Inquest told how locum administered fatal dose to Manea man

A FOREIGN doctor who gave a fatal overdose on his first out-of-hours shift was dithery and tired , an inquest heard yesterday. Daniel Ubani later admitted he had administered 10 times the recommended maximum diamorphine dose to a 70-year-old man becaus

A FOREIGN doctor who gave a fatal overdose on his first out-of-hours shift was "dithery" and "tired", an inquest heard yesterday.

Daniel Ubani later admitted he had administered 10 times the recommended maximum diamorphine dose to a 70-year-old man because of his tiredness.

The inquest heard that just moments after being injected, patient David Gray of Manea had taken the German locum by the hand and thanked him.

Dr Ubani was working for the GP out-of-hours service provider SuffDoc, now called Take Care Now (TCN), when he injected Mr Gray on February 16, 2008.

After the incident, the NHS in Cambridgeshire stopped using the Take Care Now weekend and evening GP services in Fenland and East Cambridgeshire, four months before its contract was due to end.

NHS Great Yarmouth and Waveney still have a contract with TCN and will stay with them until the summer. NHS Norfolk has never used TCN.

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In a statement read at the inquest, Rita Prchlik, from the Department of Health and Social Matters in Germany said the 67-year-old doctor had called the department to tell them he had made a mistake and that there was an investigation proceeding.

She said: "He called and said 'I have made a mistake in England due to tiredness which resulted in a death.'"

The court also heard that on the day of Mr Gray's death, Dr Ubani was flipping through a manual called the British National Formulary.

Dr Ubani's driver Lesley Dent said the doctor was looking at the manual, which is a guide to prescribing, dispensing and administering medicines, when he was between call-outs.

Mr Gray's partner Lynda Bubb, who lived with him in Manea, said on the day her partner died she called the doctor after Mr Gray refused to eat because of the pain he was suffering from kidney stones.

When the doctor arrived, she said: "The doctor seemed a bit dithery. He was muttering to himself. He took everything out that he needed and placed it on the window sill. He did not speak very much English, but what he said I understood.

"He just seemed very tired and not as alert as he could have been as a doctor. He really didn't talk. He came in and did what he did, and then left."

After Dr Ubani had administered the diamorphine, Ms Bubb said: "He (Mr Gray) then took the doctor's hand and thanked him very much."

Ms Bubb who described her partner as an "intelligent and motivated" person, said she checked on her partner half an hour after Dr Ubani left and he appeared to be asleep.

"Some time later I realised there was something wrong with David," she said. "He did not seem to be moving in any way and he did not respond to me."

She later discovered her partner was not responding.

Giving evidence at Wisbech Magistrates' Court, Mr Gray's GP Dr Richard Hirson, told the court: "Personally, I was appalled. I was also very surprised to think that such an incident could happen to anyone, and to a patient of mine who I had a sound and friendly relationship with."

The inquest, being heard by Cambridgeshire North and East Coroner William Morris, was also examining the death of another of Dr Ubani's patients.

Iris Edwards, who lived in a care home in Ely, died of a heart attack the day after she was treated by Dr Ubani.

Forensic pathologist Dr Nat Carey said a question arose at the time of Ms Edward's death as to whether she would have survived if she was treated in hospital.

He said she suffered "severe" natural heart disease but her survival rate would have significantly improved had she been in hospital.

"There was clearly an opportunity here to get her to hospital had the correct diagnosis been made," said Dr Carey.

"It seems more likely than not that she would have survived, at least in the short term."

The case of David Gray prompted the Care Quality Commission to launch an investigation into the care provided Take Care Now.

The commission's interim report, released last October, raised questions about the standard of GP out-of-hours services.

Dr Ubani is supposed to give evidence tomorrow but is not expected to attend.

Dr Ubani was charged with death by negligence over Mr Gray's death in Witten in Germany, given a nine-month suspended sentence and ordered to pay 5,000 euros in costs, according to the law firm Anthony Collins Solicitors, who are acting for Mr Gray's family.

The prosecution, which is allowed under German law, means he cannot be charged in the UK.

The inquest continues today