RESEARCH

Implementation of a ‘was not brought’ pathway

in paediatric dentistry
Amrisha Ondhia,*1 Sophie Marshall2 and Thayalan Kandiah2

Key points
This paper highlights the importance of Results of implementation of a WNB pathway and Recommendations have been made on how to
introducing a ‘was not brought’ (WNB) pathway possible barriers to adherence are discussed. create and implement a WNB pathway in general
for children who are not brought to dental dental practice.
appointments, as missed appointments could
play a part in a wider picture of child neglect.

Abstract
Introduction The dental team play a vital role in ensuring that vulnerable children are followed up and suspected
safeguarding concerns are shared, which includes recognising the importance of missed dental appointments.
Concerns are less likely to be missed when there are robust pathways in place. This paper aims to discuss the
importance of a was not brought (WNB) pathway for children who miss dental appointments and to offer advice on its
implementation in practice.
Methods A three-cycle retrospective case note review was carried out to identify follow-up children who WNB to their
dental appointments, and the follow-up that had occurred as a result.
Results In cycle one, 16% of children who were not brought were managed according to the audit standards.
Therefore, a WNB pathway was developed and audited three months and 12 months following; cycle two showed
32% adherence with the pathway, and 28% in cycle three. The biggest barrier in all cycles seems to be related to the
administration of letters.
Discussion Investigators felt that the possible barriers to achieving audit standards were the implementation of a new
dictation system, limited time on clinic and a possible anxiety surrounding the management of safeguarding issues.
Conclusion Pathways and resources have been made available for dental professionals to use in their practice to guide
management of children who were not brought to dental appointments. As we have shown, there are barriers to
implementation of such pathways which service providers must work to overcome, to protect the children that we
treat and ensure that they are being kept safe in line with General Dental Council standards.

Introduction dental caries are more likely to experience by their family or carer, which could be a
discomfort and pain affecting their ability to flag for further safeguarding concerns.’ This
Dental neglect is ‘the persistent failure to meet eat and sleep.2 WNB event, as opposed to DNA, should help
a child’s basic oral health needs, likely to result Everyone who works with children has a trigger the thoughts of ‘why was this child not
in the serious impairment of a child’s oral or responsibility for keeping them safe;3 therefore, brought?’6
general health or development’ as defined by the role of a dental team is vital to ensure that When intervening in order to identify
the British Society of Paediatric Dentistry vulnerable children are followed up and that children who are persistently not being brought
policy statement. 1 Poor dental health in suspected safeguarding concerns are shared to appointments, the aim is not to apportion
children has a large impact on wellbeing and with the appropriate health and social care blame but to ensure that children and their
quality of life; children who have untreated professionals. The General Dental Council families receive the support needed in order
(GDC) standards state that the dental team to obtain the care they need to maintain oral
have an ethical obligation to take appropriate health.1 Evidence shows that non-engagement
1
Specialty Registrar in Paediatric Dentistry, Paediatric action if there are concerns about the possible with health services is frequently noted in
Dentistry Department, Royal London Dental Hospital, Barts
Health NHS Trust, E1 1DE, UK; 2Consultant in Paediatric
maltreatment or neglect of a child.4 serious case reviews conducted when children
Dentistry, Paediatric Dentistry Department, East Surrey In recent years, healthcare professionals die or are seriously harmed by maltreatment.7
Hospital, Surrey and Sussex NHS Healthcare Trust, RH1
5RH, UK.
have been encouraged to reconceptualise Thus, realising the importance of these
*Correspondence to: Amrisha Ondhia ‘did not attend’ (DNA) to ‘was not brought’ missed appointments and then sharing this
Email: [email protected]
(WNB) to ensure that a proactive and a child- information between healthcare professionals
Refereed Paper. centred stance is taken.5 When children and has been highlighted as a way to help identify
Accepted 25 January 2021 young people miss appointments, it is rather and support these vulnerable children.
https://doi.org/10.1038/s41415-021-3572-0
that ‘they are not brought to appointments We must remember when making these

BRITISH DENTAL JOURNAL | ONLINE PUBLICATION | NOVEMBER 11 2021 1

© The Author(s) under exclusive licence to the British Dental Association 2021.
 RESEARCH

communications that the needs of the child without taking further action to ensure their robust strategies in place which the whole
should be paramount. Despite working in busy safety and wellbeing. dental team can follow.5 The British Dental
clinical settings, it is not appropriate to simply Concerns about vulnerable children Association (BDA) has recently published
discharge these potentially vulnerable children are less likely to be missed when there are an implementation guide based on a WNB
pathway developed by Jenny Harris and Jen
Fig. 1 Pathway implemented within East Surrey Hospital Paediatric Dental Department Kirby in Sheffield.8 Prior to the Harris and
Kirby publication, the paediatric dentistry
team at East Surrey Hospital completed a
Paediatric patient was not
brought to an appointment three-cycle audit to evaluate management of
children who WNB to dental appointments
and developed a pathway for management of
children who WNB as a result. In this paper,
Call the contact number for the parent/carer (check with GP if no working
numbers for change of contact details). If no working contact number is
we present the findings of our audit, the WNB
identified discuss with Paediatric Dental Consultant pathway we developed and the barriers to
implementation of the pathway and how our
team attempted to overcome these. Our aim
Parent/guardian does not answer: Parent/guardian answers: Enquire as
Leave a message for them to contact Parent/carer to reason for WNBs is to present lessons we have learnt in this
the department calls back by Remind patient/carer the importance process so that other teams can also implement
the end of of attending appointments to maintain
FULLY DOCUMENT THIS IN the clinic the patient's oral health similar pathways to improve the management
THE NOTES Rebook the patient of children who WNB to dental appointments.
FULLY DOCUMENT THIS IN
THE NOTES
Parent/carer DOES NOT call Method
back by the end of the clinic

Audit standards were set in line with the

trust’s existing local child safeguarding policies
Review the notes for any safeguarding You DO have Discuss the case with the paediatric
concerns this may include: dental team which stated that for children who WNB to an
concerns for
• Previous WNBs in dental or other the welfare appointment:
departments of the child FULLY DOCUMENT THE DISCUSSION
•Active untreated dental disease IN THE NOTES
• Parents/guardians should be contacted
•History of information sharing with by phone to identify the reason for non-
the safeguarding team from other They will advise you to either
departments rebook/discharge the patient
attendance and appropriate follow-up made
•Social services involvement with the Follow the rebook/discharge protocol • Where parents/guardians are not
family below and CC THE HOSPITAL
•A complex social history SAFEGUARDING TEAM AND SOCIAL
contactable by phone, a letter should be sent
• Siblings with safeguarding concerns WORKER IF THE FAMILY HAS ONE to the parents and referrer informing them
• Mental illness of the child or guardian
Send a separate information sharing
that the child missed an appointment and
letter to the safeguarding team describing follow-up planned
CC the GP and Paediatric Dental
You DO NOT have concerns Consultant ONLY plus the social
• This letter should be copied to the child’s
for the welfare of the child worker if the patient has one general practitioner (GP)
• Notes for children who WNB should be
Include in this letter:
If you are unsure whether to rebook or discharge the • The time and date of the missed reviewed for existing safeguarding concerns
patient, discuss the case with the paediatric dental team appointment
(that is, previous WNB, social worker, child
• Your attempts to contact the patient
WITH THE PATIENT NOTES IN PERSON • A factual account of your concerns protection plan, untreated dental disease)
FULLY DOCUMENT THE DISCUSSION IN THE NOTES for the patient and any other healthcare professionals
• Information of any follow-up made
They will advise you to either rebook/discharge the patient involved with the family (that is, social
worker, school nurses, support workers)
should be included in the WNB letter.
REBOOK
Write a WNB-REBOOK letter to the referring practitioner informing them of the date Our audit standards stated that 100% of
and time of the missed appointment and the next appointment.
There is a template for this with the dental secretaries.
paediatric patients who WNB to a dental
CC the GP and parents/guardians and Paediatric Dental Consultant/Paediatrician appointment should be followed up by this
if the patient has one
policy. The audit period for cycle one was
July to October 2016. The last 40 consecutive
paediatric WNB appointments at the East
DISCHARGE
Write a WNB-discharge letter to the referring practitioner informing them of the date Surrey Hospital Dental Department were
and time of the missed appointment and that the patient has been discharged. identified by one investigator by reviewing
cc the GP and parents/guardian, Paediatric Dental Consultant/Paediatrician if
the patient has one appointments from the Cerner database. A
retrospective case note review of each of these
patients’ records was undertaken. Children

2 BRITISH DENTAL JOURNAL | ONLINE PUBLICATION | NOVEMBER 11 2021

© The Author(s) under exclusive licence to the British Dental Association 2021.
 RESEARCH

pathway. In total, 38% (19) of patients were

Fig. 2 Results of a three-cycle audit of adherence to a WNB pathway at East Surrey Hospital
excluded as they were rebooked following a call
from our team after their missed appointment.
100
Results showed 55% (17) of parents/guardians
90
Percentage of records meeting audit standard

being contacted by phone. A WNB letter was

80
sent out in only 39% (12) of cases, of which the
70
First cycle (N=25) GP was copied in to 67% (eight) of these letters.
60 Second cycle (N=22) Overall, 26% of children who WNB were
50 Third cycle (N=31) managed according to the audit standards;
40 two of these children had known safeguarding
30 concerns but two additional children, whose
20 records did not meet all audit standards, also
had a history of safeguarding concerns.
10
Results of the three audit cycles have been
0
summarised in Figure 2.
Standard Guardians Letter dictated GP copied Total meeting
contacted if letter standards

Discussion

who were rebooked following immediate templates for letters produced, including a Investigators identified several barriers to
contact with parents/guardians by phone were request to secretaries for GPs to automatically utilisation of the WNB pathway. The majority
excluded from data collection. The following be copied into correspondence. It also explained of failures to meet audit standards in all cycles
data were collected and analysed using that the clinician involved in a patient’s care were related to administration of letters.
Microsoft Excel: had an overriding responsibility to ensure the Following review of the third-cycle results,
• Whether there is a documented record of patient was appropriately followed up. errors occurring in the automated dictation
phone contact with parents/guardians A second cycle of 32 patients was carried system were highlighted and adjusted.
• Whether a WNB letter had been sent out with the same methodology three months Clinicians also felt that time on clinic was
• Whether this letter was copied to the GP later from January to March 2017. In total, a limiting factor in terms of management
• Whether there were existing safeguarding 31% (ten) of patients were excluded as they of children who were not brought. In order
concerns for the child. were rebooked following a call from our to negate this, the department restructured
team after their missed appointment. Results and allocated two dental care professionals
Results showed 59% (13) of parents/guardians (DCPs) to have additional roles in paediatric
being contacted by phone after a missed dentistry to support clinicians in tasks, such
In the first cycle, 40 children who WNB to appointment; 64% (14) of these children had as following up children WNB, with the
appointments over a four-month period a letter generated, which included the GP overriding responsibility for management of
were investigated. In total, 37.5% (15) of in all cases. Overall, 32% of children who these children remaining with the clinician
patients were excluded as they were rebooked WNB were managed according to the audit running the clinic with support from the
immediately following phone contact and standards. Two of these children had known named clinician for child safeguarding.
therefore excluded from data collection. Of the safeguarding concerns and an additional A significant amount of turnover of staff
25 patients remaining, 48% (12) of children’s child, whose records did not meet all audit occurred between the second and third cycles,
parents/guardians were contacted by phone standards, also had a history of safeguarding which may also have contributed to the poor
but did not respond and 52% (13) had a letter concerns. results in cycle three. This highlights the need
dictated. Of these 13 letters, only 38% (five) A departmental meeting was held to identify for regular audit of a WNB pathway following
had the GP copied into the correspondence. barriers to implementation of the pathway. its introduction to assess and safeguard
Overall, only 16% of children who WNB The following themes emerged from this adherence.
were managed according to all the audit discussion: implementation of a new trust Following cycle three, departmental
standards and of these, three of the children dictation system, limited time on clinic and workforce review of level-three child
were known to have safeguarding concerns. clinician anxiety relating to management of safeguarding training was completed and those
More worryingly, of the 84% of children not safeguarding issues. Letter templates were clinicians and DCPs requiring safeguarding
managed according to the audit standards, an devised on the new trust dictation system updates were booked onto appropriate courses
additional three children also had evidence of for children who WNB which asked for to improve their confidence in managing child
previous safeguarding concerns. automatic inclusion of GPs in these letters. The safeguarding issues.
In response to this, a WNB pathway was department’s named child safeguarding lead A positive finding from the audit was that in
created for the department specifically for was made clear to all staff, who was available each cycle at least 30% of children who WNB
missed dental appointments for children in for support of clinicians managing child were managed immediately following a direct
the form of a flow chart (Fig. 1). safeguarding issues. phone call, obviating the need for a WNB
This pathway was presented at a departmental A third cycle of 50 patients was carried out letter and reinforcing the parents the need for
clinical governance meeting, with WNB nine months following implementation of the follow-up and details of the next appointment.

BRITISH DENTAL JOURNAL | ONLINE PUBLICATION | NOVEMBER 11 2021 3

© The Author(s) under exclusive licence to the British Dental Association 2021.
 RESEARCH

Our findings can be compared to a larger- helped them to make a decision quickly,’ which lead will be required to identify the contact
scale service evaluation project which was is likely to be a possible misconception or details of appropriate local authority child
undertaken by Kirby and Harris to assess the use perceived barrier to its implementation within safeguarding teams. It would be prudent to
of a WNB-children and young people (WNB- primary care settings.9 check the local named GP for safeguarding
CYP) pathway for an eight-month period in We would encourage readers to consider children, consider contacting the local
2016 within Sheffield Community and Special what arrangements are in place in their own managed clinical network for paediatric
Care team.9 This pathway involved a telephone practice for management of children who dentistry for advice and be aware of how to
call to the parent/guardian within 24 hours if a WNB to appointments and consider the use make referrals to multi-agency safeguarding
child was not brought to a dental appointment; of a pathway similar to that of Kirby and Harris hubs within your area. This information should
if contact was made, they would be rebooked. If in their local child safeguarding policies. be shared at a team meeting, with individuals
there was no response to the call, a letter would In a report based on dentists and DCPs being made aware of the role they play within
be sent out to the parent/guardian. Following with an interest in paediatric dentistry, a the child safeguarding pathway. Receptionists
this letter, if there was no response within three significant gap was seen between recognising play a large role in this communication and
weeks, the clinician should review the child’s signs of abuse and responding effectively, time may be required to ensure they are aware
records for safeguarding concerns, send a letter with 67% of respondents having suspected of their responsibilities and supported in order
to the child’s GP and consider information abuse or neglect of a child patient at some to handle sensitive scenarios that may arise
sharing with other professionals, including time in their career, yet only 29% had ever from their role and seek help where needed.
social services. For the 134 appointments made a child protection referral.10 We would Successful implementation of a WNB pathway
that were missed, the pathway was followed therefore want to remind readers that the role relies on the whole team working together, to
consistently 113 times (84.3%). For 80 (71%) of the dental team in safeguarding is not to allow for the correct management and care for
of the WNBs managed using the pathway, make a diagnosis of abuse. Rather, if a dental children.
parents or carers were successfully contacted by professional has concerns that a child may
telephone within 24 hours and re-booked. For be at risk of significant harm, a safeguarding Conclusion
17 children, there was no response to either the referral should be made and following this
phone call or a letter. Information was shared the investigation and responsibility lies with All members of the dental team have a
with various health and social care professionals a multi-agency child protection team. Making contractual, moral and ethical responsibility
for 14 of these. For one child, a child protection general practitioners and multi-agency teams to share concerns about a child if they suspect
referral was made to social care, thus reinforcing aware of missed appointments may alert them abuse or neglect. If we are to carry out our
the importance of following up these missed to increasing concerns about a child’s welfare. role effectively, we must set up structured
appointments. Prior to implementation of a pathway, the pathways and communications with healthcare
Although the results of our smaller study authors would strongly advise that all dental professionals. A missed appointment may be a
show lower success rates of pathway adherence professionals read and familiarise themselves small part of a wider picture of child neglect
than those presented by Kirby and Harris, with the document ‘Child protection and or maltreatment.
the paediatric dental team within East Surrey the dental team.’11 This resource discusses Pathways and resources have been
Hospital were able to identify the need for our responsibilities as a dental team, how highlighted in this paper and made available
a specific dental pathway with templates in to recognise and respond to safeguarding for dental professionals to use in their
place, including automatically copying in concerns and provides resources you may practice. This will of course take time to
GPs to correspondence. The team are still need. If a similar pathway to ours is to be implement and there will be local barriers
endeavouring to improve results with the help implemented by general dental practitioners, which need to be identified and overcome to
of a WNB checklist now used in the notes we recommend that templates are made protect the children that we treat and ensure
when children are not brought. This includes accessible to clinicians and reception teams to that they are being kept safe in line with GDC
prompts to contact parents, generate letters allow for consistency in the management of all standards. The team at East Surrey Hospital
and copy in GPs to these letters. As mentioned children who are not brought. The impact of are now planning annual audit of compliance
previously, dental teams must always maintain having pathways and templates in place is seen with the WNB pathway.
a child-centred approach to care. Sharing child in the increase seen in audit results between
safeguarding concerns should be supported to cycle one and two. Ethics declaration
prevent cases which seem to ‘slip though the net’ Each dental practice should have identified The authors declare that there are no conflicts of
which could potentially lead to harm to patients. a member of staff to take the lead on child interest.
Kirby and Harris have evaluated the positive protection. T h is person should be carefully
benefits of implementation of their WNB selected as an individual who possesses Acknowledgements
pathway on both dental professionals and important skills, such as being a good listener The authors would like to acknowledge the BDA
parents/guardians in realising the role they and being able to handle difficult or distressing implementation guide based on a WNB pathway
play in ensuring that children are brought to issues sensitively.11 Similarly, the BDA tool developed by Jenny Harris and Jen Kirby. We would
appointments. Staff members said it offered suggests electing a ‘WNB champion’ to lead like to thank members of the dental team in the
‘relief of professional uncertainty’. In addition, implementation of a pathway. The authors feel Paediatric Dental and Child Safeguarding teams at
they stated that ‘generally, the WNB pathway that this is an important part of promoting East Surrey Hospital for their involvement with the
did not increase the daily workload, rather it success of the pathway.8 The child protection pathway and auditing.

4 BRITISH DENTAL JOURNAL | ONLINE PUBLICATION | NOVEMBER 11 2021

© The Author(s) under exclusive licence to the British Dental Association 2021.
 RESEARCH

References 5. Powell C, Appleton J. Children and young people’s missed implementation%20guide%20AW.pdf (accessed
health care appointments: reconceptualising ‘Did Not December 2019).
1. Harris J, Balmer R, Sidebotham P. British Society of
Attend’ to ‘Was Not Brought’ – a review of the evidence 9. Kirby J, Harris J. Development and evaluation of a ‘was
Paediatric Dentistry: a policy document on dental
for practice. J Res Nurse 2012; 17: 181–192. not brought’ pathway: a team approach to managing
neglect in children. Int J Paediatr Dent 2009; DOI:
6. Care Quality Commission. Not seen, Not Heard, A children’s missed dental appointments. Br Dent J 2019;
10.1111/j.1365-263X.2009.00996.x.
2. Low W, Tan S, Schwartz S. The effect of severe caries review of the arrangements for child safeguarding and 227: 291–297.
on quality of life in young children. Paediatr Dent 1999; health care for looked after children in England. 2016. 10. Harris J, Elcock C, Sidebotham P, Welbury R. Safeguarding
21: 325–326. Available at https://www.cqc.org.uk/sites/default/ children in dentistry: 1. Child protection training,
3. Department for Education. Working together to files/20160707_not_seen_not_heard_report.pdf experience and practice of dental professionals with
safeguard children: Statutory guidance on inter-agency (accessed December 2019). an interest in paediatric dentistry. Br Dent J 2009; 206:
working to safeguard and promote the welfare of 7. Woodman J, Brandon M, Bailey S, Belderson P, Sidebotham 409–414.
children. 2015. Available at https://www.gov.uk/ P, Gilbert R. Healthcare use by children fatally or seriously 11. Committee of Postgraduate Dental Deans and Directors.
government/publications/working-together-to- harmed by child maltreatment; analysis of a. national case Child protection and the dental team: an introduction
safeguard-children--2 (accessed January 2020). series 2005–2007. Arch Dis Child 2011; 96: 270–275. to safeguarding children in dental practice. 2006.
4. General Dental Council. Standards for the Dental Team. 8. British Dental Association. Implementing ‘Was Not Available at https://bda.org/childprotection/Resources/
2019. Available at https://www.gdc-uk.org/information- Brought’ in your practice: A tool for safeguarding children Documents/Childprotectionandthedentalteam_v1_4_
standards-guidance/standards-and-guidance/standards- who miss appointments. 2019. Available at https://bda. Nov09.pdf (accessed October 2021).
for-the-dental-team (accessed January 2020). org/advice/Documents/Was%20Not%20Brought%20

BRITISH DENTAL JOURNAL | ONLINE PUBLICATION | NOVEMBER 11 2021 5

© The Author(s) under exclusive licence to the British Dental Association 2021.