Summary
C complained that the practice unreasonably failed to take the appropriate action in response to C's elevated prostate-specific antigen (PSA, a protein in the blood) test result. C requested a PSA test due to having a family history of prostate cancer. C complained about the failure to refer them to urology (specialists in the male and female urinary tract, and the male reproductive organs) based on the test result. The practice had said it was appropriate to advise C to repeat the test in one month’s time. This did not happen and C was diagnosed with prostate cancer 13 months later.
We took independent advice from a GP. We found that the practice failed to follow Scottish Referral Guidelines for Suspected Cancer. According to the guidelines, due to C’s age, their family history and the test result, the GP should have referred C to urology for further investigation. We upheld C’s complaint.
Recommendations
What we asked the organisation to do in this case: Apologise to C for failing to follow the Scottish Referral Guidelines for Suspected Cancer and to refer C to urology in light of their PSA test result. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future: Practice staff should be familiar with Significant Event Analysis (SEA) guidelines: https://learn.nes.nhs.scot/984.
The GP involved should be informed of the findings of this case.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202500555 as a PDF (26.91 KB) Updated: December 17, 2025