Wisbech Magistrates Court, Wisbech, Cambridgeshire
James Kennedy (JK) (continued to give evidence).
Fenella Morris (FM) – representing TCN
FM: “In the serious untoward incidents investigation you indicated that you had difficulty in engaging the GPs in Fenland area with out of hours care. What did TCN do to engage the Fenland GPs in out of hours care?”
JK: “We were aware that the GP population of Fenland had removed their services from out of hours care well before the changes in out of hours care. In 2003/2004 the PCT were concerned that GPs involved in out of hours care were in single figures and it was difficult to include them in such care. Before Suffolk Doctors on Call entered into a contract with TCN both Suffolk Doctors and TCN operatives visited every GP in Fenland and was able to attract local GPs in the area together with other GPs from surrounding areas to take part in offering out of hours care”.
FM: “One issue that has been discussed is the problem with foreign doctors. The more correct term should be doctors not trained in the UK. You explained that local GPs were not participating in out of hours care and you therefore had to engage with GP’ who were not local”.
JK: “That’s correct”.
FM: “You mentioned the need to engage with doctors not trained in the UK was that unique to TCN or was that happening elsewhere in the country?”
JK: “Approximately 90% of GPs opted out of out of hours care and the pct were therefore faced with a situation of 90% of the workforce saying thank you but goodbye. Most ‘Out of Hours’ providers hired GPs from outside the UK and the NHS sponsored expeditions to Germany, Spain and Italy to recruit doctors and this was sponsored by the NHS”.
FM: “You joined TCN in 2007. As far as you are aware, was the induction process something you hoped would address the problems with doctors coming in from abroad”.
JK: “That was the hope but not just with doctors from abroad but anyone working for an ‘Out of Hours’ provider much at the disquiet of local GPs. The induction process was never designed to make a GP competent.
FM: “What was the level of audit carried out by the PCT between 2006 after the alert and the incident in 2008?”
JK: “Extremely limited”.
FM: “We know that the PCT carried out a closer audit after the incident in 2008”.
JK: “Yes in February and May 2008 two members of the commissioning team of Cambridgeshire PCT plus two members of Suffolk doctors visited TCN.
FM: “Was anything said during those visits about the NPS alert?
JK: “Nothing. There was a discussion about the unfortunate death of Mr Gray and efforts we were going to take to address this issue of Diamorphine”.
FM: “Can you tell me about the two other incidents with Diamorphine?”
JK: “Yes they were person specific and two incidents did not show a pattern. We were more concerned with the fact that individuals were going to the palliative care box when you could have used drugs that were in the acute pain box”.
“It has hit me alarmingly that Dr Ubani did everything in completing the checklist and yet still broke the seals and administered the fatal dose. This therefore shows that a referee system would have been more appropriate to ensure safety”.
FM: “You were asked by Ms Hewson about a document called ‘Good Medical Practice’. Is that something the GP would be expected to know?”
JK: “Good medical practice is so fundamental to the elements of a GP that it is not something that you first come into contact with when you become a member of the GMC. You would start to learn the elements at Medical School. Good medical practice is not limited to clinicians but also to nurses and individuals outside of the medical profession”.
FM: “It was suggested that you should have checked whether Dr Ubani had good medical practice”.
JK: “One of shock because Dr Ubani was an experience clinician and I would have expected him to be competent”.
Second witness
Dr Christopher Uzokwe (CU) - Currently works at Barrack Lane Medical Centre, Ipswich. He originates from Nigeria and is a qualified medical practitioner. He has been practicing in the UK for approximately 5 years. He also works for TCN and carried out the induction with Dr Ubani on 15 February 2008.
The Coroner asked Dr Uzokwe a number of questions.
C: “When were you first told that you would be inducting Dr Ubani?
CU: At approximately 7:55 on 15 Feb 2008. I was informed that I would be giving an induction by Karen Byford. I indicated that I was not aware of this and she said that an email had been sent but I did not see that email.
C: You said you had no concerns of his competence as a doctor. Why did you say that?”
CU: “We were introduced and we chatted. I was trying to see how I could help him work as a GP in England having never worked in England. We role played a consultation. A nurse also needed an opinion on a patient and I took him through to where the patient was and we discussed the patient’s rash. He seemed to be fully aware as to what the problem was”.
C: “I noticed that you are both from the same Country. Did you converse in English or in your native language?”
CU: “We conversed in English”.
C: “Turning the induction form that you completed on 15 February 2008 you ticked the box marked ‘yes’ indicating that you had been able to cover all the points. Was this ticked marked by you at the time of the induction?”
CU: “No, at the end of the induction. I started completing the form and was told that I needed to go out on an urgent call. I therefore completed the form on my return. In relation to his competency I was concerned that he was from abroad and therefore not familiar with the geographical region or where the hospitals were or the NHS System”.
C: “The next question is the doctors standard of English adequate on the telephone, face to face and using the computer. These boxes are left blank”.
CU: “It was the first time that I was doing an induction and I did not observe in a consultation or listen to him on the telephone. I left the boxes blank as I could not answer the questions”.
C: “Did you have any concerns over his English?”
CU: “No I did not. He spoke good English. He had a bit of an accent like myself but his standard of English was good”.
C: “You wrote that this assessment was not enough to assess his competency. You also indicated that the induction was not long enough and therefore your time was not protected. What did you mean?”
CU: “I thought that if I was being asked to do an induction I should not have been training a Registrar. In addition, if the induction was to be for a duration of 2 hours it should have been that and I should not have been called out to do a visit. I felt that the induction was too short as I was being asked to do a number of other things”.
C: “Did you consider that your induction of Dr Ubani should have been longer?”
CU: “Yes, for someone working in the NHS it would have been okay but for a doctor coming from abroad he would have needed longer. My role was also to give support and to two nursing practitioners and I was called out on an urgent and therefore my time was reduced”.
C “It would have been the urgent visit that caused the induction to come to an end?”
CU: “Yes. If I did not need to go onto the visit the induction would have been longer. I actually thought that he was going to shadow me throughout my shift”:
C: “When did you complete the induction form?”
CU: “Probably lunchtime on Monday, 18 February”.
C: “When you completed the form did you know what had happened with Dr Ubani?”
CU: “I did hear that there was a problem but there was no mention that he had given an overdose”.
C: “Were you aware of any procedure that required you to hand in the induction form before Dr Ubani left the base?”
CU: “I knew I had to complete the form and return it to TCN. I knew that if I had concerns I could speak to Karen Byford or the shift leader. I did not speak to either because I had no concerns about the assessment my concerns were about the time”.
C: “Do you not feel that as worried as you were you should have reported it to someone?”
CU: “No I did not. My view is that I should not have had a home visit and also be given a registrar when I was carrying out an induction. I assisted Dr Ubani with any problems that he might experience logistically and I was not teaching competency”.
C: “Was a palliative care box ever produced to you to Dr Ubani and was there any discussion during the meeting about the palliative care box?”
CU: “We spoke about 999 calls and also talked about palliative care patients and opiates. There was no palliative care box in the room. There is usually one in the first consultation room and also in the car. I told him how to open the box and how to complete the forms once an opiate had been used. We also went through where all the drugs are located”.
C: “How did you know what you needed to cover from a limited checklist?”
CU: “I am an experienced out of hours GP and I relied on my own level of experience”.
C: “If you were not there would another doctor employed by TCN have had the same level of experience that you had to do the induction?”
CU: “It depends. If it was a newly qualified doctor who had been doing out of hours shifts for one year they would not have had the experience. Any doctor who was a GP for three years and had out of hours experience should have been able to do it”.
C: “So it seems a doctor who is only qualified for two years could be doing an induction with a tick box. Would I be right that all you had was a tick box?”
CU: “That’s all we were given. But my view is that any experienced doctor could have done the induction”.
C: “You are an experienced doctor but nonetheless did you receive any formal training in the induction process by TCN?”
CU: “None whatsoever”.
BH: Had you subsequently been asked to do any further inductions or been offered induction training?”
CU: “No”.
BH: “Were you aware that a nurse who worked with Dr Ubani on 17 February raised concerns about his competency?”
CU: “No I have had no conversations with anyone since the incidents”.
DL: “Is the summary position that you were asked to do an induction and not an assessment?”
CU: “I did an induction and not an assessment.”
DL: “You were actually being placed in a difficult position and you were asked to do an induction which you were not formally aware of. Whilst the induction was going on you also received a call to do a home visit and your time was therefore reduced by the demands of others”.
CU: “That is absolutely correct”.
DL: “You were not provided with a manual or guidance note explaining what is expected from those carrying out an induction. Had you ever seen one?”
CU: “I have not seen one”.
DL: “Your job was basically to do the best you could applying your knowledge as an experienced GP”.
CU: “Yes, when someone says that you need to do an induction that you need to familiarise someone with the system and to ensure that they can work efficiently”.
DL: “Did you believe that you were charged by TCN to make an assessment as to whether he was competent to do his shift?”
CU: “No. He had been assigned a shift and I had to help him familiarise with the procedures. In addition if I picked up anything glaringly obvious I knew I was to report it but I did not pick up anything glaringly obvious about his competence”.
DL: “Dr Browning sent an email to you which I understand that you did not see asking you to carry out the induction. You will note the email indicates that you need to ensure that the doctor is someone of an acceptable standard. I read this as you doing a clinical induction and for you to then see if Dr Ubani was up to a clinical standard”.
CU: “It is virtually impossible to determine whether someone is of an acceptable standard within two hours”.
DL: “I totally agree and that is why I say you were placed in a very difficult position and tried your best”.
The inquest continues.
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