Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
Deputy Health and Disability Commissioner Dr Vanessa Caldwell today released a report finding several medical professionals in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for inadequate communication of test results, and failing to keep clear and effective documentation.
A man in his sixties, with a known family history of prostate cancer requested that his GP test his prostate protein levels (PSA) as both his father and an uncle had died of prostate cancer in their sixties. The man’s test result was higher than normal for a man of his age. However, the GP failed to arrange for timely further tests; inform him of his abnormal test; document his family history; or enquire about other red flags for prostate cancer.
Over a two-year period, the man saw two other GPs at the same medical centre, and had his PSA levels tested on three further occasions. All three test results showed that his PSA levels were higher than normal. However, the tests were not repeated promptly (as stipulated by guidance), the results were not adequately shared with the man, and he was not referred to a urologist on these occasions. Eventually the man was diagnosed with prostate cancer.
Deputy Commissioner, Vanessa Caldwell said she considered that “the failures in this case were a result of individual clinical decision-making by multiple doctors, as well as an inadequate system that did not support its staff fully, for which the medical centre had responsibility.”
One of the blood tests was ordered under the name of and reviewed by a doctor who had not had the opportunity to examine or speak to the man. In that instance the results were communicated to the man by a nurse. The Deputy Commissioner stated that: “In my opinion there is an element of risk when a doctor reviews test results of a patient whom they have not seen or had an opportunity to ask questions, and when the expectation on the doctor is that the nurse communicates results to patients.”
Dr Caldwell considered that the first GP had breached the Code by failing to document the man’s family history of prostate cancer; failing to enquire about red flags for prostate cancer; incorrectly documenting “no red flags” in the man’s medical records; failing to repeat his PSA test in six to twelve weeks’ time; and failure to inform the man of his results, which was information he would reasonably expect to receive. These failures denied the man the opportunity to participate in his own care.
With regards to the second doctor, Dr Caldwell found that they had breached the Code, by twice failing to refer the man to urology services or to repeat the PSA test promptly and they too failed to inform the man of his results.
Dr Caldwell found that the third doctor also breached the Code by failing to refer the man to urology services or repeat the PSA test promptly.
Dr Caldwell recommended that all parties provide formal apologies to the man, which have all now been received. Dr Caldwell also recommended that the medical centre provide evidence of staff training on PSA management and prostrate screening; provide a copy of the results of an audit on the management of elevated PSA results since 2016, and, if required, an action plan regarding any high results; consider whether a review of its test recall system or its orientation process for doctors is necessary; and consider incorporating the Prostrate Cancer GP Tool (a decision support tool) into its practice.
Dr Caldwell also recommended that all three practitioners conduct an audit of their assessments of patients with abnormal PSA results over a three-month period, and, where the audit does not show that appropriate steps were taken as mandated by the Prostrate Cancer Management Guidance, to outline why, and the steps taken to remedy such issues.
