A practice in the County Durham area

3. Mrs N complains that between July and October 2021 the Practice’s ANP did not refer her urgently for treatment of severe menstrual pain and bleeding after the menopause.

4. Mrs N says:

• she experienced a lot of pain, collapsed and needed hospital treatment • both her and her family were distressed because of the delayed treatment • the hospital did not arrange a biopsy because the Practice had not referred her, despite telling her it had • the delayed referral caused a delay in treatment.

5. Mrs N is asking for an apology, improvement to service, and financial compensation for the ‘severe pain and anguish’ she experienced.

6. Mrs N had a telephone appointment with a Practice nurse on 27 July 2021. She was in her late forties and said she had been on hormone replacement therapy (HRT, a treatment to relieve menopausal symptoms) for nearly two years. She explains she had painful periods, ongoing heavy bleeding and abdominal pain.

7. The nurse advised Mrs N to come off HRT slowly. They did a cervical smear test and planned to review her symptoms when HRT had stopped.

8. On 18 August, Mrs N had a phone call with spoke the Practice’s. The ANP noted her bleeding had become worse over the last couple of months. They arranged to meet for a face to face appointment the next day.

9. On 19 August, Mrs N went to the Practice for the appointment. The ANP did a physical examination and saw there were ‘no masses…no tenderness’. The ANP noted that Mrs N had not had bleeding for two years before taking HRT. They advised her to stop taking HRT and prescribed Provera (a medication to control menstrual bleeding). The Practice took a blood sample.

10. On 31 August, Mrs N did not go to an appointment with the ANP. The ANP spoke to Mrs N on the phone on 1 September and said her blood test and smear test results were normal. The ANP noted that Mrs N was ‘still bleeding very heavily at times despite Provera’. They did an ultrasound scan and asked Mrs N to continue taking an increased dose of Provera.

11. On 24 September, Mrs N had another phone consultation s with the ANP. The ANP noted Mrs N was ‘still bleeding heavily’ but Provera did help the bleeding a little. Mrs N said her ‘bleeding [was] not quite as heavy but [she was] struggling with pain’.

12. The ANP prescribed mefenamic (a non-steroidal anti-inflammatory drug (NSAID) that is used to reduced pain and inflammation).

13. On 14 October, Mrs N went to hospital for a scan. She could not have the scan because of heavy bleeding. She went back to the hospital for the scan on 16 October.

14. On 20 October, the practice got the results of Mrs N’s scan. The ANP phoned Mrs N to talk about the results. The scan found borderline endometrium (thickening of the lining of the womb) and a possible cyst. The ANP discussed the results with a GP and they agreed to get advice from the hospital. That day the Practice asked the hospital if Mrs N needed an urgent referral.

15. On 25 October, Mrs N collapsed because of menstrual pain and went to the emergency department of the hospital.

16. On 28 October, the ANP got the advice back from the hospital. It said to refer Mrs N to the post menopausal bleed clinic as a two-week referral (fast-track referral for suspected gynaecological cancer).

17. The ANP made a referral that day. They called Mrs N to tell her about the referral and noted she ‘seems to have the impression I had referred [her] for [a] biopsy’.

18. Mrs N later had an operation at the hospital to remove a blood-filled sack from her womb. No gynaecological cancer was found.

What the guidance says

22. When we investigate a complaint, we first look at what should have happened. To do this, we consider what the clinical standards and guidelines recommend. The NMC Code tells us that nurses (including ANPs) must ‘make sure that any treatment, assistance or care for which [they] are responsible is delivered without undue delay’.

23. NICE tells us that ‘some [clinical] recommendations are made with more certainty than others. We word our recommendations to reflect this. Where there is clear and strong evidence of benefit, we will use the word 'offer'. Where the benefit is less certain we use the word 'consider'.

24. NICE’s guidelines manual says clinical guidelines are recommendations on how clinicians should care for people with certain conditions. The manual explains that guidelines are ‘advisory rather than compulsory but should be taken into account…when planning care for individual patients’ and that ‘there will be times when the recommendations are not appropriate for a particular patient’.

25. There are NICE guidelines for clinicians who have a patient who has menstrual bleeding, and further information from NICE to help clinicians decide whether to refer these patients.

26. NICE NG12 states clinicians should:

• refer women for a suspected cancer pathway appointment within two weeks if they are aged 55 and over with post-menopausal bleeding • consider a suspected cancer pathway referral (for an appointment within two weeks) for women aged under 55 with post-menopausal bleeding.

27. NICE NG88 states clinicians should:

• take a history from the woman that covers the nature of the bleeding, related symptoms and other factors that may affect treatment options • offer physical examination if the woman has a history of heavy menstrual bleeding (HMB) that is persistent or with related pain • do a full blood count test for all women with HMB • consider starting pharmacological treatment for HMB without investigating the cause if the woman’s history and/or examination suggests a low risk of fibroids, uterine cavity abnormality, histological abnormality or adenomyosis • consider use of an coil as the first treatment for women with HMB with no identified pathology, and consider NSAIDs/hormonal contraception/progesterone if they are not suitable • be aware that progestogen-only contraception may stop menstruation, which could be beneficial to women with HMB • if treatment is unsuccessful or treatment is severe, consider referral for specialist care for further investigations or alternative treatment choices.

28. NICE gives advice for primary care practitioners (like ANPs). NICE’s CKS on HRT explains clinicians should not prescribe HRT for ‘women with undiagnosed vaginal bleeding’.

29. NICE’s CKS on HMB explains women should be referred urgently if they have HMB and a pelvic/abdominal mass on examination. It also explains NSAIDs can help to reduce bleeding.

30. The NHS has a clinical pathway for the management of post-menopausal bleeding. This explains that urgent two-week referral is needed where the patient has heavy, prolonged or progressive bleeding, or ‘red flags’ including a suspicious looking cervix, or suspicious mass or lesion. It explains the potential causes of bleeding include use of HRT and cancer.

31. It explains patients should be referred for urgent ultrasound scan. If this is negative, clinicians should look at a trial of oestrogen. It also explains practices can look at ways of triaging patients with gynaecological complaints to experienced clinicians within primary care, instead of referring them to a hospital.

Our view on what happened

32. The next step is for us to consider what did happen, and whether this was in line with the above guidance.

33. Mrs N says the ANP should have referred her for treatment sooner. Mrs N says on 20 October the ANP said they had referred her to hospital for a biopsy. She explains she only found out this was not the case when the ANP called her to discuss a referral.

34. Mrs N says the ANP caused a delay in her treatment and the poor communication meant t she could not have a biopsy when she went to the emergency department on 25 October.

35. When replying to Mrs N’s complaint, the Practice asked the ANP for a statement. They said they did a full examination and thought Mrs N’s bleeding was because of HRT. They said Mrs N had not stopped HRT as advised. They said they followed the guidance by getting a full blood test and recommending a coil.

36. They said they advised taking Provera, as the bleeding was continuing. They said when Mrs N’s scan results showed borderline endometriosis (where tissue similar to the lining of the womb grows in other places, like the ovaries and fallopian tubes) they got advice from the hospital and explained it and may to do a biopsy. The ANP said they are a specialist in treating postmenopausal patients.

37. We have seen there are guidelines for treating women with post-menopausal bleeding.

38. The NHS clinical pathway for HMB suggests two-week urgent referrals for all women with heavy, prolonged, or progressive bleeding (as in Mrs N’s case). The pathway also explains that practices can choose to use experienced clinicians to treat patients rather than referring. We can see the Practice’s ANP is a specialist in women’s health and is a member of the relevant professional body.

39. When Mrs N went to the Practice with heavy menstrual bleeding the ANP took a clinical history of her bleeding, in line with NICE NG88.

40. The records show the ANP wanted to first rule out HRT as the cause of her bleeding. We can see that the other Practice nurse had already suggested she stop HRT, but Mrs N had not stopped taking it yet. We can see from the NICE CKS and the NHS pathway that HRT can be a cause of post menopausal bleeding.

41. The ANP did blood tests and did a physical examination in line with the NICE guidance. The results appeared normal. The records show us that the bloods were in normal ranges and the ANP could not find any masses or tenderness on examination.

42. The ANP prescribed Provera and NSAIDs to control her bleeding. As there was no sign of anything abnormal, this was in line with the NICE CKS and NG88 and seemed to reduce her bleeding . They also looked at the use of a coil if her ultrasound scan results were normal and this is in line with the NICE guidance.

43. As Mrs N was not over age 55, NICE guidelines did not say there should be a two-week referral and only say it should be considered. We can see from the records that the ANP did consider this but noted there were no serious symptoms.

44. Our adviser looked at the evidence and did not see any serious symptoms like endometrial risk factors (a suspicious looking cervix, or a suspicious vulval lesion/vaginal mass). They said the ANP was correct in their decision not to refer Mrs N straight away and they acted in line with the NHS pathway by doing a scan when the prescribed medications did not stop the bleeding.

45. On 20 October, the Practice got Mrs N’s scan results from the hospital which showed endometrium and a possible cyst. We can see the ANP acted quicky by getting advice from a GP and asking for advice from the hospital.

46. The hospital advised the Practice to do a two-week referral and the records show the ANP did this the same day. Their actions were in line with NMC Code. Our adviser said this was the right thing to do.

47. We have looked at the records and cannot see anything to suggest that the ANP told Mrs N they had referred her for a biopsy. recognise Mrs N’s account is different.

48. Based on what we have seen, we think it Is unlikely that the ANP told Mrs N she had been referred for a biopsy. The records show the ANP was asking for advice and guidance and the ANP planned to update Mrs N once they had got advice.

49. In summary, our decision is the ANP acted in line with the guidance in the way they treated Mrs N’s post-menopausal bleeding. There was no need for a referral initially and they acted correctly when one was advised.

50. We understand Mrs N’s circumstances were frightening for her and her family. We hope Mrs N’s health continues to improve.

1. The Parliamentary and Health Service Ombudsman has investigated Mrs N’s complaint about a practice in the Durham area (the Practice). We think the Practice’s advanced nurse practitioner (ANP) acted correctly in the way they treated Mrs N’s symptoms. We do not think they missed an opportunity to refer Mrs N urgently for treatment of her bleeding. We do not uphold Mrs N’s complaint.

2. We understand how distressing Mrs N’s symptoms and pain were for her. Below, we have explained how we reached our decision.