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0800 389 6809 

 

Our investigations

Our investigations focus on one person, but they have lessons for lots of people. We carry out an investigation into an individual's care and treatment when we believe there are similar issues in other people's care and lessons to be learnt for services throughout Scotland.

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  • Ms AB report (.pdf, 2KB)
    Ms AB report (.pdf, 2KB)
    22 April 2013
    Publication, Consent to treatment, section 47, Investigation report, Older people, Dementia, Adults with Incapacity (AWI)

    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 report (.pdf, 2KB)
    Mr N report (.pdf, 2KB)
    26 June 2012
    Publication, Investigation report

    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 investigation (.pdf, 128KB)
    Ms R investigation (.pdf, 128KB)
    15 June 2012
    Publication, professionals, Service users, Consent to treatment, Freedom, restriction and restraint, Guardianship, Investigation report, Drug and alcohol, Older people, care home, Adults with Incapacity (AWI)

    Ms R was 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.

  • Powers of Attorney and their safeguards - Mr and Mrs D (.pdf, 3KB)
    Powers of Attorney and their safeguards - Mr and Mrs D (.pdf, 3KB)
    13 February 2012
    Investigation report, Service users, professionals, Carers, Learning Disability, Power of attorney, community

    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 failing to protect them.

  • Powers of Attorney and their safeguards - easy read (.pdf, 3KB)
    Powers of Attorney and their safeguards - easy read (.pdf, 3KB)
    13 February 2012
    Publication, Service users, Investigation report, Learning Disability, easy read, professionals, Carers, Power of attorney, case study, community

    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.

  • Powers of Attorney and their safeguards - full report (.pdf, 3KB)
    Powers of Attorney and their safeguards - full report (.pdf, 3KB)
    12 February 2012
    Publication, Investigation report, Power of attorney, Learning Disability

    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 failing to protect them (full anonymised report).

  • Hard to Help - Mr O (.pdf, 2KB)
    Hard to Help - Mr O (.pdf, 2KB)
    1 January 2012
    Publication, case study, professionals, Investigation report, Drug and alcohol, Mental Health Act (MHA), Service users, Carers, Mental illness

    Mr O ended his own life by hanging himself in July 2010. He was 22. This investigation looks at his contact 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.

  • Starved Of Care - Mrs V (Full report) (.pdf, 5KB)
    Starved Of Care - Mrs V (Full report) (.pdf, 5KB)
    1 October 2011
    Investigation report, Publication, Service users, professionals, Carers, case study, hospital, Consent to treatment, Dementia, Adults with Incapacity (AWI)

    Mrs V died in a general hospital in December 2008 at the age of 80. She had dementia and was 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.

  • Starved Of Care - Mrs V (Summary report) (.pdf, 5KB)
    Starved Of Care - Mrs V (Summary report) (.pdf, 5KB)
    1 October 2011
    Investigation report, Publication, Service users, professionals, Carers, Dementia, Mental illness, hospital, Adults with Incapacity (AWI), Consent to treatment

    Mrs V died in a general hospital in December 2008 at the age of 80. She had dementia and was 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.

  • Mr A report (.pdf, 10KB)
    Mr A report (.pdf, 10KB)
    14 October 2010
    Investigation report, Publication, professionals, Freedom, restriction and restraint, Drug and alcohol, Mental illness, hospital, community, Service users, Carers, case study

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