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 16th December 2024 I resumed the inquest into the death of Mrs Pamela Anne Marking. On 19th December 2024 I concluded the Inquest. At the time of her death Mrs Marking lived independently and was 77 years of age.
The medical cause of death given was:
1a Respiratory failure and Sepsis 1b Aspiration of feculent gastric contents at induction of anaesthesia 1c. Strangulated femoral hernia
I found: On 16th February 2024 Pamela Anne Marking - who was unable to give a complete history due to cognitive issues - was admitted to the Emergency Department at East Surrey Hospital. Redhill from her home address after unknowingly vomiting blood-stained fluid, with right sided and suprapubic abdominal tenderness. She was diagnosed as having had an epistaxis (nosebleed) by a Physician Associate and discharged home later that afternoon without a medical review or direct medical supervision of the Physician Associate who had a lack of understanding of the significance of abdominal pain and vomiting and had undertaken an incomplete abdominal examination which would have been likely to have found a right femoral hernia. Mrs Marking re-presented to the Emergency Department two days later with grossly dilated small bowel obstruction due to an incarcerated right femoral hernia containing ischaemic bowel requiring emergency surgery later that evening. A rapid sequence induction (RSI) of anaesthesia to protect her airway from aspiration of gastric contents was undertaken with Total Intravenous Anaesthesia (Propofol and Remifentanil and thereafter Rocuronium), in the absence of cricoid pressure and with a nasogastric tube in situ attached to the only suction device. This approach was considered a commonly deployed and safe technique in the absence of updated national guidelines. On induction of anaesthesia, Mrs Marking aspirated feculent fluid resulting in respiratory failure in the immediate post operative period requiring re-intubation and intensive care input. Despite maximal support Mrs Marking died at East Surrey hospital, Redhill on 20th February 2024. The clinical management Mrs Marking had on her first admission and thereafter during the Rapid Sequence Induction materially contributed to her death.
Circumstances of the death
Please see my findings above
Coroner’s concerns
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.
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.
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.
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.
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.
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.
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).
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.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised10
Failure to clearly explain and differentiate the Physician Associate role from medically qualified practitioners
Assess providers’ arrangements for safe recruitment, adequate staffing, supervision, accountability, governance, information-sharing and inclusive care involving Physician Associates.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 26 February 2025.
Action
Engage medical Royal Colleges to facilitate broad aligning principles for physician associate and anaesthesia associate specialty scopes of practice.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Publish a summary of existing guidance on deploying medical associate professionals.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Issue a position statement setting standards for Physician Associate supervision, identification, patient selection and regulation.
Stated byRoyal College of Emergency MedicineStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Update workforce-tier guidance to classify Physician Associates at Tier 1 and recommend discussion or review of their patients by Tier 4 or 5 doctors.
Stated byRoyal College of Emergency MedicineStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Contribute to the ongoing review of the safety and scope of the Physician Associate role.
Stated byRoyal College of Emergency MedicineStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2025.
Action
Develop and publish website materials supporting doctors who supervise physician associates and applying relevant supervision guidance.
Stated byGeneral Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2025.
Action
Provide feedback on specialist professional bodies’ draft guidance concerning physician associate scope of practice.
Stated byGeneral Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Issue updated clinical-governance guidance supporting supervision, board-level responsibility and local governance of physician associates and anaesthesia associates.
Stated byGeneral Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Clearly distinguish doctors, physician associates and anaesthesia associates on public registers and in register searches.
Stated byGeneral Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Publish interim guidance requiring physician associates to explain their roles, supervision and educational or clinical background to patients, families, carers and colleagues.
Stated byRoyal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Clearly communicate that physician associates are not doctors and must not replace doctors.
Stated byRoyal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Campaign with fellows and members 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 26 February 2025.
Action
Publish interim guidance for physician associates working in medical specialties.
Stated byRoyal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Commission an independent review of Physician Associate and Anaesthesia Associate roles and their contribution to multidisciplinary healthcare teams.
Stated byDepartment of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Install Emergency Department signage identifying clinical team members by their scrub colours.
Stated bySurrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Issue and implement an Emergency Department Physician Associate scope of practice requiring senior doctor oversight, appropriate patient selection, escalation, and medical review before discharge or admission.
Stated bySurrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Move Physician Associates to Tier 1 of the Emergency Department rota in line with updated national guidance.
Stated bySurrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Amend the local Physician Associate governance policy to reflect changes in national guidance and regulation.
Stated bySurrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Communicate and reinforce the use of cricoid pressure for rapid sequence induction in bowel obstruction through meetings, induction training, and simulation training.
Stated bySurrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Action
Use a modified total intravenous anaesthesia technique with predetermined propofol and muscle-relaxant boluses when performing rapid sequence induction with TIVA.
Stated bySurrey and Sussex Healthcare NHS TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 26 February 2025.
Action
Identify Physician Associates through distinctive clothing, lanyards, and explicit introductions that clarify they are not doctors.
Stated bySurrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.27
Position
Limited evidence means fully evidenced national guidelines for rapid sequence induction are unlikely to be produced.
Existing CQC guidance and provider governance, supervision and competence requirements apply to Physician Associates in secondary care.
Stated byCare Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Updated national guidance for RSI, TIVA and cricoid pressure falls outside the regulatory scope.
Stated byCare Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The General Medical Council is best placed to address public terminology, role understanding and second-opinion rights.
Stated byCare Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Public terminology, role understanding and second-opinion rights fall outside the regulatory scope.
Stated byCare Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The General Medical Council is responsible for regulating individual Physician Associates, rather than this regulator.
Stated byCare Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Updated national RSI anaesthesia guidelines fall outside NHS England’s remit.
Stated byNHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Royal College of Anaesthetists and other named organisations should address updated national RSI anaesthesia guidelines.
Stated byNHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The College will not comment on the provision of general anaesthesia in operating theatres.
The supervising doctor decides whether a patient seen by a physician associate requires face-to-face review or discussion.
Stated byRoyal College of Emergency MedicineRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Individual competence and clinical context vary, so GMC standards do not impose fixed ceilings on what registered PAs may do.
Stated byGeneral Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Employers, clinical leaders and supervisors must determine PAs’ permitted activities and required supervision through local clinical governance.
Stated byGeneral Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Royal colleges and specialist professional bodies should provide detailed specialty-specific guidance on physician associate scope of practice.
Stated byGeneral Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The right to seek a second opinion should be addressed locally.
Stated byRoyal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Recipients with anaesthesia expertise are best placed to respond to concerns 6, 7 and 8.
Stated byRoyal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The GMC is responsible for regulating physician associates, while national system leaders should develop their scope of practice and supervision framework.
Stated byRoyal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
GMC regulation and existing NHS guidance already govern PA regulation, competence, scope, supervision and employer clinical governance.
Stated byDepartment of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing NICE and GMC standards require healthcare professionals to identify their role to patients, addressing role-identification concerns.
Stated byDepartment of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Medical Royal Colleges and professional bodies are considered best placed to respond on national anaesthesia guidelines.
Stated byDepartment of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing national guidance, local governance policy and competency frameworks are considered sufficient to keep Physician Associates within their scope of practice.
Stated bySurrey and Sussex Healthcare NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
“Physician Associate” is a nationally sanctioned term describing healthcare professionals with recognised training, rather than an inherently misleading title.
National guidance supports modified total intravenous anaesthesia during rapid sequence induction, which is accepted practice across the United Kingdom.
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.11
1
Monitor the trust’s actions through ongoing monitoring and engagement.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 26 February 2025.
2
Ask the trust what action it intends to take in response to the Prevention of Future Deaths Report.
Stated byCare Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 26 February 2025.
3
Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning nationally and regionally.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2025.
4
Implement Martha’s Rule across 143 locations, including 24/7 escalation, staff access, and daily family insights.
Stated byNHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2025.
5
Issue a position statement on managing emergency-department adults who may require emergency laparotomy, highlighting older people and those with cognitive impairment as higher-risk groups.
Stated byRoyal College of Emergency MedicineStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
6
Produce and maintain guidance identifying emergency-department patient groups requiring discussion with a consultant or senior doctor before discharge, including older patients with abdominal pain.
Stated byRoyal College of Emergency MedicineStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
7
Work with NHS England to implement Martha’s Rule in emergency departments, providing round-the-clock access to rapid review by a separate care team.
Stated byRoyal College of Emergency MedicineStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2025.
8
Work with the National Emergency Laparotomy Audit to improve care for patients requiring emergency laparotomy.
Stated byRoyal College of Emergency MedicineStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2025.
9
Continue working with other organisations to support patient confidence in care.
Stated byGeneral Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2025.
10
Deliver working-group findings on physician associates to the Leng review.
Stated byRoyal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
11
Work with the Patient Safety Committee to consider further support for the physician-associate safety agenda.
Stated byRoyal College of PhysiciansStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2025.
Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2
1
NAP4 found that over 50% of airway-related anaesthesia deaths, not all anaesthesia-related deaths, were due to aspiration.
GMC professional standards already protect patients’ right to choose whether to accept advice and seek a second opinion.
Stated byDepartment of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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