Inquiry into death of patient through overdose given by GP on first shift in UK finds two previous cases of same mistake

The official NHS inquiry into the death of a patient through an overdose given by a German locum GP on his first shift in Britain has revealed that two other doctors flying in from Germany had been involved in incidents of overdoses with the same drug while working for the same company the year before.

The revelation that three doctors from the same country made similar mistakes, although not fatal in the cases of the other two, will heighten concerns about EU rules governing free movement of labour that medical regulators say jeopardises patient safety.

The NHS watchdog, the Care Quality Commission (CQC), said lessons "must resonate across the health service" after finding the now defunct out-of-hours provider Take Care Now (TCN) guilty of systemic failings.

These included "potentially unsafe" staffing levels, including on occasion one nurse being the only clinical cover for 70 miles.

The watchdog also criticised NHS bodies for whom TCN ran services, saying they failed to adequately check its performance and did not share information on poorly performing doctors.

The CQC recognised that rules were tightened by the then Labour government following the death of 70-year-old David Gray in Manea, Oxfordshire, from a tenfold overdose of the painkiller diamorphine, administered by Daniel Ubani in February 2008.

But it also warned Andrew Lansley, the health secretary, that radical changes he is planning for the NHS, including giving far more power to GPs, must reflect the lessons arising from TCN's failures - that competency of overseas doctors must be properly tested, serious medical incidents investigated and quality of care closely monitored.

Ubani has been struck off the General Medical Council register of doctors in the UK, although he continues to practice in Germany.

A coroner has also ruled that Gray's death amounted to unlawful killing.

The CQC report found that TCN had not acted on a previous national safety warning over the administration of drugs. Neither had the two previous cases involving overdoses of diamorphine been reported as serious untoward incidents as they should have been. The doctors who administered them had, like Ubani, been trained and practised in Germany where the drug was not routinely used. Although the Guardian has reported these two incidents in neighbouring Suffolk before, the German connection of those responsible had not previously been revealed.

TCN did not change the way the drug was stored and used until after Gray's death.

Ubani admitted, in a letter to Gray's family months after the accident, that he had not been conversant with diamorphine saying it was not normally used in Germany for out-of-hours calls.

The way Ubani was hired for TCN shifts, through a recruitment agency and without proper checks on his competence has already caused widespread protests, with the government and the GMC pressing for an urgent review of the way professional qualifications are recognised in the internal jobs market. But the Ubani case has also revealed serious flaws in which local NHS trusts check competence and language skills too.

TCN operated out-of-hours services for NHS trusts in Cambridgeshire, Worcestershire, Suffolk, Great Yarmouth and Waveney, and with the ambulance service in south-west Essex. It began losing contracts in the wake of the Ubani affair and was then taken over by Harmoni, a larger private provider.

The CQC surveyed local GPs and found that half of them thought TCN's ability to provide clinical care in people's homes was "poor" or "very poor". Its report also said out-of-hours service was a low priority for trusts, "refelcting the national position at the time". The two strategic health authorities, in eastern England and west Midlands, also did not pay sufficient attention to evening and weekend care.

Dame Jo Williams, the commission's chairman, said that TCN had not only ignored "explicit warnings" about diamorphine, but "it failed to address deep-rooted problems across its entire out-of-hours service".

She said that "the lessons of its failure must resonate across the health service. Around 7 million people contact GP out-of-hours services every year - the provider, the primary care trusts and individual clinicians all have a responsibility to ensure its services are as safe as possible.

"We hope the family of Mr Gray will take some comfort in knowing that his tragic death has brought about significant change in the way out-of-hours services are delivered and monitored."

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Stand-up comedian Juston McKinney has a hilarious rap song out about fatherhood. You might want to watch it outside of the presence of little ears. There is some adult content that you might not want to have to explain just yet.

? Patient support group applauds Guardian report
? Bristol babies scandal seen as precedent for review

The families of patients who died after vascular surgery at a hospital with an exceptionally high death rate could be entitled to an investigation, according to an independent patient-support organisation.

Peter Walsh, chief executive of Action against Medical Accidents (Avma), made his comments following an investigation by the Guardian that revealed wide disparities in death rates across hospitals offering vascular surgery. The data, which was not in the public domain, was extracted from 116 trusts through freedom of information requests.

Some hospitals had higher numbers of deaths than expected. The average mortality rate in abdominal aortic aneurysm surgery in England was 4% in the years 2006-08. However, 10 trusts had death rates higher than 10%, and one, Scarborough, had four deaths in 14 operations ? a death rate of 29%. Recognising that mortality was too high ? and the frequency of operations too low to ensure that surgeons kept their skills ? it stopped offering the procedure.

Walsh said that complaints to hospitals were supposed to be registered within a year. But in the case of a family that had previously had doubts and had now found out about the death rates, there ought to be flexibility. "It wouldn't appear to be unreasonable to say, 'I'm not sure about my father's death and this has now come to light ? would you look into it and let me know?'" he said. The publicity surrounding the Bristol babies scandal ? where death rates were far higher than at other hospitals ? caused families to come forward years after their babies died.

Now that Scarborough is known to have had such a high death rate, "I think it would be reasonable to expect them [the hospital] to review these cases," Walsh added. Avma is campaigning for a "legal duty of candour" to force hospitals to be open with patients and their families when treatment goes wrong.

The Guardian investigation found that doctors did not always collect good data about their performance, and even when they did, it was not published. The health secretary, Andrew Lansley, said he wanted to see information in the public domain.

"A transparent NHS is a safer NHS," he said. "In the first speech I made as health secretary, I was clear about the need to devolve power to patients by providing meaningful information. Unleashing comparative data about standards and patient experience will drive up the quality of care, as the data begins to influence patient choice.

"This priority is reflected in our coalition commitment to publish detailed data about the performance of healthcare providers online, so everyone will know who is providing a good service and who is falling behind."

The data currently available about hospital outcomes is compiled by administrators, not the doctors treating patients, and is generally thought to be unreliable.

Sir Donald Irvine, the former president of the General Medical Council (GMC) and now chair of Picker Institute Europe, which represents patients' views, said: "The report shows just how vital it is that individual doctors, wherever possible, have accurate data on their clinical results. They need to know how well they are performing, compared with their colleagues, and patients need to know which doctors and clinical teams are likely to provide the best and safest care for them. That is the only basis for an informed choice of doctor."

He added: "It is a sad reflection on the NHS that it has taken a national newspaper to drag this information out of health organisations using freedom of information requests. Today only the cardiac surgeons, as a group, publish their standardised comparative results regularly, of their own free will. Full marks to them. They have shown what can be done, and what must be done by all in future."

Irvine urged the GMC to implement immediately its plan for revalidating doctors through a five-yearly performance check. "Through revalidation, the GMC could energise the development of high quality, appropriately standardised, doctor-specific performance data in healthcare across the NHS and private sector, to the benefit of patients everywhere. Such data is the basis of robust licensure and good clinical governance, on both of which safe patient care is so utterly dependant," he said.

People who are ill have to trust their doctors without thinking, he added. "The message from the Guardian report today is that the sooner the days of uninformed trust are over, the better."

Niall Dickson, chief executive of the GMC, said good information about what was happening was essential to a safe and effective healthcare system. "This is absolutely at the heart of the drive to improve quality," he said. Revalidation was "designed to help doctors in mainstream practice to have an opportunity to look at what data there is and find ways of improving on their practice".

He added: "I'm sure we are in the lower foothills in terms of gathering data and developing it."

A hospital trust has been fined £50,000 after a disabled patient died when he got his head stuck in protective bed bars.

Kyle Flack, a quadriplegic who had cerebral palsy, died in October 2006 at Basildon University Hospital.

The hospital in Essex acknowledged that 20-year-old Mr Flack died following failures in its "systems and procedures".

Basildon NHS Trust was also ordered to pay £40,000 costs after a court heard how health and safety failings were a "significant cause" of the death.

"(The trust) accepts that its offending was a significant cause of this death. Management failed to lay down correct procedures.

The Trust earlier admitted breaching health and safety law by failing to ensure patients were not exposed to risk.

It followed a prosecution by the Health and Safety Executive (HSE).

Prosecutor Pascal Bates said the hospital had failed to properly supervise Mr Flack, properly pass on information, train staff, assess risk and had not heeded warnings.

"(The trust) accepts that its offending was a significant cause of this death," Mr Bates told the judge. "Management failed to lay down correct procedures."

Gill Flack said the hospital had been the 'worst place' for her son

He said the offences amounted to a "serious" breach of duty and the hospital had fallen "markedly short" of the required standard.

Earlier this year, Mr Flack's mother Gill called for hospital bosses to be "held accountable".

Mrs Flack, of Stanford-le-Hope, Essex, said Basildon University Hospital had been the "worst place" for her son.

She described some care standards at the hospital as "absolute c***".

The hospital said standards had improved.

Six months ago a report by the Care Quality Commission (CQC) found poor hygiene and care standards at the hospital.

Patients less likely to die in bigger hospitals, reveals exclusive Guardian investigation

Doctors in the NHS do not know how well they are performing and whether they are more likely than their colleagues to kill or cure their patients, because of a widespread failure to collect the information, a Guardian investigation reveals.

The results of a major exercise looking at one particular procedure ? vascular surgery ? show a massive variation in death rates among patients admitted for planned operations and reveal that some hospitals have unacceptably high mortality.

It demonstrates the case for the closure of small hospital units, which the government has put on hold. Death rates vary from less than one in 50 in some hospitals to more than one in 10 in others.

The investigation reveals the hollowness of patient choice, which the coalition, like Labour before it, has made the centrepiece of NHS policy. The data amassed by the Guardian from surgeons at 116 hospital trusts after an extensive freedom of information trawl is not publicly available ? and is at odds with what appears on the NHS Choices website, set up to help patients choose where to be treated.

The Guardian investigation focused on vascular surgery, where there is a significant risk of dying in planned operations, but the conclusions apply to every other branch of medicine ? with the exception of heart surgery, where doctors collect and publish their individual results. They embraced transparency following the Bristol babies scandal in the late 1990s, when doctors were struck off the medical register over the deaths of babies who underwent operations for heart defects that they might have survived at other hospitals.

The investigation reveals that:

? More than a decade on from Bristol, doctors are failing to collect and publish data that would tell them and their patients how well or badly they are doing and allow patients to chose a hospital where their risks are lowest.

? Death rates in planned vascular surgery for abdominal aortic aneurysm (AAA ? to prevent a burst artery) vary from under 2% in some hospitals to at least 10% in 10 of them. More than 5,000 of the operations are carried out each year ? most of them planned admissions in which the patient decides where to go for surgery.

? Patients are less likely to die in the bigger, busier hospital units where surgical teams are more skilled because they do more of the operations. The results strongly suggest that smaller units should close. This presents a major challenge to the health secretary, Andrew Lansley, who has stopped all hospital reorganisation.

The most worrying death rates were at Scarborough hospital in Yorkshire, where 29% of patients scheduled in advance for AAA surgery died in the three-year period from 2006 to 2008. The national average was just over 4%. Scarborough says it has now stopped offering the operation.

Results for planned surgery at several other hospitals also gave cause for concern, including Gateshead on 12.9%, Hull on 9%, Pennine Acute Trust on 8.4% and Leeds on 7.1%. Gateshead and Hull blamed a high number of difficult cases, Pennine argued there had been an issue around the way transferred cases were recorded, which is now resolved. Leeds pointed out that it takes difficult cases and has brought its death rates steadily down.

Some leading surgeons believe that for best results, a hospital needs to carry out at least 50 AAA operations a year. Yet very many hospitals across the UK see less than 20 cases a year. Dartford and Gravesham had just five in three years, Mid-Staffordshire had nine and Scarborough had 14. Of the 116 hospitals that gave the Guardian data, 35 did fewer than 20 operations a year and 76 did fewer than 50.

The data also shows the UK lagging in Europe. The second Vascunet report, on vascular surgery across 10 European countries in 2008, found the average death rate was just 2.8%.

Professor Sir Bruce Keogh, medical director of the NHS and a former heart surgeon, who was involved in successful efforts to publish mortality data in cardiac surgery said: "Surgeons have a moral and professional duty to know what they are doing, how well they are doing it and to use that information to help them improve ? otherwise they have no right to be doing it at all." He intends to take steps to ensure that senior doctors personally take responsibility for the accuracy of data relating to their specialist area that is published by their trust ? whether in surgery, cancer care, diabetes or arthritis.

Peter Holt, clinical lecturer in vascular surgery at St George's Healthcare NHS Trust in London, who helped the Guardian analyse the results, said they demonstrated "significant variations in the death rates after planned and emergency aneurysm repair in England. These results support those that have been published in the medical literature since 2007. Variations in death rates do not equate to deficiencies in the quality of care received, but what is clear is that these results require further investigation, which must begin with confirming the accuracy of the data before hospitals are labelled as dangerous".

David Mitchell of the Vascular Society, which has been collecting mortality data on a voluntary basis from surgeons for several years but does not publish it, said they had embarked on a quality improvement programme, aimed at bringing the average death rate down to 3.5%.

Study shows death rate among emergency hospital admissions increases by 7% at the weekend

Patients admitted to hospital as an emergency at the weekend have a higher chance of dying than those who are brought in during the week, according to a study published today.

The death rate among emergency admissions increased by 7% at the weekend, according to a paper published in the journal Quality and Safety in Healthcare. The authors, from Dr Foster Intelligence and Imperial College, calculate that 3,369 more deaths occurred at the weekend in 2005/06 than would have been expected.

"This is more than the 3,201 killed in road accidents in Great Britain in 2006," they write, although they add: "We acknowledge that this is perhaps an unfair comparison, as it is likely that people dying on the roads are from a much younger age group and will be generally healthier compared with the population of people admitted as an emergency to hospital at the weekend."

Dr Paul Aylin, the senior author of the study, said this was clearly a significant number of people. "We need to get to the bottom of what this means.

"Staffing levels are often lower at weekends, with fewer senior medical staff around, and some specialist services are less available. We believe this may be contributing to the increase in mortality rates on Saturdays and Sundays but we would like to see more research.

"Hospitals have been reassessing the working hours and rotas of their doctors and, considering the impact that staff availability may be having on mortality rates, this is a timely reminder to hospitals that they must take care not to jeopardise the quality and standard of patient care available at weekends when devising new staffing rotas."

The researchers looked at administrative data on 215,054 deaths out of the 4.3 million emergency admissions in 163 hospital Trusts in 2005/6. They found that overall death rates were 5.2% for people admitted at weekends and 4.9% for those admitted on a weekday.

There were higher proportions of deaths at the weekend for patients with conditions including heart attacks, heart failure, stroke, some cancers and aortic aneurysms.

As well as lower staffing levels in hospitals, there may be a reduced service in specialist community and primary care services at the weekend, which the authors say may result in some terminally ill patients being admitted to hospital and dying there at the weekends.

Professor Derek Bell, another of the authors, said: "Clinicians and senior healthcare managers must begin to recognise and address these issues to improve patient care."

But the authors say more research is needed before any firm conclusions can be drawn about the reasons for the increased rate of deaths at the weekend.

?THREE nightclub bouncers have appeared in court accused of attacking and injuring a group of builders in a late-night Union Street...

British Medical Association concerned at lack of protection

The NHS does not do enough to help whistleblowers seeking to raise concerns about colleagues' behaviour, according to research in the British Medical Journal.

Among 118 hospital foundation trusts in England, 43 insist an employee raises their concerns internally before approaching an outside body, 22 warn they could face disciplinary action and 23 do not guarantee to respect the whistleblower's confidentiality, it found.

Dr Mark Porter, of the British Medical Association, said some doctors encountered problems when they spoke out, even though the right to expose problems was protected by law.

"We get very concerned about people who fall foul of these whistleblowing policies," said Porter. "People continue to raise problems with us and there are high-profile cases, some of which take place in organisations that have good policies."

Peter Gooderham, a law lecturer at Manchester University, said: "On whistleblowing, I think the NHS has failed badly over the past 10 years.".

An incident in Detroit raises several questions about street art. Renowned British graffiti artist Banksy visited a crumbling factory in the city and painted a wall.

Discovered last weekend, the stenciled work shows a forlorn boy holding a can of red paint next to the words ?I remember when all this was trees.? But by Tuesday, artists from the 555 Nonprofit Gallery and Studios, a feisty grassroots group, had excavated the 7-by-8-foot, 1,500-pound cinder block wall with a masonry saw and forklift and moved the piece to their grounds near the foot of the Ambassador Bridge in southwest Detroit.

The move ' a guerilla act on top of Banksy?s initial guerilla act ' has sparked an intense debate about the nature of graffiti art, including complicated questions of meaning, legality, value and ownership. Some say the work should be protected and preserved at all costs. Others say that no one had a right to move it ? and that the power and meaning of graffiti art is so intrinsic to its location that to relocate it is to kill it.

The gallery defends its action by pointing out that the artwork would have been destroyed soon along with the building. Others respond that Banksy may have intended for that to happen. And then there's the fact that the context gave the painting it meaning in the first place. One could say that while Banksy broke laws against trespassing and vandalism, the gallery is guilty of theft. The property owner hasn't said anything about it yet. No one yet knows who, if anyone, stands to profit from the incident. Link -via Metafilter

(Image source: Banksy)