"Autistic Bristol teenager Oliver McGowan's death was avoidable" – new independent review into Thomas Oliver McGowan’s LeDeR process - Other reports and inquiries - Patient Safety Learning

"Autistic Bristol teenager Oliver McGowan's death was avoidable" – new independent review into Thomas Oliver McGowan’s LeDeR process

Posted by Steve Turner on 21 October, 2020
2061 views

Share
https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/investigation-reports/other-reports-and-enquiries/autistic-bristol-teenager-oliver-mcgowans-death-was-avoidable-%E2%80%93-new-independent-review-into-thomas-oliver-mcgowan%E2%80%99s-leder-process-r3319/

Followers 0
Home

Learn

Investigations, risk management and legal issues

Investigations and complaints

Investigation reports

Other reports and inquiries
Article information

PUBLISHED 21 October, 2020

ORIGIN UK

TYPE Blogs

CONTENT TYPE New

SUGGESTED AUDIENCE Everyone

TAGGED

Monitoring

Treatment

Adminstering medication

Observations

Learning disabilities

Patient death

Communication problems

Omissions

System safety

Accountability

Leadership

Organisational culture

Organisational Performance

Transparency

protocols and procedures

Risk assessment

Autism

Clinical governance

Complaint

Investigation

Legal issue

Root cause anaylsis

Coroner reports
Summary

Oliver McGowan died due to a reaction to a drug he was known to react adversely to.

The learning disability mortality review (LeDeR) into his death said that "if Oliver had been assessed correctly on admission to hospital and staff had read his hospital passport, he may never have needed to be intubated and sedated".

This is the second report into Oliver's case, following campaigning from Oliver's family. #oliverscampaign

Content

I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away.

Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act.

I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.

0 reactions so far

Steve Turner

Followers 0

1 Comment

Recommended Comments

Steve Turner 34

Posted 26 October, 2020

Now I have read the full report I'm even more appalled. Three things stand out for me:

Firstly, the need for urgent action to promote safe prescribing especially around prescribing competence and use of the Mental Capacity Act.

Secondly, the need for an Executive Lead on CCGs for the LeDeR Reviews. I would ask all involved to check if your CCG has implemented this.

Thirdly, the apparent inappropriate deference to the coroner's verdict, and they way in which this was used to protect reputations. at the expense of patient safety.

In 2019 I gave a talk (see video) to the national NICE Medicines & Prescribing Team. It was based on Oliver's story / #oliverscampaign .

I always wondered if I may need to change this talk in the light of new information that comes to light. Did I miss something? Was I being unfair in discussing the possible failings of governance & best practice in prescribing, and failure to follow the Mental Capacity Act? It seems I was not.

Options

0 reactions so far

Edited 26 October, 2020 by Steve Turner

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!
Register a new account

Sign in

Already have an account? Sign in here.
Sign In Now

"Autistic Bristol teenager Oliver McGowan's death was avoidable" – new independent review into Thomas Oliver McGowan’s LeDeR process

Summary

Content

1 Comment

Recommended Comments

Create an account or sign in to comment

Create an account

Sign in

About Us

My Hub

Important Information