HEARING PARTLY HEARD IN PRIVATE* BARRIE, Charles Orr

BARRIE C O Professional Conduct Committee – April 2021 Page -1/56-

HEARING PARTLY HEARD IN PRIVATE* The Committee has made a determination in this case that includes some private

information. That information has been omitted from the text. BARRIE, Charles Orr

Registration No: 57632 PROFESSIONAL CONDUCT COMMITTEE

April 2021 Outcome: Conditions imposed with immediate conditions (with a review)

BARRIE, Charles Orr, a dentist, BDS University of Edinburgh 1983, was summoned to appear before the Professional Conduct Committee on 12 April 2021 for an inquiry into the following charge: Charge

“That, being a registered dentist: 1. At all material times you practised as a dentist at the practice identified in

Schedule1; Conduct 2. You acted in an inappropriate and/or threatening manner with colleagues in

that: a. On or around 29 August 2017 you telephoned the practice and said to

Colleague A (as identified in Schedule 2) words to the effect of, “That’s really shit of [Colleague B] (as identified in Schedule 2), to cancel my patients and not tell me, so I will be in tomorrow to kick [Colleague B’s] ass, so get lots of towels ready because there will be a lot of blood”;

b. On 15 November 2017 at a practice meeting you said words to the effect that you would “beat the shit” or “knock the shit” out of anyone who discussed your suspension outside the meeting:

Patient 1 3. You were consulted in relation to dental treatment by Patient 1, as identified in

Schedule 3, on and between 5 September 2013 and 13 February 2017; 4. Your standard of care and/or your standard of record keeping was inadequate

in that: a. Following examination on 15 February 2016 you did not diagnose and/or

treat caries at LL7 adequately or at all; b. On or after 13 May 2016 you made no diagnosis in light of the patient’s

complaint of pain, or you made no or no adequate record of any such diagnosis:

5. Your standard of record keeping was inadequate in that:

1 All Schedules are private documents which cannot be disclosed.


a. You made no or no adequate clinical record for the consultation on 5 April 2016;

b. You made no or no adequate report on the periapical radiograph taken on 13 May 2016;


Schedule 3, on and between 16 May 2005 and 12 June 2017; 7. Your standard of record keeping was inadequate in that:

a. You did not ensure that the patient’s medical history record was updated on any or all of the following dates: i. 10 February 2010; ii. 19 October 2010;

iii. 9 June 2011; iv. 8 August 2011;

b. You made no or no adequate record of any assessment of the occlusion made during examination on any or all of the following dates:

i. 10 February 2010; ii. 19 October 2010; iii. 9 June 2011; iv. 5 March 2012;

v. 21 August 2012; c. You made no or no adequate record of any basic periodontal examination

(BPE) carried out on any or all of the following dates: i. 19 October 2010;

ii. 9 June 2011; iii. 8 August 2011; iv. 5 March 2012; v. 21 August 2012;

vi. 28 February 2013; d. You made no or no adequate report on the periapical radiograph taken on

9 June 2011; Patient 3 8. You were consulted in relation to dental treatment by Patient 3, as identified in

Schedule 3, on and between 17 February 2016 and 6 January 2017; 9. Your standard of care and/or your standard or record keeping was inadequate

on 8 April 2016 in that:


a. You did not carry out six-point pocket charting when it was indicated to do so, or you made no or no adequate record of any six-point pocket charting carried out;

b. You did not diagnose periodontal disease, or you made no or no adequate record of any diagnosis of periodontal disease;

c. You did not discuss the periodontal condition with the patient adequately or at all, or you made no or no adequate record of any such discussion;

10. Your standard of care or your standard or record keeping was inadequate on 11 April 2016 in that you did not use a rubber dam during root canal treatment on UL1, or you made no or no adequate record in respect of the use of a rubber dam;

11. Your standard of care and/or your standard or record keeping was inadequate on 14 November 2016 in that: a. You did not discuss the diagnosis of periodontal disease with the patient

adequately or at all, or you made no or no adequate record of any such discussion;

b. You did not discuss oral hygiene with the patient adequately or at all, or you made no or no adequate record of any such discussion;

12. Your standard of record keeping was inadequate in that you made no or no adequate clinical record for the consultation on 17 February 2016;

13. Your standard of care was inadequate in that you did not carry out any basic periodontal examination (BPE) on 6 January 2017 when it was indicated to do so;


Schedule 3, on and between 15 February 2003 and 25 November 2016; 15. Your standard of care or your standard of record keeping was inadequate on 17

June 2015 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication;

16. Your standard of care was inadequate on or after 17 June 2015 in that you did not treat caries at UL3 when it was indicated to do so;

17. Your standard of care and/or your standard of record keeping was inadequate on 6 July 2016 in that: a. You did not discuss adequately or at all the risks and benefits of the

proposed bridge work, or you made no or no adequate record of any such discussion;

b. You did not discuss adequately or at all alternative options to the proposed bridge work, or you made no or no adequate record of any such discussion;

c. You did not obtain informed consent to the proposed bridge work; 18. Your standard of care and/or your standard of record keeping was inadequate

on 4 October 2016 in that:


a. You did not discuss adequately or at all the risks and benefits of the proposed bridge work, or you made no or no adequate record of any such discussion;

b. You did not discuss adequately or at all alternative options to the proposed bridge work, or you made no or no adequate record of any such discussion;

c. You did not obtain informed consent to the proposed bridge work; d. You did not use a rubber dam during root canal treatment on UL2 and

UR2, or you made no or no adequate record in respect of the use of a rubber dam;

19. Your standard of care and/or your standard of record keeping was inadequate on 26 October 2016 in that: a. You did not discuss adequately or at all the risks and benefits of the

proposed bridge work, or you made no or no adequate record of any such discussion;

b. You did not discuss adequately or at all the alternative options to the proposed bridge work, or you made no or no adequate record of any such discussion;

c. You did not obtain informed consent to the proposed bridge work; d. You did not carry out any basic periodontal examination (BPE) when it

was indicated to do so; 20. Your standard of record keeping was inadequate on 14 November 2016 in that

you made no or no adequate report on the periapical radiographs taken of UL2 and UR2;


Schedule 3, on and between 17 June 2003 and 7 June 2017; 22. Your standard of care was inadequate in that you did not carry out any basic

periodontal examination (BPE) on any or all of the following dates when it was indicated to do so:

i. 4 January 2010; ii. 11 January 2011;

iii. 20 September 2016; iv. 20 March 2017;


Schedule 3, on and between 14 February 2003 and 8 June 2017; 24. Your standard of care and/or your standard of record keeping was inadequate

on 12 April 2010 in that: a. You made no or no adequate report on the radiograph taken of LR6;


b. You reached no diagnosis in light of a complaint of pain in the lower right of the patient’s mouth, or you made no or no adequate record of any diagnosis;

25. Your standard of care and/or your standard of record keeping was inadequate on 10 September 2010 in that: a. You did not ensure any bitewing radiograph was taken when it was

indicated to do so, or you made no or no adequate record in relation to your decision making in respect of the taking of bitewing radiographs;

b. You did not carry out a soft tissue examination when it was indicated to do so, or you made no or no adequate record of any soft tissue examination carried out;

c. You did not carry out any basic periodontal examination (BPE) when it was indicated to do so;

d. You did not update the patient’s medical history record when it was indicated to do so, or you made no or no adequate record in respect of the patient’s medical history;

26. Your standard of care and/or your standard of record keeping was inadequate on 25 May 2011 in that: a. You did not ensure any bitewing radiograph was taken when it was

indicated to do so or you made no or no adequate record in relation to your decision making in respect of the taking of bitewing radiographs;

b. You did not carry out any basic periodontal examination (BPE) when it was indicated to do so;

c. You did not update the patient’s medical history record when it was indicated to do so, or you made no or no adequate record in respect of the patient’s medical history;

27. Your standard of care or your standard of record keeping was inadequate on 29 May 2012 in that you did not ensure any bitewing radiograph was taken when it was indicated to do so, or you made no or no adequate record in relation to your decision making in respect of the taking of bitewing radiographs;

28. Your standard of care and/or your standard of record keeping was inadequate on 2 January 2013 in that you did not use a rubber dam during root canal treatment on LR6, or you made no or no adequate record in respect of the use of a rubber dam;

29. Your standard of record keeping was inadequate on 8 June 2017 in that you did not correctly record the level of the patient’s caries risk;

Patient 7 30. You were consulted in relation to dental treatment by Patient 7, as identified, in

Schedule 3 on and between 30 March 2004 and 5 June 2017; 31. Your standard of care and/or your standard of record keeping was inadequate

on 5 June 2017 in that: a. You did not investigate adequately or at all the periodontal condition of the

patient, or you made no or no adequate record of any such investigation;


b. You did not diagnose periodontal disease, or you made no or no adequate record of any diagnosis of periodontal disease;

c. You did not discuss periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion;

d. You did not correctly assess the level of the patient’s periodontal risk; e. You did not treat the periodontal disease; f. You did not correctly assess the level of the patient’s caries risk; g. You did not report adequately or at all on the bone loss at any or all of the

following teeth: i. UR7; ii. UR3; iii. LL6;

iv. LR5; v. LR6; vi. LR7; h. You did not discuss adequately or at all the risks of not treating the

mobile LL8, or you made no or no adequate record of any such discussion;

i. You did not discuss adequately or at all the risks of not treating the mobile UL8, or you made no or no adequate record of any such discussion;

j. You did not discuss adequately or at all the risks of not treating the caries at LR5, or you made no or no adequate record of any such discussion;


Schedule 3, on and between 7 August 2003 and 15 March 2016; 33. Your standard of care and/or your standard or record keeping was inadequate

on 7 October 2015 in that: a. You did not carry out six-point pocket charting when it was indicated to do

so, or you made no or no adequate record in respect of six-point pocket charting;

b. You did not carry out root surface debridement when it was indicated to do so, or you made no or no adequate record in respect of root surface debridement;

c. You made no or no adequate plan for the treatment of caries at LL6 when it was indicated to do so, or you made no or no adequate record in relation to your treatment planning;

34. Your standard of care and/or your standard or record keeping was inadequate on 18 May 2016 in that:


a. You did not carry out six-point pocket charting in the LR sextant when it was indicated to do so, or you made no or no adequate record of any six- point pocket charting carried out;

b. You did not carry out root surface debridement in the LR sextant when it was indicated to do so, or you made no or no adequate record of any root surface debridement carried out;

35. Your standard of care and/or your standard or record keeping was inadequate on 6 January 2017 in that: a. You did not carry out any basic periodontal examination (BPE) when it

was indicated to do so; b. You made no assessment of the patient’s periodontal condition when it

was indicated to do so, or you made no or no adequate record of any such assessment;

36. Your standard of care and/or your standard or record keeping was inadequate on 15 March 2017 in that: a. You did not discuss with the patient adequately or at all the risks and

benefits of the bridge treatment proposed, or you made no or no adequate record of any such discussion;

b. You did not discuss with the patient adequately or at all alternative options to the treatment proposed, or you made no or no adequate record of any such discussion;

c. You did not obtain informed consent to the proposed bridge work; Patient 9 37. You were consulted in relation to dental treatment by Patient 9, as identified in

Schedule 3, on and between 8 April 2008 and 5 June 2017; 38. Your standard of care and/or your standard or record keeping was inadequate

on 5 June 2017 in that: a. You did not ensure any bitewing radiographs were taken when it was

indicated to do so, or you made no or no adequate record in relation to your decision making in respect of the taking of bitewing radiographs;

b. You did not diagnose caries at LL6, or you made no or no adequate record of any diagnosis of caries;

c. You made no or no adequate plan for the treatment of caries at LL6 when it was indicated to do so, or you made no or no adequate record in relation to your treatment planning;

d. You did not apply fluoride varnish when it was indicated to do so, or you made no or no adequate record in relation to your decision in respect of fluoride varnish application;

e. You did not correctly assess the level of the patient’s caries risk; Patient 10 39. You were consulted in relation to dental treatment by Patient 10, as identified in

Schedule 3, on and between 14 July 2003 and 17 May 2017;


40. Your standard of care and/or your standard or record keeping was inadequate on 13 May 2011 in that: a. You made no or no adequate report on the periapical radiograph taken of

LL5; b. You did not discuss with the patient adequately or at all the risks and

benefits of the bridge treatment proposed to replace LL5, or you made no or no adequate record of any such discussion;

c. You did not discuss with the patient adequately or at all alternative options to the bridge treatment proposed, or you made no or no adequate record of any such discussion;

d. You did not obtain informed consent to the treatment proposed; e. You did not carry out any basic periodontal examination (BPE) when it

was indicated to do so; 41. Your standard of care and/or your standard or record keeping was inadequate

on 17 November 2015 in that: a. You made no or no adequate report on the periapical radiographs taken

during root canal treatment; b. You did not use a rubber dam during root canal treatment on UR3, or you

made no or no adequate record in respect of the use of a rubber dam; 42. Your standard of care or your standard or record keeping was inadequate on 2

December 2015 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication;

43. Your standard of care or your standard or record keeping was inadequate on 13 April 2016 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication;

44. Your standard of care and/or your standard or record keeping was inadequate on 9 May 2016 in that: a. You did not use a rubber dam during root canal treatment on LL3, or you

made no or no adequate record in respect of the use of a rubber dam; b. You made no or no adequate report on the periapical radiograph taken of

LL3; 45. Your standard of care and/or your standard or record keeping was inadequate

on 18 November 2016 in that: a. You did not take a pre-operative periapical radiograph of LL4 before

commencing bridge preparation; b. You did not discuss with the patient adequately or at all the risks and

benefits of the bridge treatment proposed to replace LL4, or you made no or no adequate record of any such discussion;

c. You did not discuss with the patient adequately or at all alternative options to the bridge treatment proposed, or you made no or no adequate record of any such discussion;

d. You did not obtain informed consent to the treatment proposed;


46. Your standard of care was inadequate in that you did not carry out and/or record any or any adequate basic periodontal examination (BPE) on any or all of the following dates when it was indicated to do so:

i. 12 August 2011;

ii. 28 February 2013; iii. 1 June 2015; iv. 2 December 2015; v. 12 September 2016;


Schedule 3 on and between 2 August 2016 and 16 August 2016; 48. Your standard of care or your standard of record keeping was inadequate on 2

August 2016 in that you did not diagnose caries at UL6, or you made no or no adequate record of any diagnosis;


Schedule 3, on and between 21 January 2005 and 10 March 2017; 50. Your standard of care and/or your standard of record keeping was inadequate

on 18 November 2015 in that: a. You did not correctly assess the level of the patient’s periodontal risk; b. You made no or no adequate report on the periapical radiograph taken of

UL5; c. You did not diagnose caries at UL6, or you made no or no adequate

record of any diagnosis of caries at UL6; 51. Your standard of care and/or your standard of record keeping was inadequate

on 11 January 2017 in that: a. You did not correctly assess the level of the patient’s periodontal risk; b. You did not correctly assess the level of the patient’s caries risk; c. You did not diagnose caries at UL6, or you made no or no adequate

record of any diagnosis of caries at UL6; d. You did not carry out six-point pocket charting when it was indicated to do

so, or you made no or no adequate record in relation to six-point pocket charting;

e. You did not discuss periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion;


Schedule 3, on and between 9 April 2003 and 12 January 2017; 53. Your standard of care and/or your standard of record keeping was inadequate

on 4 November 2015 in that:


a. You made no or no adequate assessment of UL4, or you made no or no adequate record of any such assessment;

b. You did not discuss with the patient adequately or at all the options for treatment of UL4, or you made no or no adequate record of any such discussion;

c. You prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication;

d. You did not either extirpate or extract UL4 when it was indicated to do so, or you made no or no adequate record of the decision in respect of UL4;

54. Your standard of care and/or your standard of record keeping was inadequate on 12 October 2016 in that: a. You recorded scores for the basic periodontal examination (BPE) which

did not match your recorded observations; b. You did not diagnose caries at UR7, or you made no or no adequate

record of any diagnosis of caries at UR7; c. You did not diagnose caries at UL7, or you made no or no adequate

record of any diagnosis of caries at UL7; 55. Your standard of care and/or your standard of record keeping was inadequate

on 25 November 2016 in that: a. You made no assessment of UR4, or you made no or no adequate record

of any such assessment; b. You did not discuss with the patient adequately or at all the options for

treatment of UR4, or you made no or no adequate record of any such discussion;

c. You prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication;

56. Your standard of care and/or your standard of record keeping was inadequate on 12 January 2017 in that: a. You did not take a pre-operative periapical radiograph of UR4 before

commencing root canal treatment; b. You did not use a rubber dam during root canal treatment on UR4 or you

made no or no adequate record in respect of the use of a rubber dam;


Schedule 3, on and between 20 January 2003 and 11 January 2017; 58. Your standard of care and/or your standard of record keeping was inadequate

on 20 October 2016 in that: a. You did not discuss with the patient adequately or at all the options for

treatment of UL6, or you made no or no adequate record of any such discussion;


b. You did not discuss with the patient adequately or at all the risks and benefits of the root canal treatment proposed at UL6, or you made no or no adequate record of any such discussion;

59. Your standard of care or your standard of record keeping was inadequate on 8 December 2016 in that you did not use a rubber dam during root canal treatment on UL5 and UL6, or you made no or no adequate record in respect of the use of a rubber dam;

60. Your standard of care and/or your standard of record keeping was inadequate on 20 December 2016 in that: a. You made no or no adequate record in respect of the working lengths during root

canal treatment for UL5 and UL6; b. You did not use a rubber dam during root canal treatment on UL5 and UL6, or

you made no or no adequate record in respect of the use of a rubber dam; 61. Your standard of care and/or your standard of record keeping was inadequate on 28

December 2016 in that: a. You made no or no adequate record in respect of the working lengths during root

canal treatment for UL5 and UL6; b. You did not use a rubber dam during root canal treatment on UL5 and UL6, or

you made no or no adequate record in respect of the use of a rubber dam; 62. Your standard of care and/or your standard of record keeping was inadequate on or

after 28 December 2016 in that: a. You did not ensure that a post-operative periapical radiograph was taken after

completion of root canal treatment of UL5 and UL6 prior to preparing for a crown; b. You did not discuss with the patient adequately or at all the implications of

perforation, or you made no or no adequate record of any such discussion; Patient 16 63. You were consulted in relation to dental treatment by Patient 16, as identified in

Schedule 3, on and between 19 August 2003 and 17 March 2017; 64. Your standard of care and/or your standard of record keeping was inadequate on 20

May 2016 in that: a. You recorded scores for the basic periodontal examination (BPE) which were not

consistent with the radiographic evidence; b. You did not carry out six-point pocket charting when it was indicated to do so, or

you made no or no adequate record in respect of six-point pocket charting; c. You did not assess adequately or at all the periodontal condition of the patient, or

you made no or no adequate record of any such assessment; d. You did not diagnose periodontal disease, or you made no or no adequate

record of any diagnosis of periodontal disease; e. You did not discuss periodontal disease with the patient adequately or at all, or

you made no or no adequate record of any such discussion;


f. You did not adequately treat the periodontal disease; g. You did not correctly assess the level of the patient’s periodontal risk;

65. Your standard of care and/or your standard of record keeping was inadequate on 21 November 2016 in that: a. You did not carry out six-point pocket charting when it was indicated to do so, or

you made no or no adequate record in respect of six-point pocket charting; b. You did not carry out root surface debridement when it was indicated to do so, or

you made no or no adequate record in respect of root surface debridement; c. You did not discuss periodontal disease with the patient adequately or at all, or

you made no or no adequate record of any such discussion; d. You did not adequately treat the periodontal disease; e. You did not correctly assess the level of the patient’s periodontal risk;


Schedule 3, on and between 30 December 2016 and 9 March 2017; 67. Your standard of care and/or your standard of record keeping was inadequate on 30

December 2016 in that: a. You did not take a pre-operative periapical radiograph of UR6 before

commencing root canal treatment; b. You did not use a rubber dam during root canal treatment on UR6, or you made

no or no adequate record in respect of the use of a rubber dam; 68. Your standard of care or your standard of record keeping was inadequate on 11

January 2017 in that you did not use a rubber dam during root canal treatment onUR6, or you made no or no adequate record in respect of the use of a rubber dam;

69. Your standard of care and/or your standard of record keeping was inadequate on 13 February 2017 in that: a. You did not use a rubber dam during root canal treatment on UR6, or you made

no or no adequate record in respect of the use of a rubber dam; b. You prescribed antibiotics when it was not indicated to do so, or you made no or

no adequate record of any such indication; 70. Your standard of care or your standard of record keeping was inadequate on 3 March

2017 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication;

71. Your standard of care and/or your standard of record keeping was inadequate on 9 March 2017 in that: a. You did not use a rubber dam during root canal treatment on UR6, or you made

no or no adequate record in respect of the use of a rubber dam;


b. You did not verify adequately or at all the working length measurement taken during root canal treatment, or you made no or no adequate record of the verification;


Schedule 3, on and between 23 May 2015 and 20 March 2017; 73. Your standard of care and/or your standard of record keeping was inadequate on 15

July 2015 in that:

a. You did not ensure that the patient’s medical history record was updated; b. You did not carry out a soft tissue examination when it was indicated to do so, or

you made no or no adequate record in respect of any soft tissue examination; c. You did not carry out any basic periodontal examination (BPE) when it was

indicated to do so; 74. Your standard of care and/or your standard of record keeping was inadequate on 8

June 2016 in that: a. You did not diagnose caries at UL3, or you made no or no adequate record of

any diagnosis of caries at UL3; b. You did not ensure that the patient’s medical history record was updated; c. You did not ensure that the patient’s medical history record was updated; you did

not carry out a soft tissue examination when it was indicated to do so, or you made no or no adequate record in respect of any soft tissue examination;

d. You did not carry out any basic periodontal examination (BPE) when it was indicated to do so;


Schedule 3, on and between 11 April 2003 and 12 April 2017; 76. Your standard of care or your standard of record keeping was inadequate on 13 April

2012 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication;

77. Your standard of care or your standard of record keeping was inadequate on 1 June 2012 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication;

78. Your standard of care and/or your standard of record keeping was inadequate on 7 June 2012 in that: a. You made no or no adequate report on the periapical radiograph taken; b. You did not use a rubber dam during root canal treatment on LR5, or you made

no or no adequate record in respect of the use of a rubber dam; 79. Your standard of care was inadequate on 10 September 2012 in that you did not carry

out any basic periodontal examination (BPE) when it was indicated to do so;


80. Your standard of care and/or your standard of record keeping was inadequate on 27 February 2017 in that: a. You did not carry out six-point pocket charting of the UL sextant when it was

indicated to do so, or you made no or no adequate record in relation to six-point pocket charting;

b. You did not diagnose periodontal disease or you made no or no adequate record of any diagnosis of periodontal disease;

c. You did not discuss periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion;

d. You made no or no adequate plan to treat the periapical infection at UL6 when it was indicated to do so, or you made no or no adequate record of any such plan;

e. You did not correctly assess the level of the patient’s periodontal risk;

f. You did not treat the caries at UL3; g. You made no or no adequate plan to treat caries at UL3 when it was indicated to

do so, or you made no or no adequate record of any such plan; 81. Your standard of care and/or your standard of record keeping was inadequate on 29

March 2017 in that: a. You did not discuss with the patient adequately or at all the options for treatment

of UL1, or you made no or no adequate record of any such discussion; b. You did not discuss with the patient adequately or at all the risks and benefits of

the bridge treatment proposed, or you made no or no adequate record of any such discussion;


Schedule 3, on and between 5 October 2004 and 19 May 2017; 83. Your standard of care and/or your standard of record keeping was inadequate on 6

April 2016 in that: a. You made no or no adequate report on the bitewing radiographs taken; b. You did not ensure a periapical radiograph was taken of LR7 when it was

indicated to do so; c. You did not carry out vitality testing of LR7 when it was indicated to do so; d. You did not carry out six-point pocket charting when it was indicated to do so, or

you made no or no adequate record in respect of six-point pocket charting; e. You did not diagnose periodontal disease, or you made no or no adequate

record of any diagnosis of periodontal disease; f. You did not treat the periodontal disease; g. You did not discuss the diagnosis of periodontal disease with the patient



84. Your standard of care and/or your standard of record keeping was inadequate on 25 November 2016 in that: a. You did not carry out six-point pocket charting when it was indicated to do so, or

you made no or no adequate record in respect of six-point pocket charting; b. You did not diagnose periodontal disease, or you made no or no adequate

record of any diagnosis of periodontal disease; c. You did not treat the periodontal disease; d. You did not discuss the diagnosis of periodontal disease with the patient


85. Your standard of record keeping was inadequate on 27 February 2017 in that you made no or no adequate report on the bitewing radiograph taken;


Schedule 3, on and between 20 January 2003 and 19 May 2017; 87. Your standard of care and/or your standard of record keeping was inadequate on 20

March 2013 in that: a. You did not ensure a periapical radiograph was taken of LL6 and LL7 when it

was indicated to do so; b. You made no diagnosis in respect of the reported mobility at LL6/LL7, or you

made no or no adequate record of any such diagnosis; 88. Your standard of care and/or your standard of record keeping was inadequate on 24

September 2015 in that: a. You did not carry out six-point pocket charting when it was indicated to do so, or

you made no or no adequate record in respect of six-point pocket charting; b. You did not ensure a periapical radiograph was taken of the UL sextant when it

was indicated to do so; c. You did not diagnose periodontal disease, or you made no or no adequate

record of any diagnosis of periodontal disease; d. You did not treat the periodontal disease; e. You did not discuss the diagnosis of periodontal disease with the patient


89. Your standard of care and/or your standard of record keeping was inadequate on 4 May 2017 in that: a. You did not diagnose periodontal disease, or you made no or no adequate

record of any diagnosis of periodontal disease; b. You did not treat the periodontal disease;


c. You did not discuss the diagnosis of periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion;

90. Your standard of care and/or your standard of record keeping was inadequate in that:

a. You made incomplete clinical notes on either or both of the following dates: i. 20 June 2016; ii. 21 October 2016;

b. You made no or no adequate record on 20 June 2016 of any assessment of the level of periodontal risk;

c. You made no or no adequate record of any basic periodontal examination (BPE) carried out on any or all of the following dates: i. 14 September 2012;

ii. 20 June 2016; iii. 4 May 2017;

AND that by reason of the matter(s) set out above, your fitness to practise is impaired by reason of misconduct and/or deficient professional performance”.

On 13 April 2021, the Chairman made the following statement regarding the finding of facts:

“Mr Barrie The Committee has taken into account all the evidence presented to it. It has accepted the advice of the Legal Adviser. In accordance with that advice, it has considered each head of charge separately. Background This case relates allegations of inadequate care and inadequate record keeping, together with allegations that on two occasions that you acted in an inappropriate and threatening manner towards colleagues. The GDC received a letter dated 28 September 2017 from NHS England South, advising that you had been suspended from the NHS Performers List on 27 September 2017. The GDC sought further information from NHS England, who provided further background information and documents concerning a report provided by two dental professionals following their visit on 19 September 2017 to Fairfield House Dental Surgery (the Practice), where you were working. The two dental professionals were part of the Devon Practitioner Advice and Support Scheme (PASS), who had been contacted by NHS England following concerns received from the Practice about you. The two PASS members visited the Practice and met four other dentists who worked there, during the course of which they each alleged a number of clinical concerns regarding your practice, including record keeping, radiographic practice, insufficient examination and treatment, inappropriate treatment and treatment of poor quality. In conclusion, the PASS dental professionals noted that following your return to work after a period of absence in 2015 the PAG had required certain conditions to be fulfilled. From the visit carried out on 19


September 2017, it appeared that some of these conditions were no longer being met. They further noted there were alleged concerns about frequent absences, cancellations of clinics and your poor time keeping at appointments. In addition, the PASS dental professionals reported on alleged concerns by other dentists about your limited or no insight into these matters. Devon PASS considered that it was not appropriate to act in this case and decided to refer your case back to the PAG for deliberation on future actions. That report was considered by NHS England South (South West) who in turn decided to suspend your registration from the National Dental Performers List with immediate effect on 27 September 2017. Following your suspension from the Dental Performers List, Mr Fulford (NHS Dental Advisor) produced a full report into the clinical and behavioural complaints that had been raised. Mr Fulford reviewed the original 12 cases plus an additional 12 randomly selected sets of record cards, to establish whether the original sample of patient record was representative of your practice generally. Mr Fulford was critical of the treatment provided by the registrant in all 12 original cases and was critical of the treatment provided by you in 11 of the randomly selected cases. On 28 March 2019 you received notification from NHS England that the matters in Mr Fulford’s report had been referred to the Performers List Panel who would consider your removal form the Performers List. You submitted a letter to the Performers List Decision Panel accepting the criticisms and asked to be permitted to resign from the Performers List. It is also alleged that on two occasions you acted in an inappropriate and/or a threatening manner to colleagues. Evidence The Committee received a substantial amount of documentary evidence which included the clinical records in respect of 21 patients. The Committee also had sight of some radiographs. The Committee was also provided with witness statements plus exhibits from a number of witnesses, including Witness EE, Programme Manager for Performance at NHS England and NHS Improvement (South West) Medical Directorate. Witness NP, Practice Manager at Fairfield House Dental Surgery, and Witness GS a Dental Nurse at Fairfield House Dental Surgery. The Committee received written expert evidence from Ms L Tyler, on behalf of the GDC. She produced an expert report dated 20 February 2020. She also produced two addendum reports dated 20 February 2021 and 12 April 2021. The Committee noted your admissions and accepted them in reaching its findings of fact. The Committee noted the submissions made on your behalf by your Counsel, Mr Dhillon, that you could not recall having undertaken any of the treatment referred in the heads of charge where the alternatives are alleged of inadequate standard of care and/or inadequate standard of record keeping. No live witnesses were called during the stage 1 proceedings. The Committee has given careful consideration to the witness statements as well as the expert report, dated 20 February 2020, provided by Ms L Tyler. The Committee has accepted the advice of the Legal Adviser. It has borne in mind that the burden of proof is on the GDC and that it must decide the facts according to the civil standard of proof, namely on the balance of probabilities. You need not prove anything.


I will now announce the Committee’s findings in relation to each head of charge:

1. At all material times you practised as a dentist at the practice identified in Schedule 1; Admitted and found proved.

2. You acted in an inappropriate and/or threatening manner with colleagues in that: Partially admitted - You do not accept that you acted in a threatening manner.

2.a On or around 29 August 2017 you telephoned the practice and said to Colleague A (as identified in Schedule 2) words to the effect of, “That’s really shit of [Colleague B] (as identified in Schedule 2), to cancel my patients and not tell me, so I will be in tomorrow to kick [Colleague B’s] ass, so get lots of towels ready because there will be a lot of blood”; Admitted and found proved for both inappropriate and threatening. You accept that these were unacceptable and inappropriate comments, and the Committee accepts that your admission and finds this head of charge proved in relation to acting inappropriately. In respect of you making these comments in a threatening manner, the Committee notes that there has been no history of aggression or violence from you. The Committee is satisfied that there was no intent on your part to carry this out. However, the Committee noted the account of Witness GS, the dental nurse who was working with you at that time who stated “I was shocked by Charles’ comments because it was very unprofessional. I have not heard Charles that angry or make those sorts of comments before. His tone of voice was very angry and I thought he was going to come in and beat up Rob…. I was shocked and scared that Charles would act on his comments…. Everyone at the Practice was feeling stressed and frightened by Charles’ behaviour…. Rob told me to write down what happened and call the Police if Charles did come in and was acting threateningly.”

The Committee considers that your comments were graphic, threatening in nature, and were directed at one individual. The Committee is satisfied that you had acted in a threatening manner and finds this head of charge proved in relation to acting in a threatening manner.

2.b On 15 November 2017 at a practice meeting, you said words to the effect that you would “beat the shit” or “knock the shit” out of anyone who discussed your suspension outside the meeting:

Admitted and found proved only in respect of inappropriate. You accept that these were unacceptable and inappropriate comments, and the Committee accepts that your admission and finds this proved. In respect of you making these comments in a threatening manner, the Committee notes that these comments were made against the backdrop of a toxic


atmosphere between you and the other partner at the practice. These words were said at a full staff meeting, where you faced some challenging questions. It was stated on your behalf that you felt uncomfortable as this meeting was not something you had prepared for. You were taken aback that you were expected to give out information which was sensitive to you and in front of a large group of practice colleagues, some of whom you had a difficult relationship with. Witness NP’s account was that she was not frightened and stated that “Charles’s tone was not shouting or aggressive, but he was clearly distressed and exasperated. The comment was not directed at anyone in particular and audible for everyone to hear… following the meeting, several members of staff came to me and expressed their shock at Charles’ comments … We all agreed that it was not acceptable behaviour.”

The Committee considers that you were under pressure, which led to your inappropriate outburst. The Committee is satisfied that it was never your intention to be threatening, and the words were said without consideration of their impact. Taking into account all the circumstances, the Committee is satisfied that you did not act in a threatening manner and finds this head of charge not proved.


Schedule 3, on and between 5 September 2013 and 13 February 2017; Admitted and found proved.


4.a Following examination on 15 February 2016 you did not diagnose and/or treat caries at LL7 adequately or at all; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

4.b On or after 13 May 2016 you made no diagnosis in light of the patient’s complaint of pain, or you made no or no adequate record of any such diagnosis: Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


5.a You made no or no adequate clinical record for the consultation on 5 April 2016; Admitted and found proved.

5.b You made no or no adequate report on the periapical radiograph taken on 13 May 2016; Admitted and found proved.



Schedule 3, on and between 16 May 2005 and 12 June 2017; Admitted and found proved.


7.a. You did not ensure that the patient’s medical history record was updated on any or all of the following dates: Admitted and found proved.

7.a.i 10 February 2010; Admitted and found proved.

7.a.ii 19 October 2010;

Admitted and found proved. 7.a.iii 9 June 2011;

Admitted and found proved. 7.a.iv 8 August 2011;

Admitted and found proved. 7.b You made no or no adequate record of any assessment of the occlusion made

during examination on any or all of the following dates:

7.b.i 10 February 2010;

Admitted and found proved. 7.b.ii 19 October 2010;

Admitted and found proved. 7.b.iii 9 June 2011;

Admitted and found proved. 7.b.iv 5 March 2012;

Admitted and found proved. 7.b.v 21 August 2012;

Admitted and found proved. 7.c You made no or no adequate record of any basic periodontal examination (BPE)

carried out on any or all of the following dates:

7.c.i 19 October 2010;

Admitted and found proved. 7.c.ii 9 June 2011;

Admitted and found proved. 7.c.iii 8 August 2011;


Admitted and found proved. 7.c.iv 5 March 2012;

Admitted and found proved. 7.v 21 August 2012;

Admitted and found proved. 7.vi 28 February 2013;

Admitted and found proved. 7.d You made no or no adequate report on the periapical radiograph taken on 9 June

2011;

Admitted and found proved. Patient 3 8. You were consulted in relation to dental treatment by Patient 3, as identified in

Schedule 3, on and between 17 February 2016 and 6 January 2017; Admitted and found proved.

9. Your standard of care and/or your standard or record keeping was inadequate on 8 April 2016 in that:

9.a. You did not carry out six-point pocket charting when it was indicated to do so, or you made no or no adequate record of any six-point pocket charting carried out; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

9.b You did not diagnose periodontal disease, or you made no or no adequate record of any diagnosis of periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

9.c You did not discuss the periodontal condition with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

10. Your standard of care or your standard or record keeping was inadequate on 11 April 2016 in that you did not use a rubber dam during root canal treatment on UL1, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

11. Your standard of care and/or your standard or record keeping was inadequate on 14 November 2016 in that:


11.a You did not discuss the diagnosis of periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

11.b You did not discuss oral hygiene with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

12. Your standard of record keeping was inadequate in that you made no or no adequate clinical record for the consultation on 17 February 2016; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

13. Your standard of care was inadequate in that you did not carry out any basic periodontal examination (BPE) on 6 January 2017 when it was indicated to do so; Admitted and found proved.


Schedule 3, on and between 15 February 2003 and 25 November 2016;

Admitted and found proved.

15. Your standard of care or your standard of record keeping was inadequate on 17 June 2015 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

16. Your standard of care was inadequate on or after 17 June 2015 in that you did not treat caries at UL3 when it was indicated to do so; Admitted and found proved.

17. Your standard of care and/or your standard of record keeping was inadequate on 6 July 2016 in that:

17.a You did not discuss adequately or at all the risks and benefits of the proposed bridge work, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

17.b You did not discuss adequately or at all alternative options to the proposed bridge work, or you made no or no adequate record of any such discussion;


Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

17.c You did not obtain informed consent to the proposed bridge work; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

18. Your standard of care and/or your standard of record keeping was inadequate on 4 October 2016 in that:


18.b You did not discuss adequately or at all alternative options to the proposed bridge work, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


18.d You did not use a rubber dam during root canal treatment on UL2 and UR2, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.



19.b You did not discuss adequately or at all the alternative options to the proposed bridge work, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


19.d You did not carry out any basic periodontal examination (BPE) when it was indicated to do so; Admitted and found proved for both inadequate standard of care and


inadequate standard of record keeping. 20. Your standard of record keeping was inadequate on 14 November 2016 in that

you made no or no adequate report on the periapical radiographs taken of UL2 and UR2;

Admitted and found proved. Patient 5 21. You were consulted in relation to dental treatment by Patient 5, as identified in

Schedule 3, on and between 17 June 2003 and 7 June 2017;

Admitted and found proved. 22. Your standard of care was inadequate in that you did not carry out any basic

periodontal examination (BPE) on any or all of the following dates when it was indicated to do so: Admitted and found proved.

22.i 4 January 2010; Admitted and found proved.

22.ii 11 January 2011; Admitted and found proved.

22.iii 20 September 2016; Admitted and found proved.

22.iv 20 March 2017; Admitted and found proved.


Schedule 3, on and between 14 February 2003 and 8 June 2017; Admitted and found proved.

24. Your standard of care and/or your standard of record keeping was inadequate on 12 April 2010 in that:

24.a You made no or no adequate report on the radiograph taken of LR6; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

24.b You reached no diagnosis in light of a complaint of pain in the lower right of the patient’s mouth, or you made no or no adequate record of any diagnosis; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

25. Your standard of care and/or your standard of record keeping was inadequate on 10 September 2010 in that:


25.a You did not ensure any bitewing radiograph was taken when it was indicated to do so, or you made no or no adequate record in relation to your decision making in respect of the taking of bitewing radiographs; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

25.b You did not carry out a soft tissue examination when it was indicated to do so, or you made no or no adequate record of any soft tissue examination carried out; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

25.c You did not carry out any basic periodontal examination (BPE) when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

25.d You did not update the patient’s medical history record when it was indicated to do so, or you made no or no adequate record in respect of the patient’s medical history. Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

26. Your standard of care and/or your standard of record keeping was inadequate on 25 May 2011 in that:

26.a You did not ensure any bitewing radiograph was taken when it was indicated to do so or you made no or no adequate record in relation to your decision making in respect of the taking of bitewing radiographs; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

26.b. You did not carry out any basic periodontal examination (BPE) when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

26.c You did not update the patient’s medical history record when it was indicated to do so, or you made no or no adequate record in respect of the patient’s medical history; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

27. Your standard of care or your standard of record keeping was inadequate on 29 May 2012 in that you did not ensure any bitewing radiograph was taken when it was indicated to do so, or you made no or no adequate record in relation to your decision making in respect of the taking of bitewing radiographs; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


28. Your standard of care and/or your standard of record keeping was inadequate on 2 January 2013 in that you did not use a rubber dam during root canal treatment on LR6, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

29. Your standard of record keeping was inadequate on 8 June 2017 in that you did not correctly record the level of the patient’s caries risk;

Admitted and found proved. Patient 7 30. You were consulted in relation to dental treatment by Patient 7, as identified, in

Schedule 3 on and between 30 March 2004 and 5 June 2017;

Admitted and found proved. 31. Your standard of care and/or your standard of record keeping was inadequate on

5 June 2017 in that:

31.a You did not investigate adequately or at all the periodontal condition of the patient, or you made no or no adequate record of any such investigation; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


31.c You did not discuss periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.d You did not correctly assess the level of the patient’s periodontal risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.e You did not treat the periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.f You did not correctly assess the level of the patient’s caries risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.g You did not report adequately or at all on the bone loss at any or all of the following teeth:


31.g.i UR7; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.g.ii UR3; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.g.iii LL6; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.g.iv LR5; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.g.v LR6; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.g.vi LR7; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.h. You did not discuss adequately or at all the risks of not treating the mobile LL8, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.i. You did not discuss adequately or at all the risks of not treating the mobile UL8, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

31.j You did not discuss adequately or at all the risks of not treating the caries at LR5, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


Schedule 3, on and between 7 August 2003 and 15 March 2016;

Admitted and found proved. 33. Your standard of care and/or your standard or record keeping was inadequate on

7 October 2015 in that:

33.a You did not carry out six-point pocket charting when it was indicated to do so, or


you made no or no adequate record in respect of six-point pocket charting; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

33.b. You did not carry out root surface debridement when it was indicated to do so, or you made no or no adequate record in respect of root surface debridement; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

33.c You made no or no adequate plan for the treatment of caries at LL6 when it was indicated to do so, or you made no or no adequate record in relation to your treatment planning; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


34.a. You did not carry out six-point pocket charting in the LR sextant when it was indicated to do so, or you made no or no adequate record of any six- point pocket charting carried out; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

34.b You did not carry out root surface debridement in the LR sextant when it was indicated to do so, or you made no or no adequate record of any root surface debridement carried out; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

35. Your standard of care and/or your standard or record keeping was inadequate on 6 January 2017 in that:

35.a You did not carry out any basic periodontal examination (BPE) when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

35.b You made no assessment of the patient’s periodontal condition when it was indicated to do so, or you made no or no adequate record of any such assessment; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

36. Your standard of care and/or your standard or record keeping was inadequate on 15 March 2017 in that:

36.a You did not discuss with the patient adequately or at all the risks and benefits of the bridge treatment proposed, or you made no or no adequate record of any such discussion;



36.b You did not discuss with the patient adequately or at all alternative options to the treatment proposed, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.



Schedule 3, on and between 8 April 2008 and 5 June 2017; Admitted and found proved.

38. Your standard of care and/or your standard or record keeping was inadequate on 5 June 2017 in that:

38.a You did not ensure any bitewing radiographs were taken when it was indicated to do so, or you made no or no adequate record in relation to your decision making in respect of the taking of bitewing radiographs; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

38.b You did not diagnose caries at LL6, or you made no or no adequate record of any diagnosis of caries; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

38.c You made no or no adequate plan for the treatment of caries at LL6 when it was indicated to do so, or you made no or no adequate record in relation to your treatment planning; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

38.d You did not apply fluoride varnish when it was indicated to do so, or you made no or no adequate record in relation to your decision in respect of fluoride varnish application; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

38.e You did not correctly assess the level of the patient’s caries risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

Patient 10


39. You were consulted in relation to dental treatment by Patient 10, as identified in Schedule 3, on and between 14 July 2003 and 17 May 2017;

Admitted and found proved. 40. Your standard of care and/or your standard or record keeping was inadequate on

13 May 2011 in that:

40.a You made no or no adequate report on the periapical radiograph taken of LL5; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

40.b You did not discuss with the patient adequately or at all the risks and benefits of the bridge treatment proposed to replace LL5, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

40.c You did not discuss with the patient adequately or at all alternative options to the bridge treatment proposed, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

40.d You did not obtain informed consent to the treatment proposed; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

40.e You did not carry out any basic periodontal examination (BPE) when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


41.a You made no or no adequate report on the periapical radiographs taken during root canal treatment; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

41.b You did not use a rubber dam during root canal treatment on UR3, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

42. Your standard of care or your standard or record keeping was inadequate on 2 December 2015 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication; Admitted and found proved for both inadequate standard of care and


inadequate standard of record keeping. 43. Your standard of care or your standard or record keeping was inadequate on 13

April 2016 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


44.a You did not use a rubber dam during root canal treatment on LL3, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

44.b You made no or no adequate report on the periapical radiograph taken of LL3; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


45.a You did not take a pre-operative periapical radiograph of LL4 before commencing bridge preparation; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

45.b You did not discuss with the patient adequately or at all the risks and benefits of the bridge treatment proposed to replace LL4, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

45.c You did not discuss with the patient adequately or at all alternative options to the bridge treatment proposed, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

45.d You did not obtain informed consent to the treatment proposed; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

46. Your standard of care was inadequate in that you did not carry out and/or record any or any adequate basic periodontal examination (BPE) on any or all of the following dates when it was indicated to do so:

46.i 12 August 2011; Admitted and found proved for both inadequate standard of care and


inadequate standard of record keeping. 46.ii 28 February 2013;


46.iii 1 June 2015; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

46.iv 2 December 2015; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

46.v 12 September 2016; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


Schedule 3 on and between 2 August 2016 and 16 August 2016; Admitted and found proved.

48. Your standard of care or your standard of record keeping was inadequate on 2 August 2016 in that you did not diagnose caries at UL6, or you made no or no adequate record of any diagnosis; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


Schedule 3, on and between 21 January 2005 and 10 March 2017; Admitted and found proved.

50. Your standard of care and/or your standard of record keeping was inadequate on 18 November 2015 in that:

50.a. You did not correctly assess the level of the patient’s periodontal risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

50.b You made no or no adequate report on the periapical radiograph taken of UL5; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

50.c You did not diagnose caries at UL6, or you made no or no adequate record of any diagnosis of caries at UL6; Admitted and found proved for both inadequate standard of care and


inadequate standard of record keeping. 51 Your standard of care and/or your standard of record keeping was inadequate on

11 January 2017 in that:

51.a You did not correctly assess the level of the patient’s periodontal risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

51.b You did not correctly assess the level of the patient’s caries risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

51.c You did not diagnose caries at UL6, or you made no or no adequate record of any diagnosis of caries at UL6; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

51.d You did not carry out six-point pocket charting when it was indicated to do so, or you made no or no adequate record in relation to six-point pocket charting; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

51.e You did not discuss periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


Schedule 3, on and between 9 April 2003 and 12 January 2017; Admitted and found proved.


53.a You made no or no adequate assessment of UL4, or you made no or no adequate record of any such assessment; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

53.b You did not discuss with the patient adequately or at all the options for treatment of UL4, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

53.c You prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication; Admitted and found proved for both inadequate standard of care and


inadequate standard of record keeping. 53.d You did not either extirpate or extract UL4 when it was indicated to do so, or you

made no or no adequate record of the decision in respect of UL4; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


54.a You recorded scores for the basic periodontal examination (BPE) which did not match your recorded observations; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

54.b You did not diagnose caries at UR7, or you made no or no adequate record of any diagnosis of caries at UR7; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

54.c You did not diagnose caries at UL7, or you made no or no adequate record of any diagnosis of caries at UL7; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


55.a You made no assessment of UR4, or you made no or no adequate record of any such assessment; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

55.b You did not discuss with the patient adequately or at all the options for treatment of UR4, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

55.c You prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

56. Your standard of care and/or your standard of record keeping was inadequate on 12 January 2017 in that:

56.a You did not take a pre-operative periapical radiograph of UR4 before commencing root canal treatment; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


56.b You did not use a rubber dam during root canal treatment on UR4 or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


Schedule 3, on and between 20 January 2003 and 11 January 2017; Admitted and found proved.


58.a You did not discuss with the patient adequately or at all the options for treatment of UL6, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

58.b You did not discuss with the patient adequately or at all the risks and benefits of the root canal treatment proposed at UL6, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

59. Your standard of care or your standard of record keeping was inadequate on 8 December 2016 in that you did not use a rubber dam during root canal treatment on UL5 and UL6, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

60. Your standard of care and/or your standard of record keeping was inadequate on 20 December 2016 in that:

60.a You made no or no adequate record in respect of the working lengths during root canal treatment for UL5 and UL6; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

60.b You did not use a rubber dam during root canal treatment on UL5 and UL6, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

61. Your standard of care and/or your standard of record keeping was inadequate on 28 December 2016 in that:

61.a You made no or no adequate record in respect of the working lengths during root canal treatment for UL5 and UL6;



61.b You did not use a rubber dam during root canal treatment on UL5 and UL6, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

62. Your standard of care and/or your standard of record keeping was inadequate on or after 28 December 2016 in that:

62.a You did not ensure that a post-operative periapical radiograph was taken after completion of root canal treatment of UL5 and UL6 prior to preparing for a crown; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

62.b You did not discuss with the patient adequately or at all the implications of perforation, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


Schedule 3, on and between 19 August 2003 and 17 March 2017; Admitted and found proved.

64. Your standard of care and/or your standard of record keeping was inadequate on 20 May 2016 in that:

64.a You recorded scores for the basic periodontal examination (BPE) which were not consistent with the radiographic evidence; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

64.b You did not carry out six-point pocket charting when it was indicated to do so, or you made no or no adequate record in respect of six-point pocket charting; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

64.c You did not assess adequately or at all the periodontal condition of the patient, or you made no or no adequate record of any such assessment; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

64.d You did not diagnose periodontal disease, or you made no or no adequate record of any diagnosis of periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


64.e You did not discuss periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

64.f You did not adequately treat the periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

64.g You did not correctly assess the level of the patient’s periodontal risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


65.a You did not carry out six-point pocket charting when it was indicated to do so, or you made no or no adequate record in respect of six-point pocket charting; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

65.b You did not carry out root surface debridement when it was indicated to do so, or you made no or no adequate record in respect of root surface debridement; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


65.d You did not adequately treat the periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

65.e You did not correctly assess the level of the patient’s periodontal risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


Schedule 3, on and between 30 December 2016 and 9 March 2017;

Admitted and found proved. 67. Your standard of care and/or your standard of record keeping was inadequate on

30 December 2016 in that:

67.a You did not take a pre-operative periapical radiograph of UR6 before commencing root canal treatment;



67.b You did not use a rubber dam during root canal treatment on UR6, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

68. Your standard of care or your standard of record keeping was inadequate on 11 January 2017 in that you did not use a rubber dam during root canal treatment on UR6, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

69. Your standard of care and/or your standard of record keeping was inadequate on 13 February 2017 in that:

69.a You did not use a rubber dam during root canal treatment on UR6, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

69.b You prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

70. Your standard of care or your standard of record keeping was inadequate on 3 March 2017 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

71. Your standard of care and/or your standard of record keeping was inadequate on 9 March 2017 in that:

71.a You did not use a rubber dam during root canal treatment on UR6, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

71.b You did not verify adequately or at all the working length measurement taken during root canal treatment, or you made no or no adequate record of the verification; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

Patient 18


72. You were consulted in relation to dental treatment by Patient 18, as identified in Schedule 3, on and between 23 May 2015 and 20 March 2017;

Admitted and found proved. 73 Your standard of care and/or your standard of record keeping was inadequate on

15 July 2015 in that:

73.a You did not ensure that the patient’s medical history record was updated; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

73.b You did not carry out a soft tissue examination when it was indicated to do so, or you made no or no adequate record in respect of any soft tissue examination; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

73.c You did not carry out any basic periodontal examination (BPE) when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

74. Your standard of care and/or your standard of record keeping was inadequate on 8 June 2016 in that:

74.a You did not diagnose caries at UL3, or you made no or no adequate record of any diagnosis of caries at UL3; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

74.b You did not ensure that the patient’s medical history record was updated; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

74.c You did not carry out a soft tissue examination when it was indicated to do so, or you made no or no adequate record in respect of any soft tissue examination; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

74.d You did not carry out any basic periodontal examination (BPE) when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

Patient 19

75. You were consulted in relation to dental treatment by Patient 19, as identified in Schedule 3, on and between 11 April 2003 and 12 April 2017; Admitted and found proved.


76. Your standard of care or your standard of record keeping was inadequate on 13 April 2012 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

77. Your standard of care or your standard of record keeping was inadequate on 1 June 2012 in that you prescribed antibiotics when it was not indicated to do so, or you made no or no adequate record of any such indication; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

78. Your standard of care and/or your standard of record keeping was inadequate on 7 June 2012 in that:

78.a You made no or no adequate report on the periapical radiograph taken; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

78.b You did not use a rubber dam during root canal treatment on LR5, or you made no or no adequate record in respect of the use of a rubber dam; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

79. Your standard of care was inadequate on 10 September 2012 in that you did not carry out any basic periodontal examination (BPE) when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

80. Your standard of care and/or your standard of record keeping was inadequate on 27 February 2017 in that:

80.a You did not carry out six-point pocket charting of the UL sextant when it was indicated to do so, or you made no or no adequate record in relation to six-point pocket charting; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

80.b You did not diagnose periodontal disease or you made no or no adequate record of any diagnosis of periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


80.d You made no or no adequate plan to treat the periapical infection at UL6 when it


was indicated to do so, or you made no or no adequate record of any such plan; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

80.e You did not correctly assess the level of the patient’s periodontal risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

80.f You did not treat the caries at UL3; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

80.g You made no or no adequate plan to treat caries at UL3 when it was indicated to do so, or you made no or no adequate record of any such plan; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

81. Your standard of care and/or your standard of record keeping was inadequate on 29 March 2017 in that;

81.a You did not discuss with the patient adequately or at all the options for treatment of UL1, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

81.b You did not discuss with the patient adequately or at all the risks and benefits of the bridge treatment proposed, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


Schedule 3, on and between 5 October 2004 and 19 May 2017; Admitted and found proved.

83. Your standard of care and/or your standard of record keeping was inadequate on 6 April 2016 in that:

83.a You made no or no adequate report on the bitewing radiographs taken; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

83.b You did not ensure a periapical radiograph was taken of LR7 when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

83.c You did not carry out vitality testing of LR7 when it was indicated to do so;



83.d You did not carry out six-point pocket charting when it was indicated to do so, or you made no or no adequate record in respect of six-point pocket charting; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

83.e You did not diagnose periodontal disease, or you made no or no adequate record of any diagnosis of periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

83.f You did not treat the periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

83.g You did not discuss the diagnosis of periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.




84.c You did not treat the periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

84.d You did not discuss the diagnosis of periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

85. Your standard of record keeping was inadequate on 27 February 2017 in that you made no or no adequate report on the bitewing radiograph taken; Admitted and found proved for both inadequate standard of care and


inadequate standard of record keeping. Patient 21 86. You were consulted in relation to dental treatment by Patient 21, as identified in

Schedule 3, on and between 20 January 2003 and 19 May 2017; Admitted and found proved.

87. Your standard of care and/or your standard of record keeping was inadequate on 20 March 2013 in that:

87.a You did not ensure a periapical radiograph was taken of LL6 and LL7 when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

87.b You made no diagnosis in respect of the reported mobility at LL6/LL7, or you made no or no adequate record of any such diagnosis; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

88. Your standard of care and/or your standard of record keeping was inadequate on 24 September 2015 in that:


88.b You did not ensure a periapical radiograph was taken of the UL sextant when it was indicated to do so; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

88.c You did not diagnose periodontal disease, or you made no or no adequate record of any diagnosis of periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

88.d You did not treat the periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

88.e You did not discuss the diagnosis of periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

89. Your standard of care and/or your standard of record keeping was inadequate on


4 May 2017 in that:

89.a You did not diagnose periodontal disease, or you made no or no adequate record of any diagnosis of periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

89.b You did not treat the periodontal disease; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

89.c You did not discuss the diagnosis of periodontal disease with the patient adequately or at all, or you made no or no adequate record of any such discussion; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.


90.a You made incomplete clinical notes on either or both of the following dates:

90.a.i 20 June 2016; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

90.a.ii 21 October 2016; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

90.b You made no or no adequate record on 20 June 2016 of any assessment of the level of periodontal risk; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

90.c You made no or no adequate record of any basic periodontal examination (BPE) carried out on any or all of the following dates:

90.c.i 14 September 2012; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

90.c.ii 20 June 2016; Admitted and found proved for both inadequate standard of care and inadequate standard of record keeping.

90.c.iii 4 May 2017; Admitted and found proved for both inadequate standard of care and


inadequate standard of record keeping. We move to Stage Two”.

On 16 April 2021 the Chairman announced the determination as follows: “Mr Barrie: Having announced its findings of fact, the Committee has considered the submissions made by Mr McGhee on behalf of the General Dental Council (GDC) and those made by Mr Dhillon on your behalf. It has accepted the advice of the Legal Adviser. Mr McGhee confirmed that you have no previous fitness to practise history. Mr McGhee submitted that the facts found proved amount to misconduct. In support of that contention, he referred to the expert evidence of Dr Tyler. She was of the opinion that whilst she is satisfied that many of the failings identified in her report fall below but not far below the expected standard (with the exception of Patient 21, who is far below on an individual basis), the cumulative effect of these failings led to her conclusion that overall the conduct is far below the expected standard. In terms of non-clinical matters (charge 2), acting in an inappropriate manner towards colleagues on two occasions, one of which was also considered to be in a threatening manner. He submitted that fellow professionals would consider your conduct to be deplorable. He submitted that there have been a number of serious departures from elementary professional standards. The GDC’s position is that there is a need only for a finding of impairment of your fitness to practise by reason of your misconduct and not Deficient Professional Performance in this case. Turning to the clinical matters, Mr McGhee invited the Committee to find that your fitness to practise is impaired by reason of your misconduct. He submitted that although you have plainly worked towards remediating your deficiencies, you have conceded in your evidence that your journey in respect of insight is ongoing. A significant aspect of this case is the length of time which has elapsed since you were last in clinical practice and the inevitable de-skilling which will have occurred. Mr McGhee further submitted that the conduct in this case is such that a finding of current impairment is necessary in order to uphold standards and public confidence in the profession. Mr McGhee submitted that the minimum sanction necessary to protect the public and in the wider public interest would be a two-year period of conditions, with a review prior to the expiry of the order. He addressed the Committee in some detail as to the monitoring arrangements of the conditions envisaged by the GDC which would address the concerns identified in this case. Mr McGhee referred to relevant sections of the GDC’s “Guidance for the Practice Committees, including Indicative Sanctions Guidance” (the Guidance) (October 2016, last revision December 2020) in support of the sanction he sought. Mr Dhillon conceded that the facts found proved amount to misconduct. He did not make any submissions on deficient professional performance but indicated that the Committee should consider it. He also conceded that your fitness to practise is currently impaired by reason of your misconduct, given that you have not worked as a dentist for approximately 3 and a half years and therefore you have not had an opportunity to demonstrate any changes in your practice. However, you have completed a large volume of Continuing Professional


Development (CPD), and Mr Dhillon submitted that the clinical failings in this case are easily remediable, as agreed by the GDC expert. Mr Dhillon submitted that the appropriate sanction in this case was an order of conditions on your registration for 18 months, with a review before the expiry of the order. Mr Dhillon responded in some detail as to the conditions proposed by the GDC, and that a workplace supervisor (albeit not a close supervisor) would be appropriate. Misconduct The Committee has first considered whether the facts found proved amount to misconduct. In so doing, it has had regard to all of the evidence before it, as well as the submissions made by both parties. Throughout its deliberations, the Committee has kept in mind the GDC’s “Standards for the Dental Team” (September 2013). When determining whether the facts found proved amount to misconduct the Committee had regard to the terms of the relevant professional standards in force at the time of the incidents. The Committee, in reaching its decision, had regard to the public interest and reminded itself that misconduct was a matter for its judgment. The Committee applied the definition of misconduct given by Lord Clyde in Rylands v GMC [1999] Lloyd’s Rep Med 139. He said that “professional misconduct is a falling short by omission or commission of the standards of conduct expected among medical practitioners, and such falling short must be serious. The adjective “serious” must be given its proper weight, and in other contexts there has been a reference to conduct which would be regarded as deplorable by fellow practitioners.” The Committee has concluded that your conduct was in breach of the following Standards for the Dental Team (2013). It was satisfied that in respect of your behaviour towards colleagues at head of charge 2 your failings included a breach of the following standards:

Principle 6 - Work with colleagues in a way that is in patients’ best interests

Standard 6.1: Work effectively with your colleagues and contribute to good teamwork.

Standard 6.1.2: You must treat colleagues fairly and with respect, in all situations and all forms of interaction and communication. You must not bully, harass, or unfairly discriminate against them.

Standard 6.1.4: You must value and respect the contribution of all team members.

Principle 9 Make sure your personal behaviour maintains patients’ confidence in you and the dental profession

Standard 9.1: You must ensure your conduct both at work and in your personal life justifies patients’ trust in you and the public’s trust in the dental profession.

Standard 9.1.1: You must treat all team members, other colleagues and members of the public fairly, with dignity and in line with the law.

Standard 9.2: You must protect patients and colleagues from risks posed by your health, conduct or performance.


Standard 9.2.1: If you know, or suspect, that patients may be at risk because of your health, behaviour or professional performance, you must consult a suitably qualified colleague immediately and follow advice on how to put the interests of patients first.

Standard 9.2.2: You must not rely on your own assessment of the risk you pose to patients. You should seek occupational health advice or other appropriate advice as soon as possible. Head of charge 2 relates to conduct on two occasions towards other dental colleagues, in that you acted in an inappropriate manner and, in respect of one of those occasions, also in a threatening manner. In relation to head of charge 2(a) the Committee is satisfied that this reaches the threshold of serious misconduct, given that the Committee found that your conduct was both inappropriate and threatening. In relation to head of charge 2(b), the Committee found proved only in respect of inappropriate and considers that this alone would not reach the threshold for a finding of misconduct. However, the Committee is satisfied that head of charge 2 when taken as a whole constitutes serious misconduct. The Committee then went onto consider the clinical matters which were found proved in heads of charge 3-90 and is satisfied that your failings included a breach of the following standards:

Principle 1 – Put patients’ interest first.

Standard 1.1 Listen to your patients.

Standard 1.2 Treat every patient with dignity and respect at all times.

Standard 1.3 Be honest and act with integrity.

Standard 1.4 Take a holistic and preventative approach to patient care which is appropriate to the individual patient.

Standard 1.5 Treat patients in a hygienic and safe environment.

Standard 1.7 Put patients’ interests before your own or those of any colleague, business or orginisation.

Standard 1.9 Find out about laws and regulations that affect your work and follow them.

Principle 2 – Communicate effectively with patients

Standard 2.2 Recognise and promote patients’ rights to and responsibilities for making decisions about their health priorities and care.

Standard 2.2.1 You must listen to patients and communicate effectively with them at a level they can understand. Before treatment starts you must:

• explain the options (including those of delaying treatment or doing nothing) with the risks and benefits of each; and


• give full information on the treatment you propose and the possible costs.

Principle 3 – Obtain valid consent

Standard 3.1 Obtain valid consent before starting treatment, explaining all the relevant options and the possible costs.

Standard 3.1.1 You must make sure you have valid consent before starting any treatment or investigation. This applies whether you are the first member of your team to see the patient or whether you are involved after other team members have already seen them. Do not assume that someone else has obtained the patients consent.

Standard 3.1.2 You should document the discussions you have with patients in the process of gaining consent. Although a signature on a form is important in verifying that a patient has given consent, it is the discussions that take place with the patient that determine whether the consent is valid.

Standard 3.3 Make sure that the patient’s consent remains valid at each stage of investigation or treatment.

Standard 3.3.1 Giving and obtaining consent is a process, not a one-off event. It should be part of on-going communication between patients and all members of the dental team involved in their care. You should keep patients informed about the progress of their care.

Standard 3.3.2 When carrying out an on-going course of treatment, you must make sure you have specific consent for what you are going to do during that appointment.

Standard 3.3.4 You must document the discussions you have with patients in the process of confirming their ongoing consent.

Principle 4 – Maintain and protect patients’ information

Standard 4.1 Make and keep contemporaneous, complete and accurate patient records.

Standard 4.1.1 You must make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients. Radiographs, consent forms, photographs, models, audio or visual recordings of consultations, laboratory prescriptions, statements of conformity and referral letters all form part of patients records where they are available.

Standard 4.1.2 You should record as much detail as possible about the discussions you have with your patients, including evidence that valid consent has been obtained. You should also include details of any particular patients treatment needs where appropriate.

Principle 7 Maintain develop and work with your professional knowledge and skills

Standard 7.1 Provide good quality care based on current evidence and authoritative guidance.


Standard 7.3 Update and develop your professional knowledge and skills throughout your working life. These heads of charge relate to the treatment and care you provided to 20 patients between February 2003 and May 2017. It particular there are failures to maintain an adequate standard of care and record keeping in respect of most of the patients in this case, including: · Failing to diagnose, and treat caries; · Failing to investigate and treat pulpitis; · Failing to investigate and treat periodontal disease; · Failing to inform the patient of their periodontal disease; · Failing to take periapical and bitewing radiographs when indicated; · Failing to use rubber dam during RCT; · Inappropriate prescription of antibiotics; · Inappropriate treatment planning; · Failing to obtain informed consent; · Not making clinical records for consultations; · Not updating medical history forms; · Not recording soft tissue examinations; · Inadequate reports in respect of radiographs; The Committee was satisfied that the clinical failings in these themes were wide-spread, prolonged, at times repeated and serious. They went to the very heart of a dentist’s duty to ensure patient safety and to put patients’ interests first. The failures concern basic and fundamental obligations of a reasonably competent dentist, for example:

• Failures to diagnose and treat caries and pulpitis expose patients to the risks of pain and further harm if decay is not detected and treated in a timely way. Patients affected by these inadequacies may therefore have been unduly exposed to a risk of harm.

• Failures to investigate and treat periodontal disease or to inform the patient and discuss it with them could expose patients to the risks of pain and further dental harm if problems around the teeth are not detected and treated properly. The Committee noted Dr Tyler stated in her report that failure to address periodontal concerns “runs the risk of further caries, pain, swelling and tooth loss”.

• Failures in radiography. The taking of radiographs is a basic aspect of practice for any dentist. Your failure to take a radiograph might expose a patient to greater risk from a problem not able to be seen by the naked eye. Where a radiograph is inadequately reported, its clinical justification may not be clear or understood, and the clinician taking it or causing it to be taken may well be in breach of the (legal) requirements of IR(ME)R 2000. It may lead a subsequent treating dentist to take further radiographs, and lead to further exposure to ionising radiation. Patients affected may therefore be unduly exposed to a risk of harm.

• Failures to use a rubber dam during RCT can expose the patient to the risk of oral contamination and compromise patient safety. Patients affected by these inadequacies may therefore have been unduly exposed to a risk of harm.

• Your inappropriate prescription of antibiotics can expose an individual patient to the risk of harm. Dr Tyler refers to WHO guidance which deems antimicrobial resistance to be one of the biggest threats to global health and stresses the important role of dentists in addressing the concern of over-prescription.


• Record keeping failures in not recording; accurate BPE scores, working lengths during RCT, inadequate reports on radiographs, updated medical history forms, clinical assessment details such as occlusion and bone loss, and caries risk. These are all records in respect of basic aspects of dentistry. Without adequate records, it is difficult if not impossible for the practitioner, or a subsequent treating practitioner, properly to treat the patient in the future.

• Failures to diagnose or to obtain informed consent are fundamental failings in relation to a basic aspect of dentistry. Patients should be given a diagnosis and should be told their treatment options, and also the risks and benefits of a proposed treatment so they can make choices about their own treatment. Your failures to plan treatment properly can mean a patient is exposed to the risk of unnecessary further treatment.

The Committee has taken into account the evidence of Dr Tyler, who considered that the heads of charge taken cumulatively justifies a finding of misconduct. The Committee agrees. The Committee is satisfied that the heads of charge fell far below the appropriate standard expected of a reasonably competent dentist. The Committee is satisfied that the clinical failings were serious and occurred over a significant period of time. They involved a number of serious departures from basic aspects of dental practice, which were repeated in a number of the patients in this case. The Committee concluded that your conduct was a serious departure from the standards expected of a registered dental professional and would be considered deplorable by fellow professionals and members of the public. Having regard to all of the findings against you, both in relation to the clinical matters and in relation to your conduct towards colleagues, the Committee concludes that they are serious and amount to misconduct. Deficient Professional Performance The allegation in this case is that of impaired fitness to practise by reason of misconduct and/or deficient professional performance. The Committee has determined that the totality of the facts found proved amount to misconduct, so it has not been necessary for it to reach a separate finding in relation to whether those same facts amount to deficient professional performance. Impairment The Committee next considered whether your fitness to practise is currently impaired by reason of your misconduct. In deciding on the issue of current impairment, the Committee had regard to the over-arching objective of the GDC, which involves: the protection, promotion and maintenance of the health, safety and well-being of the public; the promotion and maintenance of public confidence in the dental profession; and the promotion and maintenance of proper professional standards and conduct for the members of the dental profession. The Committee decided that your failings, as identified in this case, are capable of being remedied. Notwithstanding the serious and fundamental nature of the shortcomings, the Committee considered that your deficiencies could be addressed. In assessing whether in fact your failings have been remedied, the Committee had regard to the evidence of the steps you have taken to address them, as provided in your remediation


bundle. The Committee noted the steps that you have taken to remediate your clinical failings including your CPD, which included your attendance of relevant courses, and your reflections. At the outset you admitted all of the charges against you apart from behaving in a threatening manner in head of charge 2. In addition, you have conceded that your conduct had breached the relevant standards, guidelines and regulations. You have accepted the shortcomings both in your conduct towards colleagues and also in your clinical practice and you have apologised for your failings. You explained that some of the errors and omissions were as a result of external stresses that were in your personal life, together with a strained relationship with your practice partner. In respect of your behaviour towards colleagues, the Committee has not seen any evidence of any deep-seated attitudinal issues, more likely that it was a response to the challenging circumstances that you found yourself in. [PRIVATE]. You have attended courses on effective communication and professionalism. You have also provided reflection into your behaviour at that time. When asked if you would repeat this behaviour, you were honest in that you could not guarantee that you “would not boil over again”, however, you now have support mechanisms and strategies in place in order to reduce the risk of repeating this type of behaviour in the workplace again. The Committee is satisfied that in relation to your inappropriate and threatening behaviour the risk of repetition is low. However, it is in the public interest to make a finding of impairment given the serious nature of threatening behaviour particularly in a workplace setting. The Committee went onto consider the remaining heads of charge, 3-90 which relate to the wide ranging and serious clinical concerns. The Committee was satisfied that you have demonstrated a level of insight and that you have reflected on the risk of harm to patients and the public. The Committee heard from your previous colleague Dr Chope for whom you worked with in the early 1980’s who has offered to be your supervisor should conditions be imposed on your registration. The Committee was also conscious of the passage of time since the events. However, the Committee has noted that you have been unable to provide evidence of how you have embedded your learning into your practice, given your suspension. The Committee was impressed with your written and oral evidence with regard to your reflection on your clinical deficiencies. Whilst the Committee agreed that you have made progress in addressing the issues arising from your treatment of patients, it considered that your remediation is not yet complete as you have been suspended for over three and a half years and this has hindered your ability to test your theoretical learning. Therefore, you been unable to embed effective changes into practice and to demonstrate that you are fit to practise. The Committee considers that you are currently at the start of practical remediation. In light of this, the Committee decided that there remains an ongoing risk of repetition. Therefore, the Committee concluded that the safety of the public is a continuing concern in this case. The Committee also considered the wider public interest. In its view, if members of the public had regard to your failings and the incomplete remediation, they would expect a finding of impairment to be made. The Committee decided that in the absence of such a finding, public confidence in the dental profession and the GDC as the regulator, would be undermined.


Accordingly, the Committee determined that your fitness to practise is currently impaired by reason of your misconduct. Sanction The Committee considered what sanction, if any, to impose on your registration. In reaching its decision, it took into account the ‘Guidance for the Practice Committees including Indicative Sanctions Guidance (effective from October 2016)’ (the Guidance). It noted that the purpose of any sanction is not to be punitive, although it may have that effect, but to protect the public and the wider public interest. The Committee applied the principle of proportionality, balancing the public interest with your own interests. In its consideration of the appropriate sanction, the Committee took into account what it considered to be the aggravating and mitigating factors in this case. In terms of aggravating features, the Committee noted the following:

• risk of actual harm to patients including at least one vulnerable patient;

• actual harm to one patient;

• misconduct sustained over several years;

• the considerable number of cases involved. In relation to mitigation, the Committee had regard to the following:

• evidence of your challenging personal circumstances at that time;

• evidence of your good conduct following the incident in question, including significant remedial action;

• evidence of your good character;

• evidence of remorse shown, and apology given; Taking all the above factors into account, the Committee considered the available sanctions in ascending order. Having found that there is an ongoing risk of repetition, the Committee decided that it would be inappropriate to conclude this case without taking any action in relation to your registration. It considered that such a course of action would not provide the necessary public protection and it would not address the wider public interest concern in this case. The Committee next considered whether to issue you with a reprimand. It had regard to the Guidance which states that a reprimand might be appropriate if the circumstances do not pose a risk to patients or the public which requires rehabilitation or restriction of practice. In view of the Committee’s concern about the ongoing risk to the public, it determined that a reprimand would not be an appropriate or proportionate outcome. The Committee went on to consider whether to impose conditions on your registration. In doing so, it took into account paragraph 7.18 of the Guidance which deals with the sanction of conditions. It found that a number of the factors in support of imposing conditions applied in this case. In particular, the Committee was satisfied that you are progressing well with the process of remediation. The Committee also took into account your engagement with these fitness to practise proceedings and that you have expressed a willingness to work under a set of conditions.


In the circumstances, the Committee concluded that it was possible to formulate a set of conditions that will protect the public during the period they are in force. It also considered that conditional registration would serve to satisfy the wider public interest. Furthermore, the Committee was of the view that conditions would assist you in targeting your remediation and making your practice safer. It notes that Dr Chope has also offered to act as your mentor and/or supervisor throughout your remediation process. It has noted that your remediation is well under way but not complete, and the Committee is therefore satisfied that conditions ensuring that you are supervised are required. The Committee was mindful that the sanction imposed must be the least severe sanction which deals adequately with the identified issues whilst protecting the public interest. It was satisfied that conditional registration would be sufficient to address its outstanding concerns. In deciding to impose a conditions of practice order, the Committee was mindful that it could impose a suspension. However, it concluded that the public interest and the need for public protection identified in this case was not such that it warranted the suspension of your registration. You have already begun on the pathway of remediation and shown insight. It therefore decided that a suspension would be disproportionate. It noted that you have been suspended for three and a half years now and a further period of suspension would serve no useful purpose and would prevent someone of your experience and skills from returning to dentistry. In all the circumstances, the Committee has determined to impose conditions on your registration for a period of 24 months. In deciding on this period, the Committee took into account that you have already engaged in this process and your remediation is well under way. It considered the serious failings highlighted in its findings. It decided that, even with good progress, it would take some further time for you to produce evidence of how you have embedded all your learning into your practice, particularly as the clinical environment has considerably changed since you last practised. The following conditions are worded and set out as they will appear against your name in the Dentists Register:

1. He must notify the GDC within 7 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 the Local Health Board if in Wales, Scotland or Northern Ireland.

2. If employed, he must allow the GDC to exchange information with his employer or any contracting body for which he provides dental services and any Postgraduate Dental Dean/Director, reporter, workplace supervisor or educational supervisor referred to in these conditions.

3. He must inform the GDC of any formal disciplinary proceedings taken against him, within 7 days of being notified of any such disciplinary proceedings.

4. He must inform the GDC of any complaints made against him, within 7 days of being notified of any such disciplinary proceedings.

5. He must inform the GDC within 7 days if he applies for dental employment outside the UK.


6. He must work with a Postgraduate Dental Dean (or a nominated deputy), to arrange any necessary return to work training (to be completed before his return to clinical practice) and formulate a Personal Development Plan, specifically designed to demonstrate that he has addressed the deficiencies in the following areas of his practice: (a) examination, assessment and diagnosis; (b) treatment planning (including patient consent); (c) radiography (including reporting on radiographs);

(d) record keeping; (e) prescribing antimicrobials; (f) safe practice including the use of rubber dam where appropriate; (g) working towards GDC Standard 6.1 – working effectively with colleagues.

7. He must forward a copy of his Personal Development Plan to the GDC within three months of the date on which these conditions become effective and to be updated and sent to the GDC not less than two weeks prior to any review of these conditions.

8. He must meet with the Postgraduate Dental Dean (or a nominated deputy), on a regular basis to discuss his progress towards achieving the aims set out in his Personal Development Plan. The frequency of the meetings is to be set by the Postgraduate Dental Dean (or a nominated deputy).

9. He must allow the GDC to exchange information about the standard of his clinical performance and his progress towards achieving the aims set out in his Personal Development Plan with the Postgraduate Dental Dean (or a nominated deputy), and any other person involved in his retraining and supervision.

10. At any time he is providing dental services, which require him to be registered with the GDC, he must agree to the appointment of a reporter nominated by him and approved by the GDC. The reporter shall be a GDC registrant and can be the workplace supervisor.

11. At any time he is providing dental services, which require his to be registered with the GDC: (a) he must not engage in single handed practice. (b) he must confine his dental practice to general dental practice posts; (c) he must practise dentistry only once he has completed any necessary return

to work training and under the supervision of a workplace supervisor*, to be nominated by him within 14 days, and approved by the GDC. The workplace supervisor shall be a GDC registered Dentist, and must work in the same practice in which he practises dentistry. The supervision need not extend to close or direct supervision.

12. He must ensure that the workplace supervisor can make himself/herself available to provide advice or assistance if required;


13. He must ensure his work is reviewed at least once fortnightly by the supervisor via one-to-one meetings and case-based discussion, and a record kept of these meetings. These fortnightly meetings must be focussed on all areas of concern identified by the conditions including a reflective log of how he has worked and communicated effectively with colleagues.

14. He must allow the workplace supervisor to provide reports to the GDC every three months and the GDC will make these reports available to any Postgraduate Dental Dean referred to in these conditions if requested. The reports should address their meetings and the areas of deficiency identified at condition 6 above.

15. He must carry out audits every six months in relation to the following areas and must provide these audits to the GDC within 14 days of their completion and within two weeks of any review of these conditions. Audits should be signed by the workplace supervisor after completion and prior to their submission to the GDC: (a) examinations, assessment and diagnosis; (b) treatment planning (including patient consent); (c) radiography (including reporting on radiographs);

(d) record keeping; (e) prescribing antimicrobials; (f) safe practice including the use of rubber dam where appropriate;

16. He must allow the GDC to exchange information with any Postgraduate Dental Dean, workplace reporter, or workplace supervisor referred to in these conditions.

17. He must provide copies of the following documents to the GDC at least 14 days before any PCC review hearing:

• an updated Personal Development Plan;

• a recent report from his supervisor.

• a reflective piece providing examples of how he has worked and communicated effectively with colleagues.

18. He must inform within one week the following parties that his registration is subject to the conditions, listed at (1) to (17), above:

(a) any organisation or person employing or contracting with his 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); (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).


19. He must permit the GDC to disclose these conditions to any person requesting information about his registration status.

*The registrant’s day to day work must be supervised by a person who is registered with the GDC in their category of the register or above. The supervisor need not work at the same practice as the registrant, but must make himself/herself available to provide advice or assistance should they be required. The registrant’s work must be reviewed at least once fortnightly by the supervisor via one-to-one meetings and case-based discussion. These fortnightly meetings must be focussed on all areas of concern identified by the conditions.

The Committee also directs that this direction for conditional registration be reviewed prior to the end of the 24-month period pursuant to section 27C(2) of the Act. The Committee will now invite submissions on whether an immediate order should be imposed in this case.

Decision on immediate order of conditions Having directed that your registration be subject to conditions, the Committee went on to consider whether to make an immediate order on your registration. The Committee has considered the submissions made by both parties. It has accepted the advice of the Legal Adviser. Mr McGhee, on behalf of the GDC, submitted that an order for the imposition of conditions on your registration forthwith is necessary for the protection of the public, and is otherwise in the public interest.

Mr Dhillon on your behalf did not oppose the application for an immediate order. The Committee has had regard to its reasons for finding current impairment, including the deficiencies in your clinical practice that still need to be addressed and the risk posed to members of public as well as its reasons for directing that your registration be subject to conditions. Given the risks identified in this case, the Committee is satisfied that it would not be appropriate to allow you to practise unrestricted during the appeal period. Accordingly, the Committee has determined that it is necessary for the protection of the public and is otherwise in the public interest to direct an order for the imposition of conditions on your registration forthwith. The conditions are the same as those set out in the Committee’s substantive direction, as previously announced. If, at the end of the appeal period of 28 days, you have not lodged an appeal, this immediate order will lapse and will be replaced by the substantive direction of conditional registration for a period of 24 months. If you do lodge an appeal, this immediate order will continue in effect until that appeal is determined. Any interim order on your registration is hereby revoked”.

Documents

HEARING PARTLY HEARD IN PRIVATE* BARRIE, Charles Orr