Pamela Marking

16th April 2025 

Dear Dr Henderson, 

Re: Regulation 28: Report to Prevent Future Deaths in the matter of Mrs Pamela Anne Marking 

Thank you for sending us a copy of your report regarding the sad death of Mrs Marking. We have 
jointly reviewed the information available to us in the report via our Safe Anaesthesia Liaison 
Group (SALG) in conjunction with the Difficult Airway Society. SALG is a collaborative project 
between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal 
College of Anaesthetists. One of its core objectives is to analyse anaesthesia-related serious 
incidents and to share the learning with the specialty across the UK.  

We welcome the opportunity to address the concerns raised relating to anaesthesia and the 
second episode of clinical care, numbered 6-8 in your prevention of future deaths report. 

It is worth stating from the outset that the topic of rapid sequence induction (RSI) is controversial. 
By its emergency nature it is difficult to study scientifically and robust evidence supporting or 
refuting many of its components is simply lacking. Given the challenges of designing studies to 
provide stronger evidence for or against its use, it is unlikely that fully evidenced guidelines could 
be produced. Best clinical practice relies in addition to available evidence on careful risk 
assessment and risk mitigation. In cases where there is high risk of aspiration the potential benefits 
of RSI increase and thus its use is more rational.  

You highlighted your concern regarding the “lack of ‘Updated’ National Guidelines for Rapid 
Sequence Induction (RSI) of Anaesthesia for emergency surgery” and noted that you had heard 
evidence that “the ‘traditional’ use of consecutive syringes of induction agent and muscle 
relaxant was obsolete.” Total intravenous anaesthesia (TIVA) is now used for approximately one 
quarter of all UK general anaesthetics1 and whilst the use of TIVA for rapid sequence induction 
(RSI) has been described2, surveys of practice suggest the vast majority of RSI involve a manual 
bolus, for induction. Demonstrating competence in RSI is a basic anaesthetic skill and forms part 
of the core competencies that all anaesthetists are taught in their first months of training and 
which form part of the Initial Assessment of Competency3. The Project for the universal 
management of airways (PUMA) provides recent guidance on the key components of an RSI4. 
The Difficult Airway Society are currently in the process of updating their 2015 guidelines for 
management of unanticipated difficult intubation in adults5, including the section on RSI 
underlining the key principles of the technique.  

You also highlighted your concern regarding the “lack of ‘Updated’ National Guidelines to 
support the use of TIVA for RSI”. The Association of Anaesthetists have published guidelines on the 
use of TIVA, which includes a section on the use of TIVA for RSI2. These guidelines are currently in 
the process of being updated. It is worth noting that the 7th National Audit Project (NAP7)6 found 
that high-dose or rapidly administered propofol, particularly in combination with remifentanil, 
used to induce anaesthesia in higher risk patients, was associated with profound hypotension or 
cardiac arrest and thus should be avoided in frail patients. 

You mentioned that “approximately 50% of all anaesthetic related deaths are due to aspiration 
(NAP 4)”. We would just like to clarify that the 4th National Audit Project (NAP4)7 found that over 

 50% of airway-related anaesthesia deaths were due to aspiration. More up to date data from 
NAP7, which studied perioperative cardiac arrest, indicate that aspiration was a notably less 
prominent cause of such events, but that when these cases did occur it was usually during 
anaesthesia for patients with an acute abdominal pathology8.  

Your report also raised a concern regarding the “lack of updated guidelines for use of cricoid 
pressure and other measures to protect the airway during an RSI anaesthetic”. Like other elements 
of RSI, the use of cricoid force remains a controversial topic, without robust evidence to either 
support or refute its value9. The NAP4 report7 recommended “on balance, rapid sequence 
induction should continue to be taught as a standard technique for protection of the airway. 
Further focused research might usefully be performed to explore its efficacy, limitations and also 
explore the consequences of its omission.” It also suggested “to maximise the likelihood of good 
quality cricoid force being applied, those who perform cricoid force should be trained in its 
methodology, should practise at regular intervals and should consider the use of simple methods 
of simulation.”  

More recently the NAP7 report8 stated “The current data act as a reminder that, particularly in the 
setting of the acute abdomen, harm from pulmonary aspiration remains a significant risk and all 
the elements of an RSI that might mitigate the risk of aspiration are worthy of consideration. It has 
been argued that cricoid force, when taught and applied correctly, is a low-risk procedure, 
unlikely to cause harm and which can simply be removed if it is deemed to be interfering with 
intubation”. It is also our opinion that, where there is a high risk of aspiration, the use of cricoid 
force should be considered if it is more likely to do good than harm, especially as it can be easily 
removed if difficulty is encountered, and that this will form part of the risk assessment and airway 
management strategy. 

The most important step to reduce the risks associated with RSI, as recommended by NAP4, is to 
undertake an individualised risk assessment and act on it. The NAP4 report7 states “All patients 
should have their risk of aspiration assessed and recorded before anaesthesia. The airway 
management strategy should be consistent with the identified risk of aspiration.” Furthermore, 
NAP7 report8 recommends “Anaesthetists should treat cases of acute abdomen as high risk for 
aspiration, assess the extent of that risk and plan airway management accordingly. Each airway 
manager should decide which elements of RSI they wish to use and be prepared to justify their 
use or omission.” We reinforce our support for these statements and will share the learning from 
Mrs Marking’s death with our members. As part of this we will publish a best practice statement on 
RSI. SALG publishes regular Patient Safety Updates, which are distributed to all members of the 
Association of Anaesthetists and Royal College of Anaesthetists. 

We would be happy to respond to any questions that you might have. 

Yours Sincerely 

President 
Royal College of Anaesthetists 

President 
Association of Anaesthetists 

President 
Difficult Airway Society

 
  
 
 
 
 
 
 
 
 
 
 
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 References 
1.  Royal College of Anaesthetists, 7th National Audit Project, Chapter 11, 2023 

(https://www.rcoa.ac.uk/research/research-projects/national-audit-projects-naps/nap7-
report)  

2.  Nimmo, A. F., Absalom, A., Bagshaw, O., Biswas, A., Cook, T., Costello, A., … & Wiles, M. D. 

(2018). Guidelines for the safe practice of total intravenous anaesthesia (tiva). Anaesthesia, 
74(2), 211-224. https://doi.org/10.1111/anae.14428  

3.  Royal College of Anaesthetists, 2021 Anaesthesia Curriculum Assessment Guidance, 

Entrustable Professional Activities: Initial Assessment of Competence 2022 
(https://rcoa.ac.uk/documents/2021-curriculum-assessment-guidance/entrustable-
professional-activities-iac-iacoa) 

4.  Project for the Universal Management of Airways (PUMA), Preview content: Universal 
Guidelines for Rapid Sequence Intubation, 2022 https://www.universalairway.org/rsi  

5.  Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall 
NM, Ahmad I; Difficult Airway Society intubation guidelines working group. Difficult Airway 
Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J 
Anaesth. 2015 Dec;115(6):827-48. doi: 10.1093/bja/aev371 

6.  Royal College of Anaesthetists, 7th National Audit Project, Chapter 26, 2023 

(https://www.rcoa.ac.uk/research/research-projects/national-audit-projects-naps/nap7-
report)  

7.  Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway 
management in the UK: results of the Fourth National Audit Project of the Royal College of 
Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011 
May;106(5):617-31. doi: 10.1093/bja/aer058. Epub 2011 Mar 29. PMID: 21447488. 
(https://www.rcoa.ac.uk/research/research-projects/national-audit-projects-naps/nap4-
major-complications-airway-management)  

8.  Royal College of Anaesthetists, 7th National Audit Project, Chapter 21, 2023 

(https://www.rcoa.ac.uk/research/research-projects/national-audit-projects-naps/nap7-
report)  

9.  Algie CM, Mahar RK, Tan HB, Wilson G, Mahar PD, Wasiak J. Effectiveness and risks of cricoid 
pressure during rapid sequence induction for endotracheal intubation. Cochrane Database 
Syst Rev. 2015 Nov 18;2015(11):CD011656. doi: 10.1002/14651858.CD011656.pub2.

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 03000 616161 

Fax: 03000 616171 

www.cqc.org.uk 

HM Coroner 
HM Coroner’s Court 
Station Approach 
Woking 
GU22 7AP 

07 April 2025 

Dear HM Assistant Coroner for Surrey Dr Karen Henderson, 

Regulation 28 Report following the inquest into the death of Ms Pamela Anne 
Marking 

Thank you for raising the Regulation 28 report with us, following the inquest into the 
death of Ms Pamela Anne Marking at East Surrey Hospital, Redhill, on 20 February 
2024. East Surrey Hospital is part of the Surrey and Sussex Healthcare NHS 
Foundation Trust. 

We have noted the matter of concerns listed below. 

1. 
2. 
3. 
4. 

5. 

6. 

7. 
8. 

The term ‘Physician Associate’ is misleading to the public  
Lack of public understanding of the role of Physician Associate  
The right of patients and family to seek a second opinion  
Lack of national and local guidelines and regulation of the scope of practice 
for Physician Associate  
Lack of guidelines for direct supervision and consideration of an appropriate 
level of autonomy for Physician Associates  
Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of 
Anaesthesia for emergency surgery  
Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI  
Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures 
to protect the airway in an RSI anaesthetic  

The Care Quality Commission (CQC) is the independent regulator of health and 
social care services in England. We make sure that health and care services in 
England provide people with safe, effective and high-quality care.  

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 Whilst we have legal powers to regulate providers of health and social care, we do 
not have any powers to regulate individual practitioners, such as Physician 
Associates. That is the duty of the General Medical Council from 13 December 2024. 
Prior to this date, Physicians Associates were not regulated by a formal body. 
Physicians Associates are encouraged to join the General Medical Council’s register 
if already practising in the UK, however there is a transition period of two years, after 
which, Physicians Associates must legally be registered with the General Medical 
Council. (Links: NHS England » Update on physician associates and anaesthesia 
associates ahead of GMC regulation, Registration - GMC) 

In response to the points raised.  

1.  The term ‘Physician Associate’ is misleading to the public  

We are unable to comment on this point due to it being outside of the remit of our 
regulatory scope. Please note that the General Medical Council is a Respondent and 
would be best placed to respond to this question. 

2.  Lack of public understanding of the role of Physician Associate  

We are unable to comment on this point due to it being outside of the remit of our 
regulatory scope. Please note that the General Medical Council is a Respondent and 
would be best placed to respond to this question. 

3.  The right of patients and family to seek a second opinion  

We are unable to comment on this point due to it being outside of the remit of our 
regulatory scope. Please note that the General Medical Council is a Respondent and 
would be best placed to respond to this question. 

4.  The lack of national and local guidelines and regulation of the scope of 

practice for Physician Associate 

The following are the guidelines that we would expect providers to follow: 

•  Ensuring safe and effective integration of physician associates into departmental 

multidisciplinary teams through good practice (NHS England) Link: NHS England 

» Ensuring safe and effective integration of physician associates into 

departmental multidisciplinary teams through good practice 

•  Workplace supervision for advanced clinical practice (NHS England) 

Link: Workplace Supervision for Advanced Clinical Practice: An integrated multi-
professional approach for practitioner development 

20250407 Inquest re the Death of Pamela Anne Marking_Regulation 28 Coroner response v4 (CA-048038) 
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 •  Supervision guidance (Health and Care Professions Council) Link: What our 

standards say | The HCPC 

• 

Interim guidance for physician associates working in the medical specialties  

Link: Interim guidance for physician associates working in the medical 

specialties | RCP 

5.  The lack of guidelines for direct supervision and consideration of an appropriate 

level of autonomy for Physicians Associates 

The CQC guidance whilst written for Physician Associates in primary care, is largely 
applicable in secondary care settings too.  

GP mythbuster 82: Physician associates in general practice - Care Quality 
Commission Link: GP mythbuster 82: Physician associates in general practice - Care 
Quality Commission 

Applicable and relevant statements are: 

•  Providers should be able to show how they assure themselves of the 

governance and ongoing competence of physician associates. 

•  Providers must make sure that staff are competent, and they must provide 

appropriate supervision and oversight. 

•  Governance arrangements should take account of the fact that these 

professionals are trained and registered on the basis that they should always 

work under supervision. 

o 

the supervisor is easily accessible. 

o  staff know who the supervising member of staff is. 

o  staff have enough capacity and capability to supervise. 

We use these regulations when we assess if a provider is safe, effective, caring, 
responsive and well-led. The role of Physician Associates relates to: 

•  Regulation 17: Good governance 
•  Regulation 18: Staffing 
•  Regulation 19: Fit and proper persons employed 

We will assess how providers ensure that: 

20250407 Inquest re the Death of Pamela Anne Marking_Regulation 28 Coroner response v4 (CA-048038) 
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 •  They complete safe recruitment processes. 

•  There are enough qualified, skilled, and experienced people, who receive 

appropriate and effective support, supervision, and development. 

•  These staff work together effectively to provide safe care that meets 

people’s individual needs. 

•  There are clear responsibilities, roles, systems of accountability and good 

governance to manage and deliver good quality, sustainable care, 
treatment and support. 

• 

Information about risk, performance and outcomes is managed and shared 
securely with others when appropriate. 

•  They value diversity in the workforce and work towards an inclusive and 

fair culture by improving equality and equity for people. 

6.  Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of 

Anaesthesia for emergency surgery.  

We are unable to comment on this point due to it being outside of the remit of our 
regulatory scope.  

7.  Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI  

We are unable to comment on this point due to it being outside of the remit of our 
regulatory scope.   

8.  Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures 

to protect the airway in an RSI anaesthetic 

We are unable to comment on this point due to it being outside of the remit of our 
regulatory scope.  

We will ask the trust for the action they intend to take because of this Prevention of 
Future Deaths Report and monitor those actions as part of our ongoing monitoring 
and engagement with them.  

Yours sincerely, 

South Network 

20250407 Inquest re the Death of Pamela Anne Marking_Regulation 28 Coroner response v4 (CA-048038) 
FINAL4

Minister of State for Health (Secondary Care)  

39 Victoria Street  
London  
SW1H 0EU  

09 April 2025  

Our ref: 

HM Assistant Coroner Dr Karen Henderson  
HM Coroner's Court  
Station Approach  
Woking  
GU22 7AP  
By email: 

Dear Dr Henderson,   

Thank you for the Regulation 28 report of 24th February 2025 sent to the Department of  
Health  and  Social  Care  about  the  death  of  Pamela Anne  Marking.  I  am  replying  as  the 
Minister with responsibility for secondary care, and I am also replying on behalf of the Chief 
Medical Officer for England, 

, who was also sent your report.   

Firstly, I would like to say how saddened I was to read of the circumstances of Pamela  
Anne Marking’s death, and I offer my sincere condolences to their family and loved ones. 
The circumstances your report describes are very concerning and I am grateful to you for 
bringing these matters to my attention.  

The report raises concerns in relation to the following points:  

1.  The term ‘Physician Associate’ is misleading to the public  
2.  Lack of public understanding of the role of Physician Associate.   
3.  The right of patients and family to seek a second opinion  
4.  Lack  of  national  and  local  guidelines  and  regulation  of  the  scope  of  practice  for  a 

Physician Associate  

5.  Lack of guidelines for direct supervision and consideration of an appropriate level of 

autonomy for Physician Associates  

6.  Lack  of  ‘Updated’  National  Guidelines  for  Rapid  Sequence  Induction  (RSI)  of 

Anaesthesia for emergency surgery  

7.  Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI  
8.  Lack  of  ‘Updated’  Guidelines  for  use  of  Cricoid  pressure  and  other  measures  to 

protect the airway in a RSI anaesthetic  

In preparing this response, the Department notes that the report has been sent to a  
number of medical Royal Colleges and professional bodies relating to anaesthesia. We think 
these organisations are  best  placed  to  respond  to  points  6,  7  and  8  of  your report which 

  
  
  
  
  
  
   
  
  
   
   
   
 relate specifically to guidelines around anaesthesia therefore our response focuses on points 
1 – 5 only.  

This Government takes concerns about patient safety seriously. This is why, in November  
2024, we commissioned 
 to lead an independent review into PAs 
and AAs: Independent Review of the Physician and Anaesthesia As - Hansard - UK  
Parliament.  Whilst  there  are  governance  processes  already  in  place  for  the  Physician 
Associate  (PA)  and Anaesthesia Associate  (AA)  professions,  the  review  will  consider  the 
safety of the roles and their contribution to multidisciplinary healthcare teams. The review 
will draw upon a range of national and international evidence to produce a comprehensive 
picture  of  the  physician  associate  and  anaesthesia  associate  roles.  This  will  include 
published research, real world data, and patient and professional views.  

You highlight  the  limited  awareness  and understanding of  the  PA  role  and that  the  title  is 
misleading. We are clear that an important part of being a healthcare professional is ensuring 
that  the  people  they  come  into  contact  with  understand  who  they  are.  All  healthcare 
professionals should follow the National Institute for Health and Care  
Excellence (NICE) guidelines which state that healthcare professionals directly involved in a 
patient's care should introduce themselves and explain to their role to the patient.   

Regulation of PAs and AAs by the General Medical Council (GMC) began in December 2024. 
The GMC expects the vast majority of practising PAs and AAs to join the register within the 
first six months of regulation, and they will be required to do so within two years of regulation 
commencing. PAs and AAs who are registered with the General Medical Council (GMC) are 
required to follow the professional standards and behaviour set out in Good medical practice. 
This includes introducing themselves and their role in patient care.  

In  addition,  following  public  consultation,  the  GMC  has  updated  its  standards  for  course 
providers  to  include  a  specific  requirement  for  them  to  ensure  that  student  PAs  and AAs 
inform patients when they are involved in their care.   

However, we do agree that more can be done to improve awareness of the PA and other 
associate  roles.  The  conclusions  of  the  Leng  review will  help to provide  greater clarity to 
both patients and healthcare professionals on the role  

As you rightly highlight, it is important that patients are aware of their right to seek a second 
opinion  regardless  of  who  they  have  been  seen  by.  Good  Medical  Practice  outlines  the 
principles, values, and standards of behaviour expected of all professionals registered with 
the GMC. This sets out that professionals must “recognise a patient’s right to choose whether 
to  accept  your  advice,  and  respect  their  right  to  seek  a  second  opinion”.goodmedical-
practice-2024---english-102607294.pdf.  

Your  report  also  raises  concerns  around  the  lack  of  national  and  local  guidelines  and 
regulation of scope of practice for PAs. We are clear that all healthcare professionals are 
required to only practise within their competence to ensure they are practising safely, lawfully 
and effectively. NHSE has issued guidance on the deployment of PAs and AAs in the NHS 
which describes the expectations of how organisations providing NHS care should deploy 
PAs and AAs so that they can contribute to the delivery of safe and effective healthcare in a 
supportive environment.   

  
  
  
  
  
  
  
 PAs  must  always  work  under  the  supervision  of  a  fully  trained  and  experienced  doctor, 
working  with  them,  not  replacing  them.  As  set  out  in  NHS  England’s  guidance  on  the 
deployment of PAs in the NHS: “PAs must always work within their competencies; and must 
be  supervised  appropriately.  Employers  must  ensure  that  the  overall  responsibility  for 
supervision of PAs is by a named senior doctor.” The relevant employer, in this case East 
Surrey Hospital, must follow these guidelines and have appropriate clinical governance in 
place.  NHS  Employers  has  also  published  guidance  for  employers  -  Medical  associate 
professions (MAPs) employer guidance | NHS Employers.  

All the guidance referred to in this letter remains in place and should be adhered to whilst 
the Leng review is undertaken.  

I hope this response is helpful. The conclusions of the Leng review will be published in spring 
2025  and  will  inform  the  workforce  plan  to  deliver  the  10  Year  Health  Plan.  Further 
information can be found here: Independent review of physician associates and anaesthesia 
associates - GOV.UK  

Thank you for bringing these concerns to my attention.    

Yours sincerely,   

MINISTER OF STATE FOR HEALTH

17 April 2025 

HM Coroner’s Court 

Station Approach 

Woking 

GU22 7AP 

Dear Dr Henderson  

Thank you for your letter of 24 February 2025 enclosing your report into the death of Pamela Anne 
Marking. I am truly sorry to hear of the tragic circumstances surrounding Mrs Marking’s death and I 
extend my condolences to her family and friends.  

I appreciate the opportunity to review your report and address the concerns that you raise. I am 
responding as the Medical Director and Director of Education and Standards at the GMC, and I have 
set out below answers to the questions raised in your report that fall within our remit, as the 
professional regulator of doctors, physician associates (PAs) and anaesthesia associates (AAs) in the 
UK.  

Regulation of PAs and AAs 

At the time of Mrs Marking’s death, the physician associate role was not yet subject to statutory 
regulation. Regulation helps provide assurance to patients, employers and colleagues that PAs have 
the right level of education and training required to be included on the register, meet the 
professional standards that we expect of the professions we regulate and that they can be held to 
account if serious concerns are raised.  

Since 13 December 2024 the GMC has had powers to: 

•  Set the principles, values and standards of professional behaviour expected of PAs. 

•  Set the outcomes and standards that students qualifying from PA courses must meet to 

achieve registration and approve the curricula that courses must deliver.  

•  Set a two-part assessment of clinical knowledge and skills that a PA needs to pass before 

registration.  

•  Check who is eligible to work as a PA in the UK and that they continue to meet the 

professional standards we set throughout their careers. The Law provides a two-year 
transition period for registration, meaning that PAs can legally practise without being on the 

The GMC is a charity registered in England and Wales (1089278) and Scotland (SC037750). 
You are welcome to contact us in Welsh. We will respond in Welsh, without this causing additional delay. 

 
 
 GMC register until December 2026, however employers may require earlier registration (and 
the GMC strongly encourages it). 

•  Give guidance and advice to help PAs understand what’s expected of them.  

• 

Investigate PAs who hold registration, where there are concerns that patient safety, or the 
public’s confidence in PAs, may be at risk, and take action if needed. 

In what follows I’ll outline the key parts of our regulatory approach that I believe speak to the issues 
raised in your report. It’s important to be clear at the start of my response, however, that although 
professional regulation is an important part of patient safety, it alone cannot prevent future deaths. 
A system wide approach to clinical governance is needed to ensure that PAs and AAs are supported 
to practise safely, effectively and ethically.  

I note that you have addressed your report to others who will be able to take actions relevant to the 
work of their respective organisations. The contributions of multiple organisations – including 
regulators, professional bodies, the four UK governments and respective health services – are vital in 
promoting multidisciplinary team working, delivering revalidation, determining safe practice, and 
ensuring appropriate supervision of PAs working in the UK in future. 

Being clear about roles 

PAs have been part of the UK healthcare workforce for around 20 years, but numbers are still 
relatively small, so it is even more important that they are always clear about their roles and 
responsibilities with the patients they treat.  

Now that regulation is in effect, the registers on our website are clearly marked to distinguish 
between the three professions we regulate. A prefix is used for PA and AA reference numbers, which 
provides a clear distinction between those two professions and doctors. In addition, each profession 
type is prominently labelled on our public-facing registers, and in search functions. This means that 
when patients search our registers it will be very clear whether an individual is a doctor, a PA or an 
AA. 

Good medical practice makes clear that all those registered with us must: 

•  always be honest about their experience, qualifications, current role, and they should 

introduce themselves to patients, and explain their role in patient care (paragraph 82).  

• 

recognise and work within the limits of their competence, and only practice under the level 
of supervision appropriate to their role, knowledge, skills and training, and the task being 
carried out (paragraph 2). 

gmc-uk.org 

2 

 
 
 We agree that PAs should not be described as equivalent to doctors. All the professionals on our 
register are expected to clearly establish the scope of their roles with their employers and raise any 
issues of ambiguity or uncertainty around responsibilities in multidisciplinary teams. This includes 
supervision arrangements for staff, and lines of accountability for care provided to individual 
patients. (Leadership and management, paragraph 17). 

All the professionals on our register must also be familiar with, and use, clinical governance and risk 
management structures and processes to ensure high standards of care, including raising concerns 
where there is reason to believe that patients may be at risk of harm for any reason, including where 
they have reason to believe that systems, policies, procedures or colleagues are, or may be, the 
source of the risk (Leadership and management, paragraphs 24-29). 

Making decisions and seeking second opinions 

PAs on our register must work in partnership with their patients to make decisions about treatment 
and care. They must give patients the information they want and need, in a way they can 
understand. And they must listen to patients and encourage an open dialogue by asking questions to 
help patients express what matters to them (GMP domain 2 and Decision making and consent). 

PAs must recognise a patient’s right to choose whether to accept their advice, and that they must 
respect patients’ rights to seek a second opinion (GMP paragraph 18). And they must refer patients 
to another suitably qualified practitioner when this serves their needs (GMP paragraph 7h). 

Scope of practice  

You’ve expressed concerns about PAs working outside of their capabilities due to a lack of guidelines 
relating to their scope of practice. In this part of my response, I’ll explain the legislative framework 
underpinning our regulatory approach to this, before going on to explain out how we’ll make sure 
that PAs on our register are working within their competence, keeping up to date and are fit to 
practice as they develop in their careers. 

The legislation bringing PAs into regulation requires us to set the standards for their education and 
training that will give them the clinical knowledge and skills they need to demonstrate before they 
can register with us. The registration assessments that PAs need to complete before being granted 
registration assess a standardised baseline of clinical knowledge and skills for their profession.  

A PA’s scope of practice at the beginning of their careers will therefore be informed by the clinical 
knowledge and skills they have learned during their training and that they have demonstrated 

gmc-uk.org 

3 

 
 
 
 objectively by passing our two-part assessment. Our standards do not impose ceilings on what 
individual doctors, PAs and AAs can do once registered. This is because we recognise that 
competence will vary by individual and is shaped by their supervised training and experience, and 
the clinical context of their work. 

Robust systems of clinical governance are important to ensure a consistent approach to the safe and 
effective deployment of PAs and AAs. Employers have a clinical governance responsibility to ensure 
that all their employees are appropriately trained and competent to do the activities they are tasked 
with. It is an employer’s responsibility, with the involvement of clinical leaders and supervisors, to 
determine which activities or specific tasks an individual can carry out and what level of supervision 
is required.  

To support employers, we have issued our updated guidance Effective clinical governance to support 
revalidation. It emphasises that PAs and AAs must be supervised and recommends that organisations 
identify an individual at Board level to be responsible for PAs and AAs. It also suggests establishing 
local processes to govern how these professionals are deployed and supervised. The work of a PA or 
AA must be overseen by a named senior doctor, and they must work together to agree appropriate 
limitations to their practice. 

As with other professionals that doctors supervise and work alongside in multidisciplinary teams, 
doctors are not accountable to us for the decisions and actions of PAs and AAs, provided they have 
delegated responsibility in line with the standards set out in our guidance, as described under the 
next subheading below. 

For their part, once registered with us, PAs must be competent in all aspects of their work, and 
recognise and work within the limits of that competence (GMP 1&2) They must also maintain, 
develop and improve their performance in line with the provisions in Good medical practice 
paragraphs 11-13 which include keeping their knowledge and skills up to date, taking part in 
structured support opportunities, training and professional development activities, participating in 
quality assurance and quality improvement initiatives, undergoing regular reviews and audits of 
work and participating in ongoing reflective practice using feedback.  

PAs are already expected to participate in annual appraisals with their employer, and, in future, they 
will have to go through a process of revalidation, similar to the one that doctors undertake. This 
means that PAs will need to demonstrate, with evidence, that they remain competent to undertake 
their role, and that they remain up to date and fit to practise.    

We believe that the royal colleges and other specialist professional bodies have the level of clinical 
expertise required to provide more detailed guidance on PA scope of practice within their specialty 
areas. We are grateful for the work that royal colleges have undertaken so far in developing 

gmc-uk.org 

4 

 
 guidance, and last year (2024) we provided feedback on draft scope of practice guidance documents 
developed by the Royal College of General Practitioners, the Royal College of Physicians, and the 
Royal College of Anaesthetists. We feel that guidance of this nature will be most valuable if it avoids 
unnecessary prescription and helps support safe development of roles and individuals over time, 
within robust local procedures and governance. 

GMC guidance on supervision, delegation and teamwork for PAs and the doctors who oversee 
their work. 

For the professionals on our register, the professional standards relating to supervision, delegation 
and working with colleagues are set out across several pieces of guidance including Good medical 
practice, domain 3; Delegation and referral paragraphs 1-14; and Leadership and management, 
paragraphs 24-38 and 60-62.  

We say that supervisors must make sure that the people they oversee have appropriate supervision, 
whether through close personal supervision (for newly qualified colleagues, or individuals in training, 
for example) or through a managed system with clear reporting structures. We don’t specify that 
supervision must be direct, as in the same room. Instead, we expect supervisors to take account of 
the nature of the tasks being delegated, as well as the skills and experience of the PA.  

We also expect doctors and PAs to follow local employer policies and have regard to other relevant 
national guidelines, such as relevant college guidelines - in this case, the Royal College of Emergency 
Medicine guidelines for supervision of PAs, which we note were recently updated in February 2025. 

We are currently in the final stages of developing materials for our website, to support doctors who 
are supervising PAs, and help them to apply the principles in our guidance within their practice. This 
material, due to be published in spring, brings together all of our relevant standards, expanding on 
these with further advice, as well as signposting to a range of other resources published by others. 

Now that PAs are regulated professionals, they share professional responsibility and accountability 
for ensuring that they are appropriately supervised for any task they undertake (Leadership and 
management, paragraph 60). They must recognise and work within the limits of their competence 
and only practise under the level of supervision appropriate to their role, knowledge, skills and 
training, and the task they’re carrying out (GMP paragraphs 1&2). Further, if a task is delegated to a 
PA by a colleague, and the PA is not confident they have the necessary knowledge, skills or training 
to carry it out safely, they must prioritise patient safety and seek help, even if they’ve already agreed 
to carry out the task independently (GMP, paragraph 67).  

gmc-uk.org 

5 

 
 
 
 Next steps 

Thank you for the opportunity to respond to this report. I hope this information provides 
reassurance around our regulatory approach towards PAs, which is in line with the established 
system we have in place for doctors. We hope that regulation, along with action from others, will 
help ensure a similar incident does not happen again. We will continue to work with others to ensure 
all patients have confidence in the care they receive. 

Yours sincerely 

Director of Education and Standards 
General Medical Council 
Email: 

gmc-uk.org 

6

Dr Karen Henderson  
HM Assistant Coroner  
Surrey Coroner’s Court  
Station Approach  
Woking  
GU22 7AP 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

14 April 2025   

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Pamela Anne Marking 
who died on 20 February 2024  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  24 
February 2025 concerning the death of Pamela Anne Marking on 20 February 2024. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Pamela’s family and loved ones. NHS England 
are keen to assure the family and the Coroner that the concerns raised about Pamela’s 
care have been listened to and reflected upon.   

Your  Report  raises  concerns  over  the  lack  of  public  understanding  of  the  role  of 
Physician Associate (PA) and the lack of national guidelines and regulation for their 
scope of practice and supervision. 

Your  Report  also  raises  concerns  around  the  lack  of  updated  national  guidelines 
relevant to rapid sequence induction (RSI) of anaesthesia, but these issues fall outside 
of  NHS  England’s  remit  and  would  be  best  addressed  by  the  Royal  College  of 
Anaesthetists and other associated organisations named in your Report. NHS England 
will give due consideration to their responses to the Coroner. 

Title and role of Physician Associate 

The  title  ‘physician  associate’  (PA)  is  established  by  law,  under  The  Anaesthesia 
Associates and Physician Associates Order 2024.  

The  Secretary of  State  for  Health and  Social  Care  has  established  an  independent 
review of the PA and anaesthesia associate (AA) professions, which is considering 
the safety of the roles and their contribution to multidisciplinary healthcare teams. The 
Leng  Review,  chaired by  Professor  Gillian  Leng  CBE,  will  consider  the  identity  and 
naming of the roles, including their names as set out in statute. 

NHS  England has  published a  summary  of existing guidance  on the  deployment  of 
medical  associate  professions for  NHS organisations.  This guidance  makes  it  clear 
that all staff should introduce themselves and their role clearly and be supported by 
their employer to do so. This is in accordance with National Institute for Health and 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 Care Excellence (NICE) guidelines (CG138), which state that healthcare professionals 
directly involved in a patient's care should introduce themselves and explain their role 
to the patient. 

The  NHS  England  summary  signposts  interim  guidance  from  the  Royal  College  of 
Physicians  (RCP)  from  December  2024  on  the  titles  and  introductions  of  PAs.  The 
RCP guidance, which is aimed at supervising clinicians, employers and organisations, 
stresses that “PAs must always take all reasonable steps to inform patients and staff 
of their role and to avoid confusion of roles.” 

The right of patients and family to seek a second opinion 

The General Medical Council’s (GMC) Good Medical Practice guidance, which sets 
out  the  professional  standards  for  doctors,  PAs  and  AAs,  requires  registrants  to 
recognise a patient's right to choose whether to accept their advice, and respect their 
right to seek a second opinion. 

While  patients  do  not  have  a  legal  right  to  a  second  opinion,  the  NHS  encourages 
patients  to  seek  a  second  opinion  if  they  have  any  doubts  about  their  diagnosis  or 
treatment.  

NHS  England  has  also  introduced  Martha’s  Rule,  which  provides  a  consistent  and 
understandable way for patients and families to seek an urgent review if their or their 
loved one’s condition deteriorates, and they are concerned this is not being responded 
to.  NHS  England  has  been  working  towards  implementing  the  programme  in  143 
locations across England by March 2025. 

Martha’s Rule is made up of three components to ensure concerns about deterioration 
can be swiftly responded to: 

•  Firstly, an escalation process will be available 24/7 at all 143 sites, advertised 
throughout the hospitals on posters and leaflets, enabling patients and families 
to  contact  a  critical  care  outreach  team  that  can  swiftly  assess  a  case  and 
escalate care if necessary.  

•  Secondly,  NHS  staff  will  also  have  access  to  this  same  process  if  they  have 

concerns about a patient’s condition. 

•  Finally, alongside this, clinicians at participating hospitals will also formally record 
daily  insights  and  information  about  a  patient’s  health  directly  from  their 
families, ensuring any concerning changes in behaviour or condition noticed by 
the people who know the patient best are considered by staff. 

Lack of national and local guidelines and regulation of the scope of practice and 
supervision of a PA 

The Leng Review will consider the scope of practice for PAs and AAs at the start of 
their working career; however, it will not generate a national scope of practice by either 
healthcare setting or level of experience post-qualification. 

 
 
 
 The GMC has published the generic and shared learning outcomes that PAs and AAs 
must meet to be registered by them as the professional regulator. Taken with the PA 
curriculum,  these  documents  will  describe  what  all  newly  qualified  physician 
associates must know and be able to do. 

A number of medical Royal Colleges have also developed specialty scopes of practice 
for PAs and AAs, and NHS England has engaged with these bodies to facilitate the 
establishment of broad aligning principles.   

As  stated  in  NHS  England’s  summary  of  existing  guidance,  medical  associate 
professions will work within a scope of practice that is agreed with their supervising 
senior doctor. 

NHS England has also engaged with Surrey Heartlands Integrated Care System on 
the concerns raised in your Report.  

They advise that PAs working within the Emergency Department (ED) at Surrey and  
Sussex Healthcare NHS Foundation Trust were not clinically equivalent to Tier 2 
resident doctors, but were, in line with Royal College of Emergency Medicine  
(RCEM) guidance at the time, working alongside Tier 2 resident doctors on the Tier 2  
rota. PAs at the Trust wear different colour scrubs to those worn by doctors, which  
are clearly embroidered with ‘Physician Associate’. They also wear a brightly  
coloured lanyard, also labelled as ‘Physician Associate’. There are posters in the ED  
that show all the colours of scrubs worn by staff and identifying which staff wear what  
colour. The Trust also advise that their PAs are specifically trained to introduce  
themselves as PAs.  

Following the inquest into Pamela’s death, the RCEM issued new guidance moving 
PAs  to  Tier  2  on  the  ED  rota,  and  emphasising  that  PAs  should  only  see  patients 
specifically selected for them by a senior doctor, who must also review any patients 
prior to discharge. The Trust advise that they implemented the changes immediately, 
and PAs at the Trust are also now trained to state that they are not a doctor, when 
they introduce themselves to patients for the first time.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Pamela, are shared across the NHS at both a national and regional level and helps us 
to  pay  close  attention  to  any  emerging  trends  that  may  require  further  review  and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

 
 
 
  
 
 National Medical Director

Dr K Henderson 
HM Assistant Coroner for Surrey 
HM Coroner's Court 
Woking 
GU22 7AP 

3rd April 2025 

Dear Dr Henderson, 

Further to your prevention of Future Deaths Notice following the conclusion of your inquest 
(19th December 2024) into the death of Mrs Pamela Anne Marking who died on 20th February 
2024, we would like to extend our sympathy and condolences to the family and friends of Mrs 
Marking. 

Mrs  Marking  attended  the  emergency  department  (ED)  of  East  Surrey  Hospital  with  the 
symptoms  of  blood-stained  vomiting  and  abdominal  pain  and  was  assessed  by  Physician 
Associate (PA).  Mrs Marking was known to have cognitive issues which limited her ability to 
provide a complete history.  Your prevention of Future Death Notice (24th February 2025) also 
makes reference to an incomplete abdominal examination by the PA and Mrs Marking’s case 
being  discussed  with  a  supervising  consultant  without  a  face-to-face  review.  Following 
discharge  from  the  emergency  department,  Mrs  Marking  represented  two  days  later  to the 
same  ED  and  was  diagnosed  with  a  small  bowel  obstruction  and  unfortunately  suffered  a 
complication of general anaesthesia which contributed to her subsequent death. 

Following a period of consultation and engagement with various stakeholders, in June 2024 
the  Royal  College  of  Emergency  Medicine  (RCEM)  issued  a  position  statement  regarding 
Physician Associates [1] which included the following: 

•  Supervised  Practice:  PAs  working  in  Emergency  Departments  must  always 
operate  under  the  safe supervision  of  an  EM  consultant,  Associate Specialist  or 
Specialist doctor according to local policy. 

•  Public Awareness: PAs must be clearly identifiable and identify themselves as a 

PA to members of the public and other clinicians. 

•  Undifferentiated Patients: PAs must not see undifferentiated patients within an ED 

without safe supervision, and within agreed entrustment levels. 

•  Regulation: PAs must be regulated at the earliest opportunity. 

RCEM  has  recently,  after  an  extensive  consultation  period,  updated  our  workforce  tiers 
guidance.  This guidance was originally published in February 2015 and outlines what level of 
supervision  clinicians  with  different  levels  of  experience  and training  should  be  working  at.  
The current guidance makes explicit reference to PAs as working at Tier 1 level and makes a 
specific recommendation that patients seen by a PAs should be discussed with or reviewed 

 
 
 
 
 by a  tier  4 or  5 doctor [2].    The  decision  as to whether  a patient  has  a face-to-face  review 
rather than a discussion, is for the judgement of the supervising doctor who will need to take 
into account many factors, including those which are patient related (e.g. potential seriousness 
of the presentation, co-existent illnesses) as well as those which are clinician related.   

The role and regulation of PAs has been subject to much comment in recent years [3], we 
note that there is an ongoing review into the safety and scope of the PA role [4] to which RCEM 
is  contributing.  RCEM  is  responsible  for  setting  standards  of  training,  administering 
examinations and awarding Fellowship and Membership of the College as well as supporting 
Post  Graduate  Doctors  in  Training  to  qualify  in  the  specialty  of  Emergency  Medicine.  The 
College works  to  ensure  high  quality  patient care by setting  and monitoring  standards.  We 
provide expert guidance and advice on health policy to relevant bodies on matters relating to 
Emergency Medicine and advocate and influence policy makers and politicians on behalf of 
our  members  and  the  wider  specialty.  It  should  be  noted  that  RCEM  does  not  have  any 
statutory or regulatory role.  RCEM is not responsible for monitoring or accrediting PA training.   

RCEM has been working with NHS England for over a year on the implementation of ‘Martha’s 
Rule’ in the ED setting.  ‘Martha’s Rule’ is designed to ensure that patients, families, carers 
and  staff  will  have  round-the-clock  access  to  a  rapid  review  from  a  separate  care  team  (a 
second opinion from a clinician), if they are worried about a person’s condition. 

In 2016 RCEM produced a list of patient groups which should be discussed with a consultant 
or senior doctor before patient discharge [5,6].  The patient groups were selected on the basis 
that they are important ED presentations with a risk of life-threatening disease that may not 
be  immediately  appreciated  by  less  experienced  staff;  abdominal  pain  in  patients  aged  70 
years  and  over  was  one  of  these  patient  groups.  RCEM  has  worked  with  the  national 
emergency laparotomy audit project (NELA) for several years to improve the care of patients 
who  require  an  emergency  laparotomy  (abdominal  operation).  RCEM  issued  a  position 
statement  in  October  2024  regarding  patients  who  may  require  a  laparotomy  [7];  this 
statement highlights that some patients are at greater risk of requiring surgery and part of this 
group includes the older person and those with cognitive impairment. 

RCEM does not feel it would be appropriate to comment on matters related to the provision of 
general anaesthesia in the operating theatre. 

Yours sincerely,

President  
Royal College of Emergency Medicine 

President-Elect  
Royal College of Emergency Medicine 

 
 
 
 
 
 
 
 
 
 References 

1.  https://rcem.ac.uk/rcem-physician-associates/ Accessed 02.03.2025 

2.  https://rcem.ac.uk/wp-content/uploads/2025/02/Tiers2-February-2025.pdf  Accessed 

02.03.2025 

3.  Abassi  K.  Physician  associates:  why  we  need  a  pause  and  an  urgent  review.  BMJ 

2024;384:q185 

4.  Iacobucci G. Physician associates: Government review will assess scope and safety 

of roles. BMJ 2024;387:q2585 

5.  https://res.cloudinary.com/studio-

republic/images/v1635599020/Consultant_Sign_Off_Standard_June_2016/Consultan
t_Sign_Off_Standard_June_2016.pdf?_i=AA accessed 02.03.2025 

6.  https://rcem.ac.uk/wp-

content/uploads/2024/01/Statement_on_the_Consultant_Sign_Off_QIP_January_20
24.pdf Accessed 02.03.2025 

7.   https://rcem.ac.uk/wp-content/uploads/2024/10/RCEM-Advisory-Statement-

regarding-the-management-of-adults-presenting-to-the-Emergency-Department-who-
may-require-an-emergency-laparotomy-2-2.pdf accessed 02.03.2025

Care Quality Improvement Directorate  
Royal College of Physicians  
The Spine 2 Paddington Village  
Liverpool  
L7 3FA  
Tel: +44 (0)151 318 0000  
Email: cqid@rcp.ac.uk  
www.rcp.ac.uk  

T: 

Dr Karen Henderson 
HM Assistant Coroner for Surrey   
HM Coroner’s Court 
Station Approach 
Woking  
GU22 7AP 

Ref: 2025-0107 

22 April 2025 

Royal College of Physicians response to Regulation 28 report to prevent future deaths  

Dear Dr Henderson, 

The Royal College of Physicians (RCP) notes with concern the content of the Regulation 28 
report for the prevention of future deaths related to the death of Pamela Anne Marking. 

We send our sincere condolences to the family of Mrs Marking.  

The Regulation 28 report is addressed to the RCP, but we wanted to note that whilst the 
Faculty of Physician Associates (FPA) was part of the RCP at the time of the inquest, it was 
dissolved on 31 December 2024. Additionally, effective 13 December 2024, the GMC began 
regulation of Physician Associates (PAs).  

This letter has also been addressed to recipients with expertise in anaesthesia, who may be 
best placed to respond to concerns 6, 7 and 8. 

Many of our fellows and members have significant concerns about the safe deployment of 
PAs, especially concerning regulation, scope of practice and supervision. We have now 
delivered the results of a working group on PA and have submitted our findings to the Leng 
review alongside a submission from our resident doctors. To ensure that the PA workforce is 
able to contribute to patient care actively and safely, the RCP believes that considerable 
changes need to be made. This will require time, commitment, coordination, transparency - 
and above all - collaboration between the NHS, patient groups, royal colleges, the GMC, and 
medical associate professionals, including PAs. 

 
 
  
 
 
 
 
 
 
 
 
 
 
 
 Matters of concern and the RCP response 

1.  The term ‘physician associate’ is misleading to the public 

We agree there is significant risk of confusion for the public, particularly noting patients 
and families are often in vulnerable situations when they seek healthcare advice. We also 
note that the lack of understanding around the term ‘physician associate’ is not the fault 
of the PA. We believe the term ‘assistant’ is much clearer and in line with the competence 
of the PA, and have recommended a change in name in our submission to the Leng review. 
We also note the need for clear and specific introductions from the PA when introducing 
themselves to patients and their families and suggest not using phrases such as ‘I am on 
your clinical / medical team.’ The RCP published interim guidance on titles and 
introductions for PAs in December 2024, in which we were clear that ‘PAs must clearly 
explain their role to patients, their families and carers, as well as colleagues and 
supervisors, and provide details of their educational and clinical supervision when 
required. 

2.  Lack of public understanding of the role of physician associate  

We agree that, for both patients and the wider healthcare system, the role of the PA is 
confusing. ‘Medical professional’ is another term used for a PA and, again, we believe that 
for the public and wider healthcare system this does not provide adequate clarification in 
the differences in roles, training and competency between doctors and PAs.  

3.  The right of patients and family to seek a second opinion 

This would be addressed at a local level, but we fully support the implementation of 
Martha’s Rule to enable families to ask for a second opinion when they are worried about 
a relative’s acute deterioration. In addition, we are clear that PAs should not be making 
decisions independently, particularly around discharge in patients in an emergency or 
undifferentiated setting.  

4.  Lack of local and national guidelines and regulation of the scope of practice for a 

physician associate  

The RCP believes that PAs should be working to nationally-agreed guidelines and relying 
on local guidelines only risks inconsistency, or at worst no agreed guidelines at all. The 
GMC is now responsible for regulation, but our understanding is that regulation will need 
to be supported by national guidelines to provide a clear framework for assessment. We 
would also welcome clarity of PA clinical competency at qualification; we note passing the 
PA exit exam is not synonymous with competency and ability in a clinical setting.  

5.  Lack of guidelines for direct supervision and consideration of an appropriate level of 

autonomy for physician associates 

We agree with this and the  RCP has written published interim guidance for physician 
associates working in the medical specialties. 

 
 
 
 
 
 
 
 
 
 
 
 
 The FPA closed in December 2024. The initial transfer of PA Managed Voluntary Register 
(PAMVR) data from the RCP to the GMC began on 31 October 2024, and was deleted on 31 
March 2025. The GMC register opened on 13 December 2024 and will be voluntary until 
December 2026.  

The RCP is clear that PAs are not doctors but workforce pressures are very high, 
particularly in acute care, and this leads to risk of workforce substitution and lack of 
adequate capacity for supervision and training. At worst, this risks assessment of patients 
in inappropriate spaces and pressure to rapidly discharge without ability to observe and 
review. Elderly frail patients with dementia or confusion are particularly at risk in our 
current overcrowded systems. The RCP also supports the need for the development and 
distribution of clear guidance for the consultant who is supervising the work of the PA to 
ensure standardised, adequate oversight.  

A comprehensive, national, safe and clear scope of clinical practice for PAs is essential. 
However, we note the following:  

>  There is insufficient central coordination, or agreement, within the NHS and amongst 
employers on how a national scope of practice should be developed and by whom.  

>  There is limited awareness of what a PA can safely do in a clinical setting upon 

completion of PA studies and no agreed mechanism for extended clinical practice.  
>  PAs are employed in a very wide range of clinical settings and specialties, and within 

both the NHS and private healthcare settings. 

System leaders, including the GMC, should take a leading role in developing and overseeing a 
national scope of practice and supervision of PAs. Multi-disciplinary working must be 
supported by full regulation and competency assessment. A national framework for the 
employment and deployment of PAs is needed. National policy and guidance must be clearly 
understood and delivered locally, supported by good governance structures.  

Working with our fellows and members, the RCP will continue to actively campaign to limit 
the pace and scale of roll-out of PAs in the NHS until we are reassured that there are safe 
systems in place for PA deployment. We have repeatedly made clear that PAs are not 
doctors, and they cannot and must not replace doctors. We have also called on the UK 
government and the NHS to develop and publish an evidence-base and evaluation framework 
around the introduction of PAs. This should be a priority, and we are working with the RCP 
Patient Safety Committee to consider what more we can do to support this agenda.  

Yours sincerely, 

Clinical Vice President, Royal College of Physicians

Please reply to: 
Name: 
Title:    Chief Medical Officer 
Direct Line 
Email: 

Dr Karen Henderson  
H M Assistant Coroner for Surrey  
Station Approach  
Woking  
GU22 7AP  

 Headquarters 
East Surrey Hospital 
Canada Avenue 
Redhill 
RH1 5RH 

Tel: 01737 768511 
www.surreyandsussex.nhs.uk 

17th April 2025 

Dear Dr Henderson,    

Regulation 28 Report – response by Surrey & Sussex Healthcare NHS Trust 
Inquest touching the death of Pamela Anne Marking (Date of Birth 20/09/1946)  

This response comprises the formal response of Surrey & Sussex Healthcare NHS Trust (the 
Trust), pursuant to section 7(2) to schedule 5 of the Coroners and Justice Act 2009 and 
Regulation 29 Coroners (Investigations) Regulations 2013, to the issues raised in the Regulation 
28 Report to Prevent Future Deaths, dated 24 February 2025, made subsequent to the inquest 
into the death of Mrs Marking, which was concluded on 19 December 2024. 

The Trust was given until 21 April 2025 to respond to the coroner, pursuant to Regulation 29(5) 
Coroners (Investigations) Regulations 2013. 

We would like to start this response by offering our sincere condolences to Mrs Marking’s family. 
As a Trust we are committed to learning from the issues raised during the Inquest. 

The Prevention of Future Deaths report identifies a number of areas of concern, and we address 
these in turn in the following response, where it is within the Trust’s ability to do so, and we 
describe the details of the actions that we have undertaken. 

The term ‘Physician Associate’ is misleading to the public: 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. 

The term ‘Physician Associate’ is a national term, sanctioned by national bodies, and describes 
a particular group of healthcare professionals who have completed a recognised training 
programme. However, the Trust recognises that there is a lack of awareness amongst the public 
and indeed amongst some healthcare staff that Physician Associates are not medically qualified 
practitioners. Since we first employed Physician Associates (PAs) at the Trust we have tried to 
make this distinction as clear as possible. At the Trust, PAs always wear uniquely coloured 

An Associated University Hospital of 

Brighton and Sussex Medical School 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 scrubs (turquoise), which are clearly embroidered on the front with “Physician Associate.” They 
also always wear distinct bright yellow lanyards clearly inscribed with “Physician Associate.” All 
the PAs are trained to introduce themselves to patients and their families as “Hello, my name is 
xxx, I’m a Physician Associate”. Subsequent to this Prevention of Future Deaths report, the 
Trust’s Chief Medical Officer and Chief Executive met with the Trust PAs and have instructed 
them to always introduce themselves as “Hello, my name is xxx, I’m a Physician Associate. I am 
not a Doctor, but a senior doctor will be overseeing your care.” This applies across the Trust, 
including in the Emergency Department (ED). Within the Emergency Department, since the 
Inquest, we have installed clear signage throughout, identifying the different members of the 
clinical team by the different colours of scrubs that they wear. 

Lack of public understanding of the role of Physician Associate: 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. 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 Trust has always followed national guidance regarding the scope of practice for Physician 
Associates. We recognise that PAs are not medically qualified, and we do not allow PAs to 
undertake roles outside of their competency, but they nonetheless have a valid role within the 
clinical team. Until February 2025 the Royal College of Emergency Medicine guidance was that 
in the Emergency Department Physician Associates should work on Tier 2 of the ED rota. That 
did not mean that PAs were the same as Tier 2 resident doctors, but that they could work 
alongside them. As of 28th February 2025, the Royal College of Emergency Medicine issued 
new guidance, stating that PAs should now be on Tier 1 of the ED rota. We immediately made 
that change and implemented the new guidance in full. We have issued a new scope of practice 
document for PAs in the ED which we have enclosed with this letter. This confirms that the Trust 
complies with the new guidance. 

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. 

We believe that we have explained above all that is within the remit of the Trust regarding this 
concern. 

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. No evidence was presented that the management of 
Mrs Marking was subject to a reflective practice review. 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. 

The PA involved in Mrs Marking’s care has undertaken an extensive reflective practice review 
with a number of the ED Consultants and will include this in their annual appraisal. 
We have had a local governance policy in place for all PAs that work at the Trust since 2015. 
Within this we worked to all available national guidance at the time and have amended the 

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 policy in line with changes as they were made at a national level, particularly since the GMC 
began the process towards regulation.   

The scope of practice for PAs at graduation is underpinned by the Department of Health Matrix 
of Core Clinical Conditions, enclosed with this letter, which outlines the key presentations and 
conditions that PAs are expected to manage. This framework ensures that PAs work within their 
competencies and escalate cases appropriately. At the time of Mrs Marking’s death, the Trust 
was following interim standards for PAs and AAs (GMC) published October 2021 and the Core 
Capabilities Framework for Medical Associate Professionals published June 2022, enclosed. 
The following links to the NHS England guidance that contains all the relevant guidance that the 
Trust has adhered to since we first employed PAs: https://www.england.nhs.uk/long-
read/summary-of-existing-guidance-on-the-deployment-of-medical-associate-professions-in-
nhs-healthcare-settings/  

In response to the issues raised in this Inquest, and in response to the new guidance from the 
Royal College of Emergency Medicine, enclosed with this letter, we have issued a new scope of 
practice document for PAs in our ED and implemented it immediately, as of 3rd March 2025. This 
specifically states that if it is planned for a patient to be discharged from ED after seeing a PA, 
that patient must first be reviewed in person by a senior ED doctor, Tier 4 or 5. All our PAs and 
ED Consultants have been instructed to follow this change and are supportive of it and the 
document has been circulated. 

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. This gives rise to a concern that inadequate supervision or 
excessive delegation of undifferentiated patients in the Emergency Department to 
Physician Associates compromises patient safety. 

The new scope of practice document addresses these concerns. PAs now work on Tier 1 of the 
ED rota. They do not now see undifferentiated patients, but have specific patients identified as 
suitable for them by an ED Consultant. Throughout the patient’s stay within the ED, the PA will 
escalate to a senior ED doctor if there are any concerns or any deterioration in the clinical 
condition of the patient. Any patient seen by a PA who is for discharge will be reviewed face to 
face by a senior ED doctor prior to discharge. Any patient seen by a PA and then referred for 
admission will then be seen by doctor from the appropriate admitting speciality. 

Lack of ‘Updated’ National Guidelines for Rapid Sequence Induction (RSI) of Anaesthesia 
for emergency surgery: Mrs Marking required a rapid sequence induction to protect her 
airway from aspiration of bowel contents as a consequence of small bowel obstruction. 
The consultant anaesthetist gave evidence that the ‘traditional’ use of consecutive 
syringes of induction agent and muscle relaxant was obsolete, and it was common 
practice locally and nationally to routinely undertake a RSI with Total Intravenous 
Anaesthesia, in the absence of updated local or national guidelines to support this 
practice. 

There is national guidance that describes the use of modified Total Intravenous Anaesthesia 
during Rapid Sequence Induction, and it is accepted practice across the UK as an option. This 
guidance from the Association of Anaesthetists and the Society for Intravenous Anaesthesia is 
attached. The Difficult Airway society guidance lists it as ‘accepted practice’ in RSI. The 
traditional use of consecutive syringes of induction agent and muscle relaxant is still practiced 
by the majority of the clinicians in the anaesthetic department at the Trust.  

Lack of ‘Updated’ National Guidelines to support the use of TIVA for RSI: Other than 
empirically increasing the rate of infusion of TIVA agents (Propofol and Remifentanil) no 

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 evidence was forthcoming as to the target range required to ensure and confirm an 
adequate depth of anaesthesia for patients or the length of time required prior to and 
following the administration of a muscle relaxant (Rocuronium) to facilitate intubation. 
This is despite TIVA being known to provide a slower onset of anaesthesia and 
approximately 50% of all anaesthetic related deaths are due to aspiration (NAP 4). 

At the Trust, if a clinician is using TIVA for RSI, they always use a modified TIVA technique 
which involves a predetermined dose of propofol as induction agent as a bolus and a 
predetermined dose of muscle relaxant as a bolus dose. This allows for rapid anaesthesia, as 
per the enclosed guideline. 

Lack of ‘Updated’ Guidelines for use of Cricoid pressure and other measures to protect 
the airway in a RSI anaesthetic: Evidence was heard that as cricoid pressure was 
ineffective it was not routinely applied for a RSI intubation. After aspiration on Induction, 
the only suction device was attached to the nasogastric tube giving rise to a possible 
delay in timely suctioning of the feculent aspirate which was in excess of two litres after 
intubation was achieved. 

The use of cricoid pressure during RSI is not universal in all situations as it can make intubation 
more difficult and is listed as an optional measure by the Difficult Airway Society. However, the 
Trust accepts that in the setting of bowel obstruction, with the increased risk of aspiration, 
cricoid pressure should have been used. This has been communicated across the whole 
anaesthetic team at a departmental meeting and in the Mortality & Morbidity meeting. All 
anaesthetic trainees at their departmental induction are instructed to use cricoid pressure and 
this is reiterated in regular simulation training. 

We hope the above provides you with sufficient information and assurance but if you require 
more details, please do not hesitate to contact me.  

Yours sincerely, 

Chief Medical Officer  

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