Concerns raised 10 Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners View source Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery View source Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients View source Unavailability of promptly accessible suction for aspiration during rapid sequence induction View source Failure to inform patients and families that Physician Associates are not medically qualified View source Lack of public understanding of the Physician Associate role View source Lack of guidance on TIVA dosing and timing for rapid sequence induction View source Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction View source Failure to prevent Physician Associates undertaking roles outside their competency View source Lack of regulated scope-of-practice guidance and recognised training for Physician Associates View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Difficult Airway Society; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidelines for rapid sequence induction of anaesthesia in emergency surgery
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Inadequate medical supervision of Physician Associates managing undifferentiated Emergency Department patients
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Unavailability of promptly accessible suction for aspiration during rapid sequence induction
Wider context from the report “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 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of the Physician Associate role
Wider context from the report “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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on TIVA dosing and timing for rapid sequence induction
Wider context from the report “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).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Lack of updated guidance on cricoid pressure and other airway-protection measures during rapid sequence induction
Wider context from the report “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 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent Physician Associates undertaking roles outside their competency
Wider context from the report “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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Lack of regulated scope-of-practice guidance and recognised training for Physician Associates
Wider context from the report “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 .
” Open source report
Concerns raised 4 Lack of widespread, regular, mandatory ongoing crisis-drill training for anaesthetists View source Failure to ensure sufficient understanding of capnography among clinical staff who may intubate patients View source Failure to ensure utilisation of capnography by clinical staff who may intubate patients View source Failure to observe capnography for up to 15 to 20 seconds after intubation View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Peter Saint · 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
Peter Saint was admitted for routine elective knee replacement surgery and died after an endotracheal tube was placed in his oesophagus, resulting in approximately 38 minutes without effective lung ventilation and subsequent hypoxic brain damage. The principal concerns were inadequate understanding and interpretation of capnography, failure to follow the required confirmation procedure after intubation, and insufficient ongoing training for anaesthetists in crisis situations.
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. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Lack of widespread, regular, mandatory ongoing crisis-drill training for anaesthetists
Wider context from the report “The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error”. I am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him. The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias” , and that such training would be beneficial.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure sufficient understanding of capnography among clinical staff who may intubate patients
Wider context from the report “I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure utilisation of capnography by clinical staff who may intubate patients
Wider context from the report “I am concerned that the evidence in this case, including the expert evidence, established that notwithstanding the findings and recommendations of the 2011 NAP4 there is a continuing failure to ensure that capnography is sufficiently understood and utilised by all clinical staff who may intubate patients .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Difficult Airway Society; that does not assign responsibility.
PFD Monitor interpretation Failure to observe capnography for up to 15 to 20 seconds after intubation
Wider context from the report “The evidence heard, including the expert evidence, confirmed that an integral part of the process of intubating a patient requires that the anaesthetist, following the placement of the intubation tube into the patient, observes the capnography for a period of up to 15 to 20 seconds to ensure that a “proper CO2 end tidal wave” can be detected; failure to do so would be a “fundamental and basic error” and a “serious error” . I am concerned that this procedure was not followed by either the lead consultant anaesthetist in this case or the anaesthetists who attended to assist him . The expert evidence indicated a lack of widespread, regular, mandatory on-going training for anaesthetists in drills dealing with crisis situations potentially facing an anaesthetic team particularly in relation to the issues of “task fixation” and “confirmatory bias”, and that such training would be beneficial.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations