- A five-year-old girl experienced pain and bleeding after a physician associate (PA) wrongly prescribed her a vaginal pessary for suspected thrush.
- The Parliamentary and Health Service Ombudsman (PHSO) identified multiple failures in her care, which led to her mother being questioned about possible sexual abuse.
- The PA prescribed the medication without a doctor's supervision, despite not having prescribing rights, and the pharmacy failed to query the unsuitable prescription for a child.
- The girl's symptoms were later correctly diagnosed as vulvovaginitis, and the pessary was deemed inappropriate for her age.
- The incident has prompted the GP practice and pharmacy to implement changes, and the Royal College of GPs advises that PAs should not see children under 16.
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