NHS announces top clinician and independent expert to oversee review into death of Oliver McGowan

A leading expert on learning disability services will work with a respected NHS leader to review the circumstances and lessons of the death of Oliver McGowan, a young teenager with learning disabilities.

The NHS has today announced that Dr. Celia Ingham Clark MBE, England’s medical director for professional leadership and clinical effectiveness, will oversee the completion of the learning disability mortality review (LeDeR) of Oliver’s death.

Fiona Ritchie, OBE an independent consultant, will chair the review which aims to ensure there is the necessary learning from deaths of people with a learning disability, working with the McGowan family.

Ms Ritchie, the independent chair, will now take forward – with the family and Dr. Ingham Clark – finalising the terms of reference for review and overseeing the completion.

Following agreement with Oliver’s family, further experts will join an oversight group, which will provide specialist clinical input and advice as needed to Ms Ritchie ensuring that the review process is thorough and the final findings are robust.

Oliver’s parents, Paula and Tom McGowan, said: “We continue to work with NHS England on the re-review of Oliver’s LeDeR. We welcome the decision to firstly carry out this review from the MAR minutes and Version 1 of Oliver’s original LeDeR report and supporting evidence. That report identified that Oliver’s death was potentially avoidable, and secondly the appointment of the oversight group who will handle the review entirely within NHS England independently of the Bristol CCG. We very much hope that we will be listened to throughout this process and that the causes of Oliver’s death will, at last, be fully investigated. Once completed we welcome, and indeed firmly believe in, the urgent need for NHS England to address failings identified with the LeDeR process highlighted by Oliver’s LeDeR review.”

Dr. Celia Ingham Clark MBE, NHS medical director for professional leadership and clinical effectiveness, 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.”

Fiona Ritchie OBE said: “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.”


Dr. Celia Ingham Clark, MBE, has held a number of senior positions that focus on quality improvement for the NHS, and has served as the national director for patient safety at NHS Improvement. In 2014, Celia became the NHS England director for reducing premature mortality and is currently the medical director for professional leadership and clinical effectiveness. She was awarded an MBE for services to the NHS in 2013.

Fiona Ritchie, OBE, has worked for people with learning disabilities all her adult life. She has been Managing Director for Mental Health and Learning Disabilities for a social enterprise Turning Point, national lead for the Healthcare Commission in learning disabilities as well as other strategic positions nationally and locally. She was awarded an OBE for services to people with learning disabilities in 2009.