Hospital took 7 months to inform elderly man's tumor to family

The Santo António Local Health Unit (ULSSA), in Porto, took seven months to communicate to the relatives of an 82-year-old man the diagnosis of a tumor, according to a decision by the Health Regulatory Authority released this Tuesday.

This case dates back to October 9, 2023, when the patient was admitted to the hospital emergency room due to a fall, being admitted to the urology department and being operated on the 22nd of the same month for drainage and resection of prostate fragments, with the samples being sent to pathological anatomy.

When he was discharged on November 3, 2023, an external urology consultation was scheduled for December 7 of the same year, which he did not attend because he was hospitalized again, the document states.

On November 6, 2023, after being discharged, the pathological anatomy report was made available, which concluded that “prostate involvement by primitive colon adenocarcinoma”.

According to the Health Regulatory Authority (ERS), it was only on June 18, 2024, when the patient attended an external urology consultation, that the “diagnosis of colonic tumor was transmitted to the family”.

“There were seven months between the publication of the results of the complementary diagnostic and therapeutic method and its communication to the user/family, on June 18, 2024”, concluded the ERS.

The ULSSA justified this seven-month “time lapse” between the diagnosis being made and its communication to the family by the fact that the outpatient consultation scheduled for December 7, 2023, did not take place, claiming that “there was no opportunity to communicate the result of the endoscopic resection of the prostate, which revealed primitive adenocarcinoma of the colon with invasion of the prostate”.

According to the decision, after the patient failed to attend the outpatient appointment because he was admitted to the urology department, “no other steps were taken to communicate the result of the diagnostic test to the patient and/or his/her family members.”

In view of this, the ERS concluded that the ULSSA “failed to comply with its obligation to ensure timely communication” of the results of examinations, the results of which “may imply urgent recourse to the provision of health care and the definition of a care plan”.

This case led the regulator to issue an instruction to ULSSA so that, among other points, it implements procedures to ensure that the results of any complementary diagnostic tests are delivered and/or communicated to users as quickly as possible, “especially when said results imply urgent need for healthcare”.

ERS became aware of this case through a complaint made by the daughter of the user with dementia, who died in July 2024.

In its response to the ERS, the ULSSA stated that an alert system developed internally by the Local Clinical Computerization Commission was being tested to ensure that critical results, within the scope of the Pathological Anatomy Service's activity, are consulted in a timely manner by the medical team responsible for the patient.