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Last week, the NHS published the findings of an independent review about the death of Oliver McGowan. The review has been a long time coming, and is essentially a review of a review. Oliver’s story is a stark example of why various levels of review are essential to protect patients who use the NHS. It also poses questions about whether the culture in the NHS promotes learning from mistakes.

The story of Oliver McGowan

Born strong and determined

Oliver was born a month prematurely. Only three weeks into his short life he developed meningitis. He was so poorly that doctors told his family that they didn’t think he would survive. But against all odds, he did. Only to go on and develop a second episode of meningitis, weeks later.

He managed to fight off the second bout of meningitis, but developed further complications. Oliver now had mild hemiplegia, focal partial epilepsy and a mild learning disability. He later found out he had high functioning autism.

Fast forward to October 2015

Oliver was now a vibrant teenager, but went to hospital after experiencing partial focal seizures. His parents were surprised that he was given antidepressants to treat symptoms of anxiety. They noticed his moods and seizures increased as the dosage increased. He was eventually forced to return to hospital in December 2015, when he was given antipsychotic medication. His family said this had a “catastrophic” effect on him.

His condition deteriorated to the point where his parents barely recognised him. Both he and his parents were concerned about Oliver’s treatment, thinking the drugs were causing him to deteriorate. The hospital therefore held Oliver against their will, under the Mental Health Act, for a period of time.

The hospital eventually stopped the medication when they couldn’t find a psychiatric bed for Oliver. This resulted in his mood and seizures quickly returning to a normal level so he was allowed to go home. The consultant Psychiatrist who discharged Oliver recorded that he was sensitive to antipsychotic medication.

Despite this, he was given antipsychotic medication again when he returned to the hospital with seizures. One day, his parents walked in to find him having a Oculogyric Crisis. His moods worsened; as did his seizures. Additionally, he started to have problems he’d never had before; problems with urination, high blood pressure and sweating.

He was initially treated at an adult hospital where they used physical restraint, along with different antipsychotic medication. He was eventually transferred to a specialist Psychiatric Intensive Care Unit.

Their different approach had an almost immediate improvement. They began by reducing his antipsychotic medication, meaning he could now be treated by a specialist learning disability team. They called out his sensitivity to antipsychotic and benzodiazepine in a letter.

October 2016

In October 2016 Oliver had a cluster of partial seizures. When they arrived at the general hospital, his parents gave them documentation about Oliver’s previous treatment. This included details of his previous reactions to antipsychotic medication. The hospital even noted this on his care charts in bold.

Oliver developed pneumonia and was sedated. The hospital seemed to recognise bringing Oliver out of sedation might be scary for him, waking up in an unfamiliar setting with tubes in his throat. They therefore began to plan with his family how to manage any anxiety. Unfortunately, the hospital did not stick to the plans.

A neuropsychiatrist asked Oliver’s parents about giving him antipsychotic medication. His parents made it clear that they did not consent to this because of his previous reactions. This was in addition to Oliver previously telling staff that he did not want antipsychotic medication because of the effect it had on him.

However, that evening Oliver received another antipsychotic drug, olanzapine. His parents continued reiterating that this was not with their consent.

Over the following days Oliver’s condition declined. He was diagnosed with Neuroleptic Malignant Syndrome, a rare and serve reaction to antipsychotic medication.

By the time of the diagnosis, it was already so bad that he would be left with significant brain damage; an inability communicate, reliance on a tracheotomy and feeding tube and a loss of mobility due to paralysis.

A week later, in November 2016, his parents and the medical team had to face the tough decision to turn off his life support and Oliver passed away.

Was Oliver McGowan’s death avoidable?

Oliver’s parents always felt like his death was avoidable and sent an email raising concerns and asking for an investigation. This led to an internal root cause analysis in February 2017.

In May 2017 Oliver’s mum also sent an email to STOMP (stopping over medication of people with a learning disability, autism or both with psychotropic medicines). This triggered a Learning Disabilities Mortality Review (LeDeR) process, which began in June 2017. It took until November 2018 for them to publish this report.

Meanwhile, between September 2017 and December 2017 the Trust followed their formal complaints process; completing an internal safeguarding investigation in November 2017; and in April 2018, a coroner ruled at an inquest, that the use of antipsychotic medication was ok.

The coroner ultimately made no recommendations, but it transpired that the doctor who administered Olanzapine “might have” apologised to Oliver’s mum afterwards. And told her “you were right all along” (about Olanzapine not being suitable).

A review of the review

Oliver’s family felt there had been a lack of transparency when the LeDeR was published. So in 2019 NHS England and Improvement launched an independent review.

They found a number of failings, including:

  • Asking a new and inexperienced member of staff to conduct the LeDeR
  • The person responsible for the review having too much work
  • The lack of an independent serious investigation

The full review details other failings too, but one of the most damning focuses on the answer to the question in the LeDeR “was the death potentially avoidable?”

Minutes from a Multi-Agency Review (MAR), stated that the answer to the question was “yes”. But, it transpired that this was never properly debated at the MAR, and some people even avoided answering. Given that the purpose of the MAR “is to identify avoidable contributory factors to the person’s death and any learning points and actions”, it’s hard to understand why this happened.

The family think the question wasn’t asked because of the defensiveness of the hospital’s representatives.

Undue pressure

Even more worrying, perhaps, was pressure being applied to the reviewer to reach a desired outcome. After the MAR, she felt pressured, to the point of being “bullied” to say that the death was not potentially avoidable. The legal team even told her that ticking the box which said that the death was potentially avoidable would put the Trust and the CCG “in the firing line”.

The initial review did not say that the death was potentially avoidable. Instead, it heavily relied on the coroners verdict. But the nurse who completed the report said; “I did what I was told, I had no one to talk to, I was forced to compromise my values, I am proud to be a nurse, I feel very ashamed by this and I will have to live with it”. She said that she would have lost her job had she not complied with the request.

Although the NHS’s investigations have now concluded, the police’s investigation continues.

Learning is essential

Occasionally, reviews, claims and investigations are criticised, for being time consuming and costly. But at the same time, the NHS openly recognise the importance of being able to learn from their mistakes. Victims, and their families rely on them too. Investigations give much needed answers and compensation can be a vital lifeline, to counteract the cost of loss, or injury.

But to say the systems we have are perfect would be naive. The fact that a review of a review was needed in this case is evidence of that. So, how can it be fixed?

A recurring theme appears to be a reluctance to recognise mistakes. Of course the starting point should be to avoid mistakes, at all costs. As medical negligence solicitors, we are very aware of the life changing consequences they cause. But we also appreciate that when genuine mistakes happen, they should not be something to be ashamed of. We all make them.

The investigation process should act as an opportunity to make amends; though difficult, being honest will prevent future mistakes. Likewise, compensation is not a punishment; it is to help victims of a mistake to cope with their life.

The vow to “do no harm” should not not end when the patient leaves hospital. It should apply to all interactions with the health service. Flawed attempts to cover up mistakes are not only unhelpful, but by eroding trust, they are counterproductive and harmful to people who are already victims.

But maybe us service users have a part to play too. We place health workers on a pedestal for the superhuman feats they perform. But we’d do well to remember that they’re only human, and humans make mistakes. Maybe less pressure to be flawless will promote honesty when things do go wrong?

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