Inquest into the Death of David Gray Media Briefing Update

The inquest continues into the death of Mr David Gray, who died following a massive overdose of diamorphine administered by an overseas doctor during an out-of-hours visit. Mr Gray, 70, from Manea in Cambridgeshire, suffered with kidney stones and kidney infections. On Saturday 16th February 2008, his partner, Lynda Bubb contacted Take Care Now (TCN) who provided out-of-hours medical cover on behalf of the Cambridgeshire Primary Care Trust. TCN arranged for Dr. Daniel Ubani, the on-call doctor to visit Mr Gray at home. Dr Ubani, from Witten in Germany, was on his first ever shift in the UK having arrived in the UK the day before to work for TCN. He gave Mr Gray an injection of 100 mg of diamorphine, ten times the maximum dose of 10 mg usually recommended. Mr Gray died within a few minutes. Inquest Update The inquest continues at the Coroner’s Court in Wisbech, Cambridgeshire and a summary of evidence given so far can be found at www.anthonycollins.com. Evidence will be given by the following witnesses today and tomorrow (Thursday 21st and Friday 22nd January 2010). ‘Call’ refers to witnesses who are expected to give evidence in person and ‘read’ refers to witnesses who have provided a written statement which will be read to the court. Thursday 21 January 2010 Adrian Tyas (call) - Director of Cornwall and Isles of Scilly Primary Care Support Agency. Responsible for the planning and placing of Primary Care Practitioners on the performance list, he will be asked to give evidence on Dr Ubani's clinical references, certificate of good standing and registration with the General Medical Council (GMC). Jill Challiner (call) - Medical Director of Cambridgeshire Community Services. She will be asked to give evidence on the contract between the Primary Care Trust (PCT) and Take Care Now (TCN), the out-of-hours agency. She will also be asked to give evidence on why TCN had not changed its policy in relation to diamorphine 6 months after David Gray's death in spite of a letter from her indicating that certain safeguards needed to be put in place. Christine Macleod (call) - Medical Director and Consultant in Public Health for NHS Cambridgeshire. She will also give evidence on the contract with the PCT and TCN together with their policies and procedures relating to their management of controlled Class A drugs. Friday 22 January 2010 Trevor Maynard (read) – Senior Duty Manager at SUFDOC. On Sunday 17th February 2008 Dr Ubani telephoned SUFDOC and indicated that he was experiencing problems using the computer system. Trevor Maynard’s evidence will shed light on why it was necessary to send out a trainer to show Dr Ubani how to use the system again bearing in mind he had already been trained by Karen Byford of TCN on 15th February 2008. Carol Leonard (call) - A trained nurse at Staploe Medical Centre, Soham. She will be asked to give evidence about Dr Ubani’s conduct during on 17th February 2008 as she did a shift at Newmarket Hospital. Dr Ubani was at the hospital and asked for her assistance with the computer. He also asked her about Ibuprofen and what dosages should be given, which surprised her as Ibuprofen is a very common drug that is used worldwide. She telephoned TCN to report her concerns about Dr Ubani as a patient seemed to be out of breath and Dr Ubani queried how to complete a prescription for the drug Salbutamol which you can give in an emergency in a nebuliser machine. At this stage he had not examined the patient and Carol suggested that he should before writing out prescriptions and he indicated “good idea”. Dr Andrew Saywood (call) - Independent Medical Consultant. He became a full-time locum in 2001. He has a specialist interest in medico legal matters and has investigated many sudden deaths due to negligence, violence and drug overdose. He was instructed by Cambridge Constabulary to write a report concerning a number of visits made by Dr Ubani whilst he was in the UK. He will be asked to give evidence on the patients that Dr Ubani visited on 16th and 17th February 2008. He will also be asked to give evidence on Dr Ubani’s level of competence. A summary of the evidence given will be posted on the Anthony Collins Solicitors website (www.anthonycollins.com/news-and-events/news.aspx.) no later than 6pm each day, following that day’s proceedings. A further briefing update will be issued next week detailing that week’s witnesses. The inquest is being held at Wisbech Magistrates Court, The Court House, Lynn Road, Wisbech, Cambridgeshire, PE13 3DE as follows: Thursday 14th January 2010 Friday 15th January 2010 Monday 18th January 2010 Thursday 21st January 2010 Friday 22nd January 2010 Monday 25th January 2010 Thursday 28th January 2010 Friday 29th January 2010 Monday 1st February 2010 Thursday 4th February 2010 Press Conference The inquest is scheduled to conclude on 4th February 2010. It is proposed that a press conference will be held at the conclusion of the inquest, details of which will be announced shortly on www.anthonycollins.com. End

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