Statement by the Welsh Government

TITLE The Robert Powell Investigation

DATE 17 July 2012

BY Carwyn Jones, First Minister

Today I am publishing a report by an independent investigator on the lessons to be learned from the death of ten year old Robert Powell – known to family and friends as Robbie.

On 17 April 1990, ten year old Robbie died from Addison’s disease, a rare, but treatable, hormonal deficiency. Sadly, in Robbie’s case the disease was not diagnosed prior to his death. All deaths of children are of course tragic and traumatic for the families involved.

This case is particularly so as Mr and Mrs Powell, have always felt that their son’s death was avoidable. Over the years there have been numerous investigations into the case – including a Family Practitioner Committee hearing, a Medical Services Appeal hearing, an Inquest, more than one police investigation, the Elias Review and investigation by the Public Services Ombudsman. Mr and Mrs Powell also tried to report their concerns to the General Medical Council. However, the General Medical Council indicated that, in accordance with their rules, they were unable to consider the Powell case as more than 5 years had elapsed since the events complained of.

Despite these various investigations Mr and Mrs Powell have never felt that their concerns have been properly addressed and have repeatedly requested a public inquiry into the circumstances surrounding Robbie’s death.

A number of these concerns relate to actions taken by the police and Crown Prosecution Service that fall, respectively, within the remit of the UK Home Office and Attorney General’s Department. Both departments confirmed that they did not wish to join in establishing a joint inquiry into Robbie’s case. Welsh Ministers only have the power to inquire into matters that are “wholly or primarily concerned with a Welsh matter”.

Therefore, Welsh Ministers are not able to inquire into matters relating to the police or Crown Prosecution Service. Taking this into account, together with the information already available, including the evidence given at the lengthy inquest into Robbie’s death, the nature and extent of an inquiry, its focus and of course the fact that findings and recommendations must be “wholly or primarily concerned with a Welsh matter”, I took the decision that it would not be justifiable to hold a formal public inquiry.

However, it seemed to me that there was still one final step we needed to take to ensure that the NHS learns from any outstanding issues that arise from this sad event.

I therefore announced in December 2010 my intention to initiate an independent investigation into the Robbie Powell case. In January 2011 I appointed Mr Nicholas David Jones of Counsel as the independent investigator. The terms of reference for the investigation were focused around the lessons that the Welsh NHS can learn from the circumstances of Robbie’s death.

Today I am making public the investigator’s report. In order to comply with the Welsh Government’s duty to process information fairly and lawfully a small number of sections have been redacted from the report, although I am content the redactions do not detract from the overall impact of the report. No doubt, everyone will wish to reflect on it carefully.

The report makes 12 recommendations which fall into four general groups:

• Communication to ensure continuity of care
• Involvement and communication with patients and their families
• The management of medical records
• Dealing with complaints following the death of a patient

For our part, I have asked the Minister for Health and Social Services to consider the recommendations and make a further statement in this chamber following the summer recess on the actions she will be asking the NHS to take.

Assembly Members, the report reinforces what a tragedy this was.

Robbie and his family have clearly been failed, let down badly, by a system that should have been there to protect them. The various hearings and investigations that subsequently followed Robbie’s death have also prevented Mr and Mrs Powell from having the answers that they so needed to feel that everything possible has been done to address the inadequacies in care and practice that led up to and followed Robbie’s death. Mr and Mrs Powell have pursued their quest for information with persistence and vigour – having read this report it justifies their anger.

They are owed an apology. Although Robbie’s death occurred in 1990, long before the National Assembly for Wales was established, on behalf of the Welsh Government I apologise to Mr and Mrs Powell for the failings in the system which led to Robbie’s death and for the inadequate explanations that were subsequently offered to the family. Of course since then many things have already changed for the better – but I commit the Welsh Government to make further improvements where we can still do so.

I met with Mr Powell earlier today to share the findings with him and to give him my commitment that we will learn from this – all these years on. I sincerely hope that by publishing this report today that they (Mr and Mrs Powell) will be able to find some comfort in knowing that we are determined to ensure that the NHS will take action to build on the learning that this report identifies. Even though systems, procedures and legislation within the NHS have changed considerably since 1990, we can always seek ways to improve our systems to provide better safeguards for patients.

We know that in all systems we cannot ever guarantee mistakes will not happen. What we can do is to ensure we learn from them. This investigation’s recommendations show us there are still some things we can do to further improve. I know you will share my determination to continue to learn – to provide a lasting positive legacy from Robbie’s untimely death.