OUT-of-hours care must be monitored more closely following the death of a Blakedown GP’s 70-year-old father, a health watchdog has said today.

Stuart Gray’s father, David, 70, died after being given 10 times the dose of painkiller diamorphine he required by German doctor Daniel Ubani.

Dr Ubani was working for Take Care Now (TCN), which has provided out-of-hours GP services for NHS Worcestershire since last October.

The Care Quality Commission’s interim report said NHS PCTs may not be effectively monitoring performance of GP out-of-hours services, and risk failing to spot patient safety concerns as a result.

An inquiry into Take Care Now was launched by the CQC in June, saying it would “rigorously identify where things went wrong” leading to David Gray’s death.

Following visits to the five PCTs that commission out-of-hours services from TCN, including Worcestershire, the CQC found that although trusts monitor response times of the service, they do not consistently and routinely look in detail at the quality of care.

“This could mean opportunities to spot potential problems and indications of poor care are missed,” the report said.

The report added PCTs must look at details like the quality of clinical decisions, the efficiency of call handling, the adequacy of staffing and doctors' training, to “rigorously monitor performance”.

Paul Bates, NHS Worcestershire chief executive, said an internal review had already begun before the CQC inquiry, with “extra levels of monitoring” put in place as a result.

In February 2008, Dr Ubani was called out to David Gray’s Cambridgeshire home, where he administered a fatal dose of 100mg of diamorphine and 4mg of buscopan.

The CQC report showed TCN has since withdrawn 100mg doses of diamorphine and has ensured Schedule Two controlled drugs, such as opiate-based drugs used in acute and palliative care, are stored and dispensed securely.

Mr Bates added: “The CQC has our full co-operation with regards to the next stage of their investigation and if any further actions are recommended then we shall of course implement them.”

In the meantime the TCN will be monitored “very closely in the manner suggested by CQC”, he went on.

David Cocks, chief executive of TCN, said he welcomed the interim progress report and TCN would continue to work with the CQC in its investigation.