Report Date


Case Against

Cwm Taf Morgannwg University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

In 2016 Ms A had endometriosis removed. In November 2017 she was referred to the Princess of Wales Hospital as since the 2016 procedure she suffered disabling symptoms. In December a Trust outside Wales diagnosed Ms A with pelvic pain syndrome secondary to endometriosis surgery. In January 2018 an ultrasound scan identified fibroids around the womb and the uterus’ appearance gave rise to the possibility of adenomyosis. In February she was placed on the waiting list for a total abdominal hysterectomy and bilateral salpingo-oopherctomy (“TAH BSO” – removal of ovaries and fallopian tubes through an abdominal incision). In April Morriston Hospital requested an MRI scan and conducted a nerve conduction test. On 5 June Ms A underwent the TAH BSO.

Mr A complained that this procedure at the Princess of Wales Hospital was not performed appropriately and led to nerve damage being caused.

The Ombudsman found that the procedure was undertaken to an appropriate standard with no pelvic wall nerve damage. She found that Ms A should have been referred to the University Hospital of Wales’ specialist Endometriosis Service in advance of surgery. The Trust, Morriston Hospital, and the Consultant who undertook the 2016 procedure should have been consulted before surgery and these disciplines should have been managed within the MDT framework. She found that as there had not been any liaison, the procedure should not have gone ahead. The Ombudsman also found that there should have been a documented conversation with Ms A before the morning of the procedure about its benefits, risks and to assist the decision making process.

The Health Board agreed to implement the Ombudsman’s recommendations, and within 1 month apologise to Mrs A for the failings and make a redress payment of £500 for the uncertainty caused by the identified failures.

It agreed, within 3 months, to ensure arrangements are made for Ms A to have symptomatic relief, remind relevant staff the importance of detailing conversations about procedures before obtaining consent on the morning
of the procedure, remind staff that relevant clinicians are consulted before undertaking radical surgery and that there are mechanisms in place to enable MDTs prior to such surgery.