Report sheds light on major failings in out-of-hours care
SUFFOLK: An inquiry into death of a patient by an overdose of drugs has revealed two previous cases of the same error in Suffolk.
NHS Suffolk was criticised by regulators after two GPs from Germany gave high doses of diamorphine to patients a year before the death of Cambridgeshire man David Gray.
Mr Gray was administered a fatal tenfold overdose by out-of-hours doctor Daniel Ubani in February 2008.
A Care Quality Commission probe exposed numerous blunders over out-of-hours care.
It revealed that NHS Suffolk was among five Primary Care Trusts that used out-of-hours provider Take Care Now (TCN) with limited understanding of the service and did not monitor performance adequately.
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The inquiry revealed that two other German locum doctors had been involved in overdoses of the same drug while working for TCN in 2007.
On both occasions, patients stopped breathing properly and required a drug to counter the effects of the diamorphine.
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There was no evidence that the first incident was formally reported until a written report was received from TCN two years later. The second incident was not formally reviewed until May 2009.
The county’s NHS bosses said both cases had been dealt with entirely by TCN.
Andrew Hassan, medical director at NHS Suffolk, added: “Checks and safeguards are in place for administering pain relief, including a mandatory second opinion from another doctor.”
The report found that those responsible for monitoring the contract with TCN had a “limited understanding” of the service and did not fully understand performance reports or national quality requirements.
NHS Suffolk now employs out-of-hours provider Harmoni, at a cost of �6.2m a year, to deliver services between 6.30pm and 8am on weekdays and at all times during weekends and public holidays.
It has, since 2008, taken action to improve monitoring of out-of-hours services by performing a formal monthly review of the service and spot checks on the management of services by senior clinical NHS staff.
Mr Hassan said: “We have learned some important lessons. We introduced even tougher safeguards to ensure that patients are given the best possible care by the out-of-hours service.
“We will continue to monitor the work of our new out-of-hours provider, Harmoni, very closely.”
Meanwhile, NHS East of England was one of two Strategic Health Authorities which showed no evidence of paying appropriate attention to out-of-hours care nor had a system in place to identify serious incidents.
Dr Paul Cosford, the SHA’s regional director of public health, said: “We have introduced new standards for out-of-hours services which all PCTs have adopted, including new guidelines for GP performers’ lists across the region.
“We have also set up a programme of visits to all our PCTs and out-of-hours providers.”
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