GP practice and pharmacy pay out £1,500 after five-year-old left 'traumatised’

A GP practice and pharmacy have paid a mother £1,500 after her five-year-old daughter was left ‘traumatised’ by being given an inappropriate prescription.

The Parliamentary and Health Service Ombudsman (PHSO) said the girl was left bleeding and in severe pain after being wrongly prescribed a vaginal pessary following an appointment with a physician associate (PA).

The PHSO's investigation, published last week, ‘found failings by all involved’ including the GP practice and the pharmacy which did not question the prescription before dispensing it.

The PHSO recommended the practice and pharmacy pay the girl’s mother £1,000 and £500 respectively and that they both ‘make service changes to ensure this does not happen again’.

Both ‘have complied’ with the recommendations, it added.

The PHSO said: ‘An investigation by PHSO found failings by all involved. The practice inappropriately prescribed the treatment as a pessary [which] should only be given to someone who is sexually active and the pharmacy did not do the necessary clinical checks before dispensing it.’

The PHSO said that the girl had been taken to an East Midlands GP practice in March 2023 with itching and vaginal discharge, where a PA recommended a clotrimazole vaginal pessary and cream – a treatment which should not be given to a pre-pubescent child.

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The girl's mother, who believed her child was being treated by a GP, questioned the treatment and the size of the pessary, but was reassured that it was appropriate, the PHSO said.

It added that there had been no discussion between the PA and GP before the GP authorised the prescription based on the PA’s recommendation as well as also no questioning of the prescription by the pharmacy that dispensed it.

The PHSO said: ‘After the mother administered the pessary, a treatment which should not be given to a pre-pubescent child, the child began to bleed and scream in pain.

'Her mother described the experience as deeply distressing and psychologically traumatising for them both. The mother says the cream also burnt her daughter’s skin.’

The ombudsman's investigation also found that at a later appointment with an out-of-hours doctor, the girl asked not to be examined internally due to the pain and distress caused by the administering of the pessary.

The ombudsman said: ‘Combined with her symptoms, this led the GP to raise concerns about possible sexual abuse and to have discussions with safeguarding services about this.

‘As part of those discussions, a consultant explained that the symptoms were caused by the pessary and cream, not sexual abuse. While the out-of-hours doctor acted appropriately, the mother said the experience was distressing, embarrassing, and further added to her trauma.’

The girl’s mother told the ombudsman of the ‘huge guilt’ she felt for following the PA’s advice and of the lack of trust she now had for healthcare professionals.

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 the doctor told me. How are we meant to trust healthcare professionals now? The prescription went through three professionals and no one picked it up or questioned why this was being given to a child.

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‘My daughter is neurodivergent, so it has been even harder for her to move on from the harm this caused. This deeply affected her and added to the struggles she already faces every day, I don’t think she will ever move on from it.’

The PHSO said that the practice had taken action to strengthen and improve its processes, introducing an electronic prescribing alert to flag intravaginal pessary prescriptions for children, requiring additional review before authorisation.

It also carried out a review of the scope of practice for the PA, particularly in relation to the assessment and treatment of children, taking into account current professional guidance.

The PA and GP involved underwent additional training to reinforce appropriate prescribing standards and supervision requirements and processes at the practice have also been strengthened to ensure that supervisory discussions are clearly documented before prescriptions are signed, the ombudsman added.

PHSO chief executive Rebecca Hilsenrath said: ‘This is a deeply troubling case in which a child suffered physically and psychologically and was left traumatised by her experience.

'What makes this all the more concerning is that it could so easily have been avoided by better communication between the professionals involved in caring for this young girl.'

She added: ‘I welcome the Government’s commitment through the Leng Review to providing clarity and structure around these roles for the benefit of patients, PAs and doctors.’

The Leng Review, led by Professor Gillian Leng, was launched by health secretary Wes Streeting in 2024 due to the ‘heightened controversy’ around PAs and anaesthesia associate (AA) roles.

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The review found that the PA role did not need to be scrapped, but suggested it should not remain as it was. Among its recommendations, it called for PAs to be renamed physician assistants.

The Department of Health and Social Care (DHSC) accepted all recommendations in the review and is now consulting on amending the law to change the name to assistant as part of reforming the General Medical Council legislative framework.

A version of this article was first published on The Pharmacist's sister title Pulse.