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Investigation into the care and treatment of Mr TU - homicide by a person in receipt of mental health services

Publication date: 9 Mar, 2023

The Mental Welfare Commission today published an investigation into the circumstances leading up to a homicide by a man, Mr TU, who had been in contact with mental health services prior to this tragic incident.

The report is anonymised, as all such Commission investigations are. It examines the care given in the two years prior to the homicide in relation to mental health and social work services. 

As part of its investigation, the Commission spoke to members of the victim’s family, the perpetrator and his family, mental health service staff and to the Scottish Prison Service.

The background and the homicide

Mr TU was 32 years old when he had four relatively brief admissions to psychiatric hospital between March and June 2018. He was diagnosed with drug induced psychosis. 

On each admission to hospital, he was taken there by the police and on three of these admissions he was in possession of a potential weapon. On each admission, Mr TU presented with paranoid delusional beliefs and was detained under the Mental Health Act.

There was increasing concern about the risk of future violence, however Mr TU was then not seen by NHS clinical services for a six-month period between June 2018 and January 2019. 

Mr TU was admitted to inpatient forensic mental health services under an assessment order of the Criminal Procedure Act in January 2019. Mr TU spent most of 2019 in prison, having been rearrested and imprisoned following liberation in May and again in September 2019. He had a further brief admission under the care of general adult mental health services in May 2019. 

In December 2019 he was on remand in prison and was liberated by the court with no support package in place and no accommodation. On the evening of his release, Mr TU killed a man who had offered him overnight accommodation at his flat.  


Following Mr TU’s unplanned release from prison in December 2019, although a support package and accommodation may have reduced the likelihood of further offending, evidence from a release from a previous prison sentence in September 2019 indicated that even with a comprehensive support package in place and with accommodation provided, Mr TU rapidly re-offended, was rearrested and returned to prison. 

However, if Mr TU had been offered accommodation in December 2019 this is likely to have reduced the risk to the specific victim who invited him to his home because of Mr TU’s lack of accommodation.   

The organisation of accommodation and support for prisoners in Scotland who are liberated is complex and is currently under review.  It is anticipated that a new model for care will be in place by April 2024. We identified a gap in services for prisoners on remand in our April 2022 report, Mental health support in Scotland’s prisons.

Many aspects of the care Mr TU received from NHS A services in 2018 were of high quality. There were however aspects of that care, including how risks were assessed and managed and that the concerns of Mr TU’s nearest relative were not taken into account which, if acted on, might have mitigated the risk of violence at the time of his discharge from inpatient care in June 2018. There was also a lack of consistency of senior medical staffing because of recruitment difficulties. Patient reviews therefore took place outwith the usual multidisciplinary team structures. Both of these factors are likely to have contributed to a lack of longitudinal assessment and associated risk management at that time. Mental Welfare Commission visits to NHS A had previously reported difficulties recruiting to senior clinical posts, and the subsequent impact on continuity of care. 

However, whilst the risk could have been mitigated at that time, further violence could not have been prevented with any certainty. 

Next steps

The report makes six recommendations for change for the involved health board and health and social care partnership, including issues such as risk management, hospital discharge planning and consent to share information. 

There are a further six recommendations for Scottish Government including support for those released from prison, the national mental health workforce strategy and hospital discharge standards.

The Commission also lists a series of learning points for all mental health providers including issues such as drug induced psychosis, violence, risk management and listening to family concerns. 

Alison Thomson, head of deaths in detention, Mental Welfare Commission, said:

“This was a tragedy, and we are very aware of how difficult the publication of our report must be for those involved in this incident. I thank them for taking part in our investigation.

“The range of our recommendations reflects the complexity of the case. We recognise the challenges involved for all of those who provided care and treatment for Mr TU. Nevertheless, the investigation found there was learning for clinical services that could improve the care and treatment of those with substance induced psychosis and mitigate the risk of future violence.”  

Note to editors
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.