• A five-year-old girl was left bleeding, in severe pain, and traumatized after being wrongly prescribed a vaginal pessary by a physician associate.
• The Parliamentary and Health Service Ombudsman (PHSO) found failures involving the physician associate, supervising GP, and pharmacy, with safety checks missed during prescribing and dispensing.
• Investigators found the child had vulvovaginitis rather than thrush, and that a vaginal pessary was not appropriate for a prepubescent child.
A five-year-old girl in England was left bleeding, in severe pain, and traumatised after a physician associate wrongly prescribed a vaginal pessary for symptoms later found to be caused by vulvovaginitis rather than thrush, according to a Parliamentary and Health Service Ombudsman (PHSO) report.
The child was seen at a GP practice in the East Midlands in 2023 after developing itching and vaginal discharge. The ombudsman found failures involving the physician associate, supervising GP, and pharmacy, concluding that safeguards designed to prevent inappropriate treatment were not followed.
A physician associate (PA) assessed the five-year-old after she developed itching and vaginal discharge and suspected thrush. The PA recommended a clotrimazole vaginal pessary and cream. The child's mother, who believed her daughter was being seen by a GP, questioned whether the treatment and the size of the pessary were appropriate for a young child but was reassured that it was suitable.
The mother later told investigators that she felt "huge guilt" for following the advice because she believed the physician associate was a doctor. She said the prescription had passed through multiple healthcare professionals without anyone questioning whether the treatment was appropriate for a child. According to the ombudsman, the mother felt the incident had damaged her trust in healthcare professionals.
After her mother inserted the pessary, the child began bleeding and screaming in pain, while the cream caused a burning sensation. During a later out-of-hours appointment, the girl was so distressed that she refused an internal examination, leading a doctor to raise concerns about possible sexual abuse.
A consultant later concluded that her symptoms were caused by the prescribed treatment rather than abuse.
The Parliamentary and Health Service Ombudsman noted that the subsequent safeguarding concerns and discussions about possible sexual abuse caused additional distress and embarrassment for the family, even though clinicians later confirmed the symptoms were related to the pessary and cream rather than abuse.
The ombudsman found that the physician associate and supervising GP did not discuss the prescription before it was approved, despite physician associates lacking independent prescribing authority. Investigators also found that the pharmacy dispensed the medication without questioning its suitability for a five-year-old child.
The ombudsman described the case as involving "multiple failures" across prescribing, supervision, communication, and dispensing processes. Investigators found that physician associates do not have independent prescribing rights and that prescriptions should be reviewed and authorized by a supervising doctor following an appropriate discussion. No evidence of such a discussion was found in this case.
The ombudsman found that the child's symptoms were more consistent with vulvovaginitis than vaginal thrush. Vulvovaginitis is a common condition in prepubescent girls that can cause itching, irritation, and vaginal discharge.
The condition is usually managed by addressing possible irritants and improving hygiene measures.
Unlike vaginal thrush, it does not typically require treatment with an intravaginal pessary.
The ombudsman said vaginal pessaries are not suitable for prepubescent children and should not have been prescribed to a five-year-old girl.
PHSO Chief Executive Rebecca Hilsenrath described the incident as a "deeply troubling case" and said that "the checks and balances designed to make sure patients are treated appropriately and kept safe were not followed."
The case has renewed debate about the role of physician associates in primary care.
The case emerged amid ongoing scrutiny of physician associate roles within the National Health Service. The government commissioned the Leng Review in response to concerns about the rapid expansion of physician associate and anaesthesia associate roles.
A government-commissioned review led by Professor Gillian Leng recommended clearer limits on which patients physician associates should assess, stronger supervision arrangements, clearer identification of practitioners, and greater clarity regarding scope of practice. The government has accepted the review's recommendations and is implementing them.
The Royal College of GPs has stated that physician associates should not see patients under 16 years of age.
The ombudsman recommended that the GP practice pay the child's mother £1,000 and that the pharmacy pay £500. Both organizations were required to take steps to prevent similar incidents. The GP practice has since introduced electronic prescribing alerts for vaginal pessaries prescribed to children and provided additional staff training.
The ombudsman also reported that the practice reviewed the physician associate's scope of practice in relation to assessing and treating children, strengthened documentation requirements for supervisory discussions before prescriptions are signed, and provided additional prescribing and supervision training to the physician associate and GP involved.
The incident has drawn attention to the safeguards used when physician associates are involved in patient care, particularly in children. The ombudsman said the failures in this case were avoidable and stressed the importance of effective communication and supervision to ensure patients receive appropriate treatment.
PHSO Chief Executive Rebecca Hilsenrath said poor communication remains a recurring issue in ombudsman investigations and emphasized that healthcare organizations must ensure clear communication between professionals and with patients and families to maintain safety and public trust.
References:
1. Parliamentary and Health Service Ombudsman. “Communication Failures Led to Wrong Treatment That Left Five-Year-Old Girl Traumatised.” June 5, 2026. https://www.ombudsman.org.uk/news-and-blog/news/communication-failures-led-wrong-treatment-left-five-year-old-girl-traumatised.
(Rh/TP/MSM)
