Five-year-old was prescribed an adult vaginal treatment and left screaming in pain: How multiple medical failures turned a mother’s GP visit into a traumatic nightmare

A mother's nightmare unfolded in the East Midlands after a GP practice prescribed an adult vaginal treatment to her young daughter, and nobody caught the error in time. A five-year-old girl was brought to a GP practice in the East Midlands with itching and vaginal discharge. Her mother was worried, as any parent would be. What she didn't know was that the person who assessed her daughter wasn't a GP at all, and that the treatment they were about to recommend would leave her child bleeding, screaming in pain, and traumatised.

The practitioner, a physician associate (PA), suspected thrush and prescribed a Clotrimazole vaginal pessary and cream. The mother questioned whether the treatment was appropriate and specifically raised concerns about the size of the pessary. She was reassured it was fine. She trusted that reassurance. She went home and administered the treatment to her daughter.

The result was immediate and horrifying. The child began to bleed and screamed in pain. Her mother later described the experience as deeply distressing and psychologically traumatising for them both. The cream, she said, also burnt her daughter's skin.
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What went wrong and how many people missed it

A vaginal pessary should never be given to a pre-pubescent child. It's not a close call or a grey area, it's a fundamental contraindication that should have been caught at multiple points.

The Parliamentary and Health Service Ombudsman (PHSO) investigated what happened and found serious failures across the board. The child's symptoms were consistent with vulvovaginitis, a common condition in young girls that has nothing to do with thrush and requires entirely different management. The pessary was not just the wrong dose, it was the wrong treatment entirely.

Physician associates do not have independent prescribing rights. Their work must be supervised by a doctor, who is required to have a discussion with the PA before signing off on any prescription. That discussion never happened. The GP signed the prescription without it.

And then there was the pharmacy. When a prescription raises obvious concerns pharmacists are expected to contact the prescriber before dispensing. There is no evidence that the pharmacy did that either. Three separate points where someone could have intervened. Three separate points where no one did.

"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," the PHSO said. “The breakdown in communication meant that the checks and balances designed to make sure patients are treated appropriately and kept safe were not followed. Poor communication is a recurring theme in our investigations and the NHS must make sure it operates with candour and clarity both between professionals and in relation to patients and their families."

When the mother brought her daughter to an out-of-hours doctor, the little girl was still in distress. She told the doctor not to examine her internally. Combined with her physical symptoms which were bleeding, pain, the out-of-hours GP raised concerns about possible sexual abuse and contacted safeguarding services.

A consultant later clarified that the injuries were caused by the pessary and cream, not abuse. But for the mother, this was yet another layer of trauma on top of an already devastating experience.

“PHSO also recommended both organisations make service changes to ensure this does not happen again, that the practice pay the girl’s mother £1,000 and that the pharmacy pay her £500. Both organisations have complied with our recommendations,” the PHSO said.

Why this case matters

The PHSO's findings point to something bigger than one bad prescription. Physician associates have become increasingly embedded in GP practices across England, often seeing patients who believe they're consulting a doctor. PAs are trained healthcare professionals, but they work within defined limits.

This case is a reminder that supervision cannot be a formality.