Homepage Latest news Failed by the systems and structures put in place to protect him – investigation into the care and treatment of Mr E

Failed by the systems and structures put in place to protect him – investigation into the care and treatment of Mr E

Publication date: 25 Jan, 2024

“I want people to know what I went through, what I have lost and the negative impact it has had on my life.  Most importantly for me, I hope that by sharing my story it will stop this from happening to anyone else.”
Mr E

The Mental Welfare Commission today published an investigation into the care and treatment of Mr E – a man who had been unwell for a long time, who was known by health and social work services, yet whose condition deteriorated significantly and permanently without active intervention.

The investigation is anonymised, as all Commission investigations are. 

When they became aware of Mr E’s situation, the Mental Health Tribunal for Scotland alerted the Commission to the apparent lack of involvement by health and social work services in Mr E’s care, despite his diagnoses of schizophrenia and diabetes.

Mr E’s mental illness is now reported to be partially treatment resistant, he is blind, and his mobility is poor. He needs to use a walking frame. 

He is subject to a local authority welfare guardianship order and is living in a care home for older people with dementia, despite the fact that he is in his 50s and does not have dementia. 

Mr E is unhappy living in this care home. His mood is low and there is little stimulation. Amongst the recommendations for change in its investigation, the Commission is asking for the health and social care partnership involved to review Mr E’s care, accommodation, and finances and to do that as a priority. 


Mr E was detained in hospital under the Mental Health Act in August 2020. He had been physically and mentally unwell for a long time prior to this detention.

During its investigation the Mental Welfare Commission found that when Mr E came to the attention of services there was no coordinated multidisciplinary approach. Instead, individual agencies often assumed that the responsibility to support Mr E lay elsewhere.

The Commission found that there was heavy reliance on Mr E’s brother (with whom he lived in the family home) taking responsibility for administering and accurately reporting on Mr E taking medication for physical and mental health conditions. This was despite repeated questions about the reliability of this situation, and the complexity of this relationship, which included Mr E’s brother sometimes blocking access to health care for Mr E.

Julie Paterson, chief executive, Mental Welfare Commission, said:

“Mr E was failed by the systems and structures put in place to protect and support him to claim his rights. His health deteriorated as a result, his life chances were reduced, and he is now living in a care home.

“Many chances to intervene to help Mr E were lost. Our report shows how a lack of coordination between services and a lack of joint consideration of Mr E’s circumstances contributed to this situation. 

“Our report reflects Mr E’s own views and gives some insight into who he is as a person, whilst ensuring anonymity. This is particularly important given that prior to hospital admission in 2020, evidence would suggest a failure by every agency involved to engage and form a working partnership directly with Mr E.

“We share this report to learn lessons as we always do. This was a difficult investigation for Mr E himself and he allowed us to take it forward because he wants no-one else to go through this again.

“One of our social workers has maintained contact with Mr E throughout this investigation and will continue that contact until the review we call for of his care, accommodation and finances is complete.”