The origin of Candour and a Duty of Candour in Healthcare: A Timeline

25 November 2014

The origin of Candour and a Duty of Candour in Healthcare: A TimelineThe origin of Candour and a Duty of Candour in Healthcare: A TimelineThe origin of Candour and a Duty of Candour in Healthcare: A Timeline

Photo credits: Will Powell

A Chronology of Robbie's Law and The Duty of Candour: by Will Powell

Oxford Dictionary: Candour = “The quality of being open and honest; frankness”

Robbie was born on 29th December 1979 and tragically died on the 17th April 1990 aged 10 years and 4 months as a consequence of a catalogue of negligent failures by the NHS. Rather than identify the errors and learn from them there was a cover up that continues to this day almost a quarter of a century after the child’s needless death.

5th December 1989: Robbie was rushed to Morriston Hospital by ambulance critically ill. Addison’s disease was suspected and an ACTH test ordered. Addison’s disease invariably results in death without treatment but is treatable with a daily intake of tablets. The child was an inpatient for 4 days. The suspicion of Addison’s was not communicated to the parents and they were erroneously informed that Robbie had gastroenteritis which, unknown to the parents, at the time, was an untenable diagnosis in the absence of diarrhoea. However, Robbie’s GPs, a Practice of 7 doctors, were informed of the suspicion of Addison’s disease and the need for the test.

18th January 1990: Robbie had an outpatient appointment with the Consultant who suspected Addison’s and who had ordered the ACTH test. However, a conscious decision was made by him not to do the test, not to tell the parents of the suspicion and to re-refer the child back to the care of the GPs. The erroneous diagnosis of gastroenteritis was repeated to Robbie’s mother. The Consultant wrote to the GPs reiterating the suspicion of Addison’s and informing them of his decision to delay the test. The GPs were told to re-refer Robbie immediately back to hospital if he became unwell.

2nd to 17th April 1990: Robbie was seen by 5 GPs on 7 separate occasions 2nd, 6th, 11th, 15th, 16th and twice on the 17th. Only one GP read the medical records. He informed the Powells on the 11th April; 6 days before death, that he would re-refer Robbie immediately back to hospital but then failed to do so. The GP did not inform the Powells of his knowledge that Robbie’s life was at risk from this potentially fatal disease. The GP prescribed Dioralyte for Robbie’s vomiting, a symptom of Addison’s disease, which the Consultant had specifically mentioned to the GPs in the discharge letters.

Robbie’s health deteriorated, he became critically dehydrated and so weak he couldn’t walk. The child was carried into the local hospital to see a GP on Sunday 15th April but the GP declined to re-refer Robbie back to Morriston Hospital. This was the very GP that had received the letter from the Consultant just 3 months earlier requesting immediate re-referral if the child became unwell.

Following a telephone call to Health Centre a GP was called to the Powells’ home the following day, which was Easter Monday, as Robbie was now vomiting froth and deteriorating. This GP said that the child needed a blood sugar test and went to his car. However, as his test equipment was out of date, he decided it was unnecessary notwithstanding, at this stage, Robbie’s blood sugar would have been dangerously low as the child was critically dehydrated. This GP again refused hospital admission but said if the vomiting continued or Robbie deteriorated further then he would be readmitted to hospital.

On the 17th April while being assisted to the toilet, by his mother, Robbie collapsed on the bathroom floor and lost consciousness. A GP was again summoned to the Powells’ home by which time Robbie had regained consciousness, had dilated pupils and blue lips. When he opened his eyes he said, “Mammy I can’t see you”. Although the senior partner, the day before, stated that Robbie should be readmitted to hospital, if he deteriorated, this junior GP refused to do so claiming there was nothing seriously wrong with him.

The Powells phoned the hospital for advice and were told by a Staff Nurse to trust in the GP but to call her out again if they were still worried.

The GP was called for the second time to the Powells’ home but she still refused hospital admission. Only following a heated argument did she agree to admit the child. When Mr Powell requested an ambulance, in the presence of his wife and sister, the GP threw the referral letter across the breakfast bar and said “no, take him by car”.

On arrival at Morriston Hospital [12 miles from the Powells’ home], just 30 minutes later, Robbie took his last conscious breath in the presence of his father. The child was declared dead shortly after.

20th April 1990: Following a post-mortem the cause of death was recorded as Addison’s disease, which is a disease the Powells had not heard of until that day. The senior GP who had examined Robbie, the day before death, called at the Powells’ home. Mr Powell was devastated to learn from the GP medical records, which only one GP had actually read during the 7 previous consultations, that Addison’s disease had been suspected the previous December. The discharge documents also erroneously claimed the parents had been told about the need for the ACTH test when in fact the parents knew nothing about it. There was also a clear instruction from the Consultant that Robbie should be re-referred immediately back to Morriston Hospital if he became unwell.

However, the 5 GPs had failed to do so, on 7 occasions, until it was too late to save the child’s life. It was obvious to the Powells that these crucial documents had not been shared with all 7 GPs, that Robbie had died as a consequence of a catalogue of medical errors and that the GPs had no defence whatsoever for failing to get Robbie back to hospital during a 15 day period. On that day the senior partner refused Mr Powell’s request for an investigation into the events leading to Robbie’s death.

22nd April 1990: The GP who had informed the Powells he would re-refer Robbie to the hospital on the 11th April called to see Mrs Powell, at her home, because of her need for medication.  When asked in the presence of Mrs Powell and again in the presence of a family member, if he had referred Robbie back to hospital, as he said he would, the GP falsely claimed he had done so.

23rd April 1990: The Powells had the GP medical records independently witnessed by a Reverend who took a contemporaneous note of, amongst other things, the suspicion of Addison’s disease and the need for the ACTH.

30th April 1990: The Powells made a formal complaint to Powys Family Practitioners [“FPC”] regarding the GPs.

25th May 1990: The Powells met the Consultant who had suspected Addison’s disease at Morriston Hospital. He stated that he had put the GPs on notice of Addison’s disease and that, in relation to the GPs’ failure to re-refer Robbie, as he had instructed, he said that he just couldn’t trust anyone. He also confirmed that he had not received a referral letter from the GPs, this being 5 weeks after Robbie’s death. However, had he received such a letter he would have had Robbie readmitted immediately. Please note that the Consultant made a note of the meeting with the Powells and placed it in Robbie’s hospital records.

1st June 1990: The General Manager of Powys FPC sent the Powells’ complaint to West Glamorgan FPC because the senior partner, who had seen Robbie the day before he died and had refused to investigate what had gone wrong, was a member of Powys’s Medical Services Committee. According to the General Manager this was done to be “beyond the suspicion of bias”. However, to assist the GPs the General Manager breached rules of procedure by also forwarding the Powells’ statement of complaint and permitting the GPs to keep custody of Robbie’s original GP medical records, which should have been returned to Powys FPC by no later than the 17th May 1990. This permitted the GPs to alter and falsify the medical records as and when they needed to do so to corroborate their untruthful statements in response to the Powells’ complaint and that is exactly what the GPs did do.

5th July 1990: The GPs received a copy of the Morriston Hospital records from the Consultant following a request in June. The accompanying letter invited the GPs to meet and a secret unrecorded meeting subsequently took place between the Consultant and the 5 GPs.

20th July 1990: The 5 GPs individually responded to the Powells’ complaint and also provided a combined statement signed by all 5 of them. The statements contained numerous untruths to defeat the Powells’ complaint and there had clearly been a conspiracy to do so by all 5 GPs and members of their staff. For example:

(1)  It was claimed on numerous occasions that Robbie had been referred to the Consultant and that he had not been vomiting the night before the consultation of the 11th April. There was no mention of the prescription for Dioralyte, which was prescribed specifically for the vomiting and mentioned in the Powells’ complaint.

(2)   The consultation notes of the 17th April [day of death] were not consistent with Robbie’s symptoms and condition on the day. The GP denied Robbie’s pupils were dilated, that the child had lost consciousness, that his lips were blue and that she had refused to call an ambulance when requested to do so.

12th September 1990: My formal request for copies of Robbie’s GP and Morriston Hospital records were refused.

Because the GPs claimed in their statements that Robbie had been referred to the Consultant, which the Consultant had denied at the May meeting with the Powells, I telephoned the Consultant for confirmation of the referral. The Consultant claimed he had received no referral letter dated 11th April when I hadn’t given him this date, which was the precise date of the consultation at which the GP, who previously worked for the Consultant, had said the referral would be made that day. More suspicious was the fact that there could have been a referral letter dated before Robbie’s death on the 17h April even though the Consultant had stated 5 weeks after Robbie’s death that no such referral letter had been received.  I contacted him again and received a second letter. Again, his reply was suspicious as he claimed he had received no referral letter before Robbie’s death indicating that one had been received after his death, which was contrary to what he had told me in May. I telephoned the Consultant yet again and told him if a referral letter was received by the GPs it had to have been received after our meeting on the 25th May. The Consultant refused to confirm whether a referral letter had been received.

6th November 1990: Because of the denial of vomiting and the omission of Diaoralyte I visited the chemist [E W Richards] who had dispensed the medication.  He was actually a friend of the GP who had prescribed it.  He confirmed that he had erased all records of Robbie’s medication from his computer and that he had no written records whatsoever regarding what prescriptions had been dispensed for Robbie. I asked where the prescription was and was informed that it had been sent to the Prescription Pricing Authority. The chemist then refused my request to call them. When I called they refused to speak to me as I was a member of the public.

15th November 1990: I formally requested that West Glamorgan FPC secure the prescriptions and they did, which included the prescription for Dioralyte, as mentioned in my statement of complaint.

22nd November 1990: I received a copy of Robbie’s GP and Morriston Hospital records as the GPs had introduced them as evidence for the December Medical Services Committee hearing into my complaint against the GPs. The Addison’s discharge letters witnessed by myself and the Reverend following Robbie’s death were missing from both sets of records and had been substituted with documents less incriminating that made no specific reference to the earlier suspicion of Addison’s disease. I immediately telephoned West Glamorgan FPC and the Consultant’s secretary complaining that documents were missing from both sets of medical records. I requested that my allegations be formally recorded, which they were and dated that day.

Also in the GPs records were 2 referral letters from the GP, who examined Robbie on the 11th April, which were dated 12th April and addressed to the Consultant. One was signed and the other was a copy. There was also a torn open envelope addressed to the Appointments Officer at Morriston Hospital. The presence of these documents immediately raised suspicion as it was clear that, contrary to the GPs’ July statements, Robbie had not been re-referred to the Consultant as claimed and why was the Consultant reluctant to confirm this when asked by me in September? It is believed that the Consultant, at the secret meeting in July with all 5 GPs, agreed to say that the referral letter had been received by him shortly after Robbie died. However, when I challenged this the Consultant gave the hospital copy back to the GPs who then had to come up with another story to justify why they had claimed in combined  statement, on numerous occasions, Robbie had been referred.

I immediately went down the Health Centre and challenged the senior partner regarding the missing Addison’s letter and the false claim about Robbie being referred back to the Consultant. The GP admitted my recollection that on the 20th and 23rd April there was no copy of the 12th April referral letter in the GP medical records. This confirmed that the referral letter could not have been typed on the 12th April because had it been, a copy would have been in the GP medical records pre-death. I asked who had typed the referral letter and was informed it was the junior secretary. I requested a statement from her.

5th December 1990: I received a statement, but not from the junior secretary, from the senior secretary claiming she was on leave in the week leading to Robbie’s death and had typed the referral letter on the instruction of the GP, after death, and backdated it to keep the records chronologically correct. If the letter was only typed post-death to keep the records chronologically correct then the 5 GPs have to accept that their combined statement, claiming on several occasions that the referral had been made, was untrue and they had been fully aware of this fact when the combined statement was signed in July. Furthermore, why did the secretary  copy the referral letter, have the original signed by the GP, type an envelope addressed to the Appointment’s Officer at the hospital, place the signed copy in the envelope, seal the envelope, then tear it open, put all three documents in the GP records if there was no intention to deceive anyone? The senior secretary also omitted her reference from the letter to make it look as if the junior secretary had typed it, which is something that would be completely unnecessary if it was going to be accepted, from the outset, that the letter was only typed for the record. It later transpired that the junior secretary admitted to the police that she had been asked to say she had typed the referral letter but subsequently refused to do so.

13th December 1990: West Glamorgan FPC’s Medical Services Committee [“MSC”] held an inquiry into my complaint for approximately 4 hours. The committee comprised of a Chairman, who was also a Magistrate, 2 GPs and 2 lay members. It was obvious from the outset that the Chairman and the committee was biased in favour of the GPs and was not prepared to take into account any of the evidence I presented regarding the GPs’ dishonesty. Not only did the committee prevent me from asking the GPs pertinent questions they failed to ask any questions and the GP members accepted evidence from the respondent GPs that they were fully aware was false.

11th January 1991: I received the MSC report, which did not accurately reflect the evidence given at the hearing. Only the GP that visited twice on the day of death was found guilty of breaching her terms of reference and was given the minimum reprimand. The other 4 were exonerated.  The minutes of the meeting were destroyed after I requested copies of the same and my formal complaint against the Chairman was not upheld. However, 3 of the members accepted that the Chairman was less sympathetic towards me than he should have been in the circumstances.

24th April 1991: I first complained to the Health Service Ombudsman about numerous failures and dishonesty within the NHS and continued to do so for many years. All serious complaints were either outside the Ombudsman’s jurisdiction or were not upheld. I found out subsequently following a DPA request that the Ombudsman’s Office made numerous derogatory comments about me for which I had personal and written an apology in 2004.

February 1991: I appealed to the Welsh Office against the decision of the MSC and I successfully was granted an oral hearing.

March 1992: The Welsh appeal commenced for 3 days and then was adjourned until September 1992. It was heard by a Chairman/barrister and 2 GP members.

September 1992: The Welsh Office appeal reconvened but then collapsed after 2 days when it was established there had been collusion between the appeal panel, respondent GP and Welsh Office Officials. It cost me £34,000 for representation at the appeal.

An inept/corrupt internal inquiry cleared the Welsh Office officials and panel of any wrongdoing.

27th July 1993: The then Secretary of State for Wales provided my MP with false information and dismissed cogent evidence of wrongdoing within the Welsh Office during the course of the appeal.

November 1993: The Parliamentary Ombudsman refused to investigate my MP’s complaint, on my behalf, about the Welsh Office. It was falsely claimed as being outside his jurisdiction.

March 1994: A formal complaint was made to Dyfed Powys Police regarding the GPs’ dishonesty and forgeries. The police did not declare that the GPs under investigation were employed by them as police surgeons.

May 1994: The Secretary of State for Wales offered a non-statutory inquiry, which was withdrawn 6 months later when the GPs refused to participate.

January 1995: The Chief Officer of the Community Health Council brought Robbie’s case to the attention of the GMC with a Guardian article about the GPs’ dishonesty – the GMC who took no action but confirmed there was no time limit for me to complain.

June 1995: The Secretary of State for Wales gave an untruthful response to a Parliamentary Question asked by Rhodri Morgan MP regarding the 1992 Welsh Office appeal. This resulted in a further complaint to the Parliamentary Ombudsman [PO] in 1997 by my MP. The PO investigated not only this complaint but also the previous complaint about the 1992 Welsh Office appeal. In March 1999, 7 years after the events, the Welsh Office was eventually found guilty of maladministration regarding its handling and collapse of the 1992 appeal. 

September 1995: One of the GPs from the Ystradgynlais Health Centre wrote to the Chief Officer of the Community Health Council to inform him that the police had found no evidence against the GPs and attempted to persuade him not to support Robbie’s case. As the police investigation was on-going until May 1996, some 8 months on, how did the police employed GPs know this?

April 1996: It was made public by the media that Dyfed Powys Police was considering gross negligence manslaughter. The GMC covertly opened an investigation into the GPs and named the Chief Officer of the CHC as the complainant but didn’t tell him.

May 1996: Dyfed Powys Police confirmed that no charges will be brought against the GPs and they were given immunity from prosecution. The GMC covertly closed down its investigation into the GPs.

West Glamorgan Health Authority admitted negligence and liability for Robbie’s death and paid £80,000 into court.

June 1996: The High Court ruled that doctors didn’t have to tell the truth about a child’s negligent death and the case against the GPs was struck-out.

December 1996: I jointly wrote to every MP in the House of Commons to highlight Robbie’s case.

July 1997: The Court of Appeal upheld the High Court ruling and the £80,000 compensation was taken in costs.

April 1998: The House of Lords refused to hear Robbie’s case and the challenge to the absence of a Duty of Candour.

The GMC changed its guidelines as a consequence of Robbie’s court rulings to ensure doctors were aware they had a professional and ethical duty to tell the truth to bereaved families if not a legal one.

1998: I jointly wrote with my Bereaved Parents’ Action Group to every MP in the House of Commons to highlight Robbie’s case and also the needless NHS deaths of other children. This resulted in an inquiry by the Health Select Committee at which I gave written and oral evidence. A statutory duty of candour was recommended but rejected by the government.

January 1999: Following a complaint against the Deputy Chief Constable of Dyfed Powys Police a second criminal investigation commenced.

April 2000: Further numerous complaints about Dyfed Powys Police resulted in disciplinary notices being formally served on the Head of CID and a Superintendent, a disciplinary investigation by an outside force and also a third criminal investigation into the GPs’ criminal activity by an outside police force.

May 2000: Following 10 years of correspondence with the Swansea Coroner, who continually refused an inquest into Robbie’s death, the Attorney General granted me a court order [Fiat] to take the coroner to court. In December 200 an inquest was opened and adjourned pending the outcome of the criminal investigation.

May 2000: The European Court of Human Rights confirmed the absence of a Duty of Candour for Healthcare professionals.

The GMC was put on notice regarding Robbie’s case by the police and I was informed in writing that the GMC would await the outcome of the criminal investigation before considering what, if any, action would be taken against the GPs. I was also informed that I would be contacted by the GMC if there were any significant developments.

June 2000: I again jointly wrote to every MP highlighting the ECtHR’s ruling in Robbie’s case. The Ministers at the Department of Health and the Welsh Health Minister denied that Robbie’s judgement meant that doctors could lie following the negligent death of a child.

October 2000: Both senior Dyfed Powys Police officers previously issued with discipline notices were permitted to retire and therefore did not participate in the inquiry set up to consider misconduct issues regarding them personally.

March 2002: The third criminal investigation was concluded with 35 suggested against the GPs and their secretary. The case files were sent to CPS York as I had complained about the CPS in Wales.

November 2002: The GMC covertly introduced a 5 year time limit but did not inform me of this significant development notwithstanding I had been formally informed, since 1995, that there was no time limit and in 2001 they would keep me informed.

March 2003: Avon & Somerset Constabulary’s discipline investigation found that between 1994 and April 2000 Dyfed Powys Police had been institutionally incompetent regarding the criminal investigations into Robbie’s case. Not one police officer was made accountable.

March 2003: York CPS confirmed that there was sufficient evidence to prosecute 2 GPs and a secretary for forgery and attempting to pervert the course of justice. However, no prosecutions would be initiated because of the passage of time, previous failures of the police and CPS and the police had given their employed GPs immunity from prosecution in 1996 following the first institutionally incompetent police investigation.

March 2003: Dyfed Powys Police and the 2 senior CPS prosecutors met the GMC to formally refer Robbie’s case for investigations as promised to me in 2000. They were informed of the 5 year time limit, which did not affect them as the case had been brought to the attention of the GMC 2 years earlier. According to the police the GMC’s solicitor influenced them not to refer Robbie’s case, which was the outcome. I was advised by the police and the CPS to complain to the GMC but the 5 year time limit was suppressed from me.

June 2003: I complained to the GMC about the doctors.

July 2003: My complaint about the CPS in Wales was concluded following an investigation by CPS Essex, a barrister and another employee of the CPS. CPS Wales was completely exonerated and derogatory comments were made about me in the CPS report. When I challenged the alleged cover up the then Director of Public Prosecutions told me that any further correspondence regarding my complaint about the CPS would be filed without response.

January 2004: Robbie’s inquest resumed and took place for 20 days over a period of 3 months. The verdict was natural causes aggravated by neglect, confirming there should have been an inquest in 1990.

Although the GPs committed perjury at the inquest the CPS refused to prosecute them.

2005: The GPs settled my libel action against them. They had called me a liar, a distorter of the facts and a fantasist back in 1992. I was a litigant in person and the out of court settlement included an apology and substantial compensation. The QC who represented the GPs is now a judge.

May 2008: After waiting 3 years for the police files and a further 2 years to have the police files considered by outside solicitors the GMC then rejected Robbie’s case by engaging the 5 year time limit almost 5 years after I complained.

February 2009: AvMA won permission to judicially review the GMC regarding it decision in Robbie’s case not to investigate. During the proceedings the GMC misled the court by claiming it could not investigate a doctor without receiving a complaint. Unknown to me at the time the GMC had covertly opened an investigation against the GPs in April 1996. Furthermore, a FOI established that the GMC had opened 575 investigations on newspaper articles alone from 1993 until 2009. The judge during the proceedings had stated that it had gone from prosecution to persecution against the GPs. The judge only gave me 5 minutes stating that anything I said would make no difference to his decision. Although the judge openly demonstrated bias he was still permitted by AvMA’s legal team to consider the continuance of a protected cost order – the judge refused the application and the case was withdrawn because of the risk of approximately £100,000 in costs if the challenge was unsuccessful.

March 2013: The Powells’ former MP had an adjournment debate at the House of Commons regarding the misrepresentations and untruths he was told by the Director of Public Prosecutions back in 1996. The debate was responded to personally by the Attorney General.  Following the debate the former MP wrote to the Director of Public Prosecutions requesting that the decisions in Robbie’s case, not to prosecute, be reconsidered.

May 2014: I met a CPS representative on the instructions of the current Director. The meeting took place in London and lasted approximately 7 hours.

October 2014: I was informed that the Director had ordered a reconsideration of all the CPS decisions taken in Robbie’s case.

Will Powell – November 2014 thanks Will for his powerful and detailed account of the history of Robbie's Law and the Duty of Candour. He can be found on Twitter at @willcpowell

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