Quality | 2010.02.04
Doctor Daniel Ubani unlawfully killed overdose patient
• Inquest finds German locum GP was incompetent
• Death of David Gray was gross negligence and manslaughter
• Coroner demands review of EU doctor agreements
A coroner today demanded a review of European Union agreements over the recognition of doctors as he ruled that the death of a 70-year-old patient administered a tenfold overdose by an "incompetent" German GP was "unlawful killing".
William Morris called the accidental killing of David Gray "gross negligence and manslaughter" and issued 11 recommendations to the Department of Health to improve out-of-hours GP services.
As well as the review of how the EU agreements work in the UK, he said the government must issue guidance to all NHS trusts over checking doctors\' English, their experience of the NHS, and how they acquired their GP status.
He demanded "robust" clinical and management measures, including training and induction for non-UK doctors, and said only the company actually running the out-of-hours GP services should recruit doctors in future, which will be a blow to private recruitment companies.
Daniel Ubani, a Nigerian-born German citizen, was on his first UK shift as a locum when he killed Gray. Evidence to the inquest at Wisbech, Cambridgeshire, suggested he had also inappropriately treated at least two, possibly three, other patients.
Morris said: "It is clear to me that Dr Ubani in his dealings with patients that fateful weekend was incompetent, not of an acceptable standard."
But he ruled that a woman who also died on Ubani\'s first shift, 86-year-old Iris Edwards, died from natural causes.
Graeme Kelvin, chairman of Take Care Now, the private contractor which operated the out-of-hours service that treated Gray, offered his sympathies to the family for this "tragic event" and hoped the recommendations of the coroner "will reduce the chances of a similar event happening anywhere in England".
Paul Zollinger-Read, chief executive of NHS Cambridgeshire, accepted a systems failure had occured and said: "We as an organisation have much to learn from this case."
One of Gray\'s sons, Stuart, said: "I could not have hoped for anything better [than the verdict]. I hope Andy Burnham, the health secretary, acts on this."
Another son, Rory, said: "This vindicates all the hard work we have put in."
Ubani did not want to comment on the verdict, a spokesman at his medical practice in Witten said.
Gray died after he was injected with 100mg of diamorphine – 10 times the recommended maximum dose. He was suffering from renal colic when he was treated by Ubani at his home in Manea, Cambridgeshire, on 16 February 2008.
That weekend Ubani saw 13 patients before being called off his second shift when Gray\'s death was reported to his managers. Police and doctors investigating what happened found the 66-year-old had given inappropriate treatment to two other patients, one of whom subsequently died. Both should have been sent to hospital, although they did not form part of a criminal case later built against the doctor.
The case has become a touchstone for public confidence or otherwise in the out-of-hours GP services, which were revamped more than five years ago. A new GP contract introduced then shifted responsibility for out-of-hours services from local doctors and put it in the hands of NHS bodies and private firms employing a mix of local GPs, locums from agencies, and sometimes doctors from abroad. Despite the problems identified in recent months, ministers insist services are improving overall.
However, Ubani was paid £45 an hour for his first work as a locum in this country, far less than the sums expected by British GPs. He also paid for his own flights, car hire and accommodation. Questions will be raised about how desperate some doctors from abroad are for the work.
Gray was an electronics and telecommunications specialist before his retirement. His wife had died in 2003, and he was living with his partner, Lynda Bubb, a civil servant, in the Fenland village of Manea, Cambridgeshire, when an exhausted and confused Ubani arrived on the fateful housecall.
The story of Gray\'s death and the subsequent apology from Ubani to his family were first revealed by the Guardian in May and it quickly became evident that it raised concerns about European Union rules on registration of doctors from Europe, checks on competence by local primary care trusts, the way in which drug safety warnings are given within the NHS, and how European arrest warrants work.
Police and prosecutors from the UK looking to bring a possible manslaughter charge against Ubani were stunned last April when, by letter, German authorities convicted the doctor of causing Gray\'s death by negligence, gave him a nine-month suspended prison sentence and ordered him to pay €5,000 (£4,400) costs. Nigerian-born Ubani, who is a German national, is suspended from working in Britain but is still allowed to practise in his home town of Witten, where he specialises in cosmetic surgery and anti-ageing medicine.
In August, inquiries by the Guardian prompted the General Medical Council and the Royal College of GPs to demand a rewriting of EU rules that allow doctors from Europe to be registered in the UK without tests on their English or medical competence. Doctors from the rest of the world already face such checks. The following month, it emerged that Ubani had failed in his first attempt to work in the UK but was later approved to join a performers\' list run by the NHS because a local health trust did not apply such stringent checks as the government demanded.
Soon afterwards, an interim report on the case by the NHS watchdog, the Care Quality Commission , prompted the Department of Health to order all 152 NHS organisations responsible for running out-of-hours services to do their own safety checks on induction and training of foreign doctors, call handling and prioritising of cases, clinical decisions made by GPs and other staff, and the management of powerful drugs.
In December, the scale of the communication breakdown between police and prosecutors in the UK and Germany over the handling of the criminal case against Ubani was laid bare.
Take Care Now faces an uncertain future. In recent weeks, it has lost contracts in Cambridgeshire and Suffolk although it still provides them for two other trusts – NHS Worcestershire and NHS Great Yarmouth and Waveney – and is a partner in a third in Essex.
For more information, please visit
http://www.guardian.co.uk/society/2010/f[...]bani-unlawfully-killed-patient
