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  • English and Welsh Ombudsman set out the case for '... a proper public inquiry into the tragic death of Robbie Powell'

    Summary

    Robbie Powell, 10, from Ystradgynlais, Powys, died at Swansea's Morriston Hospital, of Addison's disease in 1990. Four months earlier Addison's disease had been suspected by paediatricians at this hospital, when an ACTH test was ordered but was not carried out.

    Although Robbie's GPs were informed of the suspicion of Addison's disease, the need for the ACTH test and that Robbie should be immediately admitted back to hospital, if he became unwell, this crucial and lifesaving information was not communicated to Robbie's parents.

    At the time of Robbie's death, the Swansea Coroner refused the Powells' request for an inquest claiming that the child had died of natural causes. However, the Powells secured a 'Fiat' [Court Order] from the Attorney General in 2000 and an inquest took place in 2004, fourteen years after Robbie died. The verdict was 'natural causes contributed by neglect' confirming that an inquest should have taken place in 1990.

    Since Robbie's death, his father Will Powell, has mounted a long campaign to get a public inquiry into Robbie's  case.

    Content

    In the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell.

    The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that Addison's disease had been suspected.

    The referral letter was not typed until after Robbie had already died and was backdated to the day following the consultation.

    In a statement after Robbie's death this GP stated:

    "An Addisonian crisis is precipitated by an intercurrent illness and the stress it induces."

    Dyfed-Powys Police investigated Robbie's death between 1994 and 1996 but asserted, supported by the Crown prosecution Service in Wales, that there was no evidence of crimes committed by the GPs who, incidentally, were retained by this police force as police surgeons.

    Following a complaint by Will Powell (Robbie's father) in 1998 against the Deputy Chief Constable of Dyfed-Powys Police, regarding the inadequacies of the criminal investigation, a second criminal investigation was agreed, which commenced in January 1999.

    As with the first criminal investigation, there was a gross failure to adequately investigate the criminality of the doctors. This resulted in Will Powell making a formal complaint against the Chief Constable of Dyfed-Powys Police in late 1999.

    This complaint against the Chief Constable resulted in Dyfed-Powys Police appointing an outside police force to review Robbie's case in 2000. Detective Chief Inspector Robert Poole [DCI Poole] from West Midlands Police was appointed.

    DCI Poole’s investigation report, entitled 'Operation Radiance', which was based on the documents provided to Dyfed Powys Police in March 1994, by Will Powell and his solicitor, was submitted to CPS York in March 2002. This report put forward 35 suggested criminal charges against five GPs and their medical secretary. The listed charges were:

    • gross negligence manslaughter
    • forgery
    • attempting to pervert the course of justice
    • conspiracy to pervert the course of justice.

    DCI Poole's investigation also resulted in a disciplinary inquiry by Avon & Somerset Constabulary into Will Powell's allegations of misconduct against Dyfed-Powys Police officers with regards to their two inept criminal investigations between 1994 and 2000. Dyfed-Powys Police was found to have been 'institutionally incompetent' but no police officer was made accountable.

    In April 2003, Will Powell met representatives from the CPS in London, who accepted there was sufficient evidence to prosecute two GPs and their secretary for forgery and perverting the course of justice. However, they would not prosecuted because of (1) the passage of time, which was caused by a decade of cover ups between 1990 and the appointment of DCI Poole in 2000, (2) Dyfed Powys Police had provided the GPs with a letter of immunity, and (3) the available evidence had been initially overlooked by the police and the CPS, between 1994 and 2000, for a variety of reasons. 

    Following a 2013 adjournment debate, in the House of Commons, the Director of Public Prosecutions subsequently agreed, in October 2014, that there would be an independent review of the decisions made by Crown Prosecution Service, in 2003, not to prosecute, when there was sufficient evidence to do so. The reviewing Queen's Counsels have been provided with a report, written by myself ( a healthcare IT professional, former head of IT in an NHS trust and clinician) on major anomalies in Robbie's Morriston Hospital computerised records, which were erased during the first criminal investigation between 1994 and 1996. The review has not been concluded six years on.

    The letter below (and also attached) from the English and Welsh Ombudsman was sent on 10 November 2020 sets out the case for a Public Inquiry.

    268863238_SupportfromtheEnglishandWelshHealthOmbudsment(2020).jpg.15e6f29c5e665694a7b516f7e8c60404.jpg

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    Here's a 2 minute video on the history and current status of Duty Of Candour in UK Healthcare, which I use in my teaching work.

    Comments welcome:

    #dutyofcandour

    #robbieslaw

    #TeamNHS

    #TeamPatient

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    Something happened this week which reminded me how important a public inquiry into the circumstances and aftermath following the death of Robbie Powell is for us all, and for patient safety in general.

    I watched the ITV docudrama 'The Pembrokeshire Murders'

    In this programme it was twice mentioned that Dyfed Powys Police had previously been found to be institutionally incompetent. In my opinion, the script implied (unintentionally) that it was the media who found the Dyfed Powys Police institutionally incompetent.  In fact it was an  inquiry into the handling of the Robbie Powell case by Avon and Somerset Police that made the finding of institutional incompetence. I was saddened to see this apparent misrepresentation.

    The Robbie Powell case is the landmark case on patent safety that too few people know about.

    Important patient safety learning was lost in the cover up after Robbie's Death. I agree with the English & Welsh Health Ombudsmen and support the call for a public inquiry.

    #robbieslaw 

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    I am pleased to see this landmark case on #dutyofcandour has finally been acknowledged by the Care Quality Commission. It now appears on their web page 'Background to the Duty of Candour' :

     

    Quote

     

    'Until 2014 there was no legal duty on care providers to share information with the people who had been harmed, or their families.

    The tragic case of Robbie Powell and the perseverance of his parents through the UK courts and then the European Court of Human Rights exposed the absence of this legal duty....'

     

     

    Source: https://www.cqc.org.uk/guidance-providers/all-services/duty-candour-background
     

    Will Powell & his wife sacraficed £300K compensation to expose the absence of a Legal Duty of Candour in the High Court in 1996, Court of Appeal in 1997, House of Lords in 1998 & the European Court on Human Rights in 2000.

    In 1999 the Health Select Committee recommended a Statutory Duty of Candour as a consequence of Robbie Powell's  1997 Court of Appeal ruling, which the Government ignored.

    #share4safety

    #patientsafety

    #robbieslaw

     

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    Edited by Steve Turner

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    I'm ashamed to say I didn't know all this but then it can be tough just getting my teeth cleaned some days.

    Steve, you've done some incredible work here and so has Will clearly. No small feat to get that Duty of Candour through but I understand now much better why that is insufficient and we absolutely need to bang the drum on this one.

    I remember my Dad getting investigated by GMC over false claims. It nearly destroyed him with stress but I know he wouldn't have had it any other way as Dad absolutely believed in accountability and I know how frustrated he would get over wrongdoing or stupidity. 

    I feel we need to follow up our Dark Jedi chat with another on Duty of Candour and highlight this loophole. We did actually cover it but I feel we really need to promote awareness of this issue further.

    Thanks for being a HCP with absolute integrity, genuine compassion and committed to this just cause.

    I'm sorry for your loss Will. If you read this, I'd like to thank you (and Steve) for making Duty of Candour happen, just need to fix that loophole next.

    We will get there, just needs the good eggs to work together and never give up

    Dom 😊

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