Publication date: 29 Nov, 2023
The report is anonymised, as all such Commission investigations are.
The report is intended to highlight learning for mental health services across Scotland, as well as making specific recommendations for change to the services and organisations involved, and to Scottish Government. It focuses on care and treatment of GH prior to the homicide and does not contain information about the victim.
GH had a history of mental ill health and violent behaviour and had been in contact with mental health services over many years in two different areas of Scotland, both as an inpatient and with community mental health teams.
In a most recent contact just prior to the homicide, GH had been thought not detainable under the Mental Health Act but, as their condition deteriorated and their family’s concerns grew, they had been in contact with a community mental health team, a crisis team, and with the police.
GH had been living in the community when the homicide took place. The homicide victim was someone known to GH, not a relative or previous partner.
The report’s conclusions include -
GH had a history of mental ill health and violent behaviour. They had recently been thought not detainable under the Mental Health Act, but - as their condition deteriorated and their family’s concerns grew – they had been in contact with a community mental health team, a crisis team, and with the police.
Insufficient account was taken of concerns raised by GH’s family. Information about GH’s history of violent behaviour was lost over time and reports of more recent violence largely directed towards their nearest relative were not taken into account by inpatient services in particular. As a result, GH’s propensity to future violence was not fully recognised.
There were many examples of good quality care by mental health services in the two different health and social care partnership areas where GH lived. However, throughout GH’s care, the risk of future violence was not assessed or managed in a systematic way.
Although GH posed an increased risk of violence following discharge from hospital because of their history of convictions for violence, active psychotic symptoms and misuse of substances, the risk to the specific and unrelated victim could not have been predicted.
Suzanne McGuinness, executive director (social work), Mental Welfare Commission, said:
“This was a tragic event, and we know how difficult the publication of our report must be for those involved, particularly for the family of the victim and for GH and their family.
“Our report gives details of actions taken at each stage, and highlights learning that we hope mental health teams across Scotland will consider in relation to their own practices.
“One recurring point was that GH’s family were not listened to. There were so many times when they raised concerns but for various reasons those concerns were not acted upon. The issue of confidentiality is something we have raised many times – services can listen to families and learn from them, without disclosing private information about their patients.
“Amongst our recommendations for change we ask Scottish Government to review violence risk management training for general adult psychiatrists across Scotland in view of the learning issues identified in two health boards in this report.”
This report is one of a series of investigations carried out by the Mental Welfare Commission on behalf of Scottish Government as part of Commission proposals to review how mental health homicides are independently reviewed across Scotland, with the aim of ensuring that learning from tragic events such as these is shared nationally. Further information can be found here.