A five-year-old girl was left traumatised, bleeding and in severe pain after a physician associate (PA) wrongly prescribed a vaginal pessary, a report by the health ombudsman has found. The parliamentary and health service ombudsman said there were “multiple failures” in the care of the child, who saw a PA at a GP practice in the East Midlands after complaining of itching and vaginal discharge.
The PA suspected thrush and recommended a vaginal pessary and cream. The girl’s mother, who believed her daughter was being seen by a GP, questioned the treatment and the size of the pessary but was reassured it was appropriate. PAs do not have prescribing rights and their work must be supervised by a doctor who approves the prescription. However, the ombudsman found there was no discussion between the PA and GP before the GP authorised the prescription, even though vaginal pessaries are not suitable for prepubescent children and the girl’s symptoms were consistent with vulvovaginitis, not thrush. The pharmacy that dispensed the prescription also failed to question it.
The mother said that after inserting the pessary, her daughter began to bleed and scream in pain, while the cream burned her skin. She took her to an out-of-hours doctor, but the girl was so distressed that she asked the doctor not to examine her internally, leading the GP to raise concerns about possible sexual abuse and contact safeguarding services. Although it was established the symptoms were caused by the pessary and cream, the mother said the experience was distressing and embarrassing, adding to her daughter’s trauma.
Rebecca Hilsenrath, chief executive of the ombudsman, said the case was “deeply troubling” and could have been avoided. The ombudsman recommended the GP pay the mother £1,000 and the pharmacy pay £500, and that both organisations take action to prevent a recurrence. The British Medical Association said the case highlighted 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.”
A Department of Health and Social Care spokesperson said: “Patient safety is our number one priority – this case is unacceptable and our sympathies go out to the patient and her family.” They added that the government is working to implement recommendations from the Leng Review, which called for clearer definitions of which patients PAs can see and for newly qualified PAs to work in hospitals before GP surgeries.
