Salisbury NHS Foundation Trust

4. Ms X complains about the care and treatment she received from the Trust from September 2024 until May 2025. Specifically, she complains the Trust:

• repeatedly missed opportunities to diagnose and treat her symptoms • delayed operating on her to remove her left fallopian tube from 1 November 2024 to 7 May 2025 • provided incorrect information about her level of endometriosis.

5. Ms X says the poor care and treatment affected her ability to care for her young daughter. She says she experienced significant pain which has had a limiting effect on her day-to-day life. Ms X also says her experience with the Trust has affected her mental health and caused her to lose faith in medical professionals. Further, she tells us the incorrect information about her endometriosis caused her confusion and contributed to her poor mental health.

6. By bringing her complaint to us, Ms X is seeking acknowledgement of any failings in her care and treatment, an apology, service improvements and a financial remedy.

7. Please note that we have not included all the background to the complaint in this report as all parties already know this information. We have included the information outlined in this section to put the complaint into context.

8. Prior to the events complained about, Ms X had had investigations for endometriosis at a different hospital trust (Trust B). These had suggested Ms X had stage four endometriosis (the most advanced form of endometriosis).

9. Ms X presented at the Trust a number of times from September 2024 to May 2025, with symptoms of ongoing and worsening pelvic pain. We consider each of these attendances in our report below.

10. The Trust arranged a number of tests during this time, and it felt these did not suggest Ms X had stage four or extensive endometriosis. The Trust says the tests showed a number of other possible causes for her pain. This included her left fallopian tube being attached to her uterus (womb), fatty infiltration of her liver (when excess fat accumulates in liver cells, potentially impairing liver function), dilatation of the common bile duct (an abnormal widening of the tube that carries bile from the liver and gallbladder to the small intestine), a gallbladder polyp (growth on the inner lining of the gallbladder), and a left inguinal hernia (a swelling or lump caused by tissue or part of the bowel pushing through a weak spot in the top of the inner thigh).

11. Ms X underwent two laparoscopies (a type of keyhole surgery used to diagnose and treat conditions) at the Trust: one in in November 2024, in which the fallopian tube was freed from the uterus, and another in May 2025, in which the left fallopian tube was removed as Ms X was concerned this was the cause of her ongoing pain.

12. Ms X feels that the Trust’s treatment has been inadequate, noting that there has never appeared to be a clear plan for investigating and treating her condition. She says she continues to suffer from significant pain and does not feel the Trust have done enough to address and resolve this.

Trust repeatedly missed opportunities to diagnose and treat Ms X

16. Ms X says she attended the Trust multiple times between September 2024 and May 2025 with worsening symptoms she believes were due to her endometriosis. Ms X does not feel the Trust acted appropriately in its care and treatment of her symptoms.

September 2024

17. Ms X tells us she attended the Trust’s ED department on 27 September 2024 as she felt the abdominal pain she had was similar to when she had a previously ruptured ovarian cyst. She says she was discharged with pain medication, but the Trust planned no further management.

18. In its response, the Trust said it admitted Ms X to the surgical assessment unit (SAU) for further assessment and completed an ultrasound. It says the ultrasound noted it was possible her left ovary was stuck to her uterus. It notes her clinical observations were stable so was confident for her to be discharged home with pain medication.

19. The Trust does note Ms X’s liver enzyme levels (proteins produced by the liver that help with metabolism, and elevated levels in the blood can indicate liver stress or damage) were slightly raised and explains this can be cause by several different factors. Ms X’s electronic discharge summary (EDS) asked her GP to refer her to gastroenterology for investigation of ongoing gastrointestinal symptoms. The Trust states there was no requirement to undertake an emergency diagnostic laparoscopy at this time.

20. NICE guidance states clinicians should carry out ultrasounds in women with suspected endometriosis. It also states clinicians should identify or rule out other pathology which may be causing symptoms. Our adviser explains the ultrasound results did not indicate any evidence of deep endometriosis. They say it did show a possibility of her left ovary being stuck to her uterus.

21. We feel the Trust have followed the above guidelines in completing an ultrasound based on Ms X’s presenting symptoms. It has also asked her GP to refer her to the gastrointestinal department following Ms X’s upper chest pain and struggling to eat and drink. We do not see any indication to suggest the Trust should have done anything differently on this date.

October 2024

22. Ms X says she returned to the ED on 1 October 2024 as she was experiencing further upper right abdominal pain, which she felt was worse when eating. She says the Trust arranged an abdominal scan, MRI and CT scan (non-invasive imaging scans). Ms X says she was told staff were concerned she had an issue with her gall bladder, though nothing was found from the scans. Ms X says she was told it may be that she had passed a gallstone but her ongoing issues were due to endometriosis.

23. The Trust says it admitted Ms X under the surgical team. It says it carried out an abdominal ultrasound scan, which showed fatty infiltration of her liver, dilation of the common bile duct and a gallbladder polyp. It says the MRI scan also showed a dilated common bile duct but no gallstones.

24. The Trust says it also performed a CT scan of the abdomen/pelvis and this did not identify any other cause of Ms X’s pain other than the above reasons. It says the scan noted she has a small left inguinal hernia and was discharged home following improvement to her blood tests. The Trust says a plan was made for an outpatient follow up with the surgical team in a few months’ time to discuss management of Ms X’s gall bladder polyp. It also states it would repeat the ultrasound of her liver in six months for gall bladder polyp surveillance.

25. Our adviser says the repeated ultrasound scanning showed no indication of deep endometriosis.

26. We feel the Trust’s investigations and scans in October 2024 aligned with the NICE guidance outlined earlier in our report. We therefore see no indication the Trust did anything wrong at this time.

27. Ms X says two weeks later, she received a call from the Trust telling her it wanted to perform a diagnostic laparoscopy on 1 November 2024. She says this felt like an urgent request and this confused her as she was discharged before with no follow up. Ms X says she felt the Trust must have missed something from the scans and she was being rushed in for the procedure. She tells us she felt as if the Trust was hiding something from her.

28. The Trust says due to Ms X’s symptoms being so severe and her repeated hospital admissions, it moved her to the top of its waiting list for surgery. It states there was no clinical need for this to be booked as urgent and there was no evidence indicating something had been missed during her previous investigations.

29. We asked our adviser if the Trust missed opportunities in October 2024 to diagnose and treat Ms X’s endometriosis. They explained NICE guidance states clinicians should consider laparoscopy to diagnose endometriosis in women with suspected endometriosis and therefore it was appropriate this was arranged. Overall, they do not see indications to suggest there were missed opportunities in her earlier investigations and care or that something was being hidden from Ms X.

30. We are therefore satisfied there are no indications the Trust missed an opportunity to diagnose and treat Ms X’s endometriosis in October 2024.

November 2024

31. Ms X says the laparoscopy in November 2024 showed her fallopian tube was attached to her abdomen. Ms X feels this could have been dangerous and was linked to her endometriosis.

32. The Trust’s response states the gynaecology consultant saw Ms X post operatively and explained her left fallopian tube was stuck to the anterior wall of her pelvis (the front portion of the pelvic cavity and is composed of both bony and muscular structures) on her Caesarean section scar. It says the consultant explained this was removed and the tube was freed.

33. It says there was no evidence of stage four endometriosis , but they did find minimal superficial endometriosis spots. The Trust treated the superficial endometriosis spots and reported there was no endometriosis found on the bowel.

34. We asked our adviser what should have happened. Our adviser says there are no indications to suggest Ms X had more extensive endometriosis and says the superficial endometriosis spots were appropriately treated.

35. In Ms X’s case, there was no evidence of extensive endometriosis from the laparoscopy, so there is no indication the Trust missed an opportunity to diagnose Ms X with endometriosis.

36. On 17 November 2024, Ms X tells us she returned to the ED with abdominal pain, leg pain and leg swelling. She says she was sent home with pain relief.

37. The Trust says Ms X was admitted for pain relief and further investigations. It says Trust staff carried out a pelvic ultrasound. This did not detect any abnormal pathology, and so Ms X was discharged home with pain relief.

38. We consider the Trust carried out investigations in line with the NICE guidelines referred to above. Therefore, we do not see indications of failings in this period of care.

December 2024 to April 2025

39. Ms X says she returned to ED several times after November 2024, up to April 2025. She says the pain was becoming unbearable and other than being given further pain relief, the Trust did nothing more to help her. She says when she described the pain, a staff member told her it was likely an irritable bowel syndrome (IBS - a common condition that affects the digestive system) flare up. Ms X says she felt as though she had to fight to have a further operation.

40. The Trust says it admitted Ms X under the gynaecology department on 6 December. The Trust suggested a Zoladex treatment plan for Ms X to have a long side hormone replacement therapy (HRT) for 3 months. Zoladex is a GnRH (gonadotropin-releasing hormone) injectable hormonal therapy drug used to treat conditions such as endometriosis by lowering oestrogen levels within the body. The Trust says this drug is used for patients with similar symptoms to Ms X’s in managing and controlling ongoing abdominal pain from endometriosis.

41. The Trust also states on 20 December 2024, Ms X attended the ED with further abdominal pain. The Trust made a plan to expedite her gynaecology follow up appointment to discuss further options. The Trust says on 7 January 2024 Ms X returned to the ED with abdominal pain and Trust staff made her an appointment with the surgical team for early February 2025.

42. On 24 February 2025, the Trust say it listed Ms X for a repeat laparoscopy and removal of any endometriosis. It says the plan was to remove her left fallopian tube if it was required. The Trust also explains it was not clear whether her pain was caused from her endometriosis or from when her fallopian tube was stuck to her uterus.

43. The Trust says in March 2025, the Trust staff saw Ms X in the acute gynaecology unit (AGU) for worsening left abdominal pain. It performed an ultrasound but there was no obvious cause for her pain. The Trust booked her in for the laparoscopy for 7 May 2025. The Trust says a further ultrasound was performed in April 2025 but again there was no obvious cause seen.

44. NICE guidelines state clinicians should repeat ultrasound scans for women with persistent symptoms possibly linked to endometriosis, recommend GnRH drugs and refer patients to a gynaecology service.

45. Our adviser explained the Trust carried out appropriate investigations in each of the above dates. They explained the Trust was appropriate in repeating pelvic ultrasound scans when Ms X’s symptoms persisted. They also explained it was appropriate for the Trust to recommend the GnRH drug to treat any endometriosis Ms X may have had.

46. We are satisfied the Trust’s management of Ms X’s symptoms between December 2024 and April 2025 were in line with the above NICE guidelines. We do not see indications the Trust missed an opportunity to treat and diagnose Ms X’s endometriosis.

47. We are sorry to hear Ms X experienced significant pain throughout this period of time. We appreciate this caused a lot of distress to her when trying to care for her young daughter.

48. To summarise our decision, we have not seen any indication the Trust’s management of her pain and presenting symptoms were inappropriate. We feel the Trust has acted in line with the relevant guidelines when making a plan to treat Ms X.

Delay in removing fallopian tube

49. Ms X says she feels the Trust should have operated to remove her left fallopian tube sooner than it did. She says she attended the ED multiple times in severe pain and felt the Trust were not listening to her concerns. Ms X says she feels her fallopian tube should have been removed on 1 November 2024 during her first diagnostic laparoscopy.

50. The Trust says at an outpatient appointment on 24 April 2025, the consultant made it clear to Ms X the surgery may not alleviate her pain. It states Ms X was keen to proceed with the surgery and removal of her left fallopian tube and so the consultant agreed.

51. We can see in the records various consultants Ms X saw were not convinced her fallopian tube was the cause of her pain and have documented conversations with Ms X making this clear. It states they have wanted to manage her expectations her pain may still be ongoing following the laparoscopy in May 2025.

52. We asked our adviser if the Trust should have removed Ms X’s fallopian tube sooner than 7 May 2025. Our adviser explained following the laparoscopy in November 2024, the left fallopian tube appeared normal and did not indicate the fallopian tube needed removing.

53. The following laparoscopy also confirmed the left fallopian tube presented as normal and it was only removed on this occasion as Ms X had requested it to be. Our adviser says the cause of Ms X’s pain was unlikely to have been the fallopian tube because it was normal in its appearance.

54. GMC guidance states a clinician should adequately assess a patient’s condition, taking account of their symptoms as well as the patient’s views.

55. We can see the consultants considered Ms X’s symptoms, which did not indicate a clinical need to remove the left fallopian tube. The consultants have also considered her views and what she would like to happen and so agreed to remove her left fallopian tube. We have seen no indication the Trust delayed removal of the fallopian tube.

56. We therefore view the Trust has acted in line with the above guidance and will therefore not be taking any further action on this part of the complaint.

Trust provided incorrect information about Ms X’s endometriosis

57. Ms X says before she was under the Trust (Trust A) for her care and treatment, she was under another Trust (Trust B). She says Trust B told her she had stage four endometriosis in 2018, but Trust A says she has stage one endometriosis at most. She does not feel she has only stage one endometriosis because the pain she has experienced has been so severe. Ms X feels the staff at the Trust in charge of her care and treatment did not understand her symptoms and did not give her the same high level of care she had at Trust B.

58. In its response, Trust A has explained its clinical gynaecology department have experience managing endometriosis and regularly attend training for any new advances in the management of pelvic pain. It explains Ms X’s laparoscopy from November 2024 showed she had minimal superficial endometriosis, which it treated.

59. NICE guidelines states if during a diagnostic laparoscopy there are findings of normal and abnormal areas, to explain to the patient it is unlikely they have endometriosis and offer alternative management of their symptoms.

60. We asked our adviser if the conclusions from Ms X’s surgery were appropriate. They explained Trust A treated Ms X by freeing her fallopian tube and treating the superficial endometriosis areas during the laparoscopy in November 2024. Our adviser explains there was no indication the Trust should have done anything further as there was no evidence of more extensive endometriosis.

61. We appreciate the information regarding Ms X’s endometriosis differs from what she says she was told by Trust B in 2018. We are only investigating Trust A and therefore cannot comment on Trust B and its findings.

62. We have seen no indication the information the Trust has given Ms X is incorrect. We view the Trust have acted in line with the above NICE guidelines as it has referred Ms X to the gastroenterology department to explore a different pathology for her ongoing symptoms.

Conclusion

63. We hope we have reassured Ms X that we have not seen any indication something went wrong in her care and treatment. We wish her well as she continues to seek support for her ongoing issues.

1. We have carefully considered Ms X’s complaint about Salisbury NHS Foundation Trust (the Trust). We are sorry to hear Ms X experienced significant abdominal pain which she says had a limiting effect on her day-to-day life.

2. We have considered the evidence about Ms X’s care and treatment for her endometriosis (a condition where cells similar to those in the lining of the womb grow in other parts of the body) and pelvic pain. We have seen the Trust has acted in line with guidance when carrying out investigations and provided her with the appropriate treatment.

3. We recognise how important this complaint is to Ms X, and we would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint and provides Ms X with reassurance that the Trust followed relevant guidelines.