‘No excuse’ Health boss apologises to grieving family
Unequivocally, I want to apologise personally to Paula and Tom, and to the family Julia Ross
THE chief executive of a health authority has issued an unreserved apology for mistakes made during an investigation into the death of a Bristol teenager, who died after being given drugs he was known to be intolerant to.
Oliver McGowan died at Southmead Hospital in November 2016 after being given anti-psychotic drugs following his admission for an epileptic seizure.
The 18-year-old student from Emersons Green, who also had mild autism and learning difficulties, was a keen footballer with hopes of becoming a Paralympic athlete.
A review into his death by the South Gloucestershire Clinical Commissioning Group was flawed, mismanaged and took an “unacceptable” length of time to complete, an independent panel found.
Until this week, his parents said they had never had a personal apology for what happened to their son.
Speaking at a public meeting on Tuesday, Julia Ross, the chief executive of the now merged Bristol, North Somerset and South Gloucestershire CCG, said: “I welcome the opportunity to apologise to Paula and Tom McGowan and indeed to Oliver’s brother and sister, who were deeply impacted by Oliver’s death, but also by the process that wasn’t good enough that we went through.
“I had hoped to meet with Paula and Tom early on when this first came to light but I was too late.
“Quite understandably by that time Paula and Tom didn’t feel they could engage with us.
“Unequivocally, I want to apologise personally to Paula and Tom, and to the family.
“We welcome this report and recognise all the recommendations she and the panel have made. We’re working hard to address the issues in there.
“I’m pleased to say we’re in a different place today than we were in back then but there isn’t any excuse and we are unreservedly sorry to the whole McGowan family.”
A LeDeR (learning disability mortality review) into Oliver’s death took 17 months to complete and contained a number of inconsistencies.
The box next to the question “was the death avoidable” was ticked and later unticked. Ms A, the member of staff who led the LeDeR, said she had been warned that saying Oliver’s death was avoidable would put “North Bristol Trust and the CCG in the firing line”.
She told interviewers she was ashamed to “compromise my values”, adding: “I will have to live with it.”
An independent review into the LeDeR was launched by NHS England last year after Oliver’s family expressed their anxiety about a perceived lack of transparency in the process. Its report, published in October, said: “From the outset, Oliver’s LeDeR was mismanaged, poorly monitored and allowed to progress without due rigour or any independent oversight.
“The lack of knowledge around LeDeR systems and process meant that ultimately, Oliver’s LeDeR did not accurately nor appropriately adhere to accepted process.
“Although the action plan is a system-wide plan – an approach that is to be recommended – the fact that it is not complete after 23 months is a source of concern for the panel.
“The action plan must be completed with a sense of urgency and outcomes for people with learning disabilities and autism and their families reviewed, to ascertain how effective the changes have been.”
A report to the Bristol, North Somerset and South Gloucestershire CCG’s governing body meeting said: “The CCG is deeply sorry for the mistakes it made during Oliver’s original LeDeR review and recognises that the systems and governance that were in place at that time were not good enough.
“The CCG did not have previous experience of undertaking LeDeR reviews at that point and in hindsight should have recognised that Oliver’s case needed to be referred for a higher-level independent review from the outset.
“We accept [the recommendations] unreservedly and will implement them in full. In the three years since Oliver’s first LeDeR review significant improvements have been made to the LeDeR process and governance in BNSSG.”
Mrs McGowan welcomed the 21 recommendations in the independent review and said if they were accepted and implemented they have the potential to save lives.