A five-year-old girl was left traumatised and in severe pain after a physician associate (PA) wrongly prescribed her a vaginal pessary, according to a report by the health ombudsman. The parliamentary and health service ombudsman found “multiple failures” in the care of the child, who attended a GP practice in the East Midlands with itching and vaginal discharge.
The PA suspected thrush and recommended a vaginal pessary and cream, despite the fact that such pessaries are not suitable for prepubescent children and the girl’s symptoms were consistent with vulvovaginitis. The mother, who believed she was consulting a GP, questioned the treatment and the size of the pessary but was reassured it was appropriate. PAs do not have prescribing rights and require doctor approval, but the ombudsman found no discussion occurred between the PA and the GP before the prescription was authorised.
After inserting the pessary, the girl began to bleed and scream in pain, and the cream burned her skin. The mother took her to an out-of-hours doctor, but the child was so distressed she asked not to be examined internally, prompting the GP to raise concerns about possible sexual abuse and contact safeguarding services. Although it was later established the symptoms were caused by the medication, not abuse, the mother described the experience as “distressing” and “embarrassing,” adding: “I had huge guilt… How are we meant to trust healthcare professionals now?”
The ombudsman recommended the GP practice pay the mother £1,000 and the pharmacy pay £500, and that both organisations take action to prevent recurrence. Rebecca Hilsenrath, chief executive of the ombudsman, said the case was “deeply troubling” and “could easily have been avoided,” highlighting a “breakdown in communication” that meant checks and balances were not followed.
The British Medical Association said the case underlined the serious consequences of inadequate supervision. Dr Emma Runswick, deputy chair of BMA council, said: “This is a deeply distressing case in which a young child suffered significant and entirely avoidable harm,” adding that patients have a right to know who is treating them. The incident occurred in 2023, before a government-commissioned review recommended PAs be banned from diagnosing patients not seen by a doctor, and that they be renamed “physician assistants” to avoid confusion.
A Department of Health and Social Care spokesperson said: “Patient safety is our number one priority – this case is unacceptable… We are now working at pace to implement each of the Leng Review’s recommendations.”
