Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs G complained about the delay in diagnosis and treatment of her mother-in-law, Mrs H, for ovarian cancer between October 2019 and September 2020.

Although there were some delays (for example in Mrs H being seen following her GP referral, and in the MDT considering her case), none of the investigations carried out before an MRI scan in April 2020 gave clinicians reason to suspect that Mrs H had cancer or an ovarian mass. The actions the Health Board took following the MRI scan result were appropriate and timely, although Mrs H should have been told of clinicians’ suspicions when the Consultant Gastroenterologist made a referral for an ultrasound scan of Mrs H’s pelvis. However, when the Consultant Gynaecologist saw Mrs H on 19 June, an urgent CT scan should have been organised, and an urgent referral made to the Gynaecology MDT. The plan, to “watch and wait” for 4 months after this, was not in accordance with Royal College of Obstetricians & Gynaecologists’ guidance, although it was not influenced by an error in a letter incorrectly referring to Mrs H’s risk of malignancy for ovarian cancer score. The delay between 19 June (when Mrs H was seen by the Consultant Gynaecologist) and 17 August (when she was discussed in the Gynaecology MDT) was unreasonable, and would have caused Mrs H considerable distress and uncertainty. Mrs G’s complaint was therefore upheld. However, although the subsequent surgery might have been slightly less extensive, it would not have significantly affected the outcome for Mrs H.

Recommendations were made for the Health Board to apologise to Mrs G for the failings identified, and for the report to be used as a learning exercise by clinicians.