This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On the 17th July 2023, I commenced an investigation into the death of Susan Pollitt. Mrs Pollitt died on the 16th July 2023. The investigation concluded on the 29th July 2024. The medical cause of death was confirmed as 1a) Spontaneous Bacterial Peritonitis 1b) Prolonged Insertion of Ascitic Drain 1c) Non Alcoholic Liver Cirrhosis 2) Type 2 Diabetes Mellitus, Osteoarthritis and Fracture of the Humerus.
The Inquest concluded that Mrs Pollitt died as a result of an unnecessary medical procedure contributed to by neglect.
Circumstances of the death
On the 3rd July 2023 Mrs Pollitt was admitted to the Royal Oldham Hospital (the Hospital) following a collapse at her home address. She was treated for a number of medical issues including acute kidney injury. During her admission, she developed ascites. The Consultants involved in her care decided an ascitic drain was not required at that time.
On the 11th July, a junior doctor reviewed Mrs Pollitt and decided that an ascitic drain should be placed. The Court found that this procedure was not clinically indicated at that time. The Physician Associate who undertook the procedure was not aware of the local Hospital Guidance on the insertion of ascitic drains or that the drain should remain in place for no longer than six hours. Mrs Pollitt’s drain remained in place for 21 hours before being removed.
The Physician Associate had also directed that the drain be clamped due to a concern that the loss of fluid could cause a drop in blood pressure. This was unwarranted given the moderate level of fluid which had been drained and the Court heard that the Physician Associate did not appreciate that clamping a drain increased the risk of infection.
Mrs Pollitt developed bacterial peritonitis and died on 16th July 2023.
The situation was compounded by Mrs Pollitt’s placement on a respiratory ward rather than a gastroenterology ward since there was a lack of understanding and awareness across all the staff on the respiratory ward including the medical team as to the management of ascitic drains.
Coroner’s concerns
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.
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.
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).
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.
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.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised6
Failure to ensure clear identification and understanding of the Physician Associate role
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.24
Action
Work with royal colleges and specialist societies to develop physician associate career pathways and guidance for safe deployment within multidisciplinary teams.
Stated byFaculty of Physician AssociatesStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Remind employers to check physician associates’ voluntary register before employment and at regular intervals.
Stated byFaculty of Physician AssociatesStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
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.
Stated byFaculty of Physician AssociatesStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Action
Share the physician associate code of conduct and publish the procedure for raising and adjudicating complaints.
Stated byFaculty of Physician AssociatesStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
Action
Publish guidance for introducing physician associates and explaining their role to patients, supervisors, employers and healthcare organisations.
Stated byFaculty 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 byFaculty of Physician AssociatesStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Provide qualified physician associates with an e-Portfolio containing workplace-based, supervised learning and procedural skills assessment forms.
Stated byFaculty of Physician AssociatesStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
Action
Maintain a standardised national physician associate curriculum aligned with GMC outcomes for education and qualification.
Stated byFaculty of Physician AssociatesStated completedThe respondent said that this action was complete 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 byRoyal College of PhysiciansStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Meet regularly with the General Medical Council on physician associate regulation and post-regulation arrangements.
Stated byRoyal 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 byRoyal College of PhysiciansStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Respond to the General Medical Council consultation on physician associate regulation, raising patient-safety concerns.
Stated byRoyal College of PhysiciansStated completedThe respondent said that this action was complete 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 byRoyal College of PhysiciansStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Campaign for regulation of physician associates.
Stated byRoyal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
Action
Publish guidance supporting physician associate students and course providers pending implementation of statutory regulation.
Stated byGeneral Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
Action
Finalise updated guidance for physician associate students on professional standards and the process for approving curricula.
Stated byGeneral Medical CouncilStated 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 byGeneral Medical CouncilStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Action
Approve physician associate courses and curricula once regulation begins, ensuring they meet required clinical knowledge and skills standards.
Stated byGeneral Medical CouncilStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Action
Require course providers to update syllabuses and assessments, and check those changes through the education quality assurance process.
Stated byGeneral Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Begin statutory regulation of physician associates and anaesthesia associates from December 2024.
Stated byGeneral Medical CouncilStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Action
Support royal colleges’ development of supervision and competency guidance, while encouraging consistent alignment across guidance produced by colleges and NHS employers.
Stated byGeneral Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Action
Strongly encourage physician associates to join the GMC register as soon as possible.
Stated byGeneral Medical CouncilStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Action
Publish advice for doctors supervising physician associates and update the clinical governance handbook on their deployment and supervision.
Stated byGeneral Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
Action
Consider consultation responses and finalise the rules, professional standards and guidance required to implement associate regulation.
Stated byGeneral Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.9
Position
The DOPS process includes assessment of consent, aftercare and wider procedural care, contrary to the concern that it assesses only technical skill.
Stated byFaculty of Physician AssociatesDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The FPA cannot mandate physician-associate registration because it has no regulatory powers.
Stated byFaculty of Physician AssociatesUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
System leaders, including the GMC, should lead development and oversight of a national physician associate scope of practice.
Stated byRoyal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Regulatory oversight of physician associates falls outside the organisation’s role because it is not a regulatory body.
Stated byRoyal College of PhysiciansOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Faculty of Physician Associates, which developed the ascitic-drain competency form, is best placed to respond to concerns about it.
Stated byDepartment of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for distinct uniforms to help patients distinguish professionals rests with the NHS and employers.
Stated byGeneral Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The GMC has no role in determining the investigatory or disciplinary processes of the Faculty of Physician Associates’ voluntary register.
Stated byGeneral Medical CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
Questions about clinical governance, drain use, ward placement, delegation, supervision and local policy are better explained by the trust.
Stated byGeneral Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The GMC currently has no power to investigate concerns about physician associates because they are not yet regulated by it.
Stated byGeneral Medical CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8
1
Produce and disseminate information explaining the voluntary register, including a patient leaflet and registration advice for student physician associates.
Stated byFaculty of Physician AssociatesStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
2
Continue collaborating with regulators, healthcare organisations and professional bodies to promote safe physician associate practice and supervision.
Stated byFaculty of Physician AssociatesStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
3
Deliver the working group’s recommendations to the Royal College of Physicians Council.
Stated byRoyal College of PhysiciansStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
4
Host an online roundtable with other professional bodies to discuss developing physician associate clinical scope of practice.
Stated byRoyal College of PhysiciansStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
5
Set up an oversight group for physician associate-related activity.
Stated byRoyal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
6
Call on NHS England to review projected growth in the physician associate workforce.
Stated byRoyal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
7
Establish a working group to recommend implementation of motions from the extraordinary general meeting.
Stated byRoyal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
8
Consider further work to address concerns about physician associate safety, regulation, training, supervision and role clarity.
Stated byDepartment of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
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