Physician Associates and Patient Safety: Lessons from the Pamela Marking Prevention of Future Deaths Report

The role of Physician Associates (PAs) in the UK healthcare system has been a topic of increasing debate, particularly in light of recent high-profile cases. The recent Prevention of Future Deaths (PFD) report following the tragic death of Pamela Marking raises significant concerns about the risks associated with PAs practising without sufficient supervision and public awareness of their limitations. This case serves as a stark reminder of the importance of clear professional boundaries, proper oversight, and transparent communication in patient care.

What Happened in the Pamela Marking Case?

Pamela Marking, a 77-year-old patient who attended the Emergency Department and East Surrey Hospital, tragically died after a PA misdiagnosed her as having a nosebleed and discharged her without an assessment by a doctor. Marking’s condition deteriorated, and she returned to the hospital two days later. She underwent surgery for complications arising from a femoral hernia but sadly died on 20 February 2024.

This misdiagnosis led to a missed opportunity for timely and potentially life-saving treatment, as highlighted in the coroner’s PFD report. 

The report highlights several key issues:

1. Lack of Public Awareness – The coroner expressed a concern that the the term ‘Physician Associate’ is misleading to the public. Patients are often unaware of the difference between a PA and a fully qualified doctor. In this case, Ms. Marking believed she was being treated by a doctor, which influenced her trust in the advice given.
2. Inadequate Supervision – Despite the intended role of PAs as professionals working under the supervision of doctors, the reality in many settings is that they are operating with significant autonomy, often without adequate oversight.
3. Regulatory Gaps – While PAs are now regulated by the General Medical Council (GMC), concerns remain about the clarity of their role, accountability mechanisms, and the sufficiency of their training and oversight within clinical practice. This regulatory shift has also led to confusion regarding their scope of practice and the level of autonomy they should have in patient care.

Wider Issues 

This case follows other high-profile cases involving PAs, such as the death of Emily Chesterton and that of Susan Pollitt. A PA who poorly carried out an abdominal drain procedure was found to have contributed to the death of Mrs Pollitt, and a PFD report in that case highlighted similar concerns around the public’s understanding of the role of PAs. Emily Chesterton was a 30-year-old patient who died after being misdiagnosed twice by a PA. In that case, the PA failed to recognise that Emily had deep vein thrombosis (DVT) and was instead misdiagnosed as suffering from a calf sprain. She later developed a pulmonary embolism and sadly died three weeks after she first sought medical attention. Emily had also been under the mistaken belief that she had been seen by a fully qualified GP rather than a PA.  

These cases underscore broader systemic issues regarding the role and responsibilities of PAs within the NHS. The Government has been expanding the use of PAs to address workforce shortages, but some argue that this expansion has outpaced the development of clear regulatory structures, appropriate training, and risk mitigation strategies. Some key questions remain, including: 

• Are PAs being used as a cheaper alternative to doctors, rather than as a complementary workforce?
• Do patients fully understand when they are seeing a PA rather than a doctor?
• What safeguards should be in place to ensure patient safety when PAs are making clinical decisions?

In response to soe of these concerns, in November last year Wes Streeting ordered a review into the use of Physician Associates within the NHS questioning whether they are being deployed appropriately and safely. 

Reform is Urgent

This most recent PFD report recommends urgent reforms and may well become a turning point in the debate on PA regulation. PAs are now regulated by the General Medical Council (GMC) (see my previous blog post). However, while this shift may enhance oversight, it also raises questions about whether the GMC is the appropriate regulatory body for PAs, given their distinct training and scope of practice. Further, cases such as the present one highlight some important regulatory issues that remain. In particular, there is a need to ensure a clear distinction in professional titles; Patients should be explicitly informed when they are being seen by a PA and have the right to request consultation with a doctor. Additionally, PAs should never be practising independently in high-risk scenarios without direct supervision from a doctor.

The Future of Physician Associates in the NHS

There is no doubt that PAs can play a valuable role in healthcare delivery when properly integrated within a well-regulated system. However, this case illustrates the dangers of deploying PAs in ways that exceed their training and competency. Without urgent reform, there is a clear risk of further tragedies and an erosion of public trust in the NHS workforce.

Pamela Marking’s case should serve as a wake-up call to policymakers, healthcare providers, and regulators. The emphasis must be on patient safety first, ensuring that the expansion of the PA workforce does not come at the cost of proper medical oversight and the fundamental right of patients to receive care from appropriately qualified professionals.