Fatal flaws
The tragic death of 10-year-old Robert Powell
could have been prevented. Nick Davies unravels a shocking story of
medical negligence, cynicism and bureaucratic failure
Nick
Davies
Wednesday January 4,
2006
Guardian http://society.guardian.co.uk/health/story/0,,1677104,00.html
Fifteen years ago,
Will Powell saw his 10-year-old son die. Within days, he began to
suspect that doctors who had looked after the boy had been
negligent. He filed a complaint. Within months, he began to suspect
that somebody was tampering with his son's medical records. He filed
more complaints, and spent 15 years fighting for the truth. Now,
finally, he has it - and he was right.
During those 15 years, he
turned for help to the state - to the coroner and the local health
authority, then to the Welsh Office and the parliamentary ombudsman,
to the local police, the Crown Prosecution Service (CPS) and finally
to an outside police force and the Independent Police Complaints
Commission. They all let him down - guilty variously of indolence,
indifference, cynicism, favouritism and sheer incompetence. Now the
state that failed him is denying him the public inquiry that might
expose the depths of its weakness.
Before he came to power,
Wales's first minister, Rhodri Morgan, repeatedly supported Powell,
accepting that the case had to be investigated because the systemic
failure that Powell was uncovering was likely to be afflicting
numerous other UK citizens who lacked his tenacity to expose it. And
yet, since he has gained office and has had the power to establish
an inquiry, Morgan has delayed and prevaricated.
Robert
Darren Powell died on April 17 1990 of Addison's disease, a rare
illness that stops the adrenal glands pumping vital hormones. Four
months before his death, in December 1989, he had suffered a bout of
stomach pain and vomiting that was so bad he was admitted to
Morriston hospital, Swansea, where he recovered on a drip. His
parents were told that the problem was gastroenteritis.
Years of pressure
It has
since been revealed that the senior paediatrician at the hospital,
William Forbes, suspected at that time that Robert was suffering
from Addison's disease, but failed to tell his parents and failed to
conduct the adrenocorticotropin hormone (ACTH) test that could have
confirmed the diagnosis. After years of pressure from Powell, the
crown prosecution service finally dealt with the case and concluded
that Forbes had been negligent: "It is undoubtedly true that an ACTH
test performed in January would almost certainly have saved Robbie's
life."
On April 1 1990, Robert fell ill again and, over the
next two-and-a-half weeks, as he suffered from vomiting, weight loss
and stomach pains, he was seen seven times by five GPs in the local
surgery in Ystradgynlais, near Swansea. It has since been revealed
that four of those GPs never read his notes: they did not see each
other's diagnoses, nor the record of Robert's accumulating symptoms
nor - crucially - the letters from the hospital warning that he
might be suffering from an adrenal problem. None of the GPs
performed a blood test or took Robert's blood pressure. One tried to
test his blood sugar but found his kit was out of date. None
recognised that they were dealing with a very sick boy in need of an
urgent transfer to hospital.
On April 11, an ailing Robert
was seen by Mike Williams, the only GP who did read the notes. He
too failed to tell Robert's parents of the suspected adrenal
problem. Williams agreed to refer the boy back to the consultant at
Morriston hospital. It has since been revealed that he failed to do
so for nine days, by which time the boy was already dead. The
belated CPS report concluded that Williams had been negligent: "The
failure to refer immediately was clearly a bad mistake."
Robert continued to decline over the Easter weekend. On
April 15 and 16, he was seen by doctors Paul Boladz and Keith
Hughes. The boy had obviously lost weight and was so weak that he
had to be carried in and out of the surgery, and yet neither doctor
thought to send him to hospital. The CPS eventually concluded that
Boladz had been negligent and "should have made an immediate
referral to hospital, and there is no doubt that such a referral
would have saved Robbie's life". And, in relation to the following
day, that Hughes too had been negligent: "Robbie would have survived
if admitted to hospital at this point."
On April 17, at
about three in the afternoon, Robert collapsed at home. GP Nicola
Flower visited, diagnosed a throat infection that had gone to his
chest, and refused to send him to hospital. At 5.30pm, with the boy
complaining of stomach pains, Flower returned, refused again to send
him to hospital, had an argument with Powell, relented, scribbled a
referral note and walked angrily out of the house, leaving Robert's
parents to drive their limp son to Swansea. When they arrived at
Morriston hospital, some 30 minutes later, staff immediately called
the crash team. They subsequently said that, on arrival, Robert was
"desperately ill and close to death" and "looked like someone from a
concentration camp." The boy died as they tried to revive him.
The CPS report concluded that on both of her visits that
day, Flower had been grossly negligent: "At both times, the proper
course of action was an emergency referral to hospital, and there is
clear evidence that the risk of Robbie dying would have been obvious
to any reasonably competent GP... She failed to recognise a
seriously ill child who needed immediate hospitalisation."
Robert's parents knew nothing of this negligence until,
three days after Robert's death, Powell persuaded one of the GPs to
let him look at his son's file and there, to his amazement, he saw
two letters that showed the hospital had suspected an adrenal
problem 12 weeks earlier - but nobody had done anything about it.
Realising the importance of this, Powell arranged for a local vicar
to witness the file's contents and lodged a formal complaint of
negligence with the local family health service authority.
Seven months later, Powell was formally served with the
paperwork in the case - and was alarmed to find that one letter that
he recalled, and that the vicar had witnessed, was simply not there;
and that the second letter was of a different size and far less
emphatic in its warning than the one he and the vicar remembered.
Powell was sure somebody had tampered with the file. The doctors
have always denied this and, to this day, there is no final proof of
what really happened.
Backdated letter
However, evidence has since emerged that two of
the GPs did forge some paperwork. Having said that he would refer
Robert to the hospital consultant, Dr Mike Williams failed to get
the referral letter typed until three days after the boy was dead.
The letter was backdated by eight days, sealed in an envelope and
addressed to the hospital. Somebody then tore it open and placed it
in the file, thus giving the impression that it had been typed on
time but had missed the post. The truth emerged only because the
secretary who typed the letter turned out to have been on holiday
all through the week when it was supposed to have been written.
The CPS eventually concluded that there was evidence that
Williams and his secretary, Linda Sims, were both guilty of forgery,
and evidence that Williams was also guilty of conspiring to pervert
the course of justice. The file served on Powell also contained
Flower's notes of her two visits to Robert on the day he died. These
recorded none of the symptoms of a dying boy. Instead, she claimed
he was "fully conscious and oriented", thus supporting her refusal
to send him to hospital. As a result of scientific tests, it has
since been revealed that these notes were written some eight weeks
after the event. The CPS eventually concluded that there was
evidence Flower was guilty of forgery and attempting to pervert the
course of justice.
Back in 1990, Powell turned for help to
the West Glamorgan family health service authority, which failed to
detect a single example of negligence or forgery by any of the
doctors. He went to the Swansea coroner, JR Morgan, who refused to
hold an inquest. He appealed to the Welsh Office, which opened a
hearing that collapsed in chaos when Powell discovered that Robert's
medical file suddenly included new paperwork. He spent three years
trying to persuade the Welsh Office to admit that this file had been
in its possession when the extra paperwork was added. The then
secretary of state for Wales, John Redwood, personally denied this
in writing; his successor, William Hague, was eventually forced to
admit this was false.
Powell went to the parliamentary
ombudsman and the Welsh health ombudsman, who spent seven years
refusing to take up the case before finally investigating and
establishing that the Welsh Office was guilty of maladministration.
Powell used the Data Protection Act to uncover internal paperwork
from the ombudsman's office that revealed that, from the start,
officials had set out to dismiss his complaints and had repeatedly
described him in insulting terms. In October 2004, some 14 years
after Powell first asked for help, the new parliamentary ombudsman,
Ann Abraham, apologised in writing for the "deplorable lack of
sensitivity and understanding by those concerned".
Powell
sued, and in May 1996 the health authority admitted negligence at
the hospital. A separate case against the GPs foundered when the
doctors argued that they had no legal duty to tell parents the truth
about a child's death. Powell took the issue to the European Court
of Human Rights, which was forced to agree that "as the law stands
now, doctors have no duty to give parents of a child who died as a
result of their negligence a truthful account of the circumstances
of the death, nor even to refrain from deliberately falsifying
records".
In March 1994, Powell turned to his local Dyfed
Powys police. It conducted two inquiries and failed to uncover any
evidence of any wrongdoing. The local CPS assured Powell that "no
stone had been left unturned" by the police force, which wrote to
the GPs' solicitors to say that no action would be taken.
In
April 2000, after intense lobbying from Powell, Dyfed Powys police
agreed to invite an independent officer from another force to review
its work. Detective Chief Inspector Bob Poole, then of West Midlands
police, launched Operation Radiance, which duly uncovered evidence
against the doctors, variously of negligence, gross negligence,
forgery and conspiracy to pervert the course of justice. How had
Dyfed Powys police, in its two inquiries, failed to uncover any of
this?
It has since been revealed that whereas Operation
Radiance recorded more than 100 sworn statements under section 9 of
the Criminal Justice Act, Dyfed Powys officers recorded none at all
- not even from Powell and his wife. Since no prosecution can take
place without these section 9 statements, it is unclear how the CPS
was in a position to decide to bring no charges, let alone to tell
Powell that no further police work was needed.
It has since
been revealed, too, that whereas Operation Radiance sent the CPS
statements from a collection of experts, Dyfed Powys sent none; that
whereas Radiance sent Robert's medical files for scientific
analysis, which disclosed forgery, Dyfed Powys acquired no such
analysis; that, although Powell had given Dyfed Powys his own
expert's analysis, which suggested forgery in Flower's notes, it did
not pass this on to the CPS on the grounds that it thought it must
be confidential.
Operation Radiance found scientific
evidence of Flower's forgery and took a formal statement from her
about it; Dyfed Powys never spoke to her. Radiance explored the
backdated referral letter and took a statement from a junior
secretary in the GP practice who said she had been pressured to
claim that she had typed the letter in the absence of the normal
secretary, who had been on holiday; Dyfed Powys did speak to her but
never got this information out of her. Radiance took formal
statements from staff at Morriston hospital, whose account of
Robert's condition on arrival showed that Flower had recorded false
details in her notes; Dyfed Powys never spoke to them.
Avon
and Somerset police was called in to investigate Dyfed Powys'
failure. It produced a damning report in which it said the Welsh
force was guilty of "institutional incompetence". It found that
Dyfed Powys "failed to investigate professionally, efficiently and
effectively the circumstances surrounding and subsequent to the
death of Robert Powell ... The criminal investigations were badly
managed by senior detectives within Dyfed Powys police. The
complainant did not receive an adequate quality of service. There
was an apparent failure to grasp the investigation. It was
insensitive to the issues surrounding the death of Robert Powell ...
There has been an organisational failure to address concerns
articulated by William Powell".
‘Police
Failure’
But that was
not the end of the police failure. Avon and Somerset failed to do
its job properly. It found clear evidence of failure by Dyfed Powys
but never attempted to discover whether this was the result of
incompetence or deliberate conspiracy. There were raw and untested
allegations that the GPs were friends with senior detectives in the
area. It is a fact that the GPs worked as police surgeons, although
that does not mean they knew the detectives in their case.
The Guardian has established that the paths of the dominant
partner in the GPs' practice, Keith Hughes, and the then head of
Dyfed Powys CID, Jeff Thomas, have crossed: their parents lived
within 10 minutes' walk of each other, in Llanelli, when the two men
were born; the two men played rugby for their respective schools in
Llanelli and Ammanford at a time when the schools played against
each other; both men played for Welsh juvenile teams and, for
example, played in the same game on March 3 1967, when Keith Hughes
captained the Welsh Secondary Schools team against Welsh Youth, for
whom Jeff Thomas played No 8. But this does not mean that the two
men knew each other; and they insist that they have never met. The
point is that Avon and Somerset never attempted to find out.
Despite its unusual conclusion of institutional
incompetence, no finding against any individual officer was ever
made. The Police Complaints Authority (PCA), which was supervising
Avon and Somerset's inquiry, allowed it to be cut short, apparently
without protest.
The confusion over Avon and Somerset's
behaviour is aggravated by the fact that the chief constable of
Dyfed Powys, Terry Grange, had himself spent years working for them
and risen to become their deputy chief. Thus, his former colleagues
were investigating his current staff. It is quite possible that Avon
and Somerset were called in for the entirely benign reason that,
since they knew Grange, they would be more willing than other forces
to lend him officers who were busy with their own inquiries.
All this police activity came to nothing. Finally confronted
with the results of an effective police inquiry, through Operation
Radiance, the CPS in April 2003 agreed that there was evidence that
various doctors had been negligent or grossly negligent and/or
involved in forgery and perversion of the course of justice - but
concluded that none of them should be prosecuted because too much
time had passed.
Furthermore, the CPS stated, Dyfed Powys
police had made matters more difficult by writing to the GPs'
solicitor with an unqualified assurance that no action would be
taken against them. Since these problems were the direct result of
failure by the police and the CPS themselves, Powell found that
difficult to accept. He complained to the CPS, but it investigated
itself and concluded that it had done nothing wrong.
Powell
fights on. With the support of the attorney general, he forced the
Swansea coroner to hold an inquest. This was transferred to
neighbouring Pembrokeshire coroner Michael Howells, who proceeded to
rule that he would hear no evidence into anything that had happened
after Robert's death. This meant Powell was not allowed to show that
some of his son's medical records had been forged, which meant the
whole case was presented to the coroner's jury on a distorted basis.
Nonetheless, on April 30 2004, a jury found that Robert's death had
been aggravated by neglect.
The state continues to fail.
After the inquest, Powell filed a formal complaint against the
doctors with the General Medical Council (GMC); two years and 10
months later, it has taken no action. Dyfed Powys police promised to
give Powell a copy of the report by Avon and Somerset police; nearly
three years later, it has failed to hand it over. Dyfed Powys police
also promised to provide paperwork to the GMC; it has offered a
series of excuses and has failed to provide it. The new Independent
Police Complaints Commission recorded a complaint from Powell; 19
months later, despite repeated promises of a swift response, it has
failed to come up with anything.
'Deliberate
cover-up'
In December 1995, in opposition, Morgan
wrote to the then secretary of state for Wales, William Hague,
referring to "what is, at first sight anyway, one of the worst cases
of maladministration or deliberate cover-up that may have stained
the record of the Welsh Office in its 30-years-plus history". In a
television interview in December 1996, he said: "I think the history
of the Powell case is so serious now, in terms of the cover-up that
was involved afterwards, that I think nothing less than an
independent inquiry is probably ever going to really get to the
truth."
Powell's campaign for a public inquiry has been
supported by the children's commissioner for Wales, the new
parliamentary ombudsman and the Conservative leader in the Welsh
assembly, Nick Bourne. Morgan, however, now first minister, has
refused to make a decision - apparently acting under advice from the
same Welsh Office that stands to be criticised by the inquiry.
In 2000, when the coroner finally agreed to hold an inquest,
Morgan said he would have to wait for its result. Three years later,
with the inquest complete, he said he would have to consider its
verdict. Twenty-one months later, Morgan has still failed to make a
decision.
Nick Davies
Wednesday January 4,
2006
Guardian http://society.guardian.co.uk/health/story/0,,1677104,00.html
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Write
to Rhodri Morgan at this address:
National Assembly
for Wales
Cardiff Bay
Cardiff CF99 1NA
To e-mail Rhodri Morgan
as First Minister for Wales: rhodri.morgan@wales.gsi.gov.uk
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Here
is a comment from a mother who has written into Rhodri Morgan, First
Minister for Wales.
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Amongst all the other
things in this article, this is by far the most upsetting Robbie
"looked like someone from a concentration camp." For God's sake how
could they have done this and then lie-worse still the ECHR have
ruled that in cases such as this the doctors do not owe a duty to
tell parents how their children die-in other words doctors can lie
and it's perfectly legal to do so.
If parents had allowed a
child to die by not taking them to a hospital to be treated do you
think that they would be free? If parents had conspired to pervert
the course of justice do you think they would have avoided arrest?
If parents had forged records do you think they wouldn't have been
questioned?
The bottom line here is this, it isn't
institutional incompetence-it is corrupt and morally reprehensible
that not one doctor or any other official has been held accountable
for the death of Robbie and 15 years on Will and Diane still haven't
had justice for their son, I know Will, his dignity shines through
all he does, this isn't a pursuit of professionals driven by
revenge, all Will has ever done is to try and get to the bottom of
why his son was allowed to die the horrible death he did, this
wasn't a child killed instantly by a drink driver, this was a child
that suffered before he died and he suffered whilst everyone looked
the other way. His death cannot be in vain. Because this could
happen to every parent, none of us are exempt from the litany of
mistakes made in this case.
Rhodri Morgan is a coward-he
should keep his promise to the Powell’s and whether there has been
an abuse of process or not, the medics in this case should face a
jury and the public should decide if what they did warrants
punishment-after all Will, Diane and their surviving children have a
life sentence, nothing will bring Robbie back so the very least we,
the public and parents should do is to support Will in any way we
can to get he and his family justice and hopefully some
peace.
A
lady from the Midlands has sent the
following letter to Rhodri Morgan, the First Minister for
Wales:
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Dear Mr
Morgan
I read
today's piece in the Guardian with a growing sense of despair and
incredulity.
It is abundantly
clear that the institutional failings of the police and the CPS are
matters that need to be addressed urgently.
As a member of the voting public, whose adult
children reside in Wales, could you please
explain to me why it is you have chosen not to honour the
undertakings that you made to Mr Powell?
I would like to put to you and the Attorney General
these questions and ask that somebody answers them.
There was no evidence that
Angela Cannings had killed her children except a theory postulated
by a now discredited paediatrician, yet she found herself being
tried and then subsequently convicted for a crime that never was
with absolutely no cogent evidence to support such a prosecution.
How is it then that despite the
proven forgery of medical records relating to Robbie Powell's death,
despite clear evidence of a conspiracy to pervert the course of
justice and gross criminal negligence, not one member of the medical
profession has been prosecuted in this case?
If parents/carers failed to take a seriously ill
child to hospital in order for it to be treated they would be
arrested and charged, if they then went onto conspire with others to
cover up their negligence, they and the others would be charged with
those offences. Is the establishment sending out the message that
when a child's death involves the medical profession that they are
above the law?
It is only right
and just that there is not only a public inquiry to ensure that
there is accountability, but more importantly so that the medical
profession understand that the public will not and do not condone
their behaviour.
Secondly as the
new laws relating to double jeopardy are now in place, I would
expect the immediate prosecution of all those involved in conspiring
to hide the gross criminal negligence that resulted in the death of
Robbie Powell.
We have a right
to be protected from public servants who are now deemed to be above
the law, this case highlights the fact that there is disparity in
our criminal justice system-one that ultimately will lead to further
deaths-doctors owe parents no duty of care and furthermore can
commit crimes with impunity.
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Write
to Rhodri Morgan at this address:
National Assembly
for Wales
Cardiff Bay
Cardiff CF99 1NA
To e-mail Rhodri Morgan
as First Minister for Wales: rhodri.morgan@wales.gsi.gov.uk
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Best
Regards
L.Bevan
Parents4Protest
Wales/Cymru
www.parents4protest.co.uk
Tel: 01639
620567
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