Publications

A report into the investigation examining the care and treatment of Mrs F.

We undertook this investigation because we considered that Mr E had experienced a significant deficiency in care and treatment and had services delivered their support differently and put systems and structures in place to protect and support him, Mr E would not have suffered such poor outcomes in relation to his physical and mental health. (Mr E’s mental illness-schizophrenia- is now reported to be partially treatment resistant, his mobility is poor such that he needs to use a walking frame, and he is blind).

We undertook this investigation because we considered that Mr E had experienced a significant deficiency in care and treatment and had services delivered their support differently and put systems and structures in place to protect and support him, Mr E would not have suffered such poor outcomes in relation to his physical and mental health. (Mr E’s mental illness-schizophrenia- is now reported to be partially treatment resistant, his mobility is poor such that he needs to use a walking frame, and he is blind).

An investigation into the care and treatment of a person, GH, who had been in contact with mental health services prior to a homicide by them.

An investigation into the care and treatment of Mr D prior to his death: a death that occurred whilst a person was subject to mental health detention in Scotland; carried out by the Mental Welfare Commission for Scotland. 

This report is an investigation into the circumstances leading up to the death of an individual (AB) with a moderate learning disability whose death occurred shortly after their detention under the Mental Health (Care and Treatment) Scotland Act 2003 was revoked. AB was also subject to Adult Support and Protection (Scotland) Act 2007 procedures.

Homicide by a person in receipt of mental health services

This report was a review of the records of nine women who were receiving mental health care in HMP Cornton Vale during the time of a visit by the European Committee for the Prevention of Torture (CPT) in 2019.

The Authority to discharge project was undertaken in response to numerous concerns raised in relation to the rights of people who were not able to express their own views being moved from hospital to care homes during the pandemic period.

This document is a review of the records of nine women who received mental health care in prison custody in Scotland between 2017 and early 2020. 
We decided to pursue this subject after the publication of a report by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (the CPT) in October 2019  about their visit to police and prison premises in Scotland in October 2018.

Local intelligence gathering and calls to the Commission’s advice line in the early stages of the Covid-19 pandemic suggested that people who were in hospital and lacked capacity may have been moved from hospital to care homes without full understanding of the legal requirements to ensure rights are upheld and the move to care was lawful. Specific concerns related to the use or otherwise of Section 13ZA of the Social Work (Scotland) Act 1968 particularly in the context of the Coronavirus (Scotland) Act 2020 (‘the Coronavirus Act’).

The findings of our investigation into the care and treatment of an individual prior to his death. The report includes a number of recommendations for all NHS health boards.

The full report on our investigation into the death of Baby A who died at nine months old. Baby A was suffocated by her mother, Ms OP, who had a history of postnatal depression following a previous pregnancy.

Our executive summary of our investigation into the death of Ms MN, a 44 year old woman with complex needs who hanged herself in the care home to which she had recently been moved. (Hard copy available)

The full report of our investigation on Ms MN, a 44 year old woman with complex needs, who died after hanging herself in the care home to which she had recently been moved.

The full report on our investigation into the end of life support and treatment of Mr JL.

An executive summary of our report into the end of life support and treatment of Mr JL. (Hard copy available)

Our report on our investigation involving a man who had been admitted to hospital by police, despite his partner trying to get him admitted for some weeks. We contacted his partner to look at why her efforts to alert services to her concerns were ignored, as this is a frequent complaint of relatives and carers.

Our report on our investigation involving a woman who sadly took her own life. She had recently had a work capability assessment from the DWP and we look into the process of this. (Hard copy available)

A short report into the care and treatment of Ms FG. Ms FG did not receive enough support when she was very unwell and was involved in a serious incident.

Our investigation into the care and treatment of Mrs CD. Mrs CD was remanded to prison following a breach of peace. Concerns were raised with us because prison healthcare staff felt she should be in hospital not prison.

Our report into the care and treatment of Mr EF in easyread format.

Our investigation into the care and treatment of Mr S in easyread format.

Our investigation into the care and treatment of Mr S. Mr S is a man with learning disabilities who was repeatedly offending. We were concerned that services could not agree on how to prevent this.

Our investigation report into the care and treatment of Mr EF. Mr EF was a man with learning disabilities who sadly died. We were concerned that he did not get the same treatment as someone without learning disabilities.

Ms AB was admitted to a rural hospital after becoming confused. We had some concerns about the legality of her care and treatment and have made recommendations, particularly on the use of medication.

Mr N took his own life when he jumped from a bridge in 2008. Our report looks at his care and treatment, at the tribunal hearing where he was made subject to a hospital based CTO and at the decision to suspend his detention the day following the tribunal hearing.

Ms R was subject to welfare guardianship. She died in 2011 after refusing treatment for suspected cervical cancer. This investigation looks at her care and treatment in the years leading up to her death.

An easy read version of our report on powers of attorney. Mark and Sandra have learning disabilities. They were treated badly by Mark's brother.

Mr and Mrs D, a couple with learning disabilities, suffered years of abuse at the hands of their power of attorney. The Commission has called for the local authority to apologise for falling to protect them.

Mr and Mrs D, a couple with learning disabilities, suffered years of abuse at the hands of their power of attorney. The Commission has called for the local authority to apologise for falling to protect them (full anonymised report).

Mr O ended his own life by hanging himself in July 2010. He was 22. This investigation looks at his contract with services in the year before his death. We wanted to investigate whether the actions of any individual or organisation contributed to his death and identify wider learning for health and social care services.

Mrs V died in a general hospital in December 2008 at the age of 80. She had dementia and wad subject to a compulsory treatment order (CTO) at the time. We were extremely concerned about the amount, frequency and route of administration of medication and about the reasons for it being given. We decided to investigate further to determine the reasons for this.

Mrs V died in a general hospital in December 2008 at the age of 80. She had dementia and wad subject to a compulsory treatment order (CTO) at the time. We were extremely concerned about the amount, frequency and route of administration of medication and about the reasons for it being given. We decided to investigate further to determine the reasons for this.

An internal investigation by a council in to a man with ARBD who we felt was failed by health and social care services.

Report from our deficiency in care investigation into the care and treatment of Mrs I an older woman with dementia who was admitted to hospital following a guardianship application. Despite regular contact with services Mrs I's physical and mental health had deteriorated considerably before services moved to intervene.

Our report from our investigation into the care and treatment of Ms Z, a woman with mental illness, personality disorder and alcohol problems who died after leaving hospital while subject to a short-term detention certificate. We found a number of problems, particularly in relation to the fragmented nature of her care.

Report from our investigation into the care and treatment of Mr F, a man who experienced mental illness in combination with alcohol misuse. Our investigation found a number of deficiencies in care and treatment which contributed to a serious incident and the death of Mr F's father.

Report from our investigation into the care and treatment of Mr Q a man with Aspergers' Syndrome who was placed in an intensive psychiatric care unit, without appropriate specialist input to his care and treatment.

Report from our investigation into the care and treatment of residents in a supported landlord scheme following allegations of abuse.

Report from our investigation into the care and treatment of Mr F, a man who experienced mental illness in combination with alcohol misuse. Our investigation found a number of deficiencies in care and treatment which contributed to a serious incident and the death of Mr F's father.

Report of our investigation into the care and treatment of a young woman with a learning disability with complex needs. Includes Scotland wide recommendations in relation to risk assessment and management, deprivation of liberty and the need for strategic planning and resource allocation.

A summary of our investigation into deficiencies in the care and treatment of a woman (Ms A), with a learning disability who experienced a series of serious sexual assaults over a period of years. The report highlights the importance of appropriate responses by health, social work, police and criminal justice systems to help protect and secure justice for vulnerable adults.

Summary report of our investigation into the care and treatment of Ms Y. Ms Y was a young person aged 16, our investigation focused on the lack of provision of specialist services for Ms Y while she was cared for in an adult psychiatric setting.

Report into the investigation of a woman with dementia, living in the community in where there was suspicion of abuse. Recommendations for social work services in relation to assessment of capacity and protection of vulnerable older people.

Headline findings and recommendations relating to deficiencies in the care of Mr G, a man whose dementia went undiagnosed due largely to a previous diagnosis of Personality Disorder.

Investigation relating to deficiencies in the care of Mr G, a man whose dementia went undiagnosed due largely to a previous diagnosis of Personality Disorder.

Report of the Inquiry into the care and treatment of a restricted patient who killed another patient while on conditional discharge from hospital.

Report of the Inquiry into the care and treatment of a man with alcohol related brain damage (ARBD).

Update on Commission and Social Work Inspection Agency joint Inquiry into care of people with learning disabilities living in the Scottish Borders.

Report of the inquiry into the care and treatment of Mr B.

Report of the inquiry into the care and treatment of Mr C.

Report of the inquiry into the care and treatment of Mr J.

Report of the inquiry into the care and treatment of Mrs K.