An 'exhausted' NHS consultant died of drug and alcohol overdose in a hospital on-call room after his ninth 13-hour night shift in a row, an inquest has heard.

Dr Naeem Ahmed was discovered slumped in a chair at Poole Hospital, Dorset, with two syringes and a half-empty bottle of Jameson whiskey nearby.

During his final night shift, on June 21 2025, the 50-year-old consultant's clinical decision making was 'faultless' and concerns were only raised after his shift had finished and a doctor could not find him for the handover.

The doctor, who had finished his ninth of 11 shifts in a row, was then tragically found dead after entry was forced into the anaesthetist's on-call room.    

Toxicology tests later showed he had taken the strong pain medication fentanyl, although the level in his blood was said to have been low.

Alcohol was also detected but only 44mg per 100ml of blood, about half the drink drive limit.

But Dr Patrick Waugh said the combined use has the potential to exacerbate any toxicity and he believed that was Dr Ahmed's cause of death.

Dorset coroner Rachael Griffin concluded today that Dr Ahmed died as a result of misadventure.

She said she was satisfied he did not intend to take his life and had plans for the future.

Mrs Griffin said there was no evidence Dr Ahmed's working pattern was a causal factor in his death and noted it was his 'choice' to work that way.

But she did acknowledge that Dr Ahmed's death raised national concerns about NHS doctors working extra hours in the private sector and not having to declare those to their employers.

The inquest heard that, throughout Dr Ahmed's 17 years at the hospital, his record was 'blemish-free' and his colleagues who interacted with him on his final shift said he appeared his normal self and nothing caused concerns.

His wife Dr Laura Ahmed described him as 'fit and healthy', a regular gym goer who loved mountain climbing in his free time.

He climbed Kilimanjaro with his son in July 2024 and had planned a trip to Mount Elbrus, in the Caucasus Mountains, in October 2025 before he died.

The inquest in Bournemouth heard Dr Ahmed was from Pakistan and had studied registrar training at Oxford and a pain fellowship in London.

He was appointed as an anaesthesia and pain medicine consultant at Poole Hospital in 2008.

At the time of his death he had a private practice and had a flexible work pattern at the hospital that involved doing 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 get to him'.

The couple had been married 23 years and had three children together. She said he was kind, patient and detail orientated.

She said he drank alcohol away from work as a 'mental crutch to calm his mind' but said he would not drink if he had work the next day.

According to Dr Laura Ahmed, her husband had also been looking on YouTube for videos on reducing drinking.

She said: 'He rarely lost a patient, but if he did it really affected him. He didn't like to fail and was extremely careful with his patients.

'He was brought up in a culture where discussing mental health is highly stigmatised and was in a speciality that encourages the same - compartmentalise, move on and never face the pain.

'He admitted to having perhaps overbooked his two or three months, I think he was exhausted, physically and mentally.'

Dr Laura Ahmed added that the fact her husband used drugs and alcohol in the hospital was 'concerning'.

'I wonder about the impact his sleep deprivation had on him,' she said.

Dr Guy Titley, anaesthetic director at the hospital, said Dr Ahmed had a 'unique job plan' which allowed him to travel to Pakistan and the flexibility also suited the NHS trust as it helped them fill gaps at awkward times, like 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 adamant it suited him.

'We agreed to review the situation if it changed.

'This year he was very keen to work through his hours so he could return to Pakistan in September. He volunteered for many shifts between April to June, which was queried by the rota maker.

'He was adamant this pattern of work was in his best interest.'

Dr Titley reviewed a number of Dr Ahmed's cases over the six months before his death.

He added: 'There were no indications his clinical work was at fault. On that last shift Dr Ahmed's clinical decision making was faultless. There were no episodes of concern. His clinical record was blemish free.'

Dr Hannah McPhee, an on-call consultant who worked with Dr Ahmed on his final shift, was called in to assist in the early hours of the morning.

She said his decision-making was 'as I would expect'.

'He showed good situational awareness. Whilst we were waiting for ITU I asked about his job plan and whether it was working for him,' said Dr McPhee.

'He said he did not feel it was entirely a choice as he had children who needed him as well as elderly parents in Pakistan. He said he finds it hard to do one or two night shifts and then return to days, he prefers to do a run of them. He sounded pragmatic.'

When she left she said she had 'no doubt he expected to work the following night'.

The inquest heard there was nothing to indicate Dr Ahmed had accessed the drugs from the hospital.

At the conclusion of the hearing, Mrs Griffin said: 'There is no legal requirement for doctors to disclose private work to NHS colleagues, as in the time and shifts they work, or NHS work to private colleagues.

'That could mean doctors are working beyond what is recommended in working time directives. That could compromise their own well being, but also patients and the wider public as a whole.

'I am aware of the concerns his family and friends have raised around the fact Naeem had worked a number of shifts in the lead up to his death.

'There is no evidence that in the lead up to his death that he was tired. It was not commented at all by those who had contact with him. It appears he was alert, undertook his role as required, there was no concern regarding his ability to work.'

She added that there was no evidence that his working patterns were a 'causal factor in his death'.  

Mrs Griffin continued: 'Fentanyl is a potent opioid. Such a substance can have a more significant effect when a person does not have a tolerance to the drug.

'Naeem was known to use tramadol but there is no evidence before me he had used fentanyl before, therefore from the evidence had no tolerance to that drug.'

Dr Peter Wilson, chief medical officer at University Hospitals Dorset, gave evidence about the independent review carried out after Dr Ahmed's death.

They reviewed the fentanyl stock and could not find any missing doses.

He said they have strengthened the trust's policies around the dispensing of controlled drugs as well as the policies around secondary employment and flexible working.

They have introduced job planning consistency panels to review doctors' work plans and three-monthly well-being checks.

He said Dr Ahmed's death had 'sent shockwaves throughout UHD community'.

He added: 'Everyone I have spoken to has talked about him as a well respected and well liked colleague. His death has caused huge heartache.'

University Hospitals Dorset had a controlled drugs policy at the time to ensure drugs are checked and monitored properly, signed out and any not administered are then disposed of properly and documented.

Neither the police nor the hospital could establish where Dr Ahmed got the fentanyl from.