A child was left bleeding and in severe pain after being wrongly prescribed a vaginal pessary following an appointment with a physician associate.
The girl was taken to a GP practice in the East Midlands in March 2023 with itching and vaginal discharge. A physician associate (PA) suspected thrush and recommended a Clotrimazole vaginal pessary and cream. Her mother, who believed her child was being treated by a GP, questioned the treatment and the size of the pessary, but was reassured that it was appropriate.
After the mother administered the pessary – not generally given to a pre-pubescent child – the child began to bleed and scream in pain. Her mother described the experience as deeply distressing and psychologically traumatising for them both. The mother says the cream also burned her daughter’s skin.
At a later appointment with an out-of-hours doctor, the girl, still in pain and distressed, asked the doctor not to examine her internally. Combined with her symptoms, this led the GP to raise concerns about possible sexual abuse and to have discussions with safeguarding services.
As part of those discussions, a consultant explained that the symptoms were caused by the pessary and cream, not sexual abuse. While the out-of-hours doctor acted appropriately, the mother said the experience was distressing, embarrassing, and further added to her trauma.
“This is a deeply troubling case in which a child suffered physically and psychologically and was left traumatised by her experience. What makes this all the more concerning is that it could so easily have been avoided by better communication between the professionals involved in caring for this young girl,” said Rebecca Hilsenrath, chief executive officer of Parliamentary and Health Service Ombudsman (PHSO).
Communication breakdown
PHSO’s investigation found that the prescription given was not appropriate, as the child’s symptoms were consistent with vulvovaginitis, not thrush, and a pessary tablet should not be given to a five-year-old.
PAs do not have prescribing rights, and their work must be supervised by a doctor who signs the prescription following a discussion. No discussion took place between the GP and PA. Pharmacists should contact the prescriber when there are queries relating to a prescription. There is no evidence that the pharmacy did this.
The Ombudsman recommended that the practice and pharmacy write to the girl’s mother to apologise for their failings and acknowledge the impact on her and her daughter.
PHSO also recommended that both organisations make service changes to ensure this does not happen again, that the practice pay the girl’s mother £1,000 and that the pharmacy pay her £500. Both organisations have complied with these recommendations.
The PA and GP involved have undergone additional training to reinforce appropriate prescribing standards and supervision requirements. Processes at the practice have also been strengthened to ensure that supervisory discussions are clearly documented before prescriptions are signed.
“The breakdown in communication meant that the checks and balances designed to make sure patients are treated appropriately and kept safe were not followed. Poor communication is a recurring theme in our investigations, and the NHS must make sure it operates with candour and clarity both between professionals and in relation to patients and their families,” added Hilsenrath.
