A five-year-old girl suffered trauma, bleeding and intense pain after a physician associate at a GP practice in the East Midlands incorrectly recommended a vaginal pessary, a parliamentary and health service ombudsman report has found. The ombudsman identified multiple failures in her care. The child had attended with itching and discharge. The associate suspected thrush and advised the pessary and cream. Her mother, assuming the associate was a doctor, raised concerns about suitability and size but was assured the treatment was correct. Physician associates lack prescribing authority and require doctor supervision. No discussion occurred between the associate and a GP before authorisation, despite pessaries being unsuitable for prepubescent children and symptoms matching vulvovaginitis rather than thrush. The dispensing pharmacy also did not question the prescription. After use the girl bled and screamed in pain, and the cream irritated her skin. An out-of-hours doctor was consulted, but the child’s distress led to concerns about possible abuse and a safeguarding referral. It was later confirmed the symptoms resulted from the medication. The mother described guilt, embarrassment and added trauma. Ombudsman chief executive Rebecca Hilsenrath called the case deeply troubling and avoidable due to communication breakdowns. The GP practice was directed to pay £1,000 and the pharmacy £500, with both required to improve procedures. The British Medical Association said the incident showed risks of inadequate oversight. A health department spokesperson stated patient safety remains the priority and steps are being taken on review recommendations.
