15 July 2010
Take Care Now (TCN) did not act on previous warnings about the use of diamorphine prior to the death of David Gray, and systemic failings were not addressed. The five primary care trusts (PCTs) that used TCN had limited understanding of the service and did not monitor performance adequately.
The Care Quality Commission (CQC) today published its report into the GP out-of-hours provider, Take Care Now (TCN).
The regulator’s investigation was triggered by the tragic case of Mr. David Gray, a patient killed by an overdose of 100mg diamorphine in February 2008. The drug was administered by Dr. Ubani, an out-of-hours doctor from Germany employed by TCN.
Dr. Ubani has since been struck off the General Medical Council (GMC) register and is no longer permitted to practise in the UK.
CQC looked in-depth at TCN’s out-of-hours service to assess its performance dating back to April 2007. It also assessed whether lessons had been learned and action taken following the death of Mr. Gray.
As part of its investigation, CQC considered how the five PCTs that used TCN’s out-of-hours services monitored the quality of the service being provided.
CQC’s report shows that prior to the death of Mr. Gray, TCN did not take sufficient action to ensure the safe use of diamorphine. This is despite a senior clinician warning TCN managers that it “was only a matter of time before a patient is killed” due to an overdose of the drug.
The warning followed two non-fatal overdoses of diamorphine, which occurred in Suffolk in the year before Mr. Gray’s death (April and August 2007). In both cases the drug was administered by doctors from Germany, where diamorphine is not routinely used. Clinicians suggested changes to prevent future overdoses, but these were not implemented.
Today’s report highlights further systemic failings by TCN.
CQC's evidence can be found below.
Staffing
Staffing levels were potentially unsafe, unfilled shifts and lack of clinical cover could have compromised the care of patients and there were occasions when one nurse was the only clinical cover for 70 miles.
Acting on and learning from serious incidents
TCN failed to investigate, act upon and learn from serious incidents. This included the two previous overdoses of diamorphine.
Reporting to PCTs
Reporting of activity to the PCTs was not clear and transparent. “Double counting” of some patients would have given the impression that TCN was treating more patients and could have affected contract negotiations with the PCTs.
Information from GPs
Local GPs were not confident in the service provided by TCN. Fifty per cent of GPs surveyed by CQC said the ability of the organisation to provide clinical care in people’s home was “poor” or “very poor”.
Clinical governance
TCN grew rapidly, taking on more contracts with PCTs, but apparently without the clinical governance in place to ensure the quality of its services.
CQC reviewed the commissioning and monitoring role of the five PCTs that purchased out-of-hours services from TCN: NHS Cambridgeshire, NHS Great Yarmouth and Waveney, NHS South West Essex, NHS Suffolk and NHS Worcestershire.
CQC found that:
- NHS Cambridgeshire took significant steps to monitor TCN's services after the death of Mr. Gray.
- out-of-hours services were a low priority for PCTs, reflecting the national position at the time.
- those responsible for monitoring the contract with TCN had a limited understanding of the service and they did not fully understand the performance reports or the national quality requirements (NQRs).
- changes to services that could have had significant implications for patients were often discussed and agreed by non-clinical staff.
- none of the PCTs had robust arrangements to share information on poorly performing clinicians.
- Cornwall PCT had admitted Dr Ubani to its performers list without requiring proof of language competency and with limited checking of his references which meant that Dr. Ubani could work anywhere in the UK (the trust did not formally review how doctors were admitted to the performers list until March this year).
CQC says the PCTs involved have since taken action to improve commissioning and monitoring of out-of-hours services. But it makes national recommendations to all PCTs and out-of-hours providers across the country to ensure a safe and effective service is delivered.
In relation to the two SHAs, NHS East of England and NHS West Midlands, there is no evidence that they paid specific attention to out-of-hours care, but have since taken significant action to address issues about these services in their regions.
Dame Jo Williams, CQC chairman, 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. 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 CQC 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.
CQC says it will take the findings of its investigation into TCN, 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.
EndsFor further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.