A patient who was given a fatal overdose by an "incompetent" overseas locum was unlawfully killed, a coroner has ruled.

The death of David Gray amounted to gross negligence and manslaughter, said Cambridgeshire North and East Coroner William Morris.

In a damning conclusion, the coroner described German doctor Daniel Ubani, who treated 70-year-old Mr Gray, as "incompetent and not of an acceptable standard".

He also made a string of recommendations to improve out-of-hours care, including the setting up of a database for foreign doctors working in the UK.

Mr Gray, who was suffering from renal colic, died after he was injected with 100mg of diamorphine, 10 times the recommended daily dose.

His son Stuart, who is a GP, welcomed the coroner's verdict.

"My father's tragic death happened because of Dr Ubani's actions, and because of serious failings within the Cambridgeshire Primary Care Trust and Take Care Now," he said.
We want to see him tried under UK law for his death but we also want safeguards put in place to prevent this happening again."

He added: "We call on the Health Secretary to introduce a UK proficiency test which EU doctors have to pass before being allowed to work in the UK, just as non-EU doctors have to currently."

Dr Paul Zollinger-Read, chief executive of NHS Cambridgeshire, admitted: "We accept that someone with Dr Ubani's qualifications and experience should not have been put in a position where he was able to make this type of mistake."

Mr Gray was treated by Dr Ubani at his home in Manea, Cambridgeshire, on February 16, 2008.

The inquest heard the locum was working on his first out-of-hours shift in Britain and had only arrived in the country the day before.

Mr Gray's partner Lynda Bubb told the hearing how the German doctor seemed "tired" and "dithery" during his visit.


Doctors must be accountable for their actions, and must not be able to escape justice by simply returning to their country of origin.

David Gray's son Stuart Gray

Ms Bubb said she called SuffDoc, which is part of the out-of-hours health care service Take Care Now, when Mr Gray was in severe pain.

She told the inquest that after the lethal dose was administered Mr Gray took Dr Ubani's hand and said "thank you".

Mr Gray was pronounced dead four hours later.

Two weeks later the doctor contacted authorities in Germany to say he had "made a mistake in England due to tiredness which resulted in a death".

Dr Ubani was charged in Germany with death by negligence over Mr Gray's death. He was given a nine-month suspended jail sentence and fined 5,000 euros.

The prosecution, which is allowed under German law, means he cannot be charged in the UK.