Scrutinising Records in GDC Fitness to Practise Hearings

Clinical Context of Record Keeping

In General Dental Council (GDC) fitness to practise hearings, the quality and accuracy of clinical records are foundational to the evidence base. For instructing solicitors and legal teams, understanding how an expert witness interprets these records is essential for assessing whether a registrant’s performance has fallen below the expected standard. The GDC Standards for the Dental Team emphasise the maintenance of clear, accurate, and contemporaneous records. A professional approach to managing professional conduct and regulatory outcomes requires recognising that an absence of specific entries can be as significant as inaccurate ones. For instance, in periodontal care, the absence of periodic screening or full charting where indicated may create an evidentiary gap. An expert witness assessing these records typically evaluates longitudinal monitoring, staging of disease, and the documentation of relevant clinical history, including risk factors such as smoking or diabetes.

Legal Framework in Regulatory Proceedings

While GDC proceedings differ from civil litigation, the principles governing the use of expert evidence are often informed by the rigour required in the courts. Expert evidence in GDC proceedings must assist the panel in determining whether the clinical records reflect a systemic failure in the standard of care or a specific, isolated error. The test established in Bolam v Friern Hospital Management Committee [1957], as refined by Bolitho v City and Hackney Health Authority [1998], remains central to assessing clinical actions. An expert must determine whether the clinician’s documented actions were supported by a responsible body of professional opinion, and whether that opinion possesses a logical basis. In a regulatory context, this involves evaluating whether the record keeping was so inadequate that it hindered the provision of appropriate care, or whether the records failed to accurately represent the standard of care that was actually delivered.

Common Pitfalls in Evidence Scrutiny

Solicitors should be aware of several common errors when interpreting dental records for a hearing:

• Over-reading radiographs: Assuming that radiographic findings, such as bone loss or periapical lucency, were readily apparent at the time of imaging, without considering the clinical context or the imaging modality used.
• Causation errors: Assuming that a deficient record is synonymous with negligence in the clinical outcome. The expert must distinguish between the quality of the documentation and the clinical decision-making pathway.
• Informed consent gaps: Following Montgomery v Lanarkshire Health Board [2015], a failure to record the risks discussed with a patient, particularly regarding irreversible or elective procedures, is a critical issue that can be examined regardless of the clinical outcome.
• Assessment of diagnostic criteria: Recognising the limitations of clinical tools; for example, BPE scores are screening tools and not a substitute for comprehensive diagnostic assessment. Experts should identify when a clinician should have moved beyond screening to a more detailed examination.

The Role of the Expert Witness

The selection of an expert must be aligned with the specific dental sub-discipline relevant to the allegations. A case concerning orthodontic complications, such as root resorption, requires an expert who can assess monitoring intervals and the quality of communication. Conversely, allegations regarding oral surgery, such as nerve injury or post-operative complications, require an expert with specific clinical experience in that field who can interpret the justification for treatment and the quality of post-operative advice. The expert provides the GDC panel with an interpretation of the facts, addressing whether the records demonstrate a breach of the standard of care or whether the reported harm was a recognised risk of the procedure, provided that the patient was adequately informed.

Practical Guidance for Instructing Solicitors

When preparing to instruct an expert, solicitors should ensure the following documentation is available:

• Full, contemporaneous clinical notes and relevant correspondence with the patient.
• All relevant radiographs, including pre- and post-treatment imaging.
• Copies of GDC correspondence or patient complaints that triggered the investigation.
• Practice policies and protocols, particularly if the allegation concerns systemic failings.

Precision in questioning is vital. Rather than requesting a determination on negligence, ask the expert whether the record keeping met the standard expected of a reasonably competent practitioner at the time, and whether identifiable deficits in the records impacted the patient’s treatment. Where multiple experts are instructed in a case, they may be required to produce a joint statement to clarify points of agreement and disagreement. If the court directs evidence from a single joint expert under CPR 35.7, the instructions must be provided in accordance with CPR 35.8. An expert instructed as a single joint expert does not engage in a separate joint statement process, as they are not the advocate of any one party. By narrowing the scope of the evidence through precise, focused questioning, legal teams can ensure that the expert’s report addresses the specific allegations at the heart of the proceedings.