Saved by the record

05 January, 2015
 

Dental Protection serves more than 64,000 dental healthcare workers around the world and the accumulated experience is reflected in its many risk management publications. This series has been specially prepared for Scottish Dental magazine from the case files at Dental Protection (www.dentalprotection.org). This is a case where good record-keeping for an adverse incident ‘saved the day’.

The patient had attended the dentist in this case for a few years, and had routine dental care provided without incident or complaint. Early in the period of care, the dentist had completed a root treatment at UL4 which had been troublesome, and although the root filling was a little shorter than ideal in one root, the symptoms had reduced and it was decided that the tooth should be kept under observation.

Three years later, the tooth flared up again, and at this stage a periapical lesion was noted on a new radiograph. Several options were discussed with the patient, including extraction, or re-root treatment, either by the dentist or by referral to a specialist endodontist. For financial reasons, the patient was not interested in pursuing the specialist option.

At the next appointment, the dentist opened the UL4, removed the old root filling and irrigated the tooth; at the follow-up appointment, the tooth was asymptomatic and so the dentist proceeded to complete the root filling, using a plain local anaesthetic. Unexpectedly, irrigation of the buccal canal with hypochlorite and chlorhexidine led to bleeding and pain – the procedure was stopped, the bleeding controlled and a temporary filling placed.

Within a short space of time, the patient experienced increasing pain, and also swelling in the adjacent area. The sinus area was painful to pressure, and as a precaution the dentist asked the patient to rest while an ice pack was applied to the site of the swelling. Unfortunately, there was no improvement within 15 minutes, so a second dentist was called to assist.

The temporary filling was removed and the tooth was again irrigated with chlorhexidine – at this point, the patient experienced increased pain and was shaking, so additional plain local anaesthetic was administered, and an ambulance was called. The patient was examined by paramedics, who advised simple analgesia, rest and use of cold packs, and a review within 24 hours.

On review with a colleague, the patient’s pain had reduced but had not cleared, and it was noted that the patient’s GP had prescribed antibiotics. The left cheek was still swollen, from the mandible to the eye, and it was decided to review the patient two days later. The swelling persisted at follow-up, and further root treatment was carried out to the UL4, with a suggestion that the problems may have been caused by the irrigating agent. The future prognosis of the UL4 was also discussed, but this turned out to be the patient’s last visit to the practice.

Much to the dentist’s astonishment, some months later the General Dental Council (GDC) advised her that the patient had raised concerns regarding the treatment that had been provided by the dentist and her colleague. The GDC’s letter stated their intention to investigate whether her fitness to practise was impaired. The dentist was distressed by this development and complied with the request for information, with the advice from Dental Protection’s adviser to ‘sit tight’ and await the outcome of the initial investigation.

The dentist was subsequently very relieved to learn that the GDC did not intend to refer the matter to their Investigating Committee, and was closing the case. The National Clinical Assessment Service (NCAS) had reviewed his clinical care via the records, and had made favourable comments in relation to the following areas:

  • record keeping overall was good
  • appropriate taking of radiographs was noted
  • appropriate initial procedures for re-root treatment were carried out
  • appropriate procedures followed following the adverse incident, including diagnosis, treatment, advice and follow-up.

NCAS were of the opinion that the incident was accidental, and had been appropriately managed. This was very reassuring for the dentist, who had been understandably shaken by the involvement of the GDC, and was very thankful that she had taken the time to record the clinical care, advice given, and had suitable radiographs to provide further information. Had the records not covered the important aspects of this case, the defence may not have been as water-tight, and may have prolonged the GDC involvement in the case.

In summary, this case highlights the need for good record keeping at all times, particularly when an adverse incident occurs. The benefits of having the best available defence organisation on your side can be invaluable too.

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