Recurring concern

Failure to reliably communicate clinicians’ identities and clinical grades

First to latest report 27 Jan 2017 — 10 Aug 2025

Reports that mention this concern: 3
Times this concern has been raised: 4
Stated actions linked to this concern: 12

What this concern includes

Includes failures in healthcare processes to communicate or confirm the identity, role or clinical grade of involved personnel to supervisors, colleagues, patients or families when that information is needed for safe supervision, accountability or decision-making.

What is not included

Excludes failures to identify patients, relatives or other non-clinical parties.
Excludes inaccurate clinical records where clinician identity communication is not the unsafe condition.
Excludes general communication, supervision or staffing deficiencies without a specific failure to communicate clinician identity or clinical grade.
Excludes credentialing, registration or competence-assurance failures where the issue is not communicating who the clinician is or what grade they hold.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Cornwall Partnership NHS Foundation Trust1

Department of Health and Social Care1

Faculty of Physician Associates1

General Medical Council1

Lifestar Medical Limited1

Maidstone and Tunbridge Wells NHS Trust1

South Western Ambulance Service NHS Foundation Trust1

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

10 Aug2025
Cornwall and Isles of Scilly
Concerns raised2
1. Failure to establish ambulance staff role and assessment status
2. Failure to confirm ambulance staff clinical grade during introductions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Cornwall Partnership NHS Foundation Trust
Lifespan Medical Limited
South Western Ambulance Service NHS Foundation Trust
Stated actions 4
1. Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
  Require LML staff to identify their name, clinical role, scope and limitations, and wear correct clinical-grade epaulettes during patient and inter-organisational encounters.
2. Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
  Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
3. Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
  Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.
1. Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation Trust
  Reinforce clear staff introductions through LML’s mandatory annual face-to-face training, including role-specific discussion and scenario practice.
AI-generated summary

Brian Ingram · 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

Brian Ingram, an 85-year-old man with dementia and vascular Parkinsonism, fell and was taken to a minor injuries unit after a delay. His hip fracture was not identified there, and he was discharged before later admission to hospital, where he underwent surgery and died. Concerns included the lack of a physical assessment, failure to identify groin pain and obtain a hip x-ray, assumptions about the ambulance staff’s clinical role, exclusion of his family member, and information-sharing between organisations.

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 establish ambulance staff role and assessment status
Wider context from the report
“6) The nurse clinician did not know the ambulance staff were ECAs and had wrongly assumed they were paramedics and had conducted their own assessment. ”
Source location
Brian Ingram · 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 confirm ambulance staff clinical grade during introductions
Wider context from the report
“1) The family was under the impression that Brian was attended upon by paramedics rather than ECAs. It was accepted in evidence that proper introductions should be made when meeting a new family to include confirmation of a staff member’s clinical grade. ”
Source location
Brian Ingram · 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
Require LML staff to identify their name, clinical role, scope and limitations, and wear correct clinical-grade epaulettes during patient and inter-organisational encounters.

Verbatim wording from the response
“1.1 Since the inquest, LML has issued an organisation-wide memorandum concerning the mandatory requirement for all staff to clearly identify themselves to all patients, families and partner agencies. This information must include”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 1 · response
Published 14 October 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
Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.

Verbatim wording from the response
“2.6 There has been a team-wide communication to all MIU staff, reiterating the requirement for all patients arriving by ambulance (SWAST or otherwise), to be physically assessed and have a handover and history taken in the back of the ambulance, before the patient is accepted into the MIU. It has been clarified that the patient should only be booked in to the MIU, once the clinician has confirmed their acceptance with the admin team. Patients arriving by ambulance are not to be booked in until they have been assessed as suitable for treatment at the MIU.”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 4 · response
Published 14 October 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
Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.

Verbatim wording from the response
“3.8 From the perspective of CFT, all MIU staff have been reminded that the PCR, whether this is in paper form or any electronic PCR, should be received from the ambulance crew before the patient is booked in. Learning has been identified following the inquest in relation to patient handover at the MIU. It is acknowledged by CFT that there was an over-reliance on a verbal handover from the ambulance crew (believed by MIU staff to be paramedics), which had an impact on the initial assessment by the MIU practitioner. All staff have been reminded of the importance of taking a full patient history and all available patient documentation, prior to accepting the patient on to the MIU. This learning and required actions have been shared with staff via email and have featured on the agenda of MIU staff meetings over the last 12 months.”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 7 · response
Published 14 October 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
Reinforce clear staff introductions through LML’s mandatory annual face-to-face training, including role-specific discussion and scenario practice.

Verbatim wording from the response
“1.2 LML delivers three mandatory, annual face-to-face training days for staff, to ensure their competence and alignment to organisational standards. On each day of this training, the importance of clear introductions is reiterated to staff, and put in practice through group discussions and acting out scenarios.”

Source location
Response from Cornwall Partnership NHS Foundation Trust
Page 2 · response
Published 14 October 2025
Open published response
31 Jul2024
Manchester North
Concerns raised1
1. Failure to ensure clear identification and understanding of the Physician Associate role
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Faculty of Physician Associates
General Medical Council
Royal College of Physicians
Stated actions 6
1. Faculty of Physician Associates
  Publish guidance for introducing physician associates and explaining their role to patients, supervisors, employers and healthcare organisations.
2. Faculty of Physician Associates
  Continue working with stakeholders to improve communication of physician associates’ roles and responsibilities to colleagues, patients and the public.
3. Royal College of Physicians
  Continue campaigning to limit the pace and scale of physician associate rollout until safe deployment systems are established.
1. Royal College of Physicians
  Develop, consult on, revise, approve and publish guidance on safe and effective practice for employing physician associates.
2. Royal College of Physicians
  Work with fellows, members and the Patient Safety Committee to consider further support for evidence and evaluation of physician associate deployment.
3. General Medical Council
  Implement alphabetical prefixes and prominent profession-type labelling on public-facing registers for physician associates and anaesthesia associates.
Respondent positions 1
1. General Medical Council
  Responsibility for distinct uniforms to help patients distinguish professionals rests with the NHS and employers.
  Redirects responsibility
AI-generated summary

Susan Pollitt · 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

Susan Pollitt was admitted to hospital after collapsing at home and developed ascites during her admission. An ascitic drain was inserted, remained in place for 21 hours, and was clamped; she developed bacterial peritonitis and died on 16 July 2023. The principal concerns included the lack of regulatory oversight and national training and competency frameworks for Physician Associates, and limited understanding of their role and responsibilities in managing ascitic drains.

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 ensure clear identification and understanding of the Physician Associate role
Wider context from the report
“4. There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families. The lack of a distinct uniform and the title “Physician” gives rise to confusion as to whether the practitioner is a doctor. ”
Source location
Susan Pollitt · 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 guidance for introducing physician associates and explaining their role to patients, supervisors, employers and healthcare organisations.

Verbatim wording from the response
“In October 2023, the FPA published titles and introduction guidance for PAs, supervisors, employers and organisations. The guidance was drawn up with a multi-professional panel of stakeholders, including representation from the RCP PCN, to clarify the role of a PA within a multidisciplinary team. The aim is to ensure appropriate introductions to patients and explanation of the role, particularly highlighting that PAs are not doctors. We recognise that there is a continued need to inform the public, healthcare services and the clinical professions on the role and remit of physician associates.”

Source location
Response from Faculty of Physician Associates
Page 3 · response
Published 8 August 2024
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
Continue working with stakeholders to improve communication of physician associates’ roles and responsibilities to colleagues, patients and the public.

Verbatim wording from the response
“We agree that there should be a national public and patient information campaign to create better awareness of the PA role. We will continue to work with other stakeholders, including the RCP Patient and Carer Network (PCN), to improve how we communicate the role and responsibilities of PAs. We welcome the opportunity to work collaboratively with others on this.”

Source location
Response from Faculty of Physician Associates
Page 3 · response
Published 8 August 2024
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
Continue campaigning to limit the pace and scale of physician associate rollout until safe deployment systems are established.

Verbatim wording from the response
“Following a vote of the RCP fellowship, the RCP is now calling for a limit in the pace and scale of the roll-out of PAs. We have called on NHS England to review its projections for growth for the PA role as set out in the 2023 NHSE Long Term Workforce Plan.”

Source location
Response from Royal College of Physicians
Page 1 · response
Published 8 August 2024
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
Develop, consult on, revise, approve and publish guidance on safe and effective practice for employing physician associates.

Verbatim wording from the response
“The RCP is developing draft guidance on safe and effective practice for employing PAs. The college recently carried out an external stakeholder consultation on the first draft of this guidance. Work is now taking place to review the consultation feedback, refresh the draft guidance, consider how fellows and members should be consulted, and take the final guidance to RCP Council for sign-off and publication by the end of 2024.”

Source location
Response from Royal College of Physicians
Page 3 · response
Published 8 August 2024
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
Work with fellows, members and the Patient Safety Committee to consider further support for evidence and evaluation of physician associate deployment.

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 4 · response
Published 8 August 2024
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
Implement alphabetical prefixes and prominent profession-type labelling on public-facing registers for physician associates and anaesthesia associates.

Verbatim wording from the response
“In March this year we also announced that we would implement an alphabetical prefix for PA and AA GMC reference numbers and ensure the prominent labelling of profession type on our public-facing registers. This means that in future when patients search our registers it will be very clear whether an individual is a doctor, a PA or an AA not only because of the use of a prefix for PAs and AAs but also because the face of the register will actually spell out in full the professional title of each individual (‘Doctor’, ‘Physician Associate’, ‘Anaesthesia Associate’).”

Source location
Response from GMC
Page 4 · response
Published 8 August 2024
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
Responsibility for distinct uniforms to help patients distinguish professionals rests with the NHS and employers.

Verbatim wording from the response
“The issue you raise about the need for distinct uniforms to help patients distinguish between professionals is for the NHS and employers to address.”

Source location
Response from GMC
Page 4 · response
Published 8 August 2024
Open published response
27 Jan2017
Kent (North-West)
Concerns raised1
1. Failure to provide staff grade anaesthetists and supervisors with the respective identities of the parties involved
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Maidstone and Tunbridge Wells NHS Trust
Stated actions 2
1. Maidstone and Tunbridge Wells NHS Trust
  Establish electronic rota and induction arrangements identifying anaesthetic supervision, consultants and emergency contact routes for staff-grade, trainee and locum anaesthetists.
2. Maidstone and Tunbridge Wells NHS Trust
  Maintain and distribute real-time, paper, whiteboard and weekly emailed anaesthetic rotas with direct contact details and hospital-specific terminology.
AI-generated summary

Frances Olwyn Coppaccini · 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

Frances Olwyn Coppaccini died on 9 October 2012 at Tunbridge Wells Hospital following the birth of her child. The report raised concerns about retained placental tissue after caesarean section, failure to follow the post-partum haemorrhage protocol, supervision of anaesthetic staff, delays in obtaining urgent specialist help, and inadequate hospital note keeping.

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 provide staff grade anaesthetists and supervisors with the respective identities of the parties involved
Wider context from the report
“3. Supervision – What action has been taken to ensure that staff grade anaesthetists are supervised and that both the staff grade and supervisor are provided details of the respective identities of the parties involved. ”
Source location
Frances Olwyn Coppaccini · Prevention of Future Deaths report
Page 1 · 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
Establish electronic rota and induction arrangements identifying anaesthetic supervision, consultants and emergency contact routes for staff-grade, trainee and locum anaesthetists.

Verbatim wording from the response
“All Anaesthetists have an electronic rota app on their phones and can identify who is the staff grade on for Labour Ward and who is the consultant covering.”

Source location
2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 4 · response
Published 19 February 2017
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
Maintain and distribute real-time, paper, whiteboard and weekly emailed anaesthetic rotas with direct contact details and hospital-specific terminology.

Verbatim wording from the response
“The Anaesthetic and Obstetric departments, as well as switchboard, have access to a real-time electronic rota for the Anaesthetic department. There is also a weekly paper rota kept on Delivery Suite, and consultants add their name and bleep number to the whiteboard in the Labour Ward handover room. Additionally, the rotas are emailed out weekly to all senior staff and Delivery Suite Band 7 Midwives.”

Source location
2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 4 · response
Published 19 February 2017
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised2

Failure to establish ambulance staff role and assessment status

Failure to confirm ambulance staff clinical grade during introductions

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to ensure clear identification and understanding of the Physician Associate role

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to provide staff grade anaesthetists and supervisors with the respective identities of the parties involved

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Stated actions 4

Stated actions 6

Respondent positions 1

Stated actions 2