Progress in implementing recommendations following investigation into the care and treatment of GH – A focus on learning, not blame

The Mental Welfare Commission for Scotland published a closure report following its investigation into the care and treatment of GH, an individual with a history of mental ill health who committed homicide. The report acknowledges significant steps taken by mental health services to address key concerns and improve practices.

Notable and positive steps were taken to implement the recommendations highlighted in the 2023 investigation report, particularly around violence risk assessment and management, family involvement, and sharing of information between inpatient and community services as well as across geographical areas.

Suzanne McGuinness, executive director (social work), Mental Welfare Commission said:

"The hardest lessons often lead to the most important changes. While nothing can undo this tragedy, we've seen health boards turn recommendations into action – whether it's giving families a voice or helping clinical staff identify risks earlier.

“The progress made reflects a shared determination to prevent similar incidents in the future.

“We are grateful to all the individuals and organisations for their engagement in this process, and we hope the changes made in response will help others in the future.”

The original 2023 investigation report remains available on the Commission's website, while the closure report focuses specifically on the actions taken and progress made since its publication.

This investigation by the Commission was a pilot investigation as part of the Commission’s proposals to the Scottish Government for the review of mental health homicides across Scotland. Involving the families and the perpetrator in the investigation was an important aspect of these proposals.

This pilot work fit well with the Commission’s overall investigations function. We seek to build upon this work in our proposals to Scottish Government and remain committed to the need to review mental health homicides across Scotland.