A hospital trust has promised to improve training for staff after the death of a teenager with mild learning difficulties who was given antipsychotic medication even though he and his family had warned that the medication could cause him serious harm.

Talented athlete Oliver McGowan, who had epilepsy, cerebral palsy and autism, died at Southmead hospital in Bristol after being given a drug for schizophrenia and bipolar disorder.

During an inquest at Avon coroner’s court his family said that both they and the 18-year-old had implored doctors not to administer olanzapine. McGowan’s father, Tom, said his son had told those treating him: “Please do not give me antipsychotics, I don’t like them, they mess with my brain.”

But the teenager was given the drug and suffered a severe brain injury. His parents gave permission for life support to be withdrawn after being told that if he survived he would never walk again, be blind and have no memories or language.

Giving his conclusion, the assistant coroner Dr Peter Harrowing said olanzapine was a “significant contributory factor” to the teenager’s death. But he said the drug had been properly prescribed, and that the occurrence of the condition neuroleptic malignant syndrome (NMS) could not have been predicted as it was a “very rare adverse effect”.

Speaking afterwards, McGowan’s mother, Paula, said the family was extremely disappointed by the 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,” she said.



“We remain adamant that Oliver would not have died if he had not been administered the olanzapine, which we expressly forbade.

“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.”

She said she was horrified that the consultant neuropsychiatrist who prescribed the olanzapine, Dr Monica Mohan, said she would do the same thing again.

Sue Jones, the director of nursing and quality at the trust, said: “As the coroner heard Oliver was very ill when he arrived at our emergency department with his epilepsy becoming increasingly difficult to control.



“This was a very complex case, our staff had to make some very difficult treatment decisions, and did their very best at every stage of his care.

“The coroner has been fully supportive of the care given by staff who acted in Oliver’s best interests. As said by the coroner, Oliver sadly suffered a rare side-effect of a treatment that was properly prescribed and the side effect could not have been predicted.”

She added that the trust would learn from the case, saying: “We will be taking part in a multi-agency learning disabilities mortality review to see how all the local health and care organisations involved in Oliver’s care can further improve services.

“But more immediately, we will be seeking to improve autism training for staff, appointing a clinical lead for learning disabilities and reviewing how we support young people making the transition from children’s services to adult.”



Deborah Coles, the director of the charity Inquest, which supported the family, said: “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.”

• This article was corrected on 21 April 2018. Dr Monica Mohan is a neuropsychiatrist, not a neuropsychologist as stated in an earlier version.

