Doctor Daniel Ubani unlawfully killed overdose patient

A coroner today demanded a review of EU agreements over the recognition of doctors when he ruled that the death of a 70-year-old patient who was administered a tenfold overdose by an "incompetent" German GP was unlawful killing.

William Morris called the death of David Gray "gross negligence and manslaughter" and issued 11 recommendations to the Department of Health for the improvement of out-of-hours GP services.

As well as the review of how 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 had acquired GP status.

Daniel Ubani, a Nigerian-born German citizen, was on his first UK shift as a locum when he killed Gray, whom he injected with 100mg of diamorphine – 10 times the recommended maximum dose.

Gray had been suffering from renal colic when he was treated by Ubani at his home in Manea, Cambridgeshire, on 16 February 2008.

After Gray's death, a national database of all doctors working as out-of-hours GPs will be set up in an attempt to avoid doctors such as Ubani working in Britain.

The database was recommended by Gray's family today, and Mike O'Brien, the health services minister, agreed to implement their suggestion.

He said better sharing of information by primary care trusts (PCTs) would help ensure that only competent and properly-qualified doctors were able to treat patients.

The recommendations are designed to ensure that doctors who have been refused permission to work on call at evenings and weekends in one part of England cannot then start treating patients in another.

They are intended to close the loophole that allowed Ubani to be refused permission to work initially in Leeds but then be approved to supply out-of-hours cover in Cornwall, where entry standards were less stringent, and because of that be employed in Cambridgeshire.

At the end of the inquest into Gray's death, Morris demanded "robust" clinical and management measures, including training and induction for non-UK doctors.

He said only the company actually running an out-of-hours GP service should recruit doctors in future – a blow to private recruitment companies.

Evidence to the inquest, held in Wisbech, Cambridgeshire, suggested Ubani had also inappropriately treated at least two, and 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."

He ruled that 86-year-old Iris Edwards, who also died on Ubani's first shift, had died of natural causes.

Graeme Kelvin, the chairman of Take Care Now (TCN), the private contractor that operated the out-of-hours service that treated Gray, offered his sympathies to the family over the "tragic event".

He said he hoped the recommendations of the coroner would "reduce the chances of a similar event happening anywhere in England".

Paul Zollinger-Read, the chief executive of NHS Cambridgeshire, accepted a systems failure had taken place, 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."

Rory, another of his sons, 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, Germany, said.

During the weekend of Gray's death, 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, but their cases did not form part of a criminal case later built against him.

The case has become a touchstone for public confidence – or otherwise – in 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 have insisted services are improving overall.

Ubani was paid £45 an hour for his first work as a locum in the UK, far less than the sums expected by British GPs. He also paid for his own flights, car hire and accommodation.

The story of Gray's death and the subsequent apology from Ubani to his family was first revealed by the Guardian in May.

It quickly raised concerns about EU rules on the 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 shocked last April when, by letter, the German authorities convicted Ubani 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.

Ubani, a German national, is suspended from working in Britain but is still allowed to practise in Witten, his home town, 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 (CQC), 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 communications breakdown between police and prosecutors in the UK and Germany over the handling of the criminal case against Ubani was laid bare.

TCN faces an uncertain future.

In recent weeks, it has lost contracts in Cambridgeshire and Suffolk, although it still provides doctors for two other trusts – NHS Worcestershire and NHS Great Yarmouth and Waveney – and is a partner in a third in Essex.

Christine Braithwaite, the head of investigation and enforcement at the CQC, said: "The death of David Gray was a tragedy.

"It should not have happened, and such an incident must not happen again. The coroner has clearly highlighted what went wrong.

"Take Care Now, and the PCTs that commission its services, must learn the lessons."

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