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GPs go forth

Buried PSA test resurfaces after cancer diagnosis

Three GPs discuss a tricky problem

Case history

James, 63, has complained of intractable lumbar pain for several months and is registered with your partner Dr Smith. He attends while Dr Smith is on holiday requesting referral. After private

X-rays, blood tests and an MRI scan it is finally determined he has bony metastases from a primary prostate cancer.

He comes to discuss the outcome of the referral and is shocked because he'd had a PSA screening test only a couple of years ago.

At the end of surgery, you check his records and find he had indeed had a PSA done in 2001 and the result was very elevated at 25ng/ml. However, the result seems to have been signed and filed without being acted on. What should you do?

Dr John Couch

'You must let Dr Smith consider and act on his own mistake'

You must wish you had not checked the old PSA result as you now face a real dilemma. This is a clear and tragic failure in your practice's clinical governance. Assuming no comments were written on the pathology form other than a signature it seems the abnormal result did not register with whoever checked it. Is it Dr Smith's signature? If he was away, a locum or another partner may have been responsible.

Now you have spotted the error you must consider your choices carefully. Assuming you did not record your findings in the patient's notes, you could choose to say nothing. No one would ever find out you knew. If it were Dr Smith who signed the report you would certainly be saving him a great deal of possibly unnecessary anxiety.

The patient may never learn about the first PSA result and that knowledge would certainly not affect his current treatment. But hiding the truth is unethical, it would deny the patient or his family the option of financial compensation and, anyway, could your conscience survive intact?

You could tell the patient yourself. While this would be an honest action it would deny Dr Smith the opportunity to consider and act on his own mistake. Any apology he may subsequently make would certainly not sound as genuine and this route would be sure to affect your relationship as partners adversely.

The best compromise is to tell Dr Smith as soon as he gets back. This is his patient and his mistake. I would do this in writing and keep a confidential copy of the letter. Offer to discuss the situation further with him and be as supportive as possible. If I were advising Dr Smith I would suggest a phone call to his defence body should be the first move.

There is now an urgent need for your whole practice to review how results are checked to make your future systems as failsafe as possible. The defence bodies provide excellent literature on clinical governance.

Dr Claire Pedder

'We can't close ranks and turn our defensive backs on James'

This is a disaster for all concerned. Gone are the days when the closing of medical ranks was the standard response to mistakes ­ patients and doctors are more aware their relationship is an evolving partnership and with that comes the right to be informed of errors.

One could argue that telling James his prostate cancer may have been diagnosed and treated two years ago would serve no purpose at this stage, but it is unlikely he would not seek further answers about his management, including his previous investigations. He may exercise his right to access his medical records, or be made aware of his abnormal PSA result by another member of the primary care team.

Dr Smith needs to be made aware of what has happened and may well want to discuss the situation with James. This will take guts and Dr Smith will need the support of all the partners. If Dr Smith refuses then I would bite the bullet after discussing with my partners and taking advice from my defence union. Informing James of his abnormal PSA without apportioning blame on any one individual, I would apologise that such an error has taken place and brace myself for his response, accepting that a formal complaint is likely.

James needs to be able to develop a trusting relationship to help him face his difficulties, and I would hope that by being open and honest with him this may yet be possible. We cannot turn our defensive backs on him now, but he may feel he is unable to stay with our practice.

A significant event analysis involving all the practice team is required.

Dr Patrick Wills

'This is a critical incident and must be reported to the PCT'

There are well-known limitations to PSA as a screening test, but this result would warrant further investigation.

If my partner has made a mistake then the patient is entitled to full information and explanation. This, however, can only be given when all the facts are available and should ideally be given by Dr Smith.

The patient is distressed enough already and I could not mention this until I am sure of my facts. Is the right result filed in the right notes? A thorough check through the notes is required, to see if the result was discussed with the patient.

A mistake like this can be due to many reasons and it could happen to any doctor. If I had made the mistake, how would I want Dr Smith to treat me?

I would want to know as soon as possible. I would appreciate a phone call on a half-day but not on a holiday away from home. I would want to check through the medical records myself to see if there was any other explanation.

The doctor concerned should contact the patient with an explanation and apology, unless this would cause a long delay. It is up to the patient if they wish to formalise a complaint.

All of this is secondary to the most important issue ­ that James almost certainly has metastatic prostate cancer and needs urgent referral to a urologist. He needs support through this illness from a GP with whom he has a good relationship. This may indeed still be Dr Smith.

Tact and sensitivity is called for. James should be informed he is at liberty to re-register with a different partner or practice if he wishes, but he is not being pushed out.

Finally, this is a critical incident and needs discussion in the practice and the PCT must be informed to identify problems that could be avoided in future.

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