North West Anglia NHS Foundation Trust

5. Miss U complains about aspects of the care and treatment she received from the Trust between October 2021 and April 2024. Specifically, Miss U complains the Trust:

• missed opportunities to diagnose her gallbladder disease between October 2021 and June 2023 • should have placed her on the waiting list for gallbladder removal surgery before May 2025.

6. Miss U says the claimed failings delayed her receiving appropriate treatment for her symptoms. In turn, this has impacted her quality of life as she is unable to work, exercise, socialise or complete daily activities as she is in constant pain and suffers multiple infections. Her inability to work has impacted her financially.

7. By bringing this complaint to us, Miss U would like the Trust to acknowledge the failings and the impact these have had on her. She would also like service improvements to prevent this from happening again and financial remedy in line with our Severity of Injustice scale.

8. In August 2021, Miss U’s GP referred her to the Trust for suspected polycystic ovary syndrome (PCOS, a condition that affects how ovaries work), with symptoms of abdominal pain and heavy bleeding. Between October 2021 to April 2024, Miss U received treatment from the Trust from multiple departments.

9. From 15 October 2021 to 6 May 2022 the Trust’s gynaecology doctor investigated and treated Miss U for PCOS. We have referred to this as the gynaecology first opinion throughout this report.

10. On 1 November 2022, Miss U had another appointment with a different gynaecology consultant, following her request for a second opinion. We have referred to this as the gynaecology second opinion throughout this report.

11. In June 2023, Miss U said her GP diagnosed her with gallbladder disease and referred her to the Trust for treatment. The gallbladder is a small organ beneath the liver which stores and releases bile to help fat digestion.

12. Miss U said she was reviewed by two general surgeons who did not put her on the waiting list for surgery.

13. On 12 May 2025, Miss U saw a consultant for a second opinion and is now on the waiting list for gallbladder removal surgery.

Gallbladder disease diagnosis

17. Miss U complains the Trust missed multiple opportunities to diagnose her gallbladder disease between October 2021 and April 2024. As this is a long period of care and Miss U was under the care of multiple different departments, we have investigated her specific concerns.

18. Specifically, Miss U is concerned the Trust’s gynaecology consultant failed to refer her to gastroenterology and endocrinology to confirm or rule out PCOS. She believes these referrals could have prompted a sooner gallstone disease diagnosis.

19. Miss U is also concerned on her attendance to the Trust’s A&E on 5 June 2023, staff did not do any tests or investigations to get to the bottom of her symptoms. She believes if they had done further tests, they could have diagnosed gallbladder disease.

20. We have considered each Miss U’s specific points of concern below.

Gastroenterology referral

21. Miss U said the gynaecology consultant informed her they referred her to gastroenterology on 6 May 2022. However, she did not hear from the Trust regarding this referral until a year and a half later.

22. Miss U said the Trust’s booking team rang her for an appointment in October 2023 and said the gynaecology doctor never actually completed the referral on 6 May.

23. The Trust said the gynaecology consultant referred Miss U to the gastroenterology team on 6 May. It said the gastroenterology team accepted the referral on 20 May and placed Miss U on the waiting list.

24. The Trust explained due to the increased patient referrals following COVID-19 there was a wait of several months for an appointment. It said staff monitored the referral monthly, until it was able to offer Miss U an appointment in October 2023. It said it was unable to explain why the booking team informed Miss U she had not been referred.

25. NICE NG88 helps us understand what should happen. This sets out how doctors should assess and manage patients with heavy menstrual bleeding, which the records indicate Miss U had.

26. The guidance says doctors should take a history of pelvic symptoms and investigations should be driven by the history and examinations. It also says ultrasounds, endometrial biopsy and medical treatment such as desogestrel (a synthetic hormone) are appropriate interventions for heavy menstrual bleeding.

27. NICE CG188 defines suspected gallstone disease when typical biliary symptoms are present. These include right upper abdomen pain possibly radiating to the back/right shoulder often with nausea or vomiting.

28. GMC ‘Good Medical Practice’ says doctors should refer patients to another practitioner when this serves the patient’s needs.

29. We discussed this referral and reviewed the records with our gynaecology adviser.

30. The records show Miss U’s initial appointments with the gynaecology first opinion were on 15 October 2021 and 28 January 2022.

31. The records for these appointments indicate Miss U reported symptoms of heavy menstrual bleeding and pelvic pain. Our gynaecology adviser explained these symptoms are gynaecological in nature.

32. The records do not evidence Miss U reported symptoms of gallstone issues, as noted in NICE CG188 above, which should have triggered the Trust to refer to gastroenterology at this time.

33. On 6 May 2022, the records show Miss U had another appointment with the gynaecology first opinion. This clinic letter indicates Miss U reported symptoms of pelvic pain, heavy bleeding, bowel issues and lower back pain and abdominal discomfort.

34. The records show due to the pain and bowel issues, the gynaecologist referred Miss U to gastroenterology. This referral was transcribed on 12 May.

35. Based on the evidence available, we can see the Trust referred Miss U to gastroenterology following the appointment on 6 May This is when she reported symptoms which were not solely gynaecological. This is in line with GMC guidance which says doctors should refer patients to another practitioner when this serves the patient’s needs.

36. We are unable to explain why the Trust’s booking team told Miss U the gynaecologist had not made the referral to gastroenterology. This is because the Trust has been unable to explain this, and the records do not document this conversation. We recognise this was distressing for Miss U.

37. The records show Miss U had an appointment with gastroenterology on 10 October 2023. This is a wait of 17 months from referral.

38. Understandably, Miss U is concerned about the length of time it took for this appointment and the impact on her care.

39. We recognise it must have been concerning to experience such a long wait time whilst experiencing these symptoms. We also acknowledge this lengthy wait may have also caused Miss U to believe there was an issue with the gynaecology first opinion not completing the referral.

40. In February 2022, NHS England and the government published a delivery plan for tackling the COVID-19 backlog of elective (planned) care. This explained COVID-19 pandemic affected the amount of planned care the NHS could provide and led to long and rapidly increasing waiting lists.

41. NHS England’s delivery plan said by July 2022 nobody should wait more than two years for elective care. It said by April 2023 it aimed for nobody to wait more than 78 weeks, and by March 2024 it aimed for nobody to wait longer than 65 weeks. The plan said by March 2025 nobody should wait longer than a year.

42. Therefore, Miss U’s waiting time of approximately 73 weeks for the gastroenterology appointment (from referral in May 2022 to October 2023) was in line with NHS England’s recovery plan.

43. We do not condone long waiting lists and realise waiting for appointments can be stressful and uncomfortable. Sadly, the extension of waiting lists is a known effect of the COVID-19 pandemic and not necessarily indicative of failings on the Trust’s part.

44. We have reviewed the published current waiting times for the gastroenterology department within the Trust and have found these are now significantly lower. Currently, the average waiting time for first outpatient appointment and treatment for gastroenterology is 16 weeks.

45. We consider this to be significant improvements on the waiting times Miss U experienced. This shows the Trust is carrying out effective service improvements to ensure a reduction in their waiting times for patients, in line with the NHS England recovery plan. We hope this provides Miss U with reassurances.

46. Based on the above, we have not found a failing here.

Endocrinology referral

47. Miss U is also concerned about the Trust not referring her to endocrinology sooner. She said during the gynaecology second opinion appointment on 1 November 2022, the consultant told her this referral should have been made earlier to confirm or rule out the PCOS diagnosis.

48. The Trust said Miss U did not require an endocrinology referral during the gynaecology first opinion (15 October 2021 to 6 May 2022) as she was still undergoing investigations to determine if she had PCOS.

49. The International PCOS guidelines emphasise PCOS is a multi-faceted condition, but indicates initial assessments and management are often led by primary care or gynaecology. This includes investigating period irregularity, ultrasound scans, and metabolic tests (designed to evaluate how effectively the body processes nutrients and energy) when indicated.

50. Our gynaecology adviser said this supports a gynaecology led initial approach for mainly menstrual symptoms like heavy menstrual bleeding and pelvic pain.

51. The records show during the gynaecology first opinion, the Trust conducted an endometrial biopsy, provided medication to help with Miss U’s symptoms and requested an urgent ultrasound. Later, it referred her to gastroenterology and the pain team. This is in line with the international PCOS guidelines.

52. Our gynaecology adviser explained indications for the Trust to refer to endocrinology earlier would be if Miss U initially presented with newly diagnosed diabetes, highly abnormal glucose testing, severe androgen excess (male hormones), or non-gynaecological symptoms. Another indication would be if the diagnosis was unclear despite standard gynaecology investigations.

53. From the gynaecology advice, we understand Miss U’s documented symptoms were initially gynaecological in nature (heavy menstrual bleeding and pelvic pain). Therefore, the Trust did not need to refer to endocrinology during this time.

54. On 1 November 2022, Miss U had the first appointment for the gynaecology second opinion. The records indicate the consultant reviewed Miss U’s symptoms, test results and referred her case to the gynaecology multidisciplinary team (MDT).

55. The records show this took place on 27 January 2023. The MDT considered Miss U’s symptoms were more likely endocrine related and so the Trust referred her to endocrinology on 12 April.

56. The records show the endocrinology team reviewed her on 2 May and found her symptoms were not endocrine related.

57. From the gynaecology advice, we understand it was appropriate for the Trust to refer Miss U to endocrinology at this point, as the diagnosis was unclear despite the previous gynaecology investigations. This is in line with GMC guidelines which say doctors should refer patients to other practitioners when required.

58. For this reason, we have found the Trust referred Miss U to endocrinology at the appropriate time. Therefore, we have not found a failing here.

59. We hope our consideration provides Miss U with reassurances the Trust acted in line with the relevant guidelines regarding the endocrinology referral.

A&E attendance

60. Miss U said she attended A&E on 5 June, following advice from 111. She said she had a fever, back pain, nausea, discoloured skin, and bluish eyes. She said the triage nurse took her observations, advised her to contact her GP the next morning for urgent scans, and did not conduct further tests. Her GP arranged blood and urine tests, but an ultrasound could take up to one month.

61. Miss U is concerned the Trust did not do any tests or investigations to get to the bottom of her symptoms, during her attendance on 5 June. She believes if they had done further tests, they could have diagnosed gallbladder disease.

62. The Trust said on 5 June during Miss U’s attendance to A&E all her observations were within normal limits and so did not indicate infection or sepsis. It said it transferred her to the fit to sit area to wait for blood tests. It said the records indicate at 8.55pm Miss U wanted to self-discharge and see her GP in the morning.

63. In a subsequent complaint meeting between the Trust and Miss U, they discussed this concern. The Trust explained the usual process is for the triage nurse to take observations and explain to the patient their rights to wait in hospital to see a doctor or leave and contact a GP or other healthcare provider if they wished to do so.

64. Therefore, it would be the patient’s decision if they wished to stay in hospital or leave.

65. We reviewed the records with the help of our A&E adviser to help us understand what happened. There are very limited records available, due to the short time Miss U was in A&E (around three and a half hours).

66. The records indicate Miss U attended A&E shortly after 5.30pm. The Trust assessed Miss U’s observations. The records do not state what time staff took these observations.

67. The Trust response states it transferred Miss U to a ‘fit to sit’ area to wait for blood tests. However, this is not noted within the records available to us.

68. The discharge summary states ‘Status: Left after assessment with intent to attend other healthcare provider… Outcome: Left Dept – before being treated’ just before 9pm.

69. We recognise Miss U said she left A&E as the nurse told her to leave. As outlined above, the records indicate there was discussion between the nurse and Miss U about her leaving A&E and contacting ‘other healthcare provider’. However, the actual detail and information discussed to reach this outcome, is not documented.

70. Our A&E adviser explained further investigations would have been dependent on the Trust’s clinical assessment of Miss U and primary investigations (blood tests). This would be in line with GMC guidance which says doctors must adequately assess a patient and promptly arrange suitable advice, investigation or treatment where necessary.

71. As Miss U left before the Trust could conduct blood tests and further clinical assessment, it could not conduct further tests or investigations. For this reason, it met the GMC guidance to carry out what assessments it was able to. We have not found a failing here.

72. We recognise this will likely be frustrating for Miss U.

Surgery

73. Miss U complains the Trust should have placed her on the waiting list for gallbladder removal surgery before May 2025.

74. The Trust set out Miss U’s appointments with the surgeons in December 2023 and March 2024 and explained the surgeon did not consider surgery to remove the gallbladder would have been appropriate at either of these appointments.

75. NICE CG188 says people with gallstones but no symptoms and a normal biliary tree (network of organs and ducts that transport bile from the liver to the small intestine) do not need treatment unless they develop symptoms.

76. The guidance also says doctors should offer a removal of the gallbladder to people diagnosed with symptomatic gallbladder stones.

77. NHS website says if gallstones block a bile duct (a small tube that connects the gallbladder to the liver and other organs) they can cause stomach pain. The pain may be in the middle of the stomach, or just under the ribs on the right side (right upper quadrant pain). It can also cause sickness and vomiting. This pain is also called biliary colic.

78. We reviewed the records with the help of our surgeon adviser.

79. Based on this review, the records show Miss U did not report gallstone symptoms until her A&E attendance on 27 February and her appointment with the surgery team on 27 March 2024. On both occasions, she reported right upper quadrant pain which are gallstone symptoms as noted above.

80. The clinic letter from the appointment on 27 March states Miss U had an ultrasound scan which suggested she had a gallstone.

81. Therefore, in line with NICE CG188, the Trust should have placed Miss U on the waiting list for gallbladder removal surgery following the appointment on 27 March 2024, by the latest. This is because, by this point there were two instances of her reporting gallstone symptoms.

82. The records do not indicate the Trust did this. Instead, the records show the Trust requested a repeat ultrasound and a further review in 12 months’ time to monitor the size of the stone. Therefore, this was not in line with NICE CG188.

83. We understand from the records the Trust did not place Miss U on the waiting list for gallbladder removal surgery until May 2025.

84. Therefore, we have found this is a failing. We have considered the impact of this below.

Impact

85. We found the Trust should have placed Miss U on the waiting list for gallbladder removal surgery following the appointment on 27 March 2024. We carefully considered the impact of this and discussed this with our surgeon adviser.

86. Miss U says the failings delayed her receiving appropriate treatment for her symptoms. In turn, this has impacted her quality of life as she is unable to work, exercise, socialise or complete daily activities as she is in constant pain and suffers multiple infections. Her inability to work has impacted her financially.

87. We are very sorry to learn about the distress and pain Miss U has experienced. It is clear this has been a very difficult time for her.

88. The records show the Trust did not place Miss U on the waiting list for gallbladder removal surgery until 12 May 2025. This is 16 months after we consider the Trust should have placed her on the waiting list.

89. The Trust confirmed the wait times for gallbladder removal surgery in March 2024 were 21.2 weeks. Therefore, it is likely Miss U may have had the surgery in late August 2024.

90. From the surgeon advice we understand, gallbladder removal surgery does not always resolve all the symptoms.

91. This is noted within NICE CG188. This says there is a lack of information on the long-term impact of surgery on patient outcomes. It notes many patients report a continuation of symptoms, or the onset of new symptoms after the surgery and these affect quality of life.

92. Miss U has not yet had the gallbladder removal surgery, so we do not know if the surgery will resolve her symptoms.

93. Taking the above into account, we cannot say, on the balance of probabilities, if the Trust had listed Miss U for surgery in March 2024, this would have resolved all her symptoms sooner.

94. However, if the failings had not happened, this would have made a difference to Miss U, as it would have given her the opportunity to know whether earlier surgery would have resolved her symptoms sooner.

95. Therefore, the failings caused Miss U a loss of opportunity to know what difference sooner surgery would have had. We set out the recommendations below.

1. We have carefully considered Miss U’s complaint about North West Anglia NHS Foundation Trust (the Trust). We were very sorry to learn about her concerns and for the impact these have had on her. We recognise this has been a frustrating time for her.

2. We have not found failings in the Trust missing multiple opportunities to diagnose gallbladder disease between October 2021 and June 2023.

3. We have found failings in the Trust not placing Miss U on the waiting list for gallbladder removal surgery sooner than May 2025. We found this failing caused Miss U a loss of opportunity to know what difference earlier surgery would have made.

4. Therefore, we partly uphold Miss U’s complaint. Our recommendations are set out at the end of this report.