of patients. d) Records relating to the provision and management of regulated activities were not created and amended appropriately in accordance with current guidance. e) Staff did not receive such appropriate support, training, professional development, supervision and appraisals as is necessary to enable them to carry out the duties they are employed to carry out. f) There was limited evidence of appraisals and limited evidence of induction for new staff when they started working at the practice. 15. During an announced inspection at St James Square on 27 November 2017 you failed to ensure that the legal requirements in the Health and Social Care Act 2008 and associated regulations were met in that: - a) There were limited systems and processes that enabled the registered person to assess, monitor and mitigate the risk relating to health, safety and welfare of service users and others who may be at risk. b) Staff did not receive such appropriate support, training, professional development, supervision and appraisals as is necessary to enable them to carry out the duties they are employed to carry out. c) There was no evidence of induction for new agency or self-employed staff when they started working at the practice. d) There was no evidence that the hygienist had received any management supervision to ensure that they were following correct procedures and clinical pathways. 16. During an announced inspection at Hewlett Road on 10 February 2017 you failed to ensure that the legal requirements in the Health and Social Care Act 2008 and associated regulations were met in that: HOLLIDAY, A Professional Conduct Committee April 2019 Page -6/40-

7 a) You did not have effective governance systems in place which assessed, monitored and improved the quality and safety of services provided. b) You did not have fully effective systems in place assess, monitor and mitigate the risks relating to the health, safety and welfare of patients. c) Records relating to the provision and management of regulated activities were not created and amended appropriately in accordance with current guidance. d) Staff did not receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to carry out. e) There was limited evidence of appraisals and limited evidence of induction for new staff when they started working at the new practice. 17. From at least January 2017, in respect of Hewlett Road: a) You failed to pay your annual registration fee to the CQC; b) You failed to notify the CQC that you had entered bankruptcy; c) You failed to respond to the CQC requirement notice following an inspection on 10 February 2017; 18. For some or all of the period between 07 July 2017 and 08 January 2018 you failed to hold any professional indemnity cover. 19. For some or all of the period between 07 July 2017 and 08 January 2018 you provided dental advice and/or treatment to patients when you were not in possession of professional indemnity cover. 20. From 20 May 2015 to 22 August 2017, you failed to co-operate with conditions imposed on your practice by the NHS. 21. You breached Undertakings 3a and 3b in that you practised dentistry without having a Reporter approved by the GDC, between 29 November 2017 and 15 January You breached Undertaking 10 in that you did not provide evidence to the GDC by 21 December 2017 to demonstrate that you had provided a copy of your full Case Examiner Decision Sheet to the Postgraduate Dental Dean (or nominated deputy). 23. You breached Undertakings 14a and 14b in that you practised dentistry without having a Workplace Supervisor approved by the GDC between 29 November 2017 and 23 January You breached Undertaking 17 by engaging in single-handed practice between 29 November 2017 and 23 January Your conduct in relation to 22 and/or 23 and/or 24 was: a. Misleading; and/or b. Withdrawn 26. From 19 February 2018 to 05 April 2018 you failed to cooperate with an investigation conducted by the GDC by not providing the GDC with any or insufficient evidence of indemnity and employment information. 27. You have failed to maintain a correct and up to date registered address. HOLLIDAY, A Professional Conduct Committee April 2019 Page -7/40-

8 And that by reason of the facts alleged above your fitness to practise as a dentist is impaired by reason of your misconduct. On 10 April 2019 the Chairman made the following statement regarding the finding of facts: This is a Professional Conduct Committee (PCC) hearing. Mr Holliday was neither present nor represented. Mr Tom Day of Counsel represents the General Dental Council (GDC). Preliminary Matters Proof of service The Committee first sought to determine whether notice had been served on the Registrant in accordance with Rules 35 and 65 of the General Dental Council (GDC) (Fitness to Practise) Rules 2006 ( the Rules ). In reaching its decision, the Committee considered the documentation before it, which included a copy of the notification of the hearing sent to Mr Holliday. Notice was served on the Registrant at his address on the GDC Register by Royal Mail Special Delivery and by on 27 January The notice outlined the date, time, location and purpose of today s hearing. The notice also informed the Registrant of the Committee s power to proceed with the hearing in his absence. The Committee heard and accepted the advice of the Legal Adviser. On the basis of the information provided to it, the Committee concluded that service of the notice of today s hearing had been properly effected in accordance with the Rules. Proceeding in the absence of the Registrant As the Committee found that the notice had been properly served, it went on to consider whether to exercise its discretion under Rule 54 to proceed with the hearing in the Registrant s absence, as was the submission of the Council. The Committee remained mindful of the need to approach this issue with the utmost care and caution. The Committee was content from the notice of hearing documents that Mr Holliday should be aware of the hearing taking place today. Whilst there has been no explicit correspondence from him in relation to the hearing taking place in his absence, it is reasonable to infer from his lack of engagement with the fitness to practise process that he has voluntarily waived his right to attend. The Committee also determined there is no evidence to suggest an adjournment would secure his attendance at a later date. The Committee also had regard to the public interest in hearing the matters before it expeditiously. Having balanced the Registrant s interests with the public interest, it decided that it was fair to proceed in the absence of the Registrant. Rule 18 application At the outset of the hearing, Mr Day made an application to amend the charge, pursuant to Rule 18 of the Rules. Mr Day applied to amend head of charge 20 by changing the date 20 May 2015 to 22 December Mr Day explained that this amendment actually further limits the time frame and more accurately reflects the evidence and would not cause any injustice to Mr Holliday s case. The Committee heard and accepted the advice of the Legal Adviser. Having had regard to the merits of the case and to the fairness of the proceedings, it was satisfied that the HOLLIDAY, A Professional Conduct Committee April 2019 Page -8/40-

9 amendment could be made without causing any injustice. The charge was amended accordingly. Background The Council alleges that Mr Holliday s fitness to practise is impaired by reason of misconduct. As encapsulated in the particulars of allegation, the alleged misconduct covered clinical issues and conduct issues, extended over a significant period of time ( ), concerned a number of patients, a number of treatment plans, and different colleagues and regulators. Evidence By way of factual evidence from the GDC, the Committee was provided with the following signed witness statements and documentary exhibits: A witness statement dated 06 December 2017 from Patient A; A witness statement dated 08 December 2017 from Witness 1; A witness statement dated 27 November 2017 from Witness JR; A witness statement dated 25 April 2018 from Patient B; A witness statement dated 30 November 2018 from Patient C; A witness statement dated 30 November 2018 from Witness 2; A witness statement dated 12 September 2018 from Witness KC; A witness statement dated 19 September 2018 from Witness AW; A witness statement dated 04 December 2018 from CW A witness statement dated 01 June 2018 from Witness KE; A witness statement dated 24 June 2018 from Witness KG; A witness statement dated 17 June 2018 from Witness DL A witness statement dated 26 March 2019 from Witness FJ; Two witness statements, dated 04 December 2018 and 26 February 2019 from Witness CH. In addition to their witness statements, the Committee heard oral evidence from Patient B, Witness AW, Witness 1 and Witness KC. The Committee also received patient records relating to Patient A, Patient B and Patient C. The Committee also had sight of further evidence in relation to the Registrant s referral to the PCC on 20 July Further provided to the Committee were the reports of the GDC s expert witness, Mr Conor Mulcahy, dated 06 December 2017, 26 May 2018, 29 November 2018 and 04 December Mr Mulcahy also gave oral evidence to the Committee. HOLLIDAY, A Professional Conduct Committee April 2019 Page -9/40-

10 Applications to amend the charge After the evidence had been adduced, Mr Day applied to amend the charge under Rule 18 of the Rules to withdraw charge 25(b) relating to the Registrant s alleged lack of integrity. The Committee heard and accepted the advice of the Legal Adviser. The Committee was satisfied that the charge could be withdrawn without causing any injustice to the Registrant. The charge was amended accordingly. After the Committee retired to consider the evidence, it invited Mr Day to address the Committee on the drafting of charge 5. Mr Day applied to make a further amendment to the charge. He sought to amend head of charge 5 to replace the words individual concerned with Witness 3, to clarify an error in the original drafting of the charge and specify the individual that the charge related to. The Committee asked Mr Day whether the Registrant had been informed of the proposed amendment. He told the Committee that the Registrant had been contacted by the GDC via with regard to the proposed amendment. Given that the Registrant was absent from the proceedings, the Committee decided to give the Registrant time to respond before considering the application. After some time, the Registrant had neither downloaded nor responded to the . The Committee heard and accepted the advice of the Legal Adviser. The Committee agreed with Mr Day s submission that the amendment was of a technical nature and that it would not cause any prejudice to the Registrant to accede to the application. The charge was amended accordingly. Committee s assessment of witnesses who gave oral evidence to the Committee The Committee first considered the evidence of Patient B. It found his evidence to be helpful and detailed. It was particularly assisted by his notes of appointments with the Registrant taken at the material time that supported his oral evidence. The Committee considered that Witness AW assisted the Committee with clarification of the allegations relating to the CQC and helped taking matters forward. The Committee considered the evidence of Witness 1. It decided that she was a clear, concise and consistent witness. She gave a measured response to the questions put to her and was able to admit when she was not able to recall specific events. The Committee was satisfied that it could rely on her evidence. The Committee found that Witness KC was also a credible witness. She was clear in her recollection of the events at the material time; however, she was also forthcoming in admitting when the passage of time had hindered her memory on some points of detail. With regard to the expert evidence of Mr Mulcahy, the Committee was satisfied it could rely on his opinion. It found he was a knowledgeable and credible witness who gave evidence in a measured and balanced way. The Committee was particularly assisted by his expert reports. The Committee s Findings of Fact The Committee has taken into account all the evidence presented to it, both oral and documentary. It took account of the submissions made by Mr Day on behalf of the GDC and heard and accepted the advice of the Legal Adviser. In accordance with that advice it has considered each head of charge separately. The Committee has borne in mind that the HOLLIDAY, A Professional Conduct Committee April 2019 Page -10/40-

11 burden of proof rests with the GDC and that the standard of proof is the civil standard, that is, whether the alleged factual matters are found proved on the balance of probabilities. The Committee s findings in relation to each head of charge are as follows: 1. You failed to provide an adequate standard of care to Patient A, from 25 September 2013 to 6 March 2015 in that: 1(a). 1(b). 1(c). In the days after 26 December 2014 you were told by Patient A that she was suffering excruciating pain in her mouth and/or jaw in the upper right quadrant, and in response you advised that the cause was gingivitis and suggested she contact her GP. The Committee accepted Patient A s clear account in her written statement that she told the Registrant about the excruciating pain she was suffering from at that time and that she made that clear to the Registrant. The Registrant s only advice to her was that she should contact her GP. The Committee also accepted Mr Mulcahy s evidence that the symptoms exhibited by Patient A were not compatible with a diagnosis of gingivitis. Further, it considered that it was unacceptable to provide such a clinical diagnosis over the phone without examining Patient A. It also took into account the evidence of Witness 1, who told the Committee that Patient A was a reliable historian in terms of describing her symptoms. The Committee therefore concluded that Mr Holliday s actions in this regard amounted to an inadequate standard of care. You were not clinically justified when you informed Patient A that she had gingivitis. The Committee accepted Mr Mulcahy s oral evidence that the clinical factors in this case were very unlikely to be consistent with a diagnosis of gingivitis which required to be diagnosed visually. He suggested that it was more likely that the patient had pulpitis. In particular, he told the Committee that gingivitis does not typically present with the sort of pain Patient A was experiencing and described to the Registrant. Further, the Committee accepted Mr Mulcahy s opinion that it was unjustified to give the patient this diagnosis over the telephone without having undertaken an examination. Both Witness 1 and Mr Mulcahy told the Committee that reaching a correct diagnosis in the case of Patient A would be considered to be basic dentistry and should have been reached by any competent dentist. The Committee therefore concluded that by failing to reach the correct diagnosis, the Registrant s actions amounted to an inadequate standard of care. You failed to conduct appropriate tests to determine the cause of Patient A s presenting complaint of pain in the upper right quadrant in December 2014 and January HOLLIDAY, A Professional Conduct Committee April 2019 Page -11/40-

12 1(d). The Committee accepted Mr Mulcahy s evidence that there are a series of tests expected to be performed by a competent dentist to determine the cause of Patient A s presenting complaint. The Committee was satisfied, on the balance of probabilities, that the appropriate tests were not undertaken by Mr Holliday. It accepted Patient A s evidence that she had no recollection of any such tests taking place. Further, the Committee considered that if the Registrant had undertaken the appropriate tests, the outcome would have likely led to the correct diagnosis of Patient A having pulpitis. The Committee concluded that the Registrant s actions in this regard amounted to an inadequate standard of care. You failed to identify that the cause of Patient A s pain was an endodontic issue and may require root canal treatment. The Committee accepted Mr Mulcahy s evidence that the diagnosis reached, and the treatment adopted by the Registrant were not consistent with treating an endodontic issue. The Committee also noted that at the subsequent appointment on 06 March 2015, Witness 1 identified an endodontic issue in respect of Patient A. However, at that same appointment, Mr Holliday appeared to fail to recognise his incorrect diagnosis and persisted to treat the patient as though the pain did not indicate an endodontic issue. The Committee was therefore satisfied that the Registrant failed to identify that the cause of Patient A s pain was an endodontic issue that would require a root canal treatment. The Committee accepted the expert opinion and the evidence of Witness 1 that this was within the scope of a competent dental practitioner and therefore the Registrant s failure to identify the cause of Patient A s pain as an endodontic issue amounted to an inadequate standard of care. 2. You did not act professionally in that you sought to overrule Witness 1 s diagnosis in front of Patient A. Patient A attended an appointment with Witness 1 on 06 March Mr Holliday met Patient A in the waiting area of the Practice and told her she did not require a root canal treatment as advised by Witness 1 and would only need a simple filling. Witness 1 s evidence to the Committee was that subsequently in her surgery, Mr Holliday overruled her diagnosis in front of Patient 1 in an overbearing, patronising and rude way. The Committee accepted Witness 1 s evidence that she was recently qualified at that time and that the Registrant s actions in undermining her diagnosis were dismissive and overbearing. Notwithstanding this, the Committee found that it is not inherently unprofessional to overrule a colleague s diagnosis in front of a patient, and that the charge as written does not extend to the attitudinal behaviour of Mr Holliday s actions in doing so. HOLLIDAY, A Professional Conduct Committee April 2019 Page -12/40-

13 3. Your attempt to overrule Witness 1 s diagnosis was not clinically justified. The Committee accepted the evidence of Witness 1 and Mr Mulcahy. On 6 March 2015, Mr Holliday spoke to Patient A in the waiting room and attempted to overrule Witness 1 s diagnosis without examining the patient or reviewing the existing radiographs. Further, the Committee considered that a reasonably competent dentist could not determine from the patient s records alone that a filling would suffice. The Committee therefore concluded that the Registrant s attempt to overrule Witness 1 s diagnosis was not clinically justified. 4. You failed to maintain adequate standard of record keeping in respect of Patient A s appointments from 25 September 2013 to 6 March 2015 including: 4(a). You failed to record a prescription for metronidazole in December (b). 4(c). The Committee was satisfied from Patient A s account that the Registrant prescribed Metronidazole for her in December Patient A attended an appointment with Witness 1, 6-7 weeks later, on 18 February The records of that appointment indicate that Patient A told Witness 1 that Mr Holliday had recently prescribed Metronidazole for her. The Committee was satisfied from the records available to it that there is no written record by Mr Holliday detailing a prescription for Metronidazole to Patient A, and that this amounted to a failure to maintain an adequate standard of record keeping. You failed to record a justification for prescribing metronidazole in December Given the Committee s findings at 4(a) above, where it accepted Mr Mulcahy s evidence that there was no record detailing the prescription for Metronidazole, the Committee also finds this charge proved. You failed to record adequate details of Patient A s presenting complaint and/or any special tests carried out to investigate it. Found proved in respect of adequate records of Patient A s presenting complaint. Found not proved in respect of adequate records of Patient A s special tests. As found at charge 4(b), Patient A presented with significant pain, however the Registrant s record only indicated tenderness. This does not suffice as adequate detail of the patient s presenting complaint. There was no record made by the Registrant of the type and intensity of the pain Patient A was experiencing. As found at charge 1(c), the Committee determined that the Registrant did HOLLIDAY, A Professional Conduct Committee April 2019 Page -13/40-

14 not undertake the appropriate tests to investigate Patient A s presenting complaint, and he therefore could not record that which he did not do. 5. You failed to follow appropriate employment practice by not ensuring/recording Witness 3 was: 5(a). 5(b). 5(c). 5(d). A suitable individual to be employed as a nurse in a dental practice, Up to date with the required vaccinations including evidence of Hepatitis B sero-conversion blood test results, Provided with an adequate induction to allow her to perform her duties safely, In relation to charges 5(a)-5(c), the Committee took account of Witness 1 s evidence in her initial complaint that she and other staff were not subject to the appropriate checks before commencing work at the Practice. She said that this was consistent with the overall chaotic nature of the Practice at the time. However, the Committee found that there was insufficient evidence presented to it to find this charge proved. Whilst Witness 1 gave an account of her personal experience at the Practice, the GDC did not discharge its burden of proof in relation to Witness 3. The Committee heard no evidence from Witness 3 and only the hearsay evidence of Witness 1 about Witness 3. In the Committee s view, this was insufficient to persuade it that this charge was found proved, either substantively or in the alternative. Either enrolled on a recognised training course or intending to enrol on such a course. The Committee had sight of correspondence written by the Registrant to Witness 1 on 03 September 2015, in which he accepted that he had failed to ensure that Witness 3 was enrolled on a recognised training course or was intending to do so. 6. Your actions with respect to allegation 5 put patient safety at risk. The Committee considered that whilst there is no evidence available to it that any patients suffered actual harm, the Registrant s actions in failing to ensure an adequate level of training and competency of Witness 3 as a dental nurse, who was directly involved in patient care, compromised patient safety. 7. In relation to the treatment provided to Patient B, from 19 July 2012 to 16 September 2016, you failed to maintain an adequate standard of record keeping in respect of Patient B s appointments from 19 July 2012 to 16 HOLLIDAY, A Professional Conduct Committee April 2019 Page -14/40-

15 7(a). September 2016 including: You failed to make any records in relation to appointments on: 7 (a) (i) 3 November 2014 The Committee noted from Patient B s records that there was a radiograph dated 3 November 2014, but no other records present. The Committee concluded that this amounted to an inadequate standard of record keeping. 7(a). ii 25 November 2014 The Committee noted from Patient B s records that there was a radiograph dated 25 November 2014, but no other records present. The Committee concluded that this amounted to an inadequate standard of record keeping. 7(a). iii 3 March (a). iv 24 March (a). v 7 May (a). vi 24 August (a). vii 15 September (a). viii 16 September (b). 7(b) i. 7(b). i A In relation to charges 7(a)iii 7(a)viii, the Committee accepted Patient B s clear written and oral evidence that these appointments took place. It was also assisted by Patient B s notes of the chronology of appointments with Mr Holliday during this time period. The Committee also had regard to the electronic records from the Practice on the relevant dates. However, there are no clinical records present in relation to any of the appointments. The Committee concluded that this amounted to an inadequate standard of record keeping. You failed to make adequate records in relation appointments on: 3 August 2012, including: No record of medical history update. HOLLIDAY, A Professional Conduct Committee April 2019 Page -15/40-

16 7(b). i B 7(b). i C 7(b). ii 7(b) ii. A 7(b). ii B 7(b). ii C 7(b). ii D 7(b). ii E 7(b). iii No record of haemostasis having been achieved. No record of post-operative instructions given. The Committee accepted the expert opinion of Mr Mulcahy that a medical history update, a record of haemostasis having been achieved and a record of any post-operative instructions given formed elements of a record that should be present and were missing from the patient s notes The Committee had regard to the records of the appointment on 3 August In relation to charges 7(b)i A 7(b)i C, the Committee determined that these were matters that ought to have been recorded but were not. The Committee concluded that this failure amounted to an inadequate standard of record keeping. 3 September 2012, including: No record of medical history update. No details of the surgical protocol used. No record of whether primary stability was achieved. No record of whether the implants were submerged following surgery or left exposed through the soft tissues. No details as to temporization. The Committee accepted the expert opinion of Mr Mulcahy that a medical history update, details of the surgical protocol used and, a record of whether primary stability was achieved, a record of whether the implants were submerged following surgery and details as to temporization formed elements of a record that should be present and were missing from the patient s notes. The Committee had regard to the records of the appointment on 3 September In relation to charges 7(b)ii A 7(b)ii E, the Committee determined that these were matters that ought to have been recorded but were not. The Committee concluded that this failure amounted to an inadequate standard of record keeping. 17 October 2012, including: HOLLIDAY, A Professional Conduct Committee April 2019 Page -16/40-

17 7(b). iii A 7(b). iii B 7(b). iii C 7(b). iv 7(b). iv A 7(b). iv B 7(b). iv C Incomplete details in relation to the nature of the impression taken. No details of any jaw registration records. No details of any laboratory prescriptions. The Committee accepted the expert opinion of Mr Mulcahy that complete details in relation to the nature of the impression taken, details of any jaw registration records and laboratory prescriptions formed elements of a record that should be present and were missing from the patient s notes. The Committee had regard to the records of the appointment on 17 October In relation to charges 7(b)iii A 7(b)iii C, the Committee determined that these were matters that ought to have been recorded but were not. The Committee concluded that this failure amounted to an inadequate standard of record keeping. 9 November 2012, including: Details of a four unit implant supported bridge (replacing UR1-UR4), which was fitted on or around 9 November No record as to why the bridge was cemented when a screw retained bridge had been proposed. The Committee accepted the expert opinion of Mr Mulcahy that details of the bridge that was fitted and why it was cemented rather than being screw retained formed elements of a record that should be present and were missing from the patient s notes. The Committee had regard to the records of the appointment on 9 November In relation to charges 7(b)iv A and 7(b)iv B, the Committee determined that these were matters that ought to have been recorded but were not. The Committee concluded that this failure amounted to an inadequate standard of record keeping. No record/copy of a statement of manufacture. The Committee noted that there was nothing in the notes relating to a record or copy of a statement of manufacture. However, there was insufficient information available to it to ascertain whether the Registrant had a requirement to provide such a record or copy at the material time. It therefore concluded that the GDC did not discharge its burden of proof in HOLLIDAY, A Professional Conduct Committee April 2019 Page -17/40-

18 relation to this charge. 7(b) v. 28 July (b) v. A 7(b) v. B 7(b) v. C 7(b) v. D 7(b) v. E 7(b) v. F No record of medical history update No record of surgical protocol including: surgical flap design, and/or whether primary stability was achieved No record of any consent having been obtained. No record of radiographs taken during and/or after the surgery. The Committee had sight of a record in the form of four radiographs in respect of this appointment in the patient s notes. Accordingly, this charge is found not proved. No record of medication provided pre-operation or post-operation. No record of any post-operative instructions given. The Committee accepted the expert opinion of Mr Mulcahy that these matters formed elements of a record that should be present and were missing from the patient s notes. The Committee had regard to the appointment on 28 July In relation to charges 7(b)v A, 7(b)v B, 7(b)v C, 7(b)v E and 7(b)v F, the Committee determined that these matters ought to have been recorded but were not. The Committee concluded that this failure amounted to an inadequate standard of record keeping. 7(b). vi 1 December (b). vi A 7(b). vi B 7(b). vi C 7(b). vi D No record of medical history update. No record of any consent having been obtained. Inadequate record of the surgical protocol used including no record of whether primary stability was achieved. No record of the removal of the UL4 root apex. HOLLIDAY, A Professional Conduct Committee April 2019 Page -18/40-

19 7(b). vi E The Committee accepted the expert opinion of Mr Mulcahy that these matters formed elements of a record that should be present and were missing from the patient s notes. The Committee had regard to the appointment on 1 December In relation to charges 7(b)vi A 7(b)vi D, the Committee determined that these matters ought to have been recorded but were not. The Committee concluded that this failure amounted to an inadequate standard of record keeping. No record of radiographs taken before or after the surgery. The Committee had sight of a record in the form of three radiographs in respect of this appointment in the patient s notes. Accordingly, this charge is found not proved. 7(b). vii 25 June (b). vii A 7(b). vii B 7(b). vii C No record of medical history update. No record of any consent having been obtained. No record of whether primary stability was achieved. The Committee accepted the expert opinion of Mr Mulcahy that these matters formed elements of a record that should be present and were missing from the patient s notes. The Committee had regard to the appointment on 25 June In relation to charges 7(b)vii A 7(b)vii C, the Committee determined that these matters ought to have been recorded but were not. The Committee concluded that this failure amounted to an inadequate standard of record keeping. 7(b). viii 11 February (b). viii A Details as to whether a laboratory fabricated bridge replacing UL1 - UL5 was fabricated and/or tried in' and/or fitted. The Committee had regard to the evidence of Mr Mulcahy in that there was there was insufficient evidence that this was what was intended by the Registrant. Further, there was no evidence to suggest that an impression was taken which would have been required for a fpre-fabricated bridge to be provided by a laboratory. 7(b). viii B Details of the temporary bridge fitted on or around 11 February HOLLIDAY, A Professional Conduct Committee April 2019 Page -19/40-

20 The Committee had regard to the records and noted that a record was made by the Registrant to indicate that the temporary bridge was fitted on or around 11 February However, it accepted the evidence of Mr Mulcahy that more detail should have been recorded in notes. The Committee concluded that lack of detail amounted to an inadequate standard of record keeping. 7 (c). You failed to make adequate records in relation to: 7 (c). i Details of what action was taken with a temporary denture (fitted on or around 27 June 2014) after a colleague had recorded that the fit was poor and a reline was required. The Committee saw from the notes that the temporary denture was fitted on 27 June 2014 by a different dentist. At that appointment, the dentist noticed that the fit of the denture was poor. A subsequent treating dentist at an appointment on 03 July 2014 also indicated that the denture needed to be relined. However, there were no further records made by the Registrant of any action taken to correct the poor fitting denture. The Committee considered Mr Mulcahy s oral evidence that there was no reference to the denture at all after the record on 27 June The Committee concluded that there is no evidence available to it to conclude that any further action was taken in respect of the denture. The Registrant therefore could not have recorded that which may not have done. 7 (c). ii Whether a second temporary denture was made and/or fitted after an impression was taken on or around 1 December 2014; The Committee saw from the records of the appointment on or around 1 December 2014 that there was a reference made by the Registrant to an impression being taken. However, there is nothing subsequent in the notes to show whether a second temporary denture was later fitted. The Committee concluded that amounted to an inadequate standard of record keeping. 7 (c). iii The provision of a nightguard to the patient; The Committee accepted Patient B s evidence that a nightguard was provided to him by the Registrant, but there are no records present to indicate that. The Committee concluded that amounted to an inadequate standard of record keeping. 7 (c). iv Details of what action was taken in relation to an upper hard splint (impression taken on or around 11 March 2016); At the appointment on 11 March 2016, the records indicate that an HOLLIDAY, A Professional Conduct Committee April 2019 Page -20/40-

21 impression was taken in relation to an upper hard splint. However, there are no records available in relation to the hard splint being subsequently fitted for the patient thereafter. The Committee concluded that amounted to an inadequate standard of record keeping. 7 (c). v Details of actions involved in the fabrication and fitting of overdenture (fitted on or around 15 September 2016). The evidence before the Committee was that Patient B s overdenture was fitted. However, there is no evidence available in relation to the fabricating and fitting of the denture. The Committee concluded that this amounted to an inadequate standard of record keeping. 8. In relation to Treatment Plan 1 ( TP1 ) which concerned an implant supported bridge in the Upper Right Quadrant commenced on or around 24 July 2012: 8 (a). You failed to carry out sufficient pre-treatment investigations in that you failed to undertake a comprehensive evaluation of the patient s dental health. The Committee accepted Mr Mulcahy s oral evidence that this was an advanced and complex procedure that required comprehensive preoperative planning and preparation. Mr Mulcahy accepted that there is evidence that the Registrant undertook a ridge-mapping exercise and radiographs of the patient s upper anterior region, but his opinion was that this does not constitute a comprehensive evaluation of the patient s dental health. The Committee therefore concluded that it was more likely that not that sufficient pre-treatment investigations did not take place. 8 (b). You failed to identify that the prognosis for the bridgework in the upper left quadrant was severely compromised. The Committee accepted Mr Mulcahy s evidence that it was apparent that the bridge in the upper left quadrant had repeatedly failed in the past and the Registrant failed to identify that it was compromised, and the prognosis was poor. The patient s records also show evidence of the bridgework repeatedly failing. The Committee concluded that Mr Holliday failed to properly consider all of the patient s dentition. 8 (c). You failed to adequately consider and/or explain the implications of the compromised prognosis for the bridgework in the upper left quadrant for the proposed treatment plan. Mr Mulcahy told the Committee that it was incumbent on the Registrant to point out the implications of the compromised prognosis for the bridgework in order to give Patient B all possible options for treatment going forward. HOLLIDAY, A Professional Conduct Committee April 2019 Page -21/40-

22 The Committee accepted Patient B s evidence that he was not informed about the poor prognosis of the existing bridge work in the upper left quadrant. 8 (d). You failed to obtain informed consent in that the patient was not adequately informed of the risks and/or benefits of the proposed treatment. The Committee determined that it was clear from Patient B s evidence that he was not given sufficient information as to all the risks and/or benefits of proposed treatment of the upper right quadrant. It accepted the expert evidence that Patient B would not have been able to give informed consent unless he had been adequately informed of the risks and/or benefits of the proposed treatment. 8 (e). You failed to obtain an up to date medical history before undertaking surgical procedures. The Committee had regard to the medical history form within the notes updating Patient B s medical history relatively close in time to the procedure, but there was no evidence of a medical history update being obtained on the day of the procedure. It considered Mr Mulcahy s evidence that this would not suffice. He told the Committee that the Registrant was under a duty to obtain the patient s up to date medical history immediately before the surgical procedure took place, in case there were any changes Mr Holliday ought to have been aware of that could compromise the safety of the patient. 9. In relation to Treatment Plan 2 ( TP2 ) which concerned an implant supported bridge in the Upper Left Quadrant commenced on or around 12 May 2014: 9 (a). You failed to carry out sufficient pre-treatment investigations in that you failed to undertake a comprehensive evaluation of the patient s dental health. The Committee accepted Mr Mulcahy s oral evidence that this was an advanced and complex procedure that required comprehensive preoperative planning and preparation. Mr Mulcahy accepted that there is evidence that the Registrant only took radiographs of the patient s upper anterior region, but his opinion was that this did not constitute a comprehensive evaluation of the patient s dental health. The Committee therefore concluded that it was more likely that not that sufficient pretreatment investigations did not take place. 9 (b). You failed to obtain informed consent, including: 9 (b) i. Failing to adequately inform the patient of the risks and/or benefits of the proposed treatment; HOLLIDAY, A Professional Conduct Committee April 2019 Page -22/40-