The use of unsupervised physician associates in hospitals has been questioned again after the misdiagnosis and death of an elderly lady.
Karen Henderson, assistant coroner for Surrey, has raised concerns after an elderly lady called Pamela Marking was seen by an unsupervised physician associate (PA) in A&E in February last year and sent home without a medical review. She subsequently died.
The inquest heard that the PA at East Surrey Hospital, Redhill, had made a diagnosis of epistaxis – a nosebleed – and had sent the patient home, despite having vomited blood-stained fluid and having abdominal tenderness. She came back to hospital two days later with grossly dilated small bowel obstruction due to an incarcerated right femoral hernia.
Emergency surgery was arranged but she sadly died from a complication.
“How many times will hear the line that PAs can be left to see straightforward cases without being supervised? An elderly lady who has vomited blood-stained fluid and has abdominal pain is not straightforward,” said the interest group Anaesthetists United.
“Easy cases are only easy in retrospect; as the coroner put it: This case gives rise to a concern that inadequate supervision or excessive delegation of undifferentiated patients in the Emergency Department to Physician Associates compromises patient safety,” it continued.
Misleading to the public
In her report, the coroner raised a number of concerns.
Her most significant is that the term “physician associate” is misleading to the public. The patient’s son was under the mistaken belief that the PA was a doctor by this title, and nobody corrected that mistake.
“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,” the coroner’s report said.
Second, the lack of public knowledge that a PA is not medically qualified has the potential to hinder requests by patients and their relatives who might want to seek an opinion from a medical practitioner. It also raises issues of informed consent and protection of patient rights if the public is not aware or has not been properly informed that they are being treated by a PA rather than a medically qualified doctor.
And given their limited training and in the absence of any national or local recognised hospital training for PAs once appointed, this gives rise to a concern they are working outside of their capabilities.
Long-running debate
This is the latest case in the long-running debate about the role of PAs and anaesthesia associates (AAs) within the NHS.
The British Medical Association (BMA) has long raised concerns that attempts to make the regulation of PAs less restrictive could impact patient safety.
“Robust national scopes of practice are the basis of any solution to the dangers to patient safety raised by the way PAs are currently employed in the NHS,” said BMA chair of council Phil Banfield in January. “It has been worrying to see the General Medical Council (GMC), a patient safety regulator, resist all calls to publish its take on the Royal Colleges’ attempt to set these scopes,” he continued.
This has culminated in a court case that the BMA has brought against the GMC and which started in mid-February in London.
As Banfield has said: “Let’s be clear: patient safety should be the only priority when defining what PAs can do, not their employment prospects. Keeping patients safe is not burdensome – it is essential.”
