TEEN’S DEATH ‘WAS AVOIDABLE’
HEALTH AUTHORITY ‘DEEPLY REGRETS’ INITIAL PROBE INTO DEATH IN HOSPITAL OF MILDLY AUTISTIC OLIVER
BEREAVED parents have finally been told their beloved son’s death was “potentially avoidable”, almost four years after he died at a Bristol hospital.
A new independent review into the death of Oliver McGowan has concluded, after failures were identified with the initial review process.
The 18-year-old, from Emersons Green, died at Southmead Hospital in November 2016.
He had mild autism, epilepsy and learning difficulties, and was admitted after having partial seizures.
Despite clear instruction not to prescribe him anti-psychotic drugs due to his intolerance, doctors did so and he developed severe brain swelling, after which he died.
His parents Paula and Tom McGowan have spent years trying to hold health authorities to account, and Avon and Somerset police are now investigating his death.
A re-review commissioned by NHS England, called an LeDeR (Learning Disability Mortality Review), has now made several conclusions including that his death was “potentially avoidable”.
In a joint statement shared with the Post, Oliver’s parents 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 coroner’s 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, and who did not act in his best interests.”
They feel his care was overshadowed by “a combination of prejudice, subconscious bias and diagnostic errors”.
As well as the administering of anti-psychotic drug Olanzapine, they feel health professionals
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 coroner’s 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.
Oliver’s parents
neglected his needs as someone with autism, and also failed to identify symptoms of Neuroleptic Malignant Syndrome, which caused his brain to swell.
Tom and Paula added: “The lack of temperature control was a major contributing factor in him suffering irreversible brain damage.
“We note that this independent review does not mention this fact in either of their reports.”
The pair thanked Fiona Ritchie, who was commissioned to carry out the review, and the panel for being “open, honest and transparent” throughout the process.
They also thanked NHS England and NHS Improvement for commissioning the review, as well as their lawyers Caron Heyes and Catriona Filmer of Fieldfisher LLP, and charity Mencap, for their “unstinting support in our fight”.
Oliver was a promising sportsman, who had every hope of living
a full and happy life.
Tom and Paula said: “Oliver’s life was important. He was productive, playing football for England FA development squads; he was in training to become a future Paralympian.
“He had passed his GCSE and BTec exams at school and was attending college. Oliver had a right to a life, his life mattered.”
The initial LeDeR review did not conclude that his death was potentially avoidable, despite an initial draft report making this admission, and there were allegations of a cover-up after the change.
LeDeRs are not designed to apportion blame, but to identify any lessons to be learned.
North Bristol NHS Trust, which runs Southmead, and the Clinical Commissioning Group (CCG) which carried out the initial review, both shared statements in response to the new report.
Despite their experience, Tom and Paula say they are advocates of the LeDeR process and stressed the importance of acting on lessons learned.
Their statement added: “It is not OK that a certain group of people are dying 25 years earlier than the rest of the general public, simply due to inequality of health care, prejudice and subconscious bias from the very people who are meant to support and treat them.
“On average 1,200 learning disabled people are dying preventable deaths every year, simply due to inequality of health and social care.
“We are calling for NHS England/ NHS Improvement to allocate a senior named person to track and action all the recommendations independently of the current management of the UK LeDeR process.
“The lives of learning disabled people depend upon it.”