Investigation into Take Care Now reveals serious failings
15 July 2010
Our new report into the GP out-of-hours provider, Take Care Now, reveals the provider did not act on previous warnings about the use of diamorphine.
Our investigation was triggered by the death of David Gray, who was killed after being administered 100mg of diamorphine by Dr. Ubani, an out-of-hours doctor from Germany who was employed by TCN at the time.
The investigation took an in-depth look in to:
- TCN’s out-of-hours services dating back to April 2007
- whether the appropriate actions were taken following Mr. Gray’s death
- how the five PCTs that used TCN’s out-of-hours services monitored the quality of the service being provided
The report highlights failings by TCN including:
- failure to learn from serious incidents, specifically regarding the cases of two non-fatal patients who were also administered diarmorphine a year prior to Gray’s death
- failure to implement changes despite warnings from a senior clinician that a fatal accident would soon occur
- low levels of staff that could have compromised the care of patients
- taking on more and more services for PCTs without the clinical governance in place to ensure the quality of its services
The review into the involvement of the five PCTs, NHS Cambridgeshire, NHS Great Yarmouth and Waveney, NHS South West Essex, NHS Suffolk and NHS Worcestershire, reveals that:
- the monitoring of out-of-hours services was not prioritised
- those responsible for monitoring the contract with TCN did not fully understand its service
- none of the PCTs had influential arrangements to share information on poorly performing clinicians
- Cornwall PCT had admitted Dr. Ubani to its performers list without checking his references or requiring appropriate evidence to show language competency
After Mr. Gray’s death, NHS Cambridgeshire did take significant steps to monitor TCN's services.
Dr. Ubani has now been removed from the General Medical Council (GMC) register and is no longer able to practise in the UK.
