Another coroner has demanded action, after the death of an elderly lady seen by an unsupervised Physician Associate in A&E was sent home without a medical review. The PA had made a diagnosis of epistaxis but failed to understand the significance of her other signs and symptoms.
The inquest heard that the patient had been sent home with a diagnosis of epistaxis, 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 that contained ischaemic bowel. Emergency surgery was arranged but she sadly died from a complication.
In her Regulation 28 Report – Action to Prevent Future Deaths – Dr Karen Henderson, HM Assistant Coroner for Surrey, raised several concerns:
1. The term ‘Physician Associate’ is misleading to the public. The patient’s son was under the mistaken belief that the Physician Associate was a doctor by this title, and nobody corrected that mistake.
2. Lack of public understanding of the role of Physician Associate
The blurring of roles without the public understanding what a PA is can undermine public confidence. Worse, it can allow PAs to potentially undertake roles outside of their competency and compromise 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. 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.
The coroner also highlighted several significant issues around the conduct of the anaesthetic which certainly warrant closer investigation.
But it was just a nosebleed
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.
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.
Why is nothing being done to stop this?
Anaesthetists United, together with the bereaved parents of Emily Chesterton, are trying to take the medical regulator – the GMC – to judicial review, to force them to set proper standards over what PAs can do – their ‘scope of practice’.
Many of the medical bodies, such as the Medical Royal Colleges and Specialist Societies, agree that there should be a defined national scope. But most of them are unwilling to help fund our legal case, and we are reliant on crowdfunding from doctors and patients. We have already raised over £170,000 but need another £125,000 to take it to court.
Please help us reach our target.