Prevention of future deaths report: Susan Pollitt (8 August 2024)

Summary

On the 3 July 2023, Susan Pollitt was admitted to the Royal Oldham Hospital following a collapse at her home. She was treated for a number of medical issues including acute kidney injury. During her admission, she developed ascites—a condition in which fluid collects in spaces within the abdomen. The Consultants involved in her care decided an ascitic drain was not required at that time.

Subsequently on the 11 July, a junior doctor reviewed Mrs Pollitt and decided that an ascitic drain should be placed. The Physician Associate who undertook the procedure was not aware of the local guidance on the insertion of ascitic drains or that the drain should remain in place for no longer than six hours. Mrs Pollitt’s drain remained in place for 21 hours before being removed. She subsequently developed bacterial peritonitis and died on 16 July.

Content

Further to the details in the summary above, the Coroner noted that in this case:

• The junior doctor who reviewed Mrs Pollitt decided that an ascitic drain should be placed. However, the Court found that this procedure was not clinically indicated at that time.
• The Physician Associate who undertook the procedure also directed that the drain be clamped due to a concern that the loss of fluid could cause a drop in blood pressure. This was unwarranted given the moderate level of fluid which had been drained and the Court heard that the Physician Associate did not appreciate that clamping a drain increased the risk of infection.
• The situation was compounded by Mrs Pollitt’s placement on a respiratory ward rather than a gastroenterology ward since there was a lack of understanding and awareness across all the staff on the respiratory ward including the medical team as to the management of ascitic drains.

The Coroner set out their matters of concern as follows:

• There is no regulatory body with oversight of Physician Associates. It is understood that this is currently the subject of a consultation by the General Medical Council.
• The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so, nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate.
• There is no national framework as to how Physician Associates should be trained, supervised and deemed competent. This is placing both patients, Physician Associates and their employers at risk. The court heard that since the death of Mrs Pollitt the Northern Care Alliance have put in place a local trust framework. Unlike all other clinical roles there is no national guidance save for very recent guidance issued by the British Medical Association (March 2024).
• There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families. The lack of a distinct uniform and the title “Physician” gives rise to confusion as to whether the practitioner is a doctor.
• In June 2022 the Physicians Associate had been signed off as competent for the insertion of ascetic drains. This sign off was completed by a liver nurse specialist using a competency form which was provided by the FPA. Whilst the competency form assessed the technical aspect of placing the drain, it did not include competency around the wider aspects of care such as taking consent, risk factors and after care.