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
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.