An unusual patient notification exerciseAn unusual patient notification exercise

Hazel J HendersonHazel J HendersonConsultant in Public Health, NHS Ayrshire and Arran

Infection control breaches in two dental practices reported to NHS Board by whistleblowerreported to NHS Board by whistleblower

Why was this PNE unusual?Why was this PNE unusual?

• Practice ‘covered up’ the breaches when Board tried to i i ki i diffi l i k iinvestigate – making it difficult to assess risk to patients 

N h d b d ( i h diff d• PNE had to be repeated (with a different message second time) due to unforeseen circumstances

Wh t th ll ti ?What were the allegations?

1) Gl d b t1) Gloves re-used between patients

2) Single use matrix bands) gautoclaved then re-used

3) Aspirator tips not being autoclavedautoclaved

Initial responseInitial response1) Convene PAG

2) Assess seriousness of alleged breaches

3) Investigate allegations:• Voluntary practice inspectionVoluntary practice inspection• Staff interviews

R t f i i• Request for invoices

4) Assess risk/implement control measures4) Assess risk/implement control measures

C l l ti BBV transmission riskCalculating BBV transmission risk• Practice list aligned with HPS BBV diagnosis databases• Practice list aligned with HPS BBV diagnosis databases

• Level of undiagnosed BBV infection in Scotland used to estimateLevel of undiagnosed BBV infection in Scotland used to estimate total number of patients in the practice with BBVs 

Thi i f i bi d i h k f h• This information was combined with key factors such as probability of blood on equipment being infected and viable

• Probability of infection from different instruments/procedures was estimated using current evidence

R t i ti ti fi diResponse to investigation findingsEvidence did not refute allegations:Evidence did not refute allegations:

1. Risk assessment of transmission likelihood

2. Patient notification exercise

3. BBV risk to patients extremely low – purpose of notification was ‘transparency’ –testing notnotification was  transparency  –testing not recommended

As a result of the notification exercise new and more seriousexercise, new and more serious

allegations emerged………..

1) Reuse of:• single use endodontic files• single use stainless steel burs

i l i i• single use 3 in 1 tips• single use impression trays• gloves between patientsgloves between patients• matrix bands

2) Incomplete processing of aspirator tips

3) Th f ll i ili d b f i d3) The following were not sterilized but surface wiped:• amalgam carriers• aspirator tips and ultrasonic scaler tips for single useaspirator tips and ultrasonic scaler tips for single use

Th ‘ t’ tifi ti iThe ‘repeat’ notification exercise1) Further investigation of new allegations) g g

2) New risk assessment undertaken. Concluded:2) New risk assessment undertaken. Concluded:

Given the equipment involved, which usually comes intoGiven the equipment involved, which usually comes into contact with blood during a procedure, and the number of Hep C infected patients within the practice, there was a 

higher risk of transmission for a small number of patients who received their dental treatment following a Hep C 

positive individual (diagnosed or undiagnosed)positive individual (diagnosed or undiagnosed).

Th h t thi i id t ti t ffThroughout this incident practice staff continually denied that any breachescontinually denied that any breaches 

had occurred

S d tifi ti iSecond notification exercise

d• 5100 Patients contacted

• 2250 patients tested (44%)• 2250 patients tested (44%)

• No cases of Hep B HIV• No cases of Hep B, HIV

• <5 cases of Hep C<5 cases of Hep C

• No evidence of BBV transmission within the practicep

L l ifi tiLegal ramifications• GDC Hearing investigated allegations of breaches and• GDC Hearing investigated allegations of breaches and of ‘cover up’

• Dentist, Practice Manager struck off. Nurse placed on conditions.

• 200+ patients suing dentist

Wh thi i l?Why was this exercise unusual?• Need for repeat notification exercise• Need for repeat notification exercise

• Dental practice dishonest in relation to allegations –e a p ac ce d s o es e a o o a ega o shampered investigation (GDC Hearing findings)

Lessons learnedLessons learned1) This incident raised concerns about the ability to assure 

infection control standards are being met within dentalinfection control standards are being met within dental practices.

2) Patient notification exercises can have an adverse impact on patients. 

3) The benefits of patient notification are unclear in instances such as this, where BBV risk to patients is estimated to be very lolow.

4) The financial cost (and opportunity cost) to the Health Board4)  The financial cost (and opportunity cost) to the Health Board was substantial.

C hi hli ht dConcerns highlighted

• Can we be confident that serious breaches are not occurring in other dental practices?

• Would current inspection and regulatory system pick them up?system pick them up?

We wrote to Chief Dental Officer (Scotland) outlining concerns…

P ?Progress?The  new dental regulations for Scotland now give g gNHS Boards the right to undertake unannounced inspections of Dental Practices providing NHSinspections of Dental Practices providing NHS General Dental Services, where concerns about 

ti t f t i d d i ipatient safety are raised during a previous routine inspection by the NHS Board; or 

information comes to light that necessitates further investigation by the NHS Board. g y

Th t f th tThe rest of the team:• Elvira Garcia Consultant in Public Health MedicineElvira Garcia, Consultant in Public Health Medicine

• Gill Hawkins, Consultant in Public Health Medicine

• Kate McDade, Health Protection Nurse Specialist

• Billy Cullinane, Health Protection Nurse Specialist 

Thank You 

Hazel J HendersonHazel J HendersonConsultant in Public Health, NHS Ayrshire and ArranNHS Ayrshire and Arran