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Notifying the Commission

We are often asked about what issues and incidents should be reported to the Mental Welfare Commission.

It is difficult to be prescriptive as each and every circumstance will be different. However, the following guidance is intended to assist staff in the NHS, local authority, or independent sector services in determining whether an incident or issue should be notified to us and the form that notification should take.

Any such notification is in addition to any other notification required by, for example, the Care Inspectorate, adult support and protection officer, or Healthcare Improvement Scotland.

The term 'individual' is used throughout this guidance to refer to a person with mental illness, learning disability, dementia or a related condition.

On receipt of such a notification, the Commission will determine whether any further information is required, or any action is to be taken.

Despite this guidance, it is not possible to be prescriptive about all cases which should be reported to the Commission as circumstances vary so much. Anyone in doubt as to whether a matter is significant enough to report to the Commission should contact the Commission to discuss the situation.

All deaths should be reported using this form:
ND1 notification of death

Other notifications may be by letter or secure email. If in doubt, please contact the Commission.


  • The death of any individual who is subject to compulsory treatment under the Mental Health (Care and Treatment) (Scotland) Act 2003.
  • The suicide of any inpatient receiving psychiatric care at the time of death or who has been discharged from inpatient psychiatric care within the preceding month.
  • The death of any individual where there is a significant concern regarding any aspect of their care and treatment prior to death.
  • Where it is felt that a Fatal Accident Inquiry should, or will, be held.
  • All cases where an individual who is receiving care from mental health or learning disability services is accused of or convicted of, a serious crime, e.g. homicide, serious physical assault, or sexual assault.
  • Where it appears that an individual is being or has been detained in any care setting without appropriate legal authority.


  • Incidents where it appears there has been a deficiency in care or treatment and, as a result, an individual suffers a serious injury or adverse physical effects. This includes as a result of restraint, or where the injury has been caused deliberately by another person.
  • Where an individual is living alone or without care and is unable to look after themselves, their property, or financial affairs and no intervention is taking place to remedy the situation.
  • Incidents or circumstances in which a deficiency in care has led to the property of an individual suffering significant loss or damage, or has led to it being at risk of significant loss or damage.

In addition to the above, local authorities should notify the Commission of:

  • Any significant investigation the local authority carries out under Section 33 of the Mental Health (Care and Treatment) (Scotland) Act 2003, Section 10(1)(c) of the Adults with Incapacity (Scotland) Act 2000, or where a Protection Order under the Adult Support and Protection (Scotland) Act 2007 has been taken out in relation to an individual.

Information required by the Commission

The information provided to the Commission should be relevant and proportionate to the circumstances of the case and would normally include:

  • A brief account of the circumstances of the incident or situation, its antecedents, and any other relevant information
  • Information on the diagnosis, treatment, and the mental state of the person
  • Information on any other person involved
  • What further action is being taken or considered, including any changes in procedure, policy, or the physical environment
  • An indication of any further investigation, enquiry, or review that is being carried out or considered, and a copy of the outcome of these when available