31 Jul 2024 Susan Pollitt · Prevention of Future Deaths report Manchester North
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Concerns raised 6 Failure to ensure clear identification and understanding of the Physician Associate role View source Lack of a clear mechanism for reporting concerns about individual Physician Associates View source Failure to require employers to verify Physician Associate registration View source Failure of competency assessments to cover the wider aspects of care for ascetic drain insertion View source Lack of regulatory oversight of Physician Associates View source Lack of a national framework for training, supervision and competence of Physician Associates View source See 3 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Work with royal colleges and specialist societies to develop physician associate career pathways and guidance for safe deployment within multidisciplinary teams.
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Action
Remind employers to check physician associates’ voluntary register before employment and at regular intervals.
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Action
Review the procedural skills assessment form to determine whether it should be enhanced to cover consent, risk factors, aftercare and other wider care responsibilities.
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Action
Share the physician associate code of conduct and publish the procedure for raising and adjudicating complaints.
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Action
Publish guidance for introducing physician associates and explaining their role to patients, supervisors, employers and healthcare organisations.
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Action
Continue working with stakeholders to improve communication of physician associates’ roles and responsibilities to colleagues, patients and the public.
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Action
Provide qualified physician associates with an e-Portfolio containing workplace-based, supervised learning and procedural skills assessment forms.
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Action
Maintain a standardised national physician associate curriculum aligned with GMC outcomes for education and qualification.
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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. The report was sent to Faculty of Physician Associates; that does not assign responsibility.
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.
” 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 Faculty of Physician Associates; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear mechanism for reporting concerns about individual Physician Associates
Wider context from the report “2. The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so, nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate.
” 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 Faculty of Physician Associates; that does not assign responsibility.
PFD Monitor interpretation Failure to require employers to verify Physician Associate registration
Wider context from the report “2. The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so , nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate.
” 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 Faculty of Physician Associates; that does not assign responsibility.
PFD Monitor interpretation Failure of competency assessments to cover the wider aspects of care for ascetic drain insertion
Wider context from the report “5. In June 2022 the Physicians Associate had been signed off as competent for the insertion of ascetic drains. This sign off was completed by a liver nurse specialist using a competency form which was provided by the FPA. Whilst the competency form assessed the technical aspect of placing the drain, it did not include competency around the wider aspects of care such as taking consent, risk factors and after care.
” 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 Faculty of Physician Associates; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight of Physician Associates
Wider context from the report “1. There is no regulatory body with oversight of Physician Associates. It is understood that this is currently the subject of a consultation by the General Medical Council.
” 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 Faculty of Physician Associates; that does not assign responsibility.
PFD Monitor interpretation Lack of a national framework for training, supervision and competence of Physician Associates
Wider context from the report “3. There is no national framework as to how Physician Associates should be trained, supervised and deemed competent. This is placing both patients, Physicians Associates and their employers at risk. The Court heard that since the death of Mrs Pollitt the Northern Care Alliance have put in place a local trust framework. Unlike all other clinical roles there is no national guidance save for very recent guidance issued by the British Medical Association (March 2024).
” Open source report
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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 royal colleges and specialist societies to develop physician associate career pathways and guidance for safe deployment within multidisciplinary teams.
Verbatim wording from the response “The FPA and its members are actively involved in writing PA-related guidance with medical royal colleges, academies and specialist societies and we want to help increase understanding of our role. We recognise that there are concerns about the lack of a post-qualification national career development and competency framework for physician associates. We are working with medical royal colleges and specialist societies as they develop their own pathways, including guidance of how PAs can be safely and effectively deployed within MDTs.” Source location Response from Faculty of Physician Associates
Open published response
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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 Remind employers to check physician associates’ voluntary register before employment and at regular intervals.
Verbatim wording from the response “This statement highlights why formal regulation is so important. Neither the RCP nor the FPA has regulatory powers to mandate registration. In the absence of this, the FPA writes to employers on a regular basis reminding them of the existence of the PAMVR and, importantly, of the need to check that a PA is registered on the PAMVR before employment, as well as checking at regular intervals during their employment.” Source location Response from Faculty of Physician Associates
Open published response
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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 Review the procedural skills assessment form to determine whether it should be enhanced to cover consent, risk factors, aftercare and other wider care responsibilities.
Verbatim wording from the response “Clinicians supervising a DOPS need to be competent in the procedural skill that is being assessed, and the associated management including consent and aftercare. A key component of a DOPS is the wider aspects of the procedure as shown in the attached document. It is important that the assessor is agreed by the clinical supervisor and has the appropriate knowledge and skills, including the wider aspects that you have noted. This should be emphasised to the supervising senior doctor. In addition, continued assurance as part of appraisal is required. We will review the DOPS form to see whether it can be enhanced, and we will take on board what has been raised by your report.” Source location Response from Faculty of Physician Associates
Open published response
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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 Share the physician associate code of conduct and publish the procedure for raising and adjudicating complaints.
Verbatim wording from the response “The FPA code of conduct is regularly shared with FPA members. Should an employer, patient or others have a complaint about a PA, they can advise the FPA through emailing ████████. The FPA website sets out the complaints procedure here. Attached is the process to adjudicate complaints.” Source location Response from Faculty of Physician Associates
Open published response
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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
Open published response
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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
Open published response
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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 Provide qualified physician associates with an e-Portfolio containing workplace-based, supervised learning and procedural skills assessment forms.
Verbatim wording from the response “There is currently no national framework for post-qualification competencies (including procedures). PAs increase their clinical skills and competencies post-qualification similarly to other healthcare professionals. The FPA e-Portfolio was launched in October 2023 for qualified PAs and uses workplace-based assessment (WBPA) or supervised learning event (SLE) forms. This also includes Direct Observation of Procedural Skills (DOPS) forms, which were first made available to FPA members in October 2021.” Source location Response from Faculty of Physician Associates
Open published response
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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 a standardised national physician associate curriculum aligned with GMC outcomes for education and qualification.
Verbatim wording from the response “The draft PA curriculum sets out guidance on the competencies expected from a newly qualified physician associate. This national higher education institutions (HEIs) across all four UK nations with a standardised framework to ensure high-quality education for PA students. It is owned by the FPA and has been aligned to the GMC’s generic and shared outcomes for PAs and anaesthesia associates.” Source location Response from Faculty of Physician Associates
Open published response
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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 DOPS process includes assessment of consent, aftercare and wider procedural care, contrary to the concern that it assesses only technical skill.
Verbatim wording from the response “Clinicians supervising a DOPS need to be competent in the procedural skill that is being assessed, and the associated management including consent and aftercare. A key component of a DOPS is the wider aspects of the procedure as shown in the attached document. It is important that the assessor is agreed by the clinical supervisor and has the appropriate knowledge and skills, including the wider aspects that you have noted. This should be emphasised to the supervising senior doctor. In addition, continued assurance as part of appraisal is required. We will review the DOPS form to see whether it can be enhanced, and we will take on board what has been raised by your report.” Source location Response from Faculty of Physician Associates
Open published response
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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 FPA cannot mandate physician-associate registration because it has no regulatory powers.
Verbatim wording from the response “This statement highlights why formal regulation is so important. Neither the RCP nor the FPA has regulatory powers to mandate registration. In the absence of this, the FPA writes to employers on a regular basis reminding them of the existence of the PAMVR and, importantly, of the need to check that a PA is registered on the PAMVR before employment, as well as checking at regular intervals during their employment.” Source location Response from Faculty of Physician Associates
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations