“…LR5 previous temporary restoration, cotton pellet removed, canal located and accessed again, WL confirmed at 21mm, rubber dam applied, copious amounts of chlorhexidine used to irrigate single canal, dried with paper points and GP inserted to length, condensed laterally well, excess removed using heated plugger and condensed well, amalgam placed and condensed well in increments, articulation paper used to check bite and sound, smoothened using burnisher, pt felt happy…”
“amalgam removed, revealing existing pulpal exposure/ opening - bleeding present, caries removed from cavity”
“Patient attended today for review of LR5 post initial RCT, explained to patient symptoms suggest failure of RCT, pt admitted to understanding this being the case and informed us was aware prior to beginning process symptoms may worse. Pt would prefer to leave temporary restoration…”
“The Registrant’s records suggested that a root canal filling had been done on the tooth in May 2019 and when I took a radiograph in November 2020, I could not see that so I wanted clarification from the Registrant of what happened and whether she could remember the Patient. The Registrant told me that if she said in the clinical records that she had done a root filling she will have done a root filling…”
“20. When I arrived, I found that [Principal Dentist 1] was with Patient LT and they were both being quite aggressive towards each other. [Principal Dentist 1] asked me whether I had carried out RCT and I explained that I had, as was recorded within the patient’s notes. Patient LT seemed upset to be being told by [Principal Dentist 1] that the treatment had not been carried out. … 24. [Principal Dentist 1] said a number of times that it would not look good for me if the record was requested by NHS England as the record was missing. I explained that record cards often went missing as they were incorrectly filed by staff and that I had raised this multiple times with the manager and [Principal Dentist 2] and that nothing had been done. 25. [Principal Dentist 1] said that the record card needed to be found, with either me or staff looking for it. I commented on several occasions that I would not jeopardise my position, having GDC interim conditions and NHS voluntary undertakings, by not carrying out treatment. … 27. The next day, I checked with reception staff whether the record card had been located. I was told that it had not and that no one was looking for it as they were too busy with reception related matters. 28. Over the next few days, when I had some free time, I looked through the filing cabinets where records are located. I found a card for Patient LT within the archive section where record cards are kept in filing cabinets in no chronological or alphabetical order. The record card (a brown NHS record card sleeve) had the patient’s name written on the front and possibly also their date of birth but I do not remember and I have not seen the record card since I handed it to [Principal Dentist 2]. The sleeve only contained the odd looking x-ray. 29. I recall that the sleeve also said “duplicate” on the front. A duplicate record card would be created in circumstances where a patient’s record card could not be located. Any hard copy records, radiographs, medical history, consent forms and treatment plans along with referrals or external letters would be kept inside the duplicate record card sleeve. If the original record card was subsequently located, the original and the duplicate card would be kept together. 30. I immediately tried to give the radiograph to [Principal Dentist 2] but, on each attempt, he was busy and did not respond to my requests to speak to him. I managed to catch him at the end of the day and gave him the X-ray. He went to put the X-ray on the viewing box and I said something along the lines of “here is the card to keep it safe”, as he was just walking away from the viewing box towards his computer with the x-ray, in the wallet but without the brown card. I then gave him the brown card. 31. I emphasised to [Principal Dentist 2] that this was not my radiograph and that I just found it in the archive section. [Principal Dentist 2] commented that it was an odd looking x-ray and I agreed. He said to leave it with him. I had wanted to discuss the radiograph further but [Principal Dentist 2] just said to leave it with him. I understand from his witness statement that he was in a rush to leave that day. […] Dental Nurse, was present during our exchange.”
“6. On4 December 2020 , the Registrant came into my surgery in the daytime and gave me the post-operative radiograph which should have shown the completed root filling that the Registrant supposedly did back in May 2019. It was important because the x-ray taken by [Principal Dentist 1] did not show it had been completed. 7. I cannot recall the Registrant’s exact words, but she said something to the effect of I have found the x-ray. It was right at the end of my session, and it was the day I collect my children, so I was in a rush, and I only had a brief look but straight away from my initial look it did not look right. I think I said something like that does not look quite right. I believe my nurse at the time, […] or […], might have been present, however I cannot remember who this was. I did not take a note of this conversation. I have seen thousands of radiographs and I know what one should look it. I did not have time to explore it further at that stage. Over the course of the weekend, I reviewed it further and came to the conclusion it was not correct. 8. I did not think the radiograph was genuine because the materials we use to fill in a root filling normally are rubberised material that will show up as a white line on an x-ray. The density of the x-ray was really, really white. You can only get something that white if you have metallic in the area because it will stop the x-ray going through. Secondly, it was the perfect colour and shape of the rubber in the shape of the canal. In most cases there should be a kink along the way somewhere. My initial assumption was that there must have been a metallic object placed there to fill in the root filling area. However, later it came to light that if you turned over the radiograph the section had been scratched out by a sharp knife or similar object.”
“In my experience of the technique described, it is most likely that GP can be inadvertently removed either during the lateral condensation stage or subsequently when a heated plugger is used. If it was to be removed during lateral condensation, then the GP would either leave the canal space attached to the instrument being used or be dislodged and left lying in the access cavity. As such, it is more likely than not that it would be immediately apparent to the operator. Similarly, if it was to be removed attached to a heated plugger, it is more likely than not that it would be immediately apparent to the operator.”
“… from the clinical details recorded, it is more likely than not that [the Appellant] would have been aware if the gutta percha had been inadvertently removed from the canal during the obturation process. The experts also agree that the description of the access preparation as recorded by the subsequent treating dentist is not consistent with what would be expected if the canal had been prepared and obturated.”
“It is my opinion that the appearance on the radiograph could not have occurred accidentally”
“It is alleged that [the Appellant] ‘altered’ a PA radiograph to give the impression that endodontic treatment had been completed LR5 as recorded in her clinical records (31.5.19). A radiograph has been provided which has clearly been ‘altered’ as alleged. It is not disputed that this radiograph was provided by [the Appellant] to [Principal Dentist 2] on either the 3rd or4th December 2020 . However, [the Appellant] denies that she ‘altered’ it in any way. As such, any determination in relation to the central issues in this case will require a finding of fact as to: which x-ray was ‘altered’; who ‘altered’ it; and why?”
“As a matter of fact, the LR5 had not been successfully obturated with gutta percha as no gutta percha was present in the tooth at the conclusion of the appointment on31 May 2019 . You had intentionally made a clinical note describing in detail that the LR5 had been successfully obturated with gutta percha. As admitted and found proved under charge 42(a) above, that note was misleading as a matter of fact. The issue under this charge is whether you knew that the note was misleading at the time you made the note, or whether you genuinely but mistakenly believed that you had successfully obturated the LR5 with gutta percha. The Committee determined that it is more likely than not that you had not in fact placed any gutta percha into the tooth to begin with. This is because [JH] found evidence of an exposed pulp and caries in the LR5 when he opened up the tooth six days later: there had not been even a basic standard of endodontic preparation in advance of the placement of gutta percha as a root filling. In any event, the Committee determined that it would have been obvious to you if the gutta percha fallen out of the tooth during the treatment or if it had otherwise been removed from the tooth by becoming stuck to the heated plugger. The Committee accepted the expert opinion evidence that gutta percha was of a distinctive appearance to any other material which would have been used during the procedure. You accepted in evidence that you had used a rubber dam when placing the gutta percha into the tooth. The rubber dam would have isolated the tooth and this would have further increased the visibility of any gutta percha falling or being removed from the tooth. In the Committee’s judgment, there was no basis on which you could have reasonably believed that you had successfully obturated the LR5 with gutta percha. The Committee determined it was more likely than not that you knew you had not successfully obturated Patient LT’s LR5 and that you knew your note in the clinical records was inaccurate.”
“The issue for the Committee to determine under this charge is whether you had deliberately scratched the radiograph. This is an extremely serious allegation and one which the Committee considered with great care. Both experts examined the radiograph and agreed that it had been deliberately scratched to give the impression that a root filling was present at the LR5. Both experts agreed that the way which the radiograph had been altered could not have been accidental. The Committee accepted Mr Mulcahy’s opinion that the radiograph which had been altered was likely to have been a pre-operative radiograph of LR5 taken on12 March 2019 or30 April 2019 . One of those radiographs is missing from the records (it is not possible to tell which one) and is likely to have been the radiograph which was then deliberately scratched. The evidence before the Committee was that all practice staff had access to patient records and therefore any member of staff could have altered the radiograph. The Committee had regard to the content of the radiograph, the subject of the radiograph, what was altered on it, who was the treating dentist in relation to the subject matter of the alteration, the context of the investigation, the circumstances in which it came to be discovered and then presented to your supervisor and whether you would have had any motivation to have altered the radiograph.”
“It is beyond doubt from the evidence before the Committee that the radiograph in question was deliberately altered to give the impression that a root filling had been placed at Patient LT’s LR5. Whilst all practice staff had access to patient records, there is nothing to suggest to the Committee that any person other than you would have had any reason whatsoever to have altered the radiograph (whether out of malice, as a “prank” or for some other reason). The only person who had a motive to alter the radiograph was you. The Committee had regard to the principle that the more serious an allegation the less likely it is to have occurred. Here, the allegation is extremely serious. The Committee also had regard to the crude nature of the alteration to the radiograph and to the fact that, on close examination, it would have been obvious to Principal Dentist 2 and any other practitioner that the back of the radiograph had been deliberately scratched in order to alter the radiographic image. In the Committee’s judgment, this does not make it less likely that you had deliberately scratched the radiograph. This is because people can act recklessly and demonstrate poor judgment when desperate or under considerable pressure. This is not a decision which the Committee reached lightly or with any enthusiasm. The Committee very carefully examined and deliberated on the evidence. From whichever angle it approached the matter it reached the irresistible inference that it could only have been you who had deliberately scratched the radiograph covering the LR5, which you then provided to your workplace supervisor, Principal Dentist 2.”
“(1ZA) The over-arching objective of the Council in exercising their functions under this Act is the protection of the public. (1ZB) The pursuit by the Council of their over-arching objective involves the pursuit of the following objectives -- (a) to protect, promote and maintain the health, safety and well-being of the public; (b) to promote and maintain public confidence in the professions regulated under this Act; and (c) to promote and maintain proper professional standards and conduct for members of those professions.” (a) to protect, promote and maintain the health, safety and well-being of the public; (b) to promote and maintain public confidence in the professions regulated under this Act; and (c) to promote and maintain proper professional standards and conduct for members of those professions.”
“An expert must explain the basis of his or her evidence when it is not personal observation or sensation; mere assertion or “bare ipse dixit” carries little weight.”
“both experts examined the radiograph and agreed that it had been deliberately scratched to give the impression that a root filling was present at the LR5. Both experts agreed that the way which the radiograph had been altered could not have been accidental.”
“Q. Because you’ve accepted allegation 41B. In terms of the radiograph that you handed over, again, just to that we’re clear in terms of what’s in dispute and what’s not, you accept it’s a scratched radiograph? A. Yes, it was. Q. And do you accept that whoever scratched that radiograph would have done so deliberately? A. Yes, I would have guessed so. Q. Yes. This is not an accidental scratch, is it? A. No. Q. This is something that whoever has done it, has done it very consciously and deliberately; do you accept that? A. Yes. Q. And in terms of dealing with the location of the scratch, do you accept that it’s designed to cover the root of that particular tooth, the lower right 5? A. Yeah. Q. Of Patient LT? A. A very poor attempt to cover the --- Q. Well, quite crude. A. Yeah. Q. A poor attempt but an attempt nonetheless? A. Yes. Q. Do you accept that? A. Yes, yes. Q. And also at the top of it, we can see the scratch, it stands out, to give the appearance of an amalgam as well? A. Yes. Q. Yeah. So be it crudely, not particularly good, but it’s clear that whoever scratched that tooth is trying to give the impression of an amalgam and root fill; do you accept that? A. Yes.” albeit later in the cross-examination the Appellant said: “But I don’t know how it - how that radiograph came to look like how it does, I don’t know how it’s possible to do it, if it was scratched or not. I don’t know.”
“So it is not contested that somebody scratched this radiograph and if Ms. Photay did not then somebody else must have, and that in my submission is where the relevance of the other dentist and the chaos around radiographs and the misdated wallets do have their relevance because if this record card had been all the time in Ms. Photay’s possession or in a locked bag of hers or in a locked cabinet to which nobody else had access, well then it would have to be but no one else would even physically have had the opportunity to do this and so it is relevant to ask questions and to seek around where opportunities might have been, how well and carefully radiographs were looked after and where they were kept and so on and so forth. … The relevance is that whatever else was going on in the practice at this time. There are some very odd things about the radiographs for this patient. … … How would anyone else, it might be asked, know to mark that radiograph in that particular way? Well, the issue with the missing radiograph was widely known among the staff who were tasked to look for it so there were plenty of people in the practice who knew that there was a missing post-operative radiograph and that the notes were being called into question. Whether the records drawer was locked or not and Ms. Sangha confirmed that all the staff had access to the records, the tampered radiograph was found by Ms. Photay in the archive section where record cards were stored chaotically in no particular order. Ms. Photay has been criticised to some degree for not, as it were, nominating a candidate for who did it. She does not know who did it, she can only know whether she did or not. She does not know whether it was produced for a prank, someone who knew she had had this difficulty, done for some kind of laugh, or whether it was done more maliciously. She has no idea how, when, where it was done or who did it, and all she can do is give her evidence to you that it was not her who did it and that it would have been completely pointless for her to do it. …”
“the content of the radiograph, the subject of the radiograph, what was altered on it, who was the treating dentist in relation to the subject matter of the alteration, the context of the investigation, the circumstances in which it came to be discovered and then presented to your supervisor and whether you would have had any motivation to have altered the radiograph”
“you would have been aware at this early stage (if you were not already aware) that you had failed to take a post-operative radiograph, as it is more likely than not that you would have reviewed Patient LT’s records and would have searched for a post-operative radiograph in response to [JH]’s concerns that no root filling was present when he subsequently examined her.”
“Just on the off chance that I had failed to record it, I needed to make sure.”
“Your dishonesty is more difficult to remedy, as it is a matter which goes to your character. The Committee accepts that the dishonesty in 2017 was likely to be an isolated and spontaneous act, which as the Committee has already stated, falls at the lower end of the spectrum of seriousness. Your dishonesty in 2019 and 2020 on any view falls at the higher end of the spectrum. There is no evidence before the Committee of any insight, remorse or acknowledgement of wrongdoing. You had denied as part of the factual inquiry that you had acted dishonestly in respect of the entry you had made in Patient LT’s records on31 May 2019 and in respect of altering the radiograph in 2020 (you denied that you had scratched the radiograph). The Committee could not be satisfied that there is a low risk of you acting dishonestly again, particularly when under pressure. In the Committee’s judgment, your fitness to practise is clearly impaired by reason of both your clinical and record keeping failings and your dishonesty. There is a real risk of harm to patients should you be allowed to practise without restriction. Further, public confidence in the profession and this regulatory process would also be undermined if no finding of impairment were to be made. Your clinical failings involved basic errors in fundamental aspects of dental practice. Through these failings you had put patients at an unwarranted risk of harm in the past and you are liable to do so again if allowed to practise without any restriction on your registration. You have acted dishonestly and are liable to do so again. You have breached a fundamental tenet of the profession by acting dishonestly. Your misconduct has the potential to bring the profession into disrepute.”
“The Committee acknowledges that your dishonesty occurred whilst you were under pressure and it appears that it may have been the result of desperation. Had your dishonesty been limited only to the inaccurate record on31 May 2019 then suspension may be proportionate. However, your dishonesty persisted with the subsequent alteration of the radiograph. This demonstrates a deep seated underlying professional attitudinal problem which is fundamentally incompatible with continued registration. Your having engaged in such a calculated attempt to alter a dental radiograph to cover up your earlier dishonesty is so serious that the Committee does not believe that either patients or fellow members of the profession could be expected to place their trust in you not to act dishonestly in the future, particularly if you again felt under pressure. Furthermore, your dishonesty was so serious that public confidence in the profession and this regulatory process would be seriously undermined if you were allowed to remain on the Register.”