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Investigations and inquiry reports

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

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.

Mrs T Investigation report

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 (.doc)  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)