We produce a range of publications, for professionals, people with mental ill health and families/carers. You can download them from our website. We have copies of some materials – contact us to enquire.
11 Apr, 2024 | .pdf, 5 MB
This is the Commission’s second children’s rights report since we were made an authority under the Children and Young People (Scotland) Act 2014, with duties to report every three years on the work we have undertaken to further the rights of children and young people in Scotland.
25 Jan, 2024 | .pdf, 372.8 KB
We undertook this investigation because we considered that Mr E had experienced a significant deficiency in care and treatment and had services delivered their support differently and put systems and structures in place to protect and support him, Mr E would not have suffered such poor outcomes in relation to his physical and mental health. (Mr E’s mental illness-schizophrenia- is now reported to be partially treatment resistant, his mobility is poor such that he needs to use a walking frame, and he is blind).
25 Jan, 2024 | .pdf, 1.5 MB
We undertook this investigation because we considered that Mr E had experienced a significant deficiency in care and treatment and had services delivered their support differently and put systems and structures in place to protect and support him, Mr E would not have suffered such poor outcomes in relation to his physical and mental health. (Mr E’s mental illness-schizophrenia- is now reported to be partially treatment resistant, his mobility is poor such that he needs to use a walking frame, and he is blind).
21 Sep, 2023 | .pdf, 1.3 MB
An investigation into the care and treatment of Mr D prior to his death: a death that occurred whilst a person was subject to mental health detention in Scotland; carried out by the Mental Welfare Commission for Scotland.
3 Aug, 2023 | .pdf, 1.5 MB
This report is an investigation into the circumstances leading up to the death of an individual (AB) with a moderate learning disability whose death occurred shortly after their detention under the Mental Health (Care and Treatment) Scotland Act 2003 was revoked. AB was also subject to Adult Support and Protection (Scotland) Act 2007 procedures.
20 Jul, 2023 | .pdf, 1.6 MB
This report from 2022 reflected on the key messages highlighted in our prison themed visit report of 2011. Ten years on, we wanted to learn about how practice had evolved, whether the intended improvements linked to the transfer of health care responsibility from the Scottish Prison Service (SPS) to NHS Scotland had had a meaningful impact and we aimed to highlight and respond to any other issues identified and raised with us. It was also necessary to understand the unprecedented impact of the Covid-19 global pandemic and its effect on prisoners and their care and treatment in custody.
12 Jan, 2023 | .pdf, 1.2 MB
The Commission monitors advance statement overrides (ASOs). The aim is to focus resources on more robust, timeous monitoring of ASOs that have not been subject to any external scrutiny by a designated medical practitioner, and on follow up that is more beneficial to patients.
15 Dec, 2022 | .pdf, 928.5 KB
Over the last decade, we have seen a major shift in how and where people with additional support needs live and receive the care they need.
This advice note may be useful for all landlords and social work departments, advocacy and third sector organisations.
It may also be of interest to relatives and carers of people with additional support needs who are tenants or prospective tenants.
21 Nov, 2022 | .pdf, 1.6 MB
The purpose of this closure report on our publication Racial inequality and mental health in Scotland: a call to action is to assess whether the Commission has achieved its objectives (including outcomes, learning, quality and impact) and completed all deliverables on time and as planned, and summarises the findings and recommendations made in the report and identify the organisations and individuals to whom the recommendations were made.
10 Nov, 2022 | .pdf, 168.5 KB
Please note that from 1 August 2020, the Commission will only accept second opinion requests for a Designated Medical Practitioner (DMP) visit under the Mental Health Act (Care and Treatment) (Scotland) Act 2003 and Criminal Procedure (Scotland) Act 1995 via a completed second opinion form (SOP1). Telephone requests for Mental Health Act second opinion requests will not be accepted.
Please note that this is a new version of SOP1 form (v7.1). The old version (v7.0) will no longer be accepted. Please delete any old versions that you might have saved.
A T3B certificate for treatment becomes due two months after any medication for mental disorder is given during the current detention episode (which includes an Emergency Detention Certificate and Short Term Detention Certificate if these apply). We would like to receive the SOP1 form to request for a DMP visit (for first T3B) at least 14 days before the T3B is due. This will give us time to arrange the DMP visit. We can accept the SOP1 up to 21 days before the T3B is due.
For renewal of Compulsory Treatment Order T3Bs, please email the SOP1 form to us as soon as possible (ideally 6-8 weeks before the expiry of the current T3B), so that we have more time to arrange a DMP visit.
If a translator is needed, this will need to be arranged by the Responsible Medical Officer or the treating team, and for them to co-ordinate the visit with the DMP.
Please email the completed SOP1 form to the Commission at: mwc.2ndopinionrequests@nhs.scot
Requests for second opinions under s.48 and s.50 of the Adults with Incapacity (Scotland) Act 2000 can still be made via the Commission’s advice line or emailed to mwc.2ndopinionrequests@nhs.scot
This form has a separate document with instructions on use.
31 Oct, 2022 | .pdf, 1.6 MB
This report was a review of the records of nine women who were receiving mental health care in HMP Cornton Vale during the time of a visit by the European Committee for the Prevention of Torture (CPT) in 2019.
20 Oct, 2022 | .pdf, 1.6 MB
This is the closure report for our September 2021 themed report on care and treatment with alcohol-related brain damage in Scotland. The Commission has long standing concerns about the availability of specialist support for people with a diagnosis of alcohol related brain damage (ARBD).
6 Sep, 2022 | .pdf, 473 KB
This agreement covers the sharing of personal data by The Office of the Public Guardian (Scotland) with The Mental Welfare Commission for Scotland and vice versa.
23 Jun, 2022 | .pdf, 1.3 MB
While the lessons learned in our national investigations are widely shared, this report seeks to identify how we can extend that work, sharing lessons learned from every level of investigation – from relatively straight forward situations to the most complex.
22 Jun, 2022 | .pdf, 1.2 MB
The Mental Welfare Commission for Scotland is concerned that some private welfare guardians are not getting the information and support they need to fulfil their role. For the purposes of this guide, private welfare guardian is used to denote any non-local authority
welfare guardian.
12 May, 2022 | .pdf, 1.6 MB
The Authority to discharge project was undertaken in response to numerous concerns raised in relation to the rights of people who were not able to express their own views being moved from hospital to care homes during the pandemic period.
3 May, 2022 | .pdf, 754.1 KB
Investigating deaths occurring during compulsory care and treatment under mental health legislation in Scotland: the Mental Welfare Commission for Scotland proposals, final report to the Scottish Government.
The aim of the review was to establish whether the current arrangements for investigating the deaths of people being treated for a mental health condition or learning disability are adequate, and how well local organisations support and engage with the families and carers of people who have died.
3 May, 2022 | .pdf, 996.8 KB
The Mental Welfare Commission for Scotland proposals for the investigation of mental health homicides: final report to the Scottish Government.
In 2015, the Scottish Government called for the Commission to develop a model for Scotland for independent investigations of care and treatment prior to mental health homicides. The Commission has developed a proposed pathway for mental health homicides that we believe is innovative, inclusive and human rights compliant. We believe the proposals laid out in this document are ambitious but necessary and will require funding support from the Scottish Government.
28 Apr, 2022 | .pdf, 1.6 MB
This report reflects on the key messages highlighted in our prison themed visit report of 2011. Ten years on, we wanted to learn about how practice had evolved, whether the intended improvements linked to the transfer of health care responsibility from the Scottish Prison Service (SPS) to NHS Scotland had had a meaningful impact and we aimed to highlight and respond to any other issues identified and raised with us. It was also necessary to understand the unprecedented impact of the Covid-19 global pandemic and its effect on prisoners and their care and treatment in custody.
30 Mar, 2022 | .pdf, 305.2 KB
Designated medical practitioners (DMPs) are appointed by the Mental Welfare Commission for Scotland to assess, and where appropriate, authorise certain treatments requested by the responsible medical officer (RMO) for people subject to compulsory treatment under the Mental Health (Care and Treatment)(Scotland) Act 2003 who do not or cannot consent.
29 Mar, 2022 | .pdf, 950.5 KB
This agreement is intended to promote an effective working relationship and information sharing protocol between the Mental Welfare Commission for Scotland and the Health and Safety Executive in Scotland on areas of mutual interest.
14 Feb, 2022 | .pdf, 1.1 MB
In the context of the drive towards booster doses of the vaccine as a key part of the Scottish Government’s strategy to control Covid-19, the Commission is again experiencing an increase in calls and emails to our advice line seeking advice and guidance on vaccinations for some people who are not able to provide consent for this due to an underlying mental health condition or learning disability. We are therefore re-setting out our guidance in relation to this. This guidance note is primarily for practitioners.
27 Jan, 2022 | .pdf, 1.3 MB
To better understand how well advance statements are used in Forensic Mental Health Services (FMHS) we aimed to explore how many individuals treated in these services have an advance statement, any differences between FMHS across Scotland, and opinions of how promoting and using advance statements works in practice.
21 Dec, 2021 | .pdf, 345.1 KB
This consultation paper outlines the key elements of a proposal for a new system in Scotland for investigating the deaths of all people who, at the time of their death, were subject to an order under mental health legislation in Scotland.
16 Dec, 2021 | .pdf, 913.2 KB
This summary briefly explains the provisions in the Mental Health (Scotland) Act 2003 regarding appeals against excessive security, and gives an overview of the Commission’s advice on the rights of patients and responsibilities of public bodies concerning such appeals.
16 Dec, 2021 | .pdf, 1 MB
This guidance explains the provisions in the Mental Health (Scotland) Act 2003 regarding appeals against excessive security, and gives the Commission’s advice on the rights of patients and responsibilities of public bodies concerning such appeals.
29 Oct, 2021 | .pdf, 1.2 MB
Under the Children and Young People (Scotland) Act (2014) (“the Act”) the Mental Welfare Commission for Scotland (“the Commission”) was made a Corporate Parent and given a specific role with responsibilities towards children and young people who are ‘looked after’ or care experienced.
21 Oct, 2021 | .pdf, 987.9 KB
In mental health and learning disability services, care plans are a key mechanism by which a person’s individual care and treatment can be developed, documented and shared with all those who are involved.
1 Oct, 2021 | .pdf, 1 MB
The Commission has since received a number of enquiries in relation to the use of section 47 of the Act and has prompted this brief advice note to clarify the scope and limitations of this part of the legislation.
23 Sep, 2021 | .pdf, 2 MB
We wanted to explore how well Scotland’s mental health sector performs in relation to racial equality.
To address this we looked at six themes: ethnicity and detention under the Mental Health Act; the views of people with lived experience; the experience and training of Scotland’s mental health services workforce; racial equality in that workforce; and recording and reporting of ethnicity across mental health services; including in the Commission’s own work.
29 Jul, 2021 | .pdf, 1.5 MB
We look at detentions under the Mental Health Act between 1 March 2020 and 28 February 2021. We look in detail into how many detentions there were, where and when they took place, and if there are any differences between health boards and also in characteristics of people who were detained.
15 Jul, 2021 | .pdf, 1.2 MB
There were concerns expressed in the Scottish Government’s review of the Mental Health Act in (known as ‘the McManus Review’) about the lack of uptake of advance statements. However, there have not been any estimates on prevalence until this report.
15 Jul, 2021 | .pdf, 293.5 KB
The Commission has a statutory duty to promote best practice with the Mental Health. One way we do this is by presenting the key findings of our research and monitoring activity. Our findings on Significantly impaired decision making ability is presented in a summarised format here.
8 Jul, 2021 | .pdf, 1.3 MB
This document is a review of the records of nine women who received mental health care in prison custody in Scotland between 2017 and early 2020.
We decided to pursue this subject after the publication of a report by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (the CPT) in October 2019 about their visit to police and prison premises in Scotland in October 2018.
20 May, 2021 | .pdf, 1.4 MB
Local intelligence gathering and calls to the Commission’s advice line in the early stages of the Covid-19 pandemic suggested that people who were in hospital and lacked capacity may have been moved from hospital to care homes without full understanding of the legal requirements to ensure rights are upheld and the move to care was lawful. Specific concerns related to the use or otherwise of Section 13ZA of the Social Work (Scotland) Act 1968 particularly in the context of the Coronavirus (Scotland) Act 2020 (‘the Coronavirus Act’).
22 Apr, 2021 | .pdf, 988.1 KB
This document was reviewed in Spring 2021. The previous title was ‘The Adults with Incapacity Act in General Hospitals and Care Homes’.
6 Apr, 2021 | .pdf, 1.8 MB
This is the Commission’s first Children’s Rights Report since we were made an authority under the Children and Young People (Scotland) Act 2014, with duties to report every three years on the work we have undertaken to further the rights of children and young people in Scotland.
24 Mar, 2021 | .pdf, 1.1 MB
The current crisis with coronavirus is presenting us all with new challenges that are far reaching and constantly changing. This advice note covers a range of issues people have contacted the Commission about.
19 Mar, 2021 | .pdf, 1.3 MB
The current pandemic is raising a many questions, as practitioners face new challenges and dilemmas in a rapidly changing environment. The unprecedented circumstances and the risk to health mean that some individuals’ human rights may be restricted, and it is important that any restriction is carefully considered, legal and ethical. This advice addresses a range of issues.
This advice will be updated frequently as the situation develops, and we advise that you do not print it out, but check online to ensure you have the most up-to-date advice and information.
16 Feb, 2021 | .pdf, 1.3 MB
This report focusses on advance statement overrides (ASOs). We present the data on:
5 Feb, 2021 | .pdf, 1 MB
This advice note considers the issues for organisations such as care homes who may be considering using hidden surveillance. It also looks at the subject from the point of view of families and friends of people who are cared for by such organisations, and who may themselves be considering using hidden surveillance.
25 Jan, 2021 | .pdf, 121 KB
The Deaths in Detention Reviews project is listening to the personal experience of families and friends. Your involvement in interviews or groups is very important to the Commission and to our work. We want you to feel confident that we will not use things you tell us unless you are comfortable about us doing so.
We have prepared this privacy notice that explains how we will process your personal data, please contact us if you have any questions.
19 Jan, 2021 | .pdf, 2.2 MB
We were trying to find out from people with lived experience of mental illness what the Mental
Welfare Commission should concentrate on during its visits to psychiatric wards and wanted
this to enhance the knowledge our practitioners already had from their own practice.
15 Oct, 2020 | .pdf, 1.5 MB
In this report, we expand on data presented in the Mental Health Act Monitoring Report, to explore the context around detentions and presentations of young people detained under the Mental Health Act.
30 Sep, 2020 | .pdf, 132.3 KB
One page of graphics summarising the main findings in the AWI monitoring report 2019-20
3 Sep, 2020 | .pdf, 1 MB
As part of our eating disorders themed visit in 2020, we gathered information about services developed for individuals with eating disorders across Scotland. We are aware from our work that services that look after individuals with eating disorders are very varied across the country.
24 Aug, 2020 | docx, 34.9 KB
These are the instructions accompanying the Second Opinion request form.
13 Aug, 2020 | .pdf, 1.3 MB
In January 2020, the Mental Welfare Commission for Scotland (the Commission) undertook stakeholder feedback research. The aim of the research was to explore perceptions of the Commission and its impact, to understand what the Commission is doing well and to identify any areas for improvements.
6 Aug, 2020 | .pdf, 879.3 KB
The Act, when defining incapacity, states that it must be due to either mental disorder or inability to communicate because of physical disorder. There are important differences in how these separate disorders are managed.
6 Aug, 2020 | .pdf, 1007.6 KB
Guidance on the circumstances it would be appropriate, with the agreement of the guardian and adult, either to reduce the frequency of supervision, or cease to supervise a welfare guardianship altogether.
6 Aug, 2020 | .pdf, 885.5 KB
Except in emergencies, the Act requires that medical treatment is authorised under a certificate granted (usually) by the medical practitioner. There may also be a welfare proxy (attorney, guardian or holder of an intervention order) with the authority to consent.
16 Jul, 2020 | .pdf, 2.2 MB
The following paper reflects the voice, experience and opinions that people with lived
experience, and their families/carers, provided for the Commission around their work on the good practice guide Use of seclusion. It will inform our work and future reports on this subject but is not, in itself, an expression of the Commission’s views on this area.
8 Jul, 2020 | .pdf, 944.6 KB
This guidance has been developed to support managers and staff working in registered services for people with mental illness, learning disability, dementia or related conditions in Scotland. It is for anyone employed in caring for an individual who, because that person is not capable of making key decisions about his or her own health and welfare, has become subject to the Adults with Incapacity (Scotland) Act 2000 (AWI).
29 May, 2020 | .pdf, 1.5 MB
The Mental Welfare Commission for Scotland welcomes the opportunity to respond to the phase 1 consultation of the Scottish Mental Health Law Review. Our response is informed by the Commission’s experience of meeting its duties and responsibilities including those under the Mental Health (Care and Treatment) (Scotland) Act 2003 (the Act).
18 Mar, 2020 | .pdf, 1.1 MB
The number of young people under the age of 18 admitted to non-specialist hospital wards – mainly adult wards - for treatment of their mental illness in Scotland in 2018-19 rose for the second year running.
25 Feb, 2020 | .pdf, 716.8 KB
The Engagement and Participation Officer (Carer) at the Commission visits support groups for people looking after individuals who have mental illness, learning difficulties, autism or dementia. We also meet with carers one-to-one if they prefer, and attend relevant conferences where discussions around issues takes place. We contact new groups regularly, and revisit others when we have new issues to discuss.
19 Feb, 2020 | .pdf, 41.9 KB
Q: Do you agree that the Scottish Ministers should seek the Parliament’s approval to extend the Public Service Reform (Scotland) Act, Part 2 order making powers for a further five years from June 2020?
A: Unsure [reasons for response follow]
31 Jan, 2020 | .pdf, 97.8 KB
The Independent Review into the Delivery of Forensic Mental Health Services has made a public call for evidence. The Mental Welfare Commission for Scotland is responding as an organisation with a role in protecting the rights of people using Forensic Mental Health Services and an involvement in visiting and monitoring prisons and hospitals.
30 Jan, 2020 | .pdf, 1.2 MB
In this visit we focused specifically on NHS in-patients in rehabilitation services. The function of a specialist inpatient rehabilitation service is to help patients gain or regain the skills and confidence needed to progress their recovery.
5 Nov, 2019 | .pdf, 120.8 KB
We generally support the approach set out in section 1.2 of the Final Consultation document. We agree that we need to ensure that the law complies with the European Convention on Human Rights, and that Scotland should live up to the commitment to implement the UN Convention on the Rights of Persons with Disabilities. How this can be done is not simple, and it is important to proceed in a way which is conceptually clear, starts from where we currently are, and develops practical solutions.
28 Oct, 2019 | .pdf, 55.3 KB
The Mental Welfare Commission is grateful for the opportunity to respond to the above petition, which calls on the Scottish Parliament ‘to urge the Scottish Government to introduce a new law addressing the needs and rights of people with lifelong learning disabilities in Scotland.’
3 Oct, 2019 | .pdf, 1 MB
Guidance primarily for professionals working with young people with borderline personality disorder such as medical practitioners (mainly psychiatrists and GPs), nurses and social workers, including mental health officers.
20 Aug, 2019 | .pdf, 884 KB
This guidance is about good practice in the development of person centred care plans for people using mental health, dementia and learning disability services. This guidance may be helpful for all clinical staff who develop and use care plans in a health and social care setting and for people who use services and their carers.
15 Aug, 2019 | ,
You can download, complete online, and print forms from the Scottish Government website at Mental Health Act forms, and Adults with Incapacity Act forms.
9 May, 2019 | .pdf, 26.7 KB
The Commission's response to the Scottish Government consultation on "Equally Safe: A consultation on legislation to improve forensic medical services for victims of rape and sexual assault".
1 May, 2019 | .pdf, 622.4 KB
This document provides a framework to support the development of person centred care plans and will enable a consistently high quality approach to care planning for nurses working in all mental health settings within NHS Tayside.
1 Mar, 2019 | .pdf, 434.6 KB
This is the Commission’s strategy for engagement and participation with stakeholders, including people who use services, users, carers, professionals and organisations for the next three years. It has been developed to support the achievement of our strategic priorities, as set out in our five year strategic plan.
25 May, 2018 | .pdf, 2.5 MB
We have a statutory responsibility to monitor the use of the Mental Health Act. Here we publish a summary of its use in 2016-2017. The report also includes a broader range of figures, and comparisons over the last 10 years. This document was first published in October 2017, and was reviewed and amended in May 2018.
13 Mar, 2018 | .pdf, 628.6 KB
This report is a review of how local authorities and NHS Boards are discharging their responsibilities under the Mental Health (Care and Treatment) (Scotland) Act 2003. Information was collected in questionnaires, and full responses can be found in 'Appendix 1 - The Right to Advocacy, adults' and 'Appendix 2 - The Right to Advocacy, children and young people'.
13 Mar, 2018 | .pdf, 3.6 MB
This appendix is attached to the report 'The Right to Advocacy' which reviewed how local authorities and NHS Boards are discharging their responsibilities under the Mental Health (Care and Treatment) (Scotland) Act 2003. This document contains full responses and associated documents to a questionnaire sent out in July 2017.
13 Mar, 2018 | .pdf, 10.7 MB
This appendix is attached to the report 'The Right to Advocacy' which reviewed how local authorities and NHS Boards are discharging their responsibilities under the Mental Health (Care and Treatment) Act 2003. This document contains full responses and associated documents to a questionnaire sent out in July 2017.
23 Jun, 2017 | .pdf, 457.7 KB
Guide on best practice in responding to incidents of violence in learning disability and mental health settings. This document was reviewed in Spring 2017 in light of changes to the Mental Health Act. The previous title was 'Zero Tolerance: Responding to violence in mental health or learning disability care settings'.
31 May, 2017 | .pdf, 32.3 KB
Findings from our consultations with carers, looking at issues surrounding capacity. Carer opinion has been gathered from carer support meetings and discussions with individual carers, including those caring for individuals with mental illness, dementia, learning disability and autism.
31 May, 2017 | .pdf, 32.3 KB
Findings from our consultations with carers, looking at issues surrounding capacity. Carer opinion has been gathered from carer support meetings and discussions with individual carers, including those caring for individuals with mental illness, dementia, learning disability and autism.
24 May, 2017 | .pdf, 395.7 KB
This guide explains how and where human rights impact on mental health care delivery, and how staff can best ensure that the key rights are respected and promoted. It is intended to be both a reference guide and an improvement resource.
28 Apr, 2017 | .pdf, 295.3 KB
The following paper reflects the voice, experience and opinions that people with lived experience and carers, as individuals and as groups, provided for the Commission’s current work on supported decision making.
14 Dec, 2016 | .pdf, 320.5 KB
This strategy builds on the Stakeholder Involvement and Feedback Strategy 2014-17. It deals specifically with our engagement with organisations and professional groups, and sits alongside the Engagement Strategy for Individuals and Carers.
10 Oct, 2016 | .pdf, 35.4 KB
The Mental Welfare Commission's response to the Scottish Government's consultation on changes in regulations related to cross border transfers and absconding patients as a result of provisions in the 2015 Act.
6 Oct, 2016 | .pdf, 777.9 KB
Our annual report of key findings from our monitoring of young persons to non-specialists wards in 2015-16. This includes the results from a second, more in-depth, monitoring exercise we undertook this year over a six months period.
30 Jun, 2016 | .pdf, 591.5 KB
This report by the Commission - produced for the Scottish Government - examines Scotland's high levels of emergency mental health detention without the consent of specialist social workers.
29 Jun, 2016 | .pdf, 797.8 KB
This is the first study the Commission has carried out into perinatal mental health care in Scotland. In this themed visit, we focus mainly on the care of women with severe postnatal mental illness who require admission to hospital.
24 Mar, 2015 | .pdf, 531.3 KB
Summary of key findings from collaborative work between the Care Inspectorate and the Mental Welfare Commission - secure services for children.
13 Feb, 2015 | .pdf, 150.8 KB
Guidance on principles and best practice in implementing specified persons regulations under the Mental Health (Care & Treatment) (Scotland) Act 2003 in relation to restrictions around patients' correspondence or use of telephones, and relating to safety and security.
23 Oct, 2014 | .pdf, 414.8 KB
The Commission and the Care Inspectorate visited young people in Scottish secure care settings, who had identified mental health difficulties, and who may be supported or referred for assessment to specialist Child and Adolescent Mental Health Services (CAMHS). The visits were completed in early 2014.
8 Apr, 2014 | .pdf, 501.1 KB
Our report on our investigation involving a man who had been admitted to hospital by police, despite his partner trying to get him admitted for some weeks. We contacted his partner to look at why her efforts to alert services to her concerns were ignored, as this is a frequent complaint of relatives and carers.
10 Jan, 2014 | .pdf, 948.7 KB
This Report addresses a legal problem which determined that the admission to a psychiatric hospital an continued residence there of a person with learning difficulties such that he could not consent to being where he was represented a deprivation of his liberty, could not be characterised as "voluntary" and needed to take place under a lawful process in order to comply with Article 5 of the European Convention on Human Rights.
13 May, 2013 | .pdf, 167.4 KB
We were asked to look at a case of a patient on clozapine therapy who had died. This is a complex area of clinical practice often involving a clozapine clinic as well as the usual CMHT and GP. While we did not conclude that there was a deficiency of care, we thought there were a number of useful learning points.
26 Jun, 2012 | .pdf, 463.2 KB
Mr N took his own life when he jumped from a bridge in 2008. Our report looks at his care and treatment, at the tribunal hearing where he was made subject to a hospital based CTO and at the decision to suspend his detention the day following the tribunal hearing.
13 Feb, 2012 | .pdf, 197.9 KB
Mr and Mrs D, a couple with learning disabilities, suffered years of abuse at the hands of their power of attorney. The Commission has called for the local authority to apologise for falling to protect them.
12 Feb, 2012 | .pdf, 746 KB
Mr and Mrs D, a couple with learning disabilities, suffered years of abuse at the hands of their power of attorney. The Commission has called for the local authority to apologise for falling to protect them (full anonymised report).
1 Jan, 2012 | .pdf, 124.6 KB
Mr O ended his own life by hanging himself in July 2010. He was 22. This investigation looks at his contract with services in the year before his death. We wanted to investigate whether the actions of any individual or organisation contributed to his death and identify wider learning for health and social care services.
1 Oct, 2011 | .pdf, 195.4 KB
Mrs V died in a general hospital in December 2008 at the age of 80. She had dementia and wad subject to a compulsory treatment order (CTO) at the time. We were extremely concerned about the amount, frequency and route of administration of medication and about the reasons for it being given. We decided to investigate further to determine the reasons for this.
1 Oct, 2011 | .pdf, 99.4 KB
Mrs V died in a general hospital in December 2008 at the age of 80. She had dementia and wad subject to a compulsory treatment order (CTO) at the time. We were extremely concerned about the amount, frequency and route of administration of medication and about the reasons for it being given. We decided to investigate further to determine the reasons for this.
31 Jul, 2011 | .pdf, 487.2 KB
This report reflects our findings from a programme of visits that took place across Scotland between April and July 2011 to individuals with severe and enduring mental illness in rehabilitation and continuing care wards based in psychiatric hospitals across Scotland.
1 Jan, 2010 | .pdf, 81.7 KB
Our report from our investigation into the care and treatment of Ms Z, a woman with mental illness, personality disorder and alcohol problems who died after leaving hospital while subject to a short-term detention certificate. We found a number of problems, particularly in relation to the fragmented nature of her care.
1 Jan, 2010 | .pdf, 83.6 KB
Report from our deficiency in care investigation into the care and treatment of Mrs I an older woman with dementia who was admitted to hospital following a guardianship application. Despite regular contact with services Mrs I's physical and mental health had deteriorated considerably before services moved to intervene.
1 Jan, 2009 | .pdf, 79.2 KB
Report from our investigation into the care and treatment of Mr F, a man who experienced mental illness in combination with alcohol misuse. Our investigation found a number of deficiencies in care and treatment which contributed to a serious incident and the death of Mr F's father.
1 Jan, 2009 | .pdf, 443.4 KB
Report from our investigation into the care and treatment of Mr F, a man who experienced mental illness in combination with alcohol misuse. Our investigation found a number of deficiencies in care and treatment which contributed to a serious incident and the death of Mr F's father.
1 Jan, 2008 | .pdf, 106.1 KB
Report of our investigation into the care and treatment of a young woman with a learning disability with complex needs. Includes Scotland wide recommendations in relation to risk assessment and management, deprivation of liberty and the need for strategic planning and resource allocation.
1 Jan, 2008 | .pdf, 61.4 KB
A summary of our investigation into deficiencies in the care and treatment of a woman (Ms A), with a learning disability who experienced a series of serious sexual assaults over a period of years. The report highlights the importance of appropriate responses by health, social work, police and criminal justice systems to help protect and secure justice for vulnerable adults.
1 Jan, 2008 | .pdf, 87 KB
Summary report of our investigation into the care and treatment of Ms Y. Ms Y was a young person aged 16, our investigation focused on the lack of provision of specialist services for Ms Y while she was cared for in an adult psychiatric setting.
1 Feb, 2007 | .pdf, 203.1 KB
Report into the investigation of a woman with dementia, living in the community in where there was suspicion of abuse. Recommendations for social work services in relation to assessment of capacity and protection of vulnerable older people.