A five-year-old was left traumatised, bleeding and in severe pain after a physician associate wrongly prescribed her a vaginal pessary, according to a damning report by the health ombudsman.
The parliamentary and health service ombudsman said there were “multiple failures” in the care of the girl, who saw a physician associate (PA) at a GP practice in the East Midlands after complaining of itching and vaginal discharge.
The PA suspected thrush and recommended a vaginal pessary and cream. The five-year-old’s mother, who believed her daughter was being seen by a GP, questioned the treatment and the size of the pessary, but was reassured that it was appropriate.
PAs do not have prescribing rights and their work must be supervised by a doctor who approves the prescription. But the ombudsman found there was no discussion between the PA and 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. There was also no questioning of the prescription by the pharmacy that dispensed it.
The mother said that after inserting the pessary, her daughter began to bleed and scream in pain, while the cream burned the girl’s skin. She took her to see an out-of-hours doctor. However, the girl was so distressed and in pain that she asked the doctor not to examine her internally, causing the GP to raise concerns about possible sexual abuse and to contact safeguarding services.
Although it was established the girl’s symptoms were caused by the pessary and cream, not sexual abuse, the mother said the experience was distressing, embarrassing and further added to her trauma.
She said: “I had huge guilt for doing what the PA, who I thought was a GP, told me and feeling as if I had inflicted this trauma on my daughter.
“But I trusted what [they] told me. How are we meant to trust healthcare professionals now?”
Rebecca Hilsenrath, the chief executive of the parliamentary and health service ombudsman, said the “deeply troubling case” was all the more concerning because it could easily have been avoided.
“The breakdown in communication meant the checks and balances designed to make sure patients are treated appropriately and kept safe were not followed.”
The ombudsman said it recommended the GP pay the mother £1,000 and the pharmacy pay £500 and that both organisations had to take action to ensure this did not happen again.
Although the incident occurred in 2023, before a government-commissioned report on physician associates recommended PAs should be banned from diagnosing patients who had not been seen by a doctor, the British Medical Association said the case highlighted the serious consequences of inadequate supervision and failures in clinical oversight.
Dr Emma Runswick, the deputy chair of BMA council, said: “This is a deeply distressing case in which a young child suffered significant and entirely avoidable harm.
“It is particularly concerning that the child’s mother believed her daughter had been seen by a GP when she had in fact been assessed by a physician associate. Patients and families have a right to know who is treating them and whether they are or are not a doctor.”
Prof Gillian Leng, the president of the Royal Society of Medicine, who led the 2025 review, concluded that PAs should be called physician assistants, not associates to make it clearer they are not doctors. She also recommended clearer definitions of which patients could be seen by PAs and for newly qualified PAs to work for two years in hospitals before being allowed to work in GP surgeries.
But the BMA believes the role of PAs in general practice is fundamentally unsafe. Runswick added: “There must be clear limits on scope of practice, greater transparency for patients and robust supervision arrangements to ensure no other child or family experiences harm like this again.”
A Department of Health and Social Care spokesperson said: “Patient safety is our number one priority – this case is unacceptable and our sympathies go out to the patient and her family.
“We are now working at pace to implement each of the Leng Review’s recommendations, with some changes already delivered, and its findings will also inform our forthcoming 10-year workforce plan.”
