Lessons to be learned from patient’s death, says Cheshire social services expert
A FORMER director of social services for Cheshire has called for lessons to be learned following the death of a patient at the hands of an out of hours doctor from Germany.
Dame Jo Williams, now chairman of NHS watchdog the Care Quality Commission, was commenting on the outcome of an investigation triggered by the tragic case of Mr David Gray, aged 70, who was killed by an overdose of 100mg of diamorphine in February 2008.
The drug was administered by Dr Daniel Ubani, a doctor from Germany employed by out of hours provider Take Care Now in Cambridgeshire.
The company has now closed and Dr Ubani has been struck off.
Dame Jo says there were “serious failings” and the company had not acted on previous warnings to ensure the safe use of the drug.
“Take Care Now failed on many fronts,” says Dame Jo.
“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.
“Around seven million people contact GP out-of-hours services every year – the provider, the primary care trust and individual clinicians all have a responsibility to ensure services are as safe as possible.
“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. “Primary care trusts in particular are now scrutinising the services they commission in greater detail and demanding assurances about safety.
“We hope the family of Mr Gray will take some comfort in knowing that his tragic death has brought about significant change in the way out-of-hours services are delivered and monitored”.
Commenting about potential changes to government policy on out-of-hours services, Dame Jo added: “The Secretary of State has made it clear that there are changes around the corner. “Regardless of what these changes may look like, the lessons are clear – the competency of overseas doctors must be properly tested, serious incidents must be properly investigated and quality of care must be monitored closely.”
From April 2012, companies providing GP out-of-hours services must be registered with commission in order to legally provide services.
The new registration system brings the NHS, independent healthcare and adult social care under a single set of essential standards of quality and safety.
The commission says it will take the findings of its investigation into the company and other external reviews of out-of-hours services into account when making decisions about how it will regulate out-of-hours providers in line with the new standards.