Safer out of hours primary care

BMJ 2010; 340 doi: (Published 22 June 2010) Cite this as: BMJ 2010;340:c3194
  1. Paul A Cosford, director of public health,
  2. Justyn M Thomas, clinical adviser
  1. 1NHS East of England, Fulbourn, Cambridge CB21 5XB
  1. Correspondence to: P A Cosford paul.cosford{at}
  • Accepted 10 June 2010

The death of a patient given an overdose of diamorphine by an out of hours doctor has raised questions about out of hours services. Paul Cosford and Justyn Thomas argue that wide ranging changes are required

On rare occasions single catastrophic errors rightly lead to a complete review of a healthcare service. One such case is the death of David Gray, who was wrongly injected with 100 mg diamorphine by Daniel Ubani, a doctor based in Germany and providing out of hours primary care in Cambridgeshire. Dr Ubani had never worked in the United Kingdom, did not practise primary care in Germany, and was not familiar with local health care or with diamorphine. Yet he could fly in on Friday evening and work unsupervised on Saturday without routine access to patient notes.

Several investigations have followed,1 2 and the Care Quality Commission’s final report is due shortly. The recommendations so far aim to improve safeguards to ensure the competence of out of hours doctors and strengthen existing quality standards (table). However, we believe that wider changes to out of hours primary care are needed to systematically ensure quality and safety. The medical profession has a duty to lead these changes.

View this table:

Observations and recommendations on out of hours care from coroner’s report, Care Quality Commission interim report1 and national report2

The incident

David Gray died on a Saturday afternoon, while Dr Ubani was working for an independent out of hours service provided under contract to Cambridgeshire Primary Care Trust (PCT). This arrangement has been common in England since 2004, when general practitioners were allowed to transfer responsibility for out of hours care to PCTs.3

The direct cause of death was the injection of 100 mg diamorphine, which the coroner deemed to be gross negligence manslaughter. He acknowledged mitigating …

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