A practice in the West Suffolk area

3. Miss A complains the Practice did not diagnose or quickly refer her to an endometriosis specialist between February and June 2025.

4. Miss A says the delay in referring and diagnosing her endometriosis made her feel her symptoms were not taken seriously while she experienced significant pain.

5. Miss A wants as apology, service improvements, and financial compensation of £1,250 to £3,700.

6. Miss A had five face to face and telephone appointments with the Practice between February and June 2025 for intermittent abdominal pain.

7. The Practice arranged for Miss A to have urine and faeces investigations in February and asked for an ultrasound (using high-frequency sound waves to create images) scan of her abdomen and kidneys. The transvaginal ultrasound took place in mid-June.

8. Miss A asked the Practice to refer her to gynaecology services in April, May, and June.

9. Miss A went to a private gynaecology consultant in mid-June and after completing exploratory surgery endometriosis was diagnosed.

13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

14. Miss A complains the Practice did not diagnose or quickly refer her to an endometriosis specialist between February and June. Miss A says the delay made her feel her symptoms were not taken seriously while she had significant pain.

15. The Practice said its clinicians completed thorough examinations and made a referral for an ultrasound scan to be completed to ensure the correct referral was made.

16. NICE, CKS, When should I suspect endometriosis, tells clinician’s, ‘Suspect endometriosis in women (including young women aged 17 years and younger) presenting with one or more of the following symptoms or signs: • Chronic pelvic pain (defined as a minimum of 6 months of cyclical or continuous pain) • Period-related pain (dysmenorrhoea) affecting daily activities and quality of life • Deep pain during, or after, sexual intercourse • Period-related or cyclical gastrointestinal symptoms, in particular painful bowel movements • Period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine • Infertility in association with one or more of the above.’

17. Miss A started taking desogestrel (a progesterone only contraceptive pill or POP) in January 2025 in preparation for beginning isotretinoin, (used to treat severe acne) which had not responded to other treatments.

18. Miss A told a nurse in mid-February she was having intermittent lower abdominal pain every day for approximately two weeks and paracetamol did not help.

19. The Practice nurse noted she was taking desogestrel and completed a physical examination of Miss A’s stomach and pelvis which showed tenderness to the kidneys on both sides of the back under the twelfth rib. The nurse checked Miss A’s lower ribs, top of the hip bone and upper mid abdomen over the stomach areas.

20. The nurse noted Miss A had no suprapubic pain (just below the naval and above the pubic bone) and a kidney cause of pain was suspected rather than a gynaecological cause.

21. The Practice nurse arranged for Miss A to have urine and faeces investigations, and ordered ultrasound scans for her abdomen and kidneys. As Miss A did not have any symptoms in line with NICE, CKS, when to expect endometriosis the nurse did not make a referral to gynaecology services.

22. NMC The Code. Professional standards of practice and behaviour for nurses, midwives, and nursing associates. This tells nurses:

‘13.2 make a timely referral to another practitioner when any action, care or treatment is required 13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence.’

23. Miss A had a telephone consultation with a Practice nurse in late March. Miss A told them she was unsure if she had passed a kidney stone but said she had blood in her urine and had lower abdominal pain.

24. The records show the nurse considered Miss A’s pain could be related to eating and noted she was having vaginal bleeding while taking the POP. The nurse asked Miss A to make a face to face appointment with a GP to complete a urine test and examination of her abdomen. This was in line with NMC The Code.

25. Miss A made the appointment as asked for early April which the Practice had to cancel because she had not made the appointment to see a GP. The Practice asked her to rebook an appointment at her convenience.

26. In early April Miss A saw the nurse for a face to face appointment for abdominal pain which the nurse thought might be connected to her periods. The nurse examined Miss A and noted she appeared well with no obvious signs of pain. The nurse checked Miss A’s pulse rate, oxygen levels, reviewed her urine sample results, and did an abdominal examination.

27. The nurses examination of Miss A found no concerning issues and the nurse suggested the pain might be related to her hormones and menstrual cycle. Miss A agreed with the nurse to change her oral contraception. The nurse also prescribed naproxen (to reduce pain and inflammation) to replace ibuprofen and asked Miss A to see her GP if her pain and period symptoms did not settle.

28. This action was in line with NICE, CKS Manage endometriosis-related pain which tells clinicians ‘consider a short trial (for example 3 months) of paracetamol and/or a non-steroidal anti-inflammatory drug (NSAID) for first line management of pain.

29. Miss A asked the Practice to refer her to gynaecology services through its eConsult form in April, May, and June.

30. The Practice made a telephone appointment for Miss A in early May. The Practice GP was unable to reach Miss A and asked her to contact the Practice to organise another appointment.

31. In early May Miss A saw a Practice nurse. They discussed her symptoms of pain and completed a medical history. The nurse gave a possible diagnosis of gastritis (inflammation of the stomach lining) and Miss A agreed that treatment options would be considered once a transvaginal ultrasound scan (a scan inside the vagina to examine the reproductive organs) was completed.

32. This was in line with NICE, CKS management of endometriosis with tells clinicians to: ‘Offer a transvaginal ultrasound scan to all people with suspected endometriosis even if the pelvic or abdominal examination is normal.

The aim of the ultrasound is to screen for other pathology causing the symptoms, to identify endometriosis and deep endometriosis, and to guide referral and management.’

33. The Practice contacted Miss A in mid-May telling her it has requested the ultrasound scan to help make the correct referral for the symptoms she was experiencing.

The Practice prescribed Miss A mefenamic acid used to treat acute pain, period pain, and heavy bleeding. The Practice asked Miss A to only take paracetamol with this medication and not the anti-inflammatories previous prescribed.

34. In early June Miss A had a telephone appointment with a Practice nurse. The nurse noted Miss A’s history of pain which began in January and documented the pain was intermittent and was worse in the evenings.

35. The Nurse told Miss A the transvaginal ultrasound scan was to take place in mid-June to ensure the correct referral and possible diagnosis for her pain was made. This was in line with NICE, CKS, Endometriosis: What else might it be. This guidance tells clinicians differential diagnoses that should be considered when investigating a potential diagnosis.

36. The nurse noted Miss A agreed with the plans to wait for the scan outcome before making a referral to gynaecology services.

37. The records show during Miss A’s contact with the Practice she had one of the suspected endometriosis symptoms outlined in NICE, CKS guidelines of: • Period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine.

38. Our adviser told us it is not always straightforward to diagnose endometriosis and physical examinations and ultrasound scans are important to exclude other causes of the symptoms experienced.

39. Our adviser also said an endometriosis diagnosis can only be made definitively by laparoscopic (keyhole) visualisation of the pelvis however, other less invasive methods including ultrasound can be useful in assisting a diagnosis.

40. Based on the evidence we have seen, the Practice acted in line with NICE, CKS guidelines for suspecting and making a referral to diagnose endometriosis.

41. We understand Miss A said the Practice should have completed the referral sooner before she made the decision to take a private route for a diagnosis.

42. We have seen the Practice explained the steps it took to treat and refer Miss A in line with NICE, CKS guidelines and also recorded her agreement to these steps.

43. We acknowledge the pain and distress Miss A experienced. We hope our explanation goes some way to explain how the Practice acted appropriately with the care and investigations it completed.

1. We have carefully considered Miss A’s complaint about a Practice in Suffolk (the Practice). We are sorry to hear about the difficulties Miss A experienced in getting an endometriosis diagnosis. We understand how frustrating it is to feel you are not getting the care you need.

2. Having investigated her complaint the evidence suggests the Practice treated Miss A in line with relevant guidance. We hope she is reassured by what we have seen.