Miss Y complained on behalf of her partner, Mr X, that there was a failure to accurately diagnose his cancer between February and June 2018. Mr X had been first seen at the Royal Gwent Hospital (“the Hospital”) in February, and had undergone tests including an MRI scan in June (MRI” – the use of strong magnetic fields and radio waves to produce detailed images of the inside of the body). On reviewing the MRI (at a Multi-Disciplinary meeting – “MDT” – in July) the Hospital told Mr X that his cancer was organ confined to the prostate. It was recommended he undergo a RALP (a prostatectomy – removal of the prostate gland), which was performed on 25 September. On a subsequent Hospital review of the MRI imaging, Mr X was told in November that his cancer was being upstaged and that it was not organ confined. It had spread outside the prostate. Mr X was told that the MRI scan in June had missed this. Miss Y complained that the Hospital had missed the extent of Mr X’s cancer on the original scan leading to him undergoing the unnecessary RALP, which had resulted in him suffering debilitating side effects. Further, she said that Mr X was not able to properly consent to the RALP procedure, not being in possession of the full facts, or therefore having the opportunity to consider any alternative treatments.

The investigation identified numerous failings in Mr X’s care in the period concerned. These included the following: a failure to note enlarged pelvic lymph nodes on the June scan, which were suspicious, and so incorrectly staging them and reporting them as being normal; only one view had been taken whereas an axial sequence should have been performed in accordance with recognised guidance (which may have better identified the pelvic nodes as suspicious); the suspicion of metastatic cancer should have been raised from a lesion’s appearance (its size passing the threshold of suspicion); the MDT record in July was insufficient, so that it was not possible to discern if all the images and reports had been considered at the meeting. There was no clear evidence that Mr X was informed about possible alternative treatments to the RALP and, given the above failings, he consented to and underwent an unnecessary procedure (a RALP is only suitable for patients with organ confined cancer), so suffering the severe after effects he complained about. This was a significant injustice to him. From advice received during the investigation, nevertheless, the failings were unlikely overall to have significantly altered Mr X’s overall prognosis, but the failings found were significant ones and the complaint was upheld. The following recommendations were made, which the Health Board agreed to implement over a period of 6 months:

a) Apologise to Miss Y and Mr X for the identified failings.

b) Make a redress payment of £5000 to Mr X for the failings in his care.

c) Remind all clinicians about properly documenting the meeting/preparing minutes of MDTs.

d) To review its prostate MRI protocol to ensure a pelvic sequence view is taken (as per guidance to better allow for pelvic lymph node evaluation).

e) To provide evidence of the review of MDT meeting arrangements the Health Board indicated it had since introduced, to the Ombudsman.

f) Consider an MDT review of all prostate cases (from June 2018 to the present day) where subsequent pathology placed the patient into a higher risk category from the initial staging.

g) Reviews its MDT procedure to consider implementing a routine audit of MDT reporting against pathology outcomes.