Insight

Why the NHS

and they’re not getting it.”
Oliver died in November 2016
after suffering partial seizures. As
well as leaving behind parents Paula

must change
and Tom, he left a sister, Heather,
23, and a brother, Adam, 26.
His death from neuroleptic
malignant syndrome (NMS) is one
of a number of high-profile NHS
tragedies involving people with
learning disabilities.
When autistic teenager Oliver McGowan was
All died in NHS care
admitted to hospital, he and his family told As well as Oliver, Josanne
Wadsworth, 31, Richard Handley,
doctors not to give him an antipsychotic. 33, Connor Sparrowhawk, 18, and
Judith Benn, 54, all had learning
But they went ahead anyway and Oliver died. disabilities and all died in NHS care.

Now, his mum Paula tells Darren Devine of

The deaths all resulted in
investigations and left serious

her campaign to ensure all NHS staff receive question marks over the quality of
their care.

training in autism and learning disability
Paula and Tom McGowan watched
son Oliver go from being a
paralympian hopeful to lying intubated
and clinging to life in hospital.
He was suffering from a severe
allergic reaction to olanzapine, an
antipsychotic medication.
Southmead Hospital in Bristol gave
him the drug against his own
wishes and those of his family. This
followed Oliver being trialled on an
antipsychotic a year earlier and
reacting badly.
As Oliver was lying in his
hospital bed on a life support
machine, doctors told his parents
he would never walk again, be
blind and have no memories or
language. They took the
heartbreaking decision that their
18-year-old son’s life support could
be withdrawn.
Lasting NHS change
But the family is now working to
ensure that Oliver’s death sparks
lasting NHS change.
As well as being impacted by
autism in a relatively minor way,
Oliver had epilepsy, a mild learning
disability and cerebral palsy. Paula
believes that if Southmead Hospital
had made reasonable adjustments
it would have saved his life.
In the wake of the tragedy,
Paula and husband Tom started a
petition to prevent avoidable
deaths by making learning
disability and autism training
mandatory for all NHS staff. It had
gathered more than 44,000
signatures by the time this issue of
Autism Eye Magazine went to press.
Paula, a primary school teacher,
and Tom, a senior RAF officer, say
they have been “overwhelmed” by
support, especially from medics.
Paula says: “I’ve been approached
by many, many doctors and
nurses now, all saying the same
thing – that they support
the petition, they
believe that they
want the
training and
they need
the training
Oliver McGowan was “just a nice
young lad”, below left. After he
was admitted to hospital and given
olanzapine his appearance changed
rapidly. His father says he developed
a blue pallor around his eyes and
mouth, but doctors said “it was the
lights”. Then, two days later, when
the family said his appearance
looked swollen they were told “it was
probably water retention”. The inset
picture, right, shows Oliver’s right
hand, where a cannula was removed
and the wound became infected. His
father says that Oliver contracted
Methicillin Sensitive Staphylococcus
Aureus (MSSA), a bacterium on the
skin, “for no reason” and thinks the
wound was the source.
And earlier this year the
Learning Disability Mortality Review
(LeDeR) highlighted how those with
learning disabilities die 15-20 years
Until people like
Oliver and
Connor are seen as
fully human, health
care is not going to
improve, sadly”
earlier than the general population.
Dr Sara Ryan, Connor
Sparrowhawk’s mother, fought a
lengthy battle after her son
drowned in a bath when he was
left unsupervised in an NHS care
unit. She says: “Until people like
Oliver and Connor are seen as fully
human, health care is not going to
improve, sadly.”
Hospital passport ignored
Paula says she gave staff Oliver’s
hospital passport, describing how
his autism and learning disability
affected him and detailing
reasonable adjustments needed.
However, she says it was “placed
in a drawer without a glance”.
Among the problems Oliver
encountered during his hospital
stay was having several doctors
speaking to him at once while
using complex language. Also,
Paula says when her son wanted to

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Happier days:
Oliver with
brother Adam
and sister his behaviour when he the drug was “one of the
Heather, above, woke. However, the contributing factors” in Oliver’s
and having family, who live death. She told Paula she “might
fun with mum between Bristol and have been right” to warn her about
Paula, right. New South Wales in the drug.
A World of Possibilites Top right: a
young Oliver
Australia, say Oliver did
not have challenging
The doctor is reported as
saying: “I take responsibility. I
surfing in 2008 behaviours. prescribed olanzapine, but I don’t
He never woke from the know that I’m responsible for
SpaceKraft design and Oliver was just a sedation as he developed the NMS anything else that happened.”
that saw his brain swell after the The Department for Health and
install a full range of nice young lad. antipsychotic. Social Care (DHSC) say they want
He played for the
sensory environments.
Paula adds: “Oliver was just a staff trained to support people with
nice young lad. He played for the learning disabilities and autism.
cerebral palsy England cerebral palsy England football
football squad and squad and was training to be a Consistent approach
To find out more or to was training to be
paralympian.
“He was the president of the
The DHSC commissioned both
Skills for Health and Health
receive a free catalogue a paralympian” school council at college. He was
a school prefect.”
Education England, which oversee
the training of NHS staff, to
please call us on: walk around, a normal part of his Gravely concerned
develop core skills and a
consistent approach to people with
seizure activity, he was restrained The mother is “gravely concerned” learning disabilities. This saw a

Tel: 01274 581007

and this heightened his anxiety.
The family say while in an
ambulance Oliver made it very
clear he did not want antipsychotic
medication. When trialled on an
antipsychotic a year earlier Oliver
endured hallucinations, an increase
in seizures and tore his skin.
Paula says A&E doctors wrote
‘antipsychotic medication’ in red in
the allergies box on all of Oliver’s
intensive care unit 24-hour care
charts. Oliver was eventually
sedated, but a few days later
doctors used olanzapine to control
Or visit our website Visit this page to see and sign Oliver’s petition:
https://petition.parliament.uk/petitions/221033
www.spacekraft.co.uk
for any autistic youngster who
displays challenging behaviour if
doctors are so quick to reach for
antipsychotics when dealing with
someone as placid as Oliver.
Paula stresses her son was
assessed by two different senior
consultant psychiatrists as not
having a mental health disorder.
At an inquest into Oliver’s death,
assistant coroner Dr Peter
Harrowing ruled olanzapine was a
“significant contributory factor”. But
he also ruled the drug was properly
prescribed and that the NMS could
not have been predicted.
According to a BBC report of
the inquest, Dr Monica Mohan, the
consultant neuropsychiatrist who
prescribed olanzapine, admitted
framework published in 2016,
setting out essential skills. The
DHSC has also commissioned a
core skills framework for autism.
In a statement, the DHSC said
the framework should equip staff
“for roles that have regular contact
with autistic people”.
A North Bristol NHS Trust
spokesperson said their staff “had
to make some very difficult
treatment decisions” while caring
for Oliver and “did their very best
at every stage”.
The spokesperson added: “We
remain committed to continue
improving the way we care for
people with autism and learning
disabilities, making reasonable
adjustments for each individual.”

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