Senior figures appointed to review autistic teenager's death

Author: Mark Gould

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Dr Celia Ingham Clark, England’s medical director for professional leadership and clinical effectiveness, will oversee the completion of the learning disability mortality review (LeDeR) into the death of Oliver McGowan - a teenager with autism, who died after being given anti-psychotic medication.

Oliver, 18, from Bristol, was being treated for a seizure at the city's Southmead Hospital in 2016 when he was given olanzapine to sedate him.

His parents, Paula and Tom McGowan, say a Freedom of Information request revealed that the finding that his death was "potentially avoidable" was removed from a previous report and did not appear in a final report.

Fiona Ritchie OBE, an independent consultant, will chair the review which NHS England says, "aims to ensure there is the necessary learning from deaths of people with a learning disability, working with the McGowan family".

Following agreement with the McGowan family, further experts will join an oversight group, which will provide specialist clinical input and advice as needed to Ms Ritchie ensuring that the review process is thorough, and the final findings are robust.

It is understood that the NHS Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (CCG) rejects the accusation that staff sought to alter the report.

A spokesperson said: "We deeply regret that the McGowan family's experience of the LeDeR process was so unsatisfactory and distressing for them.

"We will of course participate fully and transparently with the review in whatever way is required."

Mr and Mrs McGowan, said: “We continue to work with NHS England on the re-review of Oliver’s LeDeR. We welcome the decision to firstly carry out this review from the MAR [medication administration record] minutes and Version 1 of Oliver’s original LeDeR report and supporting evidence.

"That report identified that Oliver’s death was potentially avoidable, and secondly the appointment of the oversight group who will handle the review entirely within NHS England independently of the Bristol CCG. We very much hope that we will be listened to throughout this process and that the causes of Oliver’s death will, at last, be fully investigated. Once completed we welcome, and indeed firmly believe in, the urgent need for NHS England to address failings identified with the LeDeR process highlighted by Oliver’s LeDeR review.”

Dr Ingham Clark, said: “This important review will ensure that Oliver’s family get the answers they need and deserve. The findings of this independent review will also help inform the ongoing assessment of existing guidance and ‘learning from deaths’ process nationally, so that we can continue to learn and improve future care.”

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Editorial team, Wilmington Healthcare

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