A coroner has issued a warning after the death of an ‘exhausted’ NHS doctor who overdosed after his ninth 13-hour shift in a row.
Dr. Naeem Ahmed was found slumped in a chair in the registration room of Poole Hospital, Dorset, on June 21, 2025, with two syringes and a half-empty bottle of Jameson whiskey nearby.
Dr. Ahmed, a consultant in anesthesia and pain medicine, had just completed his ninth 13-hour night shift in a row, on top of the extra hours he worked during the day.
During his last shift, the 50-year-old’s clinical decision-making was described as ‘flawless’, with concerns only raised after the shift when a doctor could not find him for the handover.
Dr. Ahmed, who also had a private practice, was later tragically found dead after being forced into the anesthetist’s waiting room. He was pronounced dead at the scene.
Toxicology tests later showed that he had taken the strong pain medication fentanyl. Alcohol was also detected at 44 mg per 100 ml of blood, about half the drink driving limit.
Now Dorset Senior Coroner Rachael Griffin has written a Prevention of Future Deaths Report outlining the dangers of overworked doctors.
Mrs. Griffin noted that there is no legal obligation for NHS doctors to inform their trusts of their private working patterns, or vice versa.
A coroner has issued a warning after Dr Naeem Ahmed overdosed after his ninth 13-hour shift in a row.
She also pointed out that NHS job planning and scheduling systems do not take into account the ‘accumulative workload on employers’.
As a result, the coroner said, it could lead to ‘consecutive periods of working without rest, which could endanger the lives of both NHS patients and doctors’.
Ms Griffin, whose report has been sent to the Secretary of State for Health and the Chief Executive of NHS England, said: ‘The investigation and coronial investigation found that Naeem died while working the 9th shift in a series of 11 night shifts for UHD (University Hospital Dorset Trust) which started on 12 June 2025.
‘In June 2025, on several occasions he carried out clinical work for more than one provider on the same calendar day, and on one occasion he carried out daytime work for an external provider before returning to work on a night shift for the Trust later the same day.
‘The research also found that trust systems for job planning, scheduling, appraisal and secondary employment operated independently and were not designed to provide an integrated view of employers’ timing, sequencing or cumulative workload, whether over short periods of time or over an annual cycle.’
She added: ‘While UHD has undertaken work to resolve this issue, I am concerned that this practice exists at other trusts in England and Wales and could lead to fatigue and fatal consequences for patients and doctors.’
In June, Ms. Griffin concluded that Dr. Ahmed died as a result of misadventure, finding that he had not intended to take his own life.
She noted that there was no evidence that his work pattern was a causal factor in his death and said he worked that way ‘by choice’.
Dr. Ahmed was found dead in the anesthetist’s waiting room at Poole Hospital, Dorset, with two syringes and a half-empty bottle of Jameson whiskey nearby
But the judicial inquiry heard how Dr. Ahmed started drinking and took fentanyl as a “mental crutch to calm his mind.”
His wife, Dr. Laura Ahmed, also theorized what effects a lack of sleep could have on her husband.
At the time of his death, Dr Ahmed was in private practice and had a flexible working pattern at the hospital, which required him to do a lot of ‘challenging’ work – mainly night shifts, long weekends and trauma lists.
This allowed him to travel to Pakistan several times a year to help his elderly parents, but his wife said the work pattern was “definitely starting to irritate him.”
The couple was married for 23 years and had three children together. She said he was kind, patient and detailed.
She said he drank alcohol outside of work, but that he wouldn’t drink if he had to work the next day.
She said: ‘He admitted he might have overbooked his two or three months. I think he was physically and mentally exhausted.”
Dr. Laura Ahmed added that the fact that her husband was using drugs and alcohol in hospital was ‘concerning’.
Dr. Guy Titley, director of anesthesia at the hospital, said Dr. Ahmed had a ‘unique work plan’ that allowed him to travel to Pakistan and the flexibility also suited the NHS Trust as it helped them fill gaps at difficult times such as Christmas and bank holiday weekends.
He said: ‘I encouraged Dr Ahmed to spread his flexible work over the year and tried to encourage him to take a more conventional approach, but he was convinced this suited him.
“We have agreed to review the situation if it changes.
‘This year he really wanted to work his hours so he could return to Pakistan in September. He volunteered for many shifts between April and June, which was questioned by the roster maker.
‘He was convinced that this working pattern was in his best interests.’
Dr. Titley received a number of cases from Dr. in the six months before his death. Ahmed reviewed.
He said: ‘There was no indication that his clinical work was at fault. During that last shift, Dr. Ahmed flawless. There were no episodes of concern. His clinical record was spotless.”
Dr. Hannah McPhee, an on-call consultant who worked with Dr. Ahmed on his last shift, was called in to assist in the early morning hours.
She said his decision-making was “as I would expect.”
Dr. McPhee said: “He showed good situational awareness. While we were waiting at ITU, I asked about his work plan and if it was working for him.
‘He said he didn’t think it was entirely a choice because he had children who needed him as well as elderly parents in Pakistan. He said he finds it difficult to work one or two night shifts and then return to the day shifts. He prefers to run a few. He sounded pragmatic.’
When she left, she said she had “no doubt that he expected to work the next night.”
Dr. Peter Wilson, chief medical officer at University Hospitals Dorset, also gave evidence about the independent review carried out following Dr’s death. Ahmed.
They reviewed the fentanyl inventory and could not find any missing doses.
He said the Trust’s policies around the provision of controlled drugs have now been strengthened, as have policies around secondary employment and flexible working.
They have introduced job scheduling consistency committees to review physicians’ work plans and quarterly wellness checks.
Dr. Wilson added that the death of Dr. Ahmed had ‘sent shockwaves through the entire associate professor community’.
He said: “Everyone I have spoken to has spoken of him as a highly respected and well-liked colleague. His death has caused enormous sadness.’
University Hospitals in Dorset at the time had a controlled drugs policy to ensure that medications were properly controlled and monitored, signed off and that any unadministered medications were then properly discarded and documented.
Neither the police nor the hospital could determine where Dr. Ahmed got the fentanyl from.
