HEARING HEARD IN PUBLIC. ZANDER, Markus Registration No: PROFESSIONAL CONDUCT COMMITTEE MARCH 2017 Outcome: Erased with Immediate Suspension

Transcription

1 HEARING HEARD IN PUBLIC ZANDER, Markus Registration No: PROFESSIONAL CONDUCT COMMITTEE MARCH 2017 Outcome: Erased with Immediate Suspension Markus ZANDER, a dentist, Zahnarzt Münster 1989; was summoned to appear before the Professional Conduct Committee on 27 March 2017 for an inquiry into the following charge: Charge Between 24 March 2014 and 24 June 2014, being a registered dentist, you practised as a general dental practitioner at Practice A; Inadequate clinical care 1. You did not provide an adequate standard of care to Patient A from 24 March 2014 to 24 June 2014, including by; a. not carrying out sufficient pre-treatment investigations: i. On 24 March 2014, you:- a) Did not complete a medical history; b) Did not adequately assess Patient A s intra-oral soft tissues; c) Did not undertake any or any adequate dental charting d) Did not undertake any or any adequate assessment of the periodontal tissues; e) Did not diagnose dental decay on UR7 and / or LL8. ii. On 08 May 2014, you did not update the medical history of Patient A; iii. On 24 June 2014, you did not update the medical history of Patient A; b. Not carrying out sufficient treatment planning:- i. On 24 March 2014 and/or 08 May 2014 and / or 24 June 2014, you did not:- a) Provide Patient A with a clear diagnosis in respect of Patient A s presenting problems; b) Discuss with Patient A any or any adequate risks and benefits of the root treatment of UL1 and/or LL6; c) Adequately discuss all reasonable treatment options in respect of UL1 and/or LL6; ZANDER, M Professional Conduct Committee March 2017 Page -1/19-

2 d) Provide Patient A with any or any adequate treatment plan of all treatment in respect of UL1 and/or LL6; e) Provide Patient A with any or any adequate costing for the treatment you proposed for UL1 and /or LL6; c. On 08 May 2014 and/or 24 June 2014, you failed to ensure Patient A understood whether or not temporary or permanent fillings had been placed at:- i. UL1; ii. LL6. Use of Radiographs 2. On 24 March 2014 and/or 08 May 2014 and/or 24 June 2014, you :- i. Failed to take any bitewing radiographs; ii. iii. iv. Consent Failed to evaluate the periapical radiograph of the UL1; Failed to take a pre-operative radiograph of the LL6; Failed to undertake a post-operative radiograph of the LL6 v. Failed to undertake a post-operative radiograph of the UL1 3. You did not provide an adequate standard of care, from 24 March 2014 to 24 June 2014, to Patient A as you failed to obtain informed consent for the treatment you proposed in respect of the UL1 and / or LL6. Record Keeping 4. You failed to maintain an adequate standard of record-keeping in respect of Patient A s appointments on 24 March 2014 and/or 08 May 2014 and/or 24 June 2014, including by; a. not recording sufficient pre-treatment investigations by; i. Not recording Patient A s presenting problems; ii. iii. iv. Not recording a medical history; Not recording any updates to the medical history; Not recording Patient A s past dental history; v. Not recording an intra-oral examination; vi. vii. viii. ix. Not recording a basic periodontal examination; Not recording the charting of Patient A s dentition; Not recording the justification of the periapical radiograph of UL1; Not recording the evaluation of the periapical radiograph of UL1; x. Not recording the grading of the periapical radiograph of UL1; b. Not recording sufficient treatment planning by; ZANDER, M Professional Conduct Committee March 2017 Page -2/19-

3 i. Not recording any or any adequate diagnosis in respect of Patient A s presenting problems; ii. iii. iv. Not recording any or any adequate discussion of risks and benefits of the root treatment of UL1 and/or LL6; Not recording any or any adequate discussion of all reasonable treatment options in respect of UL1 and/or LL6 Not recording any or any adequate treatment plan in respect of UL1 and/or LL6. c. Not recording the type of anaesthetic administered on 08 May 2014 and/or 24 June 2014; d. Not recording the method of tooth isolation used for the treatment to UL1 and/or LL6; e. Not recording the method of determining working length for the treatment to UL1 and/or LL6; f. Not recording that the treatment provided to UL1 and/or LL6 was temporary; g. Not recording any or any adequate details of the filling materials used for UL1 and/or LL6; h. Not recording any or any adequate details of the endodontic technique used for UL1 and/or LL6; i. Not recording any or any adequate record of informed consent being obtained for the treatment in respect of UL1 and/or LL6. 5. On or around 14 May 2015 you provided the General Dental Council with records in respect of Patient A s appointments from 24 March 2014 to 24 June 2014 which:- i. You had redrafted; ii. You knew were not contemporaneous. 6. Your conduct in relation to 5(i) and/or 5(ii) above was: i. misleading, ii. dishonest; 7. You failed to respond adequately to Patient A s complaint of 24 February 2015 regarding her dental treatment. And that by reason of the above misconduct your fitness to practise is impaired. On 29 March 2017.the Chairman made the following statement regarding the finding of facts: Mr Zander is not present or represented at this Professional Conduct Committee (PCC) hearing of his case. In his absence, the Committee first considered whether the General Dental Council (GDC) had complied with serving the Notice of Hearing on Mr Zander in accordance with Rules 13 and 65 of the GDC (Fitness to Practise) Rules Order of Council 2006 (the Rules). ZANDER, M Professional Conduct Committee March 2017 Page -3/19-

4 The Committee has seen a copy of the Notice of Hearing letter dated 15 February 2017 which was sent by the GDC to Mr Zander s registered address by special delivery and first class post. The letter sets out the date, time and location of today s hearing, as well as the particularised facts of the charge, in compliance with Rule 13. The Royal Mail receipt confirms that the item was sent to Mr Zander s registered address on 16 February 2017, which the Committee notes, is more than 28 days in advance of today s hearing. The Committee has also seen a copy of that same letter dated 15 February 2017 which was sent to Mr Zander s registered address by first class post and by on 15 February Finally, the Committee has seen a copy of an dated 15 February 2017 from the GDC to Mr Zander s address, which refers him to a link to the Notice of Hearing. The GDC subsequently received notification from Office 365 to say that Mr Zander s address was not available. Having regard to all of the documents before it, the Committee is satisfied that all reasonable efforts have been made by the GDC to serve the Notice of Hearing on Mr Zander at his registered address and that the GDC has complied with the requirements of service in accordance with Rules 13 and 65. Proceeding in absence The Committee then went on to consider whether to hear this case in the absence of Mr Zander in accordance with Rule 54. Mr Dent, on behalf of the GDC, invited the Committee to do so on the basis that Mr Zander has been consistent in his approach not to engage with the GDC in relation to these proceedings and he has voluntarily absented himself from this hearing. He referred the Committee to various letters from the GDC to Mr Zander contained in the hearing bundle which showed the numerous attempts made by the GDC to secure Mr Zander s engagement in these proceedings, as well as requests that he provided responses to the GDC by deadlines, but without any response from Mr Zander. Mr Dent also drew the Committee s attention to a letter dated 18 October 2016 from Hempsons Solicitors to the GDC which stated that they were no longer instructed on behalf of Mr Zander. The letter further stated: We are instructed to confirm that Mr Zander will not be engaging with the GDC investigation any further. The Committee has considered the submissions Mr Dent has made. It has accepted the advice of the Legal Adviser. It has borne in mind that the discretion to proceed in the absence of the respondent must be exercised with the utmost care and caution and that it must have in mind the need for fairness to Mr Zander as well as to the GDC, and the public and to bear in mind the impact on the memories of witnesses with the passage of time. The Committee notes the numerous attempts made by the GDC to secure Mr Zander s engagement in these proceedings, and the absence of any response from him. The Committee has also borne in mind the case of Burrows v General Pharmaceutical Council [2016] EWHC 1050 (Admin), as advised by the Legal Adviser, where it was said that the regulator should forewarn the registrant that the non-attendance of him/her at the hearing could be severely prejudicial to him/her. The Committee notes the letter dated 5 December 2016 from the GDC to Mr Zander concerning arrangements for this hearing, with a requirement that he complies with the GDC s requests for information by 23 December The letter advises Mr Zander that if he is unable to attend the hearing in person, the GDC can make arrangements for him to attend the hearing by alternative means, to enable him to engage with the hearing. In addition, the letter warns Mr Zander that his non-attendance at the hearing may be severely prejudicial to him. Mr Zander has not responded to that letter or to the Notice of Hearing letter dated 15 February 2017 and has chosen not to engage with the GDC at all in respect ZANDER, M Professional Conduct Committee March 2017 Page -4/19-

5 of these proceedings. His decision not to engage with the GDC is confirmed in the letter from Hempsons Solicitors dated 18 October There is nothing before the Committee to suggest that Mr Zander would attend on a future occasion, were it to adjourn this hearing. The Committee has also had regard to the serious nature of the allegations against Mr Zander and the public interest in the expeditious disposal of the case. It notes that the GDC intends to call witnesses in support of its case. Having regard to all these factors, the Committee has decided that it is fair and appropriate to proceed in the absence of Mr Zander in accordance with Rule 54. The GDC s case against Mr Zander The GDC alleges that Mr Zander provided an inadequate standard of care to Patient A between 24 March 2014 and 24 June 2014 in a number of respects. On 24 March 2014 Patient A first saw Mr Zander where a filling was completed. There is disagreement between the parties as to whether there were two or three subsequent visits but it is not in dispute that Mr Zander carried out root canal treatment to UL1 and LL6. Subsequently Patient A complained to the practice about Mr Zander s treatment of her and the amount of money she was told she had to pay. In a letter dated 3 February 2015 from Mr Zander to Patient A he stated: I am sorry you were unhappy with the treatment but I can only assume [due to] the fact you failed to make further appointments to discuss your discomfort that the matter is purely financial and would appreciate your payment by return of post. In due course Mr Zander went to the Court of Alderney to claim for outstanding dental fees from Patient A in the sum of 240. The Court found in favour of Mr Zander and granted judgement in the sum of 240 plus interest to be paid by Patient A. In April 2015 Patient A made a complaint to the GDC about Mr Zander s treatment of her. The alleged inadequacies of Mr Zander s clinical care of Patient A are set out at charges 1 to 4. The GDC carried out an investigation into the matters alleged. As part of that investigation the GDC requested that Mr Zander provide copies of Patient A s records of her appointments with him. On 11 May 2015 Mr Zander provided the GDC with details of treatment provided to Patient A (set B) in which he inadvertently wrote the wrong year in the dates for treatment, recording 2015 rather than The GDC alleges that Mr Zander s conduct in this regard was misleading and dishonest in that he knew that the records, which he had redrafted, were not contemporaneous (charges 5 and 6). Moreover, Mr Zander had not alluded to this in his covering letter to the GDC. In a letter dated 29 October 2015 from Hempsons Solicitors Mr Zander apologised to the GDC for providing redrafted notes (set B) and provided a copy of the original computer records for 2014 and his contemporaneous handwritten notes of the appointments for 24 March 2014, 8 May 2014 and 24 June 2014 (set A). Finally, the GDC alleges (charge 7) that Mr Zander failed to respond adequately to Patient A s complaint of 24 February 2015 regarding her dental treatment. The evidence In considering the allegations against Mr Zander, the Committee has had regard to all the evidence before it, both documentary and oral. The documentary evidence comprises the GDC s prosecution bundle which contains, inter alia, a copy of Patient A s signed statement dated 14 September 2016 with her exhibits referred to in her witness statement as well as copies of Patient A s dental records (Set A and Set B) in relation to Mr Zander s treatment of her. The bundle also contains copies of Patient A s dental records for the period March to April 2015 from a subsequent treating dentist. The Committee received oral evidence from ZANDER, M Professional Conduct Committee March 2017 Page -5/19-

6 Patient A in which she broadly confirmed the contents of her signed witness statement. The Committee found Patient A to be an honest and credible witness who had a good recollection of what took place at the consultations with Mr Zander, and she made it clear when she did not remember what had taken place. The Committee has had regard to the expert evidence of Mr Gladson (instructed by the GDC), who produced a report dated 21 August He confirmed the content of his report in his oral evidence. The Committee considered that Mr Gladson gave a fair and balanced opinion in respect of the allegations against Mr Zander, but on each of the facts alleged it has reached its own judgement. Finally, the Committee has had regard to Mr Zander s observations to the GDC as set out in letters from Hempsons Solicitors to the GDC dated 29 October 2015, 8 December 2015 and 5 April In the letter dated 29 October 2015 Hempsons set out the allegations which Mr Zander accepts, including the shortcomings in his radiographic practice and his record keeping. However, the letter confirms that Mr Zander denies a number of the other allegations against him. He asserts that at the appointment on 24 June 2014 he asked Patient A to return for further treatment, with a view to completing the two courses of endodontic treatment he had commenced to UL1 and LL6. However, Patient A cancelled a subsequent appointment on 2 September 2014 and never attended again. It is Mr Zander s position that he was unable to complete the two course of endodontic treatment he had commenced to UL1 and LL6. In respect of the allegation that his conduct was misleading and dishonest, Hempsons stated on behalf of Mr Zander, that having reviewed his contemporaneous notes for Patient A, he decided that they were less complete than ideal and therefore mistakenly and foolishly rewrote the contemporaneous handwritten records in order to give a more comprehensive record of the treatment he provided to Patient A. Mr Zander asserts that he had no dishonest intention when preparing the non-contemporaneous records. The Committee has borne in mind the representations made by Hemspons Solicitors on behalf of Mr Zander when considering its findings of facts. It has borne no adverse inference by Mr Zander s non-attendance at this hearing but is mindful that it has not been able to hear from Mr Zander directly on the disputed matters given that he has not attended the hearing, nor provided the Committee with a full response to the charges made against him. Regarding the charges relating to Mr Zander s record keeping, the set A notes purport to be the contemporaneous notes. These comprise copies of the computerised records for 2014 and the handwritten notes for 2014 for the appointments in question. The Committee notes that there are inconsistencies between the computerised records and the contemporaneous handwritten notes. Where there are differences between these records, the Committee has placed greater weight on the computerised records which set out the chronology of treatment provided at each appointment. In respect of the charge alleging that Mr Zander s conduct was dishonest, the Committee received advice from the Legal Adviser of the approach it must follow. During the course of his advice the Legal Adviser referred the Committee to the case of Kirschner v GDC [2015] EWHC 1377 Admin, which refers to consideration of the registrant s state of mind at the time of the events in question. The Committee has taken into account all the evidence presented to it. It has accepted the advice of the Legal Adviser. The Committee has borne in mind that the burden of proof is on the GDC and that it must decide the facts according to the civil standard of proof, namely on ZANDER, M Professional Conduct Committee March 2017 Page -6/19-

7 the balance of probabilities. Mr Zander need not prove anything. The Committee has considered each charge separately. I will now announce the Committee s findings as follows: 1. a) i) a) Found not proved The computerised records for the appointment on 24 March 2014 state: medical history updated. The Committee has also seen an unsigned and undated copy of a medical history form. Mr Gladson s evidence was that although the medical history appears to have been completed according to the computerised records, it was likely that this entry was an automatic note inserted by the computer. While noting Mr Gladson s evidence on this matter, the Committee has had regard to Patient A s oral evidence. Her evidence was that she recognised the form and although she had no recollection of completing or signing it, she accepted that the contents of it were accurate. Mr Zander asserts that he did complete a medical history at the first appointment. The Committee is not satisfied, on the balance of probabilities, that Mr Zander failed to complete a medical history on 24 March a) i) b) Found proved Patient A was unable to recollect whether or not Mr Zander carried out an assessment of her intra-oral soft tissues. Mr Gladson s evidence was that there should have been an assessment of the patient s intra-oral soft tissues. He referred to the computer records which record NAD and not assessed adjacent to the entry for extra oral tissues. Mr Zander s position is that he carried out his standard extra-oral and intra-oral examination. However, there is nothing in the patient records to support this. The Committee accepted Mr Gladson s evidence on this matter. 1. a) i) c) Found proved There is no record in the notes, either on the computerised records, or on the handwritten notes, of any dental charting. Mr Gladson was critical of this failure and considered that the failure to examine and chart the patient s dentition meant that they were at risk of progressive dental decay. The Committee agrees. 1. a) i) d) Found proved There is no record in the notes, either on the computerised records, or on the handwritten notes, of any assessment of the periodontal tissues. Mr Gladson referred to the Faculty of General Dental Practice 2009 guidance entitled Clinical examination and record keeping which indicates that in the case of a new patient, a basic periodontal examination must be undertaken. 1. a) i) e) Found not proved The GDC relies on the evidence of Mr Gladson in support of this charge. He explained that when Patient A visited another dentist a year later (2015), a pan-oral radiograph was taken which showed decay on a number of teeth, including UR7 and LL8. Based on the pan-oral radiograph taken, Mr Gladson considered that it was likely that the cavities in these two teeth were present when Mr Zander assessed Patient A. The Committee notes that there is no record in Patient A s notes of dental decay at UR7 or LL8 and that the only ZANDER, M Professional Conduct Committee March 2017 Page -7/19-

8 1. a) ii) - 1. a) iii) radiograph taken on 24 March 2014 was of the UL1. However, in his evidence, Mr Gladson agreed that an OPG is not an ideal diagnostic tool with which to establish decay and that a bitewing radiograph would have been better. The Committee has borne in mind that Mr Gladson s criticism appears to be on the basis of a diagnosis of decay being reported a year later, when Patient A visited another dentist. The Committee considered that whilst the decay may have been visible on bitewing radiographs taken one year previously, it may not have been visible in a clinical examination at that time. Found proved Mr Gladson s evidence was that the patient s medical history should be updated at the subsequent visits of 8 May 2014 and 24 June He could find no record in the notes to indicate that it was done. Mr Zander states that he took a medical history at the first appointment but makes no mention of updating it at subsequent appointments with Patient A. The Committee agrees with Mr Gladson on this matter. 1. b) i) a) Found proved Patient A s oral evidence was that at the appointment on 24 March 2014 she told Mr Zander that she had problems with two of her teeth and that he told her that the teeth needed work. She was unable to recollect whether Mr Zander used the terminology root canal treatment but that he told her that she would need to come back for further treatment on two teeth. She accepted that Mr Zander completed a filling at this appointment. The computerised notes record that an amalgam restoration was carried out at the LR6 and that a radiograph was taken of the UL1 with a further note needs RCT and later crown. Mr Zander s position is that he discussed treatment with Patient A, although Patient A had no such recollection. Indeed, the tenor of Patient A s evidence was that she did not really understand what was going on. The Committee also notes that there is no record of an initial treatment plan for Patient A or a record in the notes to say that this was given to Patient A. Mr Gladson s evidence was that even if Mr Zander had had a discussion with Patient A, it would have been of limited worth because it would have been based on an inadequate examination. The Committee agrees with Mr Gladson s evidence, particularly given its findings in relation to Mr Zander s failure to carry out sufficient pre-treatment investigations, as set out above. 1. b) i) b) Found proved Patient A s evidence was that she was not told about the risks and benefits of the root canal treatment or warned that the treatment might fail. She did, however, accept that that there was some suggestion that a veneer was going to be provided to the UL1 to improve its appearance. Mr Gladson explained that there are risks and benefits to carrying out root canal treatment, such as discolouring of the tooth, persistence of symptoms and damage to the tooth. While he acknowledged that a discussion of the use of a veneer to be provided to improve the appearance of the tooth was appropriate, he could find no record in Patient A s notes of a discussion of the risks and benefits of the root canal treatment of UL1 and/or LL6. He ZANDER, M Professional Conduct Committee March 2017 Page -8/19-

9 1.b)i)(c) considered that the discussion should have taken place and should have been recorded in the notes. He could find no record of this and the Committee agrees with Mr Gladson s opinion. Found proved Mr Zander s position is that he gave the patient a verbal indication of the treatment required but Mr Gladson could find no written evidence of what work was intended or of any discussion of treatment options for the teeth. Mr Gladson agreed that root canal treatment was appropriate for the UL1 but that it was not possible to give an opinion regarding the LL6 because there was no radiograph of it. His opinion was that an alternative treatment to root canal treatment may have been an extraction. There is no record that this was the discussed with the patient. Indeed, Patient A was clear in her evidence that from the outset she was told that root canal work was needed on both the UL1 and the lower left molar tooth, for which she was given a quote of 250 per tooth. 1. b) i) d) Found proved Patient A, in her written statement to whom it may concern which appears to be in response to the court proceedings in Alderney, and in her complaint to the GDC, said that she was not provided with a treatment plan. Furthermore, there is no treatment plan for Patient A in the records. Mr Gladson referred to the GDC s requirement that a patient must be given a written treatment plan before the treatment starts and a copy should be retained in the notes. Further, Mr Gladson explained that an amendment to the treatment plan requires an updated version in the patient notes. Having regard to all this evidence, and noting Mr Zander s acceptance that he did not provide Patient A with a written treatment plan, the Committee finds this charge proved. 1. b) i) e) Found proved 1. c) i) - 1.c) ii) Patient A s evidence was that she had asked Mr Zander to provide her with a quote for the treatment but this was only provided to her orally and not in writing. Mr Zander contended that Patient A was provided with a verbal indication of the costs of treatment throughout, noting that the costs changed when he identified more extensive treatment needs on 24 June Mr Gladson s evidence was that the treatment plan should include details of the proposed treatment, a realistic indication of cost and whether this treatment was NHS or private. There is no treatment plan or anything in writing to Patient A regarding the costing of the treatment Mr Zander proposed for UL1 and/or LL6. The Committee is of the view that any costs given orally from Mr Zander to Patient A, to be wholly inadequate. It accepts Mr Gladson s evidence that such information should be provided in writing. Found not proved Patient A s evidence was that she did not consider that her dental work was temporary and that at no point was I told it was temporary. I believed my root canals were complete. Mr Zander contends that at the appointment on 8 May 2014 he opened the pulp chamber for the UL1 and went on to clean and dress the canal using Iodoform paste and placing a dressing comprising a ZANDER, M Professional Conduct Committee March 2017 Page -9/19-

10 2. i) 2. v) gutta percha point which incorporated Calcium Hydroxide internally as a temporary root canal treatment. He further contends that Patient A was made aware that she was required to return for definitive root canal treatment. Mr Gladson opined that the work done by Mr Zander appeared to be permanent not temporary. In particular, the gutta percha material was compressed into the cavity and the material used for the restoration would normally be used for permanent work. The Committee notes that when Patient A queried with the practice the purpose of the appointment in September 2014, Mr Zander made no mention of the fact that this work was temporary. Indeed, despite the exchanges of s between Patient A and Mr Zander in 2015 regarding her complaint, Mr Zander did not suggest to her that the work was temporary. The Committee also notes that Mr Zander went to court in April 2015 for outstanding dental fees from Patient A, which it considers was an unlikely course of action if, as Mr Zander contends, the work had not yet been completed. The Committee is therefore satisfied that the work that was carried out at UL1 and LL6 was intended to be permanent and that Patient A understood it to be permanent. The Committee rejects Mr Zander s contention that the treatment was temporary. Found proved There is evidence of a periapical radiograph of the UL1 having been taken by Mr Zander on 24 March 2014 but there is no record of its evaluation or grading. Apart from this one radiograph, there is no evidence of Mr Zander having taken any other radiographs between 24 March 2014 and 24 June Mr Gladson opined that periapical radiographs should have been taken where there were heavily restored teeth and/or where root canal work was planned, as was the case for Patient A. He was critical of Mr Zander s failure to adequately radiographically assess the patient s dentition, with bitewing radiographs, as well as his failure to take periapical radiographs of the teeth for root canal treatment before and after the treatment. The Committee agrees with Mr Gladson s opinion. 3. Found proved Patient A s evidence was that she was given little information about the treatment Mr Zander proposed, save for her understanding from the outset that root canal work was needed in respect of the UL1 and the LL6. In his evidence Mr Gladson set out the explanation that should be provided to the patient in order to obtain valid consent, namely: the treatment proposed and how it will be carried out; why the treatment is necessary and what might happen if it is not carried out; the risks which may be involved in undergoing the treatment; the alternative forms of treatment that are available and the risks of these and the costs. He went on to explain the risks involved with root canal work, which he described as being a more advanced treatment than simple dental restorations. Mr Gladson also set out the GDC s requirement that valid consent must be obtained before starting treatment. It states that the discussions should be documented and that clinicians must check and document that patients have understood the information they have been given. There is nothing before the Committee to satisfy it that Mr Zander did ZANDER, M Professional Conduct Committee March 2017 Page -10/19-

11 so in respect of Patient A. Having regard to its findings at 1(b)(i)(a) to (e) relating to a failure to discuss risks and benefits of the root canal treatment, alternative treatment options and a failure to provide the patient with any or any adequate costing for the treatment proposed, the Committee finds this charge proved. 4. a) i) Found proved In relation to each of the allegations under 4(a) the Committee was satisfied on the basis of Mr Gladson s evidence that there was duty to make such records. He gave evidence of the GDC s requirement that clinicians must keep contemporaneous, complete and accurate patient records. The Set A notes comprise copies of the computerised records for 2014 and the contemporaneous handwritten notes for 2014 for the appointments in question. The Committee considers that the Set A records are woefully inadequate in that there is no record of the matters alleged in charges 4(a)(i) to (x). Furthermore, there is information contained on the computer records which is not contained on the handwritten notes for the three appointments. In relation to this charge, there is no record of Patient A s presenting problems. 4. a) ii) Found not proved in relation to the appointment on 24 March a) iii) 4. a) x) 4. b) i) 4. b) iv) Found proved in relation to the appointments on 8 May 2014 and 24 June 2014 The Committee accepts that Mr Zander completed a medical history on 24 March There are no entries relating to Patient A s medical history for the subsequent two appointments. Found proved There is no record of these pre-treatment investigations and the Committee accepts Mr Gladson s evidence that Mr Zander had a duty to record these. Found proved There is no record of the treatment planning, as set out in these charges and the Committee accepts Mr Gladson s evidence that Mr Zander had a duty to record these. Mr Zander also accepted that he did not record sufficient detail of his treatment planning. As a matter of fact, there is no record of a treatment plan. 4. c) Found not proved Hempsons, in the letter dated 29 October 2015, stated on behalf of Mr Zander that no local anaesthetic was used for the filling on 24 March There is an entry in the computer records on 24 June 2014 that no local anaesthetic was used. Mr Gladson s evidence was that he thought that local anaesthetic would have been used for root canal treatment but the Committee s conclusion was that if it was not used on two occasions, it was not satisfied that local anaesthetic was used on the third occasion. 4. d) Found not proved ZANDER, M Professional Conduct Committee March 2017 Page -11/19-

12 Mr Gladson considered that there was insufficient evidence in the notes to determine whether the airway was protected, although he accepted that the absence of a record in the notes did not necessarily mean that the airway was not protected. He also accepted that there are other methods of tooth isolation. Mr Zander s case is that he used cotton wool rolls to isolate the tooth. Although there is nothing in the records to say what method, if any Mr Zander, used to isolate the tooth, the Committee accepts that cotton wool rolls may have been used in this instance. In the Committee s view, there is no culpable failure on Mr Zander s part not to record the use of cotton wool rolls given that this is a recognised method of isolation. The charge does not mention airway protection. 4. e) Found proved There is no record of the methodology used by Mr Zander in determining the working length for the treatment to UL1 and/or LL6. 4. f) Found not proved This is in the light of the Committee s finding at 1(c)(i) and (ii) that the treatment provided was permanent and not temporary. 4. g) Found proved Mr Gladson s evidence was that there is no record in the computerised notes for the three appointments of the filling materials used for UL7 and/or LL6. He was critical of this omission in the notes. For the handwritten notes (set A) for 8 May 2014 there is a note that Calyx was used but in the Committee s view, this entry is inadequate. 4. h) Found proved There is no adequate record of the endodontic technique used for UL1 and/or LL6. 4. i) Found proved 5. i) 5. ii) The Committee has found at charge 3 (above) that Mr Zander failed to obtain Patient s informed consent for the treatment in respect of UL1 and/or LL6 and therefore it follows that there is no record of the discussions. Found proved In response to the GDC s request, in May 2015 Mr Zander provided the GDC with further information which included what appeared to be a set of handwritten patient records (Set B). In a letter dated 29 October 2015 from Hempsons Solicitors it was stated on Mr Zander s behalf that in 2015 he had cause to review his contemporaneous records and attempted, unsuccessfully, to print them off the computer. The letter states that Mr Zander took the view that these records were less complete than ideal and that he rewrote the contemporaneous handwritten records to give a more comprehensive record of the treatment he provided to Patient A. In the light of this letter, the Committee is satisfied that Mr Zander had redrafted the records and he knew that they were not contemporaneous. ZANDER, M Professional Conduct Committee March 2017 Page -12/19-

13 6. i) Found proved Mr Gladson s evidence was that there may be occasions when a pertinent point is remembered by the clinician and the notes are added to in order to record this. He explained that when this happened, the amendments should be made as soon as possible with the reasons for the addition being made explicitly clear. Further, the registrant should sign and date the records in order to draw attention to the fact that this is an amendment to the records, made subsequent to the remainder of the text. In this case, Mr Zander rewrote the notes sometime in mid-2015, approximately a year after he had treated the patient. In the Committee s view, there is nothing in the redrafted notes provided by Mr Zander to the GDC to show that they were not contemporaneous or that amendments have been made. There is no mention in Mr Zander s covering letter to the GDC dated 11 May 2015 to indicate that he had redrafted the original notes. In the Committee s view, for Mr Zander to provide the GDC with reconstructed patient notes as part of its investigation into his treatment of Patient A as though they were the original contemporaneous notes is clearly misleading. 6. ii) Found proved If Mr Zander had felt it necessary to add to or alter his contemporaneous notes he could and should have made that clear. He chose to say nothing. If it had not been for the fact that he wrote the wrong year for the treatment, the true facts might not have come to light. The Committee considered that Mr Zander attempted a deliberate deception. He must have known that the GDC would believe that the documents were contemporaneous records when they were not. The Committee is satisfied that members of the profession and the public would regard such conduct as dishonest and that Mr Zander would have known that such conduct was dishonest. 7. Found proved The Committee has seen the exchange of s between Patient A and Mr Zander regarding her complaint about the dental treatment he provided to her. In particular, the Committee has had regard to Mr Zander s letter dated 3 February 2015, which states: In response to your regarding your outstanding account for treatment received between March and June last year. I am sorry you were unhappy with the treatment but I can only assume [due to] the fact you failed to make further appointments to discuss your discomfort that the matter is purely financial and would appreciate your payment by return post. Thereafter, Mr Zander sent a chaser letter, asking her to pay the money and advising her that if the money is not paid he will be referring the matter to court. Thereafter, he did not provide a written reply to Patient A s complaint even though she continued to refute the sum of money owed and expressing her concern about the treatment in her dated 24 February Instead Mr Zander issued a court s summons to recover the alleged debt. The Committee agrees with Mr Gladson s evidence that the tone of Mr Zander s s comes across as being dismissive and unsympathetic towards Patient A. Moreover, he failed to provide a constructive and timely response to her complaint. The Committee also notes ZANDER, M Professional Conduct Committee March 2017 Page -13/19-

14 We move to Stage Two. from the exchange of s that even though Patient A remained dissatisfied with the handling of her complaint, Mr Zander failed to refer her to the Ombudsman or the Dental Complaints Service. On 30 March the Chairman announced the determination as follows: Mr Dent, on behalf of the General Dental Council (GDC), made submissions in accordance with Rule 20(1)(a) of the Fitness to Practise Rules He advised the Committee that Mr Zander has no previous fitness to practise history. Mr Dent submitted that the findings against Mr Zander amount to misconduct and that his fitness to practise is currently impaired by reason of his misconduct. He confirmed that the GDC has received no evidence of remediation from Mr Zander. Mr Dent submitted that the appropriate sanction is an order of suspension for a period up to the maximum time of 12 months, with a review to take place before the expiry of the order. He did not invite the Committee to make an order of erasure given that Mr Zander does not have a previous fitness to practise history and the dishonesty, although serious, was not sustained over a long period of time. In short, Mr Dent submitted that the sanction of erasure would be disproportionate to the findings made against Mr Zander. The Committee has exercised its own professional judgement on the matters under consideration. It has accepted the advice of the Legal Adviser. Misconduct The Committee first considered whether the facts found proved against Mr Zander amount to misconduct. In so doing, it has had regard to all the evidence before it, including the expert evidence of Mr Gladson (called on behalf of the GDC), as well as the submissions made by Mr Dent. This case concerns the treatment and care Mr Zander provided to Patient A at the Alderney Dental Practice (the Practice) between 24 March 2014 and 24 June 2014, his conduct following Patient A s complaint against him in February 2015, and his provision to the GDC in May 2015 of fabricated records of Patient s A appointments. The Committee has set out its findings and its reasons for them in detail in its determination on the facts. In summary, the Committee has found that Mr Zander failed to provide an adequate standard of care to Patient A, including by Not carrying out sufficient pre-treatment investigations such as not assessing the patient s intra-oral soft tissues, not carrying out an assessment of the patient s periodontal tissues and not undertaking any dental charting. Not updating the patient s medical history at the appointments on 8 May 2014 and 24 June Not providing the patient with a clear diagnosis of her presenting problems. Not discussing any or any adequate risks and benefits of the root canal treatment of UL1 and LL6, or discuss alternative reasonable treatment options in respect of these two teeth. Not providing the patient with any adequate costing for the treatment proposed. ZANDER, M Professional Conduct Committee March 2017 Page -14/19-

15 Failing to take sufficient pre- and post-operative radiographs at UL1 and LL6, where root canal treatment was carried out and failing to evaluate the one periapical radiograph taken of the UL1. Failing to obtain informed consent for the treatment proposed at UL1 and LL6. Failing to maintain an adequate standard of record keeping, including, but not limited to, not recording the patient s past dental history, not recording the justification, evaluation or the grading of the one periapical radiograph taken of the UL1 and not recording the filling materials used for UL1 and LL6. Failing to respond adequately to Patient A s complaint of February Providing the GDC with a set of fabricated records which was both misleading and dishonest. Mr Gladson s opinion was that Mr Zander s work fell far below the expected standard in a number of the areas identified above. He described an event which falls far below the expected standard as an event which has the potential to cause harm (to patients or others), a breach of the law or statute, a failure of basic skills, cumulative or persistent failings which amount to a gross departure from the standards expected. He referred to Mr Zander s failure to adhere to relevant guidance, including the GDC s Standards for the Dental Team (2013); The Faculty of General Dental Practitioners Guidance on Clinical Examination and Record Keeping (2009) and the Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER). The Committee agrees with Mr Gladson. Having regard to the findings against Mr Zander, the Committee is satisfied that he has breached the following GDC s Standards for the Dental Team: Standard 1.3 You must be honest and act with integrity. Standard 2.3 You must give patients the information they need, in a way they can understand, so that they can make informed decisions. Standard 2.4 You must give patients clear information about costs Standard 3.1 You must obtain valid consent before starting treatment, explaining all the relevant options and the possible costs. Standard 4.1 You must make and keep contemporaneous, complete and accurate patient records. Standard 9.1 You must ensure that conduct, both at work, and in your personal life, justifies patients trust in you and the public s trust in the dental profession. Standard 9.4 ZANDER, M Professional Conduct Committee March 2017 Page -15/19-

16 You must co-operate with any relevant formal or informal inquiry and give full and truthful information. The Committee considers that the findings against Mr Zander, which include a failure of basic skills, breaches of essential principles of good dental practice and patient care, are serious. In particular, the Committee considers that Mr Zander s failure to obtain Patient A s consent for root canal treatment and his failure to respond to her complaint adequately to be an aggravating feature in this case. In addition, the Committee has had regard to its finding of dishonesty that Mr Zander knowingly provided the GDC, as part of its investigation into his treatment of Patient A, fabricated notes of Patient A s appointments. Maintaining accurate patient records is an essential part of a dentist s duties and patients should be able to rely on a dentist s integrity to ensure their records are up to date and accurate. Mr Zander did not do so and instead provided his regulator with a copy of fabricated notes. The Committee has concluded that Mr Zander s conduct fell far below the standards reasonably expected of a registered dentist, and that fellow professionals would consider those actions to be deplorable. Accordingly, the Committee has determined that the facts found proved amount to misconduct. Impairment of fitness to practise The Committee next considered whether Mr Zander s fitness to practise is currently impaired by reason of his misconduct. Throughout its deliberations, it has borne in mind that its primary duty is to address the public interest, which includes the protection of patients, the maintenance of public confidence in the profession and the declaring and upholding of proper standards of conduct and behaviour. The Committee has had regard to the serious nature of Mr Zander s conduct in 2014 and 2015 regarding Patient A and his conduct towards the GDC in the provision of fabricated patient notes in May Although it considers that some of the clinical deficiencies in this case are remediable, the Committee has received no evidence of any remediation from Mr Zander. In their letter dated 29 October 2015, Hempsons Solicitors on behalf of Mr Zander, state that in the light of the issues arising from this complaint, their client has booked on a three day course in June 2016 on endodontics and he has purchased a CD Rom on Key Skills in Primary Dental Care to study. There is also reference to Mr Zander actively researching other relevant courses with a view to undertaking any appropriate remediation. However, there is no evidence that Mr Zander attended the three day course on endodontics or indeed any other evidence relating to these failings. There is no evidence of targeted Continuing Professional Development or a Personal Development Plan to address the concerns in this case. In short, in the absence of any evidence of remediation, the Committee considers that Mr Zander continues to pose a risk to patients. There are no testimonials provided from fellow dentists or patients. There is also no current information about Mr Zander s working arrangements. The Committee has also had regard to the question of Mr Zander s insight. It acknowledges that Mr Zander has made some admissions to the charges and he has accepted shortcomings in relation to his radiographic practice and record keeping. However, it has received no evidence from Mr Zander as to his recognition of his wrong-doing in respect of the allegations he has denied, namely the allegation of dishonesty and how he dealt with Patient A s complaint. Furthermore, the Committee considers that Mr Zander s choice of course on endodontics does not address the serious concerns identified in this case, including dishonesty, and raises concerns about his lack of insight. ZANDER, M Professional Conduct Committee March 2017 Page -16/19-

17 The Committee has concerns about Mr Zander s lack of engagement with the GDC in relation to these proceedings. Hempsons Solicitors, in their letter dated 18 October 2016, stated that they are instructed to confirm that their client will not be engaging with the GDC investigation any further. Given these circumstances, the Committee could not give Mr Zander credit for any level of insight. The Committee therefore considers that there is a risk of repetition of the misconduct found proved and that Mr Zander remains a risk to the public and therefore his fitness to practise is currently impaired. The Committee has further considered the wider public interest, including the need to declare and uphold proper standards of conduct and behaviour to maintain public confidence in the profession. The Committee has found that Mr Zander consistently failed to provide an appropriate standard of care to Patient A. The clinical failings involve shortcomings in basic areas of dentistry that were serious, including a finding that Mr Zander failed to obtain informed consent. He also failed to respond adequately to Patient A s complaint and notes that she remained dissatisfied with the handling of her complaint. It considers the tone of Mr Zander s correspondence to Patient A in response to the complaint to be dismissive and unsympathetic. Furthermore, Mr Zander failed to provide her with a constructive and timely response to her complaint and instead, asked her to pay the sum of money which he believed she owed him. Moreover, the Committee has reached a finding of dishonesty against Mr Zander, which is serious. In these circumstances, the Committee considers that public confidence would be seriously undermined if a finding of impairment were not made. Accordingly, the Committee has determined that Mr Zander s fitness to practise is currently impaired. Sanction Having determined that Mr Zander s fitness to practise is currently impaired by reason of his misconduct, the Committee has considered what sanction, if any, to impose on his registration. In so doing, it has had regard to the GDC s Guidance for the Practice Committees including Indicative Sanctions Guidance (October 2016), including paragraphs 48 to 49, which refers to dishonesty. The Committee has considered the range of sanctions available to it, starting with the least restrictive. Throughout its deliberations, the Committee has applied the principle of proportionality, weighing the interests of the public with Mr Zander s own interests. The Committee has taken into account the mitigating and aggravating features of this case. It notes that Mr Zander has no previous fitness to practise history and the fact that he has made some admissions to the allegations against him. However, the Committee has had regard to the aggravating factors including the serious nature of the findings against him, including a finding of dishonesty, the absence of any evidence of remediation or apology or insight. The Committee has determined that it would be inappropriate to conclude this case without taking any action or by the issuing of a reprimand. These courses of action would not be sufficient for the protection of patients or the wider public interest, given the serious nature of the findings in this case as well as the absence of any remediation or engagement by Mr Zander with the GDC. In addition, the Committee considers that Mr Zander poses a risk to patients and that it is necessary to take action against his registration. The Committee next considered whether a period of conditional registration would be appropriate in this case. In so doing, it is aware that any conditions imposed must be ZANDER, M Professional Conduct Committee March 2017 Page -17/19-