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Roles and responsibilities in prioritisation for first specialist assessment (04HDC13909 )

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(04HDC13909, 4 April 2006)

Urologist ~ Public hospital ~ District health board ~ PSA ~ Waiting lists ~ First specialist assessment ~ Duty of care ~ Rights 4(1), 4(5), 6(1), 6(1)(c)

A 61-year-old man experiencing urinary problems was referred to the urology department at a public hospital by his GP. He had a significantly elevated prostate specific antigen (PSA) test result, indicating a high likelihood of cancer. The following month, the urologist wrote to the man's GP requesting further investigations. With this additional information he placed the man on the urgent waiting list for first specialist assessment (FSA). The urologist notified the man and his GP by letter that the man was likely to be on the waiting list for several months. However, he did not receive the letter.

The man did not receive any further correspondence from the hospital or the urologist.  He continued to have PSA tests with the GP, who forwarded the results to the urology department. Nearly two years later, the man was experiencing urinary problems and consulted his GP's locum, an oncologist, who referred him to a private urologist. Biopsies revealed that he had adenocarcinoma of the prostate.

It was held that the urologist did not fulfil his responsibilities in relation to prioritisation. His high level of assigning patients to "urgent" meant that he was not adequately differentiating between patients in this group, breaching Right 4(1). He also had a responsibility to provide accurate information about the expected waiting time. His failure to do so was a breach of Right 6(1)(c).

It was held that the patient and the GP should have been given clear and specific advice about the option of seeking private assessment and treatment. The GP should have been told to re-refer the patient if his condition deteriorated or there was further relevant information that would affect the patient's priority. The public hospital's failure to provide the required information constituted a breach of Right 6(1). The main reason this action did not take place at an earlier stage appeared to be a difficult relationship that existed between the urologist and the DHB.  To allow that relationship to interfere with its duty to appropriately manage and monitor the FSA list clearly contributed to the failure to provide the man with timely treatment. The DHB breached its duty of care under Right 4(1).

DHBs have an obligation to put systems and procedures in place to ensure an adequate and effective system for managing waiting lists for FSA appointments, under which patients are kept informed of their status and options. Individual clinicians have an obligation to work with the DHB to appropriately prioritise and offer appointments on the basis of priority. In this case, the urologist and the DHB failed to work together effectively, and both breached Right 4(5).

The GP also had a duty to inform the patient about his options and to follow up his referral.

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