HEARING HEARD IN PUBLIC

Transcription

1 HEARING HEARD IN PUBLIC HANNA, Paulo Adel Registration No: PROFESSIONAL CONDUCT COMMITTEE JANUARY 2015 DECEMBER 2017 Most recent Outcome: Suspension extended (with a review) for 12 months *see page 23 for the latest determination Paulo Adel HANNA, a dentist, registered under s16(2a) Dentists Act 1984, with Specialty in Oral Surgery, was summoned to appear before the Professional Conduct Committee on 12 January 2015 for an inquiry into the following charge: Charge (as amended on 12 January 2015) That, being a registered dentist: 1. Between 8 March 2006 and 4 October 2011: (a) you were practising as a dental practitioner at the White House Dental Surgery, 33 Langney Road, Eastbourne, East Sussex BN21 3QD ( the Practice ); (b) you provided care and treatment to Patient A, as identified in Schedule A The dental treatment provided by you to Patient A was not of a standard to be expected in that you: (a) (b) (c) (d) (e) provided implants to the UL5 and UL6 sites which were of suboptimal angulation and/or failed to record any or any adequate clinical justification for angulation of the implants; used a poorly designed implant-retained fixed bridge for the UL5-UL6 site; took excessive radiographs of the UL5-UL6 site; took radiographs of insufficient diagnostic quality, including on: (i) 4 January 2007; (ii) 18 January 2007; (iii) 30 January 2007; (iv) WITHDRAWN; (v) 14 June took radiographs that were poorly positioned and/or coned off, including on: (i) 4 January 2007; 1 The Schedule is a private document which may not be disclosed to the public HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -1/28-

2 (ii) 18 January 2007; (iii) 30 January 2007; (iv) 28 March 2007; (v) 14 June 2007; (vi) 5 July 2007; (vii) 19 September 2007; (viii) 16 November 2007; (ix) 12 March 2008; (x) 14 June You failed to maintain adequate records of your care and treatment of Patient A in that you did not: (a) (b) (c) (d) make any or any adequate record of one or more of the matters set out in Schedule B; make any or any adequate record on the Practice s electronic computer system to indicate you had made additional notes; between 4 January 2007 and 16 November 2007 record any or any adequate clinical justification for taking radiographs of the UL5-UL6 site. ensure that full and complete clinical records were available at the Practice for Patient A, including: (i) an OPG on 20 October 2006; (ii) an OPG on 4 January 2007; (iii) a copy of a consent form dated 13 November 2006 signed by Patient A; (iv) a consent form dated 5 January 2007 signed by Patient A; (v) a note in relation to Patient A dated 5 January 2007; (vi) a note in relation to Patient A dated 1 April 2007; (vii) a note in relation to Patient A dated 26 September 2007; (viii) a note in relation to Patient A dated 12 March 2008; (ix) a note in relation to Patient A dated 14 June You failed to maintain adequate records of your care and treatment in relation to one or more of the patients set out in Schedule C, as identified in Schedule A, in that you did not: (a) (b) (c) ensure that full and complete clinical records were available at the Practice for one or more of the appointments set out in Schedule C; in the alternative to 4(a) above, make any or any adequate record for one or more of the appointments set out in Schedule C; provide the Practice with any of the records for one or more of the appointments set out in Schedule C when requested to do so. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -2/28-

3 And that in relation to the facts alleged your fitness to practise is impaired by reason of misconduct. On 15 January 2015 the Chairman made the following statement regarding the finding of facts: Mr Hanna The General Dental Council (GDC) s case against you is that the treatment you provided to Patient A was not of a standard expected in that you provided two implants to Patient A of suboptimal angulation, used a poorly designed implant-retained fixed bridge and took excessive and poorly positioned radiographs. Further the GDC s case is that you failed to maintain adequate records for your care and treatment of Patient A and a further 9 patients. At the outset of the hearing, Ms Hatt, Counsel for the GDC, made an application pursuant to Rule 18 of the GDC (Fitness to Practise) Rules 2006 to amend the Notice of hearing as follows: Withdrawing charge 2(d)(iv). Mr Peacock, Counsel, on your behalf indicated that he consented to the proposed amendments. The Committee acceded to Ms Hatt s application and amended the Notice of Hearing to remove charge 2(d)(iv). Mr Peacock then admitted, on your behalf, a number of the sub heads of charge as set out below and indicated that no issue was taken in relation to the record keeping aspect of charge 2(a). The Committee has carefully considered all of the oral and documentary evidence presented to it in this case. It has taken into account the submissions made by Ms Hatt on behalf of the GDC and those made by Mr Peacock on your behalf. Further the Committee has accepted the advice of the Legal Advisor. The Committee has reminded itself that the burden of proof lies with the GDC and that you are not required to prove or disprove any of the charges. Further it has reminded itself that the standard of proof is the civil standard. Therefore the GDC must satisfy the Committee on the balance of probabilities, that each individual head and sub-head of the charge is proved. The Committee heard the evidence of Lauren Blaskett. The Committee considered that she was honest, although there were minor inaccuracies in her evidence. The Committee considers this to be understandable given the lapse of time between the relevant events and this hearing. Overall the Committee found her to be a credible witness. The Committee heard the evidence of Michelle Hull. The Committee considered her to be an honest witness although it did consider that she was inclined to make inferences or draw conclusions that were not based on the evidence that is before this Committee. Overall the Committee found her to be a credible witness. The Committee heard the expert evidence of Paul Wilson. The Committee considered that Mr Wilson appeared to be applying a gold standard with respect to the diagnostic quality of the radiographs. Overall however the Committee found him to be an impressive, accurate and credible witness. The Committee heard evidence from you. The Committee felt that your evidence was not as full as it would have liked, in that you were not very forthcoming and some of your answers HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -3/28-

4 appeared evasive. In considering your evidence the Committee has had regard to the submissions of Mr Peacock on your behalf, that English is not your first language. The Committee has balanced this against the fact that you have been practising in the United Kingdom since The Committee considered that there were inconsistencies and contradictory statements in the oral evidence you gave. By way of example, your explanation for the loss of the OPG dated 20 October 2006 for Patient A, was that it may have been lost due to the flood in 2006 where sewage came into your practice s basement where you kept the hard copy files. The Committee notes however that you have provided some papers regarding the treatment of Patient A, which you have explained are copies of the hard copy documents from Patient A s file which was stored in the basement. The Committee notes that included in these documents is a copy of a Customer Information form for a Denplan Enhance Loan Application which is also dated 20 October On the basis of the explanation you provided, the OPG and this form should have been stored in the same file in the basement of the practice, and the Committee considers it highly unlikely that some of the documents in the file would have been affected by the sewage and have to be thrown out, while others would not. The Committee considered your explanation regarding the copies of the records you took from the practice. It notes your evidence that you took copies of some of the records regarding 15 to 16 implant patients, in order to apply for a fellowship with a professional organisation in Europe. The Committee reviewed the copies of these documents supplied by you in relation to Patient A, and does not consider that some of the documents would be the type required when applying for a fellowship, as they do not contain relevant information about treatment. These include the Denplan Loan Application mentioned above and a form of consent dated 5 January In particular the Committee noted that the consent form identified was dated the day subsequent to the treatment described. The Committee rejects your explanation that this was a typographical error. The Committee carefully considered your explanation that you had not taken the original files regarding your implant patients but that you had only taken copies of some of those patients files. You stated that when you were contacted by the new owners of the practice and told they could not find the records of the implant patients, it did not occur to you to send them these copies. You went on to state that after you were notified of the matter regarding Patient A by the GDC, you shredded the copies of the records of the implant patients you held, which included patient A, within one month. The Committee, on the balance of probabilities, did not find the explanations you provided to be credible and did not feel that it could place weight on your explanations. The Committee considered on the balance of probabilities, that you took the original hard copy records for the implant patients from the practice. The Committee has considered each head of charge separately. I will now announce the Committee s findings in relation to each head of charge: 1. a) Admitted and Proved 1. b) Admitted and Proved 2. a) The Committee considered the two parts of this sub-head of charge separately. That you provided implants to the UL5 and UL6 sites which were of suboptimal HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -4/28-

5 2. b) Proved angulation: Not Proved That you failed to record any or adequate clinical justification for the angulation of the implants: Proved. The Committee considered that the angulation of the implants was evidenced by the radiographs dated 5 July 2007 and 19 September The Committee considered the opinion of the GDC expert witness, Paul Wilson, who was only critical of the angulation if it had not been intended. While the Committee was satisfied that you did not record any clinical justification in your clinical records for the angulation of the implants, the Committee does not consider that there was evidence before it to establish that it was not your intention to angle the implants. The Committee considered the paucity of bone near the UL5 and UL6 where the implants were placed, as evidenced by the radiographs, and notes that appropriate treatment would have involved a sinus lift procedure or the angulation of the implants. The Committee notes that angulation of implants is a standard form of treatment in these circumstances and there is no evidence before the Committee to suggest that the angulation was not deliberate in order to accommodate the available bone. The Committee considered the design of the implant-retained fixed bridge you designed, which involved attaching a Maryland wing to UL4 which is a natural tooth. The Committee considered that your treatment approach in using a wing attached to the bridge to resolve sensitivity of the UL4 was not an appropriate approach to the problem. The Committee notes that attaching an implant bridge to a tooth can produce recognised complications. The Committee notes however, that the bridge is still present after 8 years and there are no recorded problems with the UL4. 2. c) Admitted and Proved 2. d) i) Admitted and Proved 2. d) ii) Admitted and Proved 2. d) iii) Not Proved 2. d) iv) Withdrawn The Committee considered the radiograph to be of sufficient diagnostic quality. 2. d) v) Not Proved The Committee considered the radiograph to be of sufficient diagnostic quality. 2. e) For head of Charge 2. e) the Committee has considered both aspects of the charge, that is that the radiographs were poorly positioned and that the radiographs were coned off. The Committee did not accept that a radiograph is poorly positioned solely because it is coned off. The Committee felt the expert witness, Mr Wilson, applied a gold standard when evaluating the positioning of the radiographs and the Committee considered that where it is possible to get adequate diagnostic information from the radiograph, that it would not be appropriate to conclude the radiograph was poorly positioned. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -5/28-

6 Where the Committee found both coning and poor positioning proved, or none of these proved, one outcome has been recorded. Where the Committee found one but not the other, two findings are recorded below. 2. e) i) Admitted and Proved 2. e) ii) Proved 2. e) iii) Poorly positioned: Not Proved 2. e) iv) Proved Coned Off : Proved The Committee notes your admission during oral evidence that the radiographs of 28 March 2007 are coned off and poorly positioned. 2. e) v) Admitted and Proved 2. e) vi) Not Proved 2. e) vii) Proved The Committee notes your admission during oral evidence that the radiographs of 19 September 2007 are coned off and poorly positioned. 2. e) viii) Admitted and Proved 2. e) ix) Admitted and Proved 2. e) x) Admitted and Proved 3. a) Proved The Committee found that there is evidence of some failures but not to the extent as suggested by Schedule B. The Committee considered your admissions in oral evidence regarding some aspects of the Schedule, for example that you did not record soft tissue examinations for all appointments when they were undertaken. The Committee has reviewed the clinical records for the appointments set out in Schedule B. While the Committee has considered all of the appointments, bearing in mind the very broad way that the charge has been drafted, in fairness to you it will only address the three appointments used as examples by Ms Hatt and Mr Peacock when making submissions, which are 4 January 2007, 12 March 2008 and 14 June The Committee notes that for the appointment on 4 January 2007, there is nothing to indicate that a medical history was taken or updated. It considered your explanation that part of patients clinical records were recorded in hard copy only and stored in a folder in a cupboard in the basement. The Committee notes that this is supported by the evidence of Ms Blaskett. Given that these files are unavailable, the Committee accepts that some of the items identified in Schedule B, such as the medical history form, may have been recorded in that other hard copy file. Further, the Committee accepted your explanation of how the local anaesthetic batch number, expiry date and dose were recorded elsewhere than in the patient clinical records. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -6/28-

7 For the appointment on 12 March 2008 the Committee did not consider that the GDC proved that it was necessary to include all of the information identified in Schedule B for that date. By way of example the Committee notes that the records do not include information of any examination undertaken. However the Committee is satisfied that the software was not being used entirely correctly in the practice and the Committee does not consider there to be evidence that this appointment was for an examination, as the records show the appointment was clearly for an implant check. For the appointment on 14 June 2010, the Committee considered that given that the patient had not been seen for some time, it would expect to see the medical history for the patient updated but there is nothing to suggest this occurred. Further the Committee would expect to see a history of the patient s presenting condition. However this is also not recorded anywhere in the available clinical record. 3. b) Admitted and Proved 3. c) Admitted and Proved 3. d) The Committee did not accept the explanation provided by you in oral evidence for the reasons set out above. 3. d) i) Proved 3. d) ii) Proved 3. d) iii) Proved 3. d) iv) Proved 3. d) v) Proved 3. d) vi) Proved 3. d) vii) Proved 3. d) viii) Proved 3. d) ix) Proved 4. a) Proved 4. b) No Vote Recorded 4. c) Proved As the Committee found sub-head of charge 4. a) proved and sub-head of charge 4. b) is in the alternative, the Committee did not record a finding against sub-head of charge 4.b). We move to Stage Two. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -7/28-

8 On 16 January 2015 the Chairman announced the determination as follows: Mr Hanna, The Committee has considered whether the facts found proved amount to misconduct. In doing so, the Committee has had regard to all the evidence before it, as well as the submissions made by Ms Hatt on behalf of the General Dental Council (GDC) and those made by Mr Peacock on your behalf. The Committee has considered the submissions of Ms Hatt for the GDC and Mr Peacock, on your behalf, regarding the issues of misconduct and current impairment. The Committee has accepted the advice of the Legal Advisor. The Committee was surprised that the submissions by both parties touched only briefly on the issue of the removal and destruction of the patient records from the practice and the failure to provide them when asked for. Misconduct The Committee first considered whether the facts found proved amounted to misconduct. In considering the issue of misconduct, the Committee has reminded itself of the extent and nature of the findings made against you. The Committee s reasons for its findings have been set out in full in its determination on the facts. The findings include: That you used a poorly designed implant-retained bridge for the UL5-UL6 site; That you took excessive, poorly positioned and coned off radiographs and took multiple radiographs of insufficient diagnostic quality; That you did not maintain adequate records for your care and treatment of patients who had received implant treatment and did not provide the practice with these records when requested. The Committee considered that a large number of radiographs were taken of one area within a short period of time and felt that many of them were very substandard. The Committee was satisfied that your radiographic practise falls far below the standard that would be expected of a reasonably competent dentist. The Committee also considered that the implant-retained bridge fell below the standard that would be expected of a reasonably competent dentist, but as the bridge is still in place and there is no evidence of damage to the UL4, the Committee felt that the bridge did not fall far below the standard expected. The Committee then considered your clinical records. The Committee considered the paucity of the clinical records. It considered the evidence that you recorded your notes in multiple places, did not use the software effectively and stored the records for individual patients in different places, some electronically and some in hard copy. The Committee felt the records were recorded in such a way as to make them very difficult to utilise effectively and considered the effect this would have on continuity of care for the patients bearing in mind there was no cross referencing identifying the additional notes. The Committee considered that your record keeping practise fell far below the standard which would be expected of a reasonably competent dentist. The Committee felt that your record keeping would be considered deplorable by a fellow practitioner, especially with respect to the patients who had received implant treatment, where continuity of care is particularly important. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -8/28-

9 The Committee then considered that you did not ensure that full and complete records were available at the practice after you sold it. When the new owners requested that you provide them with any records in your possession, you did not do so, claiming that you did not have any in your possession. This is particularly serious and at that time a patient was requesting copies of their dental records. The Committee reminded itself of your evidence that shortly after being contacted by the GDC regarding the complaint of Patient A, you shredded all of the records which were in your possession. The Committee considered this behaviour to be far below the standard which would be expected of a reasonably competent dentist and would be considered deplorable by a fellow practitioner. The Committee considered that your shredding of clinical records after being made aware of a GDC investigation and requests from the practice for the records raised an issue of personal integrity. Overall the Committee considered that your actions demonstrated a cavalier and casual attitude towards the importance of clinical records of patients which would be considered deplorable by a fellow practitioner. The Committee was satisfied that the failings found proved amount to misconduct. Impairment The Committee next considered whether your fitness to practice is currently impaired by reason of your misconduct. In reaching its decision on impairment, the Committee exercised its own independent judgement. It has borne in mind that its duty is to consider the public interest, which includes the protection of patients, the maintenance of public confidence in the profession and the declaring and upholding of proper standards of conduct and behaviour. The Committee concluded your failings overall, which include significant concerns regarding your radiographic and record keeping practises, amounts to Impairment. In reaching its decision the Committee considered that you have shown a lack of insight and a cavalier and casual attitude towards the importance of clinical records. The Committee considered that your clinical failing in regard to the design of the implantretained bridge and your radiographic practises are remediable. The Committee is not satisfied that there is evidence that there has been sufficient remediation in the area of radiographs. The Committee notes that you have started the remediation process, including attending a basic course on radiographic technique which the Committee understands is likely to have included hands on training in taking radiographs. The Committee has considered the evidence you have provided regarding the period after July 2014 when you resumed practicing. The Committee notes that the clinical log dated 27 November 2014 shows that you are now recording clinical justifications for taking radiographs. However the Committee notes your have not recorded an adequate report on the radiographs taken. The Committee also considered that your limited admissions and your oral evidence did not demonstrate insight into the extent of the problems with your radiographic practise. For example, while informing the Committee that you were now using a positioning tool, you were unable to provide the Committee with details about it. The Committee is satisfied that there is a likelihood of repetition given both the evidence referred to above and its concerns regarding your insight into the extent of your failings. The Committee then considered the design of the implant retained bridge. The Committee considered that this is a one off instance which occurred a long time ago. The Committee is satisfied that this failing is remediable and that there is a low likelihood of repetition. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -9/28-

10 The Committee then considered your failings regarding your record keeping practises. The Committee considers that failings regarding clinical records usually are remediable, but is not satisfied on the evidence before it, that you have remediated this failing. It notes you have completed just one course on record keeping. The Committee has considered the logs and audits which have been provided to it and the evidence of continuing professional development (CPD) courses attended. However it considers that further attendance of relevant CPD courses is necessary to fully remediate the paucity of the clinical records. In regards to your attitude the Committee considers that this is remediable but that it has not seen evidence to suggest that this is currently being remediated. The Committee considered that after the first failing of the computer and backup system, you did not do any checks to ensure that the second backup system was working to ensure that a similar loss of data would not occur in future. The Committee notes that there was a further loss of backup data in The Committee also considered that you gave insufficient explanation during your oral evidence of what your record keeping practise now involves and the Committee has concerns regarding inconsistencies in your oral evidence and the documentary evidence which has been provided regarding your current practices. The Committee notes that during your evidence you stated that you now use the Exact clinical records software. However the Committee notes that the records before it from the Log dated 27 November 2014 do not appear to by generated by the Exact software system with which this Committee is familiar. The Committee does not consider that there has been sufficient remediation regarding your attitude to maintaining patient records. The Committee considers that the removal of clinical records from the practice, not returning them when asked for and shredding them, demonstrates a complete lack of respect for the patients and their records and a deplorable lack of insight into their importance. Further the Committee considered that during these proceedings you have further shown a lack of insight into the importance of maintaining clinical records. In light of this the Committee is satisfied that there is a high likelihood of repetition with regards to these failings. The Committee considered the wider public interest, in particular the need to declare and uphold proper standards of conduct and behaviour, so as to maintain public confidence in the profession. The Committee considered the possibly serious effect of not having records to ensure continuity of care. The Committee also considered your actions in taking the records and not returning them when requested. In the circumstances of this case, the Committee considers that the public confidence in the profession would be undermined if a finding of impairment were not made. Having regard to all of these matters, including the wider public interest, the Committee has determined that your fitness to practice is currently impaired by reason of your misconduct. Sanction Having determined that your fitness to practise is currently impaired by reason of your misconduct, the Committee has considered what sanction, if any, to impose on your registration. It reminded itself that the purpose of a sanction is not to be punitive, but to protect patients and the wider public interest. The Committee has borne in mind the submissions made by both parties. Ms Hatt has submitted that appropriate and proportionate sanctions in this case would be conditions on your registration and suggested a number of conditions which might be appropriate. Mr Peacock submitted on your behalf that no restriction on your practice was necessary or, in the alternative, that limited conditions would be appropriate. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -10/28-

11 Given the serious attitudinal and clinical shortcomings in this case, which in the Committee s opinion have not been remediated, the Committee concluded that it would be insufficient to conclude this case by taking no action. For the same reasons the Committee determined that it would be inappropriate to conclude this case with a reprimand. The Committee next considered the imposition of conditions on your registration. The Committee considered the cavalier attitude you have demonstrated to the importance of clinical records and your actions in taking records from the practice, not returning them when requested and destroying them. The Committee considered that the imposition of conditions on your registration would not sufficiently address the wider public interest in this case to uphold the reputation of the profession and also to protect the public, given the serious implications for lack of continuity of care for patients who have received implant treatment. The Committee has considered the imposition of a suspension on your registration. The Committee considered the wider public interest and considered that the imposition of a suspension of 4 months is necessary and appropriate to mark the gravity of the Committee s concerns regarding your disregard for the importance of patient continuity of care, your lack of insight and your attitudinal failings. In considering the length of the suspension, the Committee has borne in mind that remediation is still necessary regarding the shortcomings in your clinical practice, that you will need time to demonstrate that you have remediated to a satisfactory standard and that you have embedded the remediation regarding your attitude to clinical records and radiographs. The Committee considered that a suspension of 4 months is appropriate and proportionate and that a longer period would be disproportionate. The Committee notes that it will provide you with sufficient time to reflect on your failings and undertake further steps towards appropriate remediation. While the Committee feels that it is necessary to impose a suspension on your registration in order to demonstrate the clear disapproval of your behaviour, the Committee felt that erasure would be disproportionate. The Committee has therefore decided to suspend your registration for a period of 4 months, and for the case to be reviewed prior to the end of the period of suspension. A Committee will review your case at a resumed hearing to be held shortly before the end of the period of suspension on your registration. That Committee will consider what action it should take in relation to your registration. You will be informed of the date and time of the resumed hearing, which you will be expected to attend. You will need to satisfy a future Committee that you have complied with the suspension on your registration and that you have addressed all of the concerns identified in this case. The Committee notes that a reviewing panel would be assisted by some or all of the following: Appropriate CPD and Personal Development Plan; A piece of reflective writing relating to this case. The interim order relating to your registration is now revoked in accordance with Section 27B(9) of the Dentists Act The Committee now invites submissions from both parties as to whether the suspension should be imposed on your registration immediately. The Committee considered the submissions by Ms Hatt on behalf of the GDC and Mr Peacock on your behalf. It has accepted the advice of the Legal Adviser. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -11/28-

12 Bearing in mind its findings of fact, the Committee has determined that it is necessary, for the protection of the public and is otherwise in the public interest to impose an order for immediate suspension of your registration. This order is made on the basis of the extensive and serious deficiencies that it has identified in your practice. In regards to the submission made by Mr Peacock, on your behalf, the Committee feels that it would be inappropriate to impose an immediate order for conditions rather than an order for immediate suspension. To let a dentist continue to practise because the dentist has not made provision for the care of his existing patients would be wrong in principle, particularly bearing in mind the length of these fitness to practise proceedings. In view of the Committee s findings, it finds it necessary to impose an immediate order of suspension. The effect of the foregoing direction and this Order is that your registration will be suspended forthwith and unless you exercise your right to appeal, the substantive direction will take effect 28 days from today. Should you exercise your right of appeal, this Order for immediate suspension may remain in place pending the resolution of any appeal proceedings. That concludes the case for today. At a review hearing on 7 May 2015, the Chairman announced the determination as follows: Mr Hanna, The Committee has carefully considered the submissions from Ms Price on behalf of the General Dental Council ( GDC ) and those from Mr Peacock on your behalf. It has read and considered the papers provided to it by both parties and has heard and accepted the advice from Legal Adviser in reaching its decisions. By way of background, on 16 January 2015 a suspension order for 4 months was imposed upon your registration by a Professional Conduct Committee after a 5-day hearing. During that hearing, your fitness to practise was found to be impaired based on a broad array of deficiencies identified in your practice. Those deficiencies related to your use of a poorly designed implant-retained bridge, poor quality radiographs, and inadequate record keeping of implant treatment you provided as well as a failure to disclose patient records when requested to do so. The last Committee also found that after receiving a request to disclose patient records, you shredded them, and this had serious implications for the patients. In imposing the suspension order, the last Committee noted your attitudinal failings and a lack of insight into your misconduct. This hearing is held to review the suspension order, which is currently due to expire on 12 June The Committee first considered whether your fitness to practise remains currently impaired. The last Committee, when imposing a suspension order of 4 months duration, made mention that the next Committee may benefit from evidence of your continuing professional development ( CPD ) and a personal development plan ( PDP ). The Committee carefully examined the documents provided to it by Mr Peacock on your behalf. Much of the content pre-dated the findings of the Committee in January Whilst this material is an encouraging sign of your intention to remedy the deficiencies identified in your practice, the Committee has placed limited weight on that particular material. The Committee also read the CPD gained during April Whilst the Committee noted that these targeted the areas of concern in your practice, it was of the view that your recent CPD HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -12/28-

13 did not demonstrate a sufficiently comprehensive approach to addressing the failings in your practice. For example, the on-line CPD courses appear to have been completed during April only. Further, your PDP dated 6 May 2015 is limited in its breadth. The Committee notes that your efforts have been fettered by your suspension from the register, as you state that you cannot attend a hands on course because of your suspension. The Committee has concluded that you have not yet had an opportunity to apply your learning, or to demonstrate that it has become embedded, in your day-to-day practice. The Committee notes Mr Peacock s earlier submission that English is not your first language. In spite of this, the Committee was of the view that your reflective statement does not show sufficient remorse or understanding, of the risks you caused to patients, to enable it to conclude that you have gained full insight. Accordingly, the Committee is not satisfied that the deficiencies in your practice have been remedied, and your fitness to practise remains currently impaired. Having found impairment, the Committee next considered what sanction, if any, should be applied in this case. The Committee first considered whether conditions could be formed which, as well as being workable, practicable and measurable, could address the Committee s concerns. The Committee noted that you are a sole practitioner and therefore do not have the benefit of an easily accessible support network of peer dentists in your immediate working environment. The Committee did however note that both Ms Price for the GDC and Mr Peacock on your behalf agreed that, if a sanction was to be imposed, conditions would be appropriate and proportionate in your case. Although attitudinal deficiencies can be difficult to remedy with such measures as online CPD, the Committee was of the view that engagement with your dental peers and the development of a relationship with a Postgraduate Dental Dean could provide you with an appropriate degree of insight. Accordingly, the Committee has determined to replace the suspension order with conditions of practice upon your registration for a period of 6 months, with a review prior to the expiry of the order period. The order for conditions will come into effect upon the expiry of the current suspension order. The conditions that shall appear against the name of Paulo Adel Hanna in the Dentists Register are as follows: 1. He must notify the General Dental Council ( GDC ) within seven days of any professional appointment he accepts and provide the contact details of his employer or any organisation for which he is contracted to provide dental services and the Commissioning Body on whose Dental Performers List he is included or Local Health Board if in Wales, Scotland or Northern Ireland. 2. He must allow the GDC to exchange information with his employer or any organisation for which he is contracted to provide dental services, and the workplace supervisor referred to in these conditions. 3. He must work with a Postgraduate Dental Dean / Director (or a nominated deputy), to formulate a Personal Development Plan ( PDP ), specifically designed to address the deficiencies in the following areas of his practice: a. record keeping; b. radiography; and HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -13/28-

14 c. core continuing professional development ( CPD ) requirements. 4. He must forward a copy of his PDP to the GDC at least one month prior to the review hearing. 5. He must arrange to meet with the Postgraduate Dental Dean / Director (or a nominated deputy), on a regular basis to discuss his progress towards achieving the aims set out in his PDP. The frequency of his meetings is to be set by the Postgraduate Dental Dean/Director (or a nominated deputy). 6. He must allow the GDC to exchange information about the standard of his professional performance and his progress towards achieving the aims set out in his PDP with the Postgraduate Dental Dean/Director (or a nominated deputy), and any other person involved in his retraining and supervision. 7. At any time he is providing dental services which require him to be registered with the GDC, he must appoint and remain under the supervision of a workplace supervisor nominated by him and approved by the GDC. The workplace supervisor shall also act as a reporter. The workplace supervisor shall be a GDC registrant throughout the period of supervision. 8. He must allow his workplace supervisor to provide reports to the GDC regarding his record keeping at intervals of not more than three months, and at least one month prior to the hearing. 9. If he undertakes implant treatment he must maintain a detailed clinical log of all cases to be provided to the GDC, and to his workplace supervisor at monthly intervals. 10. On his return to clinical practice, he shall carry out a monthly audit of his record keeping and radiography. This audit must be signed by his workplace supervisor. 11. He must provide copies of this audit to the GDC at least one month prior to the review hearing. 12. He must inform the GDC of any formal disciplinary proceedings taken against him, from the date of this determination. 13. He must inform promptly the following parties that his registration is subject to the conditions, listed above: a. any organisation or person employing or contracting with him to undertake dental work; b. any locum agency or out-of-hours service he is registered with or applies to be registered with (at the time of application); c. any prospective employer (at the time of application); and, d. the Commissioning Body on whose Dental Performers List he is included or seeking inclusion, or Local Health Board if in Wales, Scotland or Northern Ireland (at the time of application). 14. He must permit the GDC to disclose the above conditions to any person requesting information about his registration status. That concludes this case. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -14/28-

15 At a review hearing on 4 December 2015, the Chairman announced the determination as follows: Ms French: You are representing the General Dental Council (GDC) at today s review hearing. Mr Hanna is neither present nor represented today. In his absence, the Committee first considered whether the Notice of Resumed Hearing had been served on Mr Hanna in accordance with Rule 28 of the General Dental Council (Fitness to Practise) (GDC) Rules Order of Council 2006 (the Rules). The Committee has received a bundle of documents which contains a copy of the Notice of Resumed Hearing dated 18 September 2015 which was sent to Mr Hanna s registered address by recorded delivery. This letter sets out the information required in accordance with Rule 28. The Royal Mail track and trace receipt states that the item was delivered back to sender on 22 September 2015 as the recipient refused to receive the item. Notwithstanding the fact that the item was delivered back to the Royal Mail, the Committee has, however, seen a copy of a letter dated 1 December 2015 from Berrymans Lace Mawer (BLM) Solicitors to the GDC in which they refer to today s hearing. BLM confirm that neither Mr Hanna nor a representative from BLM will be attending the hearing. In these circumstances, the Committee is satisfied that the GDC has complied with Rule 28. The Committee then went on to consider whether to proceed in the absence of Mr Hanna, in accordance with Rule 54. You referred to the letter dated 1 December 2015 from BLM to the GDC which confirms that Mr Hanna will not be attending or be represented at this hearing. The letter further asks the Committee to consider the submissions set out in the letter on behalf of Mr Hanna. You submit that Mr Hanna has voluntarily absented himself from these proceedings and that it would be appropriate to proceed in his absence. You also informed the Committee that the current order is due to expire on 12 December You therefore submitted that there is a public interest in reviewing the order today given its imminent expiry. The Committee has considered the submissions you have made. It has accepted the advice of the Legal Adviser. The Committee notes the reasons for Mr Hanna s non-attendance at today s hearing, as set out in the letter from BLM dated 1 December It is clear from the letter that BLM have not requested an adjournment on behalf of their client and they are anticipating that the hearing will proceed today in the absence of Mr Hanna. In addition, the Committee considers that it is in the public interest to hear this case before the current order expires shortly. Taking all these factors into account, the Committee has determined to proceed with today s review hearing in the absence of Mr Hanna. This is a second review hearing of Mr Hanna s case, which is being considered pursuant to Section 27(C) of the Dentists Act Mr Hanna s case was first considered by the Professional Conduct Committee (PCC) in January 2015 when it found that his fitness to practise was impaired by reason of misconduct and directed that Mr Hanna s registration be subject to a four month suspension order. The PCC reviewed the suspension order on 7 May 2015 and determined to replace the suspension order with a six month order for conditional registration. At the hearing in January 2015 the PCC determined that Mr Hanna s fitness to practise was impaired based on a broad array of deficiencies identified in his practice. The deficiencies included his provision of a poorly designed implant-retained bridge, the taking of poor quality radiographs, inadequate record keeping of implant treatment he provided as well as a failure to disclose patient records when requested to do so, and actually destroying them. The PCC did not consider that there had been sufficient remediation regarding Mr Hanna s attitude towards maintaining patient records. In imposing the suspension order, the PCC in January 2015 had concerns regarding Mr Hanna s attitudinal failings and his lack of insight into the HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -15/28-

16 misconduct. It indicated that in reviewing the suspension order, the PCC might benefit from evidence of Mr Hanna s continuing professional development (CPD) and a personal development plan (PDP). The PCC reviewed the order on 7 May In so doing, it had regard to the documents provided on behalf of Mr Hanna. However, the PCC was concerned that much of this material pre-dated the PCC s findings in January 2015 and was of limited value. In respect of the CPD gained during April 2015, the PCC was of the view that this material did not demonstrate a sufficiently comprehensive approach to addressing the failings in Mr Hanna s practice. The Committee concluded that Mr Hanna did not show sufficient remorse or insight and considered that his PDP, dated 6 May 2015, was limited in its breadth. The PCC concluded that Mr Hanna had not yet had an opportunity to apply his learning, or to demonstrate that it had become embedded in his day-to-day practice. The PCC was not satisfied that the deficiencies in Mr Hanna s practice had been remedied, and concluded that his fitness to practise remained impaired. The PCC determined to replace the suspension order with one of conditions of practice for a period of 6 months, with a review prior to the expiry of the order period. This included a requirement (condition 3) that Mr Hanna must work with a Postgraduate Dental Dean to formulate a PDP specifically designed to address the deficiencies in the following areas of his practice: record keeping, radiography and core CPD requirements. At today s hearing this Committee has comprehensively reviewed the current order. In so doing, the Committee has had regard to the bundle of documents before it, including the written representations made by BLM on behalf of Mr Hanna. It has also had regard to the submissions you have made on behalf of the GDC. The Committee notes the exchange of correspondence between the GDC and BLM following the hearing in May In BLM s letter dated 10 July 2015 they state that since the imposition of those conditions, Mr Hanna has not returned to clinical practice and therefore some of the conditions have not been engaged. It states that Mr Hanna is presently searching for a job and BLM confirmed that it will advise the GDC of any new professional appointment, in accordance with Mr Hanna s conditions. In their letter dated 30 September 2015 BLM advised the GDC of Mr Hanna s request for Voluntary Removal (VR) from the Register. Attached with that letter was a signed application for VR. The letter also set out the decline in Mr Hanna s health, which BLM say, is a compelling reason in itself for the Registrar to grant VR. The letter states that Mr Hanna has not worked since January You informed the Committee that the Registrar considered Mr Hanna s application for VR earlier this week but refused it. This was on the basis that there is an outstanding complaint to be considered at a PCC hearing as well as two separate matters which are being referred to the Investigating Committee (IC). You also informed the Committee that Mr Hanna has given his consent to undergo an assessment of his health as part of the GDC s fitness to practise proceedings. The Committee has had regard to the recent observations made by BLM in their letter of 1 December They confirm that Mr Hanna has not been working since his suspension in January They also set out the deterioration in Mr Hanna s health, as well as his agreement to undergo a formal GDC health assessment. You have invited the Committee to conclude that Mr Hanna s fitness to practise remains impaired given the absence of any evidence of remediation. You also invited the Committee to extend the current period of conditional registration for a period of six months. BLM, in HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -16/28-

17 their letter of 1 December 2015, accept that Mr Hanna is still impaired and concurred with the GDC s position to extend the current period of conditional registration for a period of six months. The Committee notes that Mr Hanna has not been working in a clinical role since January Therefore, there is no evidence of remediation before it, such as any evidence of his work with a Postgraduate Dental Dean in formulating a copy of his PDP, or a report from a workplace supervisor or evidence of any audits. This Committee is therefore in exactly the same position as the PCC was in May It is not satisfied that the deficiencies in Mr Hanna s practice have been remedied and therefore it has concluded that his fitness to practise remains impaired. The Committee next considered what direction to give, bearing in mind its powers in accordance with Section 27C(2) of the Dentists Act Both parties have invited the Committee to extend the current period of conditional registration, with no suggestion that Mr Hanna has not complied with the order. The Committee considers that conditions are sufficient for the protection of the public and are in the wider public interest to address the concerns identified in this case. Accordingly, the Committee directs that the current period of conditional registration be extended for a period of 6 months, with a review prior to the expiry of the order period. The conditions, which remain unaltered, that shall appear against the name of Paulo Adel Hanna in the Dentists Register are as follows: 1. He must notify the General Dental Council (GDC) within seven days of any professional appointment he accepts and provide the contact details of his employer or any organisation for which he is contracted to provide dental services and the Commissioning Body on whose Dental Performers List he is included or Local Health Board if in Wales, Scotland or Northern Ireland. 2. He must allow the GDC to exchange information with his employer or any organisation for which he is contracted to provide dental services, and the workplace supervisor referred to in these conditions. 3. He must work with a Postgraduate Dental Dean/Director (or a nominated deputy), to formulate a Personal Development Plan (PDP), specifically designed to address the deficiencies in the following areas of his practice: a. record keeping; b. radiography; and c. core continuing professional development (CPD) requirements. 4. He must forward a copy of his PDP to the GDC at least one month prior to the review hearing. 5. He must arrange to meet with the Postgraduate Dental Dean / Director (or a nominated deputy), on a regular basis to discuss his progress towards achieving the aims set out in his PDP. The frequency of his meetings is to be set by the Postgraduate Dental Dean/Director (or a nominated deputy). 6. He must allow the GDC to exchange information about the standard of his professional performance and his progress towards achieving the aims set out in his PDP with the Postgraduate Dental Dean/Director (or a nominated deputy), and any other person involved in his retraining and supervision. HANNA, P A Professional Conduct Committee Jan 2015 Dec 2017 Page -17/28-