Child's Pain After Wrongly Prescribed Pessary

A five-year-old girl experienced significant physical and psychological trauma due to a severe medical misprescription. The child was wrongly given a vaginal pessary and cream by a physician associate at a GP practice in the East Midlands in March 2023, despite her symptoms being consistent with vulvovaginitis, not thrush. The medication caused bleeding and severe pain, leading to a distressing internal examination and a safeguarding referral for suspected sexual abuse.

The Parliamentary and Health Service Ombudsman’s investigation uncovered multiple failures in the care pathway. Crucially, physician associates lack independent prescribing rights and require doctor supervision, a step that was reportedly missed. Furthermore, the pharmacy did not contact the prescriber with queries. The ombudsman emphasized that better communication between professionals could have easily prevented the incident.

In response, the GP practice has implemented an electronic alert for intravaginal pessary prescriptions for children and provided additional staff training. The pharmacy has also taken corrective measures. This case highlights broader concerns about the role of physician associates, with a previous report suggesting they should not see patients unsupervised to prevent misdiagnoses.