Role confusion due to title and lack of uniform
Department of Health and Social Care received 2 coroners' reports about this hazard between 31 Jul 2024 and 24 Feb 2025.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 7 specific actions.
The story, report by report
Spacing grows with the time between reports.
“There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 3 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“The RCP has confirmed that the FPA will close in December, along with the PAMVR. The initial transfer of PAMVR data from the RCP to the GMC will begin on 31 October 2024. The GMC register will open on 13 December 2024, when regulation begins, but will continue to be voluntary for the first two years. The PAMVR will remain static, but searchable, until 31 March 2025 when it will be closed.”
Stated timescale: 31 March 2025
“the GMC will become the regulator of PAs and anaesthesia associates (AAs) in December this year.”
Stated timescale: December this year
1 more stated action in the Promises tab.
- 7 months laterClosely relatedConfidence 0.90 · higha different coroner
“Lack of public understanding of the role of Physician Associate”
Original on judiciary.uk ↗ Repeated from the earlier report:understandingrolePhysicianAssociate
Department of Health and Social Care responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“We will ask the trust for the action they intend to take because of this Prevention of Future Deaths Report and monitor those actions as part of our ongoing monitoring and engagement with them.”
“NHS England has published a summary of existing guidance on the deployment of medical associate professions for NHS organisations. This guidance makes it clear that all staff should introduce themselves and their role clearly and be supported by their employer to do so.”
2 more stated actions in the Promises tab.
- All reports to Department of Health and Social Care
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2024 → 2025Pamela Marking7 months after Susan Pollitt · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight insufficient awareness and understanding of the Physician Associate role leading to confusion about qualifications.
Susan Pollitt · 31 Jul 2024
“There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families.”
Original on judiciary.uk ↗ Pamela Marking · 24 Feb 2025
“Lack of public understanding of the role of Physician Associate”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We are clear that statutory regulation is necessary for PAs and anaesthesia associates (AAs) and the UK and Scottish parliaments approved legislation in early 2024 which provides a legal duty for the GMC to regulate PAs and AAs from December 2024.”
Stated action · timescale: 31 March 2025
“The RCP has confirmed that the FPA will close in December, along with the PAMVR. The initial transfer of PAMVR data from the RCP to the GMC will begin on 31 October 2024. The GMC register will open on 13 December 2024, when regulation begins, but will continue to be voluntary for the first two years. The PAMVR will remain static, but searchable, until 31 March 2025 when it will be closed.”
Stated action · timescale: December this year
“the GMC will become the regulator of PAs and anaesthesia associates (AAs) in December this year.”
Stated action · timescale: December 2024
“We are clear that statutory regulation is necessary for PAs and anaesthesia associates (AAs) and the UK and Scottish parliaments approved legislation in early 2024 which provides a legal duty for the GMC to regulate PAs and AAs from December 2024.”
What happened next: No evidence found either way
The legislation referenced was approved in early 2024 and sets a December 2024 start date for GMC regulation of PAs and AAs, but the provided sources do not confirm that statutory regulation was fully implemented by that date or that the promised legal duty was carried out.
“From **13 December 2026**, practising as a PA or AA without GMC registration becomes a criminal offence under the Anaesthesia Associates and Physician Associates Order 2024”
No evidence found does not mean the action did not happen.
Stated action
“We will ask the trust for the action they intend to take because of this Prevention of Future Deaths Report and monitor those actions as part of our ongoing monitoring and engagement with them.”
Stated action
“NHS England has published a summary of existing guidance on the deployment of medical associate professions for NHS organisations. This guidance makes it clear that all staff should introduce themselves and their role clearly and be supported by their employer to do so.”
Stated action · timescale: October 2024
“RCEM issued a position statement in October 2024 regarding patients who may require a laparotomy [7]; this statement highlights that some patients are at greater risk of requiring surgery and part of this group includes the older person and those with cognitive impairment.”
Stated action
“the Department notes that the report has been sent to a number of medical Royal Colleges and professional bodies relating to anaesthesia. We think these organisations are best placed to respond to points 6, 7 and 8 of your report which relate specifically to guidelines around anaesthesia therefore our response focuses on points 1 - 5 only.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Department of Health and Social Care at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2024 → 2025 | 0.86 | 0.35 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.