A five-year-old girl was left bleeding and in severe pain after being incorrectly prescribed a vaginal pessary intended for adults, according to findings by the Parliamentary and Health Service Ombudsman (PHSO).

The child was taken to a GP practice in England’s East Midlands in March 2023 with symptoms of itching and vaginal discharge. A physician associate (PA) suspected thrush and recommended a Clotrimazole vaginal pessary along with a cream.

Child suffered pain after treatment

The girl’s mother, believing her daughter was being treated by a doctor, questioned whether the medication was suitable for a child. However, she was reassured that the treatment was appropriate.

After administering the pessary, the child reportedly began bleeding and screaming in pain. The mother also claimed the prescribed cream caused a burning sensation on her daughter’s skin.

At a later appointment, concerns were briefly raised about possible sexual abuse due to the child’s symptoms and distress. However, medical specialists later confirmed that the injuries were caused by the medication and not abuse.

Investigation finds multiple failures

The PHSO investigation concluded that the prescription was inappropriate because the child’s symptoms were consistent with vulvovaginitis rather than thrush. It also found that a vaginal pessary should not have been prescribed to a five-year-old child.

Investigators identified communication failures between healthcare professionals. Physician associates do not have independent prescribing powers and must work under a doctor’s supervision. However, no evidence was found that a discussion took place between the PA and supervising GP before the prescription was issued.

The investigation also found no indication that the pharmacy contacted the prescriber despite concerns about the prescription.

Changes introduced after incident

The Ombudsman directed both the GP practice and pharmacy to apologise to the family. The girl’s mother was awarded compensation totalling £1,500.

Officials said the physician associate and supervising GP have since undergone additional training, while the practice has strengthened procedures to ensure proper supervision and documentation before prescriptions are approved.

The case has renewed concerns about patient safety, communication and oversight within healthcare services.