A five-year-old girl was left “traumatized” after what officials have described as a “deeply troubling” incident in which she was wrongly prescribed a large vaginal pessary.
The incident, which took place in the United Kingdom in 2023, is now the subject of a report by the health ombudsman, described as “damning” by The Guardian.
This details how the five-year-old (referred to in the report as “H”) and her mother (referred to as “Mrs N”) visited a clinic after the child began complaining of itching and discharge. The mom believed she was explaining this to a General Practitioner, the British equivalent of a family doctor or primary care physician.
Unbeknownst to her, she was actually speaking to a “physician associate” (a “PA”), who is not a doctor, did not attend medical school, and whose role is as part of a team assisting and being supervised by a qualified doctor.
The report explains that the PA “suspected thrush” and the girl was prescribed a vaginal pessary and cream. The mom saw the large size of the pessary and questioned whether it was safe for a five-year-old to insert, but was “reassured this was the only treatment for her daughter’s symptoms” and “she says she was told there are no child sizes.”
The mom said that after inserting the pessary, her daughter began to bleed and scream in pain, while the cream burned her skin. She took her to an out-of-hours doctor, though the child was in so much pain she refused an internal examination. That prompted the doctor to become concerned about sexual abuse and contact child safeguarding services.
“How are we meant to trust healthcare professionals now?”
The mom said this compounded an already distressing experience, adding to both her and her daughter’s trauma. The report also says that “since this has been inserted, her daughter continues to secrete a green vaginal discharge twice a week”. The mom is reported to have 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 [they] told me. How are we meant to trust healthcare professionals now?”
The ombudsman’s report underlined that the PA and the GP did not discuss the girl’s prescription, that vaginal pessaries are not suitable for prepubescent children, and that the girl’s symptoms were not indicative of thrush, but of the fairly common condition of vulvovaginitis.
The report also placed some blame on the pharmacy that dispensed the pessary and cream, saying they too did not question anything.
“We are very sorry to hear of Mrs N’s concerns about the inappropriate prescription given to her five-year-old daughter, H. We recognise the pain H endured from the medication and the traumatic experience they both had as a result. We understand the additional distress and upset it has caused Mrs N knowing she administered inappropriate medication to her child.”
Rebecca Hilsenrath, the chief executive of the Parliamentary and Health Service Ombudsman, described this case as a “deeply troubling case” and said it should have been avoided: “The breakdown in communication meant the checks and balances designed to make sure patients are treated appropriately and kept safe were not followed.”
The ombudsman’s verdict was that the GP pay the mother £1000 (about $1,350), the pharmacy pay her £500 (about $670), and they both take action to prevent this from happening again.
Published: Jun 5, 2026 10:09 am