A young woman collapsed and died after she was twice misdiagnosed by someone who was not actually a qualified doctor at her GP surgery.
Emily Chesterton died of a pulmonary embolism - a blood clot that travelled to her lung - despite attending two appointments at The Vale Practice in Crouch End.
The 30-year-old actress, originally from Salford, believed she was being seen by a GP but had actually seen a physician associate - a graduate who has undertaken postgraduate training and is supervised by a doctor.
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Ms Chesterton went to the Park Road surgery in October with calf pain and was diagnosed with a sprain when she actually had a blood clot in her leg.
At a second appointment, she was given anxiety medication after reporting further symptoms of a swollen leg and shortness of breath.
She collapsed later that day and died in hospital in November, three weeks after she first sought medical advice.
At her inquest in March, St Pancras coroner Mary Hassel concluded that after presenting with her symptoms, Ms Chesterton "should have been immediately referred to a hospital emergency unit".
She said it was likely she would then have survived.
Ms Chesterton's mother Marion told the BBC: "If I had known earlier that she had not seen a doctor, I would have marched back to the surgery or gone straight to hospital."
She suggested the job title - created in 2003 - was unclear. "Physician associate sounds grander than a GP," she added.
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She added: "It's been heart-breaking to know that if she had been referred to A&E at either of the times she attended that surgery, the outcome - according to the coroner at the inquest - was that she would have lived and those four words - 'she would have lived' - will live with me for the rest of my life."
The NHS plans to increase the number of physician associates to 10,000 by 2037, according to the Department of Health and Social Care.
The role is currently unregulated. The Government plans to introduce legislation for regulations before the end of 2024.
David Winskill, a member of the Vale practice Patient Participation Group (PPG), said: "The PPG only found out about this terrible sad death two weeks ago.
"We are working to finalise a date with the practice manager for a meeting to try and establish a better understanding of the facts and look at issues
surrounding governance supervising triage and patient safety.
"Until we have had the meeting it would be unwise to comment further."
The Vale Practice has been contacted for comment.
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