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Many errors in surgical patient care are caused by poor non-technical skills (NTS). This includes skills like decision-making and communication. How often these errors cause harm and death is not known. This goal of this study was to report how many surgical deaths are associated with NTS errors in Australia by assessing all surgical deaths from 2012 to 2019. Some 64% of cases had an NTS error linked to death. Decision-Making and Situational Awareness errors were the most common. The results of this study can be used to guide improvement and reduce future errors and patient death.

The BMA has submitted its response to Professor Gillian Leng’s independent review of the physician associate (PA) and anaesthesia associate (AA) professions in England. In it's submission, the BMA has urged the Government-commissioned review of physician associates to rename the role and set a national scope of practice.

The General Medical Council (GMC) has submitted its response to Professor Gillian Leng’s independent review of the physician associate (PA) and anaesthesia associate (AA) professions in England. In its submission the regulator emphasised the importance of statutory regulation for PA and AAs because - as with any regulated healthcare profession - PAs and AAs undertake complex work that will pose some level of risk to the public, and regulation mitigates this risk. The submission also highlighted that, as the multi-professional regulator for doctors, PAs and AAs, the GMC is well placed to work with others across the health system to identify and address issues that concern all three professions. For example, the availability of supervisors and student training placements. The GMC also said that regulation is already beginning to raise standards of practice through ensuring that only those individuals with the right clinical knowledge and skills are entered onto the GMC’s registers.

In my third year of medical school, my mother announced she wanted to become a physician associate (PA). I always encouraged her to follow her dreams — until she told me her motivation. “It’s basically the same as being a doctor, but with less time at university,” she said. Her words gave me pause. Despite years of medical training, even I wasn’t entirely sure where the line was drawn between doctors and PAs. And if I was confused, how could patients be expected to understand the difference? For some doctors, the PA role can feel less like a collaborative partnership and more like a threat to their professional identity. The British Medical Association has accused the government of using PAs as substitutes for doctors, compromising patient safety in the process. These concerns are not hypothetical.

On 9 November 2019, a woman who was pregnant with Ida, attended the Royal Lancaster Infirmary Labour Ward in early labour. Ida was a normal child whose death was caused by a lack of oxygen during her delivery. This occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress and contributed to by the lead midwife‘s wholly incompetent failure to provide basic neonatal resuscitation for Ida during the first 3 1/2 minutes of her life that further contributed to Ida’s brain damage. Ida died on 16 November 2019 at the Royal Preston Hospital neonatal intensive care unit. The inquest was one in which Article 2 was fully engaged as a result of the Trust’s clinical governance arrangements, inadequate investigations, a lack of transparency and openness, a failure to respond to a detailed complaint letter, a failure to comply with the Duty of Candour, disputing the findings of the Secretary of State for Health’s independent review panel (HSIB now MNSI), failing to notify external monitoring bodies and failing to comply with internal protocols. The Trust’s lack of compliance with clinical governance requirements in the investigation into Ida’s death had significant similarities with the criticisms made in 2015 of the Trust as set out in The Report of the Morecambe Bay Investigation, otherwise known as the Kirkup Report. [REDACTED] who gave evidence at the inquest, expressed the view that there was a deep seated and endemic culture of defensiveness in respect of maternity incidents at the Trust. [REDACTED] also said that the investigation showed elements of failing to identify significant care issues, brevity, defensiveness and was conducted by unskilled investigators. Matters of Concern A: Culture of Candour [Trust, ICB and DHSC] 1. I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Dury of Candour. 2. [REDACTED]’s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn. [REDACTED]’s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest. 3. The Trust’s approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day. 4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust’s internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust’s Patient Safety Summits .The matter was reported to the Coroner a year after Ida’s death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death”. 5. Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to [REDACTED] and [REDACTED]’s 1 June 2020 complaint. Together with the Trust’s failure to categorise Ida’s death as only “Moderate Harm” (see point 4 above) cause me also to have concern about the reliability of Trust’s data. B: Clinical Governance and Maternity Governance [Trust, ICB and DHSC] 6. I consider the clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity care. 7. As a result of the Trust’s deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust’s clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self- congratulation. The clinicians’ reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence. This approach caused additional distress to the family who had to sit through an extended court hearing to address these issues 8. [REDACTED] is now Head of Compliance and Assurance at the Trust but that there has been no investigation into her role in respect of reneging on the Trust’s acceptance of the HSIB report at senior management level and with the family as was indicated by her approval of the July 2021 position statement. Similarly, [REDACTED] is now Head of Midwifery at the Trust and there has been no investigation in respect of her disputing the HSIB findings and submission of challenge to the HSIB report in Ida’s case. 9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust. 10. The Trust’s clinical governance capability has been the subject of repeated and often severe criticism in the Flynn Review 2009, Fielding Report 2010, Central Manchester Hospital Report 2011, Price Waterhouse Cooper 2012 and Kirkup Report 2015. [REDACTED] in his evidence to the inquest said that the Trust focus on process, which means that you can comply with the process requirements and still produce an inadequate investigation, rather than focussing on outcome, which measures the quality of the investigation and the patient experience. [REDACTED] noted that the Trusts culture impeded transparent and open investigation. I am told that the Trust now uses the PSIRF model and is to appoint 3 whole time equivalent Response Leads by 30 September 2025. However, I remain concerned that the Trust has not fully engaged with the duty of candour such that I am not satisfied that the work on PSIRF to date has truly addressed the issues in respect of Trust’s investigations. C. Mandatory Training, expired training and remedial training [Trust and ICB] 11. The Band 5 midwife supporting [REDACTED] in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as [REDACTED] had not completed her mandatory training. 12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date. 13. There was no remedial training was put in place for either the midwives involved in Ida’s delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required for [REDACTED], [REDACTED], [REDACTED] and [REDACTED]. D. Grading of harm for incident reporting: Babies who have sustained hypoxic brain injury and undergo cooling [Trust, ICB, DHSC, NHSE, [REDACTED]] 14. The Trust graded Ida’s level of harm as “moderate”, even after her death. This grading should have been adjusted to “severe” by the Trust before Ida was transferred to Royal Preston Hospital as the consultant paediatrician identified that she had sustained a severe hypoxic ischaemic encephalopathy due to fetal bradycardia. 15. The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone, clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery. 16. [REDACTED] confirmed that nationally there is inconsistency in categorisation of harm for babies who sustain a hypoxic injury due to fetal bradycardia in labour and who require cooling and clarification guidance would assist prevent further maternity deaths and ensure full and proper investigation of hypoxic injuries sustained in labour. E: Funding for MSNI [DHSC and [REDACTED], NHSE and ICB] 17. But for the HSIB investigation report into Ida’s death [REDACTED] admitted that Ida’s death due to failures by the Trust would never have come to light or resulted in an inquest. 18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date. These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children. 19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida’s will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths.

An ECG is a test that records the electrical activity of a patient’s heart. It needs to be correctly carried out and accurately interpreted to determine the patient’s condition and potential diagnosis. This Health Services Safety Investigation Body (HSSIB) investigation was prompted by the case of a 29-year-old woman with chest pain. Her ECG was misinterpreted and she later died of a heart attack.  The investigation focused on paramedic education, training and competence in ECG practice and the task of carrying out and interpreting an ECG in the context of the patient’s clinical signs and symptoms. The investigation spoke to key stakeholders to understand the safety risks that may be present in this area. The way 12-lead ECGs are undertaken and interpreted was identified as a growing area of concern, with systemic safety risks that can have a significant impact on the outcome for patients. HSSIB identified safety learning for ambulance services to help train qualified paramedics. It has also made a safety recommendation to the Health and Care Professions Council and the College of Paramedics to improve undergraduate teaching for paramedic students, to reduce this safety risk for patients. HSSIB makes the following safety recommendation HSSIB recommends that the Health and Care Professions Council and the College of Paramedics work in collaboration with relevant stakeholders to improve the undergraduate teaching of 12-lead electrocardiograms by reviewing and updating any relevant standards, guidance, and curricula to provide clarification on: the level of education and expected level of competency and assessment required of student paramedics in relation to electrocardiograms any minimum expected standards for electrocardiogram education in higher education institutions, including the time spent on electrocardiogram learning, methods used, and subject matter expertise required of teaching staff how patient protected characteristics, health inequalities and other specific patient factors are taught in relation to electrocardiograms how effective feedback mechanisms can be developed between higher education institutions and ambulance services. This is to help improve consistency in the way paramedic students are educated about electrocardiograms. HSSIB makes the following safety observations Ambulance services can improve patient safety by including patient protected characteristics, health inequalities and other specific patient factors that can impact on the task of carrying out and interpreting a 12-lead ECG, when developing refresher training. Ambulance services and national organisations can improve patient safety by providing and supporting protected time and resources for paramedic training and continuous professional development, while understanding the potential impact on operational performance. Ambulance services can improve patient safety by providing additional support to paramedic students and paramedics through exposure to a range of clinical scenarios that help develop and maintain 12-lead ECG competency on a regular basis. Acute hospitals and ambulance services can improve patient safety by developing local mechanisms to share information about patient outcomes where paramedics have undertaken a 12-lead ECG. This can help to support learning for paramedics and provide feedback on where their practice may be improved.

On 16 February 2024, Pamela Anne Marking – who was unable to give a complete history due to cognitive issues – was admitted to the Emergency Department at East Surrey Hospital from her home address after unknowingly vomiting blood-stained fluid, with right sided and suprapubic abdominal tenderness. She was diagnosed as having had an epistaxis (nosebleed) by a Physician Associate  and discharged home later that afternoon without a medical review or direct medical supervision of the Physician Associate who had a lack of understanding of the significance of abdominal pain and vomiting and had undertaken an incomplete abdominal examination which would have been likely to have found a right femoral hernia. Mrs Marking re-presented to the Emergency Department two days later with grossly dilated small bowel obstruction due to an incarcerated right femoral hernia containing ischaemic bowel requiring emergency surgery later that evening. Despite maximal support Mrs Marking died at East Surrey hospital on 20th February 2024. The clinical management Mrs Marking had on her first admission and thereafter during the Rapid Sequence Induction materially contributed to her death. The medical cause of death given was: 1a Respiratory failure and Sepsis   1b Aspiration of feculent gastric contents at induction of anaesthesia 1c. Strangulated femoral hernia. Coroner's concerns 1. 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. 2. 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. 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. 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. 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. 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. 6. 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. 7. 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 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). 8. 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.

There’s been much discussion in the press and on social media about the role of physician associates and anaesthetic associates. Who exactly are they, and how are they trained? The Department of Health and Social Care says that they’re “trained in the medical model”—but what does this actually mean? Helen Salisbury gives her thoughts in this BMJ opinion piece.

Following on from the care failures highlighted in the 2021 report, 'No one's listening', the Sickle Cell Society have published a new report taking a deeper look at sickle cell nursing care. The findings show the need for vastly more resources, training and support in this critical area of care. The report highlights that not only is no-one listening, but that lives are still being put at risk.

Recently, in the wake of growing unrest, plummeting morale, and industrial action, doctors have created an increasingly hostile narrative towards physician associates (PAs) on social media and raised repeated concerns about their impact on patient safety and training opportunities. In this BMJ opinion piece, David Oliver looks at the recent history to understand how we got here and discusses why we need a mature debate about these matters otherwise interprofessional solidarity and multidisciplinary team working could be harmed by the degree of vitriol and resentment.

The aim of this investigation and report is to help improve the inpatient care of adults with a known learning disability in acute hospital settings. It focuses on people referred urgently for hospital admission from a community setting, such as a person’s home or residential home. In undertaking this investigation, the Health Services Safety Investigations Body (HSSIB) looked to explore the factors affecting: The sharing of information about people with a learning disability and their reasonable adjustment needs following admission to an acute hospital. How ward-base staff are supported to delivery person-centred care to people with a learning disability. Reference event The investigation used as a reference event a patient safety incident involving a 79-year-old man who was recorded on his GP’s learning disability register as having a mild learning disability. After being admitted to hospital due to his worsening health. Throughout the patient’s stay, up to his death following a cardiac arrest, his individual needs were not always identified and reasonable adjustments to meet his care needs were not always made. Findings The health and care system is not always designed to effectively care for people with a learning disability. People with a learning disability who are admitted to an acute hospital are often cared for by staff without specialist training, skills and experience in working with people with a learning disability. These staff often have limited support and are unable to take the time they would like to meet the person’s needs. There is no standard model or national guidance for an acute learning disability liaison service (that is, teams that are specifically trained in caring for people with a learning disability). Consequently, there is variation in how these services are funded, their availability, the size of teams and what they are expected to do. The quality of learning disability services is currently monitored via the learning disability improvement standards annual benchmarking survey which is funded until the end of 2023/24. Decisions on future years have yet to be made. Staff in acute hospitals may lack confidence and support in assessing the mental capacity of people with a learning disability, in line with the Mental Capacity Act (2005). There is no national shared system with a single point of access for storing and managing information about the needs of people with a learning disability and the reasonable adjustments required for each individual. Current mechanisms for sharing information about a person – such as ‘care passports’ (a document that gives staff helpful information about the person’s health and social needs, including their preferred method of communication, likes and dislikes) and alert flags (a way to highlight key information to staff) on the electronic patient record – can be unreliable. Instead, information is often gathered from friends and family. Evidence exists that people with a learning disability experience health inequities. Long-held societal beliefs about the abilities of people with a learning disability may influence the provision of and decisions made around their care. Safety recommendations As a result of this investigation, HSSIB recommended that NHS England should: Develops and issues learning disability liaison nursing service best practice and workforce guidance to all acute hospitals. This is to help local decision making about specialist learning disability provision and enable appropriate support for people with a learning disability and the staff who care for them. Ensure that the national learning disability improvement standards annual benchmarking survey for the care of people with a learning disability is continued for acute hospitals in order to help assure that local population needs are met. Commission the development and dissemination of guidance on the practical assessment of the mental capacity of people with a learning disability in acute hospitals. This is to ensure that appropriate decisions are made about the person’s care. With support from key stakeholders including the Professional Record Standards Body, work collaboratively to develop and publish a set of guidelines on information to be included in a health and care passport (which could be paper based, digital, or both) for people with a learning disability with consideration of the reasonable adjustments that people may need. This is to ensure the most current and accurate information about reasonable adjustments to the person’s care is accessible when and wherever it is needed. Safety observations HSSIB made four safety observations as a result of this investigation: Health and care providers can improve patient safety by ensuring that local configuration of electronic patient record systems consider the accessibility and usability of the digital record reasonable adjustments flag in patient records. Health and care curricula can improve patient safety by aligning with the national code of practice on statutory learning disability and autism training, when finalised. Health and care providers can improve patient safety by advocating for all people with a learning disability to have an up-to-date care passport.

Physician associates (PAs) work alongside doctors and form part of the multidisciplinary team. They work across a range of specialties in general practice, community and hospital settings. Anaesthesia associates (AAs), sometimes also known as physicians’ assistants (anaesthesia), work as part of the anaesthetic team. They provide care for patients before, during and after their operation or procedure. This General Medical Council (GMC) page outlines the roles of PAs and AAs and what the regulation will look like.

Physician associates (PAs) are healthcare professionals who work as part of a multidisciplinary team under the supervision of a named senior doctor (a General Medical Council (GMC)-registered consultant or GP). While they are not medical doctors, PAs can assess, diagnose and treat patients in primary, secondary and community care environments within their scope of practice. PAs are part of NHS England’s medical associate professions (MAPs) workforce grouping. MAPs add to the breadth of skills within multidisciplinary teams, to help meet the needs of patients and enable more care to be delivered in clinical settings. PAs do not fall under the allied health professions (AHPs) or advanced practice groups. The Faculty of Physician Associates has created this guidance to provide clarity around the role of PAs. It provides practical examples of how physician associates should describe their role and is aimed at increasing understanding for patients, employers, other healthcare professionals and the public. It is important that PAs take all reasonable steps to inform patients and staff of their role and to avoid confusion of roles. This includes considering the potential for verbal and written role titles to be misunderstood and taking the time to explain their role in any clinical interaction.