27-02-2025
Pensioner died of sepsis after physician associate misdiagnosed her with nosebleed
A mother who was vomiting blood died after a physician associate misdiagnosed her with a nosebleed.
The family of Pamela Marking, 77, believed that she was seen by a doctor when she was admitted to East Surrey Hospital, Redhill, in February last year with stomach pain after vomiting 'blood-stained fluid'.
However, instead of seeing a qualified doctor, the pensioner was assessed by a physician associate (PA), a type of healthcare worker employed to assist doctors by carrying out basic clinical tasks. These workers do not go to medical school but undergo training for two years.
The coroner found that the PA wrongly diagnosed Marking with a nosebleed and discharged her 'without a medical review or direct medical supervision'.
It was discovered that the associate had taken this unilateral decision despite being unable to take a full medical history as Marking also suffered from short-term memory loss.
The PA also failed to conduct the necessary abdominal examination, which would have correctly identified a 'right femoral hernia' – a medical emergency requiring urgent, likely life-saving, surgery.
Marking was discharged the same day, only to be re-admitted two days later on Feb 18 in a critical condition.
Emergency surgery
By that time, the bowel obstruction that had caused her vomiting had cut off the blood supply to her gut, and doctors performed emergency surgery in an attempt to save her life.
Despite the anaesthetist using what the coroner described as 'a commonly deployed and safe technique' to rapidly induce anaesthesia, Marking's blocked gut caused her to inhale 'feculent fluid', which triggered respiratory failure.
She was kept on a ventilator and given 'maximal support' in intensive care but died two days later on Feb 20 2024.
In a Prevention of Future Deaths report, Dr Karen Henderson, the HM assistant coroner for Surrey, found that the PA 'lacked understanding of the significance of abdominal pain and vomiting' and said their poor clinical management 'materially contributed to her death'.
'Materially contributed'
The coroner found that the management of anaesthesia also 'materially contributed' to her death.
Marking's son, Richard Marking, told The Telegraph: 'In an overstretched system, when you are massively stressed, it is easy to say, 'that seems about right', but this case might be a jolt that makes them think, 'I am also responsible for this patient'.'
This is not the first time a coroner has raised concerns that PAs have been implicated in preventable patient deaths. In the past two years, Prevention of Future Deaths notices have been released regarding the deaths of Emily Chesterton, 30, Susan Pollitt, 77 and Ben Peters, 25.
The Telegraph has previously revealed that more than 30 hospitals had replaced doctors with PAs and that some had even 'illegally' prescribed opioid painkillers.
The coroner's report into this latest fatality adds concerns to the ongoing debate about the role of physician associates in the NHS.
Dr Henderson called the physician associate title 'misleading to the public', noting that 'no steps' had been taken by NHS staff to correct Marking's family of the false impression that the PA was a doctor.
She pointed out that because many patients are unaware that PAs are not doctors, they do not know that they could or should seek a second opinion from a qualified medical practitioner.
The coroner also dismissed claims made by East Surrey Hospital witnesses at the inquest that PAs were 'clinically equivalent to a Tier 2 resident doctor' as being 'without evidence' and warned that 'blurring roles' puts lives at risk.
Both PAs and anaesthesia associates (AA) will undergo further scrutiny upon the publication of an independent review into the roles, which was commissioned by Wes Streeting, the Health Secretary, in November 2024.
The probe, led by Prof Gillian Leng, the president of the Royal Society of Medicine, intends to address mounting concerns that the associate role poses a risk to patient safety.
Around 3,500 PAs are currently employed by GP surgeries and hospitals, with the NHS planning to triple that number by 2037.
Multiple medical bodies, including the British Medical Association the doctors' union, have called for a halt to the planned expansion.
Lack of guidelines
The coroner's report into Marking's death sets out concerns about the PA role in detail – including the lack of national and local guidelines on PA responsibilities.
Dr Henderson warned against hospital staff falsely equating PAs with doctors, saying: '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.'
The absence of a national guideline stipulating what work PAs can and cannot safely do has forced doctors and bereaved families to sue the General Medical Council (GMC), which has regulated doctors and, since December, PAs and anaesthesia associates.
Dr Richard Marks, the co-founder of Anaesthetists United, the group of consultant anaesthetists leading the legal challenge against the GMC, told The Telegraph: 'Sadly, with this latest case, we can see the risks that come from the unchecked deployment of unsupervised non-doctors.
'We must act to ensure proper supervision and scope takes place, and a legal challenge is the only route that is left open.'
In her report, Dr Henderson pointed out that Marking's case 'raises issues of informed consent and protection of patient rights' and that there was 'no evidence' presented at the inquest that 'the management of Mrs Marking was subject to a reflective practice review'.
She added: '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.'
'Sombre reading'
Prof Philip Banfield, the chair of the British Medical Association, said the coroner's report made for 'sombre reading' and suggested that the 'outcome' in her case could have been different if the hospital had followed a 'scope of practice' guideline limiting the work that PAs can do, which the BMA published last year.
He said: 'Our scope makes it clear that in any emergency department setting PAs must work under direct supervision, with a senior doctor reviewing each patient in person.
'The coroner's report suggests that had that been the case for Mrs Marking the outcome could have been very different.
'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. In the meantime, the recommendations in our guidance should be implemented so that patients can be reassured that they will be safe.'
