Clinical Negligence & Catastrophic Injury Solicitors
Autistic teenager's death 'potentially avoidable' independent review says.
The parents of a teenager who died after being prescribed an anti-psychotic drug say his death was caused by the "ignorance and arrogance" of medics and are calling for a new inquest.
An independent review found Oliver McGowan's death at Southmead Hospital, Bristol, was "potentially avoidable."
His parents, Paula and Tom McGowan, said they repeatedly told doctors he should not be given the anti-psychotic drug and have called for a new inquest. A police investigation into their son’s death continues.
Oliver McGowan, 18, from Bristol, was mildly autistic and had epilepsy and learning difficulties. He was being treated for a seizure in 2016 when he was given olanzapine to sedate him.
After he was given the drug, his temperature rose and he developed symptoms of Neuroleptic Malignant Syndrome (NMS), a rare side effect that caused his brain to swell. He died in intensive care 17 days later.
The learning disability mortality review (LeDeR) into the death said that, if Oliver McGowan had been assessed correctly on admission to hospital, and staff had read his hospital passport, he may never have needed to be intubated - the insertion of a breathing tube into the trachea for mechanical ventilation - and sedated.
The review said: "There was a general lack of understanding and acknowledgement of Oliver's autism and how he presented himself when in seizure.
"Despite there being a body of written evidence, alongside verbal requests from Oliver and his family, not to prescribe olanzapine, there was no substantial evidence to illustrate that consideration had been given to explore alternatives to anti-psychotic medication."
Oliver's parents said they had always known their son’s death was avoidable. Ms McGowan said: "It is our opinion that Oliver died as the result of the ignorance and arrogance of doctors who were treating him. Doctors absolutely refused to listen to Oliver's direct instructions and to us.
“To watch your child die the most unpeaceful of deaths was horrific. It could have been prevented. It should never have happened. Eighteen-year-old teenage boys, fit and healthy, don't walk into a hospital and come out in a box.
"The bottom line is Oliver's gone and the nucleus of our family has been taken away. That scar will never heal."
Referring to the review's conclusion, his father, Tom McGowan, said: "It's almost a bittersweet feeling. To see it in black and white now on paper is a relief, but it just confirms what we already knew.”
The original inquest in 2018 ruled that the use of olanzapine was appropriate but the McGowans have now called for another, saying the first was "deeply flawed.”
Chair of the Independent Review, Fiona Richie, said: "We hope the completion of Oliver's LeDeR, and the wider recommendations for national change to the LeDeR programme, will be a part of Oliver's legacy and drive the change that is so urgently needed to prevent future deaths."North Bristol NHS Trust chief executive, Andrea Young, said: "The staff who cared for Oliver did their very best in managing his complex needs.
“We are determined to offer exceptional care for individuals with learning disabilities and autism and have significantly improved training and support for staff."
Bristol, North Somerset and South Gloucestershire Care Commissioning Group said in a statement: "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.
"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."