A long list of errors

Aberdeen Dental School has been engulfed in a very public crisis after a damning GDC report revealed a swath of failings and poor management. Scottish Dental magazine investigates

01 April, 2015 / indepth
David Cameron Mike Wilkinson

Alex Salmond at the Opening of Aberdeen Dental School

Hanging proudly on the walls of dental schools around the country are framed pictures of the graduating cohorts that universities have successfully guided into the profession.

On either side of each photograph of eager, newly qualified dentists, is a simple white glove. They are there to recognise and honour the fact that the entire class of that year passed.

In comparison, walk the corridors of the £18 million Aberdeen Dental School, opened with such ambition and expectation in 2008 by former First Minister Alex Salmond, and you’ll look a very long time before you find anything similar.

We have even been told that there were requests being made to staff to falsify information being given to GDC inspectors during their examinations

In fact, in the three years that the school has been presenting students for their finals, not once has the entire year passed. And in an unprecedented failure rate for a UK dental school, almost a third of the class of 2014 failed.

Now, the school’s fragile reputation has suffered a further damaging blow through a 52-page GDC report in which its inspectors catalogue a long and damning list of errors and deficiencies.

Most worrying for some, it includes the revelation that up to 12 NHS patients were “harmed” last year by poorly supervised and stressed senior students working under unreasonable pressure towards their final examinations. Many of the patients required remedial treatment to correct the errors that had been made.

The report, which was quietly published deep inside the GDC website in January, eight months after the GDC inspectors had visited the school, is the third consecutive critical inspection of the school that has revealed significant issues.

Alarm bells

Among the most alarming problems, the document reveals that in 2014:

Students were put under “stressful” pressure to complete clinical prerequisites within inappropriate timeframes.
School management failed to take precautions and mitigate dangers to patients.
Up to 12 NHS patients were “harmed” by students in what are described as “adverse events”.
Students were not appropriately supervised according to the level of difficulty of the clinical procedure or their skill level.
Tutors failed to appreciate students’ lack of awareness of their capabilities…particularly when mistakes were being made.
No or inadequate documentation was completed on pre-treatment assessment, anticipated risks, student/supervisor discussions and, in some cases, degree of case difficulty.
Some supervisors did not have the suitable experience for the job they were doing.
Lack of use of the reporting systems meant adverse events were not dealt with as quickly as they should have been.
The number of staff supervising clinical training had to be doubled, putting huge pressure on the limited staff resources.
Tutors on the Aberdeen staff had to be given additional safety training.
“Passports” logging all students’ clinical work were introduced as part of a major new monitoring exercise.
Management communicated poorly with students, particularly over the introduction of prerequisite timescales.
In examination assessments, the examiners placed more emphasis on knowledge than technical skill.
Decisions on student progression were weighted towards numbers rather than quality.
The school’s data collection on students’ clinical work – essential for examination assessment – lacked detail.
A number of students had to complete clinical training AFTER graduating before being accepted onto the GDC register.
Despite problems of recruitment being raised in 2012, staff claim that the school is still under-resourced.
Management had misunderstood previous GDC instructions.
The entire final year formally complained to the university management about their training.

Serious questions

The situation is so troubling that the GDC has ordered a FOURTH consecutive inspection of the school to be carried out in 2015 to ensure that a raft of almost 50 new recommendations for improvement – including patient safety – are implemented.

Management at the school has responded to all the instructions and maintain that they have either addressed the issues raised or have plans in place to do so.

However, as the cloud of concern spreads ever wider over Aberdeen, serious questions are being asked both inside and outside the dental profession about the long-term future of the school and its role in the dental teaching community in Scotland.

Staggeringly, Aberdeen has recently advertised the posts of head of school and FOUR of its most senior teaching positions, a situation described by one senior academic in Glasgow as “unprecedented”.

And fanning the flames is barely suppressed anger that the crisis of confidence in Aberdeen comes at a time when Glasgow and Dundee dental schools, internationally recognised as two of the best in the world, have been ordered by the Scottish government to cut up to 28 per cent of the places they offer each year to UK students. More cuts may be on the way.

While money continues to be poured into the troubled Aberdeen school, staff at Glasgow and Dundee are scouring the world recruiting overseas students whose fees for tuition in Scotland will keep the universities’ dental programmes alive.

Now, a growing number of academics and senior clinicians argue privately that the very existence of Aberdeen cannot be justified. It is, they maintain, little more than an expensive and failing vanity project by the former leader of the Nationalists who is, they suggest, simply currying favour in his own political backyard and ignoring the facts.

Scottish Dental magazine has carried out its own investigation into the Aberdeen school, talking to past and present tutors and students who paint a bleak, distressing and, at times, disturbing picture of what has been happening in the Granite City.

We have heard allegations of bullying, intimidation and threats to careers. We have even been told that there were requests being made to staff to falsify information being given to GDC inspectors during their examinations of the school and its operations.

We have also discovered that, in recent years, a significant number of staff have quit the school in disgust at what they have witnessed and the treatment they have been subjected to. Others are believed to be looking to leave.

At one point in its troubled history, Scottish Dental has been told that whistleblowers on the staff submitted a 24-page list of complaints and grievances – along with supporting evidence – to management, the majority of which were upheld when investigated by the university’s medical teaching hierarchy.

It has also been alleged that when quitting their posts and moving on to new jobs, many of the former staff have been obliged to agree to what are effectively “gagging orders” preventing them from talking publicly about their experiences in Aberdeen.

In addition, students have lodged complaints with the GDC and the university about their training and treatment and a number are believed to have even looked to, or asked to be, transferred out of Aberdeen to other dental schools in the country.

Fearing retribution that could blight their careers, all those we have spoken to have been willing to talk of their experiences but none are willing to have their names published. One said: “No-one would actually believe what has been going on in Aberdeen. It is a national disgrace, a scandal that has gone unaddressed for years.

“The staff worked incredibly hard to try and turn the situation around but the management just would not listen to their concerns. Instead, we were subjected to bullying, intimidation and harassment. Some of us even had direct threats made to our careers.

“It is the students that I feel most for. They are good people, many of them have committed their futures and the lives of their families to go to Aberdeen and the way they have been treated is quite simply appalling. It is unforgivable.

“They don’t know whether they are coming or going. They don’t know if the school will be there in a year or two. And it is their careers, their very livelihoods that are at stake.

“The GDC reports, which were never shared with any of the staff, are only scraping the surface of what was going on in Aberdeen and, from what I hear, is still going on.

“People are worried and shell shocked at what has been going on and they want out.”

However, it is the GDC report, issued on their website in January, that gives the most comprehensive insight into the crisis at Aberdeen.

The report breaks down into four sections, each one stipulating a number of requirements to be examined and graded as “Met”, “Partly Met” and “Not Met”.

Standard 1 is “Protecting patients”. Here there were eight requirements to be met. In fact, only two were met, and six fell below the required standard and were only partly met.

Standard 2 is “Quality evaluation and review of the programme”. This section contains seven requirements and once again, only two met the required standard. All the others were just partly met.

Standard 3 is “Student assessment” and in this section there were eleven categories. Staggeringly, not one of the requirements reached the met standard. All were only partly met.

Standard 4 is “Equality and diversity”. Here, there were three requirements and all were met.

In Section 1, the report reveals that before the inspection in April 2014, management at Aberdeen contacted the GDC to say they had two significant issues. One was the continuing lack of NHS patients on whom students could develop their skills. The other was a cluster of nine “adverse incidents” that had occurred between January and March in which a number of patients had been “harmed”.

This is in line with the timescale in which the university had stepped up pressure on students to complete their clinical prerequisites in the build up to being approved to sit their final exams.

The students were only given the detail of what they were expected to complete in February of 2014. This work had to be completed by April, dramatically and unexpectedly, ramping up the pressure on an “already stressed cohort”.

Scottish Dental has learned that a number of students were so stressed by the pressure that was being heaped on them that they required medical intervention. A number were on anti-depressants.

In addition, the report states that school management told the students that the reintroduction of prerequisites was at the specific request of the GDC, a fact that would undoubtedly have further increased the pressure on the students. This is emphatically denied by the GDC who maintain that their instruction was misinterpreted by Aberdeen and that they gave no such order.

The inspection report states: “The GDC were informed that during this time, staff had started to raise concerns, for example in relation to over-booked or over-running clinics for pressurised final year students – both of which placed the clinical team under increased pressure generally.

“The school subsequently noticed an increased trend of incidents in clinics in excess of what they would normally expect in an environment where students are developing their clinical skills.

“The incidents were all identified by clinical supervisors, either as a result of a student asking for assistance or when the supervisor checked the student’s work. On a number of occasions, it was reported that the students were not sufficiently aware to identify what had gone wrong.

“Between January and March 2014, the school identified a cluster of nine adverse events, all involving different students with no particular pattern in relation to the supervising staff member. Several incidents occurred while students were performing endodontic procedures, and included endodontic perforations; over-preparation of teeth; treatment of a wrong tooth; damage to teeth adjacent to those being prepared and tissue damage by sodium hypochlorite.

“Each of the patients involved was briefed at the time of their incident with the school immediately devising individual follow-up plans for remedial treatment.”

Action was taken by the management at the school to address the problem and the GDC inspectors acknowledged this.

However, in the subsequent weeks, a further three adverse events involving students took place. Discovery of these may have been down to the increased control and supervision of the students, according to the report.

But the inspectors go on to say: “The inspectors were grateful for the School’s openness and candour in sharing detailed information about these events. Nonetheless, they were concerned that a number of patients had been harmed and disappointed that the school did not identify the significant threats to the programme earlier.

“Previous inspection reports had highlighted the issues of patient supply, inadequate recording of clinical achievement and a lack of consistency within the programme for senior year groups.

“Further, the 2014 inspectors were concerned by the late re-introduction of the clinical prerequisites to the final year students. Students were informed in February 2014 of the numbers of treatments they would need to have completed by the end of April.

“The timeframe appeared to increase the strain in an already stressed cohort and stressful clinical environment. Early on, the school advised the inspectors that, as a result of regular discussion and monitoring, there were indications that the current final year cohort was not as strong clinically as other graduating year groups had been, yet it appeared that, at the point of direct delivery of care and treatment, there were inadequate precautions taken to mitigate the risk to patients and prevent the cluster of adverse events.”

In Standard 3 – Student assessment, the criticism continues unabated.

The report reveals that of the 22 students beginning the academic year 2013/14, three were not signed up for the finals. Of the 19 going forward, three were re-sitting students from the previous year, one of whom was not permitted to go forward after the first written paper. In total, 18 students sat the final examinations and of those, five failed.

Remarkably, and to the considerable concern of the GDC, two students had to be given more time to complete and pass their clinical work AFTER the examinations had been taken.

When looking into the process surrounding the examinations, the GDC discovered that the current model was heavily weighted towards testing students’ knowledge rather than practical skills.

It states: “There was a distinct lack of assessment of the quality of clinical work within the unseen and presentation cases. Technical skills had not been suitably assessed at the point of delivery and were not scrutinised within the examination structure at all.

“The lack of a robust consideration of the clinical work became even more of a pertinent concern to the inspectors as, upon review, they were of the opinion that the standard of clinical dentistry displayed in the presentation cases was not universally strong.

“While it was accepted that the graduating cohort’s exposure to the full range of procedures had been negatively impacted by the situation with patient supply, what was seen on occasions were examples of the lowest level of care expected of a safe beginner.”

However, having received assurances from the school on those who passed having completed the required clinical work, the inspectors said that they were satisfied that those qualifying were of a similar standard to those graduating from other dental schools around the country.

“Ultimately, the inspection panel was assured that the students who passed the programme had reached a sufficient level of being fit to practise as a safe beginner and should be permitted to join the GDC register.”

In support of the school’s actions and responses both to the adverse incidents and the requests made by the GDC following the inspection, the inspectors said that the school’s responses to the patient supply gap and the adverse incidents had been “appropriate”. And they said that they had been satisfied that processes had been put in place to prevent a repetition of the events that has caused so much concern.

The report concludes by saying that the inspectors had been pleased to see that some progress had been made on implementing to the requirements that had been set out in the previous year’s report.

They said that they had found evidence of a “good team ethos” among the senior tutors and that staff were working together to improve various aspects of the programme. They also said faculty interaction appeared to be strong.

“However, as would be expected by its seriousness, the clinical experience of the graduating cohort and the cluster of adverse events had an impact on the inspectors’ consideration of several Requirements across the Standards for Education.”

The report goes on to say: “The programme leads assured the inspection panel that processes had now been put in place to avoid difficulties with patient safety and students completing their prerequisites in future. An advertising campaign targeting an estimated 22,000 unregistered patients in the local region had been encouraging. There was also evidence that the analysis of the cluster of adverse events would allow learning for positive system changes to improve patient safety management across the school. The inspectors concluded that they would need to review evidence that the changes to programme are being implemented effectively. Therefore, a re-inspection in the 2014/15 academic year will be required.”

One external examiner who took part in the assessments summed up the depth of concern surrounding Aberdeen. He said simply: “That dental school is in melt down.”

A spokesman for the University of Aberdeen, which runs the dental school, said: “All dental schools have rigorous standards of assessment, and as a relatively new dental school we are monitored regularly by the General Dental Council.

“We welcome these inspections as an opportunity for benchmarking our performance, and providing areas for learning, so that we continually improve in training student dentists for clinical practice.

“The GDC report noted the investigation and learning processes the school was following after ‘adverse events’ which had been reported while students were treating patients (which is under the supervision of fully trained dentists).

“The patients involved were made immediately aware of any concern with their treatment and the problems were promptly addressed. There were no complaints from the patients, and all processes within the school were reviewed and further improved.”