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Out-of-hours provider ‘ignored warnings’ prior to patient’s death

By Gareth Iacobucci

The out-of-hours company which employed German locum GP Dr Daniel Ubani failed to address ‘systematic' failings in its procedures prior to the death of patient David Gray, the Care Quality Commission has found.

The CQC's damning report into the private GP out-of-hours provider Take Care Now (TCN) was triggered after Mr Gray was killed by an overdose of 100mg diamorphine - administered by Dr Ubani - in February 2008.

The regulator ruled that TCN ‘failed to investigate, act upon and learn from serious incidents' prior to Mr Gray's death, including two previous overdoses of diamorphine administered to other patients.

It also found that the five PCTs that used TCN – which has since been taken over by Harmoni - had ‘limited understanding of the service and did not monitor performance adequately'.

The report uncovered evidence that the company's staffing levels were ‘potentially unsafe', with just one nurse as ‘the only clinical cover for 70 miles' on some occasions. It concluded that ‘unfilled shifts and lack of clinical cover could have compromised the care of patients'.

The CQC also ruled that reporting of activity to PCTs was ‘not clear and transparent', with some patients being double-counted, giving the impression that TCN was treating more patients than it actually was, which may have affected contract negotiations with PCTs.

Local GPs quizzed by the CQC issued their own damning verdict, with 50% saying the provider's ability to provide clinician care in people's homes was ‘poor' or ‘very poor'.

The CQC concluded that while TCN had grown its business rapidly by taking on more contracts with PCTs, it had done so ‘without the clinical governance in place to ensure the quality of its services'.

The regulator acknowledged that all five PCTs had since taken action to improve commissioning and monitoring of OOH services, but said at the time of Mr Gray's death, ‘out-of-hours services were a low priority for PCTs, reflecting the national position at the time'.

The regulator said that changes to services at PCT level were ‘often discussed and agreed by non-clinical staff', and that none of the PCTs had ‘robust arrangements' to share information on poorly performing doctors.

CQC chair Dame Jo Williams said: ‘Take Care Now failed on many fronts. Not only did it ignore explicit warnings about the use of diamorphine, it failed to address deep-rooted problems across its entire out-of-hours service. This had tragic consequences for Mr Gray.'

‘Take Care Now is no longer in operation, but the lessons of its failure must resonate across the health service.'

‘Since the death of Mr Gray, there is no doubt that out-of-hours care is now a high priority on the NHS agenda, and rightfully so.'

GMC chief executive Niall Dickson said: ‘This report highlights disturbing failures in the provision of out of hours care. The CQC rightly emphasises the important role employers have to play in ensuring that the doctors they contract with are competent, proficient in English and fit to do the job they are being given.'

The David Gray case has led to heightened scrutiny of GP out-of-hours services The David Gray case has led to heightened scrutiny of GP out-of-hours services