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New report - Investigation into the care and treatment of Mr QR

Publication date: 4 Oct, 2017

The Mental Welfare Commission today published an investigation report into the care and treatment of Mr QR, prior to his death, by a health board in Scotland.

Mr QR died on 31 December 2014 as the result of a suicidal act by putting himself under the wheels of a lorry following discharge from a psychiatric hospital two days earlier.

The purpose of the Commission's investigation was to assess Mr QR's care prior to his death, and to provide the Commission's views on:

  • the reasonableness of Mr QR's management by health services,
  • the predictability of him carrying out a serious act of self-harm, and
  • any opportunity for prevention of the act.

The Commission found that Mr QR was not treated properly, and the manner of his discharge was completely unacceptable.

This investigation, like all such investigations by the Commission, is anonymised. Its purpose is to identify lessons that can be learned, not only by the health board concerned, but by all mental health services across Scotland.


The Commission found that the process of arriving at Mr QR's diagnosis was seriously flawed, and this had serious implications for his care, particularly with respect to the way he was discharged from hospital.

Staff who had contact with Mr QR were genuine in their intent to help him, and to support him in achieving recovery within the confines of the diagnostic approach.

Mr QR's consultant sought a second opinion about Mr QR and his presentation, but disregarded it.

The discharge planning and actual discharge of Mr QR in the days preceding his death fell well below the standard of what is expected.

It was known and accepted by the clinical team that Mr QR remained a suicide risk. What was not predicable was when he might try to harm himself.

Mike Diamond, Executive Director (Social Work) at the Mental Welfare Commission, said:

"The question of whether Mr QR's death may have been preventable under different mental health management could not be stated with certainty. However, after a thorough investigation, I can say we have serious concerns that Mr QR was not rigorously treated, and the manner of his discharge was completely unacceptable.

"We question the diagnosis given to Mr QR, and we believe that diagnosis - of personality disorder and factitious disorder - affected the way in which Mr QR was treated. Every patient, no matter their diagnosis, should be treated with dignity and respect and we do not believe that happened in this case.

"Our recommendations are not only for the health board that was involved with Mr QR, but for all mental health services throughout Scotland.

"We expect them all to reflect on this tragic case and on our recommendations. We ask that all mental health services undertake a self-assessment their own and make any necessary adjustments."

Notes to editors

Following Mr QR's death, a significant event review was conducted by NHS Board D on 9 February 2015, and its findings are referred to in the Commission's report.

The case was brought to the attention of the Commission by the Crown Office and Procurator Fiscal Service.

The Commission interviewed health service staff, Mr QR's wife, family and two friends for the report, in addition to examining clinical records.

Mary Mowat

Mental Welfare Commission

0131 313 8786