Wisbech Magistrates Court, Wisbech, Cambridgeshire
First witness
James Kennedy - A medical practitioner in Hayes, Middlesex and the Executive Medical Director of TCN.
Coroner (C)
C: If you had occasion to use an Agency in 2007/2008 who would have made the particular arrangements for the locum would it have been Suffolk doctors on call or TCN?”
James Kennedy (JK)
JK: “It would have been TCN who would have contracted with the Agency Cimarron”.
C: “Was it a requirement for locums coming in to work for TCN to have sat a Language Competency Test?”
JK: The requirement for language competency in TCN was just coming in and we were still in discussions with how to measure up to the Language Competency Test. We knew that some PCTs required a qualification level of 6 or 7 but there was no uniform level. It is true to say that English requirement was not formally part of our requirements at TCN”.
C: “Did TCN check Dr Ubani’s CV?”
JK: “Our understanding was that the agency would do the checking on our behalf. However, we were told that Dr Ubani had the required qualifications together with supporting evidence”.
C: “Dr Uzokwe who carried out the induction has indicated that he viewed the time of the induction as being too short. However, we are aware that this was not bought to anyone’s attention until after the unfortunate event”.
JK: “Yes, that’s correct Sir”.
C: “With Dr Uzokwe being unhappy was there a provision in place for him to contact someone to flag up his concerns?”
JK: “Yes, he could have bought it to the attention of the non-clinical trainer ie. Karen Byford or the Duty Manager who is always at the base”.
C: “The situation is that on 15 February 2008 Dr Ubani arrived sometime in the morning at Stansted Airport having flown in from Germany. He travelled to Colchester for a meeting with Cimarron then to Ipswich for an induction. He did not leave the base at Ipswich until approximately 10:00 pm then travelled to his lodgings in Newmarket and arrived at the B&B at approximately midnight. On reflection do you consider that this state of affairs was likely to cause great fatigue to a GP starting a shift at 8:00 am in the morning?”
JK: “Firstly, every GP in the UK works long and intensive hours. They start at approximately 8:00 am and finish at 6:00 pm. They then do training and have a number of meetings thereafter”.
Secondly, all clinicians are under a duty to ensure that they are fit for work. In hindsight there is the danger that given Dr Ubani’s age he may have overcommitted himself in trying to do that amount of training and travel in one day”.
C: “If Dr Ubani was in the situation of being unsure of what drug to administer would he have been able to get advice quickly before using the palliative care box?”
JK: “Indeed. The British National Formulary was in the car or he could have picked up the phone and talked to a Duty Manager who would have transferred him to a clinician”.
C: “I have not heard any evidence that Dr Ubani made a call before administering the Diamorphine. Do you know whether he telephoned the base?”
JK: “There is no evidence to suggest that he called the base. It just cannot be explained why a doctor would go beyond competence and administer a lethal dose without taking advice on the dose before going ahead”.
C: “As a result of the unfortunate incident TCN carried out a serious untoward investigation. It was noted that Dr Ubani wrote to the GMC on 28 February 2008 and I will read the letter as it was written which is as follows:
‘Sir, in reference to the above named case involving the death of Mr G whom I treated on 16 February 2008 during my out of hours call visit, after an administration of a Diamorphine injection I wish to tender the following explanation. As it is on record I was bought to the patient at about 16:45 pm who was having severe renal colic. I found the patient in bed lying on his belly, holding his right flank in pain. His wife explained to me he had always been having such pain. He was usually given high dosage of pethidine or morphine. Speaking to the patient he confirmed this. On feling the patient at the right renal region he expressed pains. It is not true I never examined the patient, but went ahead to make an injection, maybe I did not do an extensive body examination or measure the blood pressure.
Consequently, I went out to the car to collect the injectible drugs (Diamorphine and Buscopan). Based on the information Mr G and his wife gave me about the high dosage he had always had in the past I was in my zeal to help inadvertently carried away to administer this 100 mgs of Diamorphine and Buscopan intramuscular. This was not intended, with the aim to hurt or cause the death of this patient. This is the most unfortunate incident in my 21 years as a GP in my own practice in Germany. I am very sorry and confounded. The remorse and guilt will leave with me the rest of my life. As I was informed of this incident on the next day during my call visits by Dr C Browning I was hamstrung, indescribably shocked. This mistake is irreparable, my heartfelt apologies and condolence go the family of the deceased, most especially to the son who is also a GP and his wife.
It is very unfortunate that during my first out of hours shift such a grave incident has occurred but I wish to sincerely apologise to the GMC, NHS, PCT Cornwall and Isle of Scilly. Locum Agency Cimarron UK Limited and all concerned that this was not intentional. I plead for forgiveness and leniency in judgment. If given the opportunity in future to be more careful to fulfil the ethic of good medical practice.
Yours sincerely
Dr med Daniel Ubani’
C: “In 2007/2008 how many cases did TCN commission for out of hours locum GPs?”
JK: “We carried out an audit and 6% of the workforce were doctors of European origin. 10% of the workforce was from the Locum Agency. 6% of European doctors covered less than 5% of the shift. Recent figures show that this has decreased significantly for Locum Agencies and European doctors. We are down to 2%-3% of the shifts being covered by European doctors and 6% by Locum Agencies”.
C: “Is an English Language Test a requirement for doctors wanting to work for TCN?”
JK: “TCN’s pre-employment requirement is that all doctors need to be trained in English language and to have a Certificate of Competence in the English Language. This has been in place since 2008”.
C: “What, the findings of the serious untoward incident?”
JK:
• “Dr Ubani accessed the incorrect dose of Diamorphine despite the advice in his induction manual attached to the outside of the palliative care box”.
• The major contributing factor to the serious untoward incidence was a clinical mistake by Dr Ubani in selecting and administering a Diamorphine dosage of 100 mgs via intramuscular injection. This incident raises further questions about Dr Ubani’s basic clinical knowledge and failure to follow expected clinical practice by failing to check the dosage. Dr Ubani did not consult the British National Formulary or seek clinical advice from another clinician or clinical information source. He complied with all the recordings and notification requirements for controlled drugs and broke two seals to access the drugs. He appeared to make a conscious decision to administer 100 mgs of Diamorphine”.
C: “I understand that there was a previous incident with Diamorphine involving a Locum working for TCN. Was this a foreign Doctor?”
JK: “In 2007 TCN had an incident where a non-UK trained doctor gave a dosage of 20 mgs of Diamorphine intramuscularly to an older female patient. The patient required transfer to hospital for Naloxone injection (opiate anecdote). She was discharged home later the same day. The incident was investigated and the clinician had no previous complaints or incidents. The clinician underwent re-training in palliative care and opiate management.”
Barbara Hewson (BH) - Representing the Gray Family
BH: “You described a process of how Dr Ubani came to work for TCN. Is it fair to say that he did not require a certificate of competence in English?”
JK: “Yes”.
BH: “TCN were therefore trusting to luck that any doctor who came to work for them would be able to speak English”.
JK: “We were not leaving it to luck as we knew that the PCT performers list required a Certificate of Competency in English”.
BH: “But you did not which PCT required it and therefore in hindsight there was a loophole”.
JK: “Yes, that’s correct”.
BH: “TCN required to see a list of documents for doctors working for them but this did not include Dr Ubani’s application form or CV. In fact you saw his application and CV after the event and that’s why your knowledge on Dr Ubani improved after the incident”.
JK: “No, we had made extensive enquiries”.
BH: “Dr Ubani’s CV indicates that he has an interest in clinical surgery. His CV does not give any information to the ‘Out of Hours’ provider that show that he had the appropriate qualification does it?”
JK: “It was not sufficient and that’s why we have changed our policy”.
BH: “If you had been involved in the recruitment process would you have employed Dr Ubani?
JK: “No”.
BH: “As we are all aware Cimarron carried out the checks on Dr Ubani and yet his CV did not ring any alarm bells. This therefore shows that no one at Cimarron had a clinical background”.
JK: “It would appear so”.
BH: “There was no system in place for Dr Ubani’s CV to be sent to TCN and there was nothing in place to spark off any concerns”.
JK: There was a system in place, the CV should have been sent to TCN by fax but on this occasion this did not happen”.
BH: “Turning to the induction pack. Would you agree that it is a set of documents that does not display a sense of order as to what needs to be read first?”
JK: “I agree that it is not optimally made out”.
BH: “Do you accept that Dr Ubani did not have an induction shift?”
JK: “He had a clinical shift”.
BH: Do you believe that it was a failing on TCN’s part that the inducting doctor had no training in the induction process?”
JK: It does appear that he did not receive training for induction but he is an experienced ‘Out of Hours’ doctor”.
BH: “Dr Uzokwe was asked to observe Dr Ubani in a clinical setting but he indicated that he did not have time to observe 3 aspects of practice ie. Note taking, standard of English on the telephone, in person and on the computer and whether his use of the computer was adequate. I would suggest that the induction was intended to include this part of observations which were significant and it was an important part of the induction that had been overlooked”.
JK: “It was an important part of the induction”.
BH: “Carol Leonard who is nurse spotted very basic things that alarmed her. There were deficiencies in Dr Ubani’s practices that would have been obvious to Dr Uzokwe if he had had an opportunity to observe him”.
JK: “In hindsight that’s correct”.
BH: When you now induct locums do you ensure that the inductee is observed in clinical practices”.
JK: “Yes. They take telephone calls, lead a Triage. They are observed doing an examination and providing treatment. They generate prescriptions and referrals and also take advice from another clinician.”
BH: “In Dr Browning’s email of 15 January 2007 he makes it clear that there were two adverse incidents in close succession of each other. Dr Browning commented that one of the doctors involved felt that the current system was to blame and TCN should therefore close the loophole to avoid any fatalities. Should you not have followed through his concerns with immediate effect?”
JK: “But I did”.
BH: “Clearly not, because you had two previous incidents in April and August 2007 and then in January 2008 Dr Browning sent an email raising further concerns”.
JK: “I came into post in July 2008 and I tried to implement changes but I accept that there was some delay.”
BH: “I understand that one of the doctors who gave an inappropriate does of Diamorphine was not from the UK”.
JK: “No. He was from Germany”.
BH: “So you were aware of problems with doctors from Germany and yet you did nothing”.
JK: “There were also cases of UK doctors giving overdoses of controlled drugs who were trained in the UK”.
BH: “In your statement you refer to two previous incidents and yet you describe one incident of the doctor giving 20 mgs of Diamorphine. Why did you give such an inaccurate account when you knew that the doctor administered 30 mgs of Diamorphine. Was it not an attempt to bury the true extent of what happened with two incidents of Diamorphine?”
JK: “Absolutely not!”
C: “Dr Kennedy, can I ask you would Dr Ubani have seen the document attached to the outside of the palliative care box indicating opiate strengths before opening the palliative care box bearing in mind that a palliative care box was not used in the induction?”
JK: “It’s correct to say that he would not have seen the documents until he administered the drug”.
David Lock (DL) - representing the PCT
DL: “Dr Browning raised concerns about foreign doctors with TCN and therefore TCN was on notice that there were clinical governance risks by foreign doctors working in the UK”.
JK: “Anybody providing services knew that there were difficulties with foreign doctors providing services in the UK and their unfamiliarity with the complex NHS systems in the UK”.
DL: “Is it fair to say that the risks of foreign doctors had been highlighted to your company and there is no evidence of a response until after the incident in February 2008”.
JK: “Part of the issue was what was meant by foreign doctors. 28% of the NHS workforce has received training from outside the UK. We were conscious that if the GMC accepted these doctors on their register that they would be competent. We were also aware of the need to be fair to all nations, races, creed, and not to discriminate”.
DL: “All of that is very interesting but you have not answered the question. What steps did you take to minimise the risks of overseas doctors. If the answer is none could you please respond by saying none?”
JK: “There was no specific policy around foreign doctors”.
DL: “Could your system at the time allowed someone to come for the weekend and be inducted and work the following day. Therefore before you ever met the doctor you had already formally allocated him to deliver 24 hour care over the weekend. Would you not agree that this decision would not have allowed an inductor to say that an inductee could not proceed to a shift if they had concerns about them as it would have created very substantial problems for your company?”
JK: “It would have created a problem but not a very substantial problem”.
DL: “With the benefit of hindsight that it is not a very robust system to induct someone the night before they are due to do a shift”.
JK: “The induction process is merely to familiarise one self but the clinician should be competent to carry out the task”.
DL: “It obviously put pressure on the inductor to pass the inductee and it would have caused problems for TCN if someone had been pulled out from doing a shift at short notice”.
JK: “No, I do not agree. TCN had always been concerned with safety and would therefore have ensured that the shift was covered”.
DL: “To your knowledge were your systems consistent with other ‘Out of Hours’ Associations at that time?”
JK: “I have discussed this with other organisations. Our systems were as good as if not better than others. However, they were not sufficient. We have now made improvements”.
DL: “Is it fair to say that your focus on deficiencies has been enhanced by this tragic event?”
JK: “Yes it has had a huge impact. The event assisted us to make changes that would otherwise have been difficult to push through”.
DL: “So problems may exist elsewhere geographically”.
JK: “I cannot speak for other organisations. We still have concerns with systems as a whole:
• How a doctor gets on the GMC Register.
• How a doctors gets on the Performance List.
• The type of checks that any organisation can carry out on clinical competence when this has supposedly already been proved by being on the GMC register and performance list.
• Concerns regarding true familiarisations with the NHS more widely such as that that a GP requires.
Dr Ubani could have worked for any ‘Out of Hours’ provider”.
The inquest continues.
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