Girl, 5, left bleeding and screaming in pain after being wrongly prescribed treatment
A five-year-old girl began bleeding and screaming in pain after she was mistakenly prescribed a vaginal pessary, a new report has revealed.
The Parliamentary and Health Service Ombudsman (PHSO) said there had been “multiple failures” in the girl’s care, meaning her mother was later questioned about possible sexual abuse.
The child was taken to a GP surgery in the East Midlands in March 2023 for itching and vaginal discharge, and a physician friend (PA) suspected thrush and recommended Clotrimazole vaginal pessary and cream.
Believing that her child was being treated by a general practitioner, his mother questioned the treatment and the size of the pessary but was assured that it was appropriate.
But the health ombudsman said the girl began bleeding and screaming in pain after the mother gave her the pessary, and the cream burned the girl’s skin.
The child then asked a doctor not to examine him internally at an out-of-hours appointment, leading the GP to raise concerns about possible sexual abuse and contact protection services. A consultant later found that her symptoms were caused by an incorrectly prescribed pessary and cream.
The Ombudsman found fault with the staff involved but said the out-of-hours doctor had acted appropriately.
It was also stated that the prescription was inappropriate because the child’s symptoms were consistent with vulvovaginitis, not thrush, and the pessary tablet was not suitable for a five-year-old child.
Some children develop vulvovaginitis, an inflammation of the genital organs, many times before puberty, but this can usually be treated and resolved at home.
The investigation also found that PAs had no right to prescribe and that their work had to be supervised by a doctor who signed the prescription, but no such discussion took place.
The Ombudsman said pharmacists should also contact the prescriber when there are questions about a prescription, but there was no evidence the pharmacy did this.
The girl’s mother, 38, said: “I felt immense guilt for doing what the PA, who I thought was a GP, told me and for putting my daughter through this trauma.
“But I trusted what the doctor said. How do we trust healthcare workers now?”
“The prescription went through three specialists and no one took it or questioned why it was given to a child.
“My daughter is neurologically different, so it has been even more difficult for her to recover from the damage this has caused.
“This affected him deeply and added to the challenges he faces every day, and I don’t think he will ever be able to give it up.”
Rebecca Hilsenrath, chief executive of the health ombudsman, said: “This is an extremely disturbing case in which a child has suffered physically and psychologically and been traumatized by her experience.
“What makes this even more worrying is that this situation could have easily been prevented with better communication between the professionals involved in this young girl’s care.
“The breakdown in communication meant that checks and balances designed to ensure patients were treated appropriately and kept safe were not followed.”
The GP practice involved in this case took action to flag intravaginal pessary prescriptions for children, including an electronic prescribing alert as well as extra training for relevant staff. The pharmacy also took action.
A report prepared for the government last year said PAs should be banned from seeing patients who have not been examined by a doctor to avoid the “catastrophic” risk of misdiagnosis.
The study suggested a major shift in the role of PAs following the recognition that they were being used as replacements for doctors, despite having significantly less training.
Professor Gillian Leng, president of the Royal Society of Medicine, said at the time that much more detail was needed about which patients could be seen by PAs and that national clinical protocols should be developed in this area.
The Royal College of General Practitioners said PAs should not see children under 16.
