Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0385, written 15 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Aug 2023 |
|---|---|
| Reference | 2023-0385 |
| Deceased | Barry Lall |
| Coroner | Katrina Hepburn |
| Coroner area | Central and South East Kent |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Central and South East Kent Coroners Oakwood House Oakwood Park Maidstone Kent ME16 8AE Date: 15 August 2023 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The General Dental Council 1. CORONER I am Katrina Hepburn HM Area Coroner for Central & South East Kent 2. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 18 May 2023 I commenced an investigation into the death of Barry Anthony LALL. The investigation concluded at the end of the inquest which was held on 14th August 2023 . The conclusion of the inquest was Suicide 1a Suspension 1b 1c II 4. CIRCUMSTANCES OF THE DEATH Barry Lall was a dentist. I understand that concerns were raised with the General Dental Council (GDC) in relation to his dental work and fitness to practise as a dentist, and that such concerns were being investigated. His case was referred to the Interim Orders Committee by the Registrar of the GDC on 4 August 2022. This led to a initial hearing taking place on 13th September 2022. The IOC decision was that interim conditions be placed on Mr Lall's ability to practise for a period of 18 months, and a 7 page report being published on the GDC website. Within that report the complaints/concerns regarding Mr Lall's working practices were set out in detail. There was evidence provided by the Family that Mr Lall's mental health, affected by the GDC investigation in the first instance, then deteriorated after the detail of the complaints/concerns of his work practices entered the public domain via the GDC Website. In November 2022 Mr Lall was formally dismissed from his employment. In December 2022 he approached his GP reporting anxiety and depression with fleeting thoughts of suicide since the loss of his job and the fitness to practice enquiries. On Friday 12th May and again on Monday 15th May 2023, Mr Lall received email notifications from his legal team regarding an upcoming meeting with the said team and the GDC scheduled for 18th May 2023. . He died of suspension. 5. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. ha The MATTERS OF CONCERN are as follows. – Whilst it is accepted that the public should have knowledge of concerns raised with regards to a registered dental practitioner, my concern is regarding the level of detail placed on the GDC website in respect of those concerns, particularly when a case is at a stage where the proceedings have not been concluded and the issues not yet determined one way or another. In this case the report ran to 7 pages and set out in detail the allegations made under the 'background section' and then further detail of the allegations by way of documenting the submissions made by the Counsel acting on behalf of the GDC. Whilst I accept that the report states in its preamble that "It is not the role of the IOC to make findings of fact in relation to any charge" the report detailed significant allegations, (which Mr Lall contested) which were undetermined by the GDC at that time. The report was then made available to the public via the GDC website. Given that this was an interim order only, my concern is whether the the level of detail provided to the public at that stage of proceedings, was necessary or required. The family gave evidence at the inquest of Mr Lall that he was "an extremely private individual so the impact this had on his mental health was tremendous." By putting detailed allegations into the public domain via the GDC website, at a stage before any final determination has taken place, I am concerned that others going through a similar process may also suffer a detrimental effect to their mental health. Consequently, in my view, there exists a risk that future deaths will occur. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you,the General Dental Council, have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday 11th October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons family representative. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 15 August 2023 Signature Katrina Hepburn Area Coroner for Central and South East Kent
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
ggdc
gdc-uk.org
Private & Confidential
Katrina Hepburn
HM Area Coroner
Central and South East Kent Coroners
Oakwood House
Oakwood Park
Maidstone
Kent ME16 8AE
10th October 2023
Dear Ms Hepburn,
I write in response to your Regulation 28 Report to Prevent Future Deaths (the Report), dated 15
August 2023, in respect of the investigation and inquest into the death of Mr Barry Lall, a
registrant of the General Dental Council (GDC).
I should say at the outset of this response that it was with great sadness that we learned about
the death of Mr Lall, particularly given the circumstances, and we send our condolences to his
family.
The GDC was not made aware of the investigation and inquest and, had we known, we would
have been willing to attend to provide further information about our regulatory role, and the
specific action taken in respect of our fitness to practise investigation into Mr Lall. We have
provided some of this information as part of this response and would be happy to provide further
information should that be useful to you.
I understand that you have concerns about regulatory action taken by the GDC in respect of Mr
Lall and in particular, the extent of the information which was published with respect to Mr Lall’s
Interim Order. While there are sound legal and policy reasons to be open and transparent about
all aspects of our regulation, including Interim Orders, as we explain below, we are in the
process of undertaking a review of the policy in these areas.
I have set out below brief details of the GDC’s role, an overview of our regulatory investigations,
some relevant details in relation to Mr Lall’s case, the work we have started regarding how we
hear Interim Order applications and what information we then publish.
The General Dental Council
The GDC is the UK regulator of dentists and dental care professionals. The overarching
objective of the GDC, as set out in section 1(1ZA) of the Dentists Act 1984 (the Act), is the
protection of the public. We do this by quality assuring dental education, undertaking checks and
taking decisions about those wishing to join the register, setting standards for the professions,
and investigating concerns about the fitness to practise of registrants and taking regulatory
action where necessary.
In carrying out our functions we are obliged to pursue our overarching objective of protecting the
public, and also to pursue the objectives of protecting, promoting and maintaining the health,
safety and wellbeing of the public, public confidence in the professions, and promoting and
maintaining proper professional standards and conduct for members of the profession.
37 Wimpole Street London W1G 8DQ
ggdc
gdc-uk.org
Fitness to Practise
Concerns raised about individuals on the GDC’s register are dealt with through the Fitness to
Practise (FTP) process. The legislative requirements of this process are set out in the Act and in
The General Dental Council (Fitness to Practise) Rules Order of Council 2006 (the Rules).
FTP proceedings consist of a number of stages, with decisions taken at key points as to whether
a case should proceed to the next stage. The most serious cases proceed through all stages,
with the final stage being a hearing held in public. Decisions at a final hearing are made by an
independent panel, which includes GDC registrants. Determinations of hearings are published
on our website. There is further information about each stage of the process on our website.
In addition to the substantive proceedings, described above, and which can take some time to
conclude, the GDC may make an application to an Interim Order Committee (IOC) for an Interim
Order (IO). These applications are made when the GDC considers that there is a risk if the
registrant continues to practice unrestricted. The risk may be to the public, to the registrant
themselves, or the restriction can be made otherwise in the public interest. Restrictions that can
be imposed include conditions on the practice of the registrant (for example a requirement not to
undertake a certain treatment unsupervised or at all), or to suspend the registrant, which means
they cannot practice at all.
Unlike substantive proceedings which will look at whether allegations are proved on a balance of
probabilities an IOC will not make findings of fact. The Committee only assesses risk when
considering whether to put an IO in place. The assessment of risk takes into account concerns
that have been raised about the registrant, and other relevant information, including
representations from the registrant (or their representatives) and the GDC. Our Interim Orders
Guidance for Decision Makers—Interim Orders Committee (the Guidance) is available online.
For some considerable time, the GDC has sought amendments to its legislation to make the
FTP process quicker and more effective. In parallel, we have undertaken work to maximise the
efficiency of the current framework and to make improvements within legal constraints. Even
with changes we have implemented, we are aware that FTP matters take a long time to resolve,
and we recognise that this can put considerable stress on registrants under investigation.
We have a number of measures in place to support registrants within the FTP process, including
the provision of a participant support officer who is available to provide advice and support to
registrants and witnesses at hearings. There is further information online about the support that
is available.
Mr Lall’s FTP Case
As you have set out in your Report, Mr Lall was a dentist who had been referred to the GDC due
to concerns about his practice. A high-level timeline of the FTP case is as follows:
July 2022 - Concerns were raised by Mr Lall’s NHS employer, stating that he was under
investigation and would be required to attend a capability panel due to concerns about his
clinical performance.
August 2022 - Given the seriousness and volume of concerns raised by a credible source (an
NHS employer), Mr Lall was referred to a panel to consider whether an interim order should be
imposed.
September 2022 – Following a short postponement to accommodate Mr Lall being out of the
country, a panel imposed an interim order of conditions of practice. The hearing was held in
public (although over MS Teams) and the determination was published on the Dental
37 Wimpole Street London W1G 8DQ
ggdc
gdc-uk.org
Professionals Hearings Service website and on Mr Lall’s entry on the GDC register. In the
hearing, Mr Lall’s representative accepted, on Mr Lall’s behalf, that it was reasonable and
proportionate to impose an interim conditions of practice order.
November 2022 – the initial investigation into the case concluded, with allegations made that Mr
Lall’s fitness to practice may be impaired. These allegations were referred to the next stage of
the FTP process (Case Examiners) and Mr Lall and his representatives were asked to provide
observations about the allegations.
February 2023 – the Interim Order was reviewed without an oral hearing following agreement
between the GDC and Mr Lall’s lawyers. The IOC reviewed written submissions made by both
parties and decided to continue the interim order. Mr Lall’s representatives informed the IOC
that Lr Lall was content for the order to continue. The outcome of the review hearing was
published on the GDC website.
April 2023 – having received information from the NHS about the outcome of their hearing and
identifying some potential health issues (which were identified as stress which was being treated
by a therapist), the GDC requested occupational health records so that we could understand if
further action was necessary to support Mr Lall, and whether the FTP case should be reviewed
to take the health concerns into account.
May 2023 – the GDC was informed by Mr Lall’s legal team that he had sadly passed away.
We understand from your Report that in November Mr Lall was dismissed from his employment
and that December 2022 Mr Lall “approached his GP reporting anxiety and depression with
fleeting thoughts of suicide since the loss of his job and the fitness to practice enquiries.” We
were not aware of the information regarding Mr Lall’s interaction with his GP and were not aware
until much later that Mr Lall had been dismissed by his employer.
Concerns raised in the Report
The Report includes the following paragraphs:
“Whilst I accept that the report states in its preamble that "It is not the role of the IOC to make
findings of fact in relation to any charge" the report detailed significant allegations, (which Mr Lall
contested) which were undetermined by the GDC at that time. The report was then made
available to the public via the GDC website.
Given that this was an interim order only, my concern is whether the the [sic] level of detail
provided to the public at that stage of proceedings, was necessary or required.
The family gave evidence at the inquest of Mr Lall that he was "an extremely private individual
so the impact this had on his mental health was tremendous." By putting detailed allegations into
the public domain via the GDC website, at a stage before any final determination has taken
place, I am concerned that others going through a similar process may also suffer a detrimental
effect to their mental health. Consequently, in my view, there exists a risk that future deaths will
occur.”
We take this concern to be about the level of detail that the GDC publishes about allegations at
Interim Order proceedings and the outcome of those proceedings.
The GDC’s starting position for what properly ought to be in public about these types of
proceedings is that they are judicial proceedings taken in the public interest. You will be aware,
including through your own work, that the interests of open justice are of great importance in
ensuring that the public can have confidence in the work of regulators or other public sector
bodies.
37 Wimpole Street London W1G 8DQ
ggdc
gdc-uk.org
In pursuit of the overarching objective of public protection and of maintaining confidence in the
professions it is important that the public can see where the GDC takes substantive action
including, in the most serious cases, erasure and suspension. It is also important, particularly
given the time it takes to get to a substantive hearing, that the public can see that immediate
risks are addressed. The latter being undertaken through the IO process.
Given that restricting a registrant’s practice is a very serious matter, including in the interim, the
GDC considers it important to be clear and transparent about the circumstances as to when
happens, both to ensure public confidence in the dental professions and to ensure that those we
regulate are clear as to when we might take action.
Currently the GDC publishes the name of the registrant, the date that the IO hearing is due to
take place, and, following the hearing, the relevant details of the outcome in accordance with the
GDC’s Disclosure and Publication policy (The Policy). The outcome published includes the
reasons for an IO being imposed as they have been set out in the public hearing.
We recognise however, that there are times when matters ought properly to be heard in private,
and our legislation, guidance for our panels and our practice allows for this. Our Rules set out
that hearings before Committees (including the IOC) should take place in public. The IOC
considers guidance in relation to when hearings should be held in private. If a hearing is held in
private, then the details that are heard in private will not be made public. I set out the relevant
part of the Guidance, as follows:
“In principle all hearings, including IOC hearings, are held in public although all Committees
have discretion to allow a hearing to proceed in private in certain circumstances.
Circumstances in which all or part of a hearing may be held in private include:
where it is necessary to protect the interests of the parties or the protection of the private
•
and family life of the respondent or any other person so requires e.g. vulnerable or juvenile
witnesses; or
where the Committee is of the opinion that publicity would prejudice the interests of
•
justice.
The IOC should invite representations from the Registrant and the GDC and take advice from
the legal adviser before making a decision to hear a case in private.”
From your reporting of your concerns, it is not clear to us when Mr Lall became unwell, and
whether there was a missed opportunity to hold the initial IO hearing (held in September 2022) in
private under the circumstances. It was not an issue which was brought up by Mr Lall’s legal
representatives at the review hearing.
Registration
You asked a specific question as to why Mr Lall no longer appears on the Register. This is
because the Register is a record of all dental professionals who are currently entitled to practice
as dentists and dental professionals. Those who are taking a career break, who have been
removed, have retired or who have died do not appear on the register.
Policy review
I have set out the reasons for our current policy position regarding the publication of IO
determinations above. However, although we remain committed to transparency and to the
principles of open justice, we recognise that we need to keep the policy decisions we have taken
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ggdc
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