AC-2024-LON-003354 - [2025] EWHC 2270 (Admin)

Mr Benedict Peters

Mr Benedict Peters (aged 25 years) died on 12 November 2022 whilst staying at his parents’ home. He had been discharged from hospital the day before having presented in the early hours of 11 November 2022 with chest pain, shortness of breath, a sore throat and an aching arm. He had been reviewed in hospital by a PA, who considered that Mr Peters’ chest x-ray was normal and discussed his case with the duty consultant. Mr Peters was subsequently diagnosed with a panic attack/gastric inflammation and prescribed medication. The inquest into his death concluded that he had died from undiagnosed complications arising from an underlying heart defect. The coroner subsequently made a PFD report addressed to the Manchester University NHS Foundation Trust. The case was not notified to the defendant. The PFD report stated:

“It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined/reviewed in person by a doctor.”

On 3 July 2023, Mrs Susan Pollitt was admitted to the Royal Oldham Hospital after collapsing at home. Whilst being treated, she subsequently developed ascites. On 11 July 2023, a junior doctor determined that an ascitic drain should be placed. The drain insertion was undertaken by PA who was unaware of the local hospital guidance on the insertion of ascitic drains, or the prohibition on drains remaining in place for any longer than six hours. Mrs Pollitt’s drain remained in place for 21 hours before being removed. The PA also directed that the drain be clamped which was unnecessary given the moderate level of fluid that had been drained. The PA also failed to appreciate that clamping the drain would increase the risk of infection. Mrs Pollitt subsequently developed bacterial peritonitis and died on 11 July 2023.

In his witness statement dated 9 October 2024, Mr Pollitt set out that he did not know that the person treating his late wife was a PA. He had assumed they were a doctor. He stressed that at the time, he was wholly unaware that PAs even existed, much less the difference between their role and that of a doctor.

At the inquest, the Northern Care Alliance NHS Foundation Trust (which ran the Royal Oldham Hospital) admitted that the ascitic drain should have been removed within six hours of insertion, and that, if that had been done, Mrs Pollitt would have survived. The coroner subsequently returned a conclusion that Mrs Pollitt had died ‘as a result of an unnecessary medical procedure contributed to by neglect’. She issued a PFD report dated 31 July 2024 addressed to the DHSC, the defendant, and the FPA which listed the following Matters of Concern:

“1.

There is no regulatory body with oversight of Physician Associates. It is understood that this is currently the subject of a consultation by the General Medical Council.

…

3.

There is no national framework as to how Physician Associates should be trained, supervised and deemed competent. This is placing both patients, Physician Associates and their employers at risk. The court heard that since the death of Mrs Pollitt the Northern Care Alliance have put in place a local trust framework. Unlike all other clinical roles there is no national guidance save for very recent guidance issued by the British Medical Association (March 2024).

4.

There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families. The lack of a distinct uniform and the title "Physician" gives rise to confusion as to whether the practitioner is a doctor.

5.

In June 2022 the Physicians Associate had been signed off as competent for the insertion of ascetic drains. This sign off was completed by a liver nurse specialist using a competency form which was provided by the FPA. Whilst the competency form assessed the technical aspect of placing the drain, it did not include competency around the wider aspects of care such as taking consent, risk factors and after care.”

The Royal College of Physicians (which managed the FPA at the time) responded to the PFD report on that same date. It noted that many of its fellows and members had ‘significant concerns about the safe deployment of PAs, especially concerning regulation, scope of practice and supervision’. It disagreed that PAs’ scope of practice should be determined locally and suggested that the defendant should take a leading role in developing national-level scope of practice ‘to reduce variation and enhance patient safety’. It noted that ‘[f]ailings in scope of practice and supervision’ were important factors in Mrs Pollitt’s death.

Professor Melville for the defendant responded to the PFD report on 20 September 2024. The defendant noted that the absence of statutory regulation of PAs may have contributed to the circumstances of Ms Pollitt’s death but that regulation by the GMC due to commence at the end of 2024 would address several of the issues raised. This should, in turn, bring benefits for patients, patient safety, PAs themselves and those that employ and work alongside them. Professor Melville noted, however, that there appeared to be “wider concerns about the clinical governance arrangements at the Trust including the roles, supervision and relevant policies supporting the use of ascitic drains and the deployment of PAs.” He continued: “Regulation is an important part of patient safety, but it alone cannot prevent future deaths. Good clinical governance by healthcare providers remains the most important factor. Your report raises significant questions that cannot be answered by those to whom the report is currently addressed, and are better explained by the trust.”