line: 0131 313 8777 or
0800 389 6809
27 June 2012
Our latest report focuses on the care and treatment that Mr N
received in the period leading up to his death in 2008.
Mr N took his own life by jumping from a bridge. His death came
after many years of mental illness; he had been diagnosed with
His family contacted us because they were concerned. This report
looks at the decisions that were made in the final days of his
Mr N was subject to a hospital-based Compulsory Treatment Order
(CTO), meaning he had to remain in hospital. This decision was made
by a Mental Health Tribunal. However, the day after the tribunal,
the hospital suspended his CTO. Mr N was discharged from
Our reports do not look to apportion blame. Suicide is a complex
issue. It is impossible to know whether Mr N's suicide could have
been prevented in the long term.
However, it is our view that if the decision made by the
tribunal had been put in place- if Mr N had remained in hospital-
it would have been less likely that his suicide would have
happened at that time and in that manner.
You can read the full
report and recommendations here.
We carry out an investigation when we believe something may have gone seriously wrong with an individual's care and treatment. Here you can view all of our investigation reports.