Oliver McGowan, 18 years old, died at Southmead Bristol Hospital after being given anti-psychotic drugs to treat a seizure against his and his parents' wishes. Oliver was mildly autistic and had epilepsy and learning difficulties. In 2016, Fieldfisher lawyers, Catriona Filmer and Caron Heyes, advised Mencap and the McGowan family in the aftermath of Oliver's death which has now been declared "avoidable".Oliver's parents knew that there were fundamental flaws with his general treatment at the hospital, the subsequent inquest (where evidence allowed was very limited), and the review into his death by the local clinical commissioning group, under the Learning Disability Mortality Review process ("LEDR").
Fieldfisher represented the family pro bono in persuading NHS England ("NHSE") to hold an independent review of Oliver's care. Having persuaded NHSE to agree to a review, we worked with NHSE to appoint a panel of experts to advise the Review Chair, and agreed detailed Terms of Reference for a two stage review. The aim was for there to be a review of Oliver's case (Part 1) and review into systemic areas of learning for the LEDR process (Part 2).
The LEDR report, Parts 1 and 2, has since been published, with the panel of experts unanimously agreeing that Oliver's death was "potentially avoidable" had he been assessed correctly. Part 2 also criticised governance at Bristol, North Somerset, and South Gloucestershire Clinical Commissioning Group after the original review of Oliver's death was doctored by staff to remove any suggestion of blame of the Hospital Trust and identified a range of areas for improvement in how people with learning disabilities are provided medical treatment, especially around consent.
Beyond individual justice for the McGowan family, this report has far-reaching and long-term impacts for learning disabled people. Oliver's death sparked outrage in the community and acted as a catalyst for the review into the care of learning disabled people and autistic people, which has identified several areas for significant improvement. Changes must be made to how deaths are examined by the NHS, with recommendations that reporting a death become mandatory and families given full access to documents and meetings.
NHS England also pledged to invest £1.4m in training on how to care for autistic patients and learning disabled patients and has named the training after Oliver: The Oliver McGowan Mandatory Training in Learning Disability and Autism. | Health Education England (hee.nhs.uk). Oliver's mother, Paula, is actively involved in the delivery of some of that training, which is now being delivered.
Oliver's legacy and the battle for equal, fair, and just treatment of disabled people continues.
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