20 April 2018

Before HM Assistant Coroner Dr Peter Harrowing
Sitting at Avon Coroner’s Court
Monday 16 April to 20 April 2018

The inquest into the death of Oliver McGowan has today concluded, with the coroner finding the care which led to his death was “appropriate”, despite his parents having made clear directions that Oliver was not to be given antipsychotics due to his previous reactions.  

Oliver McGowan lived with cerebral palsy, epilepsy, autism and learning disabilities and died aged 18, on 11 November 2016. This was found to be due to a combination of pneumonia and hypoxic brain injury in Southmead Hospital, Bristol. The brain injury was caused by seizures and Neuroleptic Malignant Syndrome (NMS), an adverse effect of antipsychotic medication, Olanzapine.

The coroner, Dr Peter Harrowing, concluded that Olanzapine had been properly prescribed, and that the occurrence of NMS could not have been predicted as it was a “very rare adverse effect”. The family however believe Olanzapine should never have been prescribed, and had specified throughout Oliver’s care that he should not be given anti-psychotic medication such as this. Their wishes were ignored. The family believe the hospital not meeting Oliver’s needs on arrival increased his distress, where there was a lack of reasonable adjustment for people with learning disability and autism. They also believe alternatives to antipsychotics should have been properly explored.

It is a widely recognised issue that many people with learning disabilities are being over medicated. Oliver’s family support the NHS campaign STOMP on Stopping over medication of people with a learning disability, autism or both.

Paula McGowan, Oliver’s mother said: We are extremely disappointed by the Coroner’s conclusion. We found the inquest process to be frustrating and disheartening, with North Bristol NHS Trust adopting a defensive approach and the coroner being ferociously protective of the doctors who treated Oliver.

We remain adamant that Oliver would not have died if he had not been administered the Olanzapine, which we expressly forbade, that the coroner found triggered the NMS, a significant contributory factor to his death.

It is clear from the evidence that no reasonable adjustments were made for Oliver in A&E on his arrival at Southmead Hospital. We believe this environment heightened his anxiety and was not appropriate for a teenager with autism and a learning disability.

Nothing will bring our vibrant son Oliver back, but we have clung on to the hope that the doctors at Southmead hospital would learn from their mistakes. We were therefore horrified that during her evidence, Dr Monica Mohan who prescribed the fatal doses of anti-psychotic medication said ‘I would do it again’, irrespective of our express wishes -   and without further consultation with professionals who knew Oliver best - having acknowledged that we were ‘right all along’.

We sadly still consider that the doctors who treated Oliver were arrogant and dismissive of Oliver’s particular needs and we are therefore distressed and concerned that the coroner has made no recommendations to avoid future deaths.

We would like to put on the records out thanks to our barrister Anthony Metzer QC, who acted pro bono, McMillian Williams solicitors Bellamy Forde and Fleur Hallett, and the support we received from Mencap and INQUEST.”

Deborah Coles, director of INQUEST said: “It should not be left to grieving families to fight for answers and the necessary scrutiny of systemic failings in the care of learning disabled people. As a society we should all be grateful to families like Oliver’s, who have worked tirelessly for accountability and learning so that future deaths are prevented. Unlike the State whose legal representation at the inquest is paid for by the public purse, Oliver’s family, like many others, were denied funding. They were denied a more thorough enquiry, by way of an article two inquest or jury, despite the best efforts of their legal team.

Evidence at the inquest showed that Oliver’s family were ignored by professionals responsible for care, a familiar pattern we see in our work on state related deaths.  We must not let them be ignored now. Systemic and cultural change can only happen when these deaths receive the scrutiny they deserve. This inquest has shone a light on the over medication of learning disabled people, which is a widespread issue that must be addressed to stop yet more preventable deaths.”



For further information and interview requests, please contact Lucy McKay here

INQUEST has been supporting the family of Oliver McGowan since his death. The family is represented by INQUEST Lawyers Group members Bellamy Forde of McMillan Williams Solicitors and Anthony Metzer of Goldsmiths Chambers.

The interested parties represented at the inquest are the family and North Bristol NHS Foundation Trust.

A useful daily overview of the inquest was reported in Bristol Live.

Background and further information:

  • Oliver’s family describe him as having a can do attitude and being a natural leader. Oliver had been suffering from partial seizures for some time and had been in and out of hospital receiving treatment. Oliver’s condition worsened in October 2016 and he was admitted to Southmead Hospital. More info in the opening media release.
  • Oliver’s family support the NHS campaign STOMP on Stopping over medication of people with a learning disability, autism or both.
  • The Learning Disabilities Mortality Review Programme was commissioned by the NHS in 2015. Oliver’s death has been included as part of this review. This review programme was one of the key recommendations of CIPOLD.

  • People with learning disabilities have poorer health and shorter life expectancy than those without. The latest statistics from NHS digital found that males with learning disabilities had around a 14 year shorter life expectancy than the general population.
  • Epilepsy is more common in people with a learning disability than in the general population. About 1 in 3 people (32%) who have a mild to moderate learning disability also have epilepsy. The more severe the learning disability, the more likely that the person will also have epilepsy. (Epilepsy society)
  • 42% of deaths of learning disabled people are considered to be premature, and over a quarter are amenable to better-quality healthcare, found the first largescale inquiry of its kind published in 2013, The report of the Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD).