GP practice failed to urgently refer patient

What happened

Mr R went to his GP Practice at the end of 2007. The GP carried out a physical examination and a blood test to measure his prostate-specific antigen (PSA) levels, which were normal for his age. Mr R went back to his GP in mid-2008, spring 2010, spring 2011, and twice towards the end of 2011. During this time, the GP carried out various examinations and tests because Mr R had difficulty urinating and some discomfort. The PSA test results showed that Mr R's levels were rising and high for his age. The GP prescribed antibiotics at the mid-2008 appointment and took a 'watch and wait' approach.

The GP referred Mr R to a urologist (a specialist in problems of the kidney, bladder and genitals) in late 2011, but did not refer him under the two-week 'wait pathway' (the national guideline for how long it should take to see a specialist). Mr R was diagnosed with prostate cancer in February 2012 by a urology clinic and had to have radiotherapy and hormone treatment.

What we found

Mr R's urgent referral to a urologist should have been made as early as spring 2010 because his PSA levels continued to rise and were high for his age. When he was referred in late 2011, it was a routine referral. Although we cannot say on balance that his treatment options were limited because of this, Mr R now has to live with the knowledge that his chances of recovery have been affected for the worse.

Putting it right

The surgery acknowledged and apologised for the failings identified and put together an action plan that showed how it had learnt from its mistakes so that they would not happen again. We also recommended that the GP reflect on his actions in the case and the lessons for him personally.