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

Fecha: 05-Sep-2025

Mrs Pamela Ann Marking

(d)

Mrs Pamela Ann Marking

66.

On 16 February 2024, Mrs Marking was admitted to the A&E at East Surrey Hospital after vomiting blood-stained fluid, with right-sided and suprapubic abdominal tenderness. She was diagnosed with a nosebleed and discharged home that afternoon without a medical review having been seen by an unsupervised PA who did not understand the significance of the symptoms and had undertaken an incomplete abdominal examination. Had Mrs Marking been examined properly, the presence of a femoral hernia would have been identified. She presented again to the A&E two days later with worsening symptoms and underwent emergency surgery that same evening. Owing to the initial misdiagnosis and subsequent failings in her care, Mrs Marking died on 20 February 2024.

67.

A PFD report was issued by the coroner dated 24 February 2025 and addressed to NHS England, the DHSC, the defendant, the CQC, and the Surrey and Sussex Healthcare NHS Foundation Trust (‘the Trust’). The coroner identified a number of concerns, of which the first five are relevant:

“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 … was made by the Physician Associate without appreciating the relevance of [Mrs Marking’s symptoms] and in the absence of understanding the need to undertake … 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.”

68.

Professor Melville, on behalf of the defendant, issued a response to the PFD report dated 17 April 2025.

(a)

In respect of Issues 1 and 2, Professor Melville cited paragraphs 2 and 82 of GMP which require registered professionals to ‘always be honest about their experience, qualifications, current role, and they should introduce themselves to patients, and explain their role in patient care’; and to ‘recognise and work within the limits of their competence, and only practice under the level of [appropriate] supervision’.

(b)

On issue 3, ‘PAs on our register must work in partnership with their patients to make decisions about treatment and care’ and must give patients the information they want and need. Professor Melville further referred to both GMP and the GMC’s guidance ‘Decision making and consent’.

(c)

On issue 4, Professor Melville said that as with doctors, its standards did not impose ceilings on what individual associates could do once registered, because ‘competence will vary by individual and is shaped by their supervised training and experience, and the clinical context of their work’. Further, ‘[i]t is an employer’s responsibility, with the involvement of clinical leaders and supervisors, to determine which activities or specific tasks an individual can carry out and what level of supervision is required’. He stressed the defendant’s understanding that the Royal Colleges and other specialist professional bodies had the level of clinical expertise needed to provide more detailed national guidance on associates’ scope of practice.

(d)

On issue 5, Professor Melville explained that the professional standards relating to supervision, delegation and working with colleagues are set out in GMP, and also in other guidance issued by the defendant including ‘Delegation and referral’ and ‘Leadership and management’. He foreshadowed a future website publication intended to bring together all of the relevant standards and expand on these with advice and referring to guidance issued by other bodies to support doctors with their supervising/delegating responsibilities. This document was published in April 2025.

69.

The Surrey and Sussex Trust responded on 17 April 2025. It explained how, following the death of Mrs Marking, it had taken various steps and issued guidance to its PAs. PAs are now required to wear different-coloured scrubs with their title clearly embroidered on the front, along with distinct bright yellow lanyards. They are also required to always introduce themselves as “Hello, my name is xxx, I’m a Physician Associate. I am not a Doctor, but a senior doctor will be overseeing your care.” The Trust issued a new scope of practice document for PAs working in the Emergency Department. Amongst other things, it prohibits PAs from seeing undifferentiated patients, and requires that for a patient to be discharged after seeing a PA, they must first be reviewed in-person by a senior doctor.