The Care Quality Commission's (CQC) investigation into Take Care Now showed that prior to the killing of David Gray by a fatal overdose of diamorphine administered by Dr Ubani in Cambridgeshire in 2008, Take Care Now (TCN) did not take sufficient action to ensure safe use of the drug.
It showed that TCN ignored warnings from a senior clinician that it ‘was only a matter of time before a patient is killed’ due to an overdose of diamorphine.
The CQC also found that staffing levels were potentially unsafe and a lack of clinical cover could have ‘compromised the care of patients’.
It also criticised TCN for failing to learn from serious incidents, and for expanding too rapidly without the clinical governance in place to ensure the quality of its services.
The report concluded: ‘TCN was dominated by an agenda of growth and focused on winning contracts, not on providing high quality care.
‘TCN did not have effective governance arrangements in place and failed to identify shortcomings and implement changes. In the case of Mr Gray, the failure to identify and mitigate the risks reduced the chance of averting the tragic outcome.’
CQC chairman Dame Jo Williams said TCN ‘failed on many fronts’.
She said: ‘TCN 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 PCT and individual clinicians all have a responsibility to ensure services are as safe as possible.’
TCN has been taken over by Harmoni and is now trading as Suffolk Integrated Healthcare.