Call for 'fit to do job' checks on foreign doctors after tragedy

An investigation into the death of 70-year-old David Gray has revealed the private firm which employed the doctor had ignored warnings that a patient could be killed after two other overdose incidents in the space of 10 months.

The company, Take Care Now, which no longer exists, was used by primary care trusts in Cambridgeshire where Mr Gray was a patient and Worcestershire, Suffolk, Great Yarmouth, Waveney and South West Essex.

A report by the Care Quality Commission (CQC) has found "serious failings" in the way the firm administered diamorphine.

German doctor Daniel Ubani, who was refused work for the NHS in West Yorkshire because of his poor English, had slept for only a couple of hours the night before he gave Mr Gray 10 times the normal dose of diamorphine, and later admitted being confused about the drug.

Now a new report reveals the firm which employed him "failed to recognise problems" which could have prevented Mr Gray's death.

It repeatedly failed to respond to alerts over the storage of diamorphine and the similar drug morphine, and had far too few staff to run a competent out-of-hours service.

Just a month before Mr Gray's death, a senior doctor at the firm had warned that a patient could be killed after two incidents in Suffolk in April and August 2007, which also involved German doctors administering huge doses of diamorphine.

The first patient was given a 30mg dose of diamorphine instead of between 2mg to 5mg, resulting in the patient needing resuscitation. The second overdose also involved a patient being given 30mg of diamorphine.

Following that incident, the patient was found to be "struggling to breathe" and became unconscious.

Neither case was reported properly and neither incident was investigated in depth, according to the CQC report.

Investigators also found Take Care Now had staffing levels that were potentially unsafe.

The firm supplied information to PCTs that was "potentially misleading" and could have "concealed poor performance".

Its "systems for medicines management were inadequate, leading among other things to controlled drugs being stored and administered inappropriately", and even local GPs were not confident about its service, with some claiming its ability to provide care was "poor" or "very poor".

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."

Niall Dickson, chief executive of the General Medical Council, said: "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."