Recurring concern

Unreliable investigation and specialist referral for suspected urological cancer

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First reported 4 Feb 2015•Latest report 17 Apr 2015

Definition

What this concern includes

Includes failures in the investigation and specialist-referral process for suspected urological cancer, including obtaining clinically indicated blood or urine samples, completing cancer-upgrade or referral steps, arranging urological review and acting on relevant clinical findings such as haematuria or weight loss.

Not included

  • Excludes generic cancer referral or investigation failures where urological cancer is not the identified concern.
  • Excludes failures involving treatment after appropriate urological assessment has been obtained.
  • Excludes generic staffing, communication, documentation or escalation deficiencies unless they directly impair investigation or specialist referral for suspected urological cancer.
  • Excludes non-urological malignancies and unrelated diagnostic or specialist-review processes.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2015–2015

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Medway NHS Foundation Trust1
Nottinghamshire Healthcare NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Mid Kent and Medway

    AI-generated summary

    Robert Watt · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Robert Watt had suspected bladder cancer symptoms, including haematuria, weight loss and rectal bleeding, but investigations and specialist review did not identify the cancer until it was advanced and incurable. The report identified concerns about communication of a cancelled haematuria clinic appointment, incomplete medical records, reliance on junior doctors for specialist advice, and the lack of urological review when malignancy was suspected.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain urological review when bladder malignancy is suspected

    Wider context from the report

    “v. A urologist was not asked to review Mr. Watt in circumstances where a malignancy was suspected and he was suffering from weight loss and haematuria both of which are recognised symptoms associated with bladder cancer ”

    Source location

    Robert Watt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Nottinghamshire

    AI-generated summary

    Paul Hardy · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Paul Hardy was a serving prisoner at HMP Lowdham Grange when his local hospital confirmed that he had urological cancer, which was not the immediate cause of his death. The report identified failures to obtain and process blood and urine samples, to facilitate INR monitoring, and to conduct a Significant Event Analysis, with delays and errors causing unnecessary suffering and distress.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to act on clinical instructions to obtain and process blood and urine samples for investigation of possible urological cancer

    Wider context from the report

    “1. That there was a clear failure by Healthcare Staff to act upon instruction given by a visiting Advanced Nurse Practitioner to obtain and process blood and urine samples for the investigation of possible urological cancer. ”

    Source location

    Paul Hardy · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026