Wisbech Magistrates Court, Wisbech, Cambridgeshire
First witness
Mr Adrian Tyas was called to give evidence. He was formerly employed in the role of Director of Cornwall and Isle of Scilly Primary Care Support Agency. Amongst his many duties he had the responsibility of planning and placing of Primary Care Practitioners on to the performance list.
The Coroner said “from the evidence we can see that Dr Ubani applied to West Yorkshire NHS Central Services Agency in order to be added to the Leeds Primary Care Trust Performers List. Part of the criteria to be added to the list was for Dr Ubani to sit the international English Language Testing System. The tests results were: Listening 4.5, Reading 4.5, Writing 7, Speaking 7, overall band 6.0. A letter was sent to Dr Ubani from the Contracts Officer advising him that in order for him to join the Leeds PCT’s Primary Performers List he would need to obtain an average score of 7.0 therefore they would not accept him on their performer’s list. In addition, an email was sent to Dr Ubani indicating that the Leeds Primary Care Trust does not make individual exceptions and Dr Ubani would need to attain a score of 7.0 in order to be included on their performer’s list. Dr Ubani was unable to meet the criteria required for the International English Language Testing System and he therefore withdrew his application to join the Leeds performers list in June 2007. Is it a requirement of the Cornwall and Isle of Scilly Primary care support Agency to take the International English Language Testing System?”
Mr Tyas responded “no it is not was not as we also took into account his references and the fact that he was clinically qualified to do the job”.
The Coroner said “so that was the view of your Primary Care Trust (PCT) even though it was a requirement at West Yorkshire PCT”.
Mr Tyas responded “this is the first time that I am learning that it was a requirement with West Yorkshire PCT. It was not a requirement of our PCT”.
David Lock, Barrister representing Cambridgeshire Primary Care Trust made enquiries of Mr Tyas “is there a written policy that states what your PCT would have done if a doctor failed the International English Language Testing System?”
Mr Tyas responded “No I do not believe there is”.
Mr Lock commented “Good communication skills are essential to protect patients therefore English is required to protect patients. What tests did your PCT carry out to satisfy that any doctor coming in from the EU could speak English?”
Mr Tyas responded “No test is required”.
David Lock continued “If a doctor cannot speak English, with the benefit of hindsight, do you believe the system was faulty in employing doctors who could not speak English and therefore patient safety was at risk?”
Mr Tyas responded “Personally I would agree a doctor would need to be able to speak English to carry out a consultation”.
Barbara Hewson, the Barrister representing the Gray family drew Mr Tyas’ attention to Dr Ubani’s CV in which he indicates that his professional experience is that he set up a clinic for general medicine practice as a sole practitioner in 1986. He also runs a private clinic for cosmetic surgery and anti-aging medicine. She said “Having looked at Dr Ubani’s CV would you expect it to ring alarm bells in someone acting as a GP in the UK?“
Mr Tyas responded “it might be concerning but he had enough experience of 20 years in medical practice and this is confirmed by his referees”.
Barbara responded “Yes, let’s look at his referees. Dr Kroll indicated that he had known him as a conscientious colleague for a number of years but he could have been referring to him as a student and his reference is so general and only refers to his experience in anti-aging medicine and surely this reference raises more questions than gives answers?”
Mr Tyas responded “No it does not”.
Barbara Hewson concluded by reading an email to Mr Tyas in which a doctor from Leeds PCT indicated that they needed to obtain a reference which covered Dr Ubani’s work as a GP or had experience in an educational and training setting. He continued that more importantly for applicants from abroad they needed referees who could vouch for the competences as far as they could relate to being a GP in England, so a referee with no knowledge of UK General Practice is potentially unsuitable. Barbara queried whether this was something that Mr Tyas’ PCT should also have been concerned with.
Mr Tyas responded “No, we did not need to be concerned with this as he was registered with the GMC and his references seemed more than adequate”.
Second witness
Sharon Brooks, Company Director of Cimarron UK Limited. Her primary roles within the company are Finance, Operations Manager and Human Resources. Her company supplies amongst other things ‘Out of Hours’ General Practitioners and it was in this capacity that Dr Ubani was employed.
The Coroner queried what her impression of Dr Ubani was when she met him on Friday 15 February 2008.
Sharon responded “He left me with the impression that he was very experienced”.
The Coroner queried “Did you have a conversation of his experience as a General Practitioner in Germany”.
Sharon responded “No we just had a general conversation on his medical experience”.
The Coroner took her through her statement and said “You spoke to him about prescribing in particular budgetary constraints”.
Sharon responded “Yes. Because in the past I had been told that German doctors were known to over subscribe antibiotics and therefore I suggested that when Dr Ubani arrived at the ‘Out of Hours’ Service Provider he should check with them what their usual prescribing patterns were”.
The Coroner then went on to say “I understand that you telephoned Dr Ubani at approximately 1:30 pm on 17 February 2008 and told him that you had just received a call that he had caused a patient’s death. What was his response?”
Sharon responded “He said ‘Oh My God’, what’s the name of the person? He was extremely upset and I told him to return to the base in order to see a doctor who would meet him there”.
Barbara Hewson representing the Gray family said “In your statement you told Dr Ubani to return to Germany. Bearing in mind you did not know anything about the incident, why did you tell him to return home immediately”.
Sharon responded “I merely supported what Mr Browning had said as he suggested that he should return to Germany”.
Barbara Hewson drew Sharon’s attention to Mr Ubani’s CV and asked “You will note that his specialism is cosmetic surgery. Is this the type of service that an ‘Out of Hours’ Provider would be looking for in a locum?”
Sharon responded “No”.
Barbara drew her attention to his references and said “He appeared to be practising as a sole practitioner. Did you rely on the references to put forward his details to the ‘Out of Hours’ provider?”
Sharon responded “Not just the references. We also looked at his CV and relied on the fact that he was registered with the GMC”.
Barbara said “I have not been able to find anything that suggests that Dr Ubani had insurance in place at the time that he came to work in the UK. I note that you asked him to provide you with this information. Do you have a copy of the insurance certificate?”
Sharon responded, “I do not have my file of papers with me but it would have been essentially to have had an up to date letter from him confirming that insurance was in place”.
The Coroner interrupted “Could you make enquiries of your company to see if you received confirmation from Dr Ubani that insurance was in place and email it to my office this afternoon”.
Third witness
Dr Jill Challener, formerly Medical Director of Cambridgeshire Primary Care Trust outlined what had happened in the investigation that was undertaken following the death of David Gray and Iris Edwards. She had previously provided a statement for the Coroner's use. She highlighted that during unannounced visits during July and August 2008, it was found that the contents of the TCN - Controlled Drug Boxes still contained 100 mgs ampoules of diamorphine in addition to other dose ampoules of opiates. The boxes did not contain appropriate doses of naloxone, the antidote for reversal of overdoses of opiates.
She highlighted a letter that she had written dated 14 August 2008 to Mr C Banks, Chief Executive Officer of Cambridgeshire Primary Care Trust dealing with the continuing investigations into the events in February 2008 in which a patient was given a lethal dose of diamorphine in error by a locum GP employed by the contracted provider, Take Care Now.
It had been pointed out to Dr Kennedy, Medical Director of TCN that there was a possibility of confusion of dosage at the time and he was directed to the NPSA Alert Notice 12 issued in 2006 which explicitly requires Out Of Hours Services to ensure separation of pain relief doses from palliative care dose ampoules in emergency bags. Particular attention is drawn to the potential confusion between diamorphine and pethidine dosage where 100 mgs of the latter is a reasonable adult dose for pain relief, while 100 mgs diamorphine is only suitable for palliative care use and delivered subcutaneously by syringe driver.
She expressed astonishment to discover that the emergency box in use by the TCN doctors in July 2008 was unchanged from that which had been demonstrated in February.
On a further unannounced visit, it was found that the potentially dangerous association of doses of opiate in the same box was therefore still being carried around our County in all the cars providing transport for GPs employed by TCN.
Dr Challener said: "This is frankly astonishing and potentially negligent, considering the events of the original incident in February ... I feel strongly that this requires an explanation from the Management of TCN and urgent steps to improve safety for our population".
Barbara Hewson, Barrister representing the Gray family said to Jill Challener “In the annexes to your report you comment on the standard operating procedures for the safe management of Controlled A drugs. Would this set of guidance had been given to out of hours providers”.
Dr Challener responded, there was already guidance in place at the time of this incidents and the updated guidance was sent to out of hours providers to support that guidance that was already in place.
Barbara Hewson asked Jill Challener “If someone was coming in from outside the UK and had no understanding of palliative care would you expect the operating procedures to be in a separate section for training purposes”?
Dr Challener responded “Yes I would agree with that”.
Barbara Hewson proceeded and asked “Was not the palliative care box confusing because it contained mixed dosages for acute pain relief and palliative care and my understanding is that 100 mgs of Diamorphine would not be appropriate for someone who had had a heart attack.
Dr Challener responded “I agree. That would be entirely inappropriate”.
Barbara asked Jill to examine the palliative care box that was placed in evidence. Barbara pointed out that a document was taped to the box with a list of drugs and various ampoules were in foam. She reminded Jill that in her report she indicates that one of her concerns is that there was no mention of the anecdote Naxolene in the boxes used by TCN. She said “if you had never seen one of these boxes before it would have been difficult to know where to start, would it not?”
Dr Challener responded “I do not really want to comment on the content of the box but I would be concerned with the fact that there are a number of small capsules inside and unless you were familiar with the box you would not know where to begin”.
The inquest continues.
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