'Tired' foreign doctor gave fatal overdose

A foreign doctor who administered a fatal overdose to a 70-year-old man admitted his tiredness led to the death, an inquest heard today.

David Gray died after he was given more than 10 times the recommended daily dose of the drug by Dr Daniel Ubani - a locum doctor from Germany.

The inquest in Wisbech, Cambridgeshire, heard that Dr Ubani admitted he had made a mistake when he was on his first shift for a GP out-of-hours service provider on February 16 2008.

Frau Rita Prchlik from the Department of Health and Social Matters in Germany said that Dr Ubani contacted the authorities in Germany two weeks after the incident.

"He called and said 'I have made a mistake in England due to tiredness which resulted in a death'," said Frau Prchlik in a statement read out to the court.

Earlier Mr Gray's partner Lynda Bubb told the inquest that Dr Ubani seemed tired.

"The doctor seemed a bit dithery," she said. "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 seemed very tired and not as alert as he could have been as a doctor."

Ms Bubb said she called the out-of-hours service provider SuffDoc, now called Take Care Now, at lunchtime when Mr Gray refused to eat because of the pain he was in from kidney stones.

The inquest heard that almost four hours later Dr Ubani arrived.

Ms Bubb said she told the doctor that Mr Gray usually received 100mg of pethidine as pain relief.

She said: "I knew they did not carry pethidine so I said it needed to be diamorphine.

"To my knowledge he did not physically examine David. I did not see him take his pulse or blood pressure, but I was out of the room for a short time."

Ms Bubb said that Dr Ubani gave Mr Gray two injections and then left the syringes on the windowsill.

"David then took the doctor's hand and said 'thank you'," she said.

Ms Bubb said she checked on her partner half an hour after Dr Ubani left and he appeared to be asleep.

She said: "Some time later I realised there was something wrong with David.

"He did not seem to be moving in any way and he did not respond to me."

The inquest was told that emergency services arrived and a short while later Mr Gray, from Manea, Cambridgeshire, was pronounced dead.

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, 67.

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 by the out-of-hours service.

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

The NHS in Cambridgeshire stopped using Take Care Now weekend and evening GP services in Fenland and east Cambridgeshire four months before its contract was due to end.

Today the inquest heard that Dr Ubani was reading a medical manual on the day Mr Gray died.

Dr Ubani's driver, Lesley Dent, said the doctor was flipping through the British National Formulary, a guide to prescribing, dispensing and administering medicines, when he was between call-outs.

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

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

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

The non-jury inquest is expected to finish on 4 February.