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Investigations & inquiries
How and why we investigate
How do we decide to investigate?
The main ways we become aware of a problem are through our visiting, monitoring and telephone advice and information service. Most of the time we can deal with issues by talking or writing to people, saying what our concerns are and asking for certain actions to be taken. This is done through our standard casework approach.
If we are very concerned about an individual's care and treatment and think that his or her case highlights wider concerns within the health, social care or justice system we may decide to investigate further. When this happens, one of our practitioners will take the case to our Investigations and Inquiries Group. The group will discuss the case and decide whether a full investigation is required and what form that investigation will take. An investigation team will be set up to gather and review information.
How do we investigate?
Any investigation will involve the review of individual case notes. We will ask for copies of all relevant health and social care files. Our review of files may be supplemented with correspondence with the professionals responsible for the individual's care and treatment. If the causes are not clear, of if there are conflicting views of what happened we might decide to conduct recorded interviews with the people involved. A Commission practitioner will also talk to the individual concerned and/or family and carers to find out their views on what went wrong.
What happens as a result of an investigation?
Our investigation team will review the evidence, put together a picture of what happened, suggest where things went wrong and make recommendations for change. A report will be published and distributed to the organisations that we think need to review and respond to our recommendations.
When we meet with service providers through the year we will ask them what they have done in response to our investigation recommendations. When we visit services and individuals we will look for evidence that recommendations have been acted upon. If we don't think organisations have put necessary changes in place we will ask for action to be taken as part of our visit report.
We may also ask other organisations, such as the Care Commission, or NHS Quality Improvement Scotland, to follow up on issues with services.
How and why we investigate