Medical Centre Breaches Code For Their Treatment Of A Man With Prostate Cancer

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.

Ms Cooper 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,” Ms Cooper said.

Ms Cooper 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.”

Ms Cooper 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.

© Scoop Media