First reported 27 Jan 2017•Latest report 10 Aug 2025
Definition
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.
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.
Reports
3
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2017–2025
First to latest report issue date
Stated actions
12
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.
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
NHS trust2
Health and care professional regulator1
Ministerial department1
Private limited company1
Professional body1
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.
Cornwall and Isles of Scilly
Concerns raised2
Failure to establish ambulance staff role and assessment status
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Require LML staff to identify their name, clinical role, scope and limitations, and wear correct clinical-grade epaulettes during patient and inter-organisational encounters.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Reinforce CFT requirements to obtain complete histories and documentation, exercise professional curiosity, and independently assess patients rather than rely on previous assessments or handovers.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Reinforce clear staff introductions through LML’s mandatory annual face-to-face training, including role-specific discussion and scenario practice.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Manchester North
Concerns raised1
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Publish guidance for introducing physician associates and explaining their role to patients, supervisors, employers and healthcare organisations.
Stated by Faculty of Physician AssociatesStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
Action
Continue working with stakeholders to improve communication of physician associates’ roles and responsibilities to colleagues, patients and the public.
Stated by Faculty of Physician AssociatesStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Continue campaigning to limit the pace and scale of physician associate rollout until safe deployment systems are established.
Stated by Royal College of PhysiciansStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Develop, consult on, revise, approve and publish guidance on safe and effective practice for employing physician associates.
Stated by Royal College of PhysiciansStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Work with fellows, members and the Patient Safety Committee to consider further support for evidence and evaluation of physician associate deployment.
Stated by Royal College of PhysiciansStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Implement alphabetical prefixes and prominent profession-type labelling on public-facing registers for physician associates and anaesthesia associates.
Stated by General Medical CouncilStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for distinct uniforms to help patients distinguish professionals rests with the NHS and employers.
Stated by General Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Kent (North-West)
Concerns raised1
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Establish electronic rota and induction arrangements identifying anaesthetic supervision, consultants and emergency contact routes for staff-grade, trainee and locum anaesthetists.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Maintain and distribute real-time, paper, whiteboard and weekly emailed anaesthetic rotas with direct contact details and hospital-specific terminology.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
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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.
