PFD report

Robert John McGowan · Prevention of Future Deaths report

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Issued 15 Jan 2025•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised1

  1. Failure to overcome cultural, structural and systemic barriers to physical healthcare for people with autism and complex mental health needs
    Part of recurring concern: Failure to provide accessible care for people with complex neurodevelopmental needs
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Roll out Oliver McGowan Mandatory Training on Learning Disability and Autism for healthcare staff.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 16 January 2025.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to overcome cultural, structural and systemic barriers to physical healthcare for people with autism and complex mental health needs

Wider context from the report

“I am concerned that, as a consequence of living with Autism and complex mental health needs, Mr McGowan encountered cultural, structural and systemic barriers to receiving treatment for his physical health needs, the result of which was that the bacterial endocarditis which led to his death had only been partially treated. The court heard evidence that these barriers continued to exist notwithstanding advocacy provided by a charity which supported Mr McGowan, a range of individual adjustments healthcare professionals sought to make to facilitate his access to care and treatment, and the fact he had a Health Passport. ”

Is this part of a recurring concern?

Yes — Failure to provide accessible care for people with complex neurodevelopmental needs.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Roll out Oliver McGowan Mandatory Training on Learning Disability and Autism for healthcare staff.

Verbatim wording from the response

“We are taking action to increase awareness and understanding of autism amongst healthcare professionals, to help ensure that staff have the right knowledge and skills to provide safe and informed care. Under the Health and Care Act 2022, service providers registered with the Care Quality Commission (CQC) are required to ensure their staff receive learning disability and autism training appropriate to their role. This training will also help to improve the culture within health and social care services, including shifting attitudes and approach to ensure people with a learning disability and autistic people are treated safely, respectfully and confidently.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 16 January 2025

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Continue using the LeDeR programme to review deaths, identify learning and improvements, and inform action to reduce avoidable deaths and health disparities.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 16 January 2025.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue using the LeDeR programme to review deaths, identify learning and improvements, and inform action to reduce avoidable deaths and health disparities.

Verbatim wording from the response

“In addition to this, we are continuing to learn from the LeDeR (Learning from lives and deaths) programme, which was extended in March 2022 to include autistic people without a learning disability for the first time, the purpose of which is to review deaths to see where areas of learning and opportunities to improve can be found. This programme remains a crucial source of evidence that enables us to build up a detailed picture of the key improvements needed, both locally and at a national level, to tackle existing health disparities and help us identify what actions are required to reduce avoidable deaths of autistic people and people with learning disabilities.”

Source location

Response from Department of Health and Social Care
Page 3 · response
Published 16 January 2025

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026