The death of an autistic teenager who was prescribed medication against his and his parents’ wishes was “potentially avoidable”, a report has found.
Oliver McGowan, 18, died at Southmead Hospital in Bristol in November 2016 after being given the anti-psychotic Olanzapine and contracting neuroleptic malignant syndrome (NMS) – a rare side-effect of the drug.
In 2018, Dr Peter Harrowing, the assistant coroner for Avon, concluded that the Olanzapine had caused Oliver to suffer from NMS, which was “a significant contributory factor” in his death.
An independent review, published on Tuesday, has found that the fit and healthy teenager’s death was “potentially avoidable”.
North Bristol NHS Trust said staff who cared for Oliver “did their very best” and “sought to give him the best possible treatment”.
Oliver’s parents, Paula and Tom McGowan are calling for his inquest to be reopened and say their son died “as a result of the combined ignorance and arrogance of doctors” who treated him.
The teenager was admitted to Southmead Hospital on October 22 2016 after suffering a seizure and was intubated and sedated.
He was prescribed Olanzapine on October 25 to manage any potential psychosis when he woke up, despite his parents insisting that he should not be given the drug.
The learning disability mortality review (LeDeR) into Oliver’s death concluded: “There was a general lack of understanding and acknowledgement of Oliver’s autism and how Oliver presented himself when in seizure.
“Despite there being a body of written evidence – alongside verbal requests from Oliver and Oliver’s family – not to prescribe Olanzapine, there was no substantial evidence to illustrate that consideration had been given to explore alternatives to anti-psychotic medication.
“Additionally, given the circumstances and contentions from Oliver’s family, a multi-disciplinary best interest meeting should have taken place, and been fully documented in Oliver’s notes, in order to seek collective viewpoints of all professionals, together with family, in order to both assure and safeguard subsequent decision making.”
In July, Avon and Somerset Police confirmed that officers were investigating the circumstances behind Oliver’s death.
Oliver, from Emerson’s Green, Bristol, contracted meningitis twice during childhood and suffered with epilepsy, learning difficulties and autism as a result.
An initial CT scan when he was admitted to Southmead Hospital on October 22 did not show any changes to his brain.
After the Olanzapine was administered, Oliver’s temperature rose and he showed signs of NMS.
The medication was stopped on October 28 and a CT scan two days later showed Oliver had sustained a serious brain injury. He died on November 11.
Following a five-day inquest in April 2018, Dr Harrowing concluded that it was “appropriate” for Oliver to have been prescribed Olanzapine.
Mr and Mrs McGowan said they had “always known” that Oliver’s death was avoidable.
“It is our opinion that, Oliver died as a result of the combined ignorance and arrogance of doctors who were treating him,” they said.
“Doctors who refused to listen to Oliver’s direct instructions and us, his parents, who knew him best, and who did not act in his best interests.
“Oliver died due to a combination of prejudice, subconscious bias and diagnostic errors overshadowing treatment decisions by those caring for him.”
They said Oliver died from the “combined failings” of doctors mismanaging his care as an autistic high-functioning young person, administering Olanzapine against his wishes and failing to recognise the symptoms of NMS in intensive care.
“Oliver had a right to a life, his life mattered,” they said.
Fiona Richie OBE, who chaired the independent review into Oliver’s death, thanked the health and care practitioners who contributed to the report as well as Oliver’s parents.
“We hope the completion of Oliver’s LeDeR, nearly four years after his death, 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,” she said.
The report found that if a quiet area had been provided for Oliver – rather than an emergency department on a Saturday night – there may not have been a need to sedate and intubate him.
Oliver’s family are now pursuing a civil claim against North Bristol NHS Trust and calling for the reopening of the inquest, law firm FieldFisher said.
Andrea Young, chief executive of North Bristol NHS Trust, said it was committed to continue learning and would act on the report.
She said the staff who cared for Oliver “did their very best”, made decisions to weigh up all the risks and “sought to give him the best possible treatment”.
“We are determined to offer exceptional care for individuals with learning disabilities and autism and we have already significantly improved training and support for staff,” she said.