HEARING HEARD IN PUBLIC

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1 HEARING HEARD IN PUBLIC PIROS, Anna Ilona Registration No: PROFESSIONAL CONDUCT COMMITTEE MAY - JUNE 2016 Outcome: Conditions imposed for 36 months (with a review) Anna Ilona Piros, a dentist, Tandläkare Semmelweis University 2003, was summoned to appear before the Professional Conduct Committee on 31 May 2016 for an inquiry into the following charge: Charge (as amended 6 June) That, being a registered dentist: 1. At all material times:- (a) (b) (c) Patient 1 you were practising as a dental practitioner at the Frenchay Dental Practice, Beckspool Road, Frenchay, Bristol BS16 1NU; your practice included the provision of dental services to patients under the auspices of the National Health Service pursuant to General Dental Services Agreements with NHS South Gloucestershire or (from 1st April 2013) NHS England, including:- (i) (ii) (iii) from 6th December 2010, as one of two contracting partners; from 10th January 2011, as the sole contractor; from 1st September 2013 to 28th February 2014, as one of two contracting partners; pursuant to the agreements described at (b) above and variations to them the contractor was obliged to perform a fixed number of units of dental activity each year or (pro rata) part of each year. 2. When you saw Patient 1 on 30th June 2011 you failed to:- (a) (b) (c) (d) perform, alternatively to record, an extra oral examination; identify the extent of Patient 1 s periodontal condition; perform a radiographic examination into Patient 1 s periodontal condition; make an adequate diagnosis in respect of Patient 1 s periodontal condition; (e) prescribe periodontal treatment for Patient 1; (f) provide, alternatively to record the provision of, oral health advice. 3. When you saw Patient 1 on 11th January 2012 you:- PIROS, A I Professional Conduct Committee May June 2016 Page -1/21-

2 (a) (b) did so without the support of a dental assistant; [withdrawn]. 4. [withdrawn]. 5. When you extracted Patient 1 s UR6 tooth on 17th February 2012 you:- (a) (b) (c) did so without the support of a dental assistant; failed to provide Patient 1 with treatment options as alternatives to the extraction of his UR6 tooth; in the circumstances described at sub-paragraph (b) of this paragraph, you failed to obtain Patient 1 s informed consent to the extraction of his UR6 tooth. 6. When you saw Patient 1 in September 2012 you failed to make a record of the appointment. 7. When you saw Patient 1 on 7th January 2013 you:- (a) (b) (c) (d) did so without the support of a dental assistant; [withdrawn]; failed to perform, alternatively to record, an extra oral or soft tissue examination; failed to make, alternatively to record, a diagnosis in respect of the scores of 2 in five sextants and the score of 4 in the lower left posterior sextant of his mouth on Basic Periodontal Examination; (e) failed to perform an adequate radiographic examination into Patient 1 s periodontal condition; (f) (g) (h) 8. [withdrawn]. Patient 2 failed to record an evaluation of the radiograph you did take; failed to prescribe, alternatively to record the provision of, periodontal treatment for Patient 1; failed to provide, alternatively to record the provision of, oral health advice. 9. When you saw Patient 2 on 11th October 2011 you failed to:- (a) (b) perform, alternatively to record, an extra oral examination; make, alternatively to record, a diagnosis in respect of the scores of 2 in three sextants of her mouth on Basic Periodontal Examination. 10. When you extracted Patient 2 s LL5 tooth on 15th November 2012 you did so without the support of a dental assistant. Patient B 11. On or about 28th May 2013 you dishonestly and/or inappropriately caused or permitted a claim to be made to the National Health Service against the obligation described at paragraph 1(c) above under Band 2 of Schedule 2 to the National Health Service (Dental Charges) Regulations 2005 when the course of treatment which had been provided to Patient B was a Band 1 course of treatment. PIROS, A I Professional Conduct Committee May June 2016 Page -2/21-

3 Patient C 12. Between April 2009 and January 2014 you failed to provide Patient C with adequate preventative treatment. 13. On or about 6th February 2013 you dishonestly and/or inappropriately caused or permitted a claim to be made to the National Health Service against the obligation described at paragraph 1(c) above under Band 2 of Schedule 2 to the National Health Service (Dental Charges) Regulations 2005 when the course of treatment which had been provided to Patient C was a Band 1 course of treatment. Patient F 14. Between December 2009 and March 2014 you failed to provide Patient F with adequate preventative treatment. Patient G 15. When you saw Patient G for appointments on 21st December 2011, 3rd January 2013, 26th July 2013 and/or 18th March 2014 you failed to make an adequate record of your examination and/or any advice or treatment provided. Patient H 16. On or about 24th March 2014 you dishonestly and/or inappropriately caused or permitted a claim to be made to the National Health Service against the obligation described at paragraph 1(c) above under Band 2 of Schedule 2 to the National Health Service (Dental Charges) Regulations 2005 when the course of treatment which had been provided to Patient H was a Band 1 course of treatment. Patient J 17. Between November 2008 and February 2014 you failed to provide Patient J with adequate preventative treatment. 18. On or about 27th March 2013 you dishonestly and/or inappropriately caused or permitted a claim to be made to the National Health Service against the obligation described at paragraph 1(c) above under Band 2 of Schedule 2 to the National Health Service (Dental Charges) Regulations 2005 when the course of treatment which had been provided to Patient J was a Band 1 course of treatment. Patient K 19. Between December 2009 and November 2013 you failed to provide Patient K with adequate preventative treatment or advice. 20. On or about 15th November 2013 you dishonestly and/or inappropriately caused or permitted a claim to be made to the National Health Service against the obligation described at paragraph 1(c) above under Band 2 of Schedule 2 to the National Health Service (Dental Charges) Regulations 2005 when the course of treatment which had been provided to Patient K was a Band 1 course of treatment. Patient L 21. On or about 29th November 2013 you dishonestly and/or inappropriately caused or permitted a claim to be made to the National Health Service against the obligation described at paragraph 1(c) above under Band 2 of Schedule 2 to the National Health PIROS, A I Professional Conduct Committee May June 2016 Page -3/21-

4 Patient Z Service (Dental Charges) Regulations 2005 when the course of treatment which had been provided to Patient L was a Band 1 course of treatment. 22. When you saw Patient Z on 27th May 2009, 26th October 2011, 28th March 2012 and/or 5th April 2012 you failed to make a clinical record of the appointment in the patient s records. 23. When you saw Patient Z for appointments on 19th February 2010, 25th October 2012 and/or 2nd January 2013 you failed to make an adequate record of your examination. 24. When you saw Patient Z on 2nd September 2008 you inaccurately recorded that the patient s mother would prefer Patient Z s URA tooth to be left without treatment, in that in fact you had advised that the tooth be left. And that, in relation to the facts alleged, your fitness to practise as a dentist is impaired by reason of your misconduct. On 14 June 2016 the Chairman made the following statement regarding the finding of facts: Mr Bradly, The Committee received submissions from you on behalf of the General Dental Council (GDC) and from Mr Sheldon on Ms Piros behalf. It has taken into account all the evidence presented to it. The Committee accepted the advice of the Legal Adviser. Background The Committee was informed that Ms Piros qualified as a dentist in July 2003, in Budapest, Hungary. She then relocated to the UK and worked as a dental nurse pending her registration as a dentist. In December 2004, Ms Piros began treating patients as a registered general dental practitioner in the Frenchay Dental Practice ( the Practice ). Ms Piros became a NHS performer in November 2006 and, on 6 December 2010, joined her father as cocontractor of the Practice s NHS General Dental Services ( GDS ) contract. Some two months later, on 10 January 2011, a new GDS contract was established, with Ms Piros as the sole contractor. Around the same time, Ms Piros took over as the principal dentist of the Practice. In August 2013, another dentist ( KN ) joined Ms Piros as a co-contractor of the GDS contract. In September 2013, KN acquired the Practice from Ms Piros, although Ms Piros continued working in the Practice on a part-time basis. On 1 March 2014, KN became the sole contractor under a newly issued GDS contract, although Ms Piros remained a named NHS performer. Ms Piros began a period of leave in April 2014 and, as she informed the Committee, has not practised dentistry since then. Patients 1 and 2 had been NHS patients at the Practice since On 8 May 2013, Patients 1 and 2 complained to the GDC about the care and treatment Ms Piros had provided to them and their child (Patient Z). The complaint was also sent to the Care Quality Commission and NHS England. Upon receipt of the complaint the GDC began an investigation. In May 2014, the Investigating Committee ordered an audit of thirty clinical records relating to Ms Piros child patients. Of these, Patients B, C, F, G, H, J, K, L and Z are the only patients referred to in the charge before this Committee. PIROS, A I Professional Conduct Committee May June 2016 Page -4/21-

5 Admissions Mr Sheldon, on Ms Piros behalf, admitted the following heads of charge at the outset of the hearing: 1(a), 1(b)(i); 1(b)(ii); 1(b)(iii); 1(c); 2(e); 2(f); 7(f); 7(h); 9(a); 12; 14; 15; 17; 19; 22 and 23. In fairness to Ms Piros, the Committee deferred making any findings of fact in respect of any of the admitted heads of charge until all the relevant evidence had been adduced by both parties. Ms Piros, who was not present in the hearing at the outset, later resiled from some of her admissions and qualified some other admissions. When making his submissions at the conclusion of the fact-finding stage, Mr Sheldon helpfully provided the Committee with a document (marked as exhibit 11) in order to clarify Ms Piros position on those matters, which the Committee took into account when reaching its decisions. Amendment to the charge On 6 June 2016, Mr Bradly applied to amend the charge pursuant to paragraph 18 of The General Dental Council (Fitness to Practise) Rules 2006 ( Rules ). The application was not opposed by Mr Sheldon on behalf of Ms Piros. Having considered the submissions from both parties, the Committee concluded that the proposed amendments did not cause unfairness or injustice to either party. Accordingly, it determined to grant the proposed amendments, namely: to withdraw 3(b), 4, 7b, 8 in entirety; and to amend 5(c) to remove the reference to the withdrawn head of charge 3(b). Evidence The Committee received several bundles which included relevant clinical notes and a summary of the claims data from the NHS Dental Services Data Warehouse, showing the relevant claims for UDAs. The Committee received oral evidence from witnesses of fact Patients 1 and 2, and expert opinion evidence from the following dental professionals: Nigel Entwistle, a general dental practitioner instructed by the GDC; David Igoe, a general dental practitioner instructed by the GDC; and, Hilary Firestone, a general dental practitioner instructed by Ms Piros representatives. In addition, an agreed written statement of evidence was provided within the GDC s bundle, from Debbie Freeman of the Dental Contract Team of NHS South West, exhibiting contracts and correspondence between NHS England and Ms Piros. There was also an agreed witness statement of an employee of the GDC s solicitors, explaining the production of documents. All three expert witnesses are experienced general dental practitioners whose written and oral evidence was of assistance to the Committee in reaching its decisions. In weighing the evidence, the Committee noted that Mr Entwistle s evidence was, on occasions, confused. He appeared to have changed his opinion on some discrete aspects of his evidence, causing Mr Sheldon to refer to shifting goalposts in relation to those changes. The Committee was of the view that it is important for a registrant to know in advance the criticisms which resulted in a charge against them. Similarly, Mr Igoe was mistaken, yet inflexible, about which computer system was being used in the Practice. Accordingly, the PIROS, A I Professional Conduct Committee May June 2016 Page -5/21-

6 Committee placed limited weight on some parts of the evidence from Mr Entwistle and Mr Igoe. The Committee found Ms Firestone s evidence to be the most reliable on some of the key clinical aspects of the charge. In some instances however, in the Committee s view, given her responsibilities as an expert witness, her evidence tended towards being inappropriately supportive of Ms Piros on behalf of whom she was called. For example, when questioned about the guidelines on preventative dentistry for children (see head of charge 12 below), Ms Firestone was prepared to suggest that it may be appropriate to disregard established guidance where a dentist had made a clinical decision based on a personal philosophical opinion, rather than an evidence-based scientific opinion. This caused the Committee to treat some parts of Ms Firestone s evidence with a degree of caution. Patient 1, during his oral evidence, had difficulty recalling some of the factual details, for example concerning what had occurred during a number of his appointments. Whilst the Committee found that Patient 1 was doing his best to assist the Committee, he appeared resolute about the allegations he had made in the original complaint on 8 May 2013, despite the fact that his recollection was shown to be factually incorrect about some aspects and lacking in detail on others. The Committee concluded that, due to the lapse in time since the events in question, his memory of the relevant events was limited. The Committee also felt that his evidence was significantly influenced by his determination to stand by his allegations, even when there were inadequate grounds for him to do so. More detail of where the Committee accepted or rejected Patient 1 s evidence is included in its findings of fact below. Patient 2, the Committee found, had a clearer recollection in that she was able to explain with detail what had occurred during significant appointments. She was prepared to concede, when questioned, where she was not able to recall particular aspects in detail. Patient 2 also volunteered concessions, for example in confirming that she had badgered Ms Piros to provide treatment on an occasion when Ms Piros had wanted to make another appointment for that treatment. Accordingly, the Committee placed weight on Patient 2 s evidence. The Committee found Ms Piros herself to be a credible witness. She openly accepted that her record keeping was poor and she acknowledged without hesitation when she could not recall details of appointments. It concluded that Ms Piros had not attempted to cover up any aspects of her conduct. Where she could not recall whether or not she had acted in a way which may constitute inappropriate professional behaviour, such as potential practice failures, she did not seek to detract from the seriousness of the allegation or attempt to place a different interpretation on it. The Committee was able to rely on Ms Piros oral evidence, as described in greater detail, where relevant, in the findings of fact below. Findings of Fact I will now announce the Committee s findings in relation to each head of charge: 1.(a) 1.(b)(i) 1.(b)(ii) Admitted and proved. Admitted and proved. Admitted and proved. 1.(b)(iii) Admitted and proved. PIROS, A I Professional Conduct Committee May June 2016 Page -6/21-

7 1.(c) 2.(a) 2.(b) 2.(c) Admitted and proved. Admitted and proved in respect of the failure to record an extra-oral examination. Not proved in respect of the failure to perform an extra-oral examination. Ms Piros had made an entry st clear in the clinical record for Patient 1 30 June The Committee accepted Ms Piros oral evidence, given in significant detail, that when she made an entry including st in her clinical notes, this was her shorthand for carrying out a check which included both extra and intra-oral examinations. She stated that her routine practice included an extra-oral assessment as part of her examination. She gave a systematic description of the routine examination she performed, using her hands to demonstrate how she would start at the top and work my way down. Not proved. The GDC s criticism in relation to this head of charge was founded upon the proposition that in undertaking a Basic Periodontal Examination ( BPE ) for Patient 1 on 30 June 2011, Ms Piros underscored. The GDC s case was initially founded on the radiographic appearance of Patient 1 s lower left quadrant, as seen on an orthopantomogram radiograph ( OPG ) taken on 7 January At this stage, the criticism of Ms Piros was that, as she had recorded a BPE score of 4 on 7 January 2013, a BPE score of 2 in relation to the same quadrant on 30 June 2011 could not have been accurate. However, in oral evidence, Mr Entwistle agreed that this contention could not be supported and that the presence of an endo-perio lesion in the lower left quadrant could have explained the change from BPE 2 to BPE 4 between those dates. Mr Entwistle then contended that the criticism should be directed to the upper left quadrant, in respect of which Ms Piros arrived at a BPE score of 2 on both 30 June 2011 and 7 January In oral evidence he contended that a score greater than 2 should have been recorded on 30 June The Committee concluded that in the particular circumstances, relating to Patient 1 s upper left quadrant in the period 30 June 2011 to 7 January 2013, it was not possible to say whether or not the score of BPE 2 was inaccurate some 18 months before the x-ray on 7 January Radiographic evidence significantly pre-dating 30 June 2011 demonstrated historic bone loss and Patient 1 s gingivae could have recovered. It cannot be concluded that there was acute or progressive periodontal disease present on 30 June It therefore followed, the Committee found, that the GDC has not proved that Ms Piros failed identify the extent of Patient 1 s periodontal condition on 30 June Not proved. The GDC s case that radiographic investigation into Patient 1 s periodontal condition was required on 30 June 2011 was predicated on its case that the BPE score, as at that date, should have been higher than the 2 which Ms Piros recorded. As the Committee has found, in 2(b) above, that the criticism in relation to the BPE score has not been made out, it follows that this head of charge falls away. PIROS, A I Professional Conduct Committee May June 2016 Page -7/21-

8 2.(d) 2.(e) 2.(f) 3.(a) 5.(a) 5.(b) Proved. In the light of the finding at 2(b) above, it is necessary to consider this contention on the basis that the BPE scores of 2, which were recorded by Ms Piros on 30 June 2011, were correct, and not, as was alleged by the GDC, that the score for the upper left sextant should have been greater than 2. As the recording of a BPE score of 2 can reflect the presence of a number of different factors, the Committee found that there was a requirement for a dentist recording such a score to identify which factor or factors gave rise to the score. The Committee found that recording such a factor or factors would amount to a diagnosis. Since Ms Piros, in this instance, failed to record the factor or factors which led to the BPE score of 2, the Committee found that she failed to make an adequate diagnosis in respect of Patient 1 s periodontal condition. Admitted and proved. Ms Piros accepted that she ought to have prescribed a scale and polish on 30 June 2011 in response to Patient 1 s BPE scores of 2, however she failed to do so. Not proved in respect of failing to provide oral health advice. In her oral evidence, Ms Piros spoke in an impassioned and detailed way about the importance of giving oral health advice, as an essential aspect of her routine practice with all of her patients, and that even where oral hygiene was good or excellent, she would give such advice. The Committee accepted her oral evidence in this regard and noted the presence of oh good in her clinical record for the appointment on 30 June Admitted and proved in respect of failing to record the provision of oral health advice. Not proved. The GDC s case relied upon Patient 1 s recollection that Ms Piros was not assisted by a dental assistant at the appointment 11 January Ms Piros did not have a clear recollection of this appointment. She relied upon her usual practice, which was to work with a dental assistant and, in addition, she directed the Committee s attention to a treatment plan signed by Patient 1 and dated 11 January 2012, which contained her dental nurse s handwriting in addition to her own. Accordingly, the Committee concluded, on the balance of probabilities, that the GDC had not proved its case. Not proved. Patient 1 stated in his oral evidence that he was a hundred percent sure that Ms Piros had practised without a dental assistant when she extracted his UR6 tooth on 17 February In his oral evidence, however, he was unable to provide sufficient detail about this appointment to persuade the Committee to find that his recollection was reliable. Not proved. Consistent with the withdrawal of 3(b) and 4 above, Mr Bradly did not invite the Committee to find this head of charge proved. The Committee is satisfied that Mr PIROS, A I Professional Conduct Committee May June 2016 Page -8/21-

9 5.(c) Bradly s judgement in this regard was correct. The appointment of 17 February 2012 was for the extraction of the UR6 tooth, but this had been discussed along with other treatment options, when informed consent for the extraction had been obtained on 11 January The discussions on 11 January 2012 are recorded in the clinical notes and summarised in the signed treatment plan of that date. Not proved (as amended) for the same reasons as 5(b) above. 6. Not proved. 7.(a) 7.(c) 7.(d) In support of this head of charge, the GDC relied solely upon Patient 1 s recollection that an appointment took place during September Patient 1 stated that his assertion, that an appointment had taken place in this month, was likely to have been made after he had seen a document such as an invoice or credit card bill. However, he was unable to identify the nature of the document, or any detail of it, including the date. The Committee found that the GDC did not prove that there was an appointment during September 2012 and, this being so, Ms Piros did not have an obligation to record it. Not proved. In addition to its general finding relating to the reliability of Patient 1 s recollection, the Committee found that there was a further specific factor in respect of this head of charge. In his written statement dated 24 September 2014, Patient 1 could not recall any radiographs being taken on 7 January Ms Piros clinical records of this appointment stated opg taken and the Committee had sight of the radiograph identified in the record. In oral evidence, Patient 1 conceded that his recollection was not clear about the content of the appointment. Accordingly, the Committee found that the GDC did not prove that Ms Piros saw Patient 1 without the support of a dental assistant. Not proved in respect of failing to perform an extra oral or soft tissue examination. When Patient 1 attended the appointment on 7 January 2013, the clinical records shows that an examination was undertaken. Ms Piros was therefore under a duty to perform an extra oral and soft tissue examination as part of the process. Despite the fact that, on this occasion, Ms Piros did not record st clear or words to this effect, the Committee accepted her oral evidence that performing an extra oral and soft tissue examination was firmly established in her examination routine. Accordingly the GDC has not proved, on the balance of probabilities that Ms Piros failed to perform an extra oral and soft tissue examination. Admitted and proved in respect of failing to record an extra oral or soft tissue examination. Proved in respect of making a diagnosis following the BPE scores of 2 in five of Patient 1 s sextants, for the same reasons as in 2(d) above. Not proved in respect of making a diagnosis following the BPE score of 4 in the lower left posterior sextant of Patient 1 s mouth. The Committee accepted Ms Piros oral evidence, in which she explained that the score of 4 was identified after she had found an endo-perio lesion, in relation to Patient 1 s LL5 tooth. She recorded a negative prognosis and discussed this with Patient 1 before sending PIROS, A I Professional Conduct Committee May June 2016 Page -9/21-

10 7.(e) 7.(f) 7.(g) him away to consider the options. Proved in respect of recording a diagnosis following the BPE score of 4 in Patient 1 s lower left posterior sextant of his mouth. Ms Piros did not explicitly record that the endo-perio lesion was the sole source of the BPE score of 4. Proved. The Committee preferred the evidence of Mr Entwistle, who asserted that, having taken an OPG radiograph, recorded a BPE score of 4 and identified an endo-perio lesion, Ms Piros had a duty to carry out further radiographic investigation. The British Society of Periodontology guidelines, the Young Practitioners Guide to Periodontology, published in 2012, require practitioners to carry out further radiographic investigation where the presenting condition involves sextants scoring BPE 4 or having complex factors. Having identified an endo-perio lesion, Ms Piros should have carried out further radiographic examination. Admitted and proved. Admitted and proved. Ms Piros accepted that she ought to have prescribed a scale and polish on 7 January 2013 in response to Patient 1 s BPE scores of 2, however she failed to do so. 7.(h) Not proved in respect of failing to provide oral health advice to Patient 1 on 7 January (a) 9.(b) 10. Proved. The Committee accepted Ms Piros evidence that giving oral health advice was a routine aspect of her standard practice, as described in 2(f) above. Admitted and proved in respect of failing to record the provision of oral health advice. Admitted and proved in respect of failing to record an extra oral examination. Not proved in respect of failing to perform an extra oral examination for the same reasons as in 2(a) above. Proved as to the making of a diagnosis for the same reasons as in 7(d) above. In her oral evidence, Patient 2 had a clear recollection, describing important aspects of the appointment in vivid detail. This included the fact that the appointment occurred around lunchtime and the way in which Ms Piros was intermittently using dental instruments and suction. Patient 2 remembered badgering Ms Piros to perform the extraction of her LL5 tooth there and then, despite Ms Piros reluctance to undertake an extraction at that appointment. The Committee was satisfied on the balance of probabilities that Ms Piros did perform the extraction without a dental assistant. Claims under code 1442 At all material times, the Practice was obliged to meet a set annual target to perform a specific number of units of dental activity ( UDAs ), pursuant to its GDS contract with NHS PIROS, A I Professional Conduct Committee May June 2016 Page -10/21-

11 England. Each UDA performed was then counted against the Practice s total annual target in order to measure whether the Practice had met its target. The system of claiming was governed by The National Health Service (General Dental Services Contracts) Regulations 2005 and the National Health Service (Dental Charges) Regulations 2005 ( the Regulations ), both of which were in force since In respect of four children (Patients B, C, J and L) the GDC contended that Ms Piros provided treatment that was incorrectly recorded in the clinical notes, in that, included in a course of treatment for each child, there was an entry in the clinical notes that was described as fissure sealant with composite and thus given the code The consequence of the ascribing of code 1442 was that the claims submitted to the NHS in respect of those treatments was at Band 2, resulting in three UDAs being allocated to the treatment. The GDC s case is that the treatment should have been recorded as fissure sealant only thereby resulting in code 1441 being ascribed. Had code 1441 been given to the treatment, when submitted it would have registered as Band 1 treatment resulting in the allocation of one UDA. The four instances relied upon in this regard are reflected in heads of charge 11, 13, 18 and 21. As they appear in the heads of charge they are not alleged in chronological sequence, but for present purposes it suffices to record that the dates of the four cases spanned the period 6 February 2013 to 29 November In view of the fact that the GDC has alleged a common, pecuniary motive for the making of the allegedly inappropriate claims, in reaching its decisions on these heads of charge the Committee has had regard, not only to the evidence specifically bearing on the specific claims, but also to the totality of the heads of charge by which the GDC alleges inappropriate or dishonest claiming for treatment. These heads of charge are not only the four 1442 claims under immediate consideration, but also those where the coding for the treatment was There was no disagreement between the expert witnesses called on behalf of the parties as to the circumstances in which a claim involving the application of fissure sealant could, and could not, be claimed under the Regulations referred to above. The Committee accepted this consensus opinion, and it can be adequately summarised as follows. If during a course of treatment fissure sealant is applied to a child s tooth or teeth and no tooth preparations with a drill are undertaken for the sealant to be applied to the tooth or teeth, then the treatment can only be claimed as a Band 1 treatment. If, on the other hand, the tooth is prepared to receive the fissure sealant by the use of a drill, then a Band 2 claim would be appropriate as such treatment would amount to a sealant restoration. In order to decide if the GDC s case in relation to a 1442 claim has been proved it has therefore been necessary for the Committee to decide if the GDC has discharged the burden of proving that the treatment did not involve the preparatory work that would have justified the Band 2 claims actually submitted. The GDC s case in this regard is founded upon the proposition that the clinical recording undertaken by Ms Piros in the patients notes did not explicitly state that the preparatory work was undertaken. The Committee has carefully considered the entirety of the evidence relating to these heads of charge. The clear decision of the Committee is that the GDC has not proved the case it has advanced. The reasons for this decision are as follows: The Committee s finding that Ms Piros was a truthful witness and a person who practised dentistry honestly. PIROS, A I Professional Conduct Committee May June 2016 Page -11/21-

12 While accepting that the patient notes did not explicitly state that tooth preparation with a drill, justifying a Band 2 claim, had been undertaken, the inadequacy of Ms Piros record keeping was not limited to this issue, but was rather an issue that could fairly be described as a general failing. That being the case, it would be the more difficult to draw an inference from the absence of a record that the treatment did not occur. While the clinical records do not support the proposition that the extra work justifying a Band 2 claim was undertaken, there is nothing in those records that contradicted Ms Piros contention that she did it. The tooth preparations Ms Piros contended she undertook were consistent with her general approach towards caries prevention in children. The result is that the Committee does not find that the claims were inappropriate. The Committee was advised as to the proper two-stage approach to allegations of dishonesty. There can be no question of claims which were not inappropriate being considered to be dishonest by ordinary and honest members of the dental profession. It follows that both limbs of heads of charge 11, 13, 18 and 21 are not proved. 11. Not proved, for the reasons stated under Claims under code 1442 above. Preventative Treatment in Respect of Patients C, F, J and K Mr Igoe in his report dated 13 January 2015, criticised Ms Piros treatment of these patients primarily on the basis of inadequate offering of fluoride and her failure to investigate the teeth by way of appropriate use of routine bitewing radiographs. Where Ms Piros has made admissions, those admissions are limited to a failure to take bitewing radiographs in Patients C and F. Ms Firestone, when questioned by the Committee, agreed that the relevant guidance was Delivering Better Oral Health (published by the Department of Health in association with The British Association for the Study of Community Dentistry) ( DBOH guidelines ). In the second edition, available to Ms Piros at the relevant time, the guidance states that all children aged three years or older must be offered fluoride varnish twice a year as a minimum. Children causing concern, such as those with a higher caries risk, should be offered more than two applications of fluoride varnish per year. Fissure sealants should be offered to children aged seven years and above who are similarly causing concern. In her oral evidence, Ms Piros clearly preferred the use of fissure sealants, usually accompanied by tooth preparation, over fluoride varnish applications. The Committee noted that Ms Piros approach to preventative treatment stemmed directly from her strongly-held personal opinion about the risks associated with fluoride, rather than from the established guidelines. Ms Piros did not provide any scientific or evidence-based material to justify her departure from the guidance. Ms Firestone stated that Ms Piros had made a clinical judgement when deciding not to follow DBOH guidelines. However, she accepted that Ms Piros had not provided an acceptable rationale for deciding not to follow those guidelines. Under cross examination, Ms Firestone conceded that Ms Piros views represented a philosophical judgement rather than a clinical judgement. 12. Proved. PIROS, A I Professional Conduct Committee May June 2016 Page -12/21-

13 In reaching its decision in respect of Patient C, the Committee has applied its general findings set out above under the heading Preventative Treatment in Respect of Patients C, F, J and K. Ms Piros admitted this head of charge only in respect her failure to take routine bitewing radiographs. There was evidence that Ms Piros did not offer fluoride varnish application to Patient C, who was over three years old in April 2009 and presented with active caries. Accordingly, the Committee concluded that Ms Piros decision to disregard the established guidance, and instead follow an approach based on her own personal view, amounted to a failure of her duty to provide adequate preventative treatment to Patient C across the period concerned. 13. Not proved, for the reasons stated under Claims under code 1442 above. 14. Proved. Ms Piros admitted this head of charge only in respect of her failure to take routine bitewing radiographs. In reaching its decision in respect of Patient F, the Committee has applied its general findings set out above under the heading Preventative Treatment in Respect of Patients C, F, J and K. Ms Piros recorded in the clinical notes that Patient F had a medium caries risk. She also noted that sugar intake was high and that there was extensive caries in the ULD tooth. Under these circumstances, Patient F should have been offered more than the minimum of two fluoride varnishes per year. In fact, there was no evidence that this patient was offered any fluoride varnish on any occasion during the time period concerned. Accordingly, the Committee found that, across the period of time concerned, Ms Piros failed to provide Patient F with adequate preventative treatment. 15. Admitted and proved. The Committee examined the records for the four individual appointments, noting that a number of key components of an examination were omitted. It concluded therefore that the records were not adequate. Claims under code 1441 In respect of two heads of charge (namely 16 and 20) relating to two children, respectively Patient H and Patient K, the GDC advanced a similar case to that advanced in respect of the claims under code The similarity lies in the contention that Band 1 work was claimed as Band 2. However, in the case of heads of charge 16 and 20 the clinical notes do not allege that any work beyond the application of fissure sealant only (code 1441) was undertaken. Neither the coding nor description in the notes suggested that any tooth preparation with a drill was undertaken before the application of the fissure sealant. Furthermore, in oral evidence Ms Piros did not contend that she had undertaken any drilling work in connection with these treatments. As the claims for these Band 1 treatments were submitted as Band 2, they were clearly inappropriate. The issue the Committee has been required to decide in respect of these heads of charge is whether Ms Piros caused or permitted the inappropriate claims to be PIROS, A I Professional Conduct Committee May June 2016 Page -13/21-

14 made. The Committee accepts that in the ordinary course of events, when NHS dental work is undertaken, the clinical information electronically entered, either by the dentist or under their direction in the treatment room, is automatically translated into an NHS claim and the appropriate band is selected within the computer software process. In ordinary circumstances, a member of the practice administrative staff would then transmit completed claims in batches, electronically, to the NHS Business Services Authority. In respect of heads of charge 16 and 20, the GDC alleged that the computer software would automatically assign Band 1 when a treatment, resulting in a code 1441 (meaning fissure sealant only ), was selected in the treatment room, and that, therefore, this process must have been manipulated in order for a Band 2 claim to have been submitted. The Committee accepts the logic of the GDC s case that somewhere along the line something happened to result in a course of treatment that should have been allocated by the computer software to Band 1 in fact being claimed as Band 2. However, the Committee found that the GDC has failed to prove that it was Ms Piros who caused or permitted these two undoubtedly inappropriate claims to be submitted. The reasons for this decision are as follows: The Committee accepted Ms Piros account that she had no idea how these two inappropriate claims came to be made. Beyond proving that it was Ms Piros who was the performer who undertook and recorded the Band 1 treatment, no evidence was produced as to how, when or by whom the all-important change of banding occurred. Mr Igoe, who was called by the GDC to give evidence on the issue of manipulation, said that the software was Exact and that it was possible to change the banding of treatments undertaken. The Committee rejected his evidence that the software was Exact, preferring the evidence of Ms Piros that it was R4. The GDC did not lead any evidence that it was possible to manipulate the banding when using R4 software, or as to how that might have been done if it had been possible. The Committee accepted Ms Piros evidence that she did not know that it was possible to manipulate the banding and that she did not in fact do so. There was no evidence from interrogation of the Practice computer system that cast any light on when or by whom any manipulation of the banding was undertaken. Had Ms Piros been minded to submit an inappropriate claim the obvious thing for her to have done would have been to record these treatments as 1442, which would have resulted in them being ascribed to Band 2 without any manipulation being required. Unlike all the heads of charge relating to 1442 coded treatment, in which the claims were submitted to the NHS on the same day on which the course of treatment ended, in the case of both of the 1441 coded treatments under consideration, the claims were submitted to the NHS on days following those on which Ms Piros closed the courses of treatment. PIROS, A I Professional Conduct Committee May June 2016 Page -14/21-

15 Both claims were made after Ms Piros had ceased to have a direct pecuniary interest in the number of UDAs claimed, and in the case of head of charge 16 the claim was made a week before she ceased to practise dentistry. In any event, it was the Committee s view that the monetary value of the four UDAs that these two inappropriate claims improperly generated were unlikely to have created in Ms Piros a motivation to behave dishonesty. As the Committee has found that it has not been established that Ms Piros caused or permitted the inappropriate claims, heads of charge 16 and 20 are not proved on that basis. 16. Not proved, for the reasons stated under Claims under code 1441 above. 17. Proved. In reaching its decision in respect of Patient J, the Committee has applied its general findings set out above under the heading Preventative Treatment in Respect of Patients C, F, J and K. Ms Piros recorded in the clinical notes that Patient J had a low caries risk. She also recorded on two occasions in 2013 that the sugar intake was low; in 2014, she recorded sugar intake as medium. There was no evidence that this patient was offered any fluoride varnish on any occasion in the time period in question. Accordingly, the Committee found that, across the period of time concerned, Ms Piros failed to provide Patient J with adequate preventative treatment. 18. Not proved, for the reasons stated under Claims under code 1442 above. 19. Not proved in respect of the failure to provide adequate preventative advice. The clinical records showed that advice was provided to Patient K. Proved in respect of the failure to provide adequate preventative treatment. In reaching its decision in respect of Patient K, the Committee has applied its general findings set out above under the heading Preventative Treatment in Respect of Patients C, F, J and K. The Committee noted that Ms Piros recorded in the clinical notes that Patient K s sugar intake was low and that all four 6 s (first permanent molars) had deep fissures. Between the relevant dates in the charge, the Committee saw evidence that Ms Piros applied fluoride varnish on one occasion only. The Committee found that this was not adequate in the context of four years of treatment. Despite the fact that the dates alleged in this head of charge covered approximately four years, the Committee was only provided with clinical records for two appointments, namely 29 October 2012 and 14 November The Committee noted that a fluoride varnish treatment was applied on the earlier of these two appointments, but despite that a period of more than a year elapsed before the second appointment, there was no evidence that fluoride varnish was offered or applied on a subsequent occasion. However, in oral evidence, Ms Piros confirmed that she did not offer this patient fluoride varnish throughout the whole of the period and, therefore, the Committee found this head of charge proved. PIROS, A I Professional Conduct Committee May June 2016 Page -15/21-

16 20. Not proved, for the reasons stated under Claims under code 1441 above. 21. Not proved, for the reasons stated under Claims under code 1442 above. 22. Admitted and proved. The Committee examined the clinical records relating to Patient Z and found that Ms Piros failed to make a clinical record of the appointments for 27 May 2009 and 26 October In respect of the appointment, which either fell on 28 March 2012 or 5 April 2012, there was no associated clinical record. 23. Admitted and proved. 24. Not proved. This charge related to a conversation between Patient 2 and Ms Piros which took place during the appointment of 2 September The Committee examined the wording of the clinical record of that appointment and compared it to the wording of the charge, noting that it has not been contended that Ms Piros should positively have advised Patient 2 that the tooth should have been removed. Patient 2 stated in her written statement dated 10 February 2015 that, It is right that I preferred not to have the baby tooth removed. The Committee concluded that there was insufficient evidence to show that Ms Piros contemporaneous record was anything other than accurate. On 16 June 2016 the Chairman announced the determination as follows: Mr Bradly, The Committee has carefully considered your submissions on behalf of the GDC and from Mr Sheldon on behalf of Ms Piros, and read the documents provided to it. It has accepted the advice of the Legal Adviser. The Committee was informed that Ms Piros has sought to voluntarily remove herself from the GDC register of dentists and has declared her intention to cease practising dentistry within the UK. Nonetheless, the Committee was careful to avoid drawing any adverse inferences from this information in considering its decisions on misconduct and, where necessary, impairment. It accepted that, depending on its decision, the Committee may be required to consider Ms Piros stated intentions for her future practice as part of any decision on sanction. Misconduct The Committee considered whether the facts found proved amounted to misconduct. It took into account that, in order to make a finding of misconduct the Committee must be satisfied that Ms Piros conduct fell short of the relevant standards and that the falling short was serious. The Committee found two incidents of Ms Piros failing to make a diagnosis and prescribe periodontal treatment in respect of Patients 1 and 2. These arose from Ms Piros omitting to ascertain the reason or reasons for BPE scores of 2 in both patients and, in the case of Patient 1 only, omitting to prescribe a scale and polish in response to the BPE scores. The Committee found that, in circumstances where BPE examinations were performed and their results recorded for use by Ms Piros as well as any future treating dentist reviewing the PIROS, A I Professional Conduct Committee May June 2016 Page -16/21-

17 notes, her failure to record a diagnosis fell below, but not far below, the relevant standards. Similarly, Ms Piros failure to provide a scale and polish occurred in one patient only and in two appointments. Accordingly, the Committee concluded that these actions were not sufficiently serious to constitute misconduct. In respect of Patient 1, the Committee found that Ms Piros had failed to perform an adequate radiographic examination on 7 January 2013 by omitting to take a periapical x-ray of his LL5 tooth, and by not recording an evaluation of the OPG radiograph which she did take. Having recorded a BPE score of 4 in relation to an endo-perio lesion, Ms Piros should have used periapical radiography to investigate the matter further. She had, however, already taken an OPG radiograph which was of good quality and it is clear that she properly considered the contents of that OPG image, as she identified that a periodontal lesion was present in Patient 1 s mouth. Although she did not record a grading of the OPG in her clinical notes, the Committee concluded that her failings did not reach the threshold to be categorised as misconduct. The Committee identified deficiencies in Ms Piros clinical record keeping, some of which she had admitted along with a general concession that her record keeping was poor. She informed that Committee that she had sought to improve her record keeping later by way of the use of templates. The Committee split these deficiencies into two distinct types, firstly, the failure to adequately record information (including the failure to record an evaluation of the OPG on 7 January 2013) and, secondly, the three appointments with Patient Z which were omitted entirely from the clinical records. In relation to the former, the Committee noted that Ms Piros omitted to record certain discrete aspects of examination appointments, on an intermittent basis. Although this could place her and a subsequent treating dentist at a disadvantage when reviewing the patient s history, the Committee considered that the risk to patients was low. In relation to Patient Z s three appointments where there was no clinical record, the Committee noted that although the GDC had inspected the clinical records of 30 of Ms Piros child patients, there was only evidence of missing records for this one patient. Accordingly, in both categories concerning Ms Piros record keeping deficiencies, the Committee accepted that Ms Piros departed from the standards applicable, but not so far as to be considered misconduct. The Committee next considered Ms Piros failure to provide adequate preventative treatment to child Patients C, F, J and K, as well the single incident of her practising dentistry without a dental assistant. In respect of these findings of fact, the Committee concluded that Ms Piros breached the following standards of the GDC s publication Standards for Dental Professionals dated May 2005, which provided ethical guidance for the dental profession (in the latter period of charge, namely from September 2013 to March 2014, the applicable standards publication was Standards for the Dental Team dated September 2013): 1.1 Put patients interests before your own or those of any colleague, organisation or business. 5.2 Continuously review your knowledge, skills and professional performance. Reflect on them, and identify and understand your limits as well as your strengths. 5.3 Find out about current best practice in the fields in which you work. Provide a good standard of care based on available up-to-date evidence and reliable guidance. In its findings of fact, the Committee found proved that Ms Piros placed the dental health of four child patients at risk as a result of her decision to disregard the established guidelines for fluoride-based preventative treatments. PIROS, A I Professional Conduct Committee May June 2016 Page -17/21-