Pamela Marking was vomiting blood, but was sent home regardless. A woman died in hospital with a hernia after her condition was misdiagnosed as a nose bleed by an NHS physician associate. Now a coroner has warned that the public is being misled about the role of physician associates (PAs).
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Pamela Marking, 77, visited A&E at East Surrey Hospital in February 2024, suffering from vomiting blood and tenderness in her side. She was assessed by a PA, who incorrectly diagnosed her with a nose bleed and discharged her. Mrs Marking's son believed his mother had been treated by a doctor.
In reality, Mrs Marking was suffering from a hernia. A coroner’s report highlighted the PA’s "lack of understanding of the significance of abdominal pain and vomiting" and noted an incomplete abdominal examination that would likely have revealed a right femoral hernia.
Mrs Marking was readmitted to hospital but died four days later due to complications. Dr Karen Henderson, assistant coroner for Surrey, has issued a "prevention of future death" report to health officials at the Department of Health and Social Care and NHS England.
The report raises concerns about PAs and other aspects of Mrs Marking’s care. “The term ‘physician associate’ is misleading to the public,” she said. “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.”.
Dr Henderson also highlighted a “lack of understanding” around the role, highlighting how even some hospital staff believe a PA is the equivalent of a certain type of resident doctor. “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,” she wrote.
“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.”.
She added: “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.”.
Dr Henderson said there is a lack of guidelines for the supervision of PAs, and inadequate supervision can “compromise patient safety”. The report provides more information on the circumstances surrounding Mrs Marking’s death. After initially seeing the PA on February 16 2024, Mrs Marking, who also had “cognitive issues”, was sent home.
She went back to the emergency department two days later and needed emergency surgery that evening. A problem with her anaesthesia meant she needed intensive care after surgery. She died on February 20 2024, with the coroner concluding the cause of death was respiratory failure and sepsis, a strangulated femoral hernia and “aspiration of feculent gastric contents at induction of anaesthesia”.
“The clinical management Mrs Marking had on her first admission and thereafter during the rapid sequence induction materially contributed to her death,” Dr Henderson wrote. She also called for updated guidelines about the type of anaesthesia administered to Mrs Marking.
PAs are graduates – usually with a health or life sciences degree – who have undertaken two years of postgraduate training. According to the NHS, they work under the supervision of a doctor and can diagnose people, take medical histories, perform physical examinations, see patients with long-term conditions, analyse test results and develop management plans.
Most associates work in GP surgeries, acute medicine and emergency medicine and there are NHS plans to recruit more. In November the Government launched a review of the role of PAs and anaesthesia associates(AAs). Professor Gillian Leng, president of the Royal Society of Medicine, will lead the work looking into how the roles affect safety and how they support wider health teams, with a report expected to be published in spring.
Commenting, Professor Philip Banfield, chairman of council at the British Medical Association, said: “What happened to Pamela Marking is deeply troubling. “Mrs Marking needed care from a doctor, because they are specifically trained in more depth and more widely to consider a diagnosis that may not be obvious at first sight.
“It was inappropriate that she was sent home, with abdominal pain, vomiting blood, and misdiagnosed with a nose bleed, not only without having received appropriate care, but with both her and her son unaware that she had been seen only by a physician associate (PA) instead of a doctor.
