A German doctor in Britain has been blamed for the death of a renal colic sufferer through painkiller overdose. Danile Ubani administered ten times the recommended dose of diamorphene, back in February 2008.
Renal colic is severe urinary system pain usually from a urinary stone, and pain relief medications are a common course of treatment.
Apparently the doctor had difficulty speaking English and out of some confusion the Nigerian-born German injected 70-year-old David Gray 100mg of diamorpbine when the recommended dose is only 10mg.
At an inquest into Mr Gray's death at Wisbech Magistrates' Court, independent medical consultant Dr Andrew Saywood criticised the doctor for apparently failing to examine his patient, not staying with him after administering the huge dose of diamorphine, and leaving used syringes and vials on the windowsill of his bedroom.
Dr Saywood said: "Diamorphine is a synthetic morphine otherwise known as heroin.
"It was unusual to use it to treat renal colic and Dr Ubani gave a dose of 100mg which is 10 times the recommended dose.
"This dose would almost certainly cause respiratory arrest. To leave a patient alone who has been given diamorphine is dangerous practice.
"Dr Ubani was incompetent in dealing with this patient and caused his death by an overdose of diamorphine.
"This level of error is catastrophic and no doctor should make such a mistake, not even a medical student or a nurse."
An expert in out-of-hours services, Dr Mark Reynolds, said sufficient checks had been carried out on Dr Ubani.
He told the hearing: "I believe this tragedy was ultimately caused by the differences in training and experience of Dr Ubani to that of doctors in the UK.
"The learning should be at a national level.
"These are very strong drugs and there's definitely a lack of understanding and familiarity with them, in my opinion, among some EU doctors."
The inquest heard Dr Ubani was given an induction pack containing advice that it would "almost never be appropriate" to give doses of diamorphine higher than 30mg.
Mr Gray was given 100mg in two injections. He died soon afterwards.
Dr Reynolds said: "Should Dr Ubani have consulted this pack, he would have been able to understand the appropriate dose."
The inquest also heard how European Union doctors can apply to join the UK medical register without further assessment being needed.
Dr Daniel Ubani, it transpires, had arrived in the UK only day before he visited David Gray at his home, only to administer the lethal dose.
He admitted in a letter to Mr Gray's sons later that he was not familiar with diamorphine, because it was not routinely prescribed by doctors in Germany.
His next patient after Gray, Iris Edwards, 86, inmate of a care home in Ely, also died of a heart attack.
And Ubani's misadventures go further. in April 2009, the German authorities gave Dr Ubani a nine-month prison sentence, suspended for two years, and he was ordered to pay a £4,500 fine for causing death by negligence, BBC reported.
An agency had supplied him to Take Care Now, the company which was running the NHS out-of-hours service in Cambridgeshire. The contract was terminated at the end of last year.
He continues to practise as a cosmetic surgeon in the west German town of Witten.
The inquest in Wisbech will examine the circumstances leading to the deaths of both Mr Gray and Ms Edwards.