'Even a student nurse knows a dosage that high is lethal'

When Dr Daniel Ubani arrived to make the fateful house call at David Gray's home in the village of Manea in Fenland, Cambridgeshire, he had, by his own admission, slept only a little and was "tired and lacked concentration".

For Gray, a 70-year-old former senior technical manager at British Aerospace, and Lynda Bubb, his partner with whom he had moved into the new property six or seven years previously, that information would have been vital. A confused Ubani – on his first shift as a locum for an out-of-hours GP service – was within a short time going to accidentally give him a fatally large dose of a dangerous drug.

Gray had had renal colic and kidney stones for many years, and, for a far shorter time, heart problems. He was sometimes in extreme pain and needed pain relief. Several times in recent years, Bubb, a 58-year-old civil servant, had called the out-of-hours medical service but "it was not a regular weekly or monthly thing", she told the Guardian.

"He tried to cope with the pain himself, if he could, because he did not want to get out-of-hours regularly involved. But he did get out and about. If you had seen him, you would have said he looked like a fit 70-year-old."

On that day in February last year, Gray had been in bed because the pain was so bad. "I rang Sufdoc [Suffolk Doctors On Call, which supplies doctors to Take Care Now, a separate company contracted by the NHS to provide the service] and then someone came," said Bubb.

That someone was Ubani. "I was there most of the time, although there were times I had come out of the room," Bubb added. The doctor went to the car "and came back with all the drugs". Bubb said she thought on-call services no longer carried pethidine (another painkiller) because of the Shipman case, adding: "David had said on this occasion they needed to come with diamorphine. I don't know about diamorphine. He had had it before. Doctors usually came in and gave it and went away again. You don't question what they are doing. I thought nothing of it."

Ubani is understood to have administered 100mg of diamorphine and 4mg of buscopan. Asked how long he had stayed, Bubb said: "It was not very long. He did what he had to do, wrote up something on a laptop. I don't think it would have been more than a quarter of an hour. " After the doctor left, she looked in on her partner. "I went upstairs to make sure David was comfortable. He had gone to sleep as far as I knew. It could have been half-an-hour or longer when I went up. I was worried he was not moving so I called the emergency services. The paramedics came and tried to resuscitate him. They eventually warned me to expect the worse. Probably, he had passed away before they arrived. I just couldn't believe it."

Members of Gray's family were becoming aware a horrendous mistake had been made. Stuart, one of Gray's four sons, a GP in the west Midlands, and Rory, a satellite engineer, began digging away to find out what happened. A letter to Stuart from a senior official at Take Care Now outlined events as they believed them.

Then, in the summer, Bubb and Stuart were astonished to be forwarded a letter from Ubani himself, dated 10 July 2008. In his "letter of apology and forgiveness", Ubani misspelled both Bubb's names, but went on to give a fulsome confession, in occasionally broken English.

With "a very heavy heart", Ubani conceded that "there is no amount of remorse, grief or explanation on my part" that could satisfy the family. "The circumstances arose from the confusion between the drugs pethidine and diamorphine, which was administered to a very high dosage, a drug I have not been conversant with, which we do not normally use here in Germany in call duty."

Ubani then detailed how, before his shift, he "under went a tremendous stress situation, flying in from Germany, taking a car hire to drive to Colchester to meet my Job Agency for instructions. From there driving to Ipswich, River Side Clinic for couching [sic], after which I still had to [find the way] to New Market Base, arriving there around 4am 16 Feb".

These journeys were very tortuous, involving driving on a different side of the road than in Germany and "not easily finding the directions" without a navigation system. "I could only have just about 3hrs rest before I started my shift," Ubani wrote. "My nerves were over stretched. I was too tired and lacked concentration and these factors played a major roole [sic] in the mistake that occurred. I have my own Practise [sic] in Germany as a GP and a surgeon since almost 22 years. In this time I have not had such fatal cases."

Asked by the Guardian about her reaction, Bubb said: "I was staggered. It wasn't something I expected. I don't know whether he felt I would feel better for receiving it. I still don't know how to put in words how I felt."

Stuart Gray said of the 100mg dose of diamorphine and from his experience of training in the UK: "Even a student nurse would have known that was lethal. It is used as pain relief in acute cardiac conditions at a maximum dose of 10mg."

Rory Gray said: "The deeper one delves into this, the more disturbing it all is. How can such people just fly over for the weekend and undergo nothing more than an induction the night before to assess patients? It makes me very angry."


Diamorphine is among the most dangerous of a class of drugs called opioids. It is, in effect, a cleaned-up version of heroin, and carries the same risk of overdose. Opioids are strong painkillers which are used in the NHS to relieve severe pain in a patient who has had an accident or who has cancer. History shows these drugs carry the risk of causing harm. Doctors are told to exercise caution when using them. Diamorphine is recommended in NHS guidelines for doctors who are working out of normal hours as the best medication to give a patient who has cardiac pain.

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