Out-of-hours GP firm had systematic failings, CQC says
A company providing out-of-hours care in an area where a pensioner died after a painkiller overdose had "systematic" failings, the NHS regulator says.
David Gray, 70, from Manea, Cambridgeshire, was killed by Dr Daniel Ubani, a German medic working his first NHS shift for Take Care Now.
The now-defunct firm was criticised for failing to act on previous cases and warnings on standards.
The Care Quality Commission said the whole NHS should learn lessons too.
The death of Mr Gray in February 2008 after he was given 10 times the normal dose of diamorphine has focused national attention on weekend and night GP cover, which in many cases is provided by private firms.
The CQC criticised Take Care Now (TCN) for failing to investigate and learn from two previous cases of diamorphine overdoses prior to Mr Gray's death.
Both were given by doctors from Germany, where the drug is not routinely used.
The firm was also warned prior to the case by one of its own doctors that it was "only a matter of time before a patient is killed".
But it did not take sufficient action, the Care Quality Commission (CQC) said.
Staffing levels were also said to be potentially unsafe.
The report also criticised the NHS trusts which used the firm, which is no longer in existence. As well as Cambridge, TCN had contracts in place with NHS Great Yarmouth and Waveney, NHS South West Essex, NHS Suffolk and NHS Worcestershire.
None of the trusts had robust arrangements to share information and out-of-hours care was judged to be a low priority - reflecting the national position.
The lack of attention from regional health authorities was also highlighted.
CQC chairman Dame Jo Williams said: "Take Care Now failed on many fronts. The lessons of its failure must resonate across the health service."
A spokeswoman for the Patients Association said the findings were a "stinging reminder".
Since the case, standards have been tightened. Guidance has been issued to local health managers stressing the importance of good monitoring and information sharing, while firms providing out-of-hours care must be registered with the CQC from 2012.
But Health Secretary Andrew Lansley said more action was needed.
He said the steps outlined in a White Paper on Monday to give GPs more responsibility for running services would lead to improvements.
"Out of hours care needs urgent reform," he said.
Meanwhile, German medical authorities have signalled an intention to bring Dr Ubani before disciplinary hearings.
He has been struck off the medical register in the UK, but is still free to work in Germany.
An inquest in February ruled Mr Gray had been unlawfully killed.