NHS England to review Oliver’s death

January 25 2019

NHS England is to review the events leading up to the death of teenager Oliver McGowan, after a report failed to answer a key question.

Oliver, who was 18, died at Southmead Hospital from the side effects of an anti-psychotic drug, which he was given despite warnings of a previous adverse reaction.

Since his death his parents Paula and Tom, from Emersons Green, have been trying to ensure lessons are learned and no one else has to go through what has happened to their family.

Oliver had epilepsy, a mild learning disability and high-functioning autism.

He was fit and healthy but after a partial seizure in October 2016 he was given the anti-psychotic drug olanzapine, despite both Oliver and his parents telling doctors he had previously had an adverse reaction to such medication.

The drug caused massive, irreparable brain damage and he died 20 days later.

A report was ordered under the Learning Disabilities Mortality Review (LeDeR) to find out if there were mistakes in Oliver’s treatment that the NHS could learn from.

But Paula and Tom were left in “shock, horror and disgust” when they found that, between drafts, the answer to a vital question – was Oliver’s death potentially avoidable – had been removed from the report, which was produced by the Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group.

Paula said: “Our initial reaction was of absolute horror – how they could fail to answer that vital question? We were absolutely shocked to find what we did.

“The first draft of the report, the language was quite strong. But by draft three the language had changed. There was no explanation – it was disgraceful.”

Paula, who had already been invited to discuss Oliver’s case with ministers, MPs and senior NHS leaders to inform future training, contacted NHS England, which has launched a review.

She said: “The most important thing for us is to get Oliver’s report done properly – it must be done independently of the local trusts.”

A spokesman for Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group said: “The process of preparing the review report is iterative and the independent panel responsible for the review refined their responses over time following an initial multi-agency meeting.

“The drafts shared with Oliver’s family reflect this, including the panel’s ultimate conclusion, having considered the complexities of Oliver’s case, that they were not able to say categorically whether his death was avoidable or not.”