Investigation into the death of Ms MN

A vulnerable 44 year old woman with an autistic spectrum diagnosis and complex needs, took her own life in a care home in Scotland in December 2012.

The circumstances of Ms MN's death, and the way in which her transfer to the care home had been managed, raised concerns at the Mental Welfare Commission, which decided to conduct a full investigation. Its report is published today.

Ms MN had recently moved from hospital to an independent care home that was experienced in caring for people with learning disability, but not autism.

The Commission found that the placement was not properly planned and that arrangements for managing her care, and the risk of suicide, were confused and unsafe.

The Commission's report contains recommendations for change for Scottish Government, the Care Inspectorate, health boards, and joint health and social care bodies.

Colin McKay, chief executive of the Mental Welfare Commission, said:

"This is a desperately sad case of a vulnerable individual, who was struggling to deal with day-to-day life.

'Services tried, with varying levels of success, to support her. While there was certainly goodwill and a genuine caring attitude, there were also serious errors of judgement, and a lack of communication at key points. That resulted in her being in a home which was not able to meet her needs, and which did not have the appropriate support from specialist services when a crisis arose.

'This report is about one tragic case, but it contains lessons for all of Scotland. I hope it is read by all those involved in providing care and treatment for people with autistic spectrum disorder, and I hope all of our recommendations are acted upon'.

As with all of its investigation reports, the details of the report are anonymised.

Background

Ms MN was in contact with mental health services from 1986, when she was 18 years old, until her death in a care home that cared primarily for people with learning disability in 2012.

Ms MN did not have a learning disability; her prime diagnosis was of Autism/Asperger Syndrome.

During her lifetime she struggled with obsessional thoughts and ritualistic behaviour. She often self-harmed and regularly spoke about suicide. She had great difficulties with self care and was vulnerable to exploitation. She had frequent admissions to a mental health ward in hospital.

She was prescribed a large amount of medication to deal mostly with anxiety, and became accustomed to receiving it 'as required', when in hospital.

Ms MN spent much of 2012 in hospital and was subject to a compulsory treatment order at the time of her death. In November 2012, she had been moved to the care home. Ms MN found that move extremely difficult, frequently talking to staff about self harm and suicide. She was found hanging in her room six weeks after her arrival at the home. The home was relying for medical advice on local GP services, who had not met Ms MN, and did not have full information on her case.

The Commission's key recommendations include:

• A greater use of specialist assessments where people have autistic spectrum disorder and complex needs
• Better discharge planning, to ensure care homes and GPs have the right information and support to manage such people in community settings
• A review of the availability of specialist services for people with autistic spectrum disorders who do not fit into mental health or learning disability settings.

Mary Mowat 0131 313 8786

The Mental Welfare Commission for Scotland