HEARING HEARD IN PUBLIC GENERAL DENTAL COUNCIL PROFESSIONAL CONDUCT COMMITTEE MAY 2012 to June 2013 **
** See page 8 for the latest determination. HELL, Stephan Alexander Registration No: 84147 Stephan Alexander Hell registered as of Apartment 2, The Boiler House, Shaddon Mill, Shaddongate, Carlisle Cumbria, CA2 5WE, Zahnarzt Munich 1972, was summoned to appear before the Professional Conduct Committee on 22 May 2012 for inquiry into the following charge:
At the material times you were in practice at the Central Dental Practice, 36 Victoria Place, Carlisle, CA1 1EX (“the Practice”);
On 24 May 2010 Patient A (who is identified in the attached schedule) consulted you at the Practice on an emergency basis complaining in effect of severe toothache in her lower left jaw attributable to a left lower molar (“the tooth”);
On 24 May 2010 as regards Patient A’s records you:
failed to note the nature and/or duration of her reported pain,
made a clinically unknown entry purportedly recording “desmodontitis abces”,
failed to provide and/or make a record of alternative treatment options available to Patient A,
failed to take and/or make a record of Patient A’s medical history;
You prescribed amoxicillin on 24 May 2010 and 10 June 2010 and on each occasion did so:
without clearly and/or unambiguously recording the treatment and dosage,
in clinically incorrect dosages in any event;
As a consequence of paragraphs 3, and/or 4 (a) above you failed to maintain
As a consequence of paragraph 4 (b) and/ or 4(c) above your prescribing fell seriously below the standard to be expected of a registered dental practitioner;
Professional Conduct Committee – MAY 2012 – JUNE 2013
failed to attempt surgical drainage of the tooth without good clinical reason, by extraction or otherwise,
prescribed solely antibiotic therapy unjustifiably,
failed to manage Patient A’s pain effectively,
discontinued your attempt to extract the tooth without sufficient clinical reason,
failed to make any further attempt to obtain effective analgesia for surgical purposes,
took a radiograph inadequate for diagnostic and/or clinical management purposes,
(iv) did not seek advice and/or refer on Patient A for further advice or
failed to manage Patient A’s on-going pain effectively,
failed to attempt to extract the tooth without good clinical reason,
further prescribed solely antibiotic therapy unjustifiably,
unjustifiably sent Patient A away to return in approximately 6 – 8 weeks time,
(iv) failed to refer on and/or consider referring on Patient A for further advice or
failed to manage Patient A’s pain effectively,
(vi) spoke to Patient A unreasonably abruptly;
As a consequence of paragraphs 6 (a) and/or 6 (b) and/or 6(c) above your management of Patient A’s clinical care fell seriously below the standard to be expected of a registered dental practitioner;
By letter dated 15 June 2010 Patient A complained to the Practice about your
you made no or no meaningful response to Patient A other than an acknowledgment of the complaint,
you failed to address Patient A’s complaint in a professional manner;
And by reason of the facts alleged your fitness to practise is impaired by reason of your misconduct.”
Professional Conduct Committee – MAY 2012 – JUNE 2013
Mr Hell was not present and was not represented. On 23 May 2012 the Chairman announced the findings of fact to the Counsel for the GDC:
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.
I will now announce the Committee’s findings in relation to each head of charge:
Proved. The clinical records show that that the nature and/or duration of the pain had not been noted. The Committee accepted the expert evidence that this information would aid a correct diagnosis: it is common practice to note this and it is necessary for any subsequent treating dentist.
Not proved. Although “desmodontitis abces” would not normally be recognised in the UK, it does appear to be German or French dental terminology, as confirmed by the expert evidence.
Proved only in relation to a failure to make a record of alternative treatment options. There is a note stating ‘treatment options discussed’, Patient A’s memory was unclear as to the substance of this discussion. The Committee could not therefore find that there was no such discussion. There was not, however, any note of the range of options discussed and the Committee accepts the expert evidence that this was a failure.
Proved. The Committee finds the note of the prescription on 24 May 2010 “500mg amoxicillin 4/7” does not relate to any prescribing protocol recognised by the expert witness. The prescription on 10 June 2010 was recorded in two places in the clinical notes in two different ways.
Proved only in relation to 10 June 2010. On 24 May 2010 Mr Hell prescribed “500mg amoxicillin 4/7” and diagnosed “pulpitis purulenta” as his clinical justification. However on 10 June 2010 there is no note of any clinical justification for the repeated prescription of amoxicillin.
Proved. The Committee considered this charge on the basis presented, i.e. that 500mg was not the dosage supported in the literature that had been relied upon by the expert witness, that being the Faculty of General Dental Practitioners (UK) guidance “Prescribing in Primary Dental Care for General Dental Practitioners”. The Committee accepts the expert evidence in this respect. The Committee noted also the “4/7” dosage, which does not follow any recognisable prescribing pattern.
Proved in relation to the charges in paragraphs 3 and 4a found proved.
Proved. As a consequence of the facts found proved above relating to both Mr Hell’s failure to record a clinical justification on 10 June 2010 for a prescription, and to his prescription of clinically incorrect dosages on both 24 May 2010 and 10 June 2010, the Committee found proved that Mr Hell’s prescribing fell far below the standard expected. The Committee accepts the expert evidence in this respect.
Professional Conduct Committee – MAY 2012 – JUNE 2013
Proved. The Committee accepts the expert’s evidence that Mr Hell’s noted opinion that an injection would not work was not valid. The Committee also accepted the expert’s opinion that surgical drainage should have been attempted on this occasion and that not to do so was a failure.
Proved. Although the Committee noted that Mr Hell had given his own clinical justification for the prescription of antibiotic therapy on this date, it accepts the expert’s advice that to provide antibiotic therapy alone at this appointment was not justifiable.
Not proved. The Committee accepted the expert’s opinion that it would have been better to attempt surgical drainage of the tooth at this first appointment nevertheless Patient A’s evidence was that Mr Hell had advised her to take pain relief and the notes confirm that a follow up appointment was made to extract the tooth at a later date. The Committee accepts that it is normal practice for a clinician to recommend the use of over the counter pain relief.
Proved. The Committee noted that in the clinical records for the appointment on 7 June 2010, Mr Hell recorded his suspicion that the root of the LL8 was around the nervus mandibularis, however the Committee accepts the expert’s opinion that Mr Hell did not have sufficient clinical information on which to base this opinion, nor did he take the necessary steps to establish whether or not it was the case.
Proved. The Committee accepted the expert’s opinion that it was a failure not to attempt to administer more local anaesthetic, given both the partially extracted tooth and the Patient’s evidence that she continued to be in pain during the surgical procedure.
Proved. The Committee was shown the radiograph taken on this date. It noted that the tooth being treated was not on the radiograph, nor the apices of any of the teeth, nor the mandibular nerve.
Proved. Patient A’s evidence was that no referral was made nor any advice sought by Mr Hell from any other source to her knowledge. Nor is there any note made of any such referral or advice in the clinical record.
Proved. The Committee accepted Patient A’s evidence that Mr Hell allowed her to leave his care that day with a partially extracted tooth and that, on being questioned as to how to manage the pain when the anaesthetic fully wore off, his advice was “just take pain relief”.
Not proved. The Committee accepted that the process of taking the radiograph would be likely to cause significant discomfort. Patient A perceived this as rough treatment, but was not able to give a detailed account of what happened. The Committee is not satisfied, on the balance of probabilities, that this allegation is proved. It took into account that the attempt to x-ray the LL8 was made after two attempts to extract the tooth and in circumstances where the local anaesthetic was only partially effective.
Proved on the basis of the expert evidence and on the evidence of the clinical notes where no reason was given for this omission.
Proved on the basis of the expert evidence and on the evidence of the clinical notes.
Professional Conduct Committee – MAY 2012 – JUNE 2013
Proved. The Committee accepts Patient A’s evidence that Mr Hell told her to book her next appointment in August. The Committee noted the appointments log confirming Patient A’s evidence of the date of the next appointment.
Although the Committee accepted the Patient’s evidence that Mr Hell told her to return if her pain worsened, sending Patient A away with a partially extracted tooth was unjustifiable, particularly given the continuation and worsening of the Patient’s pain.
Proved. This was the third appointment for this patient. The Committee accepted the expert’s evidence that Mr Hell, having not resolved the problem himself, had an obligation to refer Patient A for further advice and treatment.
Proved. Given the history of Patient A’s pain up to this appointment, the Committee finds that it should have been clear to Mr Hell that neither antibiotics nor over the counter pain relief were effective in her case.
Proved. The Committee accepts Patient A’s evidence on this matter.
Proved on the basis of the expert evidence.
Proved on the basis of the expert evidence.
Proved. The Committee accepted Patient A’s evidence that she had received no response from Mr Hell personally other than the letter dated 13 July 2010 acknowledging the complaint and indicating that he had forwarded the matter to his indemnity providers, the Dental Defence Union.
Proved. The Committee took into account that various letters had been sent by the Practice which did contain apologies, however the letter written by Mr Hell himself to the Patient dated 13 July 2010 did not contain an apology, nor a timescale, as is expected by his regulatory body. The Committee accepts the Patient’s evidence that there has been no further contact from Mr Hell or on his behalf.
Head of Charge 3(d) was withdrawn on the basis that evidence was produced which established that Mr Hell did in fact take a Medical History from Patient A.
On 24 May 2012 the Chairman announced the determination as follows:
Mr Hell was neither present nor represented throughout these proceedings. The Committee determined that all reasonable efforts had been made in accordance with the Rules to notify Mr Hell of the hearing and that it was fair to proceed in his absence.
The Committee has considered all the information before it and has accepted the advice of the Legal Adviser. It has had regard to the sanctions guidance within the Guidance to the Professional Conduct Committee.
At the material time Mr Hell practised at the Central Dental Practice, 36 Victoria Place, Carlisle, CA1 1EX (“The Practice”). Patient A attended for an emergency appointment with Mr Hell at the Practice on 24 May 2010, complaining of severe toothache in relation to a lower left molar. At that appointment, Mr Hell failed to treat her complaint properly, in that he
Professional Conduct Committee – MAY 2012 – JUNE 2013
did not attempt surgical drainage of the tooth as he should have, nor did he note the nature and/or duration of the pain, nor what options had been discussed with the patient. Instead, he sent the patient away with a prescription for antibiotics which did not conform to any recognised dosage.
When the patient returned to Mr Hell on 7 June 2010, he unsuccessfully attempted to extract the tooth. He did not ensure that effective analgesia was achieved for the process of the extraction and discontinued it without good clinical reason. The tooth was left partially extracted and the patient was sent away again. The pain she was suffering was managed ineffectively, in that Mr Hell advised her to seek over the counter pain relief. He did so despite being told that such pain relief had proved ineffective in the past. On this appointment, Mr Hell also took a radiograph inadequate for diagnostic and/or clinical management purposes.
Patient A returned again on 10 June 2010 with the partially extracted tooth and still in extreme pain. Mr Hell again failed to extract the tooth, spoke to Patient A abruptly and sent her away with an inappropriately prescribed course of antibiotics. He left her to rely on over the counter pain relief. He did so again despite the fact that it should have been clear to Mr Hell that neither antibiotics, nor over the counter remedies, were effective in patient A’s case.
On both 7 June 2010 and 10 June 2010, Mr Hell should have referred Patient A when he failed to extract the tooth himself, instead of leaving her to suffer from unnecessary, extreme pain. Patient A stated in evidence that when she was finally treated by another dentist, a dentist who Patient A had to seek out herself, her tooth was extracted without difficulty and the relief was instantaneous. When she then complained to the practice about her treatment from Mr Hell, he failed to respond professionally, making no meaningful response to the complaint himself, then or since, other than an acknowledgment of the complaint.
The Committee found that Mr Hell’s record keeping was inadequate in a number of respects throughout his treatment of Patient A.
Mr Hell’s conduct breached fundamental tenets of the profession, as outlined in Standards for Dental Professionals, whichstates that Dentists should:
1.3 Work within your knowledge, professional competence and physical abilities. Refer
patients for a second opinion and for further advice when it is necessary, or if the patient asks. Refer patients for further treatment when it is necessary to do so.
1.4 Make and keep accurate and complete patient records, including a medical history, at
the time you treat them. Make sure that patients have easy access to their records.
1.5 Give patients who make a complaint about the care or treatment they have received a
helpful response at the appropriate time. Respect the patient’s right to complain. Make sure that there is an effective complaints procedure where you work and follow it at all times. Co-operate with any formal inquiry into the treatment of a patient.
2.1 Treat patients politely and with respect, in recognition of their dignity and rights as
Mr Hell also failed to do what was expected of him by the guidance outlined in the GDC document Principles of complaints handling.
Although the scope of the allegations relate to only one patient, the failings were wide-ranging, serious and constitute a catalogue of errors. There were three occasions on which Patient A encountered Mr Hell’s incompetence, and as a result she was made to suffer unnecessarily and over a significant period of time. In the aftermath of the treatment Mr Hell continued to neglect his responsibilities in relation to this patient by not responding to the
Professional Conduct Committee – MAY 2012 – JUNE 2013
complaint professionally. In the circumstances of this serious falling short from acceptable standards, the Committee had little difficulty in determining that the facts found proved amount to misconduct.
The Committee next considered whether Mr Hell’s fitness to practise is impaired by reason of his misconduct. The Committee has not drawn any adverse inference from the fact that Mr Hell did not attend this hearing. However, as a result of his failure to engage with this investigation the Committee has not had the benefit of any evidence that he has remedied his failings. He failed to make amends to Patient A, or cooperate with his employers on this matter. All contact relating to the complaint ceased when he stopped working as a dentist at the practice in September 2010 despite attempts to engage with him. The Committee considered that his misconduct represents an on-going threat to patient safety. His practice in a range of areas was not in line with current best practice, as demonstrated by inconsistencies in his note-keeping and prescribing which display a careless approach to critical aspects of patient care. In all the circumstances it determined that his fitness to practise is impaired by reason of his misconduct. A finding of impairment is necessary in the circumstances in order to maintain public confidence in the profession and to protect the public.
The Committee considered that, given the serious nature of Mr Hell’s impairment, to conclude the case with or without a reprimand would be wholly inappropriate. It then considered whether or not conditions would be appropriate. Given Mr Hell’s lack of engagement with the process, conditions would be unworkable. The Committee could not have confidence that he would have complied with them. Had Mr Hell provided evidence of insight and an intention to comply with conditions, or provided evidence of any remedial steps taken by him since the material time, the Committee might have come to a different conclusion.
The Committee next considered whether a period of suspension would be sufficient. It considered that whilst Patient A was left in pain and was treated poorly by Mr Hell, when he should have known to behave differently, the harm was not deliberate and Mr Hell did give reasoning for acting the way he did, albeit flawed reasoning. The failings related to only one course of treatment of one patient and Mr Hell was previously of good character. In these circumstances, the Committee determined, balancing the public interest against Mr Hell’s own interests, that a period of suspension, to be reviewed, would be the proportionate outcome.
The Committee has therefore determined to suspend Mr Hell’s name from the Register for a period of 12 months, to be reviewed shortly before the end of that period.
The Interim Order currently applying to Mr Hell’s registration is hereby revoked.
The Committee is minded to impose an order for Mr Hell’s immediate suspension from the Register, but first invites your submissions on this matter.
The Committee considers that it is necessary for the protection of the public and otherwise in the public interest that an order is imposed to immediately suspend Mr Hell’s name from the Dentists Register.
The effect of the foregoing direction and order is that Mr Hell’s name is suspended from when notice of this decision is deemed served upon him and, unless he exercises his right of appeal, the name of Stephan Alexander Hell will be suspended for a further period of 12
Professional Conduct Committee – MAY 2012 – JUNE 2013
months after 28 days have elapsed. The situation will be reviewed shortly before the expiry of the period of suspension.
On 17 June 2013 at the review hearing, the Chairman announced the determination as follows:
The Committee has considered all the information before it and has accepted the advice of the Legal Adviser.
On 24 May 2012 the Professional Conduct Committee suspended Mr Hell’s registration for 12 months and made an immediate suspension order after determining that his fitness to practise was impaired as a result of a number of failings relating to his treatment and handling of a Patient A.
Patient A attended for an emergency appointment with Mr Hell at the Practice on 24 May 2010, complaining of severe toothache in relation to a lower left molar. At that appointment, Mr Hell failed to treat her complaint properly, in that he did not attempt surgical drainage of the tooth as he should have, nor did he note the nature and/or duration of the pain, nor what options had been discussed with the patient. Instead, he sent the patient away with a prescription for antibiotics which did not conform to any recognised dosage.
When the patient returned to Mr Hell on 7 June 2010, he unsuccessfully attempted to extract the tooth. He did not ensure that effective analgesia was achieved for the process of the extraction and discontinued it without good clinical reason. The tooth was left partially extracted and the patient was sent away again. The pain she was suffering was managed ineffectively, in that Mr Hell advised her to seek over the counter pain relief. He did so despite being told that such pain relief had proved ineffective in the past. On this appointment, Mr Hell also took a radiograph inadequate for diagnostic and/or clinical management purposes.
Patient A returned again on 10 June 2010 in extreme pain from the now partially extracted tooth. Mr Hell again failed to extract the tooth, spoke to Patient A abruptly and sent her away with an inappropriately prescribed course of antibiotics. He left her to rely on over the counter pain relief. He did so again despite the fact that it should have been clear to Mr Hell that neither antibiotics, nor over the counter remedies, were effective in patient A’s case.
On both 7 June 2010 and 10 June 2010, Mr Hell should have referred Patient A when he failed to extract the tooth himself, instead of leaving her to suffer from unnecessary, extreme pain. Patient A stated in evidence that when she was finally treated by another dentist, a dentist who Patient A had to seek out herself, her tooth was extracted without difficulty and the relief was instantaneous. When she then complained to the practice about her treatment from Mr Hell, he failed to respond professionally, making no meaningful response to the complaint himself, then or since, other than an acknowledgment of the complaint.
The Committee at the previous hearing found that Mr Hell’s record keeping was inadequate in a number of respects throughout his treatment of Patient A.
It determined that Mr Hell’s conduct breached fundamental tenets of the profession, as outlined in Standards for Dental Professionals paragraphs1.3, 1.4 1.5 and 2.1and Principles of Complaints Handling.
Today this Committee has reviewed the case. It has addressed its deliberations to the question of whether Mr Hell’s fitness to practise remains impaired.
Professional Conduct Committee – MAY 2012 – JUNE 2013
The Committee has not drawn any adverse inference from the fact that Mr Hell did not attend this hearing. However, as a result of his continuing failure to engage with these proceedings the Committee again has not had the benefit of any evidence that he has any insight into or has remedied his failings. The Committee considers that in the light of the wide-ranging and serious failings in his practice, patient safety remains a concern.
In all the circumstances the Committee has determined that his fitness to practise remains impaired.
The Committee considered that, given the serious nature of Mr Hell’s impairment and his lack of engagement, concluding the case would be wholly inappropriate. It determined that conditions would be unworkable as it could not have confidence that Mr Hell would engage or comply with them.
The Committee determined that it is necessary for the protection of the public to impose a further period of suspension for a period of 12 months. The order is to be reviewed shortly before the end of that period.”
Professional Conduct Committee – MAY 2012 – JUNE 2013
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