Report Date


Case Against

Cardiff and Vale University Health Board


Referral to treatment time

Case Reference Number



Upheld in whole or in part

Ms C complained about the care and treatment she received from Cardiff and Vale University Health Board. Specifically, she complained about whether the delay between a large fibroid being confirmed and a hysterectomy being performed was acceptable, whether opportunities were missed to make an earlier diagnosis of endometrial cancer and whether the possibility of deep vein thromboses and pulmonary embolism should have been considered before February 2021.

The investigation found that the delay in Ms C undergoing a hysterectomy was not acceptable, even considering unavoidable delays caused by COVID-19 restrictions. There were missed opportunities for Ms C to have undergone surgery before the introduction of COVID-19restrictions and rules relating to referral to treatment times were misapplied. Opportunities were mere missed to have diagnosed Ms C’s endometrial cancer earlier. The symptoms she was expiring meant that referrals for further treatment and investigation should have been made earlier than they were, and if they had she may well have been diagnosed with endometrial cancer up to 2years earlier than her eventual diagnosis. These parts of Ms C’s complaint were upheld. The investigation found that deep vein thromboses and pulmonary embolism should have been considered when Ms C attended hospital on 1 February2021. As this falls outside the time period specified in the complaint this part of Ms C’s complaint was partially upheld

The Health Board agreed to apologise to Ms C. It also agreed to share the investigation report with relevant clinicians and to ensure that clinicians that treated Ms C were aware of symptoms that required further endometrial assessment. The Health Board also agreed to audit a sample of gynaecological cases to ensure that referral to treatment times have not been misapplied in other cases.