Report Date


Case Against

Cardiff and Vale University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Miss A complained on behalf of her late sister, Miss B,about delays by the Health Board (“the Health Board”) when diagnosing herendometrial cancer (cancer of the womb lining).

The Ombudsman found that earlier investigations for suspected cancer following an urgent referral in2017 were overly delayed and had also been inappropriate. Although excessive or abnormal thickening of the womb lining carries a risk of progression to cancer, the Health Board failed to undertake imaging of Miss B’s pelvis without her intrauterine system (a plastic device inserted into the womb) in place for accurate measurements of the womb lining to be taken. Whilst Miss B’s presenting symptoms indicated that investigations of her womb were called for, inappropriate investigations of her cervix were also pursued. It was unlikely that Miss B’s cancer was present in 2017, however it was possible that earlier pre-cancerous changes and opportunities for intervention might have been identified, potentially altering the course of Miss B’s disease.

There was also a delay of 3 months in 2019 before Miss B’s cancer was diagnosed. After Miss B’s second emergency hospital admission in March 2019, the Gynaecology Medical Team ought to have suspected cancer and arranged further investigations because her symptoms were not responding to treatment. Instead, Miss B was referred back to her GP for further management. It was unlikely that an earlier diagnosis would have affected the course of Miss B’s disease as it was aggressive and resistant to chemotherapy, however there were multiple medical appointments, futile treatments and ongoing distressing symptoms that might have been avoided. The complaint was upheld.

The Ombudsman recommended that the Health Board should apologise to Miss A for the failings in her sister’s care and review the appropriateness of the urgent cancer pathway in 2017 and the failure to consider cancer as a cause of Miss B’s symptoms in March 2019. It should also present the findings of the Ombudsman’s investigation and the review of Miss B’s care at a documented meeting of the Gynaecology Medical Team to ensure the learning from the complaint and provide assurance to the Ombudsman that it is routinely meeting the expected waiting time standard for patients to be seen following suspected cancer referrals.