Carwyn Jones apology for death of schoolboy Robbie Powell
First Minister Carwyn Jones has publicly apologised to the family of a boy who died in hospital from a treatable condition 22 years ago.
He said the family of Robbie Powell, 10, from Ystradgynlais, Powys, was let down repeatedly by the system.
The family called the report disappointing but welcomed Mr Jones' response after an investigation.
Mr Jones added he would write to Dyfed-Powys Police to raise questions about its handling of the case.
Robbie died of Addison's disease in 1990. A test that could have diagnosed the rare treatable condition was not carried out.
An inquest in 2004 into his death at Morriston Hospital, Swansea, returned a verdict of death by natural causes aggravated by neglect.
His father William Powell has campaigned for a public inquiry, alleging that there had been a cover-up.
The first minister commissioned an investigation to look at the lessons the NHS could learn from the case.
The first minister said despite numerous investigations, including by the police, Robbie's family had been let down repeatedly by the system.
The report covers Robbie's family going back and forth to GPs, as well as his treatment in hospital.
It makes 12 recommendations, some relating to family doctors, in terms of having a system of continuity of care and how referrals should be communicated to patients and parents of child patients.
Written by barrister Nicholas David Jones, his report "justifies their anger", the first minister told AMs during a statement in the Senedd chamber.
He said: "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."
The devolution settlement meant the Welsh government was not able to inquire into matters relating to the police and Crown Prosecution Service, the first minister said.
But he added: "On the face of it seems that the police in Dyfed-Powys in 1996 gave an assurance to people they were themselves investigating that those people would not be prosecuted.
"That is an exceptionally serious matter and one I am very concerned about.
"I will be writing to Dyfed-Powys Police asking why it is that it appears that people were given immunity from prosecution effectively."
One of the recommendations says that GPs need to have access to a patient's medical notes before a consultation "and the notes need to be read".
The report said Robbie was seen by five different doctors on seven occasions in 15 days, and the notes were accessible on only three of those occasions and only one occasion was the notes read.
Speaking after meeting the first minister, Mr Powell said: "The report is very disappointing. It really is the tip of the ice berg.
"The meeting I had with the first minister was very positive.
"It just seems that he has taken on board now some of the serious aspects that I have tried to identify over the last 22 years.
"This is not the end by a long shot."
A spokeswoman for Dyfed-Powys Police said in a statement: "We note that there is a commitment from the first minister to improve on the basis of lessons learnt as a result of this independent inquiry.
"Whilst there is reference in the report to the Crown Prosecution Service and Dyfed-Powys Police we note that it is accepted by the first minister that the remit of the independent inquiry did not extend to any investigation of the actions of the Crown Prosecution Service or Dyfed Powys Police.
"In the circumstances it would not be appropriate for us to comment further at this juncture other than to again express our condolences to Mr and Mrs Powell."