‘Deep regrets’ expressed by health authority over initial investigation into teen’s death

A HEALTH authority has said it “deeply regrets” its initial 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 administered 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.

An independent review commissioned by NHS England published yesterday, called an LeDeR (learning disability mortality review), makes several conclusions including that his death was “potentially avoidable”.

The report was a re-review of an earlier investigation by South Gloucestershire Clinical Commissioning Group (CCG), which was accused of a cover-up after it avoided making that same conclusion.

The new report reveals that the panel initially did agree that his death might have been avoided, but that the lead reviewer felt “bullied” into changing this after heated discussions with her superiors and their legal team.

An email she sent to senior nursing staff, quoted in the report, read: “I have endeavoured to remove anything that seems to indicate any sort of ‘blame’.”

She told the panel she felt “ashamed” and that the final report “did not reflect my views”, and she quit afterwards as she “could never work there again”.

The independent report, carried out by Fiona Ritchie, highlights “unacceptable” failures during the initial review process, including the length of time it took to complete and “inadequate” CCG governance.

It states: “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.”

The CCG, which has since merged to become Bristol, North Somerset and South Gloucestershire CCG, said it welcomed the report.

A spokesperson 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.

“Families are now central to LeDeR from the outset of each review. We have established a service user forum to ensure that the voices of people with learning disability and autism sit at the heart of our process.”

The spokesperson said more than 25 reviewers have now been trained up to lead the LeDeR process, and that “learning from Oliver’s death is also being embedded across the wider health and care system”.

A community learning disability nursing team has been introduced at North Bristol NHS Trust, which runs Southmead Hospital.

The CCG spokesperson added: “We recognise there is more to do to improve care and reduce the inequalities that people with learning disabilities and autism experience.

“We will be embedding the review’s recommendations into our action plan as we continue our improvement journey, and will regularly publish our progress.”

North Bristol NHS Trust has continued to defend doctors’ decision to administer the psychotic drug to manage Oliver’s condition.

Chief executive Andrea Young 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.”

It remains a deep source of regret to us that the McGowan family’s experience of LeDeR was so poor

CCG spokesperson