Overdose GP Unlawfully Killed Patient
A foreign doctor, hired by the company which provides out of hours healthcare in Suffolk, was guilty of "gross negligence manslaughter'', a coroner said today.
German Dr Daniel Ubani injected a pensioner with a fatal overdose in February 2008. He gave 70-year old David Gray from Cambridgeshire ten times the recommended dose of painkiller diamorphine when covering a weekend shift for the Ipswich based out of hours healthcare company Take Care Now.
The inquest heard Dr Ubani, 67, was providing cover for GPs in and around Newmarket, when called to treat Mr Gray at his home in Manea, Cambridgeshire.
Coroner William Morris said Nigerian-born Dr Ubani had been "incompetent'', tired and ill
"If he did not know the properties or the size of the drug he was administering, he should not have administered it,'' he said.
"If he had any doubts or queries, I am satisfied he could seek advice. Nonetheless, he went ahead and injected the fatal overdose. This was gross negligence manslaughter.
"Accordingly, the verdict I return is: 'David Gray was unlawfully killed'.''
Dr Ubani, a specialist in cosmetic medicine, who was based in Witten, Germany, had flown into the UK the day before and had a few hours sleep before starting a 12-hour shift.
Two years earlier Dr Ubani had been refused permission to provide out-of-hours cover in West Yorkshire after failing a language test, but he had reapplied and been given the green light in 2007.
Mr Gray's son Stuart, himself a GP, called for safeguards to be put in place to prevent any repeat of the tragedy.
Mr Morris recommended setting up a national database for overseas doctors working in the UK.
Dr Ubani was given a nine month suspended sentence and fined by a court in Germany after being convicted of causing death by negligence.
European Union laws prevent him from also being prosecuted in the UK.
Mr Gray's family said they would seek compensation and may attempt to force changes in European Union laws which prevent suspects from being prosecuted more than once.
"My father's tragic death happened because of Dr Ubani's actions and because of serious failings,'' said Dr Gray.
"We want to see Dr Ubani tried under UK law and we also want safeguards put in place nationwide to prevent this happening again.''
Today's inquest hearing was followed by the publication of a Government-ordered review into out-of-hours health care. The report said NHS trusts were failing to carry out thorough checks on GPs providing out-of-hours care.
The challenges posed by offering care at night and at weekends - such as seeing unfamiliar patients without access to their medical records - means doctors need to be properly assessed for their clinical skills and competence in English, it said.
The report's authors found "limited evidence'' of robust checks on clinical skills alongside "misunderstandings'' over whose responsibility it was to ensure doctors had good written and spoken English.
It also said there were "unacceptable'' variations in the standards of care offered by primary care trusts (PCTs) around England, who are responsible for out-of-hours GP services.
The report called for proper inductions for all doctors who have never worked out-of-hours or in the NHS before.
The Department of Health has accepted all 24 recommendations in the report in full.