Mills & Reeve represented Cambridgeshire Primary Care Trust at the recent inquest into the deaths of David Gray and Iris Edwards. Both patients were treated by Dr Ubani, a locum doctor from Germany who was working his first out of hours shift in this country. Dr Ubani was engaged by the PCT’s provider, Take Care Now

On 5 February, HM Coroner William Morris returned verdicts of unlawful killing in respect of David Gray – who was given a 10 times overdose of diamorphine - and natural causes in respect of Iris Edwards. He made a number of recommendations under Rule 43 of the Coroners Rules 1984 to the Secretary of State for Health concerning guidance that should be issued to PCTs.

These recommendations impact on both PCT contracts with out-of-hours (OOH) providers and PCT management of Medical Performers Lists. The key recommendations are:

  • Guidance should be issued to PCTs requiring them to risk assess every non-UK based doctor involved in OOH services care including an assessment of their experience in the NHS and whether the doctor gained accreditation in his home state via the acquired rights system or through examination.
  • There should be a nationally drawn up protocol for PCTs to follow when deciding whether to admit performers to the list to avoid regional variation in standards.
  • When considering applications to the Medical Performer’s List, PCTs should
    • check that GPs have sufficient knowledge of the English language;
    • establish an intention to deliver services in the PCT’s area;
    • check whether an applicant has failed to progress applications to other PCTs or whether any applications have been refused; and
    • ensure an appropriately qualified person is responsible for robustly applying regulation 6 of the Performer’s List regulations.
  • PCTs should ensure that the providers of OOH services remain responsible for assessing the quality of the OOH doctors they engage and they should not delegate that responsibility to any recruitment or locum agency.
  • PCTs should ensure that all contractual arrangements with OOH providers provide for a thorough induction procedure and robust clinical governance and risk management structures.
  • All contracts between PCTs and OOH providers should be regularly and robustly monitored to ensure quality service standards

A fuller Mills and Reeve briefing on the case can be accessed here .