Select Committee on Health Minutes of Evidence


Memorandum by Mr William Powell

PROCEDURES RELATED TO ADVERSE CLINICAL INCIDENTS AND OUTCOMES IN MEDICAL CARE (ACI 101)

  This submission refers to the death of my 10-year-old son, Robert Darren Powell, and the failure of, inter alia, the appropriate NHS Authorities and the Government to impartially, honestly and thoroughly investigate Robert's death. It is a summary and therefore does not include every detail of my complaints.

  I have attached 11 Appendices at the end of this document.[2]

  In the light of my nine-year personal experiences with the NHS complaint procedures and in my advisory capacity to many others I am making a formal request to be interviewed by the Health Committee. I am the founder member of the Bereaved Parents Group [which instigated this Inquiry] and Sufferers of Iatrogenic Neglect "SIN". I have attached the objectives of SIN, which contains proposed changes to the NHS complaint procedures. I formally request that the Select Committee comments on SIN's objectives and fully considers them in any subsequent reccomendations [Appendix 1.="A-1"].

ROBERT DARREN POWELL

  Born—29 December 1979

  Died—17 April 1990—aged 10 years 4 months

  Cause—Addison's Disease—this is a treatable condition, however, if untreated, invariably results in death. The adrenal glands are destroyed and therefore cannot produce the corticosteriods that are paramount for survival.

RELEVANT MEDICAL HISTORY

  1980—Robert was registered with Dr Keith Hughes who is a senior partner and one of seven General Practitioners [GPs] at the Ystradgynlais Health Centre. The Powell family was also registered at the health centre at the material time under various GPs.

  1983—Robert was in contact with tuberculosis [TB] and given a BCG vaccination.

  1985—Further contact with TB and attended Neath Hospital with all family members. Robert was given the all clear, as was the family, and they were allocated five consecutive hospital numbers. Robert's number was 153819. These numbers and a record of this and the previous episode were placed in individual medical files and also entered into Neath Hospital's computer system, which was interlinked with local hospitals ie Morriston and Singleton. Please note that TB causes one in five cases of Addison's disease.

  1987—Robert's skin became much darker. This was more noticeable around the area of the elbows, neck, knuckles and knees. Unknown to the Powells, this was being caused by an overproduction of hormones [ie ACTH] from the pituitary gland as a consequence of adrenal failure [ie Addison's disease] and is a classical sympton which can precede any other symptom by up to 10 years. Please note that Robert's skin pigmentation and the contacts with TB, were not taken into consideration when Addison's disease was suspected in December 1989.

EVENTS LEADING TO THE DEATH OF ROBERT DARREN POWELL

1990

  Robert died of Addison's disease on 17 April 1990. This is a treatable condition which, if untreated, invariably results in death. Unknown to the Powells until after Robert's death, this disease had been suspected four months earlier when he had been an in-patient at Morrison Hospital. The test to confirm the diagnosis [ie an ACTH test] was requested by the hospital consultant, Dr Forbes, but never performed [the Powells were not informed of the necessity of the test]. The information regarding the suspicion of Addison's disease and the need for the test was communicated to the Ystradgynlais Health Centre [the health centre] with clear instructions to re-refer Robert immediately if he had a recurrence of the symtpoms which gave rise to the suspicion of this potentially fatal condition. Between the 2 and 17 April Robert was seen by five GPs from the health centre on seven separate occasions.

  2 April: Dr Elwyn Hughes saw Robert at the health centre in the presence of Mr Powell. He had a sore throat and jaw and was feeling unwell with vague symptons. Although Dr Hughes admitted Robert to hospital, by ambulance, the previous December, without a diagnosis, he failed to read the discharge letters confirming Addison's disease had been suspected and that Robert should be re-admitted if he had a recurrence of the symptons of this potentially fatal condition. Please note that the GPs accept that the early stage of Addisons disease presents vague symptoms. He said that he could find nothing wrong with Robert. Dr Hughes reassured Mr Powell who in turn reassured Mrs Powell.

  Please note that the GPs had been forwarded Mr Powell's complaint before they were asked to respond to the Powell's version of events.

  In response to the formal complaint Dr Hughes said that he diagnosed a viral illness and advised analgesics. However, no prescription was given notwithstanding the Powells were entitled to free prescriptions and Robert was under the age of 16 which also permitted him to free prescriptions. There is no mention of a viral illness in Dr Hughes' consultation note. Dr Hughes' evidence was accepted at the subsequent Medical Service Committee [MSC] hearing.

  6 April: Dr Nicola Flower saw Robert at the health centre in the presence of Mr Powell. Robert had been sent home from school unwell the previous day. Dr Flower said she could find nothing wrong with him and like Dr Hughes, failed to read the discharge letters. Dr Flower reassured Mr Powell who in turn reassured Mrs Powell.

  In response to the formal complaint Dr Flower said that she diagnosed a viral illness and advised calpol. Again, no prescription was given but the viral illness and calpol was recorded in the consultation note. It is alleged that, like the consultation note of the 17th April, this note was also written post-death to corraborate Dr Flower's untruthful statement.

  11 April: Dr Mike Williams saw Robert at the health centre in the presence of Mr & Mrs Powell. Although Mr Powell had communicated the earlier GPs' opinions [ie nothing wrong with Robert] to Mrs Powell, she wanted to be present at this consultation. Robert had vomited the night before, was weak and had obvious weight loss due to the fact he was not eating and the underlying problem of Addison's disease. Again,Dr Williams could not diagnose what was wrong with Robert. However, after reading the discharge letters, which alerted him to the supspicion of Addison's disease, he informed the Powells that he would refer Robert immediately back to the consultant at the hospital. Dioralyte was prescribed for the vomiting but Dr Williams did not give the Powells any advice if Robert deteriorated. In the light of the suspicion of Addison's disease and the fatal consequences if not treated promptly, it would appear that Dr Williams intended to contact the consultant that day.

  In response to the formal complaint Dr Williams stated, inter alia, "I was also reassured by the fact that Robert had not complained of vomiting with the knowledge that vomiting is a frequent occurrence in Addison's disease. Robert's complaint was one of vague malaise." The prescription for dioralyte was omitted from Dr Williams' statement as it clearly contradicted the absence of vomiting. Dr Williams said that he had diagnosed a viral illness and asserted that he had referred Robert back to the consultant. Please note that combined statement of all five GPs supported this untruth. However, as a result or Mr Powell's evidence, it was later accepted that the referral letter was typed after death and back dated and had not been sent.Dr Williams subsequently admitted that dioralyte had been prescribed but only after Mr Powell secured a copy of the prescription. Dr Williams' consultation note and the concocted referral letter also omits the prescription of dioralyte and suggests that they were fabricated, post-death, to corroborate his untruthful assertion that, a viral illness had been diagnosed and Robert had been vomiting. The above verbatim statement of Dr Williams confirms that if Robert had been vomiting, he would have referred him back to the hospital immediately. This clearly demonstrates the motive behind the denial of vomiting and mitigates Dr Williams' failure to refer Robert to hospital immediately. Please see Rhodri Morgan MP's letter of 9 November 1993 regarding his view of the prescription of dioralyte [A-8]. Please note that there are also 8 appendices in A-8.

  15 April: Following a request for a home visit, Mr & Mrs Powell took Robert to the Community Hospital, as instructed by Dr Boladz [senior partner]. Robert was so weak, at this stage; he couldn't walk unassisted and had to be carried into and out of the hospital. Dr Boladz suspected Glandular Fever, in the absence of any relevant symptoms and inappropriately prescribed amoxicillin. Please note that penicillin is not prescribed when a viral illness is suspected. Dr Boladz arranged for Robert to have blood tests on the 17 April, at the health centre. Robert's medical records were not available at this consultation and the Powells were not in a position to inform Dr Boladz of the suspicion of Addison's disease. However, it subsequently came to light that the discharge letters were addressed to Dr Boladz. It would appear that the crucial information contained within the discharge letters was not discussed with the doctors in the practice. This was a serious breakdown in communications as any doctor in the practice could see Robert, at any time, if he had a recurrence of the symptoms of Addison's disease and therefore should have been fully aware of the dangers of this potentially fatal condition. Sadly, this breakdown in communication contributed to Robert's death.

  In response the formal complaint Dr Boladz agreed with the Powells' evidence. However, his consultation note is a photocopy, which has been struck into Robert's notes post death. At the MSC hearing Dr Bodalz confirmed that the Powell's did not inform him that Drs Elwlyn Hughes, Flower and Williams had diagnosed a viral illness at the earlier consultations.

  16 April: Following a request by the Powells, Robert had a home visit from Dr Keith Hughes [senior partner]. Robert was deteriorating, losing weight and had been vomiting again. Dr Hughes said that Robert needed a blood sugar test but returned from his car saying that his test equipment was out of date. He agreed with Dr Boladz that Robert needed blood tests but unnecessarily delayed them to the 18th April. He stated that if Robert deteriorated or continued to vomit he would be admitted to hospital.

  In response to the formal complaint Dr Hughes agreed with the Powells' evidence and accepted that the Powells did not inform him that Drs Elwyn Hughes, Flower and Williams had diagnosed Robert as having a viral illness.

  17 April: Robert collapsed and fainted while being assisted to the toilet. The health centre was telephoned immediatley and Dr Flower arrived. On examination Robert's pupils were dilated and his lips were blue. However, Dr Flower stated that there was nothing seriously wrong with Robert and ignored the previous two week history and the advice of her senior partner the day before. [ie Robert should be admitted to hospital if he deteriorated]. Dr Flower made no diagnosis and prescribed a different medication. She then left with no further advice. By this time the Powells were frantic with worry and telephoned the hospital for advice. A staff nurse advised them to believe in the GP but if they were still concerned they should call her out again. The Powells were informed that they could not go directly to the ward without a referral letter from the GP.

  In response to the dormal complaint Dr Flower denied that Robert had been unconscious, that he had dilated pupils and blue lips.

  Robert complained of abdominal pain and the health centre was called again. Dr Flower arrived and again said there was nothing seriously wrong with Robert and refused hospital admission. Following a heated argument Dr Flower agreed to admit Robert to hospital to put the Powells' mind at rest. In the presence of Mr and Mrs Powell and Mr Powell's sister, Dr Flower threw the referral letter at Mr Powell and refused his request for an ambulance. On arrival to Morriston Hospital, Robert stopped breathing and never regained consciousness. Robert was declared dead two and a three quarter hours later.

  In response to the formal complaint Dr Flower again denied that on examination Robert had dilated pupils and blue lips. She also denied that an ambulance had been requested and that it had been refused. However, unknown to the Powells until six months after Roberts death, the hospital records confirmed, inter alia, that on arrival, Robert was peripherally shut down [no blood pressure]; had dilated pupils and central cyanosis [ie blue]. It is the opinion of medical experts that Robert would not have significantly deteriorated from the time he was examined by Dr Flower and the time he arrived at the hospital [ie 30 minutes]. Furthermore, forensic evidence has confirmed that Dr Flower's consultation notes were not written contemporaneously and were written post death.

POST DEATH EVENTS

  20 April: The post mortem confirmed that Robert died of Addison's disease. As this was a natural cause of death, the Powell's request for an inquest was refused. It later came to light that:

    (i)  In the light of the Powell's allegation of medical negligence the coroner failed to have preliminary inquiries. The coroner subsequently admitted that if gross medical negligence came to light at an inquest the cause of death would not be natural causes. "The more likely verdict would be accident or misadventure, or possibly in an extreme case, one of unlawful killing". However, when Mr Powell submitted a medical expert report [A-2] confirming gross medical negligence the coroner then stated, "In my view, that natural cause is not made unnatural by a failure of diagnosis and/or treatment on the part of the General Practitioners or Morriston Hospital." Please note that in the light of Professor Brook's report the health authority which admitted liability for Robert's death deny that Dr Forbes' negligence caused, or even contributed to, Robert's death;

    (ii)  The pathologist inappropriately performed the post mortem as the health authority, which subsequently admitted liability for Robert's death, employed her. This was a clear breach of the Coroner's Act;

    (iii)  The pathologist had access to Robert's hospital records during the course of the post mortem. However, she omitted from the report, inter alia, that Addison's disease had been suspected four months earlier; that Robert needed an ACTH test, which had not been performed; that Robert was seen several times by the GPs with nil significant and that the GPs had been informed of the suspicion of Addison's disease with clear instructions to re-refer the child to hospital if he had a recurrence of vomiting and abdominal pain;

    (iv)  The pathologist also misrepresented Robert's external appearance by stating; "Young male child who appeared normally nourished." There was no mention that Robert was yellow when he died and had skin pigmentation as a result of his condition. Several witnesses can confirm Robert's skin pigmentation before and post death. Please note that Robert's hospital notes confirmed he had lost 25 per cent of his body weight when he suffered an Addisonian Crisis four months earlier following a two day illness and that this weight was gained within five weeks of discharge. Furthermore, Robert's obvious weight loss was recorded six days before his death by the GPs. The pathologist conveniently failed to weigh Robert; and

    (v)  The pathologist discussed Robert's death with the consultant and Dr Keith Hughes before the post morterm result had been officially given to the coroner.

  On 20 April, Dr Keith Hughes also called at the Powells' home to discuss Robert's death and post-mortem. He accepted that Robert need not have died. Dr Hughes refused Mr Powell's request to have an investigation about the events leading to Robert's death. Mr Powell requested to see Robert's GP medical records and was devastated to learn, for the first time, that Addison's had been suspected, by the hospital consultant, and that Robert needed an ACTH test. The discharge letters wrongly asserted that the parents had been informed and there was a clear instruction for the GPs to re-refer Robert immediately to hospital if he had a recurrence of vomiting and abdominal pain. It was obvious at this stage that the GPs had failed Robert and they knew it.

  23 April: Mr Powell asked his neighbour, the Reverend Thomas, to witness and contemporaneously note the content of the discharge letters. Please see the Reverend Thomas' Affidavit [A-3]. In the presence of the Reverend Thomas, Dr Keith Hughes reiterated that Robert did not have to die.

  30 April: Mr Powell had no other option but to formally complain to Powys Family Practitioner Committee. This authority was renamed Family Health Service Authority [FHSA] in November 1990.

  25 May: The Powells met Dr Forbes at Morriston Hospital. Dr Forbes severely criticized the GPs for failing to comply with his instructions to re-refer Robert back to hospital. He actually stated, "You just can't trust anyone". Please note that there has been no hospital enquiry into Robert's death and it has been publicly stated that no individual doctor was to blame for Robert's death.

  1 June: Powys FHSA forwarded the complaint to West Glamorgan FHSA in order that the complaint be investigated "beyond the suspicion of bias"—this was because Dr Keith Hughes was apparently a member of Powys FHSA's Committee. Dr Hughes later denied this in the presence of the Community Health Council [CHC]. It subsequently came to light that Powys FHSA prejudiced the complaint by inappropriately sending Dr Keith Hughes the Powells' statements, on the same day as the complaint was sent to West Glamorgan FHSA. This was done with the knowledge that Dr Hughes had inappropiate custody of Robert's original GP records. This gave the GPs the opportunity to alter the medical records to corroborate their untruthful statements.

  Please note that Robert's original GP records, in compliance with the GP's terms and conditions of service, should have been, by no later than 17 May 1990, safely in the possession of Powys FHSA.

Part 3. Statutory Instrument 3-466 records 30 (c)

    "Within 14 days of being informed by the [Authority] of the death of a person on his list and in any case no later than one month of otherwise learning of such a death, forward the records relating to that person to the [Authority]."

  It subsequently came to light that the GPs not only had inappropriate custody of Robert's original medical records for over six months they also tried to conceal this impropriety. This deception involved the assistance of both Powys and West Glamorgan FHSAs by the following acts and/or omissions:

    (i)  Powys FHSA failed to secure the original GP records following the complaint regarding Robert's death when it was custom and practice to do so;

    (ii)  West Glamorgan FHSA also failed to request the original records on receipt of the complaint from Powys [ie 2 June 1990] notwithstanding it was subsequently admitted that the medical records were central to the investigation and complaint;

    (iii)  West Glamorgan FHSA again failed to secure the original records when Mr Powell informed them inadvertently, in September 1990, that they were inappropriately in the possession of the GPs;

    (iv)  When the GPs belatedly sent the original records to West Glamorgan FHSA they did not enclose a covering letter; and

    (v)  On receipt of the original records from the GPs, West Glamorgan FHSA did not (a) follow proper procedure by cipher date stamping the FP 111 folder on the date it was received and (b) failed to write the GPs acknowledging the receipt.

  Please note that had it not been for Mr Powell calling at the health centre, on the 22 November 1990, to inspect Robert's original GP records, and requesting a letter from Dr Boladz confirming they had been sent to West Glamorgan FHSA two weeks earlier, there would be no record whatsoever that the GPs had inappropriate custody of medical records for six months. As stated above, having custody of the original records for this period permitted the GPs to make omissions and additions to the medical records to corroborate their untruthful evidence at each stage of the investigation. The altering and fabrication of the medical records is supported by forensic evidence. Furthermore, why did the GPs breach their terms of service by keeping the original medical records when photostat copies would have served the same purpose, unless there was an ulterior motive [ie the omission and addition of documents prior to their disclosure to West Glamorgan FHSA].

  12 September: Mr Powell's request to West Glamorgan FHSA for a copy of Robert's GP records was refused. A request for the hospital records was also refused.

  22 September: Mr Powell received copies of the GP and hospital records as the GPs had introduced them as evidence. The original discharge documents had been removed and subsituted with less discriminating information. Mr Powell immediately telephoned both West Glamorgan FHSA and Health Authority and complained that the medical records did not contain the original discharge documents. [A-4].

  13 December: West Glamorgan FHSA's MSC investigated Mr Powell's complaint. The hearing was a whitewash from start to finish. The Chairman was rude, intimidating and refused Mr Powell the opportunity to establish the truth. In the light of cogent evidence the MSC, which included the Chairman, two GPs and two lay persons, accepted evidence from the respondent GPs that was clearly untruthful and failed to ask any pertinent questions regarding the conflicts in evidence. For example:

EVIDENCE REGARDING DR WILLIAMS' CONCOCTED REFERRAL LETTER

  1.  Mr Powell confirmed in his statement that Dr Williams had informed the Powells that Robert would be referred to hospital immediatley;

  2.  In response to Mr Powell's statement Dr Williams asserted in his statement of 20 July 1990 that he had referred Robert to hospital on 11 April—this was supported by a combined statement of all five GPs and Robert's referral to hospital was asserted on six separate occasions;

  3.  As a result of Mr Powell's and the Reverend Thomas' evidence it was eventually accepted in a statement dated 5 December 1990 [8 days before the MSC hearing], from the health centre's secretary, that the referral letter was not typed until after Robert's death and was back dated and not sent [A-5]. Please note that the content of the referral letter is also fabricated;


2   Appendices not printed. Back


 
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