May 11, 2009 | Mark Paradies

Monday Accident and Lessons NOT Learned – Doctor’s Mistake Kills Patient in UK – Now What?

Dr. Daniel Ubani made a mistake. No doubt about it, he injected a patient with a fatal dose of a pain killer while making a house call. (Yes – they still do these in the UK.) David Gray, pictured below, died from the error.


Dr. Ubani was NOT intentionally trying to kill the patient (this wasn’t a premeditated homicide).

What do we do next?

Criminal prosecution!

Will this improve the system? You tell me…

The UK Guardian reported on the sentinel event. Read about the political response here:

There’s more information in this article:

Read the Doctor’s apology letter to the family here:

Hear the radio story here:

One year later, I’m not sure there’s been action to fix “the system.” One person interviewed did say that they had removed the 100 mg bottles of diamorphine from the bags that doctors carry on house calls.

But have they addressed fatigue? The language issues? Doctor qualifications? What about the reasons why the patient hadn’t been treated for the kidney stones so that he wasn’t in pain (and didn’t require a house call)? No mention is made of any of these issues.

Instead, they are arguing about whether a criminal prosecution in Germany is adequate or if the Doctor should have been prosecuted in the UK.

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