- The Guardian, Monday 4 May 2009
Dr Daniel Ubani. Photograph: African Courier
A foreign doctor on his first shift providing out-of-hours cover for GPs killed a patient by giving him 10 times the normal recommended maximum dose of a pain-killing drug, the Guardian can reveal.
The NHS watchdog is launching an investigation after a German doctor who flew into the UK the day before the incident admitted he was "too tired" to concentrate when he administered the drug.
The case, which was subject to a police inquiry into possible manslaughter, raises fundamental questions for the NHS over GP cover, regulation of doctors and drug safety measures.
The doctor, Daniel Ubani, accidentally killed 70-year old David Gray in Cambridgeshire in February 2008, but details have not previously been made public.
The watchdog Care Quality Commission will announce the scope of its inquiries soon, but its head of investigations and enforcement, Christine Braithwaite, said: "This is a deeply disturbing case and one that must be thoroughly looked into. We have to ensure any lessons are learned."
She added that the body was "aware of a number of concerns in relation to out-of-hours care" provided by Take Care Now (TCN), a company which has four contracts for such NHS services in Cambridgeshire, Suffolk, Great Yarmouth and Waveney, and Worcester.
David Gray was killed when Dr Daniel Ubani gave him an accidental overdose of diamorphine. Photograph: Gray family
The case has also sparked a row over how Germany responded to a UK request to extradite the doctor. Last month Ubani was given a nine-month suspended prison sentence there for the UK incident and fined €5,000 (£4,450) for causing death by negligence. He is continuing to practise in Witten, Germany, although he has been suspended from working in the UK by the General Medical Council's interim orders panel.
The Crown Prosecution Service is seeking a meeting with Eurojust, which mediates between EU prosecuting bodies, and the Department of Health told the Guardian: "It is disappointing that this doctor, although now convicted of an offence, was not held to account in this country."
Ubani, in a letter of apology to Gray's family written last July, said the "fatal mistake" derived from a confusion between drugs, one of which was not used by on-call services in Germany, and the "tremendous stress" he had been under, having only had about three hours rest before he started his shift.
David Gray's partner, Lynda Bubb, said: "I want no one else to go through what we have been through. They have to work out a way this does not happen again." The family is taking civil legal action against Ubani, Cambridgeshire NHS, which oversees primary care in the county, and TCN.
Gray's son Stuart, a GP, said Ubani had not even seemed to realise that the dose of the drug he used, diamorphine, was lethal. The family's lawyer, Inez Brown, said it was "a very serious and tragic case".
Peter Walsh, chief executive of the charity Action against Medical Accidents, said: "What is worrying is this was a disaster waiting to happen and not enough is being done to ensure nothing like this happens again. There should be a wholesale review of out-of-hours provision and the way it is regulated. The response of the NHS so far is totally inadequate."
More than 100 foreign doctors flew into the UK to cover out-of-hours GP shifts, according to figures for 2007.
The tragedy in the fen village of Manea happened after Bubb asked Suffolk Doctors On Call, a company which supplies doctors for TCN, to visit the couple's home where David Gray, who suffered from kidney stones and renal colic, was in severe pain. Later that afternoon Ubani arrived and administered 100mg of diamorphine, a potent painkiller. Within hours the patient was dead, but it was the following day before the severity of the incident was clear to health managers and Ubani was suspended from his second shift.
Cambridgeshire police launched an investigation and in April 2008 the Crown Prosecution Service formally requested assistance in obtaining evidence from the German authorities. By November, the CPS decided there was sufficient evidence to charge Ubani with manslaughter.
In February this year, a warrant for his arrest was issued by magistrates and on 12 March the CPS issued a European arrest warrant. But 12 days later, it was told legal proceedings against Ubani were underway in Germany. These were "finalised" on 15 April.
Throughout the period, NHS authorities tried to establish what went wrong. In a letter to Stuart Gray in April last year, David Johnston, of TCN, said Ubani had given David Gray 100mg of diamorphine and 4mg of Buscopan. The doctor was not "and never has been an employee of TCN. He was employed on a self-employed sessional basis to provide out-of-hours cover". He had been recruited from the Cimarron Locum Agency.
Chris Banks, the chief executive of NHS Cambridgeshire, said Ubani "failed Mr Gray and his family". He added: "We are concerned that Mr Gray's family may not feel justice has been done."
TCN's chief executive, David Cocks, said: "Our response has been focused on doing everything we can to ensure such a tragedy could never happen again."
Cimarron's director, Tom Stewart, said: "We have robust processes in place to ensure all important checks are undertaken before deploying a GP and I can confirm all these checks were undertaken for Dr Ubani."
Ubani, contacted by the Guardian last week, said: "Please understand this could be very damaging for my name and reputation. It is not appropriate for you to put an extravagant array of questions to me about this very unfortunate matter."
A spokesman for the state prosecutors' office in Bochum, near Witten, confirmed Ubani had been given his sentence in absentia, after admitting the charge of causing death by negligence in written correspondence.
Cambridgeshire constabulary said it was disappointed any prosecution "was not allowed to reach its natural conclusion in this country".
