"In this case, it appears it was a binary systems failure.....The full abstract was alarming and we requirement to see lessons from that, and I conceive we are doing now."
This cannot just be written off a a 'systems failure'. There are certain parts of the system that are clearly to blame and that have been blatantly failing patients for some time.
It is far too easy for any old doctor from the European Union (EU) to register with the GMC and then work in the UK. Despite the fact that a lot of medical degrees from certain EU countries are not worth the paper they are written on, the GMC is bound by European law to accept them all as being good and proper. Despite the fact the English is spoken very poorly by many EU trained doctors they can still obtain registration with the GMC without any formal testing of their command of the English language.
The government and GMC will try to claim that this 'systems failure' also involved the PCT who are involved in hiring these doctors, however it is clear in my eyes that the buck should stop with the registration of these doctors, and the blame lies squarely at the GMC's door in my opinion.
As a result of the government's short sighted and racist reforms it is very hard for now for non-EU doctors to work in the UK, ironically many doctors from countries such as Australia, New Zealand and India have a much better command of English and a much better training background than a lot of EU doctors. Bizarrely Australians and New Zealanders have to sit an English language test to work in the UK, why on earth the same does not apply to the Germans and the Poles for example, I have no idea.
The EU's free labour market is a shambles. Not only has it led to a lot of racial tension as a result of unemployment pressures and an excessive pressure on state services as a result of rapid uncontrolled population shifts, but it has led to the UK being forced to accept a lot of dodgy foreign qualifications as being good enough when they clearly are not, it has also stopped out own governing bodies from being able to safely regulate certain specialist labour markets such as doctors. Until the GMC sorts its act out and is empowered to be properly able to weed out the incompetent, then preventable deaths like Mr Gray's will continue to happen.