Review finds that Oliver’s hospital death was potentially avoidable

October 27 2020

Oliver McGowan

AN independent review into the death of an Emersons Green teenager at Southmead Hospital has ruled that it was "potentially avoidable".
Oliver McGowan, who was 18, was given an anti-psychotic drug after suffering a partial seizure in 2016, even though both he and his parents told staff he had previously had an adverse reaction and his medical records confirmed this.
The drug caused his brain to swell, causing massive, irreparable damage: his life support machine was later turned off after doctors told the family there was no hope of recovery.
Oliver's parents Paula and Thomas fought for an independent report into his death after a conclusion that it was avoidable was removed from an official review produced locally.
The independent review, for NHS England and NHS Improvement, has found that the initial Learning Disabilities Mortality Review (LeDeR) was "mismanaged, poorly monitored and allowed to progress without due rigour or any independent oversight".
Oliver had a mild learning disability, epilepsy and high-functioning autism, and the LeDeR was part of a programme to improve the standard and quality of care for people with learning disabilities.
But the independent report found that the local clinical commissioning group responsible for the LeDeR gave it to a new employee "still on induction" who had never undertaken one before, something the panel said was "highly inappropriate".
The reviewer, who was not named in the independent report, was not given enough dedicated time to complete it and said she "felt bullied, overworked and overly stressed".
The key question of whether to record Oliver's death as potentially avoidable was discussed at a meeting only after his parents had left: they were invited only to the first two hours, "despite the LeDeR documentation advocating that families should be central to the process".
The NHS review said "four individuals" had decided that Oliver’s death should not be recorded as potentially avoidable "at the end of the meeting after all other participants had left".
The review, chaired by an independent consultant and working with Oliver's parents and experts from the health, social care and voluntary sectors, concluded "unanimously that Oliver’s death was potentially avoidable".
Oliver's parents, Paula and Tom, welcomed the results of the review and said: "We have always known that Oliver’s death was avoidable.
"He was a healthy, fit teenage boy who walked into Southmead hospital having absence type seizures and left in the back of a coroners' van, headed for the local mortuary.
"It is our opinion that Oliver died as a result of the combined ignorance and arrogance of doctors who were treating him, doctors who refused to listen to Oliver’s direct instructions and us, his parents, who knew him best."
They said they hoped the NHS would treat the results of the review "with the due diligence they deserve and act upon them in a meaningful way", adding: "The lives of learning disabled people depend upon it."
Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group, which carried out the initial review, said: "It remains a deep source of regret to us that the McGowan family’s experience of LeDeR was so poor.
"In the three years since Oliver’s review was completed we have significantly improved our processes and will continue to do so on an ongoing basis."
Andrea Young, chief executive of North Bristol NHS Trust, which runs Southmead Hospital, said: "The staff who cared for Oliver did their very best in managing his complex needs as his health was deteriorating.
“They made decisions, as they do on a daily basis, to weigh up all the risks and sought to give him the best possible treatment.
“Sadly Oliver died in our hospital and we are sorry for his loss.
“We are determined to offer exceptional care for individuals with learning disabilities and autism and we have significantly improved training and support for staff.
“We are committed to continue learning and will act on this report.”
In July Avon and Somerset police confirmed that they are carrying out an inquiry into Oliver's death.