A grieving mum and dad turned detective to expose what they believe is an NHS cover-up over their teenage son’s death.
Tom and Paula McGowan claim a report into the death of mildly autistic Oliver, 18, was altered.
He died after an allergic reaction to anti-psychotic drugs they say he should never have been given. The parents say they repeatedly told staff about his allergy.
But they say he was given the drugs three times.
They watched in horror as Oliver – a high-achieving pupil and school prefect – deteriorated rapidly.
He suffered hallucinations, endured dozens of seizures and was, they allege, restrained aggressively by NHS staff “in attack mode”.
The couple say they applied for paperwork via the Freedom of Information Act after authorities failed to take responsibiity.
They uncovered a draft report which originally questioned why Oliver was wrongly given the drugs.
Tom said: “This looks like a cover-up. The final report has been watered down because it seems no one wants to question the system.”
The Sunday Mirror has seen initial findings of an NHS probe in which one question asks: “Was the death, on balance, potentially avoidable?”
A box below is ticked “Yes”. But in the published version the same box is blank and key passages are changed.
Teacher Paula, 53, and Air Force squadron leader Tom, 50, now want a fresh inquest into Oliver’s death, taking in their new evidence.
Paula said: “As he lay dying, we made a promise to Oliver this would never happen to anyone else.”
Oliver, who also suffered from epilepsy and mild cerebral palsy, endured “catastrophic” brain damage after being given olanzapine while being treated for a seizure.
The drug is usually used to treat schizophrenia and bipolar disorder.
His parents say they had repeatedly begged doctors not to give it to him.
At an inquest, the coroner did not blame medics. But a Learning Disabilities Mortality Review (LeDeR) was ordered and conducted by the local Clinical Commissioning Group.
An early draft of its report said: “It remains unclear exactly how this clinical decision was arrived at or the underpinning rationale.
"The family did not feel listened to, despite their efforts to have theirs and Oliver’s wishes heard and understood.”
Documents show the report was edited four times before its release. The above passages were altered and conclusions of the final version are different from the original.
The final report reads: “The coroner found the death unavoidable and actions taken by the clinical team were reasonable.”
In a rare move, NHS England has stepped in to probe the investigation process. Paula said it was “astounding” how different the two reports are and she questioned why the first inquest was not conducted with a jury.
Oliver – who hoped to run the 200 metres for Britain in the Paralympics – developed health problems after suffering meningitis as a baby.
He was taken to Bristol Children’s Hospital in late 2015 following a mild epileptic seizure.
His family say doctors mistook his autism symptoms for a psychotic episode and gave him olanzapine for the first time.
Paula, also mum to Adam, 26, and Heather, 23, said: “The reaction was so severe – he was biting his skin, sweating, shuffling.
"Oliver started hallucinating. It was horrific. We demanded it was stopped. I saw him nearly die of meningitis but what I observed that day was far worse.”
Paula and Tom claim the drug caused Oliver, briefly, to have 30 seizures a day – despite the fact he typically had just two per month.
“His reaction to the drug was filed in his notes and a consultant psychiatrist concluded there was “no clear evidence” he suffered from psychosis.
But when Oliver went back to hospital in May 2016, after more seizures, he was given the antipsychotic drug haloperidol.
Heartbreakingly, he was restrained by medics while clutching his mum.
Paula said: “He had his arms around me to hug me. Staff jumped on to him and restrained him and threw him on a beanbag.
"We were shocked, frightened. It was a very aggressive reaction, like they were in attack mode.”
Oliver was taken to hospital one final time in October, 2016, after a seizure. Choking back tears, Paula said: “I took my son to hospital with a mild seizure and he ended up dead.
“He told me he’d only go if they didn’t give him drugs. He said ‘They mess with my brain, don’t give them to me’. I promised they wouldn’t and got the documents to show he was allergic.”
Oliver was placed in a coma at Bristol’s Southmead Hospital to allow doctors to run tests. Within days, he developed double pneumonia and sepsis .
Paula added: “Oliver was looking blue and puffed up. The doctors were saying, ‘It’s fine, it’s the lighting’. He was having seizures, jerking off the bed. Something was going badly wrong in his brain.”
Oliver’s parents learned he had again been given olanzapine, despite being unconscious. Doctors later said it was to “prevent behavioural disturbance” when he came round.
Paula said: “We’d done everything to stop this but they still gave him the drug.”
Five days later, Paula and Tom were told Oliver needed an op on his severely swollen brain.
Tom said: “He’d had a strong allergic reaction to the drugs, like we’d predicted. We felt shock and disbelief, it was like being punched in the face.”
Scans later showed “catastrophic and irreversible brain damage”.
Oliver’s life support was switched off and he survived four days before dying on November 11.
Paula said: “We talked to him and played his favourite James Arthur song, Don’t Let Go. His body was so strong, I kept stroking his head, hoping he’d wake up.”
At an inquest last year, assistant coroner Dr Peter Harrowing said the drug was a “significant contributory factor” in Oliver’s death but concluded medics could not have predicted his “very rare” reaction to it.
Oliver was buried near his childhood home and his parents commissioned a stained glass headstone with five poppies – to represent each family member and the fact he died on Armistice Day.
The McGowans now live in Australia but are campaigning for NHS staff to be trained to understand behavioural effects of conditions like autism.
Paula said: “We’ll never get over his death, it’s like a light has gone out. We want to make sure it doesn’t happen to another family.”
Health officials expressed sadness at Oliver’s death and pledged to continue improving care.
The CGC declined to comment on why the two final reports differed, but said: “We are grateful to his family for working with us.”
North Bristol NHS Trust said: “As the coroner concluded, the treatment was properly prescribed and Oliver sadly suffered a rare side effect that could not have been predicted.”
University Hospitals Bristol NHS Foundation Trust added: “We fully recognise the importance and value LeDeR reviews have in improving care.”
For more information on Oliver’s case, visit olivermcgowan.org
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