Report Date


Case Against

Hywel Dda University Health Board


Clinical treatment in hospital

Case Reference Number



Upheld in whole or in part

Mrs A complained about her gynaecology treatment at Glangwili Hospital after she developed symptoms of postmenopausal bleeding in 2019. She was diagnosed with endometrial cancer the following year.
The Ombudsman found that ongoing post-menopausal bleeding against a background of endometrial hyperplasia, should have prompted discussion and offer of hysterectomy surgery in line with clinical guidance (RCOG 67) in 2019. This may therefore have affected the clinical outcome for Mrs A. There was also a delay in treating her subsequent iron deficiency anaemia.
The Health Board agreed to the following recommendations:
• A written apology to Mrs A for the failings identified.
• Redress payment to Mrs A in respect of the delay in treating her iron deficiency anaemia.
• That Mrs A should be invited to engage with the PTR redress process in respect of the failure to offer her appropriate treatment for her ongoing post-menopausal bleeding.
• That the findings of this investigation should be shared at an appropriate Gynaecological Oncology consultant forum to ensure wider learning from the complaint, noting in particular the record keeping requirements around counselling for treatment and the accuracy of the terminology used in the records.