If we think that someone with a
mental illness or learning disability is not
getting the right care and treatment, we will look into
We are particularly keen to investigate when we think other
people may be having similar problems, and where there have been
mistakes that we feel other professionals could learn from. We
want to help make sure the same things don't happen again to other
people in similar circumstances. Sometimes, after initial
investigations, we find nothing of concern. Other times, we
want to look further into the case.
When we do this we publish the results and recommendations from
our investigations. We then follow up with services to find out
what changes they have made in response to our recommendations.
How do we decide to investigate?
We usually find out about cases through our visits to
individuals or services. We might also follow up on
a call to our advice line, or if we see something in a
service user's paperwork that concerns us.
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.
If we are very concerned about an individual's care
and treatment, and think that their 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 Operational Management 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?
We review individual case notes. We will ask for copies of all
relevant health and social care files. Our review
of files may be supplemented by correspondence with
the professionals responsible for the person's care and
If the causes are not clear, or 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 person, or people, concerned
and/or their family and carers to find out their views on what
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
sent to the organisations that we think need to review
and respond to our recommendations.