A coroner has raised concerns about the physician associate title ‘misleading’ patients as well as a lack of national guidelines on their scope of practice.
Yesterday, coroner Dr Karen Henderson released her prevention of future deaths report concerning the death of Pamela Marking, a 77-year-old woman who died following care by a PA in an emergency department.
The inquest found that both Mrs Marking’s clinical management by the PA, who diagnosed her with a nosebleed despite abdominal pain, as well as the method used for anaesthesia induction by other staff members ‘materially contributed to her death’.
Dr Henderson’s report, which was sent to NHS England, the GMC, and the health secretary, raised concerns that ‘the term “Physician Associate” is misleading to the public’ and also that there is a ‘lack of public understanding’ around the role.
The patient’s son ‘was under the mistaken belief that the physician associate was a doctor by this title’, and no steps were taken by either the hospital or the PA to correct this, according to the coroner.
Staff from East Surrey Hospital who gave evidence at the inquest also claimed that a PA is ‘clinically equivalent’ to an F2 resident doctor ‘without evidence to support this belief’, the report said.
On scope, Dr Henderson warned that there is a ‘lack of national and local guidelines and regulation of the scope of practice’ for the role, citing the PA’s ‘absence of understanding’ of the patient’s abdominal discomfort.
She said that in the ‘absence of any national or local recognised hospital training’, this case ‘gives rise to a concern they are working outside their capabilities’.
The report also raised concerns about ‘inadequate supervision’ or ‘excessive delegation of undifferentiated patients’ in ED, which ‘compromises patient safety’.
Mrs Marking was admitted to the emergency department of East Surrey Hospital in February 2024 with abdominal tenderness, and was seen by a physician associate.
The inquest found: ‘She was diagnosed as having had an epistaxis (nosebleed) by a Physician Associate and discharged home later that afternoon without a medical review or direct medical supervision of the Physician Associate who 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.’
Two days later, Mrs Marking re-presented to ED and needed emergency surgery, at which point hospital staff undertook a rapid sequence induction (RSI) of anaesthesia to protect her airway from aspiration of gastric contents.
The approach used ‘was considered a commonly deployed and safe technique in the absence of updated national guidelines’, according to the coroner.
But this subsequently caused aspiration of ‘feculent fluid resulting in respiratory failure’ immediately after her surgery.
Despite ‘maximal support’ via intensive care, Mrs Marking died on 20 February 2024.
As well as the concerns about PA deployment, the coroner raised three further issues about the lack of updated national guidance for anaesthesia administration in hospitals, and the report was sent to the Royal College of Anaesthetists among others.
Recipients of her report have 56 days to respond with details of action taken or proposed to be taken to prevent future deaths.
Coroner’s concerns about PAs in full
1. 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.
2. Lack of public understanding of the role of Physician Associate
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. 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.
3. The right of patients and family to seek a second opinion
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.
4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in an abdominal examination in a patient who was unable to give a proper clinical history because of short term memory loss. No evidence was presented that the management of Mrs Marking was subject to a reflective practice review. Given their limited training and in the absence of any national or local recognised hospital training for Physician Associates once appointed, this gives rise to a concern they are working outside of their capabilities.
5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
Whilst there were discussions with the ‘supervising’ consultant the Physician Associate was effectively acting independently in the diagnosis, treatment, management and discharge of Mrs Marking without independent oversight by a medical practitioner. This gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety.
Source: Chief Coroner
The GMC’s medical director and director of education and standards, Professor Colin Melville, said: ‘Our sincere condolences are with Mrs Pamela Marking’s family and friends following her tragic death.
‘We have received a copy of a Prevention of Future Deaths report from the Coroner, and we will be responding in due course.’
In 2023, Pulse reported on a GP practice which stopped employing PAs after a coroner found that ‘poor quality care’ had contributed to the death of 30-year-old Emily Chesterton.
Ms Chesterton’s parents have joined with a doctors’ group, Anaesthetists United, to bring a judicial review against the GMC over its refusal to set an official scope of practice for PAs.
This case will be heard at the High Court on 13 May.
My nephew is an excellent PA in America. But his training took 7 years including thousands of hours of supervised clinical rotations in acute settings. UK 2 years quick fix, off you go, lambs to the slaughter ..
Having the same regulator as doctors sends a very mixed message….
Very shocking. Points raised by coroners are thought provoking. Various terms are used to disguise and make public fool , one of that recently emerged is “clinician “ used for nurses, GPs and PA and pharmacist. It will eventually lead to lack of trust over genuine GOs in near future.
Why would the Trust staff intentionally try to mislead the Coroner about the level of training and clinical equivalence of a PA ? They should know that the PA must be directly supervised at all times.
This is diabolical. It is a huge risk to PAs AND Doctors, AND patients. It is as bad as Nuses calling themselves Consultants, knowing that everybody else would take the understanding of a Hospital Consultant being a Senior Fully-Qualified Specialist Doctor ! This remarketting needs to stop and revert to plain simple standard titles in Simple Pplain English – especially when so many people in NHS speak other languages.
The coroner’s concerns expose a systemic cheapness—not just in resources but in commitment to training, regulation, and clarity. “Paying peanuts” here ensures “monkeys”: a shaky setup where confusion, overreach, and danger persist. Without a fundamental shift, this isn’t a one-off lapse—it’s an eternal pitfall, destined to haunt healthcare until properly addressed.