The Trust’s diagnosis
14. Mrs S thinks that the Trust misdiagnosed her and the consultant missed her vaginal prolapse. In its complaint response, the Trust said its diagnosis of grade one uterine prolapse was accurate at the time and it did not misdiagnose her.
15. The General Medical Council’s ‘Good medical practice’ says doctors should adequately assess a patient’s conditions, taking into account of their history and symptoms. It says professionals must propose, provide, or prescribe effective treatment based on the best available evidence.
16. We have looked at Mrs S medical records. The GP’s referral to the Trust says Mrs S had suffered a vaginal prolapse. It said she had tried pelvic floor exercises, which only had a partial effect.
17. The February 2023 Trust clinic letter said general examination of Mrs S was unremarkable. Her abdomen was soft and lax and the consultant could not feel any masses. He said on vaginal examination, there was a grade one slightly dropped uterus, her cervix looked healthy and there was no vaginal prolapse. He noted that Mrs S had a loss of sensation during sexual activity.
18. So there was a difference of opinion between the GP and the consultant. Our adviser explained that it is not uncommon for clinicians to have different opinions about a mild prolapse. We understand Mrs S thinks Mr G misdiagnosed her because Hospital B diagnosed a first degree cysto-rectocele and a deficient perineum after her assessment there. Our adviser explained there is a significant descriptive overlap between this and the Trust’s diagnosis. The NICE guidance also sets out the same initial treatment for a dropped uterus and vaginal prolapse. We look at the Trust’s treatment plan in the next section.
19. On the basis of the evidence we have seen, Mr G made the diagnosis in February 2023 in line with Good medical practice, and we cannot say the Trust misdiagnosed Mrs S. We have not found a failing in this part of the complaint.
20. We understand Mrs S was distressed when the Trust gave her the diagnosis that was different from the GP. We acknowledge she was going through an incredibly difficult time and when Hospital B gave her another diagnosis, this strengthened her view that the Trust misdiagnosed her in February 2023. We hope our explanation is clear about why we cannot say the Trust made a mistake here.
The Trust’s treatment plan
21. In Mrs S’s February 2023 appointment, Mr G asked her GP to refer her to for pelvic physiotherapy to help with her pelvic floor. Mrs S says she had already been practising pelvic floor exercises which had not helped her symptoms.
22. In its response the Trust said as Mrs S is young and was having laxity of the pelvic floor, the consultant suggested pelvic physiotherapy to help strengthen the pelvic floor. It said 60-70% of young patients have a good outcome from physiotherapy.
23. The NICE guidance says that for a dropped uterus (and vaginal prolapse) a clinician should consider a programme of supervised pelvic floor training for at least 16 weeks as a first option.
24. Mrs S’s GP had explained she had been practising pelvic floor exercises. Our adviser said it has been proven more effective if a qualified physiotherapist teaches and oversees this. So we think the Trust’s initial treatment plan of guided physiotherapy was appropriate and in line with the NICE guidance. We acknowledge the Hospital B consultant decided in December 2023 to list Mrs S for surgery even thought she had not yet had supervised physiotherapy. That different clinical decision does not mean the Trust’s decision to recommend physiotherapy was wrong.
25. Mrs S’s GP referral explained she could not enjoy intercourse. Mrs S said she could feel a bulge in her vagina and could not use tampons.
26. In the clinic letter, the consultant said if Mrs S did not enjoy intercourse because of laxity, an option would be vaginoplasty. But he said the Trust could not do this on the NHS because it is cosmetic surgery.
27. Our adviser said there is no evidence in the records to suggest Mrs S was concerned about the appearance of her vagina. She described definite physical symptoms of a vaginal bulge and loss of sensation during sexual activity. They explained surgery would not have been classed as cosmetic because it would have been to correct physical symptoms, not concerns about appearance. If Mrs S’s symptoms had continued after physiotherapy, in line with the NICE guidance, the Trust should have assessed her again and considered her for NHS-funded surgery.
28. In summary, based on the evidence we have seen, we cannot say the Trust was wrong to diagnose a dropped uterus, and the first line treatment of physiotherapy it advised was appropriate. But we think it was wrong for the Trust to say Mrs S would not be eligible for NHS-funded surgery. It should have explained this may be an option after physiotherapy had ended and a further assessment.
29. We next look at the impact of this failing.
30. Mrs S was still on the waiting list for physiotherapy when her GP referred her to Hospital B and it gave her a different clinical opinion. This was ten months after her initial appointment, and she had the surgery two months after this. She says she was in pain for a year and the months following the February 2023 appointment at the Trust were filled with frustration as she struggled with her symptoms. Mrs S told us by the time she had her appointment at Hospital B, she was desperate.
31. When we weigh up the evidence we have seen, we know there is a good chance guided pelvic physiotherapy would have made a difference for Mrs S. We can never know what difference it would have actually made, because she did not have it. But we cannot say this was because of a failing by the Trust. Regrettably, there was a long wait locally for this treatment.
32. We think if Mrs S had known the Trust would review her again if the physiotherapy did not resolve her symptoms, and that surgery may have been an option, she may have felt more reassured. But it would not have prevented her waiting for physiotherapy. And the Trust could not have done anything to expedite the physiotherapy.
33. From the evidence we have seen, we cannot say the pain Mrs S suffered for a year or the mental impact of the pain was because of what the Trust got wrong. This was because of the wait for physiotherapy.
34. We can understand Mrs S’s distress when she found out at Hospital B that she could have surgery on the NHS. It is clear she had spent over a year in pain and was incredibly worried about her future treatment. We are sorry she has had this experience. We acknowledge that although we cannot say the Trust made a mistake which led to her pain, Mrs S did suffer and is still incredibly frustrated about her experience.
35. We are pleased to hear Mrs S received treatment from Hospital B, and we hope this has helped with her symptoms.