Search the hub

Aarav died from the consequences of a cardiac arrest caused by severe bleeding following damage to an intercostal artery during a liver biopsy which went undiagnosed and untreated at the time of the procedure. His death was contributed to by poor planning before the procedure when there was no consideration of stopping antiplatelet medication, poor written and oral communication about the complication that occurred during the procedure all of which hampered treatment after his collapse. His death was contributed to by neglect.  MATTERS OF CONCERN Prophylactic antibiotics for severely immunocompromised patients: The inquest heard evidence that patients like Aarav who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. The concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients. Experience and competence of trainees: The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. The concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their training. Consent forms: The parents of Aarav were unaware that a trainee would be doing the liver biopsy. The concern is that there is currently no way to obtain consent when a trainee will be doing the procedure. Individual patient risk factors: Aarav had a complex medical background and several risk factors for any procedure. The concern is that there is currently no mechanism to identify individual patient’s risk factors so that all clinicians involved in their care are aware. Learning from deaths: The initial M&M meeting after Aarav’s death was described as inadequate. The concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity. Electronic patient records: Evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient’s medication details. The concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment.

Physician Associates were supposed to ease doctor’s caseloads. Instead they’ve been accused of stealing jobs, confusing patients and failing to prevent at least four deaths. Are their days numbered? Dr Phil Whitaker gives his prognosis in this Times article. You’ve probably phoned your local surgery — or filled in the online form — only to be told the GP can’t fit you in, but a physician associate can see you. Or perhaps you’ve been to A&E and been assessed by a scrubs-clad “PA”, introducing themselves as “one of the medical team”. It’s better to be seen by somebody than nobody, you thought, and you trust the NHS to ensure you’ll be seen by someone qualified to help. Together, the words “physician” and “associate” at least sound reassuring. Yet a series of revelations over the past three years, including four coroners’ reports into patient deaths, have raised serious concerns about the way the health service has deployed this type of NHS worker. Some in the medical profession are asking: should the job even exist at all? Maryam Habib was on her way to the waiting room to collect her first patient of the morning when she spotted something odd on her consulting room door: someone had changed her job title. When she’d left for her summer holiday two weeks earlier the sign had identified her as a “physician associate”, as it had done for the three years she’d been working at her GP surgery in Manchester. Now her own door told her she was something else: a “physician assistant”. The change wasn’t just cosmetic for Habib. She noticed that the appointment slots earmarked for her to assist the duty doctor with the day’s urgent workload had been blocked. She was also told by the practice manager that she was now banned from seeing anyone under the age of 16. Young patients she’d been working with for months, building rapport and trust, were abruptly transferred to an unfamiliar GP. “For the first time I didn’t feel welcome in my workplace,” Habib, 27, tells me. “I felt like a lesser colleague.” She started to overthink every decision, feeling acutely vulnerable in case she put a foot wrong. “It went from 0 to 100 really quickly.”

Educating clinicians about artificial intelligence (AI) is urgent as the UK General Medical Council places liability with practitioners and the European Union AI Act with employers for appropriate training, but also because AI, like any tool, requires training to use safely. The NHS England Capability Framework provides guidance, but frontline clinicians’ perspectives are unknown, so this study published in BMJ Digital Health & AI sought to identify their priorities. The authors surveyed over 300 clinicians to identify their exact priorities and "blind spots" when it comes to AI education. The findings show that clinicians prioritise practical concerns, such as liability and determining confidence in algorithmic outputs. In contrast, critical appraisal and explaining AI to patients were deprioritised, despite their relevance to clinical safety. This infographic from Grazia Antonacci summarises the findings of the study. Read Grazia's LinkedIn post on the study here.

Matilda Gwen Pomfret-Thomas was born on 29 October 2023 at Queen Alexandra Hospital following a difficult labour at home. Hypoxic ischaemic encephalopathy had developed over a period of hours. Meconium had been observed, decelerations were later observed. On 15 November 2023 an investigation into the death of Matilda Gwen Pomfret-Thomas aged 15 days commenced. The investigation concluded at the end of the inquest on 4 December 2025 and the medical cause of death was hypoxic ischaemic encephalopathy. The birth of the family’s first child had been traumatic and, for the birth of their second child, Matilda, they were focussed on achieving a different birth experience and elected to use a doula to provide them with support at a home birth. The hospital’s preference was for a hospital delivery, there was discussion as to what circumstances would result in the mother being blue lighted to hospital. Signs of fetal distress developed but the mother was not immediately transferred to hospital. A difficult atmosphere had developed, the midwives felt access was being restricted by the doula: the coroner found that she did not actively discourage midwife access but that she was seen as, in effect, a buffer by members of the midwifery team. The doula was following the birth plan. The doula was supporting the parents per the birth plan, and this appears to have been perceived as grounds for hope that a home birth was still possible. Matters of concern Doulas provide continuity of care and give emotional, informational and practical support throughout pregnancy, labour and after the birth of a baby: those words come from Doula UK’s website. Doula UK is the largest representative body for Doulas, but it is not a regulatory body, it does not represent all doulas, indeed many doulas are not members of Doula UK. Doula UK have put in place membership requirements, training offers and much guidance, but the role of a doula is clearly diffuse in practical terms and capable of multiple understandings not just by doulas but their clients and midwives. It appears that doulas have been increasingly used and increasingly offer services – as here – on a paid basis. As MNSI (Maternity & Newborn Safety Investigations – formerly HSIB) put it in their report into this birth, “MNSI acknowledges that there is no regulation of doula care or any guidance on how the two services interact with each other. MNSI considers the dynamics of a situation, where a third party are involved can provide additional challenges for staff, such as making clinical recommendations against personal recommendations or views and providing usual care that could be viewed as interference rather than surveillance.” MNSI have identified 12 cases in which there was evidence that doulas worked outside of the defined boundaries of their role and in which the care or advice provided by the doula was considered to have potentially had an influence on the poor outcome for the family. There was evidence given at the inquest by experienced midwifery professionals highlighting that provision of guidance would be helpful for all involved with a birth at which a doula was present. The issues of doula registration, regulation and training are therefore points of concern the coroner would commend for review.

On 25 March 2025, John Rust was admitted to the Queen Elizabeth Hospital for a elective thoracic aortic replacement, having been diagnosed with a Type B aortic dissection in October 2019. On the 26 March 2025 he had a cerebrospinal fluid (‘CSF’) catheter inserted to minimise post-operative risks of paraplegia that is common with the type of surgery. On 27 March 2025, the surgery went ahead without major complications, and he was transferred to ITU to recover. The next day there was over-drainage of the CSF drain, and there were concerns raised about a possible CSF leak, which were not acted upon. John’s neurological status started to deteriorate which was put down to side effects of medication. At 20.32 hours, Johns’ CSF drain was noted to have become disconnected which had resulted in him having a period of unmonitored and uncontrolled CSF loss, and sadly which caused him to suffer a catastrophic and unsurvivable brain injury. John died at 18:36 on 29 March 2025. Based on information from the deceased’s treating clinicians the medical cause of death was determined to be:  1a Intracerebral haemorrhage    1b  Excess CSF drainage  1c  Lumbar drain, replacement of thoracic-abdominal aortic aneurysm  1d     II Chronic Type B Dissection, Hypertension.  Matters of concern In accordance with the PSII report (#SE-48448 ), a specific recommendation was made that “All clinical staff (medical and nursing) using automated CSF drainage systems such as Liquoguard must have completed adequate training to ensure that they are familiar with the functionality of the device prior to use...” The evidence at inquest was that this training was not mandatory at present, and that at the time of the inquest, approximately 55% of the relevant staff have received the training. This has been slowed down somewhat due to a representative of the company being off sick, but further training sessions have been planned. However, the evidence of [REDACTED] (author of the PSII report and consultant neurosurgeon) indicated that it was his view that the training should be mandatory, and that consideration must be given to ensuring this is rolled out in a “sustainable” way to staff – both current and future – as opposed to a “knee-jerk reaction” where training is only given to a limited number of staff following an incident. There was no evidence before the court that there was any plan to embed this training and ensure that it is carried out in a “sustainable” way, with a particular focus on ensuring that future staff are adequately and properly trained. This was particularly concerning given the apparent high rotation and through-put of staff in the ITU department. It became apparent to me that the training being offered was the type of “knee-jerk reaction” that [REDACTED] was fearful of. There is a risk of future deaths occurring where clinical staff (medical and nursing) do not receive adequate training on equipment.

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.