Homepage Publications

Publications

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.

44 matching publications.

Publication

Investigation into the delayed discharge of Ms ST

12 Sep, 2019 | .pdf, 1.3 MB

Publication

Investigation into the care and treatment of Mr QR by Health Board D

4 Oct, 2017 | .pdf, 836.1 KB

The findings of our investigation into the care and treatment of an individual prior to his death. The report includes a number of recommendations for all NHS health boards.

Publication

Ms OP Investigation Report

8 Sep, 2016 | .pdf, 767.4 KB

The full report on our investigation into the death of Baby A who died at nine months old. Baby A was suffocated by her mother, Ms OP, who had a history of postnatal depression following a previous pregnancy.

Publication

Ms MN summary report

27 Jan, 2016 | .pdf, 129.1 KB

Our executive summary of our investigation into the death of Ms MN, a 44 year old woman with complex needs who hanged herself in the care home to which she had recently been moved. (Hard copy available)

Publication

Ms MN full report

27 Jan, 2016 | .pdf, 846.9 KB

The full report of our investigation on Ms MN, a 44 year old woman with complex needs, who died after hanging herself in the care home to which she had recently been moved.

Publication

Left alone - Mr JL full report

8 Jul, 2014 | .pdf, 762.1 KB

The full report on our investigation into the end of life support and treatment of Mr JL.

Publication

Left Alone - Mr JL executive summary

8 Jul, 2014 | .pdf, 170.2 KB

An executive summary of our report into the end of life support and treatment of Mr JL. (Hard copy available)

Publication

Mr GH - listening to relatives and carers - a case study

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.

Publication

Who benefits? - Ms DE

26 Mar, 2014 | .pdf, 218.4 KB

Our report on our investigation involving a woman who sadly took her own life. She had recently had a work capability assessment from the DWP and we look into the process of this. (Hard copy available)

Publication

Ms FG

24 Mar, 2014 | .pdf, 484.2 KB

A short report into the care and treatment of Ms FG. Ms FG did not receive enough support when she was very unwell and was involved in a serious incident.

Publication

Mrs CD report

24 Feb, 2014 | .pdf, 736.5 KB

Our investigation into the care and treatment of Mrs CD. Mrs CD was remanded to prison following a breach of peace. Concerns were raised with us because prison healthcare staff felt she should be in hospital not prison.

Publication

Mr Ef easyread

3 Feb, 2014 | .pdf, 190.5 KB

Our report into the care and treatment of Mr EF in easyread format.

Publication

Mr S Easyread

3 Feb, 2014 | .pdf, 182.1 KB

Our investigation into the care and treatment of Mr S in easyread format.

Publication

Investigation into the care of Mr S

3 Feb, 2014 | .pdf, 266 KB

Our investigation into the care and treatment of Mr S. Mr S is a man with learning disabilities who was repeatedly offending. We were concerned that services could not agree on how to prevent this.

Publication

Investigation into the care of Mr EF

3 Feb, 2014 | .pdf, 209.4 KB

Our investigation report into the care and treatment of Mr EF. Mr EF was a man with learning disabilities who sadly died. We were concerned that he did not get the same treatment as someone without learning disabilities.

Publication

Ms AB report

22 Apr, 2013 | .pdf, 164.3 KB

Ms AB was admitted to a rural hospital after becoming confused. We had some concerns about the legality of her care and treatment and have made recommendations, particularly on the use of medication.

Publication

Mr N Report

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.

Publication

Ms R investigation

15 Jun, 2012 | .pdf, 128.5 KB

Ms R was subject to welfare guardianship. She died in 2011 after refusing treatment for suspected cervical cancer. This investigation looks at her care and treatment in the years leading up to her death.

Publication

Powers of Attorney and their safeguards - easy read

13 Feb, 2012 | .pdf, 107.9 KB

An easy read version of our report on powers of attorney. Mark and Sandra have learning disabilities. They were treated badly by Mark's brother.

Publication

Powers of Attorney and their safeguards - Mr and Mrs D

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.

Publication

Powers of Attorney and their safeguards - full report

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).

Publication

Hard to Help - Mr O

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.

Publication

Starved of Care - Mrs V (summary report)

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.

Publication

Starved of Care - Mrs V (Full report)

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.

Publication

Mr A report

14 Oct, 2010 | .pdf, 278.3 KB

An internal investigation by a council in to a man with ARBD who we felt was failed by health and social care services.

Publication

Loss of Focus - Ms Z

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.

Publication

Best of Intentions - Mrs I

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.

Publication

A Recipe For Abuse ?

1 Jan, 2009 | .pdf, 64.9 KB

Report from our investigation into the care and treatment of residents in a supported landlord scheme following allegations of abuse.

Publication

Too Close to See - Mr F (Summary report)

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.

Publication

Too Close to See - Mr F (Full report)

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.

Publication

Mr Q Enquiry

1 Jan, 2009 | .pdf, 106.6 KB

Report from our investigation into the care and treatment of Mr Q a man with Aspergers' Syndrome who was placed in an intensive psychiatric care unit, without appropriate specialist input to his care and treatment.

Publication

Investigation into the care and treatment of Ms L

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.

Publication

Justice Denied - Ms A

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.

Publication

Wrong Place, Wrong Time - Ms Y

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.

Publication

Inquiry into the care and treatment of Mrs T

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.

Publication

Not my problem - Mr G (Full report)

1 Jan, 2007 | .pdf, 445.8 KB

Headline findings and recommendations relating to deficiencies in the care of Mr G, a man whose dementia went undiagnosed due largely to a previous diagnosis of Personality Disorder.

Publication

Not My Problem - Mr G (Summary report)

1 Jan, 2007 | .pdf, 135.5 KB

Investigation relating to deficiencies in the care of Mr G, a man whose dementia went undiagnosed due largely to a previous diagnosis of Personality Disorder.

Publication

Inquiry into the care and treatment of Mr H

1 Jan, 2006 | .pdf, 156 KB

Report of the Inquiry into the care and treatment of a man with alcohol related brain damage (ARBD).

Publication

Mr L and Mr M Enquiry

1 Jan, 2006 | .pdf, 205.2 KB

Report of the Inquiry into the care and treatment of a restricted patient who killed another patient while on conditional discharge from hospital.

Publication

No fears As Long As We Work Together

1 Jan, 2005 | .pdf, 976.8 KB

Update on Commission and Social Work Inspection Agency joint Inquiry into care of people with learning disabilities living in the Scottish Borders.

Publication

Mr B Report

10 Feb, 2003 | .pdf, 401.9 KB

Report of the inquiry into the care and treatment of Mr B.

Publication

Mr C Report

2 Oct, 2002 | .pdf, 443.2 KB

Report of the inquiry into the care and treatment of Mr C.

Publication

Mr J Report

18 Sep, 2002 | .pdf, 299.4 KB

Report of the inquiry into the care and treatment of Mr J.

Publication

Mrs K Report

16 Oct, 2001 | .pdf, 271 KB

Report of the inquiry into the care and treatment of Mrs K.