Ombudsman Finds GP Practice and Pharmacy Failures After Child Given Inappropriate Vaginal Pessary

A five-year-old girl suffered bleeding and severe pain after a physician associate at a GP practice in the East Midlands prescribed her a vaginal pessary in 2023. The parliamentary and health service ombudsman found multiple failures in her care. The girl had complained of itching and vaginal discharge.

The physician associate suspected thrush and recommended a vaginal pessary and cream. Her mother, who believed her daughter was being seen by a GP, questioned the treatment and the size of the pessary but was reassured it was appropriate. Physician associates do not have prescribing rights and their work must be supervised by a doctor who approves the prescription.

The ombudsman found there was no discussion between the physician associate and the GP before the GP authorised the prescription, even though vaginal pessaries are not suitable for prepubescent children and the girl’s symptoms were consistent with vulvovaginitis, not thrush.

The pharmacy that dispensed the pessary also did not question the prescription. After the mother inserted the pessary, the girl began to bleed and scream in pain, and the cream burned her skin.

The mother took her to an out-of-hours doctor. The girl was so distressed she asked the doctor not to examine her internally, prompting the GP to raise concerns about possible sexual abuse and contact safeguarding services. It was later established that the symptoms were caused by the pessary and cream, not sexual abuse.

The mother said she experienced huge guilt for inserting the pessary as instructed. ” She added: “But I trusted what [they] told me. ” The ombudsman recommended the GP pay the mother £1,000 and the pharmacy pay £500.