Physician associate title misleading, says coroner after woman dies in hospital
The public is being misled over what an NHS physician associate (PA) does, a coroner has said after a woman died following hospital failings, including being misdiagnosed with a nose bleed.
Pamela Marking (pictured) went to A&E at East Surrey Hospital in February last year after vomiting blood and having tenderness in her side.
She was seen by a PA and told she had a nose bleed before she was sent home, with her son believing she had been cared for by a doctor.
Mrs Marking actually had a hernia, and a coroner’s report highlighted how the PA “had a lack of understanding of the significance of abdominal pain and vomiting and had undertaken an incomplete abdominal examination which would have been likely to have found a right femoral hernia”.
Mrs Marking, 77, had to be readmitted to hospital and died four days later after complications with her care.
Dr Karen Henderson, assistant coroner for Surrey, has sent a “prevention of future death” report to health officials at the Department of Health and Social Care and NHS England, raising a series of concerns about PAs, along with other aspects of Mrs Marking’s care.
The medic said: “The term ‘physician associate’ is misleading to the public.
“Mrs Marking’s son was under the mistaken belief that the physician associate was a doctor by this title in circumstances where no steps were taken by the emergency department or the physician associate to explain or clearly differentiate their role from that of medically qualified practitioners.”
Dr Henderson also highlighted a “lack of understanding” around the role, highlighting how even some hospital staff believe a PA is the equivalent of a certain type of resident doctor.
“Witnesses from the trust gave evidence that a physician associate was clinically equivalent to a Tier 2 resident doctor without evidence to support this belief,” she wrote.
“This blurring of roles without public knowledge and understanding of the role of a physician associate has the potential to devalue and undermine public confidence in the medical profession whilst allowing physician associates to potentially undertake roles outside of their competency, thereby compromising patient safety.”
She added: “The lack of public knowledge that a physician associate is not medically qualified has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner.
“It also raises issues of informed consent and protection of patient rights if the public are not aware or have not been properly informed that they are being treated by a physician associate rather than a medically qualified doctor.”
Dr Henderson said there is a lack of guidelines for the supervision of PAs, and inadequate supervision can “compromise patient safety”.
The report provides more information on the circumstances surrounding Mrs Marking’s death.
After initially seeing the PA on February 16 2024, Mrs Marking, who also had “cognitive issues”, was sent home.
She went back to the emergency department two days later and needed emergency surgery that evening.
A problem with her anaesthesia meant she needed intensive care after surgery.
She died on February 20 2024, with the coroner concluding the cause of death was respiratory failure and sepsis, a strangulated femoral hernia and “aspiration of feculent gastric contents at induction of anaesthesia”.
“The clinical management Mrs Marking had on her first admission and thereafter during the rapid sequence induction materially contributed to her death,” Dr Henderson wrote.
She also called for updated guidelines about the type of anaesthesia administered to Mrs Marking.
PAs are graduates – usually with a health or life sciences degree – who have undertaken two years of postgraduate training.
They are supposed to support the work of doctors but hit the headlines after the death of Emily Chesterton, 30, in November 2022 from a pulmonary embolism. She was misdiagnosed by a PA on two occasions.
According to the NHS, they work under the supervision of a doctor and can diagnose people, take medical histories, perform physical examinations, see patients with long-term conditions, analyse test results and develop management plans.
Most associates work in GP surgeries, acute medicine and emergency medicine and there are NHS plans to recruit more.
In November the Government launched a review of the role of PAs and anaesthesia associates (AAs).
Professor Gillian Leng, president of the Royal Society of Medicine, will lead the work looking into how the roles affect safety and how they support wider health teams, with a report expected to be published in spring.
Commenting, Professor Philip Banfield, chairman of council at the British Medical Association, said: “What happened to Pamela Marking is deeply troubling.
“Mrs Marking needed care from a doctor, because they are specifically trained in more depth and more widely to consider a diagnosis that may not be obvious at first sight.
“It was inappropriate that she was sent home, with abdominal pain, vomiting blood, and misdiagnosed with a nose bleed, not only without having received appropriate care, but with both her and her son unaware that she had been seen only by a physician associate (PA) instead of a doctor.
“As the coroner says, the continued blurring of the lines between PAs and doctors is compromising patient safety.
“This is why the BMA has raised concerns about the use of the term ‘medical professionals’ to describe both doctors and PAs.
“This is not the first coroner’s report to raise these safety concerns and we repeat our call for the NHS to make immediate steps to ensure that any PA works to the BMA’s safe scope of practice – our scope makes it clear that in any emergency department setting PAs must work under direct supervision, with a senior doctor reviewing each patient in person.
“The coroner’s report suggests that had that been the case for Mrs Marking the outcome could have been very different.
“A government review is ongoing, but this tragic case already shows it must result in nationally agreed safe scopes of practice for these assistant roles. In the meantime, the recommendations in our guidance should be implemented so that patients can be reassured that they will be safe.”
A spokesperson for Surrey and Sussex Healthcare NHS Trust said: “Our deepest sympathies remain with Mrs Marking’s family and loved ones at this very difficult time, and we wish to express our profound regret for their loss.
“We thank the Coroner for their report and will continue to look carefully at the details of this case to ensure we learn any lessons to keep improving our services and deliver the safest possible care to our patients.”
The spokesperson said that PAs in the hospital emergency department “work within a very specific scope of practice under the direct supervision of a consultant” and “use the recommended introduction of their role when meeting patients”.
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