Daniel Ubani inquest: NHS failings allowed killer doctor to work
Systemic failings in the way the National Health Service provides out-of-hours care led to the death of a pensioner at the hands of “incompetent” German locum Daniel Ubani, a coroner ruled.
By Caroline Gammell
Published: 7:30AM GMT 05 Feb 2010
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Inherent “weaknesses” in the vetting procedures meant that Dr Ubani was allowed to treat patients despite the fact he had failed an English language test and had no experience of the NHS, an inquest found.
On Feb 16, 2008, working his first out-of-hours shift and “tired out” after only arriving in the country the day before, Dr Ubani gave 70-year-old David Gray up to 20 times the recommended amount of diamorphine to treat pain in his kidneys.
The pensioner died at his Cambridgeshire home just a few hours later.
Dr Ubani escaped prosecution in Britain after police missed two chances to arrest him. He was prosecuted in Germany where he never had to appear in court and was given a fine and a nine-month suspended sentence.
After a 10-day inquest into Mr Gray’s death, which has highlighted serious concerns over the standard of out-of-hours GP care provided by the NHS, William Morris, the coroner for Cambridgeshire North and East, recorded a verdict of unlawful killing.
He said Dr Ubani was not of an “acceptable standard” and had committed “gross negligence manslaughter”.
He also called on Andy Burnham, the Health Secretary, to introduce 11 measures designed to make sure such a “tragic situation” did not arise again.
After the verdict, Mr Gray’s family condemned the “serious failings” at the primary care trust that employed Dr Ubani.
He was hired through a private out-of-hours care provider called Take Care Now and the family said there were no adequate checks on his abilities.
They also said they felt “let down” by the failure of British police to bring Dr Ubani to justice.
Nigerian-born Dr Ubani, 67, continues to work as a doctor in his home town of Witten, northern Germany.
Mr Gray’s sons, Rory and Stuart, fought “tirelessly” for two years to uncover the series of blunders which led to their father’s sudden death.
Their determination helped lead to an independent review of the out-of-hours system nationwide, which was published last night.
The review found widespread failings, a lax approach to interviews and misunderstandings about language testing responsibilities.
It also found that NHS trusts had been failing to carry out thorough checks on GPs providing out-of-hours care.
A series of new measures, tighter regulations and new guidance is to be brought in by the end of the year, ministers said.
Stuart Gray, 50, a GP himself, said: “The whole system is just abysmal.”
His younger brother Rory, 45, a mission control engineer at the European Space Agency, added: “It has been a long hard struggle.”
Dr Ubani, whose ability to be responsible for out-of-hours care was first questioned by a hospital boss 35 years ago, admitted in a letter to the family that he was “exhausted” while treating Mr Gray’s renal colic, having had just four hours sleep.
He also admitted having never come across diamorphine before.
Concerns have also since been raised over Dr Ubani’s treatment of two other patients in Britain.
He also saw Iris Edwards, 86, who died of a heart attack a day later and Sandra Banks, 59, who was admitted to hospital for two days.
Delivering his verdict at Wisbech magistrates’ court, Mr Morris said: “It is clear to me that Dr Ubani in his dealings with patients of that fateful weekend was incompetent, not of acceptable standards.’’
Peter Walsh, the chief executive of Action Against Medical Accidents, said there were “systemic failings” which could affect anyone using out-of-hours care.
It emerged during the inquest that Dr Ubani had failed an English test for Leeds Primary Care Trust and simply applied to another where the rules about language were not enforced.
After the verdict, the Gray brothers said they were taking civil action against Dr Ubani, the Primary Care Trust and Take Care Now.
They have also lodged a complaint with the European Court of Human Rights over the way the British and German justice systems dealt with the case.
Norman Lamb, the Liberal Democrat health spokesman, said: “It is scandalous that Dr Ubani will not face a court in this country.’’
