Recipient

General Dental Council

First report 7 Mar 2016•Latest report 20 Aug 2024

Recipient record

Reports, concerns and published responses

Other public bodies · Health and care professional regulator. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
3

Naming this recipient

Published responses
67%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
4

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

67%published responses found
4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from General Dental Council linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. East London

    AI-generated summary

    Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Hannah Enola Ayamo Jacobs, aged 13, developed anaphylactic symptoms after being served a dairy hot chocolate despite her reported dairy allergy and later died following cardiac arrest. The concerns included dental staff not recognising excessive salivation as inability to swallow and a sign of anaphylaxis, possible misunderstanding of symptoms by her mother, and the availability and use of adrenaline auto-injectors during shortages.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Dental Council; that does not assign responsibility.

    PFD Monitor interpretation

    Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom

    Wider context from the report

    “• The other symptom Hannah demonstrated was swelling of her lips which is listed on allergy plans as a mild to moderate symptom and thus provided a false sense of reassurance to her mother that cetirizine was what she needed. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Dental Council; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient education of parents and patients on safe AAI use when in doubt

    Wider context from the report

    “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction, and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Dental Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings

    Wider context from the report

    “• The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. Hannah displayed what appeared to be excessive salivation at the dentist which her paediatric consultant (who gave evidence) said, with the benefit of hindsight was actually a manifestation of her inability to swallow. This is a sign of anaphylaxis This was not recognised by dental staff as an inability to swallow and thus of anaphylaxis. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Dental Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of sufficiently clear distinction between anaphylactic and mild reactions

    Wider context from the report

    “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction, and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Dental Council; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of AAI stock in chemists for emergencies

    Wider context from the report

    “• I was made aware there had been a shortage of AAI at the time but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review CPD requirements and consider proposing changes to medical-emergency recommendations.

    Verbatim wording from the response

    “We are currently in the process of reviewing our CPD requirements, and we will consider whether we should propose changes to the recommendations regarding medical emergencies as part of the review. The review is expected to conclude in 2025, but some potential changes would require legislative changes, the timing of which is not under our control.”

    Source location

    Response from General Dental Council
    Page 3 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Write to NICE requesting review of anaphylaxis symptoms and related guidance for dental professionals.

    Verbatim wording from the response

    “Whilst I note your concern that dental professionals did not recognise the early symptoms of anaphylaxis, I also note that the symptom of excessive salivation is not listed as a potential symptom in the NICE guidance. We will write to NICE to highlight this, and to ask them to consider reviewing the listed symptoms of anaphylaxis and their guidance to dental professionals more broadly.”

    Source location

    Response from General Dental Council
    Page 3 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Potential CPD changes requiring legislation may be delayed because the timing of legislative changes is outside the respondent’s control.

    Verbatim wording from the response

    “We are currently in the process of reviewing our CPD requirements, and we will consider whether we should propose changes to the recommendations regarding medical emergencies as part of the review. The review is expected to conclude in 2025, but some potential changes would require legislative changes, the timing of which is not under our control.”

    Source location

    Response from General Dental Council
    Page 3 · response
    Published 30 August 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The current standards and guidance provide clear obligations, so additional or different standards are not currently considered necessary.

    Verbatim wording from the response

    “The current framework of standards and guidance sets out clear obligations for dental professionals to have appropriate training and keep medication on their premises to use in the event of a medical emergency. I think that it is appropriate to continue to require adherence to the RCG as set out at Standard 1.5 and other appropriate guidance, including the NICE guidance as set out in Standard 7.1.”

    Source location

    Response from General Dental Council
    Page 3 · response
    Published 30 August 2024

    Open published response
  2. Central and South East Kent

    AI-generated summary

    Barry Anthony LALL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Barry Anthony LALL was a dentist whose fitness to practise was being investigated by the General Dental Council after concerns about his dental work. He was dismissed from his employment and later reported anxiety, depression and fleeting suicidal thoughts. The principal concern was the level of detail about undetermined allegations published on the GDC website during interim proceedings, and the potential detrimental effect on the mental health of those undergoing similar processes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Dental Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to limit publication of detailed undetermined allegations during interim proceedings

    Wider context from the report

    “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 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. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the policy governing publication of Interim Order outcomes to balance open justice with registrants’ interests.

    Verbatim wording from the response

    “in relation to our legal framework under review. Work to review the Guidance and the Policy and reviewing our position in relation to holding hearings in public had already been started by our Policy Team prior to receiving your report. Following the sad news of Mr Lall’s death and your Report, this work has been prioritised.”

    Source location

    Response from General Dental Council
    Page 5 · response
    Published 2 November 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review guidance and arrangements governing whether Interim Order hearings are held in public or private.

    Verbatim wording from the response

    “in relation to our legal framework under review. Work to review the Guidance and the Policy and reviewing our position in relation to holding hearings in public had already been started by our Policy Team prior to receiving your report. Following the sad news of Mr Lall’s death and your Report, this work has been prioritised.”

    Source location

    Response from General Dental Council
    Page 5 · response
    Published 2 November 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Open-justice requirements, published interim-order reasons and discretion to hold hearings privately currently address transparency and registrant-protection concerns.

    Verbatim wording from the response

    “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.”

    Source location

    Response from General Dental Council
    Page 4 · response
    Published 2 November 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Changes to the statutory Rules cannot be implemented solely by the regulator and may take longer because approval is outside its full control.

    Verbatim wording from the response

    “This work is reviewing the policy in relation to the publication of outcomes of IOs and, due to the overlapping nature of the issues involved, the position set out in the Rules in relation to holding IO hearings and the guidance provided to the panel in relation to holding hearings in public or private is also being reviewed. The aim of the review is to ensure that we are correctly balancing the public interest in open justice against the interests of the registrant, particularly when considering as yet untested allegations. The timeframe for completion of this work depends on the outcome of the review. In some circumstances public consultation to any changes that we may wish to make is required, which will inevitably mean a longer timeframe.”

    Source location

    Response from General Dental Council
    Page 5 · response
    Published 2 November 2023

    Open published response
  3. Swansea and Neath Port Talbot

    AI-generated summary

    Patricia Margaret Thomas · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Patricia Margaret Thomas died at Morriston Hospital on 30 October 2013 after suffering an intracerebral haemorrhage, following an episode of unresponsiveness and left-sided weakness. The report identified a potential interaction between Miconazole Gel and Warfarin, a lack of awareness of this interaction among health professionals, and possible difficulties locating clear interaction-checking resources.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Dental Council; that does not assign responsibility.

    PFD Monitor interpretation

    Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR

    Wider context from the report

    “It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding. (2) There is a significant lack of knowledge of the interaction among health professionals and/or (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Dental Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals

    Wider context from the report

    “It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding. (2) There is a significant lack of knowledge of the interaction among health professionals and/or (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Dental Council; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction

    Wider context from the report

    “It became apparent in the course of the evidence that (1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding. (2) There is a significant lack of knowledge of the interaction among health professionals and/or (3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

67%
67%All other recipients 58%
0%100%

How actions were described at the time

This respondent
75%25%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026