Care in 2016
14. Before we decide if we should carry out a detailed investigation into a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.
15. We understand how important this complaint is to Ms P and her concerns about the care her husband received. In this case we have not seen indications the Trust should have carried out further investigations into Mr E’s symptoms in 2016 or that it should have offered alternative treatment.
16. Ms P told us the Trust did not investigate her husband’s LUTS appropriately when he presented to it with raised PSA levels and LUTS. Ms P says the Trust did not tell her husband his GP would need to refer him under the LUTS pathway for further investigations into his symptoms.
17. Ms P says the Trust told her husband to take a medication he had previously taken which had no effect. She says her husband declined the medication as he had experienced poor results and side effects from this medication. Ms P said the Trust considered Mr E’s LUTS to be mild/moderate without carrying out a full assessment. She says his symptoms were very problematic for him and he considered them more serious.
18. Ms P is also concerned the Trust did not consider surgery in 2016. She says the Trust told her husband in 2009 he would need surgery at some point to resolve his LUTS and yet this was not considered in 2016.
19. In its response letter, the Trust said Mr E’s GP referred him with marginally raised PSA and LUTS under the suspected cancer pathway. The Trust decided a biopsy was not indicated, but it recommended PSA surveillance. The Trust said when it discussed Mr E’s LUTS with him it did not feel he had severe symptoms that required further investigation. It said that Mr E’s symptoms did not indicate surgery was needed at this time.
20. EAU guidance says that prostate cancer is usually suspected on the basis of digital rectal examination (DRE) or PSA levels. It goes on to explain a biopsy is necessary for a definitive diagnosis.
21. We have reviewed the referral form from Mr E’s GP. The referral form indicates that the GP referred Mr E for suspected prostate cancer. This was due to ‘Raised age-related PSA’. The GP did not select the option on the form for ‘significant symptoms (incl. symptoms of metastases) and raised PSA’.
22. The GP also included notes from two consultations with the referral. One from November 2016 says that Mr E had a long-standing history of urinary symptoms. He told the GP he had the symptoms checked five years ago and was told he had an enlarged prostate. Mr E explained that he had opted to manage his symptoms conservatively. This means he was not taking medication to manage his symptoms.
23. At the GP appointment on 29 November, Mr E explained that he had experienced worsening symptoms over the last six months. These included more dribbling, poor urine flow, increased number of times he urinates in the day, but also intermittent pain when urinating. He told the GP that he was ‘overall not too bothered’ by the symptoms but just wanted them checked.
24. Following this appointment, the GP requested a PSA test which came back as raised. As such, the GP notes say they referred him to urology under the 2 week wait for suspected cancer as Mr E had ‘worsening LUTS and raised PSA’.
25. The Trust’s clinic letter from 2016 explains Mr E reported urinating 8-9 times a day and once at night. It also says he has some post void dribbling. This is when some urine is left in the urethra after urination associated with an urgent need to urinate. It is not clear from the clinic letter if Mr E and the consultant discussed how his symptoms were affecting him.
26. As Mr E’s GP referred him with suspected cancer, the key purpose of the appointment was to ensure he did not have prostate cancer. Our adviser explained the Trust investigated Mr E’s raised PSA levels appropriately. It did this by conducting a DRE, a transrectal ultrasound and calculating his PSA density. We have seen evidence the investigations the Trust carried out were in line with EAU guidance for suspected prostate cancer.
27. We asked our adviser how the severity of a patient’s LUTS are usually assessed. They explained that an international prostate symptom score (IPSS) and a frequency volume chart is normally recorded. The IPSS is a questionnaire which patients complete to help clinicians understand how their symptoms affect their day-to-day life. A frequency volume chart records fluid intake and urine output over a 24-hour period.
28. We can see at this appointment in 2016 neither of these investigations into Mr E’s LUTS were carried out. We do not think this was an indication of a failing in care because investigating LUTS was not the purpose of the appointment.
29. As not all the investigations for LUTS were carried out at the 2016 appointment, it is difficult to say whether the Trust’s view that Mr E’s symptoms were mild/moderate is accurate. The Trust’s records do not contain very detailed notes of discussion with Mr E about the severity of his symptoms. We have noted the GP recorded that Mr E was ‘not too bothered’ by his symptoms around that time and had shared this information with the Trust. We have considered this against Ms P’s recollection that Mr E’s symptoms were more problematic at that time.
30. When we are considering conflicting evidence to try to reach a view on what is more likely to have happened, we generally find it reasonable to place more weight on information that was documented at the time of the events than on recollections of events that happened some time ago. For this reason, we think that on balance, taking into account the GP record, it is not likely that the Trust should have taken further action than it did to assess or treat Mr E’s LUTS at that time, based on the information available. We acknowledge there is uncertainty around this; it is possible that Mr E experienced symptoms that were more problematic at the time than either the GP or the Trust recorded.
31. We saw that following the consultation the Trust wrote to Mr E’s GP and advised it to offer him medication if his symptoms worsened. We have carefully considered Ms P’s view that the Trust should have told Mr E he would need to be referred under the LUTS pathway for his symptoms to be assessed further. We think it would be reasonable for the Trust to assume Mr E would have seen his GP if his symptoms had worsened and for the GP to have discussed his options at this point.
32. It is clear the possibility of prostate cancer was the main concern for Mr E’s GP, and the Trust investigated him for this. We also note that the Trust recommended treatment for Mr E’s LUTS and provided advice to his GP. On the balance of probabilities, we do not think that the Trust should have considered his symptoms to be more severe or should have taken any other action to assess or treat them at that time. For these reasons, we will not take further action on this complaint.
2019
33. Ms P complains that following a transurethral resection of the prostate (TURP) in 2019 the Trust failed to provide a pathway for follow-up. TURP is a surgery to remove parts of the prostate. She says when her husband suffered from complications he did not know where to go. Ms P told us there did not seem to be a post-surgical pathway to manage complications.
34. The Trust’s guidance says that following a TURP patients will have a follow-up appointment with the consultant three months after surgery. At this point most patients will be discharged back to their GP.
35. We have reviewed Mr E’s medical records. The discharge summary dated February 2019 says ‘you will be seen in outpatients follow-up clinic in 12 weeks…’ This is in line with the Trust’s guidance.
36. Following the TURP the Trust prescribed Mr E a 7-day course of nitrofurantoin, an antibiotic prescribed to treat urinary tract infections. The Trust also advised him to ‘continue medication and analgesia as prescribed’ and to ‘see your GP if you have any concerns’.
37. The nursing discharge summary instructs Mr E to contact his GP with any concerns or call the number provided. Alternatively, he was told to contact emergency services.
38. The records show that Mr E was readmitted to hospital in February 2019, five days after his discharge, with urinary retention. This is a condition when a person cannot fully empty all the urine from their bladder. The discharge summary from this admission says that an outpatient appointment is ‘to be arranged’.
39. Following this admission Mr E had problems with the catheter which required multiple visits and admission for catheter replacement and removal.
40. We have seen the Trust’s initial plan was to see Mr E in three months following discharge. He was in fact seen much earlier than this as he suffered from post-operative issues. We also note that when Mr E was discharged, he was advised to contact his GP or emergency services if he had any problems.
41. While we understand how concerning it must have been for Mr E to suffer from complications after the surgery, taking into account our clinical advice we do not see an indication that the Trust failed to provide a pathway for follow-up. We have seen the Trust planned appropriate follow-up care 12 weeks after the procedure and that this was in line with the Trust’s guidance. However, we have seen that unfortunately prior to this follow-up appointment Mr E suffered from complications and he was seen much sooner than this. We do note that the Trust gave Mr E advice if he suffered complications prior to the follow-up appointment. We have not seen any indications of failings in the Trust’s actions.
Consent
42. Ms P has said she was never told the Trust had ‘reservations’ about carrying out the TURP until she complained, and that her husband was not told the procedure may not be successful.
43. The Trust has said that in December 2018 it carried out a urodynamics study. This is to test how well the bladder, sphincters and urethra hold and release urine. The Trust said tests showed Mr E’s bladder was only functioning at 50%. The Trust decided at this stage to carry out prostate surgery. However, it did have some reservations about the success rate as Mr E’s bladder function was lower than expected.
44. The Trust has said it completed the procedure and discharged Mr E without any immediate complications. It has said the procedure had a good outcome as he was able to pass urine naturally.
45. We asked the Trust to explain why it had ‘reservations’ about carrying out the TURP. It said urodynamics tests showed signs that Mr E may have bladder failure or weakness. It said this is the result of long term bladder outlet obstruction. This is means there is a blockage at the base or neck of the bladder. In this case, Mr E’s prostate was causing the obstruction. The Trust also said that pain free urinary retention with a huge amount of urine is another indicator of bladder failure.
46. GMC guidance says clinicians must give patients the information they want or need to make a decision. This will usually include:
a. diagnosis and prognosis
b. uncertainties about the diagnosis or prognosis, including options for further investigation
c. options for treating or managing the condition, including the option to take no action
d. the nature of each option, what would be involved, and the desired outcome
e. the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action. By ‘harm’ we mean any potential negative outcome, including a side effect or complication.
47. We have reviewed Mr E’s records. A clinic letter from May 2018 says: ‘He is a very anxious person and worried about the prospect of doing intermittent self-catheterisation which is not excluded yet as his bladder is not the best one with adequate contraction’.
48. The records show in October 2018 Mr E suffered from urinary retention. Urodynamics tests in December 2018 confirmed an obstruction. Prostatic obstruction is when an enlarged prostate puts pressure on the urethra and blocks the urine flow. It also showed borderline weak/adequate bladder contraction.
49. A clinic letter from October 2018 says: ‘DRE today still reveals a 20 plus cc prostate and it is surprising that he had chronic urinary retention. This means he might have bladder failure (atonic bladder) I am going to arrange a flexible cystoscopy and standard urodynamics for this gentleman for further diagnosis. He may end up needed to do intermittent self-catherisation if bladder failure is confirmed.’
50. A clinic letter from December 2018 says: ‘have discussed with him and his wife who were absolutely delighted by the result that his bladder is still functional which is quite reassuring. After a short discussion regarding TURP, I have put him on my waiting list for the same.’
51. The consent form Mr E signed before the TURP in February 2019 explained the benefits and risks of the procedure. The risks include: ‘injury to the urethra, bladder neck and urinary output’.
52. The records show that following the TURP Mr E’s urine flow was good which indicated good bladder contraction and no obstruction. Our adviser said this indicated the procedure was successful. However, Mr E went on to develop a false passage and tight bladder neck. A false passage is when a catheter is not placed in the opening of the urethra. This causes a false opening the catheter goes into. These are both complications of the surgery which were noted on the consent forms signed prior to surgery.
53. We acknowledge how distressed Mr E was to suffer from urinary retention despite the TURP and how undoubtedly distressing this was for Ms P to witness. We have seen evidence that Mr E was aware of the complications associated with the procedure prior to it being carried out. We have seen no indications of failings in the care provided to Mr E so we will not be taking further action on this complaint, we do hope the Trust’s further response provides Ms P with the answers she was looking for.