Manchester University NHS Foundation Trust

5. Mrs A complains about the care and treatment provided to her by the Trust for her endometriosis. Endometriosis is a condition in which small pieces of the womb lining (the endometrium) are found outside the womb (uterus).

6. Mrs A complains that when her referral was triaged in November 2023, the endometriosis team failed to appropriately triage her referral as urgent and when she was seen in March 2024, the endometriosis team failed to refer her on appropriately for urgent investigations.

7 Mrs A also says that when the results of the MRI scan were received in June 2024, the complex endometriosis team failed to put an appropriate treatment plan in place including not listing her urgently for surgery.

8. Mrs A says the failure to triage her as urgent led to her being treated routinely, which delayed her subsequent investigations and treatment. Mrs A says the delays in appropriate care meant she experienced prolonged, unnecessary and severe pain, as well as mental distress, which meant she needed to take time off work. Mrs A tells us the delays in her care led to her paying for surgery privately.

9. Mrs A also says the delays left her infertile and led to her needing in vitro fertilization (IVF) treatment. IVF is a fertility treatment to help people get pregnant.

10. Mrs A is seeking a financial remedy of £6000.

11. Before her referral to this Trust, Mrs A had a diagnosis of endometriosis including adenomyosis (where the endometrium is present within the walls of the uterus) and a right a cyst on the ovary (endometrioma). Mrs A had previously had surgery to remove the cyst (a cyst is a fluid-filled sac) and adhesiolysis due to this. Adhesiolysis is a surgical procedure to remove adhesions, which are bands of scar tissue that can make body tissues and organs stick together.

12. On 3 November 2023 Mrs A’s GP referred her to the specialist endometriosis team at the Trust because of ongoing severe symptoms. On 13 November the Trust accepted and triaged her referral.

13. On 6 March 2024 Mrs A had an appointment at the benign gynaecology endometriosis clinic who referred her to complex endometriosis team and the infertility team in reproductive medicine.

14. On 4 April Mrs A had an MRI scan of her pelvis. MRI (magnetic resonance imaging) scans take detailed pictures of the inside of your body. They are used to help diagnose conditions, plan treatment and check how well treatment is working.

15. These scans revealed deep infiltrating endometriosis, bilateral endometriosis (endometriosis on both sides of the body) and tethering of rectum/uterus. This is where the uterus and rectum become stuck to each other (the rectum is the final section of the large intestine which ends at the anus). Deep infiltrating endometriosis is sometimes called ‘severe’, ‘stage 4’, or ‘advanced disease’ and refers to endometriosis that is deeper embedded in the abdomen and into structures in the pelvis and abdomen such as the bowel, bladder, nerves and blood vessels.

16. On 25 June, the consultant discussed possible surgical options and risks with Mrs A. The consultant added her to the surgical waiting list and offered pain relieving treatment for her endometriosis. A surgical plan was agreed which included the removal of damaged fallopian tubes (the pair of tubes along which eggs travel from the ovaries to the uterus), cysts and endometriosis both in the uterus and on the bowel surface.

17. Mrs A chose to undergo surgery privately in September 2024 as she felt she could not wait any longer due to unbearable symptoms. The surgeon excised all the stage 4 endometriosis and removed Mrs A’s fallopian tubes. The surgeon also advised further surgery was required with support from colorectal specialists. These are surgeons that specialise conditions that affect the colon (part of the large intestine) and rectum.

18. Mrs A said she visited her GP and Accident & Emergency (A&E) multiple times from before referral to when she had private surgery due to pain and symptoms. Since the surgery Mrs A is reliant on fertility treatment as she cannot get pregnant naturally.

22. Before we decide if we should investigate a complaint in more detail, we look at a few different factors. We consider whether there are signs the organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing.

23. We also look at whether what happened had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right. If we think there was a failing, and that this had an impact that has not been put right, we will usually investigate in more detail.

Triage in November 2023

24. Mrs A told us that when her referral was triaged in November 2023, the endometriosis team failed to appropriately triage her referral as urgent and so she had to wait too long to be seen.

25. In response to Mrs A’s complaint, the Trust said that following Mrs A’s referral by her GP on 9 November, she was triaged on 13 November by a consultant gynaecologist and seen in the benign gynaecology endometriosis clinic on 6 March 2024.

26. The NG73 guidelines do not define urgent versus routine referral criteria, waiting time standards or triage categories. Instead, they explain the urgency of referrals is based on clinical opinion based on clinical presentation. For example, if there are any time-critical features of the clinical presentation referrals will be ‘fast tracked’.

27. The NHS England RTT rules say that patients have a right to start consultant-led treatment within 18 weeks of referral or request an offer of alternative providers that can start their treatment sooner.

28. The referral letter indicates the GP asked for an urgent rather than a routine appointment because of Mrs A’s symptoms. The available records indicate there were no time-critical features, such as impending bowel obstruction, cancer or sepsis (serious blood infection), which would indicate a clinical need to fast track.

29. We understand this means while Mrs A’s condition may have been considered severe, there was no reason to triage her differently because the available records do not demonstrate clinical features that would clearly justify prioritisation ahead of other patients awaiting specialist assessment.

30. We have considered this alongside the context outlined by our adviser. Our adviser explained, sadly, many women referred to endometriosis specialist services experience severe pain and significant impairment to their quality of life and expediting an appointment would result in a delay to other patients with similar conditions. They told us that to avoid this, and to ensure fairness, patients are usually put in a queue and seen in date order.

31. We note the wait from Mrs A’s referral to her appointment with a consultant was within the 18 week RRT rules.

32. Having considered the evidence and advice provided, we conclude that Mrs A’s triage was routine and appropriate, in line with relevant guidelines. We have not identified any indications that Mrs A should have been seen before 6 March 2024 based on her symptoms and history.

33. The Trust has acknowledged it is trying to improve waiting times. While we recognise the four month period between triage and Mrs A’s appointment in March might be considered longer than ideal, for the reasons outlined above, this timeframe does not in itself indicate a failing in care.

Referral for urgent investigations

34. Mrs A told us that when she was seen on 6 March 2024, the endometriosis team failed to refer her on appropriately for urgent investigation and so she had to wait too long to be reviewed and treated.

35. In response to the complaint, the Trust said in the appointment on 6 March the consultant in the benign endometriosis team reviewed Mrs A’s pain management and treatments for her symptoms. The consultant also referred her to the complex endometriosis team and the infertility team in reproductive medicine.

36. The Trust explained Mrs A had an MRI scan on 4 April, and telephone appointments with a specialist nurse on 10 April and 16 April. The Trust also said the nurse wrote to Mrs A on 17 June with MRI scan results, and on 25 June she had a consultation with the consultant in the complex team.

37. NG73 section 1.10 says that if fertility is a priority, the management of endometriosis-related subfertility should have multidisciplinary team involvement with input from a fertility specialist and access to fertility services. We consider this means Mrs A should also been referred to an infertility team.

38. In 1.71 of NG73 it says to consider outpatient follow-up (with or without pelvic examination and pelvic imaging) for women with confirmed endometriosis. We consider this means Mrs A should have been reviewed thoroughly at her appointment and potentially sent for an MRI scan while continuing to be reviewed as an outpatient.

39. In NG73 part 1.9 it says that doctors should discuss surgical management options with women with suspected or confirmed endometriosis, which means the consultant should have discussed surgical options with Mrs A.

40. The clinic letter from 6 March demonstrates the doctor carried out a detailed assessment of her symptoms, previous surgery, fertility history, previous imaging, menstrual history, pain symptoms and examination findings.

41. At the appointment in March, the consultant suspected recurrent bilateral endometriomas (cysts filled with old blood that form on the ovaries due to endometriosis), hydrosalpinx (when fluid accumulates in one or both fallopian tubes, creating a blockage) and severe endometriosis.

42. From the evidence we have reviewed, we understand the treatment plan following the assessment was appropriate because it included an MRI scan of the pelvis, referral to a specialist endometriosis team, referral to the infertility team and a discussion on pain management options to help with ongoing symptoms.

43. There was evidence of severe endometriosis and thus an MRI to ‘stage’ the disease (this means determining the extent and severity of a disease) was appropriate with onward referral to an endometriosis specialist. We consider this is consistent with the advice in NG73.

44. Our adviser told us that an MRI is an accepted investigation for mapping deep infiltrating endometriosis (DIE) and staging the disease prior to complex surgery. DIE is a severe form of endometriosis where tissue similar to the lining of the uterus invades other pelvic organs, such as the ovaries, bladder, and rectum. Our adviser explained MRI scans are invaluable because the findings determine the extent of surgery and the expertise required.

45. We understand the MRIs were necessary as records indicated there was already evidence suggesting advanced disease potentially requiring complex multidisciplinary surgery. We consider that before committing to a definitive operative plan, MRI scans were clinically appropriate and consistent with accepted specialist practice. We conclude this is in line with the principles outlined in NG73 as it represents an appropriate specialist assessment.

46. The appointment for scans was 4 April, approximately four weeks after the referral for the scans. Taking account of advice given and relevant guidelines, we consider that the MRI scans were carried out within a reasonable timeframe.

47. Having considered the evidence and advice provided, we consider when Mrs A was seen on 6 March 2024, she was referred appropriately for investigation and, while she felt she had to wait too long to be reviewed and treated, the waiting times between appointments was acceptable and the treatment plan was appropriate and in line with guidance.

48. We recognise, although the long waiting times do not amount to a failing in themselves, while Mrs A remained on the waiting list she unfortunately continued to experience significant pain and ongoing symptoms, which adversely affected her to day-to-day life.

Treatment plan following MRI scans

49. Mrs A told us that when the results of the MRI scan were received in June 2024, the complex endometriosis team did not put an appropriate treatment plan in place or list her urgently for surgery. She said this meant she did not receive treatment quickly enough.

50. In response to the complaint, the Trust said a specialist nurse wrote to Mrs A on 17 June with MRI scan results, then on 25 June she had a consultation with a consultant in the complex team who discussed surgical options. Mrs A was added to the surgical list on that day.

51. The Trust also said there was a backlog and patients referred for complex endometriosis care were waiting approximately 50 weeks for their first outpatient appointment. It explained treatment is usually provided within 65 weeks and it is working to reduce waiting times.

52. According to the NHS England TAT guidelines, the MRI the interval between an imaging examination and a verified report being made available to the referring clinician should be 28 days.

53. As stated in paragraphs 38 and 39 above, NG73 indicates that Mrs A should have continued to be reviewed as an outpatient and the consultant should have discussed surgical management options with her as she had confirmed endometriosis.

54. There is no specific guidance to time intervals between outpatient appointments for treatment and care of endometriosis. This means that timing of review appointments are based on clinical judgements and capacity at clinics.

55. Mrs W had her scans on 4 April and the MRI reports were dated 24 May, approximately eight weeks later. The reporting interval appears longer than expected.

56. Mrs W had a follow up appointment and was listed for surgery on 25 June, which was approximately 13 weeks after her assessment in March, and nine weeks after the MRI scans were done.

57. Our adviser explains that a follow up appointment approximately three months after the initial appointment would be reasonable as this would allow time for an MRI to be arranged, performed and reported in time for a follow up appointment. Having considered the evidence and advice provided, we conclude it unlikely that an earlier follow up appointment would have been given even if the scan reports had been available sooner.

58. The scans revealed that Mrs W had severe endometriotic disease including DIE, bilateral endometriosis, and tethering of rectum/uterus, which required complex surgery and potentially required support from colorectal specialists. The treatment plan suggested after the scan results was surgery. We consider this was reasonable and in line with national guidance (NG73).

59. The NG73 guideline details the importance of appropriate multidisciplinary skills being available for such surgery. Our adviser explained the surgery Mrs A required was complex, although not time critical, and would involve specialist tertiary level involvement, with multi-specialty surgical teams. We acknowledge the importance of planning such surgery properly and ensuring this was not rushed, to ensure it was effective and safe.

60. Importantly, the MRI findings demonstrated severe disease but did not demonstrate bowel obstruction, ureteric obstruction (blockage in the ureters, the tubes that carry urine from the kidneys to the bladder), hydronephrosis (when the kidneys swell and cannot get rid of urine) or other any other immediately time-critical complication.

61. Mrs A elected to have the planned surgery privately in September 2024. The Trust telephoned Mrs A in January 2025 with a date for the surgery planned in June 2024, which she no longer needed due to her private surgery in September.

62. Since Mrs A had surgery privately, we cannot say or take a view on how long she would have waited to have the surgery with the NHS.

63. The only delay we noted was potentially the time it took in reporting on MRI scans, which may or may not have delayed the follow up appointment. Our adviser explained that the overall timeline from first appointment to planned surgery was not irregular, and although lengthy, we do not consider it to be contrary to guidelines set.

64. We do not consider there are any indications of failings because we consider that a clinically appropriate treatment plan was put in place and Mrs A was listed for surgery correctly. Our understanding is that the waiting time for surgery was determined by the availability of the appropriate specialists.

65. Whilst we are not taking any further action on Mrs A’s complaint, our decision is not made without recognition of the fact Mrs A had severe endometriosis, which was diagnosed before her appointment in March 2024 at this Trust. Nor that the length of time from referral to surgery meant, unfortunately, Mrs A experienced prolonged and painful symptoms, which she told us severely affected her and was extremely distressing.

1. We have carefully considered Mrs A’s complaint about Manchester University NHS Foundation Trust (the Trust). We are sorry to hear of Mrs A’s experience as we recognise that Mrs A had an extremely difficult time due to her condition, which causes severe pain and discomfort and has affected her fertility.

2. We have reviewed the information provided by Mrs A and the Trust, as well as seeking advice from a consultant gynaecologist, and considering the guidance and standards relevant to the care provided.

3. After doing so, we have seen no indication that anything went wrong when Mrs A was triaged, reviewed and treated by the endometriosis teams. We have, therefore, decided not to investigate in more detail or take any further action.

4. We will explain the reasons for this decision in this statement. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mrs A for sharing her experience with us. It is important to acknowledge that where we have not identified any indications something went wrong in the care provided to Mrs A, it does not detract from her experience, nor the impact this had on her.