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15 July 2010, 12:08 | Updated: 15 July 2010, 12:51
The NHS watchdog has criticised an out of hours care firm, which employed a German doctor who killed a Cambridgeshire pensioner.
The Care Quality Commission says Take Care Now, which is now defunct, didn't act over two previous incidents where patients were given overdoses.
Doctor Daniel Ubani was working his first shift for the firm in February 2008 when he injected 70 year old David Gray [pictured - above right], from Manea, with ten times the recommended level of diamorphine.
Doctor Ubani had only slept for a couple of hours the night before he gave Mr Gray the overdose, which soon killed him.
The CQC report claims Take Care Now "failed to recognise problems" which could have prevented Mr Gray's death.
It also states the firm repeatedly failed to respond to alerts over the storage of diamorphine and similar drug morphine, and didn't have enough staff to run a competent out of hours service.
The report states that two previous incidents in Suffolk in 2007 also involved German doctors administering huge doses of diamorphine, with neither case being reported properly.
Mr Gray's son, Dr Stuart Gray, a GP in Worcestershire, said: "My father's tragic death happened because of his actions and because of serious failing within the Cambridgeshire PCT and Take Care Now.
We want to see safeguards put in place nationwide to prevent this happening again."
Dr Paul Zollinger-Read, chief executive of NHS Cambridgeshire said: "On behalf of NHS Cambridgeshire I would like to repeat the apology made to the families of Mr Gray and Mrs Edwards, and to the other patients seen by Dr Ubani.
NHS Cambridgeshire accepts that Dr Ubani made a terrible error.
NHS Cambridgeshire has co-operated fully with the Care Quality Commission throughout this investigation and we accept their report and the recommendations made within it, many of which have already been implemented.''
Take Care Now had it's contract with the NHS to provide out of hours care terminated following Mr Gray's death.