Dental care and vulnerable adults

After the investigation at Winterbourne View Care Home, that focused attention on the mistreatment of vulnerable adults, it should be no surprise that ‘Safeguarding people from abuse’ was one of the four outcomes most commonly checked by the Care Quality Commission (CQC) during its first round of dental care inspections1.

As registered providers, dental practices are expected to ensure those who use services ‘are protected from abuse, or the risk of abuse, and their human rights are respected and upheld’2. The CQC places particular emphasis on the need for written practice policies and appropriate staff training and practices may wish to review their procedures in this area.

All dental professionals should know what to do if they encounter patients who are unable to take care of themselves or protect themselves from harm or exploitation. In the following fictional scenarios, which are based on the kind of queries the DDU receives, we look at the points to consider. DDU members should contact our advice line if they have specific concerns.

1) Restraint
An elderly woman arrived for a dental check-up accompanied by her son who confided that her memory had been getting worse and that she sometimes seemed confused. However, he said that she seemed in pain and she had been complaining about a throbbing ache in her back tooth.

On examination, the dentist found an inflamed swelling below the patient’s lower left 7 which he quickly diagnosed as a periodontal abscess. He told the patient what he had discovered and explained he would need to drain the abscess by cleaning the pocket. But, at this point, she became upset and tried to get out of the dental chair.
While the dentist was reluctant to treat her because he was worried he would add to the patient’s distress, her son urged him to continue. He contended that the treatment was ‘for her own good’ and that she would be grateful later when she was pain free. He suggested he could restrain his mother while the dentist drained the abscess.

DDU advice
It is important not to automatically assume from the patient’s demeanour that she does not have the capacity to refuse consent. Your first task is to carry out a mental capacity assessment to determine whether the patient is able to:
•    Understand the information relevant to the decision. This includes information about reasonably foreseeable consequences of deciding to agree to or refuse treatment, or failing to make a decision
•    Retain that information
•    Use or weigh up that information as part of the process of making the decision
•    Communicate their decision verbally or by any other means.
Should you decide that the patient meets the above criteria, which is set out in the Mental Capacity Act 2005, and has capacity, then it would be unlawful for you to treat her against her will. Patients with capacity have a right to make decisions about their own care, even if those decisions seem to place them at greater risk or appear unwise.
If, on the other hand, you decide the patient does not have capacity, you still need to decide what treatment, if any, is in her overall best interest. In this situation, forcing treatment on the patient may be unwise for the following reasons:
•    The significant risk that restraining her will leave her traumatised
•    The practical difficulties of carrying out the procedure on an unwilling patient that could lead to her suffering further harm
•    Given that the patient has periods of lucidity, it is possible she may regain capacity at a later date.
The most sensible approach may be to explain it would not be appropriate to continue and reassure the patient as best you can. Given that the abscess cannot be ignored, you will need to explore the options, such as providing pain relief and antibiotics to stop the infection spreading or making an urgent referral to a special care dentist who may be able to provide suitable treatment. As always, you should make a careful note of what has occurred.
In general, we advise practices to have written policies on assessing capacity, and on physically restraining patients which would set out the very limited circumstances when this might be permissible. The CQC’s Essential Standards of Quality and Safety sets out what it expects in relation to restraint, including that it should ‘only be used as a last resort, and that the type of restraint used should be the least restrictive and for the minimum amount of time to ensure that harm is prevented and that the person, and others around them, are safe’3.

2) Suspected abuse
A dental therapist made a domiciliary visit to a patient in his twenties with severe learning difficulties who was being cared for by his parents. She had been treating the patient for several years but, in recent visits, she felt the atmosphere in the house had been increasingly strained. During the appointment, the therapist noticed the patient appeared subdued and had a number of old bruises on his arms. She asked his mother if there was anything wrong and, after initially insisting that everything was fine, she broke down and admitted she had become so frustrated she had lost her temper and shaken her son. She swore this was a one-off and begged the therapist not to report the matter, as she did not want him to be taken away from her.

DDU advice
Any dental professional who suspects that a patient is being abused has a professional and ethical duty to report it to the relevant authorities. While the mother may be in need of help and support, there is a risk she may do this again and you cannot accept her word that this has not happened before.
When reporting concerns, you need to follow the procedures set out by your local Safeguarding Adults Board led by the local authority. We advise practices to have a senior person with the training and skills to advise staff how to document and report concerns. In addition, guidance from the Department of Health, Safeguarding vulnerable adults – the role of health service practitioners4 sets out, with case examples, how health professionals should respond when they have concerns.

References
1 Page 17, Market Report Issue 1: June 2012, CQC
2 Page 93, Essential standards of quality and safety, CQC, March 2010oviders
3 Page 96, Essential standards of quality and safety, CQC, March 2010
4 Safeguarding Adults: The Role of Health Service Practitioners, DH, 14 March 2011

Leo Briggs qualified from University College Hospital, London in 1989. Leo gained a masters degree in periodontology from the Eastman Dental Institute, London in 1995 and is on the GDC specialist register for periodontics.

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