Doctor in overdose tragedy 'tired and dithery'

Victim David Gray died after he was given more than 10 times the recommended daily dose of diamorphine, according to his family's lawyers.

Dr Daniel Ubani, a locum doctor from Germany, was on his first shift for a GP out-of-hours service provider when he injected Mr Gray on February 16, 2008.

Mr Gray's partner Lynda Bubb told the first day of the inquest in Wisbech, Cambridgeshire: "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 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 window sill.

"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 died a day after she was treated by Dr Ubani, 66.

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.

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

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 callouts.

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.

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

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