The grieving parents of a young actress who died after a doctor misdiagnosed her are joining a unique legal case by leading doctors against the General Medical Council.
They say they feel “cheated” by the regulator’s chief executive, who they say has failed to deliver on his promise to ensure such tragedies do not happen again.
Marion and Brendan Chesterton’s beloved daughter Emily, 30, died in 2022 from a lung clot that a physician associate (PA) – a healthcare worker with just two years’ training – wrongly diagnosed as anxiety and a sprain. Amid growing concerns across the country about the use of “cheap medics” to fill staff shortages, the couple met General Medical Council boss Charlie Massey in July and he assured them there would be “no more Emilys” when the body begins regulating PAs in December, The Mail on Sunday can reveal.
Emily Chesterton died in 2022 from a blood clot in the lung, which was wrongly diagnosed by a doctor as anxiety and a sprain
The Chestertons left the meeting with the ‘reassurance’ that limits would be placed on what PAs could and could not do.
They believed that the GMC would ensure that PAs were properly supervised by qualified doctors, rather than working with little or no supervision as has too often been the case, and that they should be clear to patients that they were not doctors.
These points, especially the last one, were crucial in Emily’s case: she was not told she was going to a PA. Otherwise, her mother Marion says, the family would have sought a doctor’s opinion and they don’t believe she would have died.
But they now feel ‘let down’ by the General Medical Council after legal documents revealed the regulator has no plans to restrict the scope of PAs or anaesthetists – claiming it has ‘no authority’ to do so.
The documents, seen by this newspaper, came to light as part of a criminal investigation launched by action group Anaesthetists United.
They also argue that the regulator will not require staff to explain their “skills and experience” to patients, nor will it define how they should be supported.
The revelations have prompted the Chestertons – and other grieving families whose loved ones have been victims of PA errors – to join Anaesthetists United’s legal action. Their aim is to force the council to clearly define the boundaries of PA roles to prevent them from carrying out the duties of doctors. The NHS plans to recruit 10,000 doctors and nurse anaesthetists – known as AAs – by 2038 to ease the pressure on the service.
But over the past year, The Mail on Sunday has repeatedly uncovered incidents of PAs going above and beyond their remit, performing basic tasks such as filling in forms and carrying out simple health checks to free up time for doctors.
We found evidence that PAs diagnosed patients, performed surgeries, prescribed medications, and took over the services of physicians.
As part of our campaign to keep Physician Associates’ health in check, we have also reported a number of deaths and even a baby left disabled due to PA blunders.
Doctors are also concerned. On Friday, the Royal College of GPs voted overwhelmingly to ban PAs from working in GP surgeries.
Ms Chesterton, a retired language teacher, told the Department for Education: ‘During our conversation, Mr Massey agreed with almost everything I said we wanted to achieve. He also said that patient safety must come first.
“At the end he looked at me and said, ‘I promise you, no more Emilys.’ We left there feeling very reassured, knowing that the regulations we wanted would come.
‘I even sent him a photo of Emily and asked him to keep her at the forefront of his mind when he was planning how the regulation would go. It was one of her with Paul McCartney, taken at her 2017 graduation from the Liverpool Institute of Performing Arts – she was beaming and we were so proud of her.
‘But now that I understand from the legal literature that there will be no proper regulation, I wonder whether we have not been somewhat appeased and fooled.
‘We are taking legal action to prevent other families from going through the same hell. The General Medical Council must live up to its responsibilities. We need absolute clarity about what PAs and AAs can and cannot do.’ In a letter sent to lawyers representing Anaesthetists United in August, the regulator stressed that the government was not requiring it to restrict PAs’ duties – it was merely setting ‘standards’ for their training and skills. It said the Department of Health could have ordered the regulator to impose such restrictions, ‘however it decided not to’.
Emily beams in a photo with Paul McCartney taken during her 2017 graduation from the Liverpool Institute of Performing Arts
Furthermore, while the General Medical Council website says that PAs should have ‘some level of supervision’, this should be determined by employers – in other words, hospital trusts or GP practices. The letter also says that ‘there is no requirement’ for staff ‘to inform patients of their experience or qualifications before treating them’ – although the regulator has urged the MoS that they would still be required to introduce themselves to patients and explain their role.
Ms Chesterton said the tone of the letter was ‘completely different’ to her meeting with Mr Massey. ‘It is so arrogant and an abdication of responsibility, yet again. ‘Families who have lost loved ones do not care about the distinction between standards or limits, we just want to know that the regulation will be robust.’ The letter added that medical Royal Colleges would be the ‘appropriate bodies’ to provide guidance on their area of work.
However, the Royal Colleges have no regulatory powers and the General Medical Council has not indicated whether it will enforce the guidelines they produce.
Solicitor John Halford of Bindmans, acting for Anaesthetists United, said: ‘Royal College guidelines have no teeth. Without clear boundaries from the General Medical Council, AAs and PAs can do whatever they think they can, or what their Trust tells them to do.
‘There is no limit – that’s the kind of Wild West we have at the moment and that led to Emily Chesterton’s death. It’s a regulatory loophole.’ Evidence suggests that existing Royal College of Anaesthetists guidelines on the use of AAs – with an updated draft guideline due soon – are already being ignored by hospitals and are open to interpretation.
Mr Halford said documents obtained by Anaesthetists United under Freedom of Information legislation revealed “truly shocking” policies at a local level.
They show that AAs can sedate patients, including children, without direct physician supervision. In some cases, supervising physicians do not need to be in the same room or hospital building, but must be able to arrive within a few minutes. Others say that physicians should be reachable only by telephone.
In some cases, AAs are allowed to choose which medications to give their patients.
A recent study of patients who suffered cardiac arrest during surgery found that 47 percent died when an AA provided anesthesia, compared to 30 percent if not.
On the scope of PAs, there is no guidance at all from the Royal College of Physicians. It is embroiled in a separate controversy, accused of ‘deliberately misleading parliament’ by suggesting in a government consultation that its members were in favour of the General Medical Council regulating PAs. Indeed, many oppose the General Medical Council’s oversight of PAs, arguing that it further blurs the lines between PAs and doctors.
Doctors wrote an open letter to the British Medical Journal (BMJ) last week condemning the leadership of the RCP.
Further FoI documents show the General Medical Council has received £8.1 million over three years from the Department of Health to put together the regulatory package, with a further payment of £2.2 million expected to be needed this year.
According to Dr David Nicholl, a neurologist in Birmingham and one of the signatories of the letter to the BMJ, this suggests the regulator is “acting as some kind of government agency rather than putting patient safety first”.
Another case included in the lawsuit is that of Susan Pollitt, who died last year after an unnecessary medical procedure performed by a PA.
Emily graduates in 2017. Concerns about the use of “cheap doctors” to fill staff shortages are growing nationwide.
Emily, front right, as a young girl with her mother Marion, father Brendan and sister Jasmine
Susan, 77, went to the Royal Oldham Hospital in Greater Manchester after falling and breaking her arm in July 2023. She died from a bacterial infection as a result of the procedure.
Coroner Joanne Kearsley said there was “no adequate process” to ensure PAs were able to carry out such operations at the Northern Care Alliance, which runs the hospital. She took the unusual step of writing to the General Medical Council and now Health Minister Wes Streeting, warning of a risk of further deaths unless action was taken to better regulate PAs.
A spokesperson for the General Medical Council said: ‘We have consistently said that we expect PAs and AAs to always work under some level of supervision and to act within their competence. They have a responsibility to communicate clearly who they are and what their role is in the team.
‘To register with us, PAs and AAs must also demonstrate that they have the knowledge, skills and experience to treat patients safely and that there are no doubts about their fitness to practice.
‘By bringing PAs and AAs under regulation, patients, colleagues and employers can be confident that they can practice safely and be held accountable if serious concerns are raised.’
- Anaesthetists United needs to raise £200,000 by the end of the month to fund the legal case against the General Medical Council. Donate here: crowdjustice.com/case/stop-misleading-patients