Pamela Marking
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. misleading title causing public confusion
“The term 'Physician Associate' is misleading to the public”
2. public unaware of non‑doctor status
“Lack of public understanding of the role of Physician Associate”
3. informed consent compromised
“The right of patients and family to seek a second opinion”
4. practice beyond competence
“Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate”
5. inadequate supervision
“Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates”
6. outdated anaesthetic practice
“Lack of 'Updated' National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery”
Linked reports
Earlier report
“There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families.”
This report
“Lack of public understanding of the role of Physician Associate”
Responses
2025-0107-Response-from-Association-of-Anaesthetists-RCOA-Difficult-Airways-Society.pdf ↗· The Difficult Airway Society
2025-0107-Response-from-CQC.pdf ↗· Association of Anaesthetists of GB and Ireland
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.”
2025-0107-Response-from-DHSC.pdf ↗· Surrey and Sussex Healthcare NHS Trust
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.”
2025-0107-Response-from-General-Medical-Council.pdf ↗· General Medical Council
2025-0107-Response-from-NHSE.pdf ↗· Royal College of Physicians
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.”
2025-0107-Response-from-RCEM.pdf ↗· Care Quality Commission
Stated action · 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.”
2025-0107-Response-from-Royal-College-of-Physicians.pdf ↗· Royal College of Physicians
2025-0107-Response-from-Surrey-and-Sussex-NHS.pdf ↗· Surrey and Sussex Healthcare NHS Trust