Term ‘Physician Associate’ Misleads Public, Coroner Says After Woman Dies Following Misdiagnosis

The coroner said there was a lack of public understanding around the role, which has the potential to devalue or undermine confidence in the medical prevention.

A general view of staff on a NHS hospital ward at Ealing Hospital in London, on Jan. 18, 2023. PA Wire/PA Images

The term “physician associate” (PA) is “misleading to the public,” a coroner has said after a woman died following hospital failings, including a PA misdiagnosing her hernia as a nosebleed.

Assistant Coroner for Surrey Dr. Karen Henderson made the statement in her Action to Prevent Future Deaths report published on Wednesday, which evaluated the care of 77-year-old Pamela Marking who died last year.

Henderson went on to say that there was a lack of public understanding around the PA role, which has the potential to devalue or undermine confidence in the medical prevention as well as potentially hinder patients’ and their families’ requests to seek an opinion from a doctor.

“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,” she said.

PAs are graduates who have degrees in health or life sciences and who have two years of postgraduate training, but do not have medical degrees. They have been deployed across hospitals and GP surgeries to support doctors in treating patients.

Mistaken for Doctor

Marking attended the emergency department at East Surrey Hospital on Feb. 16, 2024, suffering from abdominal pain and vomiting blood. She was seen by a PA who told her she had a nosebleed and sent her home. She was readmitted to hospital two days later and died on Feb. 20 after complications with her care.

Henderson said the PA “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.”

The coroner also noted that Marking’s son “was under the mistaken belief that the Physician Associate was a doctor by this title.” She said no steps were taken by either the PA or emergency department to clarify what that role was or how it differed from qualified doctors.

“The clinical management Mrs Marking had on her first admission and thereafter during the Rapid Sequence Induction materially contributed to her death,” Henderson wrote.

A spokesperson for Surrey and Sussex Healthcare NHS Trust told reporters that it would continue to look carefully at the details of this case “to ensure we learn any lessons to keep improving our services and deliver the safest possible care to our patients.”

The spokesperson added that PAs in emergency departments “work within a very specific scope of practice under the direct supervision of a consultant” and “use the recommended introduction of their role when meeting patients.”

An NHS spokesperson said that it was carefully considering the coroner’s report and will respond in due course, but that it “has always been clear that physician associates are not replacements for doctors and should only practice with appropriate medical supervision.”

Undated family handout photo of Emily Chesterton, who died from a pulmonary embolism after being misdiagnosed on two occasions by a physician associate. PA

Emily Chesterton

According to the NHS, PAs work under the supervision of a doctor and perform a range of tasks including diagnosing illnesses, analysing test results, and performing physical examinations. Similarly, anaesthesia associates (AAs) work under a consultant anaesthetist and provide support anaesthetic services.

The government’s current plan is to almost triple the number of PAs in England from 3,5000 to 10,000 by 2036/37 and to recruit 2,000 more AAs.

The use of PAs and AAs—collectively known as medical associate practitioners—has come under scrutiny following concerns raised from the public and the British Medical Association, and after high-profile cases of patients dying following misdiagnoses by PAs.

One case was that of Emily Chesterton, who died at the age of 30 in 2022 of a blood clot that was misdiagnosed by two PAs as anxiety. She had been under the impression she had seen a doctor.

A coroner later ruled Chesterton “should have been immediately referred to a hospital emergency unit,” where she would have likely been treated for a pulmonary embolism and would have survived.

‘Legitimate Concerns’

In November, the government launched a review into the role of medical associate practitioners which is being led by Professor Gillian Leng, the president of the Royal Society of Medicine.

Speaking at the time, Health Secretary Wes Streeting said that while many associates are providing good care and freeing up doctors to perform other specialist tasks, “there are legitimate concerns over transparency for patients, scope of practice, and the substituting of doctors.”

Streeting said the review “will establish the facts, take the heat out of the issue, and make sure that we get the right people, in the right place, doing the right thing.”

The Leng review is expected to be published in the spring.