Recurring concern

Failure to inform patients about clinicians’ qualifications and experience

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First reported 24 Feb 2025•Latest report 17 Sep 2025

Definition

What this concern includes

Includes failures by healthcare providers to disclose clearly and appropriately to patients or their families the clinician’s professional qualification or status and materially relevant experience where that information affects informed care decisions, expectations of competence or the ability to seek an appropriate second opinion.

Not included

  • Excludes failures to verify or credential clinicians internally before independent practice; those belong to clinician competence or credentialing concerns.
  • Excludes misuse or lack of legal protection for healthcare professional titles where patient disclosure is not the deficient control.
  • Excludes general Duty of Candour, transparency or complaint-handling failures that do not concern disclosure of the involved clinician’s qualifications, professional status or relevant experience.
  • Excludes disclosure of routine staff identity, grade or role where qualifications or materially relevant experience are not the safety-relevant information.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2025–2025

First to latest report issue date

Stated actions
8

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission2
Department of Health and Social Care2
Association Of Anaesthetists (Great Britain & Ireland)1
Difficult Airway Society1
General Medical Council1
Goring Hall Hospital1
NHS England1
NHS Surrey and Sussex Integrated Care Board1
Royal College of Anaesthetists1
Royal College of Emergency Medicine1
Royal College of Physicians1
Surrey and Sussex Healthcare NHS Trust1
Sussex Medical Chambers Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. West Sussex, Brighton and Hove

    AI-generated summary

    Keith James Hankin · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Keith James Hankin was admitted for an elective optical urethrotomy on 8 September 2023, developed sepsis shortly after the procedure, was transferred to Worthing Hospital, and died there on 11 September 2023. The report identifies concerns about poor clinical governance and lack of integration, oversight and clinician assessment within the Community Urology Service, as well as multiple omissions in his pre-operative, intra-operative and post-operative care at Goring Hall Hospital, including delays in recognising and treating sepsis and transferring him for further management.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to fully inform patients of clinicians’ relevant experience

    Wider context from the report

    “4. Practicing Privileges within the private sector ████████ set up and led the CUS under the auspices of SMC. The ICB contractually required this service to be run by a consultant urologist. ████████ had not held a formal consultant urologist position within the NHS prior to tendering for this work. It remains unclear as to how ████████ was provided with practicing privileges at a private hospital as a consultant and was therefore able to practice independently and without scrutiny. This gives rise to a concern that there is a lack of robust assessment and guidelines, both locally and nationally, as to how clinicians are given practising privileges to work independently outside of the NHS to the potential detriment of patient care. It also gives rise to a concern that patients are not being fully informed of the relevant experience of such clinicians thereby breaching the statutory duty of candour responsibility of all hospitals. ”

    Source location

    Keith James Hankin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish personal profiles for consultants on the hospital website, alongside GMC Specialist Register information, to provide patients with transparent experience information.

    Verbatim wording from the response

    “Turning to the second part of the concern, which suggests a breach of the statutory duty of candour placed on all hospitals regulated by the CQC. This duty requires healthcare providers to be open and transparent with their patients. For the reasons stated above, I have found no basis on which it can fairly be asserted that CHG is breaching the statutory duty of candour or otherwise failing to be transparent. It should also be noted that CHG’s website publishes personal profiles for all consultants who provide services at CHG facilities. This is in addition to the detail provided on the GMC Specialist Register, which confirms their registration and any restrictions on it. Taking the example of the treating surgeon in Mr Hankin’s case, the personal profile on CHG’s website is detailed and fully transparent about his extensive experience.”

    Source location

    Response from Circle Health Group
    Page 2 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    CHG disputes breaching the statutory duty of candour, relying on consultant profiles and GMC registration information as transparent disclosures to patients.

    Verbatim wording from the response

    “Turning to the second part of the concern, which suggests a breach of the statutory duty of candour placed on all hospitals regulated by the CQC. This duty requires healthcare providers to be open and transparent with their patients. For the reasons stated above, I have found no basis on which it can fairly be asserted that CHG is breaching the statutory duty of candour or otherwise failing to be transparent. It should also be noted that CHG’s website publishes personal profiles for all consultants who provide services at CHG facilities. This is in addition to the detail provided on the GMC Specialist Register, which confirms their registration and any restrictions on it. Taking the example of the treating surgeon in Mr Hankin’s case, the personal profile on CHG’s website is detailed and fully transparent about his extensive experience.”

    Source location

    Response from Circle Health Group
    Page 2 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    CHG considers no additions or changes to its current practising-privileges and transparency processes necessary.

    Verbatim wording from the response

    “Having considered your concerns carefully, CHG is satisfied that no additions or changes to its current processes are required, and that medical practitioners working within its facilities have the necessary qualifications, expertise and experience to do so, and that this is fully transparent to CHG patients.”

    Source location

    Response from Circle Health Group
    Page 2 · response
    Published 19 September 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Further information about clinicians' experience and competency cannot be provided because of confidentiality constraints.

    Verbatim wording from the response

    “In the absence of you requesting further information as to experience and competency, CUS was not in a position to address your concerns and is unable to do so in this response for confidentiality reasons.”

    Source location

    Response from Sussex Medical Chambers
    Page 4 · response
    Published 19 September 2025

    Open published response
  2. Surrey

    AI-generated summary

    Pamela Anne Marking · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners

    Wider context from the report

    “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. ”

    Source location

    Pamela Anne Marking · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to inform patients and families that Physician Associates are not medically qualified

    Wider context from the report

    “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. ”

    Source location

    Pamela Anne Marking · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish a summary of existing guidance on deploying medical associate professionals.

    Verbatim wording from the response

    “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”

    Source location

    Response from NHSE
    Page 1 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue a position statement setting standards for Physician Associate supervision, identification, patient selection and regulation.

    Verbatim wording from the response

    “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:”

    Source location

    Response from RCEM
    Page 1 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish interim guidance requiring physician associates to explain their roles, supervision and educational or clinical background to patients, families, carers and colleagues.

    Verbatim wording from the response

    “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.’”

    Source location

    Response from Royal College of Physicians
    Page 2 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Identify Physician Associates through distinctive clothing, lanyards, and explicit introductions that clarify they are not doctors.

    Verbatim wording from the response

    “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”

    Source location

    Response from Surrey and Sussex NHS
    Page 1 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Install Emergency Department signage identifying clinical team members by their scrub colours.

    Verbatim wording from the response

    “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.”

    Source location

    Response from Surrey and Sussex NHS
    Page 2 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Clearly distinguish doctors, physician associates and anaesthesia associates on public registers and in register searches.

    Verbatim wording from the response

    “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.”

    Source location

    Response from General Medical Council
    Page 2 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Clearly communicate that physician associates are not doctors and must not replace doctors.

    Verbatim wording from the response

    “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.”

    Source location

    Response from Royal College of Physicians
    Page 3 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Public terminology, role understanding and second-opinion rights fall outside the regulatory scope.

    Verbatim wording from the response

    “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.”

    Source location

    Response from CQC
    Page 2 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The General Medical Council is best placed to address public terminology, role understanding and second-opinion rights.

    Verbatim wording from the response

    “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.”

    Source location

    Response from CQC
    Page 2 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing NICE and GMC standards require healthcare professionals to identify their role to patients, addressing role-identification concerns.

    Verbatim wording from the response

    “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.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    “Physician Associate” is a nationally sanctioned term describing healthcare professionals with recognised training, rather than an inherently misleading title.

    Verbatim wording from the response

    “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.”

    Source location

    Response from Surrey and Sussex NHS
    Page 1 · response
    Published 26 February 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Trust considers that it has explained everything within its remit regarding patients’ and families’ ability to seek a second medical opinion.

    Verbatim wording from the response

    “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.”

    Source location

    Response from Surrey and Sussex NHS
    Page 2 · response
    Published 26 February 2025

    Open published response
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Data last updated 7 September 2026