Mother thought physician associate was GP before child was given vaginal pessary

A five-year-old girl was ‘traumatised’ after being inappropriately prescribed a vaginal pessary by a physician associate (PA) who the girl’s mother thought was a GP. 

The Parliamentary and Health Service Ombudsman’s (PHSO) investigation into the case said it ‘found failings by all involved’ including the GP practice and the pharmacy which did not question the prescription before dispensing it.  

Doctor leaders commented that it was ‘particularly concerning’ that the mother believed her daughter was seen by a GP.

The PHSO said a PA recommended a clotrimazole vaginal pessary and cream after the girl was taken to an East Midlands GP practice in March 2023 with itching and vaginal discharge. 

The PHSO said: ‘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. The mother says the cream also burnt her daughter’s skin.’ 

The investigation also found that at a later appointment with an out-of-hours doctor, the girl asked the doctor not to examine her 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 PHSO concluded: ‘An investigation by PHSO found failings by all involved. The practice inappropriately prescribed the treatment as a pessary 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 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 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.  

‘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.’

Since the incident in 2023, a review into the safety and effectiveness of the PA role has been published which recommended PAs should not see ‘undifferentiated’ patients and should identify themselves with ‘standardised’ clothing. 

However, the BMA has criticised the review for not setting a scope of practice for PAs which it says means patients will still ‘find it hard to know whether they have seen a doctor or not’.

Commenting on the specific case, the BMA said the role of PAs in general practice was ‘fundamentally unsafe’ and called on the Government to move quicker to implement the Leng review’s recommendations.

BMA deputy chair of council Dr Emma Runswick said: ‘This is a deeply distressing case in which a young child suffered significant and entirely avoidable harm. No child should have to endure such pain, and no parent should be left carrying the guilt and trauma that this family has experienced as a result of failures in their care.

‘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.’

She added that the case ‘highlights the serious consequences that can arise when there is a lack of clarity, inadequate supervision and failures in clinical oversight.’

‘The BMA has repeatedly warned that patient safety must come first. For this reason, we believe the role of PAs in general practice is fundamentally unsafe, while the RCGP also opposes the role of PAs working in general practice.

‘Almost a year since its publication, many of the recommendations of Professor Leng’s review remain unfulfilled, despite the Government accepting those recommendations in full. In the meantime, 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.’

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 BMA recently criticised proposed GMC reforms for not going far enough to distinguish PAs from doctors. In a response to a Government consultation, the union said new legislation should create ‘separate regulatory arrangements’.