Source · Prevention of Future Deaths

Pamela Marking

Ref: 2025-0107 Date: 24 Feb 2025 Coroner: Karen Henderson Area: Surrey Responses identified: 8 / 10

Misleading titles and public misunderstanding of Physician Associate roles, coupled with inadequate national guidelines and direct supervision, risk patient safety through PAs working beyond their competency.

Date 24 Feb 2025

56-day deadline 21 Apr 2025 est.

Responses identified 8 of 10

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

View full coroner's concerns

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 of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in 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.

6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery

Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice.

7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI

Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).

8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic

Evidence was heard that as cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.

Responses

8 respondents

NHS England NHS / Health Body

24 Feb 2025 PDF

Action Taken

NHS England acknowledges concerns about public understanding of Physician Associates (PAs). It highlights the Leng Review of PA and AA professions, the establishment of PA title by law, and existing guidance on PA deployment. The RCEM issued new guidance moving PAs to Tier 2 on the ED rota. The Trust implemented the changes immediately, and PAs at the Trust are also now trained to state that they are not a doctor. (AI summary)

View full response

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Pamela Anne Marking who died on 20 February 2024

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 February 2025 concerning the death of Pamela Anne Marking on 20 February 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Pamela’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Pamela’s care have been listened to and reflected upon.

Your Report raises concerns over the lack of public understanding of the role of Physician Associate (PA) and the lack of national guidelines and regulation for their scope of practice and supervision.

Your Report also raises concerns around the lack of updated national guidelines relevant to rapid sequence induction (RSI) of anaesthesia, but these issues fall outside of NHS England’s remit and would be best addressed by the Royal College of Anaesthetists and other associated organisations named in your Report. NHS England will give due consideration to their responses to the Coroner.

Title and role of Physician Associate

The title ‘physician associate’ (PA) is established by law, under The Anaesthesia Associates and Physician Associates Order 2024. The Secretary of State for Health and Social Care has established an independent review of the PA and anaesthesia associate (AA) professions, which is considering the safety of the roles and their contribution to multidisciplinary healthcare teams. The Leng Review, chaired by Professor Gillian Leng CBE, will consider the identity and naming of the roles, including their names as set out in statute. 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. This is in accordance with National Institute for Health and National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

14 April 2025

Care Excellence (NICE) guidelines (CG138), which state that healthcare professionals directly involved in a patient's care should introduce themselves and explain their role to the patient. The NHS England summary signposts interim guidance from the Royal College of Physicians (RCP) from December 2024 on the titles and introductions of PAs. The RCP guidance, which is aimed at supervising clinicians, employers and organisations, stresses that “PAs must always take all reasonable steps to inform patients and staff of their role and to avoid confusion of roles.” The right of patients and family to seek a second opinion The General Medical Council’s (GMC) Good Medical Practice guidance, which sets out the professional standards for doctors, PAs and AAs, requires registrants to recognise a patient's right to choose whether to accept their advice, and respect their right to seek a second opinion. While patients do not have a legal right to a second opinion, the NHS encourages patients to seek a second opinion if they have any doubts about their diagnosis or treatment. NHS England has also introduced Martha’s Rule, which provides a consistent and understandable way for patients and families to seek an urgent review if their or their loved one’s condition deteriorates, and they are concerned this is not being responded to. NHS England has been working towards implementing the programme in 143 locations across England by March 2025. Martha’s Rule is made up of three components to ensure concerns about deterioration can be swiftly responded to:
• Firstly, an escalation process will be available 24/7 at all 143 sites, advertised throughout the hospitals on posters and leaflets, enabling patients and families to contact a critical care outreach team that can swiftly assess a case and escalate care if necessary.
• Secondly, NHS staff will also have access to this same process if they have concerns about a patient’s condition.
• Finally, alongside this, clinicians at participating hospitals will also formally record daily insights and information about a patient’s health directly from their families, ensuring any concerning changes in behaviour or condition noticed by the people who know the patient best are considered by staff.

Lack of national and local guidelines and regulation of the scope of practice and supervision of a PA

The Leng Review will consider the scope of practice for PAs and AAs at the start of their working career; however, it will not generate a national scope of practice by either healthcare setting or level of experience post-qualification.

The GMC has published the generic and shared learning outcomes that PAs and AAs must meet to be registered by them as the professional regulator. Taken with the PA curriculum, these documents will describe what all newly qualified physician associates must know and be able to do. A number of medical Royal Colleges have also developed specialty scopes of practice for PAs and AAs, and NHS England has engaged with these bodies to facilitate the establishment of broad aligning principles. As stated in NHS England’s summary of existing guidance, medical associate professions will work within a scope of practice that is agreed with their supervising senior doctor. NHS England has also engaged with Surrey Heartlands Integrated Care System on the concerns raised in your Report. They advise that PAs working within the Emergency Department (ED) at Surrey and Sussex Healthcare NHS Foundation Trust were not clinically equivalent to Tier 2 resident doctors, but were, in line with Royal College of Emergency Medicine (RCEM) guidance at the time, working alongside Tier 2 resident doctors on the Tier 2 rota. PAs at the Trust wear different colour scrubs to those worn by doctors, which are clearly embroidered with ‘Physician Associate’. They also wear a brightly coloured lanyard, also labelled as ‘Physician Associate’. There are posters in the ED that show all the colours of scrubs worn by staff and identifying which staff wear what colour. The Trust also advise that their PAs are specifically trained to introduce themselves as PAs.

Following the inquest into Pamela’s death, the RCEM issued new guidance moving PAs to Tier 2 on the ED rota, and emphasising that PAs should only see patients specifically selected for them by a senior doctor, who must also review any patients prior to discharge. The Trust advise that they implemented the changes immediately, and PAs at the Trust are also now trained to state that they are not a doctor, when they introduce themselves to patients for the first time.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Pamela, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Royal College of Emergency Medicine Education

3 Apr 2025 PDF

Action Taken

The RCEM issued a position statement in June 2024 regarding Physician Associates which included supervised practice, public awareness, undifferentiated patients, and regulation. RCEM has worked with the national emergency laparotomy audit project (NELA) for several years to improve the care of patients who require an emergency laparotomy (abdominal operation). (AI summary)

View full response

Dear Dr Henderson, Further to your prevention of Future Deaths Notice following the conclusion of your inquest (19th December 2024) into the death of Mrs Pamela Anne Marking who died on 20th February 2024, we would like to extend our sympathy and condolences to the family and friends of Mrs Marking. Mrs Marking attended the emergency department (ED) of East Surrey Hospital with the symptoms of blood-stained vomiting and abdominal pain and was assessed by Physician Associate (PA). Mrs Marking was known to have cognitive issues which limited her ability to provide a complete history. Your prevention of Future Death Notice (24th February 2025) also makes reference to an incomplete abdominal examination by the PA and Mrs Marking’s case being discussed with a supervising consultant without a face-to-face review. Following discharge from the emergency department, Mrs Marking represented two days later to the same ED and was diagnosed with a small bowel obstruction and unfortunately suffered a complication of general anaesthesia which contributed to her subsequent death. Following a period of consultation and engagement with various stakeholders, in June 2024 the Royal College of Emergency Medicine (RCEM) issued a position statement regarding Physician Associates [1] which included the following:
• Supervised Practice: PAs working in Emergency Departments must always operate under the safe supervision of an EM consultant, Associate Specialist or Specialist doctor according to local policy.
• Public Awareness: PAs must be clearly identifiable and identify themselves as a PA to members of the public and other clinicians.
• Undifferentiated Patients: PAs must not see undifferentiated patients within an ED without safe supervision, and within agreed entrustment levels.
• Regulation: PAs must be regulated at the earliest opportunity. RCEM has recently, after an extensive consultation period, updated our workforce tiers guidance. This guidance was originally published in February 2015 and outlines what level of supervision clinicians with different levels of experience and training should be working at. The current guidance makes explicit reference to PAs as working at Tier 1 level and makes a specific recommendation that patients seen by a PAs should be discussed with or reviewed

by a tier 4 or 5 doctor [2]. The decision as to whether a patient has a face-to-face review rather than a discussion, is for the judgement of the supervising doctor who will need to take into account many factors, including those which are patient related (e.g. potential seriousness of the presentation, co-existent illnesses) as well as those which are clinician related. The role and regulation of PAs has been subject to much comment in recent years [3], we note that there is an ongoing review into the safety and scope of the PA role [4] to which RCEM is contributing. RCEM is responsible for setting standards of training, administering examinations and awarding Fellowship and Membership of the College as well as supporting Post Graduate Doctors in Training to qualify in the specialty of Emergency Medicine. The College works to ensure high quality patient care by setting and monitoring standards. We provide expert guidance and advice on health policy to relevant bodies on matters relating to Emergency Medicine and advocate and influence policy makers and politicians on behalf of our members and the wider specialty. It should be noted that RCEM does not have any statutory or regulatory role. RCEM is not responsible for monitoring or accrediting PA training. RCEM has been working with NHS England for over a year on the implementation of ‘Martha’s Rule’ in the ED setting. ‘Martha’s Rule’ is designed to ensure that patients, families, carers and staff will have round-the-clock access to a rapid review from a separate care team (a second opinion from a clinician), if they are worried about a person’s condition. In 2016 RCEM produced a list of patient groups which should be discussed with a consultant or senior doctor before patient discharge [5,6]. The patient groups were selected on the basis that they are important ED presentations with a risk of life-threatening disease that may not be immediately appreciated by less experienced staff; abdominal pain in patients aged 70 years and over was one of these patient groups. RCEM has worked with the national emergency laparotomy audit project (NELA) for several years to improve the care of patients who require an emergency laparotomy (abdominal operation). 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. RCEM does not feel it would be appropriate to comment on matters related to the provision of general anaesthesia in the operating theatre.

CQC Regulator / Inspectorate

7 Apr 2025 PDF

Noted

The CQC acknowledges the coroner's concerns regarding Physician Associates and rapid sequence induction but states that some points are outside of their regulatory scope. They 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 their ongoing monitoring and engagement with them. (AI summary)

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Dear HM Assistant Coroner for Surrey Dr Karen Henderson,

Regulation 28 Report following the inquest into the death of Ms Pamela Anne Marking Thank you for raising the Regulation 28 report with us, following the inquest into the death of Ms Pamela Anne Marking at East Surrey Hospital, Redhill, on 20 February
2024. East Surrey Hospital is part of the Surrey and Sussex Healthcare NHS Foundation Trust.

We have noted the matter of concerns listed below.
1. The term ‘Physician Associate’ is misleading to the public
2. Lack of public understanding of the role of Physician Associate
3. The right of patients and family to seek a second opinion
4. Lack of national and local guidelines and regulation of the scope of practice for Physician Associate
5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in an RSI anaesthetic

The Care Quality Commission (CQC) is the independent regulator of health and social care services in England. We make sure that health and care services in England provide people with safe, effective and high-quality care. Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161 Fax: 03000 616171

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Whilst we have legal powers to regulate providers of health and social care, we do not have any powers to regulate individual practitioners, such as Physician Associates. That is the duty of the General Medical Council from 13 December 2024. Prior to this date, Physicians Associates were not regulated by a formal body. Physicians Associates are encouraged to join the General Medical Council’s register if already practising in the UK, however there is a transition period of two years, after which, Physicians Associates must legally be registered with the General Medical Council. (Links: NHS England » Update on physician associates and anaesthesia associates ahead of GMC regulation, Registration - GMC)

In response to the points raised.
1. The term ‘Physician Associate’ is misleading to the public We are unable to comment on this point due to it being outside of the remit of our regulatory scope. Please note that the General Medical Council is a Respondent and would be best placed to respond to this question.
2. Lack of public understanding of the role of Physician Associate We are unable to comment on this point due to it being outside of the remit of our regulatory scope. Please note that the General Medical Council is a Respondent and would be best placed to respond to this question.
3. The right of patients and family to seek a second opinion We are unable to comment on this point due to it being outside of the remit of our regulatory scope. Please note that the General Medical Council is a Respondent and would be best placed to respond to this question.
4. The lack of national and local guidelines and regulation of the scope of practice for Physician Associate The following are the guidelines that we would expect providers to follow:
• Ensuring safe and effective integration of physician associates into departmental multidisciplinary teams through good practice (NHS England) Link: NHS England » Ensuring safe and effective integration of physician associates into departmental multidisciplinary teams through good practice
• Workplace supervision for advanced clinical practice (NHS England) Link: Workplace Supervision for Advanced Clinical Practice: An integrated multi- professional approach for practitioner development

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• Supervision guidance (Health and Care Professions Council) Link: What our standards say | The HCPC
• Interim guidance for physician associates working in the medical specialties Link: Interim guidance for physician associates working in the medical specialties | RCP

5. The lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physicians Associates The CQC guidance whilst written for Physician Associates in primary care, is largely applicable in secondary care settings too. GP mythbuster 82: Physician associates in general practice - Care Quality Commission Link: GP mythbuster 82: Physician associates in general practice - Care Quality Commission Applicable and relevant statements are:
• Providers should be able to show how they assure themselves of the governance and ongoing competence of physician associates.
• Providers must make sure that staff are competent, and they must provide appropriate supervision and oversight.
• Governance arrangements should take account of the fact that these professionals are trained and registered on the basis that they should always work under supervision. o the supervisor is easily accessible. o staff know who the supervising member of staff is. o staff have enough capacity and capability to supervise.

We use these regulations when we assess if a provider is safe, effective, caring, responsive and well-led. The role of Physician Associates relates to:
• Regulation 17: Good governance
• Regulation 18: Staffing
• Regulation 19: Fit and proper persons employed We will assess how providers ensure that:

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• They complete safe recruitment processes.
• There are enough qualified, skilled, and experienced people, who receive appropriate and effective support, supervision, and development.
• These staff work together effectively to provide safe care that meets people’s individual needs.
• There are clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support.
• Information about risk, performance and outcomes is managed and shared securely with others when appropriate.
• They value diversity in the workforce and work towards an inclusive and fair culture by improving equality and equity for people.
6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery. We are unable to comment on this point due to it being outside of the remit of our regulatory scope.
7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI We are unable to comment on this point due to it being outside of the remit of our regulatory scope.
8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in an RSI anaesthetic We are unable to comment on this point due to it being outside of the remit of our regulatory scope.

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.

Department of Health and Social Care Central Government

9 Apr 2025 PDF

Action Taken

DHSC acknowledges concerns regarding Physician Associates, rapid sequence induction, and guidelines. They highlight that healthcare professionals must practice within their competence. NHSE has issued guidance on the deployment of PAs and AAs in the NHS and NHS Employers has also published guidance for employers. (AI summary)

View full response

Dear Dr Henderson,

Thank you for the Regulation 28 report of 24th February 2025 sent to the Department of Health and Social Care about the death of Pamela Anne Marking. I am replying as the Minister with responsibility for secondary care, and I am also replying on behalf of the Chief Medical Officer for England, , who was also sent your report.

Firstly, I would like to say how saddened I was to read of the circumstances of Pamela Anne Marking’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns in relation to the following points:
1. The term ‘Physician Associate’ is misleading to the public
2. Lack of public understanding of the role of Physician Associate.
3. The right of patients and family to seek a second opinion
4. Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate
5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for Physician Associates
6. Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery
7. Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI
8. Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic

In preparing this response, 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.

This Government takes concerns about patient safety seriously. This is why, in November 2024, we commissioned to lead an independent review into PAs and AAs: Independent Review of the Physician and Anaesthesia As - Hansard - UK Parliament. Whilst there are governance processes already in place for the Physician Associate (PA) and Anaesthesia Associate (AA) professions, the review will consider the safety of the roles and their contribution to multidisciplinary healthcare teams. The review will draw upon a range of national and international evidence to produce a comprehensive picture of the physician associate and anaesthesia associate roles. This will include published research, real world data, and patient and professional views.

You highlight the limited awareness and understanding of the PA role and that the title is misleading. We are clear that an important part of being a healthcare professional is ensuring that the people they come into contact with understand who they are. All healthcare professionals should follow the National Institute for Health and Care Excellence (NICE) guidelines which state that healthcare professionals directly involved in a patient's care should introduce themselves and explain to their role to the patient.

Regulation of PAs and AAs by the General Medical Council (GMC) began in December 2024. The GMC expects the vast majority of practising PAs and AAs to join the register within the first six months of regulation, and they will be required to do so within two years of regulation commencing. PAs and AAs who are registered with the General Medical Council (GMC) are required to follow the professional standards and behaviour set out in Good medical practice. This includes introducing themselves and their role in patient care.

In addition, following public consultation, the GMC has updated its standards for course providers to include a specific requirement for them to ensure that student PAs and AAs inform patients when they are involved in their care.

However, we do agree that more can be done to improve awareness of the PA and other associate roles. The conclusions of the Leng review will help to provide greater clarity to both patients and healthcare professionals on the role

As you rightly highlight, it is important that patients are aware of their right to seek a second opinion regardless of who they have been seen by. Good Medical Practice outlines the principles, values, and standards of behaviour expected of all professionals registered with the GMC. This sets out that professionals must “recognise a patient’s right to choose whether to accept your advice, and respect their right to seek a second opinion”.goodmedical- practice-2024---english-102607294.pdf.

Your report also raises concerns around the lack of national and local guidelines and regulation of scope of practice for PAs. We are clear that all healthcare professionals are required to only practise within their competence to ensure they are practising safely, lawfully and effectively. NHSE has issued guidance on the deployment of PAs and AAs in the NHS which describes the expectations of how organisations providing NHS care should deploy PAs and AAs so that they can contribute to the delivery of safe and effective healthcare in a supportive environment.

PAs must always work under the supervision of a fully trained and experienced doctor, working with them, not replacing them. As set out in NHS England’s guidance on the deployment of PAs in the NHS: “PAs must always work within their competencies; and must be supervised appropriately. Employers must ensure that the overall responsibility for supervision of PAs is by a named senior doctor.” The relevant employer, in this case East Surrey Hospital, must follow these guidelines and have appropriate clinical governance in place. NHS Employers has also published guidance for employers - Medical associate professions (MAPs) employer guidance | NHS Employers.

All the guidance referred to in this letter remains in place and should be adhered to whilst the Leng review is undertaken.

I hope this response is helpful. The conclusions of the Leng review will be published in spring 2025 and will inform the workforce plan to deliver the 10 Year Health Plan. Further information can be found here: Independent review of physician associates and anaesthesia associates - GOV.UK Thank you for bringing these concerns to my attention.

Association of Anaesthetists RCOA Difficult Airways Society

16 Apr 2025 PDF

Noted

The Association of Anaesthetists and RCOA Difficult Airways Society address concerns raised and reference existing guidelines; they state that the topic of rapid sequence induction (RSI) is controversial and best clinical practice relies in addition to available evidence on careful risk assessment and risk mitigation. (AI summary)

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Dear Dr Henderson, Re: Regulation 28: Report to Prevent Future Deaths in the matter of Mrs Pamela Anne Marking Thank you for sending us a copy of your report regarding the sad death of Mrs Marking. We have jointly reviewed the information available to us in the report via our Safe Anaesthesia Liaison Group (SALG) in conjunction with the Difficult Airway Society. SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists. One of its core objectives is to analyse anaesthesia-related serious incidents and to share the learning with the specialty across the UK. We welcome the opportunity to address the concerns raised relating to anaesthesia and the second episode of clinical care, numbered 6-8 in your prevention of future deaths report. It is worth stating from the outset that the topic of rapid sequence induction (RSI) is controversial. By its emergency nature it is difficult to study scientifically and robust evidence supporting or refuting many of its components is simply lacking. Given the challenges of designing studies to provide stronger evidence for or against its use, it is unlikely that fully evidenced guidelines could be produced. Best clinical practice relies in addition to available evidence on careful risk assessment and risk mitigation. In cases where there is high risk of aspiration the potential benefits of RSI increase and thus its use is more rational. You highlighted your concern regarding the “lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery” and noted that you had heard evidence that “the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete.” Total intravenous anaesthesia (TIVA) is now used for approximately one quarter of all UK general anaesthetics1 and whilst the use of TIVA for rapid sequence induction (RSI) has been described2, surveys of practice suggest the vast majority of RSI involve a manual bolus, for induction. Demonstrating competence in RSI is a basic anaesthetic skill and forms part of the core competencies that all anaesthetists are taught in their first months of training and which form part of the Initial Assessment of Competency3. The Project for the universal management of airways (PUMA) provides recent guidance on the key components of an RSI4. The Difficult Airway Society are currently in the process of updating their 2015 guidelines for management of unanticipated difficult intubation in adults5, including the section on RSI underlining the key principles of the technique. You also highlighted your concern regarding the “lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI”. The Association of Anaesthetists have published guidelines on the use of TIVA, which includes a section on the use of TIVA for RSI2. These guidelines are currently in the process of being updated. It is worth noting that the 7th National Audit Project (NAP7)6 found that high-dose or rapidly administered propofol, particularly in combination with remifentanil, used to induce anaesthesia in higher risk patients, was associated with profound hypotension or cardiac arrest and thus should be avoided in frail patients. You mentioned that “approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4)”. We would just like to clarify that the 4th National Audit Project (NAP4)7 found that over

50% of airway-related anaesthesia deaths were due to aspiration. More up to date data from NAP7, which studied perioperative cardiac arrest, indicate that aspiration was a notably less prominent cause of such events, but that when these cases did occur it was usually during anaesthesia for patients with an acute abdominal pathology8.

Your report also raised a concern regarding the “lack of updated guidelines for use of cricoid pressure and other measures to protect the airway during an RSI anaesthetic”. Like other elements of RSI, the use of cricoid force remains a controversial topic, without robust evidence to either support or refute its value9. The NAP4 report7 recommended “on balance, rapid sequence induction should continue to be taught as a standard technique for protection of the airway. Further focused research might usefully be performed to explore its efficacy, limitations and also explore the consequences of its omission.” It also suggested “to maximise the likelihood of good quality cricoid force being applied, those who perform cricoid force should be trained in its methodology, should practise at regular intervals and should consider the use of simple methods of simulation.”

More recently the NAP7 report8 stated “The current data act as a reminder that, particularly in the setting of the acute abdomen, harm from pulmonary aspiration remains a significant risk and all the elements of an RSI that might mitigate the risk of aspiration are worthy of consideration. It has been argued that cricoid force, when taught and applied correctly, is a low-risk procedure, unlikely to cause harm and which can simply be removed if it is deemed to be interfering with intubation”. It is also our opinion that, where there is a high risk of aspiration, the use of cricoid force should be considered if it is more likely to do good than harm, especially as it can be easily removed if difficulty is encountered, and that this will form part of the risk assessment and airway management strategy.

The most important step to reduce the risks associated with RSI, as recommended by NAP4, is to undertake an individualised risk assessment and act on it. The NAP4 report7 states “All patients should have their risk of aspiration assessed and recorded before anaesthesia. The airway management strategy should be consistent with the identified risk of aspiration.” Furthermore, NAP7 report8 recommends “Anaesthetists should treat cases of acute abdomen as high risk for aspiration, assess the extent of that risk and plan airway management accordingly. Each airway manager should decide which elements of RSI they wish to use and be prepared to justify their use or omission.” We reinforce our support for these statements and will share the learning from Mrs Marking’s death with our members. As part of this we will publish a best practice statement on RSI. SALG publishes regular Patient Safety Updates, which are distributed to all members of the Association of Anaesthetists and Royal College of Anaesthetists.

We would be happy to respond to any questions that you might have.

GMC Regulator / Inspectorate

17 Apr 2025 PDF

Action Planned

The GMC highlights its new powers to regulate PAs and AAs and states that it is developing website materials, due to be published in Spring, to support doctors who are supervising PAs. (AI summary)

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Dear Dr Henderson Thank you for your letter of 24 February 2025 enclosing your report into the death of Pamela Anne Marking. I am truly sorry to hear of the tragic circumstances surrounding Mrs Marking’s death and I extend my condolences to her family and friends. I appreciate the opportunity to review your report and address the concerns that you raise. I am responding as the Medical Director and Director of Education and Standards at the GMC, and I have set out below answers to the questions raised in your report that fall within our remit, as the professional regulator of doctors, physician associates (PAs) and anaesthesia associates (AAs) in the UK. Regulation of PAs and AAs At the time of Mrs Marking’s death, the physician associate role was not yet subject to statutory regulation. Regulation helps provide assurance to patients, employers and colleagues that PAs have the right level of education and training required to be included on the register, meet the professional standards that we expect of the professions we regulate and that they can be held to account if serious concerns are raised. Since 13 December 2024 the GMC has had powers to:
• Set the principles, values and standards of professional behaviour expected of PAs.
• Set the outcomes and standards that students qualifying from PA courses must meet to achieve registration and approve the curricula that courses must deliver.
• Set a two-part assessment of clinical knowledge and skills that a PA needs to pass before registration.
• Check who is eligible to work as a PA in the UK and that they continue to meet the professional standards we set throughout their careers. The Law provides a two-year transition period for registration, meaning that PAs can legally practise without being on the

gmc-uk.org 2 GMC register until December 2026, however employers may require earlier registration (and the GMC strongly encourages it).
• Give guidance and advice to help PAs understand what’s expected of them.
• Investigate PAs who hold registration, where there are concerns that patient safety, or the public’s confidence in PAs, may be at risk, and take action if needed. In what follows I’ll outline the key parts of our regulatory approach that I believe speak to the issues raised in your report. It’s important to be clear at the start of my response, however, that although professional regulation is an important part of patient safety, it alone cannot prevent future deaths. A system wide approach to clinical governance is needed to ensure that PAs and AAs are supported to practise safely, effectively and ethically. I note that you have addressed your report to others who will be able to take actions relevant to the work of their respective organisations. The contributions of multiple organisations – including regulators, professional bodies, the four UK governments and respective health services – are vital in promoting multidisciplinary team working, delivering revalidation, determining safe practice, and ensuring appropriate supervision of PAs working in the UK in future.

Being clear about roles PAs have been part of the UK healthcare workforce for around 20 years, but numbers are still relatively small, so it is even more important that they are always clear about their roles and responsibilities with the patients they treat. Now that regulation is in effect, the registers on our website are clearly marked to distinguish between the three professions we regulate. A prefix is used for PA and AA reference numbers, which provides a clear distinction between those two professions and doctors. In addition, each profession type is prominently labelled on our public-facing registers, and in search functions. This means that when patients search our registers it will be very clear whether an individual is a doctor, a PA or an AA. Good medical practice makes clear that all those registered with us must:
• always be honest about their experience, qualifications, current role, and they should introduce themselves to patients, and explain their role in patient care (paragraph 82).
• recognise and work within the limits of their competence, and only practice under the level of supervision appropriate to their role, knowledge, skills and training, and the task being carried out (paragraph 2).

gmc-uk.org 3 We agree that PAs should not be described as equivalent to doctors. All the professionals on our register are expected to clearly establish the scope of their roles with their employers and raise any issues of ambiguity or uncertainty around responsibilities in multidisciplinary teams. This includes supervision arrangements for staff, and lines of accountability for care provided to individual patients. (Leadership and management, paragraph 17). All the professionals on our register must also be familiar with, and use, clinical governance and risk management structures and processes to ensure high standards of care, including raising concerns where there is reason to believe that patients may be at risk of harm for any reason, including where they have reason to believe that systems, policies, procedures or colleagues are, or may be, the source of the risk (Leadership and management, paragraphs 24-29).

Making decisions and seeking second opinions PAs on our register must work in partnership with their patients to make decisions about treatment and care. They must give patients the information they want and need, in a way they can understand. And they must listen to patients and encourage an open dialogue by asking questions to help patients express what matters to them (GMP domain 2 and Decision making and consent). PAs must recognise a patient’s right to choose whether to accept their advice, and that they must respect patients’ rights to seek a second opinion (GMP paragraph 18). And they must refer patients to another suitably qualified practitioner when this serves their needs (GMP paragraph 7h).

Scope of practice You’ve expressed concerns about PAs working outside of their capabilities due to a lack of guidelines relating to their scope of practice. In this part of my response, I’ll explain the legislative framework underpinning our regulatory approach to this, before going on to explain out how we’ll make sure that PAs on our register are working within their competence, keeping up to date and are fit to practice as they develop in their careers. The legislation bringing PAs into regulation requires us to set the standards for their education and training that will give them the clinical knowledge and skills they need to demonstrate before they can register with us. The registration assessments that PAs need to complete before being granted registration assess a standardised baseline of clinical knowledge and skills for their profession. A PA’s scope of practice at the beginning of their careers will therefore be informed by the clinical knowledge and skills they have learned during their training and that they have demonstrated

gmc-uk.org 4 objectively by passing our two-part assessment. Our standards do not impose ceilings on what individual doctors, PAs and AAs can do once registered. This is because we recognise that competence will vary by individual and is shaped by their supervised training and experience, and the clinical context of their work. Robust systems of clinical governance are important to ensure a consistent approach to the safe and effective deployment of PAs and AAs. Employers have a clinical governance responsibility to ensure that all their employees are appropriately trained and competent to do the activities they are tasked with. It 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. To support employers, we have issued our updated guidance Effective clinical governance to support revalidation. It emphasises that PAs and AAs must be supervised and recommends that organisations identify an individual at Board level to be responsible for PAs and AAs. It also suggests establishing local processes to govern how these professionals are deployed and supervised. The work of a PA or AA must be overseen by a named senior doctor, and they must work together to agree appropriate limitations to their practice. As with other professionals that doctors supervise and work alongside in multidisciplinary teams, doctors are not accountable to us for the decisions and actions of PAs and AAs, provided they have delegated responsibility in line with the standards set out in our guidance, as described under the next subheading below. For their part, once registered with us, PAs must be competent in all aspects of their work, and recognise and work within the limits of that competence (GMP 1&2) They must also maintain, develop and improve their performance in line with the provisions in Good medical practice paragraphs 11-13 which include keeping their knowledge and skills up to date, taking part in structured support opportunities, training and professional development activities, participating in quality assurance and quality improvement initiatives, undergoing regular reviews and audits of work and participating in ongoing reflective practice using feedback. PAs are already expected to participate in annual appraisals with their employer, and, in future, they will have to go through a process of revalidation, similar to the one that doctors undertake. This means that PAs will need to demonstrate, with evidence, that they remain competent to undertake their role, and that they remain up to date and fit to practise. We believe that the royal colleges and other specialist professional bodies have the level of clinical expertise required to provide more detailed guidance on PA scope of practice within their specialty areas. We are grateful for the work that royal colleges have undertaken so far in developing

gmc-uk.org 5 guidance, and last year (2024) we provided feedback on draft scope of practice guidance documents developed by the Royal College of General Practitioners, the Royal College of Physicians, and the Royal College of Anaesthetists. We feel that guidance of this nature will be most valuable if it avoids unnecessary prescription and helps support safe development of roles and individuals over time, within robust local procedures and governance.

GMC guidance on supervision, delegation and teamwork for PAs and the doctors who oversee their work. For the professionals on our register, the professional standards relating to supervision, delegation and working with colleagues are set out across several pieces of guidance including Good medical practice, domain 3; Delegation and referral paragraphs 1-14; and Leadership and management, paragraphs 24-38 and 60-62. We say that supervisors must make sure that the people they oversee have appropriate supervision, whether through close personal supervision (for newly qualified colleagues, or individuals in training, for example) or through a managed system with clear reporting structures. We don’t specify that supervision must be direct, as in the same room. Instead, we expect supervisors to take account of the nature of the tasks being delegated, as well as the skills and experience of the PA. We also expect doctors and PAs to follow local employer policies and have regard to other relevant national guidelines, such as relevant college guidelines - in this case, the Royal College of Emergency Medicine guidelines for supervision of PAs, which we note were recently updated in February 2025. We are currently in the final stages of developing materials for our website, to support doctors who are supervising PAs, and help them to apply the principles in our guidance within their practice. This material, due to be published in spring, brings together all of our relevant standards, expanding on these with further advice, as well as signposting to a range of other resources published by others. Now that PAs are regulated professionals, they share professional responsibility and accountability for ensuring that they are appropriately supervised for any task they undertake (Leadership and management, paragraph 60). They must recognise and work within the limits of their competence and only practise under the level of supervision appropriate to their role, knowledge, skills and training, and the task they’re carrying out (GMP paragraphs 1&2). Further, if a task is delegated to a PA by a colleague, and the PA is not confident they have the necessary knowledge, skills or training to carry it out safely, they must prioritise patient safety and seek help, even if they’ve already agreed to carry out the task independently (GMP, paragraph 67).

gmc-uk.org 6 Next steps Thank you for the opportunity to respond to this report. I hope this information provides reassurance around our regulatory approach towards PAs, which is in line with the established system we have in place for doctors. We hope that regulation, along with action from others, will help ensure a similar incident does not happen again. We will continue to work with others to ensure all patients have confidence in the care they receive.

Surrey and Sussex NHS NHS Trust

17 Apr 2025 PDF

Action Taken

Surrey & Sussex Healthcare NHS Trust acknowledges concerns regarding public understanding of Physician Associates, rapid sequence induction, and the use of cricoid pressure. It states PAs wear different coloured scrubs, and are trained to introduce themselves as PAs. They communicated the importance of cricoid pressure to the anaesthetic team and trainees, and that modified TIVA technique is used with a predetermined dose of propofol and muscle relaxant. (AI summary)

View full response

Dear Dr Henderson,

Regulation 28 Report – response by Surrey & Sussex Healthcare NHS Trust Inquest touching the death of Pamela Anne Marking (Date of Birth 20/09/1946)

This response comprises the formal response of Surrey & Sussex Healthcare NHS Trust (the Trust), pursuant to section 7(2) to schedule 5 of the Coroners and Justice Act 2009 and Regulation 29 Coroners (Investigations) Regulations 2013, to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 24 February 2025, made subsequent to the inquest into the death of Mrs Marking, which was concluded on 19 December 2024.

The Trust was given until 21 April 2025 to respond to the coroner, pursuant to Regulation 29(5) Coroners (Investigations) Regulations 2013.

We would like to start this response by offering our sincere condolences to Mrs Marking’s family. As a Trust we are committed to learning from the issues raised during the Inquest.

The Prevention of Future Deaths report identifies a number of areas of concern, and we address these in turn in the following response, where it is within the Trust’s ability to do so, and we describe the details of the actions that we have undertaken.

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.

The term ‘Physician Associate’ is a national term, sanctioned by national bodies, and describes a particular group of healthcare professionals who have completed a recognised training programme. However, the Trust recognises that there is a lack of awareness amongst the public and indeed amongst some healthcare staff that Physician Associates are not medically qualified practitioners. Since we first employed Physician Associates (PAs) at the Trust we have tried to make this distinction as clear as possible. At the Trust, PAs always wear uniquely coloured

Please reply to: Name: Title: Chief Medical Officer Direct Line Email:

Dr Karen Henderson H M Assistant Coroner for Surrey Station Approach Woking GU22 7AP

Headquarters East Surrey Hospital Canada Avenue Redhill RH1 5RH

Tel: 01737 768511

scrubs (turquoise), which are clearly embroidered on the front with “Physician Associate.” They also always wear distinct bright yellow lanyards clearly inscribed with “Physician Associate.” All the PAs are trained to introduce themselves to patients and their families as “Hello, my name is xxx, I’m a Physician Associate”. Subsequent to this Prevention of Future Deaths report, the Trust’s Chief Medical Officer and Chief Executive met with the Trust PAs and have instructed them 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.” This applies across the Trust, including in the Emergency Department (ED). Within the Emergency Department, since the Inquest, we have installed clear signage throughout, identifying the different members of the clinical team by the different colours of scrubs that they wear.

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.

The Trust has always followed national guidance regarding the scope of practice for Physician Associates. We recognise that PAs are not medically qualified, and we do not allow PAs to undertake roles outside of their competency, but they nonetheless have a valid role within the clinical team. Until February 2025 the Royal College of Emergency Medicine guidance was that in the Emergency Department Physician Associates should work on Tier 2 of the ED rota. That did not mean that PAs were the same as Tier 2 resident doctors, but that they could work alongside them. As of 28th February 2025, the Royal College of Emergency Medicine issued new guidance, stating that PAs should now be on Tier 1 of the ED rota. We immediately made that change and implemented the new guidance in full. We have issued a new scope of practice document for PAs in the ED which we have enclosed with this letter. This confirms that the Trust complies with the new guidance.

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.

We believe that we have explained above all that is within the remit of the Trust regarding this concern.

Lack of national and local guidelines and regulation of the scope of practice for a Physician Associate: A diagnosis of epistaxis was made by the Physician Associate without appreciating the relevance of the vomiting and lower abdominal discomfort and in the absence of understanding the need to undertake palpation of the groins in 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.

The PA involved in Mrs Marking’s care has undertaken an extensive reflective practice review with a number of the ED Consultants and will include this in their annual appraisal. We have had a local governance policy in place for all PAs that work at the Trust since 2015. Within this we worked to all available national guidance at the time and have amended the

policy in line with changes as they were made at a national level, particularly since the GMC began the process towards regulation.

The scope of practice for PAs at graduation is underpinned by the Department of Health Matrix of Core Clinical Conditions, enclosed with this letter, which outlines the key presentations and conditions that PAs are expected to manage. This framework ensures that PAs work within their competencies and escalate cases appropriately. At the time of Mrs Marking’s death, the Trust was following interim standards for PAs and AAs (GMC) published October 2021 and the Core Capabilities Framework for Medical Associate Professionals published June 2022, enclosed. The following links to the NHS England guidance that contains all the relevant guidance that the Trust has adhered to since we first employed PAs: https://www.england.nhs.uk/long- read/summary-of-existing-guidance-on-the-deployment-of-medical-associate-professions-in- nhs-healthcare-settings/

In response to the issues raised in this Inquest, and in response to the new guidance from the Royal College of Emergency Medicine, enclosed with this letter, we have issued a new scope of practice document for PAs in our ED and implemented it immediately, as of 3rd March 2025. This specifically states that if it is planned for a patient to be discharged from ED after seeing a PA, that patient must first be reviewed in person by a senior ED doctor, Tier 4 or 5. All our PAs and ED Consultants have been instructed to follow this change and are supportive of it and the document has been circulated.

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.

The new scope of practice document addresses these concerns. PAs now work on Tier 1 of the ED rota. They do not now see undifferentiated patients, but have specific patients identified as suitable for them by an ED Consultant. Throughout the patient’s stay within the ED, the PA will escalate to a senior ED doctor if there are any concerns or any deterioration in the clinical condition of the patient. Any patient seen by a PA who is for discharge will be reviewed face to face by a senior ED doctor prior to discharge. Any patient seen by a PA and then referred for admission will then be seen by doctor from the appropriate admitting speciality.

Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia for emergency surgery: Mrs Marking required a rapid sequence induction to protect her airway from aspiration of bowel contents as a consequence of small bowel obstruction. The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive syringes of induction agent and muscle relaxant was obsolete, and it was common practice locally and nationally to routinely undertake a RSI with Total Intravenous Anaesthesia, in the absence of updated local or national guidelines to support this practice.

There is national guidance that describes the use of modified Total Intravenous Anaesthesia during Rapid Sequence Induction, and it is accepted practice across the UK as an option. This guidance from the Association of Anaesthetists and the Society for Intravenous Anaesthesia is attached. The Difficult Airway society guidance lists it as ‘accepted practice’ in RSI. The traditional use of consecutive syringes of induction agent and muscle relaxant is still practiced by the majority of the clinicians in the anaesthetic department at the Trust.

Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI: Other than empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no

evidence was forthcoming as to the target range required to ensure and confirm an adequate depth of anaesthesia for patients or the length of time required prior to and following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. This is despite TIVA being known to provide a slower onset of anaesthesia and approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4).

At the Trust, if a clinician is using TIVA for RSI, they always use a modified TIVA technique which involves a predetermined dose of propofol as induction agent as a bolus and a predetermined dose of muscle relaxant as a bolus dose. This allows for rapid anaesthesia, as per the enclosed guideline.

Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect the airway in a RSI anaesthetic: Evidence was heard that as cricoid pressure was ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, the only suction device was attached to the nasogastric tube giving rise to a possible delay in timely suctioning of the feculent aspirate which was in excess of two litres after intubation was achieved.

The use of cricoid pressure during RSI is not universal in all situations as it can make intubation more difficult and is listed as an optional measure by the Difficult Airway Society. However, the Trust accepts that in the setting of bowel obstruction, with the increased risk of aspiration, cricoid pressure should have been used. This has been communicated across the whole anaesthetic team at a departmental meeting and in the Mortality & Morbidity meeting. All anaesthetic trainees at their departmental induction are instructed to use cricoid pressure and this is reiterated in regular simulation training.

We hope the above provides you with sufficient information and assurance but if you require more details, please do not hesitate to contact me.

Royal College of Physicians Education

22 Apr 2025 PDF

Action Planned

The RCP acknowledges concerns about the safe deployment of PAs and notes that the Faculty of Physician Associates was dissolved on 31 December 2024. It highlights concerns regarding regulation, scope of practice and supervision and states they have now delivered the results of a working group on PA and have submitted their findings to the Leng review alongside a submission from their resident doctors. (AI summary)

View full response

Dear Dr Henderson,

The Royal College of Physicians (RCP) notes with concern the content of the Regulation 28 report for the prevention of future deaths related to the death of Pamela Anne Marking.

We send our sincere condolences to the family of Mrs Marking.

The Regulation 28 report is addressed to the RCP, but we wanted to note that whilst the Faculty of Physician Associates (FPA) was part of the RCP at the time of the inquest, it was dissolved on 31 December 2024. Additionally, effective 13 December 2024, the GMC began regulation of Physician Associates (PAs).

This letter has also been addressed to recipients with expertise in anaesthesia, who may be best placed to respond to concerns 6, 7 and 8.

Many of our fellows and members have significant concerns about the safe deployment of PAs, especially concerning regulation, scope of practice and supervision. We have now delivered the results of a working group on PA and have submitted our findings to the Leng review alongside a submission from our resident doctors. To ensure that the PA workforce is able to contribute to patient care actively and safely, the RCP believes that considerable changes need to be made. This will require time, commitment, coordination, transparency - and above all - collaboration between the NHS, patient groups, royal colleges, the GMC, and medical associate professionals, including PAs.

Matters of concern and the RCP response

1. The term ‘physician associate’ is misleading to the public

We agree there is significant risk of confusion for the public, particularly noting patients and families are often in vulnerable situations when they seek healthcare advice. We also note that the lack of understanding around the term ‘physician associate’ is not the fault of the PA. We believe the term ‘assistant’ is much clearer and in line with the competence of the PA, and have recommended a change in name in our submission to the Leng review. We also note the need for clear and specific introductions from the PA when introducing themselves to patients and their families and suggest not using phrases such as ‘I am on your clinical / medical team.’ The RCP published interim guidance on titles and introductions for PAs in December 2024, in which we were clear that ‘PAs must clearly explain their role to patients, their families and carers, as well as colleagues and supervisors, and provide details of their educational and clinical supervision when required.

2. Lack of public understanding of the role of physician associate

We agree that, for both patients and the wider healthcare system, the role of the PA is confusing. ‘Medical professional’ is another term used for a PA and, again, we believe that for the public and wider healthcare system this does not provide adequate clarification in the differences in roles, training and competency between doctors and PAs.

3. The right of patients and family to seek a second opinion

This would be addressed at a local level, but we fully support the implementation of Martha’s Rule to enable families to ask for a second opinion when they are worried about a relative’s acute deterioration. In addition, we are clear that PAs should not be making decisions independently, particularly around discharge in patients in an emergency or undifferentiated setting.

4. Lack of local and national guidelines and regulation of the scope of practice for a physician associate

The RCP believes that PAs should be working to nationally-agreed guidelines and relying on local guidelines only risks inconsistency, or at worst no agreed guidelines at all. The GMC is now responsible for regulation, but our understanding is that regulation will need to be supported by national guidelines to provide a clear framework for assessment. We would also welcome clarity of PA clinical competency at qualification; we note passing the PA exit exam is not synonymous with competency and ability in a clinical setting.

5. Lack of guidelines for direct supervision and consideration of an appropriate level of autonomy for physician associates

We agree with this and the RCP has written published interim guidance for physician associates working in the medical specialties.

The FPA closed in December 2024. The initial transfer of PA Managed Voluntary Register (PAMVR) data from the RCP to the GMC began on 31 October 2024, and was deleted on 31 March 2025. The GMC register opened on 13 December 2024 and will be voluntary until December 2026.

The RCP is clear that PAs are not doctors but workforce pressures are very high, particularly in acute care, and this leads to risk of workforce substitution and lack of adequate capacity for supervision and training. At worst, this risks assessment of patients in inappropriate spaces and pressure to rapidly discharge without ability to observe and review. Elderly frail patients with dementia or confusion are particularly at risk in our current overcrowded systems. The RCP also supports the need for the development and distribution of clear guidance for the consultant who is supervising the work of the PA to ensure standardised, adequate oversight.

A comprehensive, national, safe and clear scope of clinical practice for PAs is essential. However, we note the following:

> There is insufficient central coordination, or agreement, within the NHS and amongst employers on how a national scope of practice should be developed and by whom. > There is limited awareness of what a PA can safely do in a clinical setting upon completion of PA studies and no agreed mechanism for extended clinical practice. > PAs are employed in a very wide range of clinical settings and specialties, and within both the NHS and private healthcare settings. System leaders, including the GMC, should take a leading role in developing and overseeing a national scope of practice and supervision of PAs. Multi-disciplinary working must be supported by full regulation and competency assessment. A national framework for the employment and deployment of PAs is needed. National policy and guidance must be clearly understood and delivered locally, supported by good governance structures.

Working with our fellows and members, the RCP will continue to actively campaign to limit the pace and scale of roll-out of PAs in the NHS until we are reassured that there are safe systems in place for PA deployment. We have repeatedly made clear that PAs are not doctors, and they cannot and must not replace doctors. We have also called on the UK government and the NHS to develop and publish an evidence-base and evaluation framework around the introduction of PAs. This should be a priority, and we are working with the RCP Patient Safety Committee to consider what more we can do to support this agenda.

Report sections

Investigation and inquest

On 16th December 2024 I resumed the inquest into the death of Mrs Pamela Anne Marking. On 19th December 2024 I concluded the Inquest. At the time of her death Mrs Marking lived independently and was 77 years of age.

The medical cause of death given was:

1a Respiratory failure and Sepsis 1b Aspiration of feculent gastric contents at induction of anaesthesia 1c. Strangulated femoral hernia

I found:

On 16th February 2024 Pamela Anne Marking - who was unable to give a complete history due to cognitive issues - was admitted to the Emergency Department at East Surrey Hospital. Redhill from her home address after unknowingly vomiting blood-stained fluid, with right sided and suprapubic abdominal tenderness. She was diagnosed as having had an epistaxis (nosebleed) by a Physician Associate and discharged home later that afternoon without a medical review or direct medical supervision of the Physician Associate who had a lack of understanding of the significance of abdominal pain and vomiting and had undertaken an incomplete abdominal examination which would have been likely to have found a right femoral hernia. Mrs Marking re-presented to the Emergency Department two days later with grossly dilated small bowel obstruction due to an incarcerated right femoral hernia containing ischaemic bowel requiring emergency surgery later that evening. A rapid sequence induction (RSI) of anaesthesia to protect her airway from aspiration of gastric contents was undertaken with Total Intravenous Anaesthesia (Propofol and Remifentanil and thereafter Rocuronium), in the absence of cricoid pressure and with a nasogastric tube in situ attached to the only suction device. This approach was considered a commonly deployed and safe technique in the absence of updated national guidelines. On induction of anaesthesia, Mrs Marking aspirated feculent fluid resulting in respiratory failure in the immediate post operative period requiring re-intubation and intensive care input. Despite maximal support Mrs Marking died at East Surrey hospital, Redhill on 20th February 2024. The clinical management Mrs Marking had on her first admission and thereafter during the Rapid Sequence Induction materially contributed to her death.

Circumstances of the death

Please see my findings above

Copies sent to

1. Mr MarkingSignedDATED this 24th Day of February 2025

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2025-0107
Date of report: 24 February 2025
Coroner: Karen Henderson
Coroner area: Surrey

Responses identified

Responses identified 8 of 10

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Apr 2025 (estimated).

Sent to

Association of Anaesthetists of GB and Ireland

Care Quality Commission

Department of Health and Social Care

Difficult Airway Society

General Medical Council

NHS England

Royal College of Anaesthetists

Royal College of Emergency Medicine

Royal College of Physicians

Surrey and Sussex Healthcare NHS Foundation Trust

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