Ombudsman case highlights inappropriate prescribing

A child who was left bleeding and in pain was wrongly prescribed a vaginal pessary following an appointment with a physician associate (PA), an inquiry by the Parliamentary and Health Service Ombudsman (PHSO) has concluded.

The case exposed multiple failures in the 5-year-old’s care and led to her mother being questioned about possible sexual abuse. The practice has committed to learn from this complaint and strengthen its systems to prevent the same mistake happening again.

The value of effective communication for public services and its importance in maintaining citizens’ trust and confidence forms a central part of the NHS long-term strategy, the Ombudsman said.

There was no discussion between the PA and GP before the GP authorised the prescription based on the PA’s recommendation. Nor did the pharmacy that dispensed the prescription question it.

The girl was taken to a GP practice in East Midlands in March 2023 with itching and vaginal discharge. A PA suspected thrush and recommended a clotrimazole vaginal pessary and cream. Her 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.

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.

At a later appointment with an out-of-hours doctor, the girl, still in pain and distressed, asked the doctor not to examine her internally. Combined with her symptoms, this led the GP to raise concerns about possible sexual abuse, which they discussed with safeguarding services.

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.

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

Rebecca Hilsenrath, Chief Executive Officer of PHSO, 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.’

PAs do not have prescribing rights and their work must be supervised by a doctor who signs the prescription following a discussion. No discussion took place between the GP and PA. Pharmacists should contact the prescriber when there are queries relating to a prescription. There is no evidence that the pharmacy did this.

The PHSO reports that the practice has taken action to strengthen and improve its processes. It introduced 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. Processes at the practice have also been strengthened to ensure that supervisory discussions are clearly documented before prescriptions are signed.