East Kent Hospitals University NHS Foundation Trust

Practice

9. Mr C complains that a GP practice within the East Kent and East Sussex area (the Practice) did not take the right action after his prostate-specific antigen (PSA) test in June 2017. He says it did not arrange a PSA test at his appointment July 2020. He also says when the Practice received details of his abnormal PSA level in August 2020 it should have checked that suitable action had been taken. He says the Practice should have arranged regular follow up PSA tests.

Trust

10. Mr C complains that East Kent Hospitals University NHS Foundation Trust (the Trust) did not act on his raised prostate-specific antigen (PSA) level in late July 2020. He says the result should have triggered action to make an earlier diagnosis of prostate cancer.

11. He says in August 2023 he was diagnosed with a recurrence of prostate cancer that had been present for several years. He says the delay caused by both the Trust’s and Practice’s mistakes meant his cancer had spread to his lymph nodes, he developed rectal cancer, his treatment was delayed, and he needed severe radiation therapy. He experienced additional pain and suffering. He has a permanent colostomy which psychologically affects him. He says his family has suffered stress and frustration.

12. Mr C says his daughter feels ashamed working for the Trust that let her father down.

13. He has lost faith in the Practice for blaming him and not accepting its duty of care.

14. Mr C wants the Trust and the Practice to acknowledge what they got wrong and apologise for the impact on him and his family. He wants the Trust and the Practice to offer him a financial remedy for the impact of the failings in his care. He wants both organisations to take action to improve their service.

15. Mr C had a radical prostatectomy in 2006. He had a PSA test in June 2013 at a hospital within the Trust. The result was 0.1(ng/mL). In October 2013 the urology clinic advised regular PSA checks by his GP who could refer him to the oncology team if his PSA level increased.

16. Mr C saw a GP in June 2017 as he was worried about prostate symptoms. The GP arranged a PSA blood test.

17. He saw a GP in mid-July 2020 with blood in the urine (haematuria). The GP made an urgent two-week referral to urology.

18. At the end of July 2020 Mr C saw the Trust’s urology team. It arranged a CT urogram (a scan that looks at the kidneys and bladder area) and arranged a PSA test. The urology team wrote to the Practice on 4 August and said he did not need any follow up.

19. Mr C had a telephone consultation with his GP in August 2020 to talk about the result of the PSA test urology had arranged.

20. Mr C next saw his GP about his prostate on in late July 2023 when he had right sided flank pain. The GP arranged a blood test which included a PSA. The result was 23 and in early August, the GP sent a referral for a two-week wait urology appointment.

21. In August the Trust urologist told him his prostate cancer was back. He started radiotherapy in February 2024, which was successful. But in June 2024 he was diagnosed with bowel cancer and in January 2025 with rectal cancer.

26. Mr C had a radical prostatectomy (removal of the prostate) in 2006. The notes show he had a moderately aggressive form of prostate cancer, localised to the prostate without any spread to nearby lymph nodes. Not all patients will be cured with a prostatectomy and lifelong PSA surveillance is needed to detect a possible recurrence.

27. Biochemical recurrence of prostate cancer is when the PSA level rises after the prostate has been removed. It does not cause symptoms. The EAU guidelines state between 27% and 53% of all patients undergoing radical prostatectomy develop a rising PSA. It can sometimes mean the cancer may spread in the future. However, this can take a long time, and some people may have a detectable PSA for many years without ever developing symptoms or obvious spread of the cancer.

28. Our urologist adviser said they would expect a PSA blood test to be less than 0.1 after a prostatectomy. Any increase above this level would be consistent with cancer recurrence. Our oncologist adviser said recurrence can be either local (also known as a prostate bed recurrence), in lymph nodes, or distant metastases (usually in the bones) or a combination of these.

29. We considered Mr C’s complaint by interaction with the Practice and Trust. We looked at whether either or both organisations should have done a PSA or further investigations, when it would have showed a recurrence of his cancer and the impact of this.

Practice: June 2017

30. Mr C feels the Practice did not take the right action after his PSA test in June 2017.

31. The Practice felt it did not do anything wrong. It said he had normal age-related results, regardless of whether he had previous abnormal results and he was advised to arrange a six-monthly PSA blood test.

32. However, the local ICB also looked at Mr C’s concerns. Its senior clinical adviser looked at the Practice clinical records and found there were several missed opportunities by the Practice to detect the abnormal PSA blood result, and to act at an earlier stage. One of those occasions was in June 2017.

33. Mr C’s PSA in June 2013 was 0.1. When his GP arranged a PSA test in June 2017 the result was 0.7 and the Practice recorded this as ‘normal no action’.

34. The NICE prostate cancer guidance (NG131) says doctors should continue to check PSA levels after radical treatment. A rising PSA alone should not mean an immediate change in treatment is needed. The EAU guidelines define biochemical recurrence after radical prostatectomy as two consecutive PSA rises. NG131 says to measure PSA three times over six months.

35. The PSA result of 0.7 in June 2017 indicated a rising PSA compared to 2013. This was concerning and required further action to check if it was biochemical recurrence.

36. Our GP adviser said the Practice should either have arranged further PSA testing or referred Mr C to urology for them to manage and advise the Practice about the monitoring frequency to follow. Either way, in line with the guidance, he should have had more PSA tests.

37. But the evidence indicates the Practice did not do anything. We know the Practice said in its complaint response it advised Mr C to book in for six-monthly PSA tests. We cannot see any reference to this within the GP notes. It says ‘Normal – no action’. Mr C says the Practice did not tell him to book follow up PSA tests. When we weigh up the evidence we have seen, on the balance of probabilities, the Practice did not do that.

38. It is more likely than not that if the Practice had made sure Mr C had follow up PSA tests, these would have shown rises, because the later tests were all much higher. So, it is likely this would have led to further investigations (we explain later in the report what those investigations would have been). We do not know exactly when the Practice would have referred him, but most likely in late 2017 or early 2018.

39. We have found a failing here because the Practice did not take the right action for Mr C based on his PSA test result in June 2017.

Practice: Mid-July 2020

40. Mr C says the Practice should have arranged a PSA test during his appointment in mid-July 2020.

41. The NICE CKS on urological cancers says a doctor should consider a PSA test and digital rectal examination to assess for prostate cancer in men with symptoms including visible haematuria. Our GP adviser highlighted that this is framed as ‘consider’ which means that it is not an absolute requirement. The CKS also says unexplained visible haematuria is a red flag symptom for bladder cancer, and a doctor should made a two-week wait referral. This is what the GP did.

42. So, the GP could have done another PSA test at this point but based on the evidence we have seen, it was not a failing that they did not do this. The GP made an appropriate two-week wait referral, in line with guidelines, based on Mr C’s symptom. We have not found a failing here. We can understand Mr C’s concerns, given what happened later.

Trust: Late July 2020

43. Mr C says the Trust did not act on his raised PSA level at his late July 2020 appointment. He says the result should have triggered action to make an earlier diagnosis of prostate cancer.

44. The Trust reviewed Mr C’s care. The consultant urological surgeon and professor of urology and cancer biology found there were significant shortcomings. His PSA result was elevated at 16.2, a significant rise in PSA in a man who had a radical prostatectomy, irrespective of the timeframe.

45. The PSA test the Trust did in late July 2020 showed Mr C’s PSA level was 16.2. This was very high. The clinic letter says the Trust did a flexible cystoscopy which indicated no tumour and a CT urogram was planned. But these investigations were to investigate the new symptom of blood in the urine and rule out bladder cancer. Our urologist adviser said they were not tests to exclude recurrent prostate cancer.

46. Our urologist adviser said that in line with the NG131, the urology team should have arranged further restaging imaging in the form of a bone scan or prostate specific membrane antigen positron emission tomography (PSMA PET/CT, an advanced imaging technique that helps in diagnosing and monitoring prostate cancer). This would have checked for metastatic disease (if it had spread). The urology team should also have referred him to an oncologist for consideration of further treatment.

47. We have found a failing here because the Trust did not act on Mr C’s raised PSA level in late July 2020.

Practice: August 2020

48. Mr C says when the Practice received details of his abnormal PSA level in August 2020 from the Trust, it should have done more.

49. The ICB’s senior clinical adviser said the GP was misled by the Trust’s letter because the absence of cancer related to the flexible cystoscopy CT urogram results that confirmed he did not have bladder cancer.

50. The GMC’s ‘Good medical practice’ says doctors should promptly provide (or arrange) suitable advice, investigation or treatment where necessary.

51. We know the Trust did the PSA test in July 2020, so it should have acted on the result. But neither this nor the information in the Trust’s clinic letter excused the Practice of any responsibility.

52. The Practice had the information that Mr C’s PSA level was very high. The Trust letter also set out the investigations it had done and that no tumour was seen in his bladder or kidney. Mr C had a telephone consultation with the GP in August specifically to discuss the outcome of the Trust’s investigations.

53. If the Practice had critically analysed the information, it would have shown that the Trust did not check for prostate cancer recurrence. The Practice should have recognised Mr C had a significantly abnormal result which was not followed up. It advised him to repeat the PSA test in six months instead and then depending on results it would decide on the next steps.

54. The NICE suspected cancer guidance says doctors should make a two week wait referral if the patient’s PSA level is above the threshold for their age. Mr C was in his mid-70s at the time. The threshold for people between 70 and 79 is more than 6.5. His level was 16.2, significantly higher. So, the Practice should have made the referral. If it had done that, as mentioned above, Mr C would have had a bone or PSMA PET/CT scan.

55. We have found a failing in the Practice’s lack of action in response to the information it had in August 2020.

56. Mr C says the Practice did not recall him for repeat PSA tests between August 2020 and July 2023. Our GP adviser said there is no guidance on whose responsibility it is to arrange blood tests when a clinician recommends serial testing.

57. The records show that at the August 2020 appointment, the GP advised Mr C to book regular six-monthly repeat PSA tests. Mr C says he contacted the Practice and the receptionist told him that if he had not heard anything then everything was fine. There is no documentary evidence of this conversation.

58. Mr C was under the impression the Practice would recall him for PSA tests if he needed them. On the basis of the evidence we have seen, we cannot say why that was or that it was because the Practice did something wrong. However, this does not take away from the Practice’s lack of action in August 2020.

Impact

59. Mr C saw his GP in July 2023 with right sided flank pain. The GP arranged blood tests which included a PSA. The PSA level was 23. The GP made a two-week wait referral to urology. In mid-August 2023 Mr C saw the urologist and was told that his cancer was back and most likely had been back since 2017. Mr C had scans in September. These indicated a pelvic lymph node recurrence. He started hormone therapy in late October and had salvage radiotherapy to his prostate, which he completed in February 2024.

60. Mr C believes the Practice and Trust’s failure to act on his abnormal PSA results in 2017 and 2020 and subsequent delay in diagnosing his cancer recurrence impacted on the outcomes. He says the delay meant the cancer spread to his lymph nodes, delayed further treatment, and resulted in the need for more intensive radiotherapy.

61. We know if the GP had taken the right action in 2017 or 2020 and the Trust in 2020, Mr C would have had further scans. On the balance of probabilities, this would have shown recurrent prostate cancer. The prostate cancer website says PSA is a biomarker for prostate cancer cells, and if cancer cells have escaped the prostate gland and are multiplying elsewhere, they will start producing PSA. PSA levels usually fall to zero or very close to it after surgery, but some prostate tissue may remain and continue to produce PSA.

62. The EAU guidelines recommend offering early salvage radiotherapy to men with two consecutive PSA rises. This provides the possibility of cure for patients with an increasing PSA after radical prostatectomy.

63. Our oncologist adviser said it is unlikely the delay in diagnosis was the reason the prostate cancer spread to the pelvic lymph nodes. They said the scans in 2023 showed lymph node recurrence only, not a recurrence in the prostate bed. Our oncologist adviser also noted that the margins of the 2006 prostatectomy were clear, showing all the cancer had been removed from the prostate then. They said it is more likely than not that the cancer cells that later caused the recurrence in the lymph nodes were already present as a microscopic lymph node deposit at the time of Mr C’s diagnosis and prostatectomy in 2006.

64. Our oncologist adviser said if the cancer recurrence had been diagnosed in 2017, the evidence indicates the clinical team would have thought this was prostate bed recurrence. Mr C would still have needed salvage radiotherapy and may have had hormone therapy, in line with the EAU guidelines. Our oncologist advice noted it would have been impossible at this early stage for the clinical team to have known the lymph nodes were involved. The EAU guidelines say routine staging scans would not have been indicated as they have a very low sensitivity when the PSA level is 0.7.

65. If the cancer recurrence was diagnosed in 2020, when Mr C’s PSA level was 16.2, our oncologist adviser said routine scans may have picked up the lymph node recurrence. His treatment would have been the same as in 2023, but three years sooner.

66. But the evidence we have seen indicates Mr C would always have needed treatment for the pelvic lymph node recurrence. Our oncology adviser said this would not have been prevented by earlier treatment to the prostate bed.

67. We recognise Mr C says if he had had treatment earlier, he would have been much younger and fitter for this. We can see in May 2025, Mr C’s PSA result was less than 0.1, which shows a continued good response to the hormone treatment, despite the delay. Our oncologist adviser says there is no impact on Mr C’s overall life expectancy as a result of the delay in diagnosing and treating his prostate cancer recurrence.

68. Mr C believes the delay contributed to the development of his rectal cancer. Our oncologist adviser said prostate and rectal cancers are unrelated. There is a weak association (only reported in a small number of studies) between prostate radiation (the salvage radiotherapy) and the risk of rectal cancer. But Mr C would always have needed salvage radiotherapy. Based on the evidence we have seen, his rectal cancer was not caused by the delay in diagnosing his prostate cancer recurrence.

69. Mr C also says his long-term prognosis is terminal. We cannot see from his hospital records that he has terminal disease. But our oncologist adviser said the greatest risk to his health is his rectal cancer. As we have explained, this was not caused by the delay.

70. However, we recognise that when Mr C got his diagnosis in August 2023, he and his family were worried and distressed that the Practice and Trust had missed important test results and were concerned about the impact this had. We understand his daughter’s frustration and disappointment at the failings of the Trust she worked for. We can also see how they lost faith in the Practice for not taking the right action and prompting further assessments.

71. We recognise that Mr C and his family were always going to have a difficult time when he was diagnosed and while he was going through treatment. This has been compounded by the diagnoses of further cancers. But we think what the Practice and Trust got wrong made an already traumatic experience worse for him.

72. In summary, when we weigh up the evidence we have seen, we found the following.

• The Practice should have identified and acted on Mr C’s PSA results in June 2017 and August 2020 and it should have referred him for further investigation.

• The Trust should have acted on his abnormal PSA result in July 2020, and it should have carried out further investigations for treatment of his prostate cancer recurrence.

• Mr C did not need more or different treatment in 2023 and 2024, and his life expectancy is not worse because of what the Trust and Practice got wrong. There is no indication the delay in his prostate cancer recurrence caused his rectal cancer.

• We can see the mistakes caused him worry and distress after he was diagnosed in 2023.

What the Practice has done to put things right

73. The Practice did not find any failings in its care of Mr C. But it did discuss his complaint in a clinical meeting and decided to introduce a process for contacting patients who need regular testing to make those appointments.

74. The Practice said it was sorry to hear that Mr C’s prostate cancer had returned and for the distressing time the family experienced.

75. Therefore, we think there is more the Practice should do to put things right.

What the Trust has done to put things right

76. The Trust apologised for the distress and anxiety the situation caused the family and for the inconvenient and inadequate service he received.

77. The Trust reviewed Mr C’s care and the consultant urological surgeon and professor of urology and cancer biology found there were significant shortcomings. It acknowledged it should have acted on his significantly raised PSA level in July 2020. It apologised and set out some learning actions.

78. It created an action plan including: presenting the case at its urology, morbidity and mortality meeting and setting learning objectives, and revising its cancer pathway letters. It said staff who request investigations now take responsibility for follow up and the implementation of formal safety nets.

79. The ‘NHS Complaint Standards’ say NHS organisations should acknowledge when they have made mistakes, offer sincere apologies for the impact these have had and show how they have learned from a complaint. We think the Trust has done this. But we think there is more it should do to recognise the impact its mistake had on Mr C.

1. We have set out below our final decision on this case. Based on the information we have seen, we party uphold Mr C’s complaint about the Practice and partly uphold the complaint about the Trust.

Practice

2. We found the Practice should have identified and acted on his abnormal PSA results in June 2017 and August 2020 and it should have referred him for further investigation.

Trust

3. We found the Trust should have acted on his abnormal PSA result in July 2020, and it should have carried out further investigation.

4. We found these mistakes delayed Mr C’s diagnosis of prostate cancer recurrence, but we do not think he needed more treatment because of the delay or that his overall prognosis is worse. We have also found no link between the delay and his later diagnosis of rectal cancer. But we do think the mistakes caused him additional worry and distress when he got his diagnosis and worry about the impact of the delay.

5. We recommend the Practice acknowledges what it got wrong, apologises to him and pays him a financial remedy.

6. The Trust has already acknowledged its mistake and taken action to put things right. We recommend the Trust pays Mr C a financial remedy.

7. It is on this basis that we partly uphold this complaint. We have detailed this in the ‘Findings’ section below.

8. It is clear from Mr C’s and his daughter’s comments that this has been a very difficult time for them. We hope our report is clear about how we have come to our findings.