Wisbech Magistrates Court, Wisbech, Cambridgeshire
First Witness - Karen Byford, employed by TCN as a support trainer gave evidence on the computer training that she gave to Dr Ubani.
Barbara Hewson who is the Barrister representing the Gray family asked “you resumed your role as a support trainer who trained you?”
Karen Byford said “no one trained me I trained myself”.
Barbara Hewson said “you said when you provide training you select a few sheets from the training pack that you show to the Locum Doctor and you also draw their attention to the manual. Has anyone ever given you guidance on what you should be drawing to the attention of the Locum Doctor?"
Karen Byford said “No”.
Barbara Hewson asked “you said you worked as a support trainer. Was your work ever reviewed, monitored or appraised? "
Karen Byford said “No”.
Karen Byford said “Dr Ubani’s training took longer than normal because he seemed to be taking a lot of notes. After approximately 2 hours I was confident that he was able to use the system. The induction started at 6:00 pm and concluded at approximately 8:00 pm. He then joined Dr Uzokwe for a clinical induction which finished at approximately 9:50 pm.”
Second Witness - Mr Edward Mark Royce Reynolds, who is employed as a Chief Executive and Medical Director of On Call Care Limited. He is also a qualified General Practitioner.
He was asked by DC Paul Brown from Cambridgeshire Constabulary to provide a witness statement giving some kind of expert opinion into best practice for an out of hours GP.
Mark Reynolds said “GP’s need to do 3 years further training in the UK after qualifying as a doctor. Whereas there seems to be a lack of training of GP’s and Paediatricians in the EU who do not need to undergo this additional training and they are able to apply for registration as a GP in the UK.”
“My report is dated 19 March 2008. At the time of preparing my report there was no understanding of the lack of knowledge that European doctors had on the administration of drugs. This case has highlighted the lack of practice in Europe. This case will definitely change procedures.”
“The Coroner asked Mr Reynolds whether it was unusual for cars to carry 100 mgs of Diamorphine in the palliative care box. Mr Reynolds said “my impression is that it is unusual to carry 100 mgs ampoules, but there may be specific circumstances regarding the organisation of terminal care facilities in the TCN area to make the practice desirable”.
Barbara Hewson asked Mr Reynolds if he had any previous training in expert evidence or experience of giving evidence in Court and his response was “No”.
Barbara Hewson reminded Mr Reynolds that on 22 November 2008 he provided an advice on two previous incidents where dangerous and inappropriate doses of Diamorphine had been administered by Locum Doctors employed by TCN. The first incident was on 22 April 2007. The Locum Doctor administered 30 mgs of Diamorphine to a patient. Dr Reynolds indicated that this would have been a dangerous and inappropriate dose. He stated in his letter that “My impression is that the doctor may have confused Diamorphine with Morphine. I would be interested to know if the doctor was trained overseas”.
The second incident occurred on 17 August 2007 where a Locum administered 30 mgs of Diamorphine. Dr Reynolds stated “The doctor seemed to have been confused about the relative strengths of Morphine and Diamorphine and so calculated a potentially fatal dose. Again, I would be interested to know if this was an overseas trained doctor”.
Barbara Hewson asked “What steps would you expect an organisation to take where there have been two near misses of Diamorphine”.
Dr Reynolds responded “There are a number of steps that the organisation should take but in particular they should follow the national Patients Guidelines. They should also have guidance in the palliative care box on the drugs. Doctors should familiarise themselves with the different dosages in order to manage risk”.
Barbara Hewson said “Dr Ubani’s CV states that he has experience in anti-aging medicine and general practice. My understanding is that anti-aging medicine involves Botox surgery. Would it be unusual for such a surgeon to practice as a GP in the UK?”
Dr Reynolds said “yes, it would be highly unlikely that such a doctor would work as a gp in this country”
Barbara Hewson said “if someone sent a CV to you such as Dr Ubani’s, wanting to practice as a General Practitioner would you not want to know how much time he spent as a Cosmetic Surgeon and as a General Practitioner because it is not clear on his CV?”
Dr Reynolds responded “if I received such a CV it would send alarm bells. If this CV had been presented to me I would not have wished to employ him”.
Barbara Hewson indicated that insofar as Dr Ubani’s references were concerned he received a reference from a doctor who indicated he had known him for over 20 years but it did not indicate that he had had experience of working with him. She said “The PCT were looking for a reference from someone who had experience of working with him. Does this not expose a further variant of that which arose with Dr Shipman of a lone Practitioner who is not employed by an organisation and you do not get the sense that anyone working with them can speak about them. Was not this absence of information a big red flag?”
Dr Reynolds responded “It is always a red flag and a worry to have a combination of these things together”.
Dr Reynolds said “In my opinion this tragedy was ultimately caused by the difference in training and experience of Dr Ubani compared to similar GP’s of his age who trained and have worked in the UK. In my opinion the learning from this case should lead to action at a national level”.
David Lock representing Cambridgeshire PCT questioned Dr Reynolds and said “It is my understanding that an EU doctor who has good training in their country but is not up to the same standard of the training in this country, that they can still be on the General practice register. Is that correct?”.
Dr Reynolds responded “Yes”.
David Lock said “So full and proper registration of an EU doctor with acquired rights is in fact no sufficient guarantee of the required competency for a GP in the UK as you now know?”
Dr Reynolds responded “I agree”
David Lock went on to say “I suggest that in order for an out of hours service to deliver on its service any overseas locum doctor that they employ should undertake a comprehensive induction and shadowing process. Do you agree?”
Dr Reynolds responded “Yes I agree”.
David Lock asked “Would you support the Coroner issuing a report on how to train out of hours doctors including acquired rights of EU doctors?
Dr Reynolds said “Absolutely”.
The inquest continues.
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