'Matter of time' warning on deadly drug dose

A damning investigation into the company, which ran out-of-hours GP services for the NHS, has found there were "serious failings" at every level over its use of diamorphine – the drug which killed 70-year-old David Gray and was involved in the two other incidents.

The company, Take Care Now, further put patients at risk by inadequate levels of staffing which left it reliant on foreign doctors who flew in and out of the country to cover shifts.

German doctor Daniel Ubani had slept for only a couple of hours the night before he gave Mr Gray 10 times the normal dose.

Now a report from the Care Quality Commission has revealed the firm failed to listen to a warning from one of its own senior doctors just a month before Mr Gray's death, in Cambridgeshire, in February 2008.

Minutes from a meeting a month before Mr Gray's death show a senior doctor warned "it is only a matter of time before a patient is killed by an overdose of morphine".

There had been two previous incidents involving overdoses of diamorphine being administered by Take Care Now doctors, in 2007. Both doses were given by doctors from Germany, where the drug is not routinely used.

The report found Take Care Now failed to act upon a 2006 alert from the National Patient Safety Agency on the risks.