In a report released today, Aged Care Commissioner Carolyn Cooper found a medical centre breached the Code of Health and Disability Services Consumers’ Rights (the Code) for their care of a man with prostate cancer.

The man was diagnosed with prostate cancer in 2016 and had a surgical procedure to remove the prostate and surrounding tissue.

In 2019 the man’s care was handed back to his medical centre and his urologist provided instructions to the centre to check his PSA levels every six months and complete an immediate referral back to urology if levels became detectable. PSA is a protein in the blood that is produced by normal, as well as malignant, cells of the prostate gland.

Over the next three years, five test results showed the man’s PSA levels were detectable.

However, because these results were not picked up by the medical centre, they were not relayed back to the man accurately, and he was not referred to a urologist.

This meant that the cancer spread to other parts of the man’s body, including his pancreas and, sadly, he passed away.

Carolyn identified deficiencies in the standard of care and communication provided to the man by the medical centre. She found that 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," says Carolyn.

Carolyn found the medical centre company in breach of Right 4(1) of the Code - the right to services provided with reasonable care and skill - for failing 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 coordinated care and communication amongst individual providers.

She also found the medical centre company in breach of Right 6(1)1 of the Code, the right to be fully informed, and for failing to explain to the man the results of his PSA tests.

"I acknowledge the distressing impact of this on the man and his family and express my sincere condolences to the family for their loss."

Carolyn also made adverse comments about one of the GPs and a nurse practitioner at the medical centre who reviewed the man’s PSA tests for failing to accurately interpret the results. She recommended they both write letters of apology to the man’s whānau.

She also recommended the medical centre confirm: the implementation of a proposed inbox management process; that a patient portal has been implemented to communicate test results to patients; and that all post-prostatectomy patients have a double recall system established in its practice management system to facilitate timely clinician review of test results and interventions.

The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).