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Investigations and inquiry reports
Too close to see
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.
Download: 'Too close to see' summary report from our investigation into deficiencies in the care and treatment of Mr F (.pdf)
Download Full version of 'Too close to see' (.doc)
A recipe for abuse?
Report from our investigation into the care and treatment of residents in a supported landlord scheme following allegations of abuse.
Download: A recipe for abuse (.pdf)
Mr Q Investigation
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.
Download: Investigations into the care and treatment of Mr Q (.pdf)
Ms L Investigation
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.
Download: Investigation into the care and treatment of Ms L (.pdf)
Wrong place, wrong time
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. Download: Wrong place, wrong time (.pdf)
Justice Denied
A summary of our investigation into deficiencies in the care and treatment of a woman 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.
Download: Justice Denied (.pdf)
To request a copy of the full, anonymised report please contact us on 0131 313 8777.
Mrs T Investigation
Report into investigation of 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.
Download: Mrs T Investigation report (.pdf)
Not my problem
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.
Download ; Not my Problem - full report (.pdf) Not my problem - summary report (.pdf)
Inquiry into the care and treatment of Mr H
Report of the Inquiry into the care and treatment of a man with alcohol related brain damage (ARBD).
Download: Inquiry into the care and treatment of Mr H (.pdf) |
Mr L and Mr M Inquiry
Report of the Inquiry into the care and treatment of a restricted patient who killed another patient while on conditional discharge from hospital.
Download: Mr L and Mr M Inquiry (.pdf)
A joint response from the agencies involved in the care and treatment of Mr L and Mr M can be accessed from the Scottish Executive website.
No fears as long as we work together
Update on Commission and Social Work Inspection Agency joint Inquiry into care of people with learning disabilities living in the Scottish Borders.
Download: No fears as long as we work together (.pdf)
Borders Inquiry Joint Report
Inquiry into deficiencies in care of people living in the Scottish Borders can be found on the Scottish Government website.
Inquiry into the care and treatment of Mr B
Download: Full report (pdf.)
Inquiry into the care and treatment of Mr C
Download: Full report (.pdf) | Summary (.pdf)
Inquiry into the care of Mr J
Download: Full report (.pdf) | Summary (.pdf)
Inquiry into the care and treatment of Ms K
Download: Full report (.pdf) | Summary (.pdf)
Investigations reports