A five-year-old girl suffered severe pain and bleeding after a wrong vaginal pessary prescription, leaving her screaming and her skin burned, according to a report by the Parliamentary and Health Service Ombudsman (PHSO). The case, which also led to her mother being questioned about possible sexual abuse, has exposed what the ombudsman described as “multiple failures” in the child’s care.
The child 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. The mother, believing her daughter was being treated by a GP, questioned the treatment and the size of the pessary but was reassured it was appropriate.
After the mother administered the pessary, the girl began to bleed and scream in pain, and the cream burnt her skin. The child later attended an out-of-hours appointment where she asked the doctor not to examine her internally. That GP raised concerns about possible sexual abuse and contacted safeguarding services. A consultant subsequently identified that the symptoms were caused by the wrongly prescribed pessary and cream. The PHSO noted that the out-of-hours doctor acted appropriately in raising the safeguarding concern, but the chain of errors earlier had caused the harm.
The ombudsman’s investigation found that the prescription was not appropriate on several grounds. The child’s symptoms were consistent with vulvovaginitis—a common inflammation of the genitalia in prepubertal girls—not thrush. Vulvovaginitis can often be treated at home with hygiene measures and avoidance of irritants; vaginal pessaries are not suitable for a five-year-old. Clotrimazole cream is used for fungal infections but can cause local irritation, burning or stinging, especially in children.
Systemic failures in prescribing and supervision
Physician associates in the UK do not have independent prescribing rights. Their work must be supervised by a doctor who signs off on prescriptions. The PHSO found that no discussion took place between the PA and the GP before the prescription was authorised. This meant the required checks and balances were bypassed.
Pharmacists are also expected to contact the prescriber if they have queries about a prescription. In this case, there is no evidence the pharmacy questioned or queried the prescription for a five-year-old girl, despite the unusual nature of the treatment. The ombudsman highlighted that the prescription went through three professionals—the PA, the GP who authorised it, and the pharmacist—and none picked up the error.
The GP practice involved has since taken action, including introducing an electronic prescribing alert to flag intravaginal pessary prescriptions for children, and providing extra training for the staff involved. The pharmacy has also taken action, though the PHSO did not release specific details. In addition, the ombudsman recommended that the practice pay the girl’s mother £1,000, and the pharmacy pay £500, both of which have been complied with.
The case has intensified scrutiny of the role of physician associates in primary care. A report for the government last year, led by Professor Gillian Leng, president of the Royal Society of Medicine, recommended that PAs should be banned from seeing patients who have not been reviewed by a medic, to prevent the risk of “catastrophic” misdiagnoses. The Leng review, published in July 2025, also called for renaming PAs to “physician assistants” to reduce confusion with doctors, and for national clinical protocols to be developed. The Royal College of GPs has stated that PAs should not see any children under 16.
PAs and anaesthesia associates came under the regulation of the General Medical Council in December 2024, but the GMC has confirmed that PAs will not gain independent prescribing rights in the future. The lack of robust supervision in this case underscores the concerns raised by the Leng review about PAs being used as substitutes for doctors despite having significantly less training.
Mother’s trauma and ombudsman’s response
The girl’s mother, 38, said she experienced “huge guilt” for following what she believed was a doctor’s advice and felt she had inflicted trauma on her daughter. “But I trusted what the doctor told me. How are we meant to trust healthcare professionals now?” she said. “The prescription went through three professionals and no one picked it up or questioned why this was being given to a child.” She added that her daughter is neurodivergent, making it even harder for her to move on from the harm. “I don’t think she will ever move on from it,” the mother said.
Rebecca Hilsenrath, chief executive officer of the health ombudsman, said the case was “deeply troubling” and that the child suffered physically and psychologically. “What makes this all the more concerning is that it could so easily have been avoided by better communication between the professionals involved,” she said. “The breakdown in communication meant that the checks and balances designed to make sure patients are treated appropriately and kept safe were not followed.”