Coroner warns about NHS physician associates after woman died following misdiagnosis

A coroner has issued a warning about the role of physician associates in NHS hospitals after a woman with severe abdominal problems was wrongly diagnosed as having a nosebleed and died four days later.

The family of Pamela Marking, 77, were under the mistaken impression she had been seen by a doctor when she was examined in an emergency department, rather than a physician associate (PA) with far less training.

Surrey assistant coroner, Karen Henderson, has written to 12 health leaders or bodies including the UK health secretary,  West Streeting, and NHS England expressing concerns about the “limited training” PAs have and the lack of public understanding about their roles.

Karen Henderson said Pamela Marking was taken to East Surrey hospital in Redhill on 16 February last year after she vomited blood-stained fluid and had a tender abdomen.

The coroner said the PA who saw her had “a lack of understanding of the significance of abdominal pain” and sent her home the same day. Mrs Marking deteriorated, and returned to the hospital two days later. She underwent surgery for complications arising from a femoral hernia but died on 20 February 2024.

Karen Henderson said the PA had acted independently in the diagnosis, treatment, management and discharge of Pamela Marking without independent oversight by a medical practitioner.

The coroner said: “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.”

Karen Henderson added that the term physician associate was misleading to the public. She said:  “Mrs Marking’s son was under the mistaken belief that the physician associate was a doctor and 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.”

She added that the lack of public knowledge about PAs “has the potential to hinder requests by patients and their relatives who would wish to seek an opinion from a medical practitioner”.

At the end of an inquest into Pamela Marking’s death, Karen Henderson concluded the clinical management she was given on her first visit to hospital, and later the issues with anaesthesia when she had an operation, “materially contributed to her death.”

In November, the UK government ordered a review of the role of PAs  in the NHS, amid growing alarm in the medical profession about patient safety. It will examine the safety of their roles and how patients should be made aware that, despite their titles and ability to diagnose illness, they are not doctors and can perform only certain tasks.

About 3,500 PAs and about 100 equivalents in anaesthesia, called anaesthetic associates, are working in hospitals and GP surgeries in England.

PAs can take a patient’s medical history, conduct physical examinations, analyse test results, diagnose illnesses and help draw up the plan for managing a person’s condition. They do two years of medical training, far less than a doctor.

Chair of the BMA council, Philip Banfield, said: “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.

“As the coroner says, the continued blurring of the lines between PAs and doctors is compromising patient safety. 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.”

A spokesperson for Surrey and Sussex healthcare NHS trust said: “We will continue to look carefully at the details of this case to ensure we learn any lessons. Physician associates follow a nationally recognised programme of training and work within a very specific scope of practice under the direct supervision of a consultant, as was the case here.

“All of our physician associates wear designated scrubs with their job title, physician associate lanyards, and use the recommended introduction of their role when meeting patients.”

An NHS spokesperson said: “The NHS has always been clear that physician associates are not replacements for doctors and should practise only with appropriate medical supervision, but legitimate concerns remain about the roles and so the government-ordered review will gather insight from across the NHS to ensure they are being used appropriately.”