Benedict Peters

Joint Group Executive Medical Directors’ Office 
Trust Headquarters 
Room 218, Cobbett House 
Oxford Road 
M13 9WL 

11 July 2023 

Mr C Morris 
Area Coroner Manchester South 
HM Coroner’s Office 
The Coroner’s Court 
1 Mount Tabor 
Stockport 
SK1 3AG 

Dear Mr Morris 

Mr  Benedict  Peters, Paragraph 7,  Schedule  5 of  the Coroners’  and  Justice  Act  2009 and 
Regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 

Thank you for your PFD report dated 16 May 2023, addressed to 
 in his capacity 
as the Group Chief Executive, Manchester University NHS Foundation Trust (the ‘Trust’), which 
has been passed to me for review on his behalf. 

I  have  now  had  the  opportunity  to  look  into  the  concerns  you  raise  in  respect  of  this  case.  
Manchester  Royal  Infirmary  (MRI)  acknowledge  the  matters  of  concern  that  were  raised  within 
your report of 16 May 2023, and which emerged during the inquest for Mr Peters. 

On behalf of the Trust, I would like to extend my condolences to the family of Mr Peters for their 
very great loss. 

As  the  inquest  heard;  Mr  Peters  presented  to  the  Emergency  Department  (ED)  at  MRI  on  11 
November 2022 at 09.00am with chest pain, shortness of breath, a sore throat and an aching arm.  
In the ED, an ECG was undertaken which showed normal sinus rhythm and his other recorded 
observations were essentially normal. 

Whilst awaiting review, Mr Peters experienced a severe episode of vomiting.  Blood tests were 
taken, and the prothrombin time was noted to be marginally elevated.  Troponin and d-dimer levels 
were within normal limits. 

Mr Peters was reviewed on the Ambulatory Care Unit (ACU) by a Physician Associate (PA).   A 
chest x-ray was performed which was reported as being normal and following discussion with the 
duty consultant, Mr Peters was discharged with a diagnosis of panic attack/gastric inflammation 
and a prescription of propranolol and omeprazole. 

Mr Peters was found to have died the following day, at his parent’s home, having been staying 
there following his discharge from the MRI the day before. 

Subsequent autopsy indicated Mr Peters had died as a result of acute aortic dissection. 

, 
Following  receipt  of  your  concerns,  I  have  received  assurances  from  Professor 
Consultant Physician and Associate Medical Director for Clinical Governance in the MRI that this 
is an extremely rare condition and that none of the investigations performed on Mr Peters during 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 his attendance at the MRI ED revealed any suggestion of aortic dissection or rupture.  Professor 
  informs  me  that  Mr  Peters’  management  has  subsequently  been  reviewed  by  several 
different consultants from emergency medicine, acute medicine and cardiology, all of whom agreed 
that  there  was  no  indication  in  the  mode  of  Mr  Peters’  presentation  or  investigation  results  to 
indicate such a diagnosis.   Moreover, they were all in agreement that they would have adopted 
the same approach to management had they been caring for him. 

Turning to your specific concerns: 

1)  “Despite the patient’s reported symptoms, in view of his age and extensive family history of 
cardiac  problems,  Mr  Peters  was  discharged  from  the  Ambulatory  Care  Unit  without  being 
examined/reviewed in person by a doctor” 

Whilst I accept that Mr Peters was discharged without being examined or reviewed in person 
by a doctor (other than the junior doctor in ED who undertook his ECG), this does not mean 
that his case had not been properly reviewed and considered by a consultant. 

their 

guidance 

regarding 

responsibilities 

Mr Peters had been seen and assessed by a Physician Associate (PA), these are professional 
practitioners working under the aegis of the Royal College of Physicians of London which has 
produced 
practice 
of 
(https://www.rcplondon.ac.uk/news/faculty-physician-associates). 
  Within  Manchester 
University NHS Foundation Trust (MFT), PAs work within an agreed governance framework 
(enclosed).  This makes it clear that PAs are not independent practitioners (paragraph 12.7) 
but work under the delegated authority of a consultant (paragraph 14.2).  It is the responsibility 
of  the  supervising  consultant  to  ensure  that  the  level  of  supervision  is  appropriate  to  the 
knowledge  and  skills  of  each  individual  PA.    However,  as  they  are  not  independent 
practitioners,  PAs  are  not  authorised  to  prescribe  medication,  order  ionising  radiation 
investigations nor discharge on their own initiative, which was not the case in this instance. 

scope 

and 

,  Consultant 
In  Mr  Peters’  case,  the  PA  discussed  the  clinical  picture  with 
Physician in Acute Medicine, who agreed with the diagnosis and plan formulated by the PA 
and went on to prescribe the discharge medication himself.  In doing this, 
 was acting 
in the same way as he would had the case been presented to him by a junior doctor or nurse 
clinician seeking approval for their diagnosis and management plan, however; in these latter 
instances  it  would  have  been  the  practitioner  themselves  who  would  have  prescribed  the 
discharge  medication.    In  all  these  circumstances  it  is  the  professional  responsibility  of  the 
supervising  consultant  (in  this  case 
)  to  ensure  that  they  have  confidence  in  the 
information provided by the practitioner (be they doctor, nurse or PA) and to seek any additional 
information  they  require  directly  from  the  patient  should  they  believe  it  necessary  before 
reaching a clinical decision. 

 did not review Mr Peters in person, he did 
I would like to reassure you that although 
review  the  detailed  information  provided  by  the  PA  as  a  result  of  which  he  had  sufficient 
confidence  to  confirm  the  diagnosis  and  management  plan;  following  which  he  also  had 
sufficient confidence to issue a discharge prescription. 

2)  “No policy or protocol exists within the Trust as to when patients may or may not be discharged 

from the Ambulatory Care Unit without a medical review taking place” 

As you will have noted from the response above, it is policy within MFT that patients should 
only  be  discharged  by  appropriately  qualified  and  registered  practitioners.    As  PAs  are  not 
independent practitioners, they all understand that they are not permitted to discharge patients 
on their own authority and need to discuss any potential discharge decision and seek medical 
authorisation.  Accordingly, there is no circumstance where a patient might be discharged from 
the Ambulatory Care Unit by anyone other than an independent practitioner without medical 
review of the case (‘medical review’ including discussion of the clinical picture and investigation 
results with a senior colleague). 

 
 
 
 
 
 
 
 
 
 
 The Trust remains wholly committed to providing safe and effective care to all patients delivered 
in accordance with national guidance.  I hope that my replies above provide you with appropriate 
assurance that this guidance was indeed followed in the care given to Mr Peters. 

We  will  remind  all  our  PAs  of  the  need  to  discuss  patients  for  discharge  with  senior  medical 
colleagues  and  reiterate  to  all  junior  medical  staff  and  non-medical  clinical  practitioners,  that  it 
remains good practice to discuss cases with their seniors for learning and development. 

If you require anything further, please do not hesitate to contact me. 

Yours sincerely 

Joint Group Executive Medical Director / Responsible Officer 

Encl.  MFT Physician Associate Governance Framework 

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • 
Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester •  
Wythenshawe Hospital • Withington Community Hospital • Community Services