Robbie Powell, aged ten from Ystradgynlais in Wales, suffers from a two day illness of vomiting and abdominal pain. Dr. Elwyn Hughes arranges emergency travel to Morriston hospital by ambulance, where he stays for four days, critically dehydrated and having lost 25% of this body weight. The hospital suspects Addison’s disease, an adrenal condition that’s highly treatable, but results in death without treatment. Doctors order an ACTH test but this isn’t followed through. It’s communicated to Robbie’s GPs, but not his parents. Instead the Powells are told by the hospital that Robbie suffers from gastroenteritis caused by a throat infection.
Robbie again suffers from vomiting, weight loss and acute stomach pains. He is seen seven times by five doctors. Although these doctors have information about the December hospitalisation and the suspected Addison’s disease, except for one doctor, none read about the crucial warnings in the medical records. None of them:
- Read each others diagnoses
- Record accumulating symptoms
- Do a blood test or take blood pressure
- Refer Robbie to the hospital – until it’s too late to save his life
2nd April 1990
The same doctor who arranged for the emergency hospital stay four months earlier, Dr. Elwyn Hughes sees Robbie again. Robbie has a sore throat and jaw and is lethargic. Dr. Hughes can’t find anything wrong with Robbie. He doesn’t read the medical records or arrange for a follow up.
6th April 1990
Robbie is sent home sick from school, lethargic and unwell. At the health centre, Dr Nicola Flower examines Robbie. She too finds nothing wrong, fails to read medical records or book a follow up appointment.
11th April 1990
After a bout of sickness, vomiting and obvious weight loss, Robbie is back at the health centre this time seeing Dr. Mike Williams. The doctor reads the medical records and advises the Powells that he will refer immediately to the hospital. He prescribes dioralyte for the vomiting. He doesn’t mention that Robbie is at risk of death due to suspected adrenal failure and doesn’t book a follow up appointment.
15th April 1990
Robbie sees Dr. Paul Boladz at the community hospital, who records further weight loss. Robbie is so weak that needs to be carried into the hospital. Dr. Boladz cannot access medical records, he thinks that Robbie has glandular fever and prescribes medication for this, he arranges blood tests for the following Tuesday.
16th April 1990
After even further weight loss and deterioration, Dr. Keith Hughes visits Robbie at home. He finds the child vomiting froth and with poor circulation. The medical records aren’t available. The doctor goes to his car to get a blood sugar kit, and finds that it’s out of date. He refuses to refer to the hospital but says that if Robbie continues to deteriorate, he will get the boy admitted. He delays the blood tests ordered by Dr. Boladz, from Tuesday to Wednesday.
17th April 1990
Robbie is being assisted to go to the bathroom, but he collapses and loses consciousness. An emergency call is made to the health centre, and Dr. Nicola Flower arrives shortly afterwards. Robbie regains consciousness, but has blue lips, dilated pupils and cannot see properly. Dr. Flower believes that nothing seriously wrong with Robbie. She thinks it’s a throat infection that has gone to his chest. She ignores the Powell family’s pleas, and her senior partner’s advice from the day before, that Robbie needs to go to hospital. The Powell’s are so worried that they call Morriston Hospital. They are told to trust the GP, and call her out again if they are worried.