• Fiona Ritchie to lead new review into death of Oliver McGowan
  • Review will be overseen by Celia Ingham Clark
  • HSJ previously revealed CCG staff altered 18-year-old’s mortality review to remove suggestions his death was avoidable

An independent review is to be held into the death of a teenager after a clinical commissioning group interfered in an earlier investigation.

NHS England has confirmed Fiona Ritchie will lead a new review into the death of Oliver McGowan. The 18-year-old died in 2016 after he was given anti-psychotic medication against his own and his parents’ wishes and despite medical records showing he had an intolerance to anti-psychotics.

Earlier this year, HSJ revealed Bristol, North Somerset and South Gloucestershire CCG staff rewrote parts of a learning disability mortality review to remove suggestions Oliver’s death was avoidable.

His parents, Paula and Tom McGowan, obtained internal documents from the CCG showing how staff altered the documents from final to draft and discussed how to alter sections of the report they felt were inappropriate.

This was after an expert review panel had considered Oliver’s case and concluded his death was avoidable.

NHS England has now committed to a new review of Oliver’s case which will also feed into a review of the wider learning disability mortality review process amid concerns they lack independence.

Ms Ritchie is a former national lead for learning disabilities at the Healthcare Commission, a forerunner to the Care Quality Commission, and was awarded an OBE for services to people with learning disabilities in 2009. She has been managing director for mental health and learning disabilities for social enterprise Turning Point since 2012.

The review will be overseen by Celia Ingham Clark, NHS England’s medical director for professional leadership and clinical effectiveness.

The review will also include a panel of experts as part of an oversight group to provide specialist clinical input.

Speaking to HSJ, Oliver’s father Tom said: “We now hope for an open and honest investigation into the circumstances surrounding Oliver’s death. It is a real shame we have had to work this hard just to try and get to the truth.

“This also calls into question the whole LeDeR process ‘as-is’ and the validity of the current LeDeR conclusions. How many other potentially avoidable deaths have not been accurately recorded and/or investigated?”

Oliver’s mother Paula added: “We should never have had to fight as hard as we have. We are happy that Oliver’s LeDeR will now at long last be re-reviewed but the journey getting to this stage has been barbaric. We should never have had to get freedom of information requests to reveal the lies and corruption that has taken place from Bristol CCG to cover Oliver’s death up.

“Due to what we have uncovered, we have to sadly conclude that there will be other deaths investigated by LeDeR that will have reached the wrong decisions as Oliver’s.”

Ms Clark said: “This important review will ensure that Oliver’s family get the answers they need and deserve.

“The findings of this independent review will also help inform the ongoing assessment of existing guidance and ‘learning from deaths’ process nationally, so that we can continue to learn and improve future care.

Ms Ritchie added: “Now is our opportunity to get to the facts of Oliver’s tragic and untimely death, ensuring any learning is identified and enacted throughout the NHS.

“We too often see premature deaths of people with learning disabilities which should shock society and we must do things differently to change this. The panel and I will do our utmost to drive this forward.”