Steve Mee Oliver McGowan, an 18-year-old with autism and learning difficulties, died in 2016 in hospital. The subsequent Learning Disability Mortality Review (LeDeR) concluded that his death was not potentially avoidable. This outcome was challenged by his family and a review was commissioned by NHS England that commenced in August 2019. It was carried out by an oversight panel comprising eight members, whose work included conducting interviews, analysing records and writing two reports. The review’s conclusion was that Oliver’s death was potentially avoidable. The reports are now in the public domain and action has started in response to their recommendations. I was a member of that oversight panel.