UK: The Robert Powell Investigation

The implications for governance processes in the NHS in Wales

The Welsh Government has published an action plan detailing how it intends to build on recommendations set out in the independent investigation commissioned by the First Minister into the circumstances of the tragic death of Robbie Darren Powell.

Robbie died in hospital on 17 April 1990. The cause of his death was Addison's disease. Sadly this had not been diagnosed prior to his death and so consequently went untreated. An independent investigation published in February 2012 reviewed the evidence to determine whether any lessons could be learnt to promote the improvement of the social well-being of Wales and the operation of the Welsh health service.

The Welsh Government's action plan sets out a number of key actions focused on ensuring that robust and reliable governance process are in place in the health service in Wales.

The recommendations and Welsh Government's actions for implementation

The independent investigation makes a total of 12 recommendations. The recommendations are wideranging and straddle a number of areas of both clinical practice and operation management. In outlining how the recommendations will be implemented the Welsh Government have grouped them into four key themes:

1. Better communication and involvement with patients and their families

The investigation recommended that:

• The parent or guardian of a child or an adult patient needs to be informed of the material facts and intended course of further investigation on discharge from hospital; and
• The outcome of a referral needs to be communicated to the parent or guardian of a child or an adult patient by the referring GP.

Welsh Government will implement these recommendations by:

• Reviewing the guidance for "Copying letters to patients" taking into account advances in technology; and
• Including specific guidance in respect of children and young people who are capable of giving consent to treatment themselves or who might therefore be the appropriate recipient of letters or direct communication.

2. Accessing and managing medical records

The investigation recommended that:

• The important points made in correspondence from a hospital need to be recorded and highlighted;
• GPs need to have access to a patient's medical notes prior to a consultation and the notes need to be read; and
• Hospitals need to have in place a system whereby the medical notes of a patient can be accessed quickly, when the patient is being admitted onto a ward in out of office hours.

Welsh Government will implement these recommendations by:

• Completing the roll-out of the electronic Individual Health Record by 2013/2014;
• Requiring LHBs to assure themselves that all GP practices are able to demonstrate that robust and comprehensive record keeping is in place using up to date electronic systems.

3. Communication to ensure continuity of care

The investigation recommended that:

• GPs need to be adequately informed, in writing, of the material facts and intended course of further investigation when a patient is discharged from hospital;
• Correspondence of the type identified above needs to be addressed to the GP who made the referral;
• All correspondence from a hospital should be considered by the GP who made the referral, or a designated GP in the event that the referring GP is absent; and
• GPs need to have a system in place which ensures continuity of care in respect of a patient with an ongoing problem, and that those systems are in force.

Welsh Government will implement these recommendations by:

• Rolling out The Welsh Clinical Communications Gateway to all practices during 2012, giving GPs the ability to electronically refer patients to secondary care/hospitals and for those institutions to send information on discharge electronically;
• Making the Welsh Clinical Portal available across Wales in the next 12 months, giving clinical staff a single immediate view of the important data needed to support vital clinical decisions.
• Requiring LHBs to seek assurance that suitable handover arrangements have been made for patients' medical care when doctors are off duty, thereby ensuring continuity of care. Various tools, including the Clinical Governance Self Assessment Toolkit, are available for this purpose.

4. Dealing with concerns and complaints following the death of a patient

The investigation recommended that:

• Where a complaint against a GP has been made following the death of a patient and the complaint is related to the death then the deceased's medical notes should be called for straight away (whether or not the complaint is made within a month of the death) if they have not already been returned to the appropriate authority;
• When a relative or guardian of a deceased patient wants to discuss the contents of the notes of a GP relating to the patient and/or the care and treatment provided to that patient, that should be done, where practicable, in the GP's surgery, with the practice manager present and with an independent advocate present on behalf of the relative or guardian; and
• The hearing of a complaint against a GP should be in an appropriate forum, with sufficient time allocated to it, and where appropriate tape recorded and with an advocate present.

Welsh Government will implement these recommendations by:

• Commissioning a review of the existing arrangements for accessing and storage of records which may involve updating the existing regulations.
• Requiring LHBs to satisfy themselves that robust processes are in place to deal with non-compliance with requirements in the retrieval and handling of medical records from GP practices following the death of a patient.

The Welsh Government is focused on ensuring that lessons are learnt from Robbie's death. The recommendations demonstrate the need for a patient/family centred system ensuring continuity of care at all times. The arrangements seek to ensure that health care in Wales is focused on the needs of children and young people and that their voice is heard and their rights upheld.

LHB's and GPs should ensure therefore that children are seen as users or patients in their own right, being able to give valid consent and shared decisions which clearly reflect their views and feelings. They should also ensure that they have good communication systems in place as well robust and reliable governance processes and quality assurance process to continuously drive improvement and ensure high standards of care. This will include putting systems in place to ensure that the integration between primary care and hospital care is such that patient safety is not compromised and that there are reliable communication channels and information sharing processes in place.

It is widely expected that NHS bodies will come in for further criticism in the autumn when the Public Inquiry into the serious failures of care at Mid Staffordshire NHS Foundation Trust reports. The Francis Report is likely to propose far-reaching changes at all levels of the system, particularly in respect of who will be responsible for taking action if there is a serious failing in a hospital or practice. We will keep you informed in respect of the report's recommendation and the implications for LHB's and GPs.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.