Effective communication is a critical tool in preventing harm. This has been highlighted in a case where a child was left bleeding and in severe pain after being wrongly prescribed a vaginal pessary following an appointment with a physician associate (PA).
The case exposed multiple failures in the five-year-old’s care and led to her mother being questioned about possible sexual abuse. The practice has committed to learn from this complaint and strengthen its systems to prevent the same mistake happening again.
The value of effective communication for public services and its importance in maintaining citizens’ trust and confidence forms a central part of the long-term strategy of the Parliamentary and Health Service Ombudsman (PHSO) published in April.
There was no discussion between the PA and GP before the GP authorised the prescription based on the PA’s recommendation. There was also no questioning of the prescription by the pharmacy that dispensed it.
The girl was taken to a GP practice in East Midlands in March 2023 with itching and vaginal discharge. A 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.
In 2024, the Government commissioned the Leng Review to address concerns about the safety and rapid deployment of PAs and Anaesthesia Associates (AAs) within the NHS. Following the publication of that review last year, the Government accepted its recommendations, including about improving the identification and supervision of PAs. They are in the process of implementing them.
After the mother administered the pessary, a treatment which should not be 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 burnt 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 about this.
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.
An investigation by PHSO found failings by all involved. The practice inappropriately prescribed the treatment as a pessary should only be given to someone who is sexually active and the pharmacy did not do the necessary clinical checks before dispensing it.
Rebecca Hilsenrath, Chief Executive Officer of PHSO, said,
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.
“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.
“I welcome the Government’s commitment through the Leng Review to providing clarity and structure around these roles for the benefit of patients, PAs and doctors.”
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 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 our recommendations.
The practice has taken action to strengthen and improve its processes. It introduced an electronic prescribing alert to flag intravaginal pessary prescriptions for children, requiring additional review before authorisation. It also carried out a review of the scope of practice for the PA, particularly in relation to the assessment and treatment of children, taking into account current professional guidance.
The PA and GP involved underwent 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 girl’s mother, 38, said,
I had huge guilt for doing what the PA, who I thought was a GP, told me and feeling as if I had inflicted this trauma on my daughter.
“But I trusted what the doctor told me. How are we meant to trust healthcare professionals now? The prescription went through three professionals and no one picked it up or questioned why this was being given to a child.
“My daughter is neurodivergent, so it has been even harder for her to move on from the harm this caused. This deeply affected her and added to the struggles she already faces every day, I don’t think she will ever move on from it.
“I have three neurodivergent children and have been battling for them to receive the right education services they need, and then I had to deal with this. It was a breaking point for me and caused so much stress for the whole family.”