Wisbech Magistrates Court, Wisbech, Cambridgeshire
First witness
Carol Leonard is a trained nurse and works fulltime at Statloe Medical Centre, Soham. She also works part time for TCN between 20 25 hours per month at the weekend. She works as a Minor Illness Nurse or as a Dental Nurse, whichever is required. She gave the following evidence “On Sunday 17 February 2008 I was working a shift at Newmarket Hospital between 9:00-1:00 pm. I was taking Triage dental calls in a little office just behind the main reception. Liz Scrivener, the receptionist was also on duty.
On this particular day I didn’t see patients I just dealt with Triage calls on the phone. I remember that on 17 February it was particularly busy in the waiting room as there were lots of patients. My first contact with Dr Ubani was when he asked Liz to help him sort out a couple of things on the computer. Liz came and asked me to assist the doctor because he also wanted advice in relation to prescriptions. Dr Ubani appeared to be a very nice chap. I recall that he was dark skinned, about 5’ 6 - 5’ 8 in height and he was thick set but not overweight. He was aged around late 40’s to early 50’s. He was very polite and I found his English to be very good. I could understand him with no problems. Throughout my shift there was 3 occasions when I was required to assist Dr Ubani”.
On the first occasion Dr Ubani wanted to know how to enter a prescription onto the computer and how to print it off. This was not an unusual request for a doctor to make as many doctors forget or need assistance occasionally. However, I did expect Dr Ubani to be more competent on the computer.
The second occasion was a short time later when Dr Ubani asked me about Ibuprofen. He asked me what dosages he should be giving. I was taken back by this question because Ibuprofen is a very common drug which is used worldwide. However, I accept that people have off days so I gave him the advice and also pointed out to him that there was a BNF manual that he could refer to if he got stuck. Dr Ubani informed me that he already had one and that it was in fact on his desk.
The third occasion Dr Ubani asked for my help was not long before I was due to finish my shift. I noticed that the waiting room was busy and there was a patient who appeared to be out of breath, I therefore assumed he was asthmatic. Dr Ubani asked me to help him fill out a prescription for the patient using a drug Salbutamol which you can give in an emergency in a nebulizer machine. I asked him whether he had seen the patient yet to which Dr Ubani “No”. I continued “Do you not think you should see the patient first?” to which Dr Ubani smiled and said “Good idea”. Dr Ubani then called the patient into the room and at this point I left the room.
I returned to my office and thought about what had just occurred and about the other occasions that Dr Ubani had needed assistance that morning. I was very concerned and therefore decided to ring Head Office and report my concerns about Dr Ubani. I explained that Dr Ubani had been willing to give a prescription without first seeing the patient and that I didn’t feel that he could cope without having someone around to ask for help.
After finishing my shift I had nothing further to do with Dr Ubani. I feel that it is important that I point out that during the 4 years I have worked for TCN, I have never reported my concerns regarding a doctor before”.
Barbara Hewson repesenting the Gray family asked “Have you seen any paperwork generated by the person at the other end of the TCN phone dealing with the concerns that you raised?”
Carol Leonard responded “No”.
Barbara Hewson continued “At this time you obviously had no idea of the tragic events of the previous day. TCN were obviously carrying out their investigations. Did anyone from TCN contact you to interview you?”
Carol Leonard responded “No”.
Second witness
Helen Kathleen Palmer is the Drugs Coordination Manager with Suffolk Doctors and has held this position since November 2004. She has sole responsibility for maintaining the Controlled Drugs Register with Suffolk Doctors and Take Care Now.
The registers hold comprehensive information on the use of palliative care controlled drug usage. It gives a patient’s personal details, the doctor who administed the medication, records of the box number used, the numbered ID for the call within the system and the number from the prescription used to enable the box to be restocked. She gave evidence of copies of the relevant paperwork specific to each entry which are stored with the register. She explained that the registers are area specific and are completed by her as and when needed.
She continued to give evidence that the drugs that are available to on call doctors are:-
(1) A Silver box which holds patient’s medication available to the doctor for dispensing at the time of consultation together with an injectable vial case provided for immediate necessary personal use.
(2) A black pilot, lockable bag holding diagnostic equipment and the numbered palliative care green box. She explained that the palliative care green boxes are supplied by Heath Road Hospital Pharmacy, Ipswich and they are received with a yellow seal in place, thus giving a secure package. She continued that when they receive these boxes they are secretly stored and are transported to the central store area from which they are received.
Barbara Hewson representing the family queried “Are you a trained clinician?
Helen Palmer responsed “I am not a trained clinician, I am a dispenser and I am less qualified than a pharmacist.”
Barbara Hewson asked “What type of training did you receive when you joined TCN
Helen Palmer responded “I did not receive any training, I jointed TCM as a dispenser”.
Barbara Hewson asked “Following the incident on 16 February 2008 did you receive any training on palliative care boxes?”
Helen Palmer replied “No”.
David Lock representing the PCT commented “I understand that after this unfortunate incident it took a long time for TCN to get rid of the 100mg files of Diamorphine. Would you agree?”
Helen Palmer responded “That’s correct as there were over 60 boxes that they had to deal with.”
Fenella Morris representing TCN queried “After the unfortunate event did TCN make any other changes to how palliative care boxes were carried?”
Helen Palmer responded “Yes a stop notice was added to each palliative care box indicating that this box may only be opened with the express permission of the Duty Manager. It further added that it was for patient safety reasons and failure to comply with the request would lead to detailed enquiries being made”.
Third witness
Dr Christopher Browning, General Practitioner in Suffolk. He also works as Clinical Governance Lead for Suffolk Doctors on Call / Take Care Now.
He gave evidence as follows:-
“At approximately 14.15 on 17 February 2008 I received a telephone call from Trevor Maynard, Senior Duty Manager indicating that a patient had died within a few hours of being seen by one of the on call doctors which may have been related to an excessive overdose. The patient that he referred to was a David Gray who lived Manea and had been suffering from renal colic. After carrying out checks I realised he had been attended to by Dr Ubani on 16 February when he administered 100 mgs of Diarmphone at 16.45hrs. I ascertained that Dr Ubani had been working his first shift for what should have been a whole weekend.
There was also a record by the ambulance team who knew what had happened and they were unable to resuscitate Mr Gray. I was very well aware that 100 mgs of Diamorphone is an extremely high dosage. As a result I decided to audit Dr Ubani’s calls and realised that this was the only administration of such a dosage for that day. Due to warning lights I could not allow him to continue working. I also looked at the other visits of the day and was not comfortable with his actions and therefore made a call and told him to return to the base at Newmarket.
When he returned I spoke to him by telephone. He was very upset and shocked. He remembered the patient with renal colic. He told me that he recalled being asked to give Mr Gray 100 mgs of Diamorphine. However, when I checked the record I saw that he should have given 100 mgs of Pethidine as Mr Gray had received this dosage on 3 previous occasions.
When I spoke to Dr Ubani he was at pains to tell me that he had been in clinical practice for 16 years without adverse events. He was clearly devastated. He did not indicate that he had never come across Diamorphine before”.
The Coroner asked Dr Browning to read the exhibits to his statement which were an email dated 15 January 2008 which was almost a month and a day before the fatal incident. The email read as follows:
‘Dear Colleagues, you will be aware that we have had an adverse incident with palliative care boxes which has happened in almost identical fashion on 2 occasions during the last year. Briefly, in attempting to relieve patients in acute pain, doctors in two different situations erroneously selected the 30 mg Diamorphine vial from the palliative care box and administered the entire contents to their patients by injection. This six fold overdose caused respiratory depression and collapse; the patient had to be admitted to hospital for resuscitation. If this is repeated and the patient is not resused in time, death could well result.
One of the doctors involved was required to undergo a session of mentoring and the doctor doing the mentoring feels very strongly that our current system is to blame for allowing the erroneous action and that we should close the loophole before a patient dies from a repeat of the error. I have felt similarly myself and raised the matter at governance but a less clear view emerged there. I reported at the last governance meeting that I did in fact feel that some action had to be taken. The attached paper is a proposal for that action. Please read it and let me have your views. I am very happy to consider a better suggestion if anyone is able to come up with one.
I attached proposals where there was to be a referee system to be put in place where if a doctor wanted to use any controlled drug from the palliative care box they would seek a second opinion before opening the box and any advice was to be given to the duty manager.
The Coroner said “I would say in that you were not mincing your words when you sent this email. Could you confirm whether your proposed changes are now in place?”
Dr B responded “Yes they are and they were put in place from 17 February 2008”.
Barbara Hewson (BH)
BH “How soon did you become aware of the incident that took place on 22 April 2007?“
Chris Browning (CB)
CB “It was some 2 or 3 months later when I got a call from someone from the Ambulance Service who was trying to clear their desk and wanting to close their file when they realised they had not reported it”.
BH “Did the incident strike you as a serious untoward incident?”
CB “No, not at the time”.
BH “The second incident occurred on 17 August 2007. Do you agree with Dr Reynolds that these doses were dangerous and inappropriate and could have been potentially fatal?”
CB “Yes”.
BH “So what action did you take?”
CB “I reported it to the PCT who wanted to ensure that steps were taken and also for the incident to be discussed with the doctor concerned”.
BH “What follow up steps were taken with the doctor?”
CB “I corresponded with him in writing”.
BH “As the Clinical Governance Lead, did you discuss the two incidents at your next Clinical Governance Meeting?”
CB “No because it was not clear that the two incidents were a pattern. No thought was given to the dosage and furthermore we did not want to discuss a system that was in place at the time”.
BH “But surely you have seen a copy of the Safer Practice Notice 12 which was cascaded to all GP Practitioners which highlights the risk of the administering of 30 mgs of diamorphine. Did you not think to revisit the notice and address the incidents with the Clinical Governance Team?”
CB “No”
David Lock (DL)
DL “Turning to the email dated 8 January 2008 from David Ward of Cimarron this is the first reference to Dr Ubani working a shift in the UK on 16 and 17 February. A series of emails followed and on 14 February there was an email from Cimarron to Dr Uzokwe informing him that he would be trainer. No email was sent from TCN to Cimarron requesting a copy of Dr Ubani’s qualifications or experience. Had you ever seen a copy of such an email?”
CB “No”.
DL “In fact, details of Dr Ubani’s past experience was not emailed until Tuesday 19 February 2008. Therefore the system ensuring that a doctor from abroad did not cross the threshold unless they had previous qualifications did not work”.
CB “We deputised this to the locum agency.
DL “I would draw your attention to Dr Kennedy’s statement which indicates all doctors working for TCN in ‘Out of Hours’ are required to satisfy the following requirements before they can be employed:
1. A valid registration on the General Practice Register of the GMC.
2. A valid registration withstanding from a UK PCT General Practitioners Performance List.
3. A current Criminal Record Bureau approval.
4. A current Certificate of Valid Insurance
5. For doctors trained in a language other than English TCN requires a Certificate of Competence in the English Language.
The above documents, a complete TCN recruitment form and wherever possible a candidates Curriculum Vitae are checked by our TCN Human Resources Department before the doctor is cleared for employment.
CB “This document was post incident”.
DL “With respect, I asked you if it was the system at the time of the incident and you said yes”.
CB “You asked me about the second paragraph and not the third paragraph as to whether it was checked by TCN”.
DL “But that does not allow any requirements for you to check a doctor’s qualification in accordance with the regulations and in hindsight was it not your obligation to check the suitability of the doctor”.
CB “We deputed to all Locum Agencies and I do not care to answer any further questions on this point”.
DL “Let’s consider the question of the induction. TCN had a number of foreign doctors coming to work weekend shifts. There were particular risks for those attempting to work in a wholly unusual environment. Was it not your obligation to check their clinical competence as a part of the clinical process?”
CB “You cannot assess a doctor’s competence in one induction.
DL “You obviously had concerns with doctors from foreign countries with acquired rights in delivering services in the NHS. However as Clinical Governance Lead you did not highlight these concerns”.
CB “I did not raise my concerns in any documents but I discussed my concerns on a number of occasions but not everyone shared my concerns. I believe that is down to the licensing Agency ie. The GMC to take on the role of advising on a doctor’s competency”.
DL “If that’s correct why is it that you were happy to accept your company was able to determine whether someone was suitably qualified to work for the out of hours providers but now you are saying it is a matter for the GMC”.
CB “What we give at the time was the custom and practice of the rest of the country?”
DL “Now turning to the Patients Safety Notice, had you been aware of this notice?”
CB “Yes”.
DL “Were you aware that the notice referred to obligations for General Practitioners and do you accept that in August 2007 you should have researched the guidance to support your concerns about the two previous incidents relating to the potential overdose of diamorphine”.
CB “I accept that that is where I should have gone”.
DL “Would you agree that if you had been able to persuade your colleagues to put safety measures in place after the two other incidents there would not have been a third fatal incident”.
CB “I agree”.
Fennella Morris (FM)
FM “Insofar as the previous incidents of diamorphine are concerned was it the administration of 100 mgs of diamorphine?”
CB “No it was 30 mgs”.
FM “Looking back at the issue of competency would a competent doctor have had difficulty in knowing the difference between 30 mgs and 100 mgs”.
CB “No”.
FM: “Do you think it was Dr Ubani’s intention to give 100 mgs of diamorphine? Was it an error of a different kind between the drug and not the dose?”
CB “Yes I believe the error was between the drugs pethidine and diamorphine and not necessarily the dose”.
FM: “If he had looked at the British National Formulary (BNF) would it have made difference?
CB “Yes because 100 mgs of pethidine is mentioned in the BNF but there is no mention of diamorphine.”
FM: “Before the fatal incident did you receive any complaints from the PCT about recruitment, induction or the palliative care box?”
CB “No”.
FM: “How was Dr Ubani’s English?”
CB “Not too bad. He spoke with a Nigerian accent but otherwise it was not too bad”.
FM “It has been suggested that you told Dr Ubani to go home after you spoke to him on 17 February. Why did you do that?”
CB “Yes, I told him to go home because anyone who is in severe shock needs support. He was in a foreign country and I merely advised him to advance his departure and to go home because he was in a state of shock and he needed to be supported.”
The inquest continues.
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