A CANCER patient's prostate gland was removed unnecessarily after staff at a Gwent hospital failed to diagnose his disease accurately, an investigation has found.

The man had the gland removed in an operation in September 2018 - but staff at the Royal Gwent Hospital in Newport had failed to diagnose the cancer accurately during February-June that year, when his problem was being investigated.

Now the Public Services Ombudsman for Wales, Nick Bennett, has said the man - not identified in a case report - suffered a "gross injustice".

Aneurin Bevan University Health Board said it "deeply regrets" the failings in his care and apologises "unreservedly".

The Ombudsman's report describes "numerous failings" in his care, including: A failure to note "suspicious" enlarged pelvic lymph nodes in an MRI scan that June; not enough views being taken during the scan, against recognised guidance; suspicion of metastatic cancer not being raised from scan evidence about a lesion; an insufficient record of a multi-disciplinary team meeting that July.

“While his overall prognosis is unlikely to have been significantly altered, he has sadly suffered with the debilitating effects of a surgery that he needn’t have gone ahead with," said Mr Bennett.

He added that his investigation had found the man "was not in possession of the full facts to make an informed decision about his treatment".


The man's partner launched a complaints process after it was revealed to them firstly, several weeks after surgery, that the cancer had been 'upstaged' - moved into a higher stage, indicating it had been further advanced than originally thought - and secondly, in December 2018, that it was likely the cancer had spread from the prostate to surrounding tissue at the time of diagnosis, the previous summer.

The report states there was "no clear evidence" the man had been informed about possible alternative treatments to the operation eventually performed, a robotic-assisted laparoscopic prostatectomy.

Thus, "he consented to and underwent an unnecessary procedure", as this operation is only suitable for patients whose cancer is confined to an organ, "so suffering the severe after effects he complained about".

The report describes this as a "significant injustice", and though the failings were unlikely overall to have significantly altered his prognosis, they were "significant".

Mr Bennett upheld the three aspects of the complaint:

  • There was a failure to accurately diagnose the man's cancer between February and June 2018;
  • He was thus unable to make an informed choice regarding his treatment;
  • The delay in accurate diagnosis - until December 2018 - impacted on his quality of life and prognosis.

Aneurin Bevan University Health Board has been recommended to apologise for the identified failings, and to pay £5,000 to the man in recognition of these.

Other recommendations relate to records of multi-disciplinary team meetings, wider MRI scanning for prostate cases, and the carrying out of a review of prostate cases since June 2018 where patients were subsequently placed in a higher risk category at a review of staging.

The health board has accepted the report and its recommendations. A spokesman told the Argus the health board "deeply regrets" the failings.

“We unreservedly apologise for the failings identified in the Public Ombudsman for Wales' report and the effect that this has had," he said.

“A detailed action plan is being prepared to ensure that actions are undertaken to meet the recommendations".

"The implementation of these actions will be monitored and shared with the Ombudsman. We are committed to learning from concerns raised about our services to further improve the care we offer to our patients."