Sample policy · Dental

Medical emergency policy (dental)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 18 (staffing) for the competence and training duties. · primary source

1. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))

ensuring that the equipment used by the service provider for providing care or treatment to a service user is safe for such use and is used in a safe way, (Reg 12(2)(e) (equipment safety))

where equipment or medicines are supplied by the service provider, ensuring that there are sufficient quantities of these to ensure the safety of service users and to meet their needs, (Reg 12(2)(f) (sufficient equipment + medicines supply))

the proper and safe management of medicines, (Reg 12(2)(g) (medicines management))

where responsibility for the care and treatment of service users is shared with, or transferred to, other persons, working with such other persons, service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users. (Reg 12(2)(i) (shared / transferred responsibility))

The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations.

3. Purpose

This policy sets out how the Practice prepares for, responds to and records medical emergencies in primary-care dental premises.

It covers emergency drugs, emergency equipment, basic life support competence, simulation, escalation, transfer and post-event review.

4. Sources to verify before adoption

Resuscitation Council UK, Quality Standards: Primary dental care: https://www.resus.org.uk/library/quality-standards-cpr/primary-dental-care
Resuscitation Council UK, Primary dental care equipment list: https://www.resus.org.uk/library/quality-standards-cpr/primary-dental-care-equipment-list
GDC Scope of Practice guidance, current version: https://www.gdc-uk.org/standards-guidance/standards-and-guidance/gdc-guidance-for-dental-professionals/scope-of-practice
GDC Standards for the Dental Team: https://standards.gdc-uk.org/
British National Formulary, dental section on medical emergencies, to be checked by the Practice through its current BNF access route

5. Scope

This policy applies to:

all patients, visitors, staff and contractors on Practice premises
all clinical and non-clinical staff
emergency preparation in surgeries, waiting areas, reception and decontamination areas
emergencies during NHS and private dental care
emergencies during sedation where the Practice offers sedation

Before adoption, the Practice records the exact emergency-kit and AED locations, role allocation for each shift, 999 calling method, ambulance entrance and access instructions, staff who meet and guide the crew, local handover route and any sedation-specific emergency plan. The map is tested during simulation and updated after premises, staffing or service changes.

6. Roles and responsibilities

Registered Manager: ensures suitable emergency medicines, equipment, staffing, checks, training, simulation and governance review are in place.
Clinical lead: verifies the current clinical sources, approves the local emergency plan and reviews clinical response, competence and post-event learning.
First responder: starts the trained emergency response, directs immediate care and confirms when 999 is required.
Emergency coordinator: allocates tasks, clears the area and maintains oversight until handover. In a small team this may be the first responder where it is safe to combine roles.
999 caller and entrance guide: gives the correct address and clinical summary, stays available to the call handler, then meets and directs the ambulance crew.
Equipment or medicine runner: brings the emergency kit and AED, checks seals or status, and reports what is available.
Event recorder: records times, observations, medicines, equipment use, advice and handover details contemporaneously where staffing allows.
All staff: know the role allocated to them, summon help promptly, work within competence and attend simulation.

7. Emergency drugs

The Practice keeps emergency drugs appropriate to its service and verifies the list against the current BNF dental section and Resuscitation Council UK guidance before adoption.

The Verivius default check list covers readiness for:

anaphylaxis
hypoglycaemia
asthma
angina or suspected cardiac chest pain
seizure
opioid reversal where IV sedation is offered and the Practice's sedation protocol requires it

The Practice records:

drug name
strength and formulation
quantity held
expiry date
storage location
weekly check outcome
replacement action

Emergency drugs are stored so they are accessible in an emergency and secure under the Practice medicines policy.

8. Emergency equipment

The Practice keeps emergency equipment appropriate to primary dental care and verifies the list against the current Resuscitation Council UK equipment list before adoption.

The Verivius default check list includes:

automated external defibrillator
oxygen cylinder and delivery equipment
bag-valve-mask equipment
pocket mask
suction equipment
oropharyngeal airways
oxygen masks with reservoir
sphygmomanometer or other approved blood-pressure equipment
pulse oximeter where included in the Practice's local process
scissors, razors and spare AED pads
personal protective equipment

The Practice records weekly checks, servicing, expiry dates and replacement action.

9. Basic life support competence

All staff understand their role in a medical emergency.

Clinical staff maintain basic life support competence appropriate to their role.
Non-clinical staff know how to summon help, identify the emergency kit location and support the clinical team.
Staff who may use the AED, oxygen or airway equipment receive role-appropriate training.
New staff complete induction before working unsupervised.
The Practice records training and refreshers in the staff training matrix.

The Practice checks the exact training cadence against current GDC, Resuscitation Council UK and commissioning expectations before adoption.

10. Simulation and scenario practice

The Practice carries out medical-emergency simulation. Verivius defaults are:

at least annual whole-team simulation
additional simulation after a serious event
additional simulation after major staff, layout or equipment change
scenarios covering collapse, anaphylaxis, hypoglycaemia, asthma, chest pain and seizure over the review cycle

Each simulation record includes:

date
scenario
staff present
learning points
equipment or process issues
actions assigned
date for action review

11. Incident escalation pathway

When a medical emergency occurs, staff:

stop treatment and make the area safe
call for immediate help inside the Practice
assess the patient according to training
call 999 where emergency transfer or ambulance support is needed
use emergency equipment and drugs only within role and competence
keep a staff member with the patient until handover
document the event and treatment given
inform the Registered Manager as soon as practicable
record the event in the Practice incident register
assess statutory notification, duty of candour and safeguarding implications

The Practice does not use this policy as a clinical treatment algorithm. Staff follow current clinical training and emergency guidance.

12. Transfer and handover

Where the patient transfers to ambulance or hospital care, the Practice provides:

patient details
relevant medical history
treatment being provided when the emergency happened
observations recorded
drugs administered
time of each action where known
allergies and current medication where known
contact details for follow-up

The Practice records who received the handover.

13. Post-event debrief and record

After every medical emergency, the Registered Manager or clinical lead arranges a debrief.

The debrief covers:

what happened
what went well
what did not work
equipment availability
communication
training needs
whether the incident record is complete
whether an improvement action is needed

The debrief record is stored with the incident record. Any action is tracked to completion.

14. Audit

The Practice audits:

weekly emergency drug and equipment checks
staff training records
simulation records
incident records
action completion after medical emergencies

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

15. Related policies and tools

16. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

CQC Regulation 12: Safe care and treatment
CQC Regulation 18: Staffing
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)
Resuscitation Council UK (primary dental care quality standards and equipment list)
GDC Standards for the Dental Team
Emergency medicines and equipment guidance (current BNF dental section; MHRA alerts; manufacturer servicing guidance)

17. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

18. Document control

Version	Date	Author	Changes
v1	2026-06-10	Verivius (sample)	Conformed to the Verivius policy standard: added statutory anchor, verbatim Regulation 12 quotes, plain-English summary, sources and document control. Original operational sections preserved.
v1.1	2026-07-19	Verivius (sample)	Added the local emergency role and access map, named response responsibilities and links to the supporting emergency, medicines, incident and duty-of-candour policies.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

A dental surgery is one of the few places where a person can lose consciousness lying almost flat with instruments in their mouth, in a building with no crash team and often a treatment room reached by stairs. The events that actually happen here are largely predictable: the diabetic patient who skipped breakfast before an early appointment and goes hypoglycaemic, the faint after local anaesthetic that does not settle when the chair is tipped back, and a reaction to latex, chlorhexidine or an antibiotic prescribed at the chair. The sealed kit on the wall is necessary, but on its own it is not readiness. What decides how the next few minutes go is whether the three or four people on shift today know who starts the emergency response, who calls 999, who fetches the automated external defibrillator (AED) and who goes down to hold the door open for the ambulance crew. The patient and the relative in the waiting room feel that difference immediately: a team that moves calmly and says out loud what is happening leaves a very different impression from one hunting for the key to a cupboard. The records of checks, training, simulation and debriefs matter because they are how a registered manager knows readiness is real on a Tuesday when the usual clinical lead is on leave, rather than something everyone assumes.

The emergency drugs and equipment are in date and genuinely checked, with replacement actioned, not just a sealed kit on the wall. Expired stock, gaps against the current Resuscitation Council UK list and check sheets signed retrospectively all mean the person who collapses gets a kit that cannot help them.
Strong evidence: The weekly drug check record (name, strength and formulation, quantity, expiry date, storage location, weekly check outcome, replacement action) in section 7 and the equipment log of weekly checks, servicing, expiry and replacement in section 8.
Weak evidence: Ampoules and inhalers sitting in the kit past their expiry with "ordered" pencilled beside them and no record of a replacement ever arriving, or a quantity held that would not cover a second dose. The check sheet is a column of ticks with no expiry dates written against them, or a month of entries in the same pen and the same hand, clearly completed in one sitting. The drug list itself has not been re-checked against the current British National Formulary dental section or Resuscitation Council UK guidance since the day the policy was adopted, so a change in the recommended formulation would never have been noticed.
The defibrillator, oxygen and airway kit are present, serviced and the rostered staff can actually use them, not present but unusable. What matters in the moment is whether the people on shift that day can open the case and operate the automated external defibrillator (AED), oxygen and airway equipment.
Strong evidence: The emergency equipment list (AED, oxygen and delivery equipment, bag-valve-mask, suction, oropharyngeal airways, spare AED pads) with servicing and check records (section 8), cross-referenced to role-appropriate training (section 9).
Weak evidence: The automated external defibrillator (AED) is on the wall with nobody reading its status indicator, the pads expired last year, and the oxygen cylinder is recorded as present without anyone checking the contents gauge. Servicing certificates stop a year or two back. On the day, the person rostered to fetch the kit has never opened the case, and the bag-valve-mask is still sealed in its packaging with no sign that anyone has handled one since induction. The kit has never been reconciled against the current Resuscitation Council UK primary dental care equipment list, so absences such as spare pads, a pocket mask or oropharyngeal airways in the sizes held go unnoticed.
Basic life support competence is current for every clinical role and non-clinical staff know their part, evidenced in the matrix rather than assumed. Lapsed refreshers and new staff working unsupervised before induction leave the patient depending on whoever happens to be nearest.
Strong evidence: The staff training matrix showing basic life support training and refreshers by role and induction completed before unsupervised work (section 9).
Weak evidence: A training matrix where the basic life support refreshers all lapsed around the same date with nothing rebooked, and where reception and decontamination staff are left blank because they are counted as non-clinical even though the policy gives them a named part in the response. A new associate seeing patients in their first week with induction marked "to be completed", and no way to tell from today's rota who has been trained to use the oxygen or the airway equipment.
Whole-team simulation happens and produces tracked actions, not a signed attendance sheet. Learning points become assigned actions with review dates, so the thing the team could not find in the rehearsal is found in the real emergency.
Strong evidence: The simulation record (date, scenario, staff present, learning points, equipment or process issues, actions assigned, action review date) in section 10, including additional simulation after a serious event or major change.
Weak evidence: An attendance sheet with six signatures, the scenario recorded as "collapse" and nothing written about what actually went wrong. Learning points phrased as observations, such as "we struggled to find the glucagon", with no owner and no review date, the same point reappearing in the following year's record, and no extra session run after the practice changed surgeries or after a real emergency. Every scenario on file is a collapse, so anaphylaxis, hypoglycaemia, asthma, chest pain and seizure have never been rehearsed.
After a real emergency the escalation pathway is followed and the statutory follow-ups are assessed separately, not left implicit. The incident is logged, and three distinct questions each get their own answer: whether a statutory notification to the Care Quality Commission is due, whether the Regulation 20 duty of candour threshold is met (candour is owed to the person and is not a notification, and a dental practice is not a health service body, so the notifiable safety incident definition for registered persons other than health service bodies applies), and whether a safeguarding referral to the local authority is needed. None of the three discharges the others. The handover names who took the patient.
Strong evidence: The incident register entry and event record (times, observations, drugs, equipment use, handover) with the separately documented assessment of statutory notification to the Care Quality Commission, the Regulation 20 duty of candour owed to the person, and any safeguarding referral to the local authority (section 11), and the handover record naming who received the patient (section 12).
Weak evidence: An entry in the clinical notes and nothing in the incident register, or a register entry written days later with times reconstructed from memory. Nowhere is it recorded that the practice actually considered whether a statutory notification to the Care Quality Commission was due, whether the duty of candour threshold was met and whether a safeguarding referral to the local authority was needed, so those answers look assumed rather than assessed. A dental practice is not a health service body, so it is the notifiable safety incident definition for registered persons other than health service bodies that has to be read against what happened, and nothing on file shows anyone did that. The handover section does not name the crew or unit who took the patient.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 20(2) and reg 20(9) (duty of candour; notifiable safety incident for registered persons other than health service bodies), and Care Quality Commission (Registration) Regulations 2009, reg 18 (notification of other incidents)
Every emergency gets a debrief stored with the incident record and its actions closed out. The debrief names what did not work and what the team could not find, so the next person in that chair benefits, rather than a one-line note that changes nothing.
Strong evidence: The debrief record (what happened, what went well, equipment availability, training needs, whether the incident record is complete) stored with the incident record with actions tracked to completion (section 13), and the audit of weekly checks, training, simulation and action completion (section 14).
Weak evidence: One line at the foot of the incident form reading "debrief held, all fine", with nothing about what did not work, what the team could not find or what training was needed, and no sign the debrief record was filed with the incident record. Actions from earlier emergencies still sitting open with no closure date, and an audit that counts how many weekly checks were completed rather than testing whether the gaps those checks found were put right.

Last verified 20 July 2026

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Last reviewed 19 July 2026