CQC responds to the coroner’s inquest on the death of David Gray

Responding to the coroner’s inquest on the death of David Gray, Christine Braithwaite, head of investigation and enforcement at the CQC said:

“The death of David Gray was a tragedy. It should not have happened and such an incident must not happen again. The coroner has clearly highlighted what went wrong. Take Care Now, and the PCTs that commission its services, must learn the lessons.

“We are already looking at Take Care Now’s current procedures as part of our review, as well as contractual and monitoring arrangements at the NHS trusts that buy its services. Any relevant information arising from the inquest will feed into our work, and we will of course take the coroner’s views and final verdict into account. Our enquiries are nearing completion, and we will be reporting in full on the findings in due course.”

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About CQC’s review of TCN

CQC’s review of out-of-hours care provided by TCN was triggered by the death of Mr David Gray, a patient treated by an out-of-hours locum doctor from Germany who died following the administration of 100mg of diamorphine.

NHS East of England, the strategic health authority, alerted CQC to concerns about GP out-of-hours services provided by TCN.

The CQC announced the scope of its enquiries in June 2009, outlining that it would look at Take Care Now's out-of-hours service. It is focusing on current systems, including contractual and monitoring arrangements between PCTs and Take Care Now, as well as changes made after recent incidents. The terms of reference can be found here:

http://www.cqc.org.uk/newsandevents/newsstories.cfm?widCall1=customWidgets.content_view_1&cit_id=34923

CQC published its early observations in October 2009, following the initial phase of its enquiries:

http://www.cqc.org.uk/newsandevents/newsstories.cfm?widCall1=customWidgets.content_view_1&cit_id=35381

for further information please contact the CQC press office on 0207 448 9401 or out of hours on 07817 232 143.