The Health and Disability Commissioner has reprimanded a medical centre over "deficiencies" in care ahead of a man's cancer death.
The name and location of the medical centre aren't included in the report.
The incident began when the man was diagnosed with prostate cancer in 2016. He had an operation to remove his prostate and surrounding tissue – and in 2019, his care was handed back to his medical centre.
"His urologist provided instructions to the centre to check his PSA levels every six months and complete an immediate referral back to urology if levels became detectable," a statement from the Health and Disability Commissioner (HDC) said.
PSA is a protein found in blood. It's produced by both normal and malignant prostate gland cells.
"Over the next three years, five test results showed the man's PSA levels were detectable," the HDC found.
"However, because these results were not picked up by the medical centre, they were not relayed back to the man accurately, and he was not referred to a urologist.
"This meant that the cancer spread to other parts of the man's body, including his pancreas and, sadly, he passed away."
Aged Care Commissioner Carolyn Cooper said the case included "deficiencies in the standard of care and communication provided to the man by the medical centre".
The urologist's letter was overlooked by multiple clinicians, she said.
"There were several opportunities for clinicians to review the man's clinical notes, and it must be acknowledged that had an earlier urology referral been made, it is possible (but not inevitable) that his pancreatic tumour may have been detected at an earlier stage.
"I acknowledge the distressing impact of this on the man and his family and express my sincere condolences to the family for their loss."
Cooper found the medical centre company breached the Code of Health and Disability Services Consumers' Rights.
She also "made adverse comments" about a GP and a nurse practitioner at the centre for "failing to accurately interpret the results".
Cooper recommended the pair each write a letter of apology to the man's family, and urged the medical centre to confirm a number of measures aimed at preventing anything similar happening again.
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