The man's father and an uncle had both died from prostate cancer in their sixties, which doubled his risk of developing the disease. He told the HDC he was aware of the family history which he detailed to every doctor he dealt with to ensure they were his risk profile was higher than normal.
Dr Caldwell found the three doctors had breached of the Code of Health and Disability Services Consumers' Rights by inadequately communicating his test results, and failing to keep clear and effective documentation.
A locum doctor had breached the code by failing to document the man's family history of prostate cancer, failing to enquire about red flags for prostate cancer, then incorrectly documenting "no red flags" in his medical records, and failing to repeat the test promptly.
By not informing the patient of his abnormal test result, the doctor had also breached the Code, she said.
A second doctor at the medical centre had twice failed to refer the man to urology services, repeat the test promptly and failed to tell the patient of his irregular results.
A general practitioner was also found guilty of the same breaches.
Dr Caldwell considered the failures were a result of individual clinical decision-making by multiple doctors, as well as the medical centre's inadequate system that did not support its staff fully.
One of the blood tests was ordered under the name of and reviewed by a doctor who had not had the opportunity to examine or speak to the man.
Instead the results were communicated to the man by a nurse.
"In my opinion there is an element of risk when a doctor reviews test results of a patient whom they have not seen or had an opportunity to ask questions, and when the expectation on the doctor is that the nurse communicates results to patients," she said.
It was recommended all parties provide formal apologies to the patient.
Dr Caldwell also requested the medical centre provide evidence of staff training on PSA management and prostrate screening.
The centre was also required to provide a copy of the results of an audit on the management of elevated PSA results since 2016, and, if required, an action plan regarding any high results, consider whether a review of its system or its orientation process for doctors was necessary and consider incorporating a decision making support tool into its practice.
All three doctors were required to conduct an audit of their assessments of patients with abnormal PSA results over a three-month period, and, where the audit did not show appropriate steps were taken outline why, and what was done to remedy the issues.
