University Hospitals Coventry and Warwickshire NHS Trust

6. Mrs P complaints about the care she received at University Hospitals Coventry and Warwickshire NHS Trust (the Trust) between June 2023 and May 2025.

7. She complains:

• about the length of time she has waited for a hysterectomy since her referral in June 2023 • about the continued use of Prostap injections between June 2023 and May 2025 • about the delay in receiving her scan results from August 2024.

8. She says the injections has caused weight gain, heart problems and bone problems. She says she suffered with symptoms of endometriosis during the delay waiting for a hysterectomy.

9. She says her mental health deteriorated during this time, and she has lost trust in the NHS. Due to the delay in an appointment, she says she paid for private treatment.

10. As outcomes, Mrs P would like an acknowledgement and apology from the Trust. She would like a financial remedy.

11. Mrs P had a history of pelvic pain, cramps and other symptoms. In 2015, she had a laparoscopy (a minimally invasive procedure to examine a patient) which found endometriosis.

12. Mrs P was prescribed Prostap injections (a hormone therapy injection used to treat endometriosis) by the Trust in December 2022.

13. In June 2023, the Trust referred Mrs P for a hysterectomy consideration. The Trust continued Mrs P’s prescription of Prostap injections.

14. In September 2023, Mrs P had an MRI scan which showed endometriosis.

15. In October 2023, the Trust referred Mrs P to a private endometriosis centre as there was no endometriosis specialist at the Trust.

16. In June 2024, as the private service was not accepting NHS patients, the Trust referred Mrs P to a different Trust with an endometriosis specialist. The Trust continued treating Mrs P with Prostap injections.

17. In May 2025, Mrs P was seen at the Trust for consideration of a hysterectomy, as a new endometriosis specialist had begun working at the Trust.

Delay in getting a hysterectomy appointment

21. Mrs P complains about the time she has waited for an appointment with an endometriosis specialist since she was first referred in June 2023.

22. In June 2023, Mrs P’s consultant referred Mrs P to another gynaecologist at the Trust for consideration of a hysterectomy.

23. In October 2023, Mrs P had an appointment at the Trust to discuss a hysterectomy operation to treat her endometriosis and possibly relieve her symptoms. It is noted the consultant explained she was a general gynaecologist, and Mrs P would prefer to have the surgery with an endometriosis specialist.

24. The Trust did not have an endometriosis specialist working there at the time of Mrs P’s referral. The Trust referred her to an endometriosis consultant at a private hospital for her surgery. She was told she may be on the waiting list for up to two years.

25. The Trust has told us during this period, NHS referrals at the private hospital were put on hold. Due to this, in June 2024, at Mrs P’s review, it referred Mrs P to a different NHS Trust with an endometriosis specialist.

26. Mrs P complained to the Trust in November 2024 that she had still not been seen following her referral in June 2024. The Trust said a new endometriosis specialist began working at the Trust, so Mrs P was offered an appointment with the consultant in May 2025.

27. At this appointment, it is noted Mrs P wanted time to think about the surgery and she was not added to the waiting list. It arranged to see Mrs P in four months’ time for her to decide whether she would like the surgery.

28. The NHS England RTT standard says treatment should be started within 18 weeks of referral.

29. The Trust has explained due to the Trust not having an endometriosis specialist, and it had to refer Mrs P elsewhere.

30. The GMC guidance says a clinician must refer a patient to another practitioner when this serves the patients’ needs and promptly provide or arrange suitable advice, investigations or treatment where necessary.

31. We contacted the private endometriosis centre about Mrs P’s referral. It advised us the consultant Mrs P was referred does not accept NHS referrals and only holds private clinics at the private hospital. It said it was filed in the private database with the impression the Trust would arrange a private consultation and cover the costs.

32. We asked the Trust why it referred Mrs P to this consultant, if they did not accept NHS patients. The Trust said the letter was intended as an NHS referral, to what the consultant believed was an NHS endometriosis centre, and it assumes the consultant was unaware this was a private centre.

33. In line with the GMC guidance, the Trust should have made a prompt referral to an NHS endometriosis centre. Instead, the Trust inappropriately referred Mrs P to a private hospital who was not accepting NHS patients. We consider this an indication of failing by the Trust.

34. This caused an eight-month delay in Mrs P’s referral being sent to an NHS organisation. Mrs P has told us she was in physical pain during this period, and waiting for this surgery impacted her mental health.

35. The NHS My Planned Care website provides an average waiting time for treatment. Had Mrs P been referred to the NHS Trust in the first instance in October 2023, the website says the average waiting time for treatment around this time at this Trust is 25 weeks. As such, Mrs P would likely have been seen earlier at an NHS Trust had she been referred correctly. We cannot say she would have had the surgery, as we do not know what the outcome of this appointment would have been.

36. We consider, as an impact of this failing, Mrs P experienced unnecessary distress and worry, and she missed an opportunity to be seen earlier at an NHS Trust.

37. Our NHS Complaint Standards say organisations should openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these. They make sure staff can offer a range of ways to put things right for the individual.

38. In the complaint response, the Trust did not acknowledge this mistake or apologise for the impact this had on Mrs P. In line with our NHS Complaint Standards, we consider the Trust needs to take further action to remedy the impact Mrs P experienced.

39. As outcomes, Mrs P is looking for an apology and acknowledgement from the Trust, and a financial remedy.

40. We have reviewed our guidance on financial remedy and similar cases we have investigated. Following this review, we asked the Trust if it would pay Mrs P a financial remedy of £700 to remedy the impact on her. We also asked the Trust if it would provide Mrs P with an apology.

41. The Trust agreed to provide an apology and pay Mrs P £700 to remedy the impact it caused. Mrs P also agreed to this resolution.

42. We are sorry about the unnecessary delay Mrs P faced in receiving an appointment for her hysterectomy surgery. We recognise she experienced pain, worry and distress during this period. We consider the Trust has offered a resolution that remedies the impact it caused Mrs P. As Mrs P accepts this resolution, and we would not recommend anything further, we consider this complaint resolved.

Prostap injections

43. Mrs P complains about the Trust continuing to prescribe Prostap injections without appropriate review.

44. The Trust said she was reviewed yearly to monitor her progress and she has been counselled extensively about the use of injections.

45. Mrs P was first prescribed Prostap injections in December 2022. This is a gonadotrophin-releasing hormone (GnRH) used in treating endometriosis.

46. She had a Dexa scan (a scan to measure bone density) in June 2023, which was normal, and her Prostap was continued. She had been using Tibolone as add-back therapy (a hormone replacement therapy used alongside the Prostap injections to prevent bone loss and other side effects), but she reported it affected her bowel, so it did not suit her.

47. The Trust advised she could stop add-back therapy, due to her normal Dexa scan, or consider an alternative form as add-back therapy to reduce the risks. The Trust prescribed her with HRT patches if she wished to use them.

48. In October 2023, the Trust told Mrs P’s GP to add in an oestrogen patch (a form of add-back therapy) for continuous use of Prostap injections. It is noted Mrs P said her pelvic pain had reduced since taking Prostap, so it continued with this treatment.

49. She had another Dexa scan in August 2024, which was normal.

50. In June 2024, the Trust reviewed Mrs P and in agreement with Mrs P, it continued with Prostap injections due to it alleviating some of her pain and to manage her bleeding. It documented this was off-licence (it is prescribed in a way outside of its official licence), due to the prolonged use of Prostap injections. It noted she had been prescribed with HRT patches as add-back therapy because of this.

51. In May 2025, Mrs P was seen at the Trust. She said her bowel symptoms had improved since being on Prostap. She said she stopped using add-back therapy. The consultant advised about the risk of being on Prostap for prolonged use, including the risk to her heart and bones. The consultant prescribed Ryeqo, an alternative hormonal treatment for her to consider, and if she did not want this, she could continue with Prostap.

52. NICE NG73 says to offer hormonal treatment to women with suspected, confirmed or recurrent endometriosis.

53. The ESHRE guidance recommends prescribing women GnRH therapy to reduce endometriosis-associated pain, although evidence is limited regarding dosage or duration of treatment. It says clinicians should consider prescribing combined hormonal add-back therapy to prevent bone loss and hypoestrogenic (lower than normal level of estrogen) symptoms.

54. Our adviser said the use of GnRH therapy, such as Prostap, is a well-established treatment for endometriosis. They said the effects of the treatment should be actively managed and the use of add-back therapy is recommended when treatment is being offered long-term.

55. In line with NICE NG73, it was appropriate for the Trust to offer Prostap injections to Mrs P as a form of hormonal treatment. The Trust recommended add-back hormone therapy such as hormone patches, to reduce the risk of side effects, in line with the ESHRE guidance.

56. The GMC prescribing guidance says when a clinician proposes, prescribes or provides medications, they must make sure that suitable arrangements are in place for monitoring, follow-up and review. They should take account of the patients’ needs and any risks arising from the medicines.

57. In line with the GMC prescribing guidance, the Trust arranged for yearly Dexa scans, to monitor Mrs P’s bone health. The Trust also considered the risks involved with this medication at her review appointments and prescribed add-back therapy to reduce these risks.

58. The Trust also discussed the use of Prostap injections with Mrs P at her appointments, where she documented it had helped some of her symptoms, and it agreed a plan with Mrs P to continue the injections. This is in line with the GMC prescribing guidance by taking account of Mrs P’s needs.

59. Our adviser said prescribing Prostap injections long-term and advising the use of add-back therapy was appropriate in managing her condition.

60. The BNF page for Leuprorelin acetate (Prostap) outlines side effects can include bone pain, palpitations, weight change and more. We are sorry Mrs P experienced some side effects, including weight gain, from using Prostap injections. We have not seen evidence Mrs P reported these side effects during her reviews at the Trust.

61. We are sorry Mrs P feels she was prescribed Prostap injections inappropriately, and for any side effects she experienced.

62. We consider it was appropriate and in line with NICE NG73 that Mrs P was prescribed Prostap injections. We consider the Trust appropriately monitored Mrs P and advised her to use add-back hormone therapy to minimise the risks of using Prostap injections, which is in line with the ESHRE guidance, and the GMC prescribing guidelines. Therefore, we are not going to investigate this further.

Delay in receiving scan results in August 2024

63. Mrs P complains she was not provided with her Dexa scan results from August 2024, until she chased the Trust for these results. The Trust wrote to her in January 2025 explaining her results were normal and another one would be scheduled if continuing to use Prostap.

64. In the Trust’s response, it says it is not usual practice to contact patients in writing if their Dexa scans are normal, and the consultant would reassure Mrs P during her next review as she was being seen yearly.

65. The GMC guidance says clinicians must give patients the information they want or need in a way they can understand. We understand that Mrs P wanted to be updated about her test results in line with this guidance.

66. The NHS England guidance advises if the policy is to only contact patients when results are abnormal, patients should be informed of this.

67. As the Trust reviewed Mrs P yearly, and her results were normal, we consider it reasonable for the Trust to discuss this with her at her next review, if its standard practice is to only contact patients when results are abnormal.

68. We do consider the Trust should have explained to Mrs P how it would provide her with the test results, in line with the GMC guidance and the NHS England guidance about clear communication.

69. Mrs P said she was worried about her test results, and wondering when she was going to hear from the Trust about this.

70. We have considered what the Trust has already done to remedy Mrs P’s impact. Our NHS Complaint Standards say organisations should openly identify instances where things have gone wrong, or where services have had an unfair impact and take responsibility for these.

71. After Mrs P complained about not having these test results in November 2024, the Trust wrote to Mrs P in January 2025, explaining her test results were normal. In the Trust response, it apologised for not communicating to Mrs P about when results would be shared and acknowledged she was worried about her results.

72. We consider the Trust has acknowledged what went wrong and provided an apology for this in line with our NHS Complaint Standards. We consider this appropriately remedies the impact caused to Mrs P. As such, we would not recommend any further action for this issue.

73. We are sorry for any worry Mrs P experienced about her scan results. We recognise the Trust did not communicate clearly with Mrs P about when her scan results would be discussed with her, which caused her to worry about her results. We consider the Trust has taken action to remedy the impact it caused, and we would not recommend anything further. Therefore, we are not investigating this any further.

1. We have carefully considered Mrs P’s complaint about University Hospitals Coventry and Warwickshire NHS Trust (the Trust). We are sorry to hear Mrs P is unhappy with the care she received at the Trust, and she has been suffering with physical symptoms. We are sorry to hear how this has negatively impacted her mental health.

2. We have seen evidence the Trust inappropriately referred Mrs P to a private service, which caused an eight-month delay in Mrs P’s referral being sent to an NHS Trust.

3. We have had further conversations with the Trust, and it has agreed to take further steps to put things right. The Trust has agreed to pay Mrs P £700 as a financial remedy and to provide Mrs P with an apology. We consider these steps taken by the Trust remedies the impact it caused. Therefore, we consider this complaint issue resolved and we will not take any further action.

4. Mrs P complains the Trust continued to prescribe Prostap injections inappropriately. We are sorry for the side effects Mrs P has experienced from these injections, and for any worry she has had about the long-term use. We have seen evidence the Trust prescribed Prostap injections in line with guidance. Therefore, we are not investigating this complaint issue further.

5. Mrs P complains the Trust did not discuss her scan results with her in August 2024. We are sorry Mrs P had to chase this up with the Trust and for any worry she experienced. We consider the Trust did not advise Mrs P about how results are communicated. We consider the Trust has already appropriately remedied the impact caused, so we are not investigating this any further.