Wiser heads than mine have often pointed out that failure is more educational than success, provided you can pinpoint the reason.

It is depressing to finally get round to reading the report into the failures of Take Care Now and its commissioners that led to the death of David Gray.

The accompanying note states that
"The report highlights failings by TCN including:
failure to learn from serious incidents, specifically regarding the cases of two non-fatal patients who were also administered diarmorphine a year prior to Gray’s death
failure to implement changes despite warnings from a senior clinician that a fatal accident would soon occur
low levels of staff that could have compromised the care of patients
taking on more and more services for PCTs without the clinical governance in place to ensure the quality of its services

"The review into the involvement of the five PCTs, NHS Cambridgeshire, NHS Great Yarmouth and Waveney, NHS South West Essex, NHS Suffolk and NHS Worcestershire, reveals that:
the monitoring of out-of-hours services was not prioritised
those responsible for monitoring the contract with TCN did not fully understand its service
none of the PCTs had influential arrangements to share information on poorly performing clinicians
Cornwall PCT had admitted Dr. Ubani to its performers list without checking his references or requiring appropriate evidence to show language competency"

The word 'avoidable' seems to be written all over that lot.

Depressing, too that its report garnered relatively little media coverage. This is partly media boredom with the story, and partly the length of time elapsed to production of the report. How much of this had to take a year?

To cheer you up, we have a fresh dose of Maynard Doctrine to take you into the weekend. Have a good one.