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.