Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss X complained that Betsi Cadwaladr University Health Board failed to make a diagnosis, and/or communicate a diagnosis, of endometriosis (a condition where tissue similar to the lining of the womb grows in other places such as the ovaries), either internally, or to Miss X, within a reasonable and appropriate timescale.

The Ombudsman found that whilst a possible diagnosis of endometriosis was first considered in 2014 when Miss X had 2 ovarian cysts removed, analysis of samples from the cysts did not suggest they were endometriosis. Miss X was diagnosed with endometriosis in 2021, but whilst an earlier diagnosis might have been possible in hindsight, this was not unreasonable given the histology findings in 2014 and an earlier diagnosis would not have altered Miss X’s management. Although the diagnosis of endometriosis was made in February 2021, the Health Board’s response to Miss X’s complaint after this date inaccurately stated that this was not the case. To that extent only the Ombudsman upheld the complaint.

The Ombudsman recommended that the Health Board should apologise and pay Miss X £250 to reflect the distress the inaccuracies in the complaint response caused her.