Late this morning I received the SIRI report via email - paper one on the way to me in the post. I read the report and I am scratching my head in that the investigation team had failed to pinpoint where and how the biopsy samples got mixed up. It appears that the Histopathology and Radiology departments have somehow avoided being blamed and therefore avoided being reprimanded. The DTTO investigation team labelled the incident as an occurence with a severity level of 5/5 and made a list of few recommendations to avoid future re-occurrence. It reads something like a whitewash.
Now, the report mentioned that the situation came to light when patient A (the other man) was given my biopsy result, he was advised to return 3 months later for another PSA test because the docs did not understand how he, with a PSA of 41, came out with my result. 3 months later, he was tested and found that his PSA rose to 59. He was then sent for MRI scan and it revealed possible signs of tumours. He was further sent for a template biopsy in March 2018 and this result revealed he had adenocarcinoma Grade Group 3, Gleason 7 (4+3) - exactly the same result that was handed to me! It was from that point the hospital became aware that there might have been a mixup of biopsy samples. Patient A gave blood sample for DNA, which later confirmed a match with his template biopsy samples but not the original TRUS samples taken on 8 December 2017. (It turned out that he had his biopsy at 5.10pm, 20 minutes before mine on the same day!)
The hospital then recalled other patients for DNA samples to discover which patient received the wrong result. They dismissed a good number of men and it was not until late October that the hospital came to me. They noticed a pathoogy report on my prostate gland matching the biopsy report that was wrongly given to Patient A. I gave a blood sample and from there my DNA matched my samples involved in the mixup.
Patient A was not too badly affected by the situation, according to the report, as his treatment was delayed by only 3 months and there was no significant raise in his cancer. He elected for radiotherapy.
The report turned on me, Patient B. Here is one paragraph from the report.
"Patient B, whose correct biopsy results should have been high grade PIN following biopsy obtained on 8 December 2017, decided to proceed with RP with extended lymph node dissection based on incorrect report finding of prostatic adenocarcinoma Grade Group 3 (Gleason 4+3=7) in 13/17 cores. Patient B did not require surgery and the best alternative option he could have had was to be put on active surveillance, his final pathology low risk prostate cancer Gleason 3+4 and 1% prostate volume."
These are the main bits from the report. Not good enough for me. I am more annoyed about the lack of a letter of apology from the hospital.
He who lives, loves and knows what it means to die - Jiddu Krishnamurti