Public interest report: Betsi Cadwaladr University Health Board (202404388)

This report is issued under s.23 of the Public Services Ombudsman (Wales) Act 2019.

We have taken steps to protect the identity of the complainant and others, as far as possible.  The names of the complainant and others have been changed as well.

Mr C complained about the care and treatment he received between September 2023 and July 2024 following his prostate cancer diagnosis.  In particular, we considered the significance of the delays in Mr C receiving a prostate-specific membrane antigen positron emission tomography scan (“PSMA PET scan” – an advanced imaging test that uses a radioactive tracer to identify and visualise prostate cancer cells).  We also considered the delay in Mr C receiving hormonal therapy, and the impact this had on the spread of the cancer.

The investigation found that whilst the care and treatment Mr C received, overall, followed the NHS Wales National Optimal Pathway (“NOP”) for Prostate Cancer, there were significant delays in Mr C’s journey on the NOP which led to him waiting more than 3 times as long as he should have done before his treatment was started.  A biopsy in January 2024 indicated that a PSMA PET scan was appropriate for Mr C, but it did not happen for almost 4 months.  This delay was unacceptable and amounted to service failure.  The delays in Mr C’s pathway more likely than not contributed to his cancer being more advanced.  This uncertainty will sadly be an enduring injustice for Mr C and his family, so this part of his complaint was upheld.

In relation to Mr C receiving hormonal therapy sooner, the investigation found that it was appropriate for Mr C not to have started this therapy before the outcome of the PSMA PET scan was known as this would have had a potentially significant impact on the interpretation of the PSMA PET scan itself.  However, as there had been a significant and unnecessary delay in Mr C undergoing the PSMA PET scan, it followed that there was also a subsequent delay in his hormonal therapy commencing.  This was also an injustice to Mr C and this part of his complaint was also upheld.

Of further concern was the Health Board’s failure to recognise the delays highlighted when it responded to Mr C’s complaint.  In the thematic report “Groundhog Day 2”, this office emphasised that when public bodies responded to complaints poorly, this compounded the feeling of injustice and can be an exhausting experience for complainants to have to escalate their concerns to this office.  Mr C’s case is a prime example of this: it must have been especially hard for Mr C considering his diagnosis and need for ongoing treatment.  Although not specifically outlined within the scope of the complaint, there will be a recommendation that the Health Board reviews its handling of Mr C’s complaint in line with its Duty of Candour and a further recommendation in light of the Health Board’s complaint handling and failure to uphold Mr C’s complaint when there was clear evidence there had been service failures.

This office had previously issued 4 reports about delayed prostate cancer management by the Health Board.  The Health Board had been urged to fully commit to change and improvement so that men do not have cause to approach this office again with similar concerns.  It is bitterly disappointing to have to report once again on the failings of the Health Board in the same area.

The Health Board agreed to the following recommendations:

a) Apologise to Mr C for the failings identified in this report, especially for the delay in receiving a PSMA PET scan and the uncertainty of whether this delay contributed to his cancer being more aggressive and advanced.

b) Share this report with those clinicians involved in Mr C’s care between September 2023 and July 2024 so the findings can be considered and discussed and feedback to this office any improvements or changes presented during those discussions.

c) Share this report with and remind its complaint handling staff of the need for in-depth and robust investigations.

d) Review its local prostate cancer pathways and benchmark it against the NOP, and with those used by other health boards in Wales. A formal audit before and after changes would be required to provide evidence about the impact of any changes.

e) Review this case, in line with its legal requirements under the Duty of Candour, to determine how Mr C’s cancer pathway journey took more than 180 days. The Health Board should then report its findings to its Quality and Patient Safety and Audit Committees and include its findings in its Annual Report on the Duty of Candour.

f) The Health Board should audit those patients that have required a PSMA PET scan in the last 2 years to establish the interval between the Point of Suspicion (“PoS”) and commencement of definitive treatment. It should also establish the length of time patients had to wait to receive the scan and take appropriate remedial action to ensure patient management is in keeping with national guidance.

1. Mr C complained about the care and treatment he received between September 2023 and July 2024 following his prostate cancer diagnosis. In particular, we considered the significance of the delays in Mr C receiving a PSMA PET scan.  We also considered the delay in Mr C receiving hormonal therapy, and the impact this had on the spread of the cancer.

2. My investigator obtained comments and copies of relevant documents from Betsi Cadwaladr University Health Board (“the Health Board”) and considered those in conjunction with the evidence provided by Mr C.

3. We also obtained professional advice from one of my Professional Advisers, Dr John Staffurth, an experienced professor of Clinical Oncology. The Adviser was asked to consider whether, without the benefit of hindsight, the care or treatment had been appropriate in the situation complained about.  I determine whether the standard of care was appropriate by making reference to relevant national standards or regulatory, professional or statutory guidance which applied at the time of the events complained about.

4. I have not included every detail investigated in this report, but I am satisfied that nothing of significance has been overlooked.

5. Both Mr C and the Health Board were given the opportunity to see and comment on a draft of this report before the final version was issued.

6. NHS Wales National Optimal Pathway (“NOP”) for Prostate Cancer (2023)[1]. This pathway recommends that the period from the first point of suspicion (“PoS”) to first definitive treatment should be less than 62 days.

7. NHS Wales Positron Emission Tomography (PET) Commissioning Policy (2024) (“the Commissioning Policy”). At the time of the events in question, PSMA PET scanning was, and still is, good practice and the standard diagnostic test for men with high risk localised prostate cancer in Wales.  Although this policy was issued in April 2024 and post dates some of the events in question, the evidence review for recommending the PSMA PET scan was undertaken in 2021.

8. Public Services Ombudsman for Wales: Groundhog Day 2 – An opportunity for cultural change in complaint handling? (2023). This thematic report built on my predecessor’s report from 2017 (“Ending Groundhog Day – Lessons in Poor Complaint Handling”), focusing on how our complaints standards training and the requirements of the Duty of Candour provide a fresh opportunity for change to the ways health boards engage with their patients and respond robustly to complaints.

9. Welsh Government – The Duty of Candour Statutory Guidance (2023). This guidance requires local health boards in Wales to talk to service users about incidents that have caused harm, apologise and support them through the process of investigating the incident, and then to learn and improve and find ways to stop similar incidents happening again.

[1] https://performanceandimprovement.nhs.wales/functions/networks-and-planning/cancer/wcn-documents/clinician-hub/prostate3rdnop/

10. I previously issued a public interest report in July 2024[2] about a patient’s delayed prostate cancer management by the Health Board. My predecessor also issued a public interest report in 2020 against the same Health Board[3] about delays in prostate cancer treatment.  Following this report, under section 4 of the Public Services Ombudsman (Wales) Act 2019, the Public Services Ombudsman for Wales (“PSOW”) also carried out an investigation using the PSOW’s Own Initiative power of investigation into suspected further delays in prostate cancer treatment for 17 patients within the Health Board[4].  In addition, as far back as 2016, this office issued a public interest report about delays in the Health Board’s management of prostate cancer (case reference 201503554).

11. It is of great concern to me that I find myself once more issuing a public interest report about the Health Board’s management of a patient with prostate cancer. Following my report last year, the Health Board informed me of an improvement plan it had drawn up following recommendations by the Royal College of Surgeons.  Whilst this was welcomed, it appears to date, that the majority of the tasks remain outstanding and there have been delays in progressing the plan.  I will comment further on this later in the report.

[2] Case 202207270 – Betsi Cadwaladr University Health Board – 202207270 – Public Services Ombudsman for Wales

[3] Case 201905373 – Betsi Cadwaladr University Health Board – 201905373 – Public Services Ombudsman for Wales

[4] Case 202002273 – https://bcuhb.nhs.wales/about-us/governance-and-assurance/com46261-final-public-interest-own-initiative-report/

12. On 27 September 2023 Mr C was referred to the Urology Unit at Ysbyty Gwynedd (“the Hospital”) due to a raised PSA prostate-specific antigen (“PSA”) test level. This is a blood test that measures the amount of PSA (a protein produced by the prostate gland).  It is used to help diagnose prostate problems, including cancer.

13. Mr C was reviewed in clinic by a consultant urologist on 27 October and a plan was made for a multi-parametric magnetic resonance imaging scan (“mpMRI” – a specialised MRI scan of the prostate that uses multiple types of imaging to create highly detailed pictures of the prostate).

14. The mpMRI was performed on 28 November and it was reported as being, suggestive of Mr C being at “high risk of having clinically significant prostate cancer”. Mr C was scheduled for a local anaesthetic trans‑perineal (“LATP”) biopsy of the prostate.

15. Mr C underwent the LATP biopsy on 22 January 2024. The histology results were available on 30 January and it was reported that cancer has been identified in over half of the biopsy samples taken.  Mr C’s cancer was graded as Gleason Grade 4+5=9 (ISUP Gleason grade group 5 – a score of between 6 and 10 means prostate cancer is present, and the higher the grade the more likely it is that the cancer will grow and spread outside the prostate).

16. Mr C’s scan and histology results were discussed on 7 February in a urology multi-disciplinary team meeting (“MDT” – a group of specialists who work together to discuss a patient’s care and treatment). The plan was for Mr C to be reviewed in 1 week and for him to undergo further investigations including a computerised tomography scan of the thorax, abdomen and pelvis (“CT TAP”) and a bone scan.

17. On 13 February Mr C was reviewed in clinic by a consultant urologist and a clinical nurse support worker who informed him of his diagnosis and explained the high aggressiveness of the tumour. Mr C was advised of the MDT recommendations and radical treatment options were discussed.

18. Mr C underwent a bone scan on 23 February which was unremarkable.

19. Mr C’s CT TAP scan on 29 February did not report any metastatic features (this is when cancer spreads from the original site).

20. Shortly afterwards, Mr C chose to undergo a prostatectomy (a procedure to remove part or all of the prostate gland). Arrangements were then made to refer Mr C to a hospital in England.

21. On 5 March Mr C met with a clinical nurse specialist who explained that the hospital in England required a PSMA PET scan report as part of the referral process.

22. The PSMA PET scan was eventually performed on 9 May in Cardiff. It was reported that Mr C had metastatic disease which had spread to the lymph nodes and to his bones.

23. Mr C’s case was discussed at an MDT meeting on 22 May. It was recommended that he should receive hormone treatment, chemotherapy and radiotherapy.  Mr C was informed of the MDT recommendations the following day.  The prostatectomy in England was cancelled.  Mr C commenced hormonal therapy on 15 June and he began chemotherapy and radiology treatment on 23 July.

24. Mr C complained to the Health Board on 23 and 25 June about the delay in his treatment. The Health Board responded on 9 August.  It apologised to Mr C and said the delay was due to staff sickness and capacity issues as there was at the time a UK-wide shortage of PSMA tracer (the radioactive substance injected into the patient) and a lack of PET scans locally.  The Health Board, however, concluded that the treatment Mr C received was appropriate and reasonable.

25. Mr C said that he disagreed with the Health Board that the care and treatment he received was appropriate and reasonable. He said that following his diagnosis, he received no treatment (bar the hormone therapy) until July 2024.  Mr C said that nothing was done in time to stop the spread of the cancer.

26. The Health Board provided no further comments beyond those in its complaint response to Mr C.

27. The Adviser said that, overall, the care and treatment Mr C received followed the NOP; however, the time for him to complete the pathway went far beyond NHS Wales targets. He said that delays had occurred around decision-making and appointments being booked following outpatient appointments and MDT meetings:

28. The Adviser said that there were particular delays with time taken for a mpMRI, a LATP biopsy, to complete conventional imaging and finally the length of time taken before a PSMA PET scan was performed. He added that the potential need for a PSMA PET scan would have been predictable following Mr C’s biopsy result in January 2024 as he was considered at risk of harbouring microscopic metastatic disease due to his high Gleason score.

29. The Adviser said that the oncological management (specifically the decision not to use hormonal therapy whilst waiting for the diagnostic pathway) was appropriate as the hormonal therapy (androgen deprivation therapy – a prostate cancer treatment that lowers male hormone levels in the body) would have been expected to alter the interpretation of the PSMA PET scan.

30. The Adviser added that in Mr C’s case, the only 2 options were to accept the delay in accessing PSMA PET scans and the risk of disease spread or to continue to treatment with sub-standard staging. As the treatment plan involved outsourcing to a provider in England, the latter option would have required a change in therapeutic approach.  The Adviser said it was unclear from Mr C’s notes exactly what discussions occurred around this.

31. The Adviser said that it was impossible to know categorically whether the delays resulted in a more advanced disease for Mr C than if the NOP timelines were followed, but it was certainly possible that his disease spread during his prolonged diagnostic and staging journey.

32. In reaching my conclusions I have considered the advice that I have received from the Adviser, which I accept. However, the conclusions reached are my own.

33. I considered the significance of the delay in Mr C receiving a PSMA PET scan and the impact this had on the spread of his cancer. Based on the evidence I have seen, I am satisfied that the care and treatment Mr C received, overall, followed the NOP.  However, as the table above clearly illustrates, there were significant delays in Mr C’s journey on the NOP which led to him waiting more than 3 times as long as he should have done before his treatment was started.  The Adviser said that the delays were due to a combination of the Health Board using MDT meetings and face-to-face appointments to reach management recommendations, inform Mr C of next steps and arranging investigations, and to some extent, delays in access to PSMA PET scanning.  Whilst this seems on the face of it as if Mr C’s pathway was carefully managed, it deviated significantly from the NOP.  The Health Board’s reasons, stating staff sickness and capacity issues, were ones provided during previous investigations by my office, which ultimately led to previous reports being issued in the public interest (see paragraph 10).  This does not, however, fully explain why Mr C waited more than 180 days from PoS to FDT.

34. I accept that the biopsy in January 2024 indicated that a PSMA PET scan was appropriate for Mr C, but I cannot understand why this did not happen for almost 4 months, especially considering the Commissioning Policy. It was not until the hospital in England recommended that Mr C undergo a PSMA PET scan prior to his referral that the Health Board then considered this type of scan.  The Health Board has pointed to a UK-wide shortage of the PSMA tracer as the reason for the delay in Mr C receiving the PSMA PET scan.  Whilst I accept that there was a shortage, it does not explain why the Health Board did not appreciate the need for a PSMA PET scan before the hospital in England requested it, contributing to the approximate 12‑week delay between the biopsy results and the PSMA PET scan taking place.  This delay was unacceptable and amounts to service failure.

35. Therefore, on the balance of probabilities, these delays in Mr C’s pathway more likely than not contributed to his cancer being more advanced. This uncertainty will sadly be an enduring injustice for Mr C and his family, so I uphold this part of his complaint.

36. In relation to Mr C receiving hormonal therapy sooner, I am satisfied that it was appropriate for Mr C not to have started this therapy before the outcome of the PSMA PET scan was known as this would have had a potentially significant impact on the interpretation of the PSMA PET scan itself. However, as I have already determined that there had been a significant and unnecessary delay in Mr C undergoing the PSMA PET scan, it follows that there was also a subsequent delay in his hormonal therapy commencing.  This was also an injustice to Mr C and I uphold this part of Mr C’s complaint.

37. Of further concern is the Health Board’s failure to recognise the delays I have highlighted when it responded to Mr C’s complaint. In my thematic report “Groundhog Day 2”, I emphasised that when public bodies responded to complaints poorly, this compounds the feeling of injustice and can be an exhausting experience for complainants to have to escalate their concerns to my office.  Mr C’s case is a prime example of this: it must have been especially hard for Mr C considering his diagnosis and need for ongoing treatment.  Although not specifically outlined within the scope of the complaint, I am therefore recommending that the Health Board reviews its handling of Mr C’s complaint in line with its Duty of Candour and I have made further recommendations to the Health Board in light of its complaint handling and failure to uphold Mr C’s complaint when there is clear evidence there had been service failures.

38. As I mentioned above (paragraph 11), since my last public interest report the improvement plan shared by the Health Board with this office remains incomplete. Although this plan was agreed with the Royal College of Surgeons, I am extremely concerned that some of the high priority tasks remain outstanding and there has been little progress with others.  Previously, I shared my report and its findings with Healthcare Inspectorate Wales (“HIW”) to inform its considerations when planning its future work in this area.  I will, again, be sharing this report with HIW; however, in addition I will also share it with Audit Wales and the Welsh Government’s Cabinet Secretary for Health and Social Care.

39. I previously urged the Health Board to fully commit to change and improvement so that men do not have cause to approach my office again with similar concerns. It is bitterly disappointing to have to report once again on the failings of the Health Board in the same area.

40. It for these reasons I consider that it is appropriate for me to issue this report in the public interest in the expectation that the Health Board will take swift and decisive action to address this unacceptable lack of progress in delivering the Health Board’s improvement plan and the impact it is and potentially will have on men in North Wales.

41. I recommend that, within 1 month of the final report being issued, the Health Board should:

a) Apologise to Mr C for the failings identified in this report, especially for the delay in receiving a PSMA PET scan and the uncertainty of whether this delay contributed to his cancer being more aggressive and advanced.

b) Share this report with those clinicians involved in Mr C’s care between September 2023 and July 2024 so the findings can be considered and discussed and feedback to this office any improvements or changes presented during those discussions.

c) Share this report with and remind its complaint handling staff of the need for in-depth and robust investigations.

42. I recommend that, within 6 months of the final report being issued, the Health Board should:

d) Review its local prostate cancer pathways and benchmark it against the NOP, and with those used by other health boards in Wales. A formal audit before and after changes would be required to provide evidence about the impact of any changes.

e) Review this case, in line with its legal requirements under the Duty of Candour, to determine how Mr C’s cancer pathway journey took more than 180 days. The Health Board should then report its findings to its Quality and Patient Safety and Audit Committees and include its findings in its Annual Report on the Duty of Candour.

f) The Health Board should audit those patients that have required a PSMA PET scan in the last 2 years to establish the interval between the PoS and commencement of definitive treatment. It should also establish the length of time patients had to wait to receive the scan and take appropriate remedial action to ensure patient management is in keeping with national guidance.

43. I am pleased to note that in commenting on the draft of this report the Health Board has agreed to implement these recommendations.

4 March 2026

Michelle Morris

Ombwdsmon Gwasanaethau Cyhoeddus | Public Services Ombudsman