Ombudsman Finds Supervision and Pharmacy Failings After East Midlands Child Given Vaginal Pessary for Misdiagnosed Vulvovaginitis

A five-year-old girl in the East Midlands received a Clotrimazole vaginal pessary and cream in March 2023 after a physician associate at a local GP practice diagnosed suspected thrush. The child had presented with itching and vaginal discharge. The physician associate recommended the pessary and cream, but the girl’s symptoms were later identified as vulvovaginitis, a condition that can usually be treated at home.

After the mother administered the pessary, the girl began to bleed and scream in pain. The cream also burnt the girl’s skin. At an out-of-hours appointment the child asked the doctor not to examine her internally.

The out-of-hours GP raised concerns about possible sexual abuse and contacted safeguarding services. A consultant later determined that the symptoms resulted from the wrongly prescribed medication. The Parliamentary and Health Service Ombudsman found that a pessary tablet is not suitable for a five-year-old and that no discussion between the physician associate and a supervising doctor occurred before the prescription was issued.

The ombudsman also found no evidence that the pharmacy contacted the prescriber despite queries that should have prompted such contact. The out-of-hours doctor acted appropriately, the report stated. The girl’s mother, 38, said she believed her child was being treated by a GP.

The mother noted that her neurodivergent daughter has found it especially difficult to recover. ” The GP practice has since introduced an electronic prescribing alert to flag intravaginal pessary prescriptions for children and has provided extra training for the staff involved. The pharmacy has also taken action.