The centre was told to send Mr A to a specialist if prostate-specific antigen (PSA) was found in his body. File photo Photo: 123rf
A medical centre has been asked to apologise to the family of a man who died after complications from prostate cancer.
A report from the Health and Disability Commissioner found that the centre failed to refer the man to a urologist which lead to his death.
The man, referred to only as Mr A, had surgery to remove the prostate in 2016. The centre was told to send him to a specialist if prostate-specific antigen (PSA) was found in his body.
"A recall was set for six-monthly PSA testing, with reminder texts being sent to Mr A. However, it appears that no patient alert was set up," the report said.
"PSA first became detectable (0.10µg/mL) following a routine test. The lowest reportable total PSA value is 0.05µg/mL. [The doctor] reviewed the PSA result and annotated it as 'OK', despite PSA being detectable."
Despite tests showing the increase on the man's PSA levels, he was not referred to a specialist, the report showed.
"[A year later] Mr A's PSA levels were reviewed again and demonstrated an ongoing increase (0.60µg/mL), but again the result was annotated as 'OK' by [the nurse]," the report said.
After persistent nausea in 2020, the patient went through more exams, with a GP completing a urgent urology referral.
"I was alarmed to see a PSA of 5.7 and looked back through his notes. There was a plan from urology that he should be referred back if the PSA became detectable.
"This occurred [eight months after the prostate surgery] and has never been acted upon. In the meantime the PSA has been steadily climbing," the GP noted.
The man died later as the cancer spread to other parts of his body, including his pancreas, the report said.
Aged Care Commissioner Carolyn Cooper said multiple clinicians who reviewed the man's PSA levels overlooked the urologist's letter and did not fully understand his clinical history.
"There were several opportunities for clinicians to review the man's clinical notes, and it must be acknowledged that had an earlier urology referral been made, it is possible (but not inevitable) that his pancreatic tumour may have been detected at an earlier stage."
Cooper said the medical centre company was in breach of the Code of Health and Disability Services Consumers' Rights.
"I acknowledge the distressing impact of this on the man and his family and express my sincere condolences to the family for their loss."
The commissioner found the medical centre failed to read and adhere to the urologist's recommendations.
"Failing to interpret rising PSA results in the context of the man's past clinical history, and failing to have effective administrative systems that supported co-ordinated care and communication amongst individual providers."
In a long list of recommendations, the commissioner suggested the medical centre should start using a new inbox process, set up a patient portal for sharing test results, and establish a double recall system for post-prostatectomy patients to make sure doctors review results and intervene quickly.
She also recommended one of the GPs and a nurse practitioner who reviewed the man's PSA tests formally apologise to the man's family.
In the report, the GP said the case was a lesson to be learned.
'[Mr A's] case has been a salutary lesson for me.
"I ensure any blood tests such as PSA tests are fully checked against past clinical history and trends of previous tests, and to familiarise myself further with the history and need for further treatment relevant to each test."
