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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Deputy Commissioner, Carolyn Cooper has highlighted the importance of providing clear information to allow consumers to make an informed decision about their care and give informed consent in a decision published by the Office of the Health and Disability Commissioner.
In her decision, Ms Cooper found a dentist in breach of the Code of Health and Disability Services Consumers’ Rights for care provided to twin girls when they received early orthodontic (orthotropic) treatment between 2017 and 2019. The treatment was provided by a general dentist with assistance from various orthodontic auxilliaries at a dental service.
In May 2017, a mother took her daughters (twin girls) for an orthodontic consultation with a dentist for concerns she had about their “crooked” teeth. The dentist recommended a two-phased orthodontic approach for both girls. The treatment undertaken over a two year period was considered “early orthodontic treatment” and included removable plates, braces, and retainers.
The girls attended the dental service for various appointments with the dentist and orthodontic auxiliaries. The mother sought a review from another dentist when she became concerned about the progress of her daughters’ treatment, and, following this, she terminated the therapeutic relationship.
Ms Cooper considered expert advice provided, that “early orthodontic treatment” is a contentious area of dental practice with little evidential basis, and it is crucial to ensure the patient has all the facts, and appropriate literature on both sides so they can make up their own mind, without being swayed one way or the other by the practitioner”.
“I would expect the mother to be informed there was a lack of clear evidence supporting early orthodontic treatment, and of the clinical justifications for recommending the treatment plan, despite the lack of clear evidence, the risks specific to the procedure, and details of alternative treatment options specific for her daughters.
“Without this information, the mother was not in a position to give her informed consent to the treatment for her daughters, so I find the dentist in breach of the Code,” says Ms Cooper.
Adequate documentation is an integral part of clinical practice, and the requirement for practitioners to keep clear and accurate clinical records is a fundamental obligation. These standards are set out by the Dental Council of New Zealand. It is important when undertaking treatment, practitioners thoroughly document in the clinical notes all assessments, diagnoses, treatment undertaken, progress, reasoning, recommendations, and discussions.
“I am critical the dentist, did not record robust and detailed clinical notes to support his clinical view, and ensure details of the treatment and subsequent consultations for both girls were clearly documented,” says Ms Cooper.
As a healthcare provider, the dental service is responsible for providing services in accordance with the Code. Ms Cooper was concerned several examples of inadequate record-keeping and provision of information reflected deficiencies at a practice level.
While Ms Cooper did not find the dental service in breach of the Code, she made an adverse comment regarding the insufficiency of processes in place at the dental service to support its practitioners to provide patients with adequate information and obtain informed consent for treatment.
Ms Cooper recommended the dentist provide a written apology to the family, and arrange an external audit to ensure adequate informed consent was obtained and clinical documentation was of an appropriate standard. She further recommended the dental service develop and provide training to staff on clinical documentation and informed consent, develop a written information sheet containing information specific to early orthodontic treatment and consult with the Dental Council of New Zealand (DCNZ) to ensure the dental service’s informed consent forms and policies are consistent with DCNZ guidance.
Following events of this case, the dentist has made changes to their practice to improve record-keeping, underwent two competence reviews with DCNZ with recommendations made to improve communication, written information, and informed consent and completed training on informed consent and patient communication.
The dental service has also made changes to its practice, which include ensuring its note-keeping practices are more detailed and thorough and updated their consent forms and letters.
This case relates to a complaint made to HDC in 2020. We aim to investigate complaints as promptly as possible, while ensuring natural justice and the interests of all the parties involved to provide information, and respond to evidence put forward by others is considered. 
Names have been removed from the report to protect privacy of the individual involved in this case. We anticipate that the Commissioner will name Te Whatu Ora (previously DHBs), and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. HDC’s naming policy can be found on our website here.