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Duty of Candour - examples including considerations for activating the procedure (v3.0)

Healthcare Improvement Scotland set up a Duty of Candour short life working group in October 2017 with representation from the adverse events community of practice network. One of the aims of the group is to develop materials to support a consistent approach to the implementation of Duty of Candour (DoC). The group have developed illustrative examples of incidents that may, or may not, activate the Duty of Candour procedure. The examples listed are for illustrative purposes only and are not intended to be an exhaustive list. The conclusions represent the views of the short life working group on these specific scenarios. It is the responsibility for each organisation to have a local decision making process that considers, on a case-by-case basis, whether the duty of candour procedure will be activated for an individual incident.

We will continue to add to the document with further examples as the implementation of this new legislation progresses.

Cardiac arrestA patient in a general medical ward had a cardiac arrest at 7pm. The resuscitation team arrived within 5 minutes and worked with the patient for 30 minutes before concluding that the patient was not going to recover and declared confirmation of death. Looking back at the condition of the patient before this happened, there were signs of deterioration that had not been acted on. A blood result from that morning had not been reviewed and the previous set of vital signs recordings indicated some worrying results that had not been escalated to medical staff. The organisation decided to activate the DoC procedure as, although we cannot be sure if the patient would still have had a cardiac arrest, had the monitoring of the patient been better, other interventions could have been implemented that would have reduced the patient’s chances of cardiac arrest.

A patient in a general medical ward had a cardiac arrest at 7pm. The resuscitation team arrived within 5 minutes and worked with the patient for 30 minutes before concluding that the patient was not going to recover and declared confirmation of death. It was very surprising that this patient arrested as their clinical indicators leading up to this were all good. It was concluded that the sudden nature of this event could not have been avoided. The organisation decided not to activate the DoC procedure. Although the clinical staff would explain to relatives what had happened, there would be no need to implement the procedure or investigate further if initial findings concluded this was not preventable.

ChemotherapyFollowing a course of chemotherapy that was predicted to significantly reduce the chance of cancer reoccurring, the patient returned with a recurrence of cancer. When the chemotherapy schedules were reviewed, it became clear that the patient had received less of the dose than they

Following a course of chemotherapy that was predicted to significantly reduce the chance of cancer reoccurring, the patient returned with a recurrence of cancer. When the chemotherapy schedules were reviewed, everything was given as it should have been and unfortunately it would

THESE EXAMPLES ARE PURELY FOR ILLUSTRATIVE PURPOSES AND SHOULD NOT BE TAKEN AS DIRECTIVES. IT IS THE RESPONSIBILITY OF EACH ORGANISATION TO DECIDE BASED ON THE INDIVIDUAL CIRCUMSTANCES OF EACH CASE

should have done due to a weight miscalculation. The patient required further surgery and more chemotherapy. The organisation decided to activate the DoC procedure as, although we cannot be sure if the cancer would have reoccurred anyway, something had been identified that did not happen as planned that could have influenced the outcome for this patient.

appear that the chemotherapy was not as effective for this patient as it was hoped. The patient required further surgery and more chemotherapy. The organisation decided not to activate the DoC procedure as everything was done as planned and the unfortunate outcome was not the result of any omissions on the part of the organisation.

Clinical complication A patient underwent a procedure for radiologically inserted gastrostomy (RIG) tube. Before leaving the department it was confirmed that the RIG had been inserted correctly and was in the right place. There were no complications but sometime later in the patient’s hospital stay the patient became increasingly unwell and when finally re-examined the tip of the tube was shown to be in the peritoneal cavity. The patient had to undergo an emergency laparotomy and referral to Intensive Care Unit (ICU). On review, it was identified that protocols had not been followed to carry out chest and abdominal x-rays upon the patient reporting severe abdominal pain and the RIG tube had been dislodged for some time. The organisation decided to activate the DoC procedure as, although this is not a straightforward procedure and does carry an element of risk that had been fully explained and consented, protocols were not followed that should have identified the dislodgement before symptoms were so severe and this could have worsened the outcome for the patient.

A patient underwent a procedure for radiologically inserted gastrostomy (RIG) tube. Before leaving the department it was confirmed that the RIG had been inserted correctly and was in the right place. There were no complications but later in the patient’s hospital stay the patient became unwell and was re-examined which showed the tip of the tube to be in the peritoneal cavity. The patient had to undergo an emergency laparotomy and referral to ICU. All aspects of the procedure had been handled appropriately and followed up within protocol. The organisation decided not to activate the DoC procedure as on review it was clear that all processes had been followed correctly and the shift of the tube was identified at the earliest opportunity. This is not a straightforward procedure and does carry an element of risk that had been fully explained and consented to by the patient.

FallsGeneral considerations for a fall that have caused death, fracture or head injury. If, on review, it is revealed that processes that were supposed to be in place were not, such as:

a falls assessment not being carried out, or up to date the level of supervision was not as it should have been equipment was not available that could help prevent falls, or the wrong use of equipment (hoist), for example


The organisation should decide to activate the DoC procedure as procedures have not been followed that could have prevented the fall.

A patient who had Alzheimer’s disease was admitted to hospital from a nursing home in the early hours of the morning following a fall. She had fallen before. She was admitted to an orthopaedic ward with a fractured elbow and was awaiting review on the ward round for surgery – she was fasting in case surgery would be later that day. At 11am she had still to be reviewed, the ward was very busy with admissions and patients going to and from theatre. The patient was very hungry and decided to go and look for something to eat. She had been told to press her buzzer and told why she was fasting but she had forgotten that due to the Alzheimer’s. The patient wandered into a stockroom at the back of the ward and fell. She was not found until approximately 30 minutes later and had a fractured neck of femur. Her falls assessment had not been completed since admission and she did not have a level of supervision assigned to her care plan. The organisation decided to activate the DoC procedure as this was a vulnerable patient who was a known risk of falling who had not been appropriately assessed.

A patient was admitted with nausea/vomiting and abdominal pain. The patient was assessed as being a low risk of falls and had not had a fall during this admission or at home. The patient went to the toilet but as she reached it she fainted. Unfortunately she hit her arm on the sink on the way down and sustained a fractured radius. The organisation decided not to activate the DoC procedure as all appropriate assessments had been carried out and the fall could not have been predicted or prevented.

Healthcare Associated Infection (HAI) An Endoscopy unit had a system of removing used scopes at the end of each case to be sent for decontamination and only when the next patient was in the room was a clean scope brought in. During a busy list staff changed over between cases and the dirty scope was not removed from the room. The new member of staff assumed that someone had brought in a clean scope ready for the next patient. After the scope was used, it was recognised to be the same one used previously as the barcode had already been scanned. Although the first patient was not known to have a blood borne virus (BBV) the risk of cross contamination had to be investigated. Both patients were informed of the error and that the risk of cross infection was low. Both patients required to have blood taken for analysis. While there was no indication that any cross infection occurred, there was psychological harm as both patients were very concerned waiting for the

A patient had developed SAB from an intravenous cannula. Investigation showed that the patient frequently pulled out the cannula or disconnected IV lines due to a cognitive impairment. The health records showed good recording of regular checks of the cannula and of insertion bundles. It was noted that staff repeatedly tried to explain to the patient the risks of possible infection if continued attempts to remove. The organisation decided not to activate the DoC procedure as, on review, it was determined that the patient’s continuous interference with the cannula was the main contribution to contracting the infection.


results which took several weeks. The organisation decided to activate the DoC procedure as both patients suffered psychological harm awaiting the results and their anxiety was caused by an avoidable error due to a system failure. A patient required a blood transfusion and a peripheral vascular catheter (PVC) was inserted for administration. PVC insertion was problematic requiring multiple attempts. The transfusion was uneventful but the PVC was not removed afterwards as staff were unsure if further transfusion would be required at a later stage. While the PVC insertion bundle was completed, the maintenance bundle was not. The patient had many care interventions but no one challenged the PVC’s presence. The patient developed a Staphylococcus Aureus Bacteraemia (SAB), was acutely unwell with sepsis and required urgent transfer to another hospital. This led to distress for the patient and their family, with the patient requiring intravenous antibiotic therapy, and an extended stay in hospital. The organisation decided to activate the DoC procedure as processes had not been followed which could have influenced the outcome for this patient.

A patient had an IV cannula inserted for administration of antibiotics for a chest infection. The cannula was required to be checked on a daily basis. Once the course of antibiotics was complete the staff forgot all about the cannula as it was sited near the patient’s elbow and not obvious. The patient did not realise they no longer needed the cannula or that it should be checked. A week later the patient became unwell and was diagnosed with a SAB infection that required an extensive stay in hospital and further treatment. The source of the SAB was the cannula which had become infected. The organisation decided to activate the DoC procedure as the patient suffered harm as a result of the failure of a system to remove unused peripheral intravenous devices and to ensure early detection of infection.

A patient had abdominal surgery and the wound was dressed with an appropriate dressing. The patient had received prophylactic antibiotics. Three days after surgery it was noticed that the dressing had been removed by the patient and the patient had been trying to remove the stitches. Despite the wound being cleaned, redressed and antibiotics started, the patient developed a wound infection and required a longer stay in hospital. It was not predicted that the patient would have reacted the way they did. The organisation decided not to activate the DoC procedure as there were no failures in the care pathway for the patient and although the patient suffered harm it was not due to any actions or omissions of the healthcare organisation

Medicines – antibiotic allergic reactionA patient was prescribed the antibiotic Amoxicillin for a chest infection that A patient was prescribed the antibiotic Amoxicillin for a chest infection that


they developed while in hospital. Three minutes after the dose was given, the patient complained of becoming very hot and feeling short of breath. They had an increased heart rate and looked like they were having an anaphylactic reaction. They were treated with other medication and fluids and were required to be transferred to high dependency due to the deterioration in condition. When another doctor reviewed the patient’s prescription kardex it was noted that she was allergic to Penicillin and therefore should not have been prescribed Amoxicillin. The organisation decided to activate the DoC procedure as the doctor should have checked the allergy status on the kardex before prescribing and the nurse should have checked it before administering. The event could have been avoided.

they developed while in hospital. Three minutes after the dose was given the patient complained of becoming very hot and feeling short of breath. They had an increased heart rate and looked like they were having an anaphylactic reaction. They were treated with other medication and fluids and were required to be transferred to high dependency due to the deterioration in condition. The patient had never received a Penicillin type antibiotic before and did not realise they would take a reaction. The organisation decided not to activate the DoC procedure as there was no way to know that the patient was allergic and therefore could not have been avoided. When the reaction was identified, appropriate measures were taken.

Missing specimenDuring an endoscopy, biopsies were taken for diagnostic purposes to decide a course of treatment for a patient. Three biopsies were taken from different suspicious areas identified. When the clinician was looking for the results, one of the specimens did not turn up in the lab. Despite searching the endoscopy suite the specimen did not turn up. The clinician therefore could not rule out any problems with this area and the patient was required to be re-scoped. The organisation decided to activate the DoC procedure as, not only was there a delay in diagnosis, a repeat procedure was also required which exposes the patient to any risks associated with endoscopy for a second time, as well as possibly cause psychological harm if the repeat procedure is not carried out within 28 days.

During an endoscopy, biopsies were taken for diagnostic purposes to decide a course of treatment for a patient. Three biopsies were taken from different suspicious areas identified. When the clinician was looking for the results, one of the specimens did not turn up in the lab. Despite searching the endoscopy suite the specimen did not turn up. Two of the specimens were from the same area and one of them did arrive in the lab that confirmed the presence of cancer cells which meant that the clinician did not need the pathology result from the missing specimen for the treatment plan and therefore a further scope was not required. This would not activate the DoC procedure as the patient was unaffected by the error and there was no change to the treatment plan. However, there would be a review to ascertain how the missing specimen was lost.

Pressure ulcersOn admission to hospital, assessments including PURA (Preliminary Pressure Ulcer Risk Assessment), and SSKIN (Surface, Skin condition, Keep moving, Incontinence, Nutrition) were initiated and showed the patient had intact skin. CPR (Check, Protect Refer) for Feet was not completed nor was the MUST (Malnutrition Universal Screening Tool) completed within

An elderly patient who was underweight and diabetic with osteoporosis was admitted to hospital. A risk assessment was carried out that identified a risk of developing pressure ulcers so measures were to be put in place (pressure relieving mattress and cushion with 2 hourly repositioning). The patient refused to comply with repositioning, was often abusive to staff


the recommended 24 hours. Weeks later, the patient had an ungradeable pressure ulcer on a heel. No photographs were taken of this which is contrary to accepted practice. A review found some prevention methods were in place but the reliability of implementation was unclear. There was lack of contemporaneous documentation with at one point, a gap of more than 1 week, making it difficult to determine any deterioration in the wound. The organisation decided to activate the DoC procedure as processes had not been followed which could have prevented or highlighted the deterioration in the patient’s skin condition.

and resistant to care. Consequently, the patient developed a grade 3 pressure ulcer. The organisation decided not to activate the DoC procedure as, despite extensive efforts by staff to tailor an approach to meet the patient’s needs, the patient would not comply with preventative care measures that would have prevented pressure ulcers.

A patient was being cared for in a hospice who was nearing the end of their life. A risk assessment was carried out that identified a risk of developing pressure ulcers so measures were to be put in place (pressure relieving mattress and cushion with 2 hourly repositioning). After discussing pressure relieving measures with colleagues and the patient’s family members, the decision was made to consider the patient’s comfort at that time rather than repositioning. Consequently, the patient developed a grade 3 pressure ulcer. The organisation decided not to activate the DoC procedure as, although procedures were followed and determined preventative measures, the individual’s wishes, comfort and dignity must also be considered. Staff must regularly communicate with family and, if possible, the patient to ensure their wishes are continually being met.

Public healthA health visitor in a GP practice noticed that the fridge storing childhood immunisation vaccines was warmer than usual – closer inspection revealed that the fridge had stopped working. Daily recordings of the fridge temperature had not been undertaken for 5 days and therefore maintenance of the cold chain could not be guaranteed since the last recording. Records indicated that 50 children had received a vaccine in the interim period. There was no indication that any recipient had been harmed as a consequence of receiving the vaccine(s). However, an inadequate immune response, as a result of the ineffective vaccine could result in the unprotected individual being at risk of infection, and harm as a consequence of said infection, at a future point. The effect of the cold chain failure was vaccine specific, and therefore the potency of each vaccine affected was assessed, to establish who may have been given sub-

No alternative example available for this scenario.


potent vaccine and may require remedial vaccination. Specific vaccines given to 5 children were found to be sub-potent and those children required to be re-vaccinated. The organisation decided to activate the DoC procedure for the 5 children who needed to have further vaccinations.

SuicideCurrently sourcing example scenarios.

E.g. Suicide of a patient who we have a duty of care for i.e. under mental health services or in an acute hospital where there was a failure of care that could have prevented the suicide.

Suicides involving equipment and facilities, specifically window restrictors, points of ligature, etc.

Retained SwabA patient was not recovering as well as expected following surgery and was complaining of abdominal pain. When an x-ray was taken, a retained surgical swab was evident. The patient returned to theatre to have the swab removed via a laparoscope. The patient made a full recovery. The organisation decided to activate the DoC procedure as the patient suffered prolonged pain and required to have a further surgery (albeit minor) to have the swab removed. This would be a major breach in systems which would have an investigation shared with the patient.

A patient had abdominal surgery for an emergency bowel procedure. There was a lot of swelling in the abdomen and therefore it was not possible to close the abdominal wound following the procedure. A decision was made to leave some abdominal packs (large swabs) in place to cover the gap over the abdominal contents and to cover with a sterile dressing. The plan was to return to theatre once the swelling had decreased to remove the swabs and close the wound. When the patient returned three days later for this procedure it was noted that there should be two abdominal packs in the wound however when the wound was explored there were actually four. This identified an error in the original count and meant there was a risk that once the first two were removed, the other two might not have been noticed or looked for. The organisation decided to carry out an internal investigation into why the process failed but did not activate the DoC procedure as the patient was unaffected and it would not be thought helpful to share this information with them.

OptometryA patient attends the optometry practice due to a three-day history of flashing lights and floaters, symptoms suggestive of a retinal detachment. Due to inadequate triaging of the patient by reception staff, patient is

A patient attends the optometry practice due to a three-day history of flashing lights and floaters, symptoms suggestive of a retinal detachment. The patient is correctly triaged by reception staff and is seen by the


booked into the next available routine appointment in two weeks’ time, and not booked in as a same day emergency. The optometrist examines the patient and they have a complete retinal detachment in one eye and refers the same day to ophthalmology. Ophthalmology are unable to successfully treat the retinal detachment. Thus, leading to lifelong vision loss in that eye. The organisation decided to activate the DoC procedure as reception staff did not follow correct triage procedures for the patient leading to a delay in the patient being seen by the optometrist. As a result the patient suffered permanent harm with loss of vision in one eye. This may have been avoided had the patient been seen immediately by the optometrist and emergency referral to ophthalmology.

optometrist as a same day emergency. The optometrist examines patient and they have a macula off retinal detachment in one eye and refers same day to ophthalmology. Ophthalmology are unable to successfully treat the retinal detachment. Thus, leading to partial vision loss in that eye. The organisation decided not to activate the DoC procedure as there were no failures in the care pathway for the patient and although the patient suffered harm it was not the result of any actions or omissions on the part of the organisation

A patient attends for a routine sight test. Examination reveals bilateral homonymous superior quadrantopia visual field defect arising suspicions that a transient ischaemic attack may have occurred. The optometrist fails to refer patient on to GP/Stroke clinic for relevant investigation. The patient then goes on to have a stroke 4 months later and as a result has affected mobility lasting >28days. The organisation decided to activate the DoC procedure as the optometrist should have referred the patient to GP/Stroke clinic for appropriate investigation and treatment. This would have reduced the risk of the patient going on to have a stroke and suffering harm.

A patient attends for a routine sight test. Examination reveals bilateral homonymous superior quadrantopia visual field defect, arising suspicions that a transient ischaemic attack (TIA) may have occurred. The optometrist refers patient on to GP/Stroke clinic for relevant investigation, TIA is confirmed and relevant medication commenced. The patient then goes on to have a stroke 4 months later and as a result has affected mobility lasting >28days. The organisation decided not to activate the DoC procedure as there were no failures in the care pathway for the patient and although the patient suffered harm it was not the result of any actions or omissions on the part of the organisation

An independent prescribing optometrist prescribes oral doxycycline to treat blepharitis. The patient is already on warfarin and develops complication because of elevated international normalized ratio (INR) (doxycycline can increase warfarin blood thinning effects). The patient suffers a haemorrhage requiring admission to hospital and further treatment. The organisation decided to activate the DoC procedure as the patient suffered harm as a result of the failure of the optometrist to check what other medications the patient was taking before prescribing doxycycline.


72-year-old asymptomatic patient attends for annual sight test. He is routinely dilated with 1% tropicamide, optometrist does not assess anterior chamber depth prior to dilation and fails to issue patient with

72-year-old asymptomatic patient attends for annual sight test. He is routinely dilated with 1% tropicamide, prior to dilation optometrist assesses anterior chamber depth and notes that angles are very narrow in


guidance of what to do if any adverse reaction to dilation occurs. Patient then goes on to develop angle closure glaucoma later that day in their left eye. Patient then self refers to A&E the next evening with symptoms of blurred vision, pain and nausea and is diagnosed and treated as an emergency for angle closure glaucoma. The organisation decided to activate the DoC procedure as the patient suffered harm because of the failure of the optometrist to check anterior chamber depth prior to instillation, check post dilation intraocular pressure and issue patient with guidance on risk of angle closure and what to do if symptoms arise.

both eyes and advises patient of potential risk of angle closure. Optometrist takes necessary steps and checks intraocular pressure after dilation and notes an increase in intraocular pressure. Pressures are repeated an hour later and have increased further, optometrist then refers patient to ophthalmology as an emergency for treatment of angle closure glaucoma. The organisation decided not to activate the DoC procedure as there were no failures in the care pathway for the patient and although the patient suffered harm it was not the result of any actions or omissions on the part of the organisation.

A patient just moved into the area and attends an optometry practice for the first time for a routine sight test. The patient’s last sight test was 2 years ago. The patient has previously been attending the same optometrist every 2 years for the past 15 years and was always advised the eye were healthy and no signs of ocular disease. The new optometrist examines patient and suspects he has advanced glaucoma and refers to ophthalmology for investigation and possible diagnosis. The ophthalmologist diagnoses the patient with advanced glaucoma and confirms the patient has significant irreversible visual field loss which may have been prevented if the condition was detected and treated earlier. Following further enquiry, it was noted that during the previous 15 years the original optometrist had not undertaken automated visual field testing and had only carried out confrontation visual fields. The ophthalmologist informs patient he no longer meets the driving standards due to the visual field loss. The organisation decided (in line with its professional duty of candour) to contact and advise the previous optometrist that they should be activating the duty of candour procedure for this patient. The previous optometrist should activate duty of candour because they failed to spot signs of glaucoma and refer on to ophthalmology for treatment which led to the patient suffering harm. Diagnosis of glaucoma is challenging as is made up of several variables.


DentistryPatient attends dental surgery with a complaint of dental pain and swelling. Upon examination, dentist notes the swelling and advises patient that this

Patient attends dental surgery with a complaint of dental pain and swelling. Upon examination, dentist notes the swelling and advises patient that this


is due to a dental abscess. Dentist explains treatment options to patient and gets consent to start root canal treatment. The tooth is opened but there is not much drainage. In addition, the dentist tried to incise the swelling for drainage beside the tooth. After dressing the tooth, the dentist prescribes antibiotics to help reduce the swelling. At the next visit, the patient informs the dentist that he had an episode of significant bruising after a bump on his leg, after the attempted root canal treatment. The patient attended his GP who had checked his INR levels which had risen significantly. Measures were taken to reduce his INR level but the GP was concerned that the dentist had prescribed an antibiotic known to potentially affect the Warfarin currently being taken by the patient. The dentist checked his records and the medical history had not been updated at the previous appointment to include the Warfarin medication. He had forgotten, in the heat of the moment of an emergency appointment, to check and update the medical history. The organisation decided to activate the DoC procedure as the dentist did not follow procedure to seek clarification on any medications that the patient was currently taking in order to update the medical history for this patient. The patient had suffered harm as a result of the failure of the dentist to check what other medications the patient was taking before prescribing that antibiotic leading to the patient requiring treatment to reduce his elevated INR.

is due to a dental abscess. Dentist explains treatment options to patient and gets consent to start root canal treatment. Before the dentist starts the procedure the patient is asked to confirm if they are currently taking any new medications. The patient confirms that they have not started any new medications recently. The tooth is opened but there is not much drainage. In addition, the dentist tried to incise the swelling for drainage beside the tooth. After dressing the tooth, the dentist prescribes antibiotics to help reduce the swelling. At the next visit, the patient informs the dentist that he had an episode of significant bruising after a bump on his leg, after the attempted root canal treatment. The patient attended his GP who had checked his INR levels which had risen significantly. Measures were taken to reduce his INR level but the GP was concerned that the dentist had prescribed an antibiotic known to potentially affect the Warfarin currently being taken by the patient. The dentist checked his records and the medical history had been correctly updated due to the information provided by the patient. However, the patient had not mentioned the Warfarin medication at this time. The organisation decided not to activate the DoC procedure as all procedures were followed. The harm caused to the patient could not have been prevented by the dentist as the patient has provided incorrect information for the medical history.

A child is referred by their dentist to a Specialist Orthodontic Practice for an opinion and treatment of crowding. The referral practice write back to the dentist with a treatment plan which includes extraction of all four second premolars and asks that the dentist does this before the planned date of the orthodontic appliance fitting. The child is booked in for the extractions and consent is obtained for the treatment to be carried out over two visits. At this first visit, the dentist extracts the first molars on one side, and while the patient is recovering, he reads the letter and immediately realises that the wrong teeth have been extracted. The dentist immediately informs and apologises to the patient and parent, who are upset and demand to know

A child is referred by their dentist to a Specialist Orthodontic Practice for an opinion and treatment of crowding. The referral practice writes back to the dentist with a treatment plan which includes extraction of all four second premolars and asks that the dentist does this before the planned date of the orthodontic appliance fitting. The child is booked in for the extractions and consent is obtained for the treatment to be carried out over two visits. At this first visit, the dentist extracts the first premolars on one side, and while the patient is recovering, he reads the letter and immediately realises that the wrong teeth have been extracted. The dentist immediately informs and apologises to the patient and parent, who are upset and


what can be done. The dentist contacts the Orthodontist and explains what he has done. The Orthodontist explains to the dentist and the family that the long-term management and treatment will be affected by this mistake. The organisation decided to activate the DoC procedure as the dentist did not check which teeth were to be extracted before commencing with the procedure. The resultant orthodontic treatment will be more difficult, take longer and may have a compromised long term result.

demand to know what can be done. The dentist contacts the Orthodontist and explains what he has done. The orthodontist reassures both the dentist and the family that the long-term management and treatment will not be affected by this mistake and confirms with the dentist that the treatment plan should be amended to extract the first premolars on the other side, instead of the second premolars, to match those removed at the first appointment. The organisation decided not to activate the DoC procedure. While the dentist did not check which teeth were to be extracted before commencing with the procedure, when the error was identified appropriate measures were taken and the result and long-term management were unaffected.

Patient attends for extraction of an upper molar. The procedure proves to be difficult and on the final delivery, there is a ‘crack’, and the tooth is removed. The patient comments on the noise and the dentist confirms that it is quite normal for an extraction to involve a bit of noise when the tooth comes away from the bone. The dentist checks for any opening into the maxillary sinus. After bleeding stops, the patient is discharged with the usual post-operative advice given. A week later, the patient attends with pain from the socket and the dentist diagnoses a dry socket and dresses this. Noting that the patient has been informed that a dry socket is common after an extraction. The following week, the patient returns and sees a different dentist in the practice for an emergency appointment. At this appointment, the dentist notes swelling and tenderness at the extraction site. The patient record and questioning of the patient reveal nothing so the dentist offers to take a radiograph and consent is given. The radiograph shows a retained root at the extraction site. This dentist immediately offers an apology, on behalf of the Practice and provides the patient with a short course of antibiotics to reduce the swelling prior to a further appointment to remove the root. The organisation decided to activate the DoC procedure as the dentist did not extract the tooth completely and should have offered radiography of the extraction site when the patient returned 7 days after the procedure complaining of

Patient attends for extraction of an upper molar. The procedure proves to be difficult and on the final delivery, there is a ‘crack’, and the tooth is removed. The patient comments on the noise and the dentist confirms that it is quite normal for an extraction to involve a bit of noise when the tooth comes away from the bone. The dentist checks for any opening into the maxillary sinus. After bleeding stops, the patient is discharged with the usual post-operative advice given. A week later, the patient attends with pain from the socket and the dentist, remembering the extraction, takes a radiograph which confirms the presence of the retained root. He explains this to the patient who consents to the removal of the root. The dentist apologises for thinking that all the tooth had been removed at the first appointment.The organisation decided not to activate the DOC procedure. A retained root is a known possibility with any extraction and the dentist recognised this and took appropriate measures to identify and remove the retained root.


swelling and pain. If the original dentist had carried out a radiograph of the extraction site at the second visit this would have highlighted the retained root. The patient suffered harm resulting in an increase in their treatment.

Patient attends for routine replacement of a failed restoration which was picked up from bitewing radiographs taken at the routine exam, three weeks previously. Consent is obtained for the treatment after reviewing the plan on the computer. Local anaesthesia is administered, the tooth is prepared, and the dentist is surprised that there is no decay present in the tooth. The dentist completes the restoration and at the end of the appointment reviews the radiograph that he had taken at the previous appointment. The dentist realises that the equivalent tooth on the other side has been treated in error. The error is compounded by the realisation that the tooth that was charted requiring a restoration was an unrestored, caries free tooth and that the tooth requiring treatment on the other side, had a previous restoration. The dentist immediately explains to the patient what has happened, using the radiograph to aid the discussion. The organisation decided to activate the DoC procedure as the dentist should have checked the radiograph and charting before starting the procedure. The patient suffered harm due to an irreversible procedure being carried out on a tooth that required no treatment.

Patient attends for routine replacement of a failed restoration which was picked up from bitewing radiographs taken at the routine exam, three weeks previously. Consent is obtained for the treatment after reviewing the plan on the computer. Local anaesthesia is administered, the restoration removed, and the dentist is surprised that the decay noted on the radiograph doesn’t appear to be present. The dentist completes the restoration and at the end of the appointment reviews the radiograph that he had taken at the previous appointment. The dentist realises that the treatment has been charted on the wrong side. The dentist immediately explains to the patient what has happened, using the radiograph to aid the discussion. He reassures the patient that replacing the restoration in the tooth he did today will not result in any detriment to that tooth and offers a further appointment for the correct tooth to be treated. The organisation decided not to activate the DoC procedure. The dentist should have checked the radiograph before starting the procedure. However, the patient suffered no harm from the procedure being carried out on the wrong tooth although further treatment was required.

A patient attends for a routine exam, the dentist notes an ulcer on the side of the tongue which has no obvious cause. The dentist discussed the ulcer, which the patient is unaware of and a review of medical and social history reveals no significant risk factors. The dentist advises the patient to make a review appointment in 1 week and that if the ulcer is still present or has increased in size, this will be followed up with an urgent referral to the local maxillo-facial department. The patient makes this review appointment but fails to attend. The dentist, during his busy day, misses this, and reception staff also fail to note this or contact the patient to rearrange the appointment. Subsequently, the patient is referred by their

A patient attends for a routine exam, the dentist notes an ulcer on the side of the tongue which has no obvious cause. The dentist discussed the ulcer, which the patient is unaware of and a review of medical and social history reveals no significant risk factors. The dentist advises the patient to make a review appointment in 1 week and that if the ulcer is still present or has increased in size, this will be followed up with an urgent referral to the local maxillo-facial department. The patient attends this review appointment, and with no obvious improvement, the Dentist refers the patient to the local maxilla-facial department. The patient fails this appointment but attends his GP when the condition worsens with difficulty


GP after attending with difficulty swallowing. The diagnosis of squamous cell carcinoma is made by the maxillo-facial team and treatment commences. The patient remembers that this had been discussed some months previously at a routine dental appointment and the maxillo-facial team asks why the patient hadn’t been referred then. The organisation decided to activate the DoC procedure as, although we cannot be sure if the delay in diagnosis affected the prognosis for this patient, something had been identified that was not followed up as planned and could have influenced the outcome for this patient. The patient may also have suffered psychological harm as a consequence of this failure to follow up and refer onwards.

swallowing. The patient is referred by their GP. The diagnosis of squamous cell carcinoma is made by the maxillo-facial team and treatment commences. The organisation decides not to activate the DoC procedure as there were no failures in the dental care for this patient. Although the patient suffered harm it was not the result of any actions or omissions on the part of the dental organisation.

A patient attends for root canal treatment of an upper premolar. Consent is obtained and at the visit, the root canal is located and cleaned after rubber dam has been placed. The root canal is then irrigated with Sodium Hypochlorite and at this point the patient reports significant discomfort. The dentist immediately irrigates the root with saline and dresses the tooth. The dentist gives the patient a quick explanation of what has happened, namely that the irrigant has extruded beyond the end of the root and caused an acute tissue reaction. Further immediate treatment of pain relief, cold compress over the affected area and antibiotics is given. The patient is distressed and asks why this risk hadn’t been explained. The dentist apologises and says that it is such a rare occurrence that it had been omitted from his pre-treatment explanation. An onward immediate referral to secondary care was made. The organisation decided to activate the DoC procedure as the dentist should have properly explained all risks when obtaining consent. Had the patient known about the rare risk then they could have been better prepared to deal with the consequences. The patient suffered harm resulting in further treatment being required.

A patient attends for root canal treatment of an upper premolar. Prior to treatment consent is obtained and at the visit the normal risks are discussed including telling the patient to alert the dentist if they feel discomfort. The root canal is located and cleaned after rubber dam has been placed. The root canal is then irrigated with Sodium Hypochlorite and at this point the patient reports some discomfort inside their mouth. The dentist immediately irrigates the root with saline and dresses the tooth. The rubber dam is removed, and the patient is asked to rinse immediately with water. The dentist gives the patient an explanation of what has happened, namely that the irrigant has extruded below the rubber dam and has irritated the soft tissues inside the mouth. After a few minutes rinsing, the patient reports that the discomfort has subsided. This is not an uncommon incident when rubber dam is placed, and the dentist reacted quickly. The organisation decided not to activate the DoC procedure since this was a known risk of the procedure which was identified at the earliest opportunity and appropriate measures taken. The risk had been fully explained and consented to by the patient.


The Knowledge Network Scotland - Duty of Candour ... · Web viewThe health records showed good...

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