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A small price to pay for patient safety

I'm responding to your recent editorial about the lack of language testing in the wake of the Daniel Ubani case.

A small price to pay for patient safety

What I do not understand about the Ubani situation, and his use of a huge amount of diamorphine on an out-of-hours call, is this: was not Dr Ubani using a supply of drugs provided by the out-of-hours service? And if so, why on earth was there an ampoule of 100mg diamorphine available for him to use?

That sort of dosage has no place in out-of-hours work, so should not have been in the stock cupboard at all. Surely, there could be no situation in out-of-hours work where that sort of dose could be in any way justified. So why was it available?

From Dr Selwyn Goodacre
Woodville, Derbyshire

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