A damning report from the parliamentary and health service ombudsman has revealed a shocking case in which a five-year-old girl suffered significant trauma after being wrongly prescribed a vaginal pessary by a physician associate. The incident, which left the child bleeding and in intense pain, has raised urgent questions about the safety and supervision of healthcare professionals operating within the NHS.
A Distressing Misdiagnosis
The incident occurred at a GP practice in the East Midlands when the girl visited a physician associate (PA) due to complaints of itching and vaginal discharge. The PA, suspecting a case of thrush, recommended a vaginal pessary and cream. Unbeknownst to the mother, who believed her daughter was being examined by a qualified GP, the PA does not have independent prescribing rights and should have consulted a physician before proceeding.
Despite the mother expressing concerns over the appropriateness of the treatment and the size of the pessary, she was reassured that the prescribed course was suitable. The ombudsman’s findings indicate that no discussion took place between the PA and the supervising GP prior to the prescription being authorised. Alarmingly, the symptoms presented were more indicative of vulvovaginitis, rather than thrush, and vaginal pessaries are not recommended for prepubescent children.
Harrowing Aftermath
Following the insertion of the pessary, the young girl experienced severe pain and began to bleed, prompting her distraught mother to seek help from an out-of-hours doctor. The child’s distress was so pronounced that she begged the doctor not to perform an internal examination, which raised unfounded concerns regarding potential sexual abuse and led to the involvement of safeguarding services.
Fortunately, it was later established that the injuries were a direct result of the inappropriate treatment rather than any form of abuse. However, the traumatic experience left a lasting emotional impact on both the girl and her mother. “I felt immense guilt for trusting what the PA, whom I thought was a GP, told me,” the mother recounted. “How can we be expected to trust healthcare professionals now?”
Accountability and Recommendations
Rebecca Hilsenrath, the chief executive of the parliamentary and health service ombudsman, expressed deep concern over the case, noting that the “breakdown in communication” allowed critical safeguards intended to protect patient welfare to be overlooked. The ombudsman has recommended that the GP practice compensate the family with £1,000 and that the pharmacy involved pay £500. Both organisations have been urged to implement measures to prevent any recurrence of such incidents.
This distressing event occurred in 2023, prior to a government-commissioned review that suggested limiting the diagnostic capabilities of physician associates. The British Medical Association (BMA) has asserted that this case underscores the risks associated with inadequate supervision and clinical oversight, highlighting the need for better clarity around the roles of healthcare professionals.
Dr Emma Runswick, deputy chair of the BMA council, stated, “This situation is deeply troubling, especially given that the mother believed her child had been seen by a GP. Patients deserve to know who is treating them and whether or not they are qualified doctors.”
The Call for Reform
In response to the findings, Prof Gillian Leng, president of the Royal Society of Medicine and leader of the 2025 review, suggested that physician associates should be more accurately referred to as physician assistants to clarify their role. She also advocated for stricter guidelines regarding which patients could be treated by PAs and recommended that newly qualified associates spend two years in hospital settings before working in GP practices.
Despite these proposals, the BMA maintains that the current role of PAs in general practice poses significant risks. Dr Runswick highlighted the necessity for “clear limits on scope of practice, greater transparency for patients, and robust supervision arrangements to ensure no family suffers harm like this again.”
In response to the outcry, a spokesperson for the Department of Health and Social Care acknowledged the unacceptable nature of the incident, stating, “Patient safety is our number one priority. We extend our sympathies to the patient and her family and are committed to implementing the Leng Review’s recommendations swiftly.”
Why it Matters
This case underscores a critical need for systemic reform within the NHS to ensure that all patients receive safe and appropriate care. As the healthcare landscape continues to evolve, it is imperative that robust safeguards are established to prevent similar incidents from occurring in the future. Trust in healthcare professionals is paramount, and transparency about qualifications and roles is essential for safeguarding patients, particularly the most vulnerable among us. The fallout from this tragic oversight is a stark reminder of the importance of stringent oversight and communication in medical practice.
