• NHS England to issue new guidance to CCGs on LeDeR process
  • Shadow health minister calls on Simon Stevens to ensure reviews are “completely independent”
  • CCG staff altered Oliver McGowan’s LeDeR review to remove suggestions his death was avoidable

NHS England is to issue new guidance to clinical commissioning groups in the wake of an alleged cover-up of a teenager’s avoidable death.

The national body said it would be issuing new advice to CCGs to make clear how they should be using the Learning Disabilities Mortality Review process following the revelations in HSJ about the handling of 18-year-old Oliver McGowan’s mortality review.

It comes as shadow health minister Barbara Keeley MP has written to Simon Stevens demanding a new review for Oliver’s parents and for CCGs to be removed from the process.

Emails seen by HSJ revealed Bristol, North Somerset and South Gloucestershire CCG staff rewrote parts of Oliver’s LeDeR mortality review to remove suggestions his death at North Bristol Trust in 2016 was avoidable. The emails showed staff not involved in the original expert panel discussing how to edit the review based on advice from the CCG’s lawyers.

HSJ understands NHS England will be reopening Oliver McGowan’s LeDeR review. His parents have asked for it to be reconsidered from the point at which the panel concluded his death was avoidable and before the CCG intervened.

In her letter to Mr Stevens, Ms Keeley said the revelations about how Oliver McGowan’s LeDeR review had been handled “raised serious concerns about the integrity of the process”.

She added: “It is not acceptable that the CCG which was responsible for Oliver’s care should be able to make these changes outside of the recognised process, with changes made by staff who had not received training.

“Additionally, a member of the CCG staff is quoted as saying in an email about this review ‘have endeavoured to remove anything that seems to indicate any sort of blame’. This is a clear example of the CCG marking its own homework and attempting to protect its own reputation rather than to discuss the causes of Oliver’s death honestly.

“If this can happen in one review in one CCG, it can happen in others.”

The Labour MP told Mr Stevens it called into doubt the data being published about learning disabled deaths via the annual LeDeR report compiled by Bristol University.

She called on Mr Stevens to take personal responsibility for ensuring Oliver’s review was re-examined transparently.

She also called for action on the wider weaknesses in the LeDeR process, saying Mr Stevens “must also address the systemic issue of CCGs having responsibility for reviewing deaths which happened on their watch”.

She added: “It is clear that the current process is open to abuse by people looking to evade responsibility rather than learn the lessons of early deaths.”

The mortality reviews must be “completely independent,” she said.

An NHS England spokesman told HSJ: “The NHS is committed to improving care for people with a learning disability, autism or both.

“We will shortly be issuing national guidance making clear the difference between LeDeR reviews and coroners’ processes as well as dealing with other issues highlighted by the Oliver McGowan review.

“We have also offered to meet with Barbara on these matters and will be replying to her letter.”