Watchdog says failure by trusts to comply with alerts is unacceptable by risking patients’ lives

Hospitals were accused of putting patients’ lives at unnecessary risk after research revealed they were failing to comply with NHS orders designed to prevent deaths from mistakes involving drugs, surgery or equipment.

Information released by the ­Department of Health after a freedom of information request showed that hospitals were not complying with safety alerts issued by the National Patient Safety Agency (NPSA).

The NPSA’s chairman, Lord Patel of Dunkeld, told the Guardian that the behaviour of the trusts was unacceptable and endangered the health of patients.

“It’s not good enough,” he said. “What’s the point of us developing these alerts if they don’t pay any attention to them? Alerts are produced to reduce risk and hopefully avoid many deaths, so not to implement them to me is alarming. If they aren’t implemented then they run the risk of harm occurring and the danger will continue.”

The Department of Health research revealed that:

• 104 hospitals and other providers of NHS care in England have not confirmed they have implemented an NPSA alert issued in March 2007 to ensure that ­injectable medicines are used more safely – even though new systems are meant to be in place by March 2010. 

The alert came after 25 patients died and 28 others experienced serious harm in 18 months.

• 25 NHS organisations have not ­confirmed compliance with an NPSA safer-practice notice designed to reduce the risk of patients ­falling out of bed. It was issued after about 90 patients who rolled out of bed on to the floor in ­hospitals, mental health and learning disability units, fractured their neck or femur; 11 of them died.

• 81 hospitals and other care providers had not taken the “required actions” outlined in patient safety alerts covering opioid (painkilling) medicines. The alert was originally issued in July 2008 with a deadline of January 2009; the 81 had not complied by 29 December 2009.

• 10 NHS trusts have not said they have complied with a February 2005 alert on nasogastric feeding tubes, which can sometimes be wrongly placed into the lungs during insertion. Errors involving the feeding tubes caused at least 11 deaths before the alert came out, according to the NPSA.

Patel acknowledged that complying with alerts can be difficult for the NHS. “They can’t be implemented overnight because they involve system changes, for example to IT systems or clinical practice. But having said that, the level of implementation is not good enough and needs major improvement,” he added.

The research, sought by the patient safety charity Action Against Medical Accidents (AvMA), also reveals that 50 trusts have not showed they have ­followed the NPSA’s advice in 2008 on hand hygiene, which is a major source of hospital-acquired infections; 37 have not taken steps set out in 2006 to improve the safety of blood transfusions; 56 did not comply with 2009 advice on reducing the risk of children being injured or killed by parents with mental heath conditions; and six have not implemented a 2008 alert on avoiding patients undergoing brain surgery accidentally having burr holes drilled in the wrong side of their head, as at least 15 did between 2005 and 2008.

Peter Walsh, AvMA’s chief executive, said: “The fact that so many NHS bodies are failing to act on potentially life-saving alerts from the NPSA is shocking. It is putting lives at unnecessary risk and adds insult to injury for patients who have been harmed or lost loved ones as a result of NHS lapses in safety.”

Lisa Richards-Everton, whose husband, Paul, died in July 2007 after a drugs blunder while he was a cancer patient in Birmingham’s Heartlands hospital, said the report was shocking. 

“It shows how the government and the NHS are failing everyone,” she said. “The systems that are currently in place are inadequate and urgent changes need to be made. These are people’s lives we are talking about; everyone deserves to be safe in hospital. We trust adequate safety measures are in place, but clearly this is not the case.”

In addition, a total of 119 trusts did not comply with a 2008 NPSA alert on the risk to patient safety of not using the NHS number as the method of identifying patients nationally across England. That was despite the NPSA declaring that local hospital patient numbering systems involved “real danger to patients of serious harm or death”.

The Department of Health revealed which NHS trusts had confirmed they had complied with the 53 patient safety alerts the NPSA issued between 2004 and 2009. University Hospitals Coventry and Warwickshire NHS Trust had not implemented the largest number: 37.

However, after becoming aware that the charity planned to publicise the department’s data, the trust recently told the NHS’s central alerts system that it had in fact complied with most of the 37. A trust spokesman said that its adherence to NPSA alerts had been examined by the Care Quality Commission (CQC), the NHS watchdog in England. “The CQC found absolutely no issues of concern and gave the trust a clean bill of health,” he said.

Lewisham Hospital NHS Trust in south London had not acted upon the joint second highest number of alerts: 31. Joy Ellery, its director of knowledge, governance and communications, said it had delayed notifying the central alerts system because it took the alerts so seriously.

“We are so thorough with implementing safety alerts that until we’ve complied with them fully, we don’t sign them off. We have now signed off a number of the 31 and are down to 18 that haven’t been implemented.” Asked if 18 was still poor, Ellery replied: “I would like it to be better.”

The DH said it expected all NHS trusts to comply with safety alerts and to record and action them. It will issue the health service with a reminder about the need to update the alerts system reliably and as soon as possible, a spokeswoman said.

The new responsibility on all NHS trusts from April to register with the CQC will make mandatory the reporting of threats or potential threats to patient safety, she added.


Hospital made profit on NHS drugs sold abroad

A Surrey hospital sold millions of pounds worth of NHS medicines abroad during the past year, despite official warnings calling for an end to such arbitrage for fear it could lead to shortages for British patients.

The Royal Surrey County Hospital in Guildford confirmed a report in the Health Service Journal that it had made £300,000 in profit by exporting £4.6m in medicines in the 10 months to January.

The revelations precede a conference convened next month by Mike O’Brien, the health minister, designed to clamp down on such “parallel trade” after pressure by the pharmaceutical industry. They provide a clear example of NHS entities trading for profit, despite a statement by the Department of Health to the Financial Times last week that it was unaware of any particular examples.

The weakness of sterling against the euro has turned the UK into a low priced source of medicines in the past two years, allowing intermediaries to buy them for resale at a higher price elsewhere in Europe, such as Germany.

The UK was formerly a net importer of drugs from lower-priced countries such as Greece, as part of the widespread practice of parallel trade, transferring potential drugs company profits into the hands of intermediary traders.

While individual pharmacies and some drugs wholesalers have long taken part in this cross-border arbitrage, which is legal under European Union law, the government became concerned in recent months at the possible involvement of NHS hospital pharmacies. The chief pharmacist wrote to them last July, calling the practice “irresponsible”.

The arbitrage runs the risk of creating medicine shortages in the UK. Officials were particularly concerned because of extra pressure on medical services caused by the flu pandemic. 

Bad weather in recent weeks also caused breaks in the normal drugs supply chain, causing stock shortages that could have threatened patients’ lives.

Monitor, the hospital regulator, said it had inspected the Royal Surrey’s practices in preparation for its conversion into a foundation trust in December but found no fault with the practice.

“As long as what they are doing is not illegal and doesn’t affect their ability to focus on NHS patients, it is not an issue for us,” Monitor said. It cited other commercial activities, such as childcare, while saying that car parking had become subject to ministerial  scrutiny.

The hospital said it had discontinued the parallel export of medicines last month in response to negative publicity and when a shift in exchange rates made the practice less lucrative. It said it was satisfied it did not run the risk of forming any medicine shortages for NHS patients.

The Department of Health told the FT last week that it had “received anecdotal evidence of NHS trusts being approached to become involved in such activities but has no concrete evidence that NHS trusts are involved”.

The department said that it was “aware of a report that a hospital has considered trading in medicines for short-term financial gain. Such activities are wrong and threaten the medicines supply chain and patient care.”


Victims misdiagnosed by doctor paid £4m in compensation

The victims of a doctor who reduced children to “zombies” after misdiagnosing them have been paid more than £4m in compensation.

Dr Andrew Holton mistakenly declared more than 600 patients epileptic during one of the biggest cases of misdiagnosis in the history of the NHS.

Many of them were prescribed a debilitating cocktail of drugs when in fact they were only suffering from headaches or simply badly behaved.

In total, 105 pay-outs have been made to former patients of Dr Andrew Holton who were treated by him at Leicester Royal Infirmary between 1990 and 2001.

The amounts paid out have varied from sums of just a few thousand pounds to one of around £240,000.

Dr Holton was suspended in 2001 after a series of complaints dating back to 1995.

An inquiry found he had misdiagnosed 618 cases and put 500 children on the wrong doses of medication.

In January 2006 the General Medical Council’s Fitness to Practice Panel ruled that his professional performance was “seriously deficient”.

But he was later allowed to return to work with certain conditions – including one banning him from working with children – placed on his registration.

Dr Holton, now 56, misdiagnosed 618 youngsters while working as a paediatric neurologist, prescribing many a mix of anti-convulsant drugs.

Even his own colleagues raised concerns about his “individualist” methods as early as 1998, yet he was allowed to continue working in virtual isolation.

Only afterwards was it revealed he had no formal qualifications in paediatric neurology.

Parents said the medication caused their children to suffer side-effects, such as black-outs and drug-induced hazes.

Solicitor Jane Williams, from law firm Freeth Cartwright which has handled most of the compensation cases, said: “The families have been able to sit down round a table with three independent consultants and it takes as long as it needs to.

“Invariably, some parents feel guilty about what happened. With the panel, they get independent experts telling them it was not their fault.”

A total of £4.4m has been paid out since legal proceedings began in 2003. A further 89 compensation cases are expected to be decided by the end of next year.

An independent inquiry commissioned by the Department of Health criticised the hospital’s response and lack of effective management.

It found Dr Holton should have had extra training when he joined Leicester University Hospitals NHS Trust from Charring Cross Hospital, London.

Dr Holton now works as a consultant neurophysiologist at Leeds Teaching Hospitals Trust. A  spokesman for the trust said: “Dr Holton does not feel it is appropriate for him to comment.”

Last night a Leicester hospitals spokeswoman said: “Our solicitors are working hard to fully co-operate with claimants so that all outstanding matters can be brought to a conclusion.”


Dementia costing UK £23bn a year

Dementia costs the country £23 billion per year- more than cancer and heart disease combined but receives a fraction of the funding, according to a new “wake-up call” report.

The number of sufferers at 822,000 is also 17 per cent higher than has previously been estimated and will pass the one million mark before 2025, the Alzheimer’s Research Trust (ART) said.

Revealing stark differences in research funding, it calculated that for every pound spent on dementia studies, £12 is spent on investigating cancer and £3 on heart disease.

Rebecca Wood, chief executive of the ART, called for greater resources to fight the condition, saying: “The true impact of dementia has been ignored for too long.

“The UK’s dementia crisis is worse than we feared. This report shows that dementia is the greatest medical challenge of the 21st century.”

She added: “If we spend a more proportionate sum on dementia research, we could unleash the full potential of our scientists in their race for a cure.

“Spending millions now really can save us crippling multi-billion pound care bills later.”

According to the report, which was prepared with experts from Oxford University, dementia’s overall annual cost dwarfs the £12 billion cost for cancer care and the £8 billion for heart disease.

The £23 billion is made up of £9 billion in social care costs, £12 billion in unpaid care and £1.2 billion in health care costs.

Each dementia patient costs the economy £27,647 each year, researchers found, nearly five times more than a cancer patient and eight times more than someone suffering from heart disease.

The expense is driven mainly by the extent of unpaid carers and long-term institutional care – in contrast to cancer and heart disease whose costs are mainly taken care of by the NHS.

Big differences in research funding were also revealed in the study, called the Dementia 2010 report.

At £590 million, cancer research funding is 12 times the £50 million devoted to dementia, while heart disease received more than three times as much. Only stroke research received less.

The report calculated that £295 is spent on research for every person with cancer, compared with just £61 for each person with dementia.

Alastair Gray, professor of health economics at Oxford University and report author, contrasted the perception of the disease with cancer.

He said: “Many of us know people who have had cancer or heart disease but have been successfully treated and survived, so there is a perception that something can be done, and that more research will allow even more to be done.

“In contrast there are no cures for dementia at present; there are not even many ways of delaying it or slowing it down, so there may well be a feeling of inevitability surrounding it.

“However the lack of of effective treatments is surely an argument for devoting more effort to research, not less.”

The report also documents a “diagnosis gap”, between the expected number of people with dementia and the number of patients with dementia on GP registers.

In England, it is estimated only 31% of people with dementia are registered on GP lists.

Reasons for the low rate include GPs’ lack of training and low confidence in diagnosing dementia.

Health minister Phil Hope said on BBC Radio 4’s Today programme: “I would fully agree that dementia is one of the most important issues we face as a population, particularly as more and more people are living longer.”


NHS’s major trauma services – not good enough

England has an unacceptably poor service for dealing with major trauma, in spite of 20 years of reports identifying the problem, and a real terms doubling of NHS spending in the past decade, the National Audit Office found.

Some 450 to 600 lives a year could be saved, and much long-term disability prevented, if the NHS had an effective network of centres to deal with multiple injuries from road crashes, burns, blasts, serious falls and major crush injuries, the NAO said.

Death rates from major trauma are 20 per cent higher in the UK than in the US, which has well organised trauma centres, and almost certainly higher than in Germany and some other European countries, according to spending watchdog’s research.

Victims of major trauma need specialist surgical teams that may include orthopaedic, cardiac and neuro-surgeons, but such consultants are not normally on duty at night and weekends when most major trauma occurs. 

Few hospitals have sufficient CT scanning available round the clock to help with diagnosis, and what data there is shows that barely a third of patients who need moving to a more specialist centre in fact get transferred.

Not enough of the patients who need a critical care bed get one, and access to rehabilitation services which can improve quality of life and reduce hospital stays varies widely, the NAO said.

Major trauma services are simply “not good enough”, Amyas Morse, head of the NAO, said. They “have not significantly improved in the last 20 years, despite numerous reports identifying poor practice”.

The result is unnecessary deaths and disability and poor value for money, and while the health department has just appointed a national director for trauma it and the NHS “must get a grip,” Mr Morse said. Co-ordinated trauma networks need developing, with much better information on costs and outcomes. 

The performance of 40 per cent of hospitals cannot even be measured because they do not submit data to the voluntary network which does audit trauma care.

The NAO’s warning came as the department told primary care trusts they must do a better job of monitoring the quality of care delivered by out-of-hours GP services following the death of David Gray, a patient given a fatal overdose by Dr Daniel Ubani, a German flown over as a weekend locum by Take Care Now, Cambridgeshire’s private contractor for out-of-hours care.


NHS spending squeeze to hurt PFI hospitals most

NHS hospitals built under the private finance initiative will face a much tougher time making the productivity and efficiency gains that are needed as public spending is squeezed, PFI experts and NHS managers are warning.

Under PFI, hospitals pay a single annual charge, typically for 25 or 30 years. It covers the cost of the capital, maintenance of the building and often other “soft” services such as cleaning, catering and laundry and sometimes equipment replacement.

While the soft service contracts are usually renegotiated every five or seven years, the main payments are fixed at the interest rates prevailing when the deal was done. In the current financial climate there is no possibility of refinancing them to produce lower annual payments, and the cost of buying out the contracts is prohibitive, according to PFI specialists.

Figures published by the Department of Health this week show big variations in the percentage of annual turnover that hospitals pay for their PFI buildings, largely depending on how extensive the rebuild was.

For some it is only 1-3 per cent but for others it is 10-12 per cent. For Walsgrave Hospital in Coventry, Dartford and Gravesham and Queen Elizabeth, Woolwich, it is 16 per cent and more. For Bromley Hospital it is almost 20 per cent of turn­over.

Traditionally, when spending has been tough, NHS hospitals have put back maintenance to retain doctors and nurses and other services.

“If you do that for too long, it is a thoroughly bad thing,” Nigel Edwards, head of policy for the NHS Confederation, said. “But for a year or two it can help you cope.

“But a hospital with a PFI scheme does not have that option. They are contractually bound to keep the maintenance up – and if you are spending 10 or 15 per cent on your buildings it means all the other efficiency and productivity gains you need have to come out of only 85 or 90 per cent of your budget.”

Hospitals without PFIs still paid a capital charge, so the comparison was not quite that bad, Mr Edwards said. “But some of these hospitals with PFIs are going to find it incredibly tough” to make their share of the £15bn-plus savings that the health department says are needed, he said.

Treasury officials privately acknowledge that there is an issue and hope PFI providers will prove flexible as public spending gets tougher. But David Florry, director-general of NHS finance, told MPs that while the level of cleaning of back-office areas, for example, could be reduced at the break points in the soft service contracts, there was no evidence yet that payments had gone down as a result.

William Moyes, chairman of Monitor, the foundation trust regulator, said lack of maintenance in the past had left the NHS estate in an appalling state. “On balance, having to keep up the maintenance is not a bad thing because it means patients will be treated in buildings that have been kept up to scratch.”


More patients die as lone GPs cover thousands in opt out services

Some parts of Britain are relying on just one out-of-hours GP at night to serve more than 240,000 residents.

An investigation by The Sunday Times into the inadequacy of round-the-clock cover has established two further deaths, including that of a three-year-old boy, after failures in the system.

Brighton, Bolton and Wigan are among the areas where a lone doctor is responsible for dealing with late-night emergencies. The news follows revelations last weekend that just two GPs provide cover for Suffolk and its 600,000-strong population on some nights.

Mark Simmonds, the Tory health spokesman, said repeated warnings about out-of-hours cover had gone unheeded by ministers: “It’s disgraceful that the government hasn’t taken action over this before.”

Brighton and Hove primary care trust (PCT) has one GP to cover an area with 248,000 residents on most nights. It claimed the doctor can receive as few as 10 calls each evening. However, in one case involving the trust, a three-year-old boy from Hove died from blood poisoning after the failure of the out-of-hours service.

The frantic parents of Joseph Seevaraj phoned the duty doctor at 11pm on a Sunday and asked whether they should take their son to hospital because he was vomiting and suffering from diarrhoea.

Joseph was already taking antibiotics for tonsillitis and the doctor advised his parents, Jean and Nicola, to wait for those to take effect. They watched over the toddler closely, but he died a few hours later.

A consultant in paediatric intensive care later said she believed the child would have survived if his parents had received proper advice from the out-of-hours service.

“He needed basic medical attention,” said Veronica Hamilton-Deeley, the coroner, at the inquest. “The failure to provide it was gross failure.”

South East Health, which provides round-the-clock services for Brighton and Hove PCT, said it had learnt from the incident in January 2008.

This weekend it emerged that only one GP serves 310,000 residents in the Wigan area on most nights, while 270,000 residents in the Bolton area also have to routinely rely on a single out-of-hours doctor.

In North Somerset there is just one GP for 200,000 residents on a week night. Cambridgeshire has three GPs at night, Norfolk has four and Cumbria has six.

Such skeleton cover was introduced when labour negotiated new contracts with GPs in 2004, boosting their average salary to more than £100,000 and allowing them to opt out of providing round-the-clock care.

While some PCTs say that just one or two GPs can adequately cover a population of more than 250,000, others have more doctors available for home visits.

Under South Birmingham PCT there are 11 doctors on overnight duty, each covering an average population of about 35,000.

Hampshire has 13 GPs on duty at night and Devon has eight, working at medical centres across the county.

Patients are often unaware if their local service is in crisis because most trusts do not publish performance reports. NHS Bristol said last week that a report on the quality of its out-of-hours GPs’ service was “confidential” and “commercially sensitive”.

Most round-the-clock services struggle to fill shifts with local GPs. Instead they use doctors from other parts of the country or foreign GPs who fly in for their shifts. A parliamentary debate was told last week of a case in Cornwall in which a patient had been confronted with a foreign doctor who used “an electronic word converter” to communicate. Other patients have complained of waiting eight hours for a doctor to arrive.

There have also been complaints that out-of-hours GPs do not have access to patient notes and sometimes fail to diagnose serious conditions. In one case, a doctor working as a duty GP in West Yorkshire was suspended from the General Medical Council register after he failed to examine an elderly patient properly. She died the next day.

Dr Krzysztof Robak, 62, commuted more than 175 miles from Surrey, where he worked for a diet clinic, to his Yorkshire employer, Local Care Direct. When he visited the 86-year-old patient, he failed to check her blood pressure or take her temperature and did not consider her seriously ill.

Local Care Direct, a non profit organisation which provides out-of-hours care services for 2.5m people in Yorkshire, said it had vetted Robak rigorously before employing him.

It said it did not consider that he had contributed to the patient’s death in July 2007, but it had raised concerns about his conduct.


Free elderly care expansion promises spark row over affordability

Plans to expand free home care for the elderly sparked furious exchanges at Prime Minister’s questions yesterday as a new report said “radical changes” were needed to maintain the care system in the face of increasing demands.

The Care Quality Commission’s (CQC) annual report on health and social care services in England said a predicted 1.7 million more adults will need care by 2030, putting pressure on already stretched public finances.

The Government’s Personal Care at Home Bill, which would provide 400,000 vulnerable elderly people with free care in their homes, was criticised by council leaders earlier and Tory leader David Cameron accused Gordon Brown of using it to promote “cheap dividing lines” between the parties ahead of the general election.

Mr Cameron demanded to know where the funding was coming from and insisted the Prime Minister wanted the “benefits” of the policy before the election, leaving the costs to afterwards.

But as Speaker John Bercow struggled to keep the noise down, Mr Brown hit back, attacking the Opposition leader for breaking cross-party “consensus” on the policy.

Mr Cameron asked the Prime Minister if he could rule in or rule out a compulsory levy on the elderly to pay for care, but Mr Brown sidestepped the question and said developing a “full social care system” would take time and needed consensus.

The CQC report, which was published yesterday, said tailoring services to meet people’s individual needs would help save money while allowing people to remain independent.

CQC chairwoman Dame Jo Williams said: “We all know that the context is changing. Trends such as increasing demand and rising expectations will be exacerbated by pressure on finances. That means we cannot go on as we are. To cope, we need some radical changes in the way that we organise and deliver services.

“This means shifting the culture away from a one-size-fits-all approach to care that puts the needs of individuals and carers at the centre of everything. A key part of this will involve helping people maintain their independence and health.”

The Government has said around £2.7 billion could be saved every year by helping patients avoid making unnecessary hospital visits.

But the CQC said this would require “a fundamental cultural shift” allowing patients to control their own care.

Stephen Burke, chief executive of the charity Counsel And Care, said “an honest and serious” debate was needed about funding.

He said: “Politicians, nationally and locally, owe it to older people, their families and carers to prioritise care reform and funding. As the University of Birmingham has highlighted this week, there are massive economic and social benefits to be gained from a new, properly funded care system.

“Older people and their families want to know what care they will get and how much they will have to pay.

“One way to fund better care would be a care duty on estates but it must be done fairly through a percentage on all estates above a certain value. For example, 2.5% on estates above £25,000 would raise enough to meet the current shortfall in care funding. And it would help older people and their families who currently face losing their home to pay for care.”

Director of the Patients Association Katherine Murphy said she welcomed the report’s “clear direction” that the NHS and social care services had to start working more closely.

She said: “It is vital this approach becomes widespread if we are to make the most of increasingly restricted budgets and ensure users get a responsive service.”

Simon Lawton-Smith, Head of Policy for the Mental Health Foundation, said: “There has been a lot of talk about person-centred services and joined-up health and social care over the last 20 years, so in a way it’s disappointing that the CQC still has to make these arguments.

“The hope now is that the likely need to reduce funding might concentrate minds on reform. An often-overlooked benefit of treating people as individuals and focusing on maintaining their independence and health is that it has the potential to save money.”


Doctors are addicted to every drug under the sun

Doctors are addicted to “every drug under the sun” the head of the first ever confidential GP service for health professionals has warned.

In its first year the clinic has treated NHS staff hooked on drugs including heroin, ketamine, a horse tranquilliser, and methadrone, a drug linked to amphetamines, said Dr Clare Gerada, medical director of the Practitioner Health Programme.

The service also uncovered six cases of undiagnosed psychosis, in which sufferers see things or hear voices.

The clinic was set up amid fears many health professionals were treating themselves or avoiding their local GP or hospital because of worries colleagues could learn of their health problems.

Overall, two of the doctors and dentists treated were reported to to the General Medical Council (GMC), because of fears that they could be putting patients in danger.

Another six were encouraged to report themselves to the regulator.

So far the service has operated only in London but there are plans to roll it out across the country, starting initially in Newcastle.

Two thirds of the 184 treated in the first 12 months had mental health problems, while one in three who came to the specialist service had some form of addiction.

Of these 51 were alcoholics and 16 drug addicts.

Dr Gerada said: “We are seeing every drug under the sun. Ketamine, methadrone, amphetamines, heroin, every drug you have ever heard of is coming through the door.”

The service has also treated unexpectedly high numbers of paediatricians, anaesthetists and psychiatrists.

The stress of the jobs, easy access to drugs, and the extra stigma attached to psychiatrists suffering from mental health problems could be reasons for the high demand, Dr Gerada said.

More than 80 per cent of those treated for drug or alcohol addictions were now sober, the first report on the service shows.

Prof Sir Liam Donaldson, the Chief Medical Officer for England, praised the success of the scheme.

“It has uncovered problems that would otherwise not have been seen and the interventions been highly effective,” he said.


Doctor Daniel Ubani unlawfully killed overdose patient

A coroner has 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)

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.