Mark Foster of the Child Protection Company examines the language dental teams use in regard to missed appointments, and explains why one simple referral could quite literally mean the difference between life and death for a patient at risk.
Maintaining your person-centred focus is essential in any safeguarding investigation or indeed any instance where you might be concerned about someone's welfare. Whether this happens within the dental practice or outside of working hours is not important; what matters is that you respond appropriately to any safeguarding suspicions in such a way that the individual who may be at risk gets the right support as soon as possible.
Sadly, when it comes to abuse and neglect, there are many ways in which an individual can manipulate us to believe there is nothing wrong. Usually, this behaviour comes directly from the perpetrator, though it isn't uncommon for relatives, close friends, or people in the role of carer to 'cover up' abuse. Similarly, many factors can play a part in a victim's decision to keep quiet about their experiences too.
None of us like to assume the worst of course, but we must pay attention to the signs and indicators of abuse and neglect. Under the surface, there could be any number of hidden issues seriously affecting a child, vulnerable adult, or family's wellbeing.
Did Not Attend vs. Was Not Brought
In the United Kingdom, all dental teams are encouraged to treat missed appointments as a cause for concern, particularly in the case of children and vulnerable adults. Rather than referring to these appointments in terms of the patient 'Did Not Attend,' you need to consider them as the patient 'Was Not Brought.'
This might seem like an overreaction in some cases, particularly if this is the patient's first missed appointment, but imagine what would happen if you reported a missed appointment only for the safeguarding authorities to further investigate and confirm no suspicious reason why the individual did not attend. This would be the best-case scenario; after all, it's our duty to ensure the safety of our patients, and you should not feel any guilt or embarrassment for reporting something that doesn't seem right.
However, imagine if you reported a missed appointment and later found out that when the safeguarding authorities investigated the issue further, they discovered weeks, months, or even years' worth of ongoing abuse. In this case, your reported concern would be the thing that led to the child or vulnerable adult getting the intervention they needed. You would be protecting them from further abuse, and your one simple referral could quite literally mean the difference between life and death for an individual at risk.
This is why it is so important to take safeguarding seriously. Safeguarding training teaches you the signs of abuse and neglect you may otherwise overlook. Applying safeguarding best practice at all times empowers you to empower others.
Safeguarding, in essence, saves lives.
But why does the 'Did Not Attend' vs. 'Was Not Brought' language matter?
It matters to pay attention to the language we use in this regard because these two phrases have to reflect what is actually going on.
In the case of children (anyone under the age of 18) and vulnerable adults (anyone over the age of 18 who cannot take care of themselves for any reason), most cannot attend dental appointments without being accompanied by a parent or carer. So, when we say that a patient 'Did Not Attend' an appointment, we are allowing for the idea they might have chosen not to attend. This might be the case of course, but when we take a person-centred approach to safeguarding, we must always allow for the possibility that something else might be going on under the surface to influence their decision.
When we instead say that a patient 'Was Not Brought' to their missed appointment, we reflect the idea that children and vulnerable adults do not have the means to attend without a parent or carer. Therefore, when appointments are missed without genuine reason, it could be a sign of more serious issues — such as abuse and neglect — that could be going on at home.
You should always rely on your safeguarding knowledge and report all concerns through your dental practice's Safeguarding Lead, no matter how "small" your suspicions may be.
Should you report cancelled appointments?
We recommend you make it standard procedure to report any dental appointments a patient has missed without reason or contact, particularly if no follow-up is made after the missed appointment to arrange a new date. This is a worrying sign that something may not be right at home and could be an indicator of dental neglect.
With that said, sometimes, a patient may call the practice to cancel an appointment with a reason that may not feel 'right' to the person taking the call. This can be anything from a strange excuse to the tone of voice of the person calling to cancel. Perhaps shouting or screaming in the background of the call could be a sign that something isn't right, or in some cases, confused messages and calls arriving at different times or from different people.
Again, it is important to work with a person-centred focus, which means looking deeper than the information that is given to you on the surface — such as the reason a parent or carer might provide when cancelling an appointment — to empathise with the patient themselves. It should always be a cause for concern when a patient who is capable of taking care of themselves does not call to cancel their own appointment but has someone else call on their behalf without arranging a date for a future appointment.
Essentially, there are lots of reasons why you might find it appropriate to report a missed or cancelled appointment even when a reason is given. You should always rely on your safeguarding knowledge and report all concerns through your dental practice's Safeguarding Lead, no matter how 'small' your suspicions may be.
Should you ask a patient why they missed an appointment on future visits?
In cases where a patient has missed a previous dental appointment but then shows up for a different appointment at a later date, it is sensible to follow up with them personally. Even children, if they are of speaking age, can answer simple non-confrontational questions such as, 'We missed you last time, where did you go instead of coming to the dentist?'
Remember to listen and react in an appropriate manner when a child or vulnerable adult makes any type of disclosure to you. This means not overreacting or doing anything to make the individual feel like they have told you something shocking. Remain calm and professional in your responses and in all cases, try to ascertain as much information as possible without making the patient feel uncomfortable or like they are being put under the spotlight. Reassure them that you are on their side and do not repeat anything they have told you to anyone other than to your Safeguarding Lead or the appropriate safeguarding agency.
Disclosures can often be subtle enough that they might not sound like any cause for concern at first. This is where safeguarding training takes effect, as it prepares you to notice the difference between a passing comment and a sign that something isn't right.
However, statistically, in the United Kingdom, healthcare professionals are some of the most likely to be trusted with disclosures of abuse or neglect. In many cases, you might be the only person a child or adult at risk might have trusted to reveal their truth to. This is a huge responsibility and one you should take very seriously by reporting your concerns according to the current safeguarding policy.
Missed appointments are only the tip of the iceberg when it comes to effective dental safeguarding…
You are likely to encounter all sorts of different safeguarding concerns in your career as a dental professional. Reporting missed appointments is just one of many ways in which you can make a difference to the life of a child or adult at risk. There are countless signs and indicators of abuse and neglect, but a verifiable safeguarding training course will teach you the most common signs.
Remember, it is your legal and professional duty to have an up-to-date safeguarding training certificate at the appropriate training level at all times. Failure to evidence training can result in lost marks during inspection but it can also carry much more severe consequences.
The Child Protection Company (www.childprotectioncompany.com) offers a suite of dental-specific online safeguarding courses recommended by the British Dental Association (BDA) and worth three hours of verifiable CPD under the General Dental Council Lifelong Learning Scheme. Their Introduction to Adult/Child Protection and Further Adult/Child Protection courses will help you to prepare for difficult safeguarding incidents and disclosures, which can happen to any member of staff at any time. For this reason, you need to ensure that every member of staff, volunteer, trainee, work experience, peripatetic staff, or temporary staff has completed at minimum an introductory dental safeguarding course and any staff working in a clinical capacity needs to take a higher level 'Further' course too.
For more information about your dental safeguarding training requirements or to arrange a tailor-made quote for your dental team's training, please get in touch with the Child Protection Company by visiting their website at www.childprotectioncompany.co.uk, call their office on 01327 552030, or email the team at firstname.lastname@example.org today.
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Foster, M. 'Did Not Attend' vs. 'Was Not Brought'. BDJ Team 6, 16–17 (2019). https://doi.org/10.1038/s41407-019-0166-7