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If we think that someone with a mental illness or learning disability is not getting the right care and treatment, we will look into it.

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 treatment.

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 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 sent to the organisations that we think need to review and respond to our recommendations. 

We carry out an investigation when we believe something may have gone seriously wrong with an individual's care and treatment. Here you can view all of our investigation reports.

View reports