An inquest into the death of 70-year-old grandfather David Gray from Cambridgeshire has heard how the locum doctor treating him appeared ‘tired, dithery and was muttering’ at the time he administered a fatal dose of diamorphine to Mr Gray.

The Daily Mail reports that 66-year-old locum Dr Daniel Urbani – originally from Nigeria but resident in Germany – was working on his first shift for a GP out-of-hours service provider when he injected Mr Gray with more than 10 times the usual amount of painkilling medication on 16 February, 2008.

Witnesses also said that, on the day of Mr Gray’s death, Dr Urbani was also seen ‘flicking’ through a medical book known as British National Formulary between callouts. The book gives information about dispensing medications, including prescription amounts and how to administer drugs to patients. When he gave the fatal dose to Mr Gray at around 4.45pm, Dr Urbani had had just three hours of sleep.

Mr Gray's partner Lynda Bubb said that her partner usually received 100mg of pethidine as pain relief for kidney stones. She called out-of-hours service SuffDoc – which has now been renamed Take Care Now – at around lunchtime and when Dr Urbani attended four hours later, she told him Mr Gray usually was given 100mg of pethidine.

Ms Bubb told the court Dr Urbani seemed ‘dithery’ and did not appear to speak much English – although she could understand everything that he did say. She told the inquest that, as she knew the callout doctors did not carry pethidine, she told Dr Urbani that Mr Gray would need diamorphine.

She said to her knowledge, Dr Urbani did not examine Mr Gray or check his blood pressure. He administered the drug and left two syringes on the windowsill before leaving.

When Ms Bubb later checked her partner half-an-hour after Dr Urbani had left, he appeared to be asleep. Some time later she realised that something was wrong, she told the inquest.

The emergency services were called and pronounced Mr Gray dead shortly after their arrival.

The Cambridgeshire North and East Coroner, William Morris, is also examining the death of an 86-year-old woman who was treated by Dr Urbani – who failed to send her to hospital even though she was suffering from an increased pulse rate and low blood pressure. Iris Edwards died from a heart attack the day after Dr Urbani had examined her.

The Care Quality Commission has launched an investigation into the care provided by Take Care Now. NHS Cambridgeshire stopped using the service four months before its contract expired.

Dr Urbani has chosen to be tried in Germany, following a move by Cambridgeshire police to arrest him for manslaughter should he return to the UK – he had been due to attend a hearing of the General Medical Council in London in January 2009, but failed to attend.

The prosecution in Germany means that he cannot stand trial for manslaughter in the UK and will face a charge of bodily harm caused by negligence that will carry a suspended sentence and a fine of £4,500.

He is not expected to attend the inquest – a non-jury hearing – in Cambridgeshire, which is expected to continue until the beginning of February.

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