Summary of the events following the death of Robbie Powell – Part 1

9 June 2015

Summary of the events following the death of Robbie Powell – Part 1

Summary of the events following the death of Robbie Powell – Part 1

If you have not already done so please read the summary of events that led to Robbie’s negligent death on the 17th April 1990. You can access the article at:

http://www.mistreatment.com/news/article/robbies-law-25-years-in-the-making-275/#.VWWoTtJViko

The NHS cover up of Robbie’s death actually started before the child was cold on his death-bed.

The Swansea Coroner and Morriston Hospital’s Pathologist

18th April 1990: Although I had been requested on the night of death to provide signed authority for a hospital post-mortem, Robbie’s death was subsequently reported, by Morriston Hospital, to the Coroner for Swansea. When the Coroner’s Officer telephoned me I informed him in detail of the negligent events that had led to Robbie’s death and formally requested an inquest. The Coroner’s Officer was made aware of Robbie’s deteriorating condition over the previous 15 days and that the child had been seen by 5 different GPs on 7 separate occasions, that he had been seen twice on the day of death and that I had been refused an ambulance, on the GP’s second visit, to take Robbie to hospital. He was also told that Robbie fainted earlier that afternoon and had stopped breathing on arrival at Morriston Hospital, after I drove him there, by car, and that the child was pronounced dead some 3 hours later.

This information was communicated to the Coroner who appointed a pathologist employed by Morriston Hospital to perform a post mortem to determine the cause of death and to establish whether or not the death was exclusively natural. If the death was not recorded as exclusively natural there would have to be, by law, an inquest.

However, the Coroner failed in his duty to secure Robbie’s original GP and Morriston Hospital medical records and made no preliminary enquiries whatsoever, as appropriate, in the light of serious allegations of neglect regarding the death of a child.  The Coroner decided that he would rely solely on the findings of the post mortem.

It came to light some years later that the appointment of the pathologist was in breach of the Coroner’s Act because West Glamorgan Health Authority, who was responsible for Morriston Hospital, had been negligent in Robbie’s care, by failing to diagnose Addison’s disease when suspected 4 months earlier. Please note that West Glamorgan Health Authority subsequently admitted liability for Robbie’s death. You can access the letter setting out the reasons for the admission of liability at:

https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxyb2JiaWVzbGF3dHJ1c3QwMHxneDozYzU3NzI2Nzk0OTMwYWM0

With the knowledge of the content of Robbie’s Morriston Hospital medical records and that her employer/colleagues had been negligent the pathologist nevertheless continued with the post-mortem and inappropriately had discussions with her negligent colleagues and at least one of the negligent GPs who had suggested she examine Robbie’s adrenal glands. This is confirmation that, had this GP, who had examined Robbie the day before death, actually read his medical records, he would have been put on notice of the suspicion of Addison’s disease, the need for the ACTH test and the request for immediate re-referral if Robbie became unwell.

As mentioned previously Robbie had been suspected of having Addison’s disease four months earlier when he had been an inpatient at Morriston Hospital, in December 1989, for 4 days. Furthermore, the ACTH test that would have confirmed the disease was ordered but not carried out. Had it been Robbie would have received appropriate treatment and would have gone on to live a full and almost normal life.

Please note it wasn’t the Addison’s disease that killed Robbie but the fact that he was permitted by the GPs to become critically dehydrated during the 15 days leading to his death, which resulted in (a) a loss of blood pressure and (b) two heart attacks, the second being fatal.

On the night of Robbie’s death the child was so emaciated and dehydrated that he was described by one of the attending doctors as having the appearance of a concentration camp victim. A nurse also described Robbie’s hyperpigmentation to the police as being “gold” a colour that she hadn’t seen before or has she seen since. You will recall that Robbie’s hyperpigmentation, which first appeared a couple of years before his death, was denied post death by the hospital paediatricians, the GPs and the pathologist.

The post-mortem report confirmed the cause of death as being Addison’s disease and it was falsely claimed, by the pathologist, that the death was exclusively due to natural causes, which resulted in the Coroner’s refusal of an inquest. However, the crucial and negligent information regarding the events leading to Robbie’s death and the suspicion of Addison’s disease, the need for the ACTH test and the fact that Robbie had been seen by 5 GPs 7 times, in the lead up to his death, was conveniently omitted from the post-mortem report as was the hyperpigmentation confirmed by the nurse and the family.  The pathologist also falsely claimed in her report that Robbie’s body was well nourished notwithstanding he had died as a consequence of fatal dehydration.

The acts and omissions of the pathologist ensured:

(a)  That an inquest would be refused by the Coroner, which would in turn suppress the gross negligence of her employer, colleagues and the GPs; and

(b)  Provide the GPs with a defence regarding the fact they had negligently ignored Robbie’s obvious and critical dehydration in the days leading to his death.

Please note that 14 years after Robbie’s death the inquest verdict was ‘natural causes aggravated by neglect’ confirming that there should have been an inquest back in 1990.

20th April 1990: I was informed by the Coroner’s Officer that Robbie had died of Addison’s disease and that my formal request for an inquest had been refused because Addison’s disease was a natural cause of death. Please note that this was the first time both my wife and I had ever heard of this disease.

To be continued.

RIP Robbie xx

Will Powell

NHS Adviser for Mistreatment.com