The Coroner's Ruling in the Death of David Gray
The inquest into the death of Mr David Gray who died following an overdose of diamorphine administered by an EU doctor during an out-of-hours visit, concluded today with a verdict of unlawful killing.
The coroner recorded as part of his Ruling:
"I must consider whether unlawful killing is the appropriate verdict. I look at causation. I am satisfied that the injection of 100mg of diamorphine was what killed David Gray. This, by his own admission in various letters and e-mails, was administered by Dr Ubani. The actions of Dr Ubani killed Mr Gray.”
“Although Dr Ubani selected the 100mg vial of diamorphine from the box, and after having injected the drug, he completed the records to show this, I am quite satisfied he did not mean to kill Mr Gray.”
“That said, has the killing come about through the negligence, and if so, was such negligence gross?”
“For there to be negligence, there has to be a duty of care. There clearly was such duty, owned by Dr Ubani as treating physician of his patient.”
“Was the negligence gross? I take into account the imperfect induction of Dr Ubani, his lack of familiarity with the NHS and the systems he was operating, and the fact that he was probably tired. Even so, those factors do not exculpate him from gross negligence. If he did not know the properties or size of the drug he was administering, he should not have administered it. He had the British National Formulary to consult, stuck on the lid of the box was a list of the drugs, attached to the box were instructions and inside the box was a list of opoid strengths. The phial he selected was far larger than any of the other phials, and if he had any doubts or queries I am satisfied he knew he could seek advice.”
“Nonetheless, he went ahead and injected the fatal overdose. This was gross negligence manslaughter.”
“Accordingly, the verdict I return is that David Gray was unlawfully killed.”
The Coroner also recommended that the Lord Chancellor and the Health Minister instruct Take Care Now and the Cambridgeshire Primary Care Trust to investigate the issues and failings highlighted by the inquest to bring about changes to the way out-of-hours care is delivered in this country and to ensure that sufficient safeguards are put in place to prevent a repeat of this tragic situation. These recommendations are supported by the Cambridgeshire Primary Care Trust.
Prior to the Coroner giving his verdict the representatives of Cambridgeshire PCT made a formal apology to the families of those affected by the treatment given by Dr Ubani in February 2008. A spokesperson said:
“Cambridgeshire PCT accepted that the treatment fell significantly below the standard of care that they were entitled to expect.“
“We apologise to the families of all of the patients affected for the suffering caused, which ought to have been prevented.”
“We assure the families that we have sought to learn the lessons from these terrible events.”
“We express our profound apology for what the families have had to endure as a result of NHS Treatment.”