Review of the arrangements for investigating the deaths of patients being treated for mental disorder

This report gives the findings of the Scottish Ministers’ Review and the actions that will be taken to address them.

Summary of actions

1 The Scottish Government will ask the Mental Welfare Commission for Scotland to develop a system for investigating all deaths of patients who, at the time of death, were subject to an order under either the Mental Health (Care and Treatment) (Scotland) Act 2003 or part VI of the Criminal Procedure (Scotland) Act 1995 (whether in hospital or in the community, including those who had their detention suspended).

This process should take account of the effectiveness of any investigation carried out by other agencies and should reflect the range of powers the Commission has to inspect medical records, carry out investigations, and hold inquiries (as set out in sections 11-12 and 16 of the 2003 Act). The design and testing of the new system should involve, and be informed by the views of carers, families and staff with direct experience of existing systems. It should include appropriate elements of public scrutiny and should involve staff, families and carers. The new system should have clear timescales for investigation, reporting and publication.

2 The Scottish Government will consider the further actions required to better support multi-agency co-ordination of investigations.

3 The Scottish Government will begin an options appraisal in conjunction with partner organisations, to determine an appropriate process of review for the deaths of people who are in hospital on a voluntary basis for treatment of mental disorder. This will support delivery of action 10 in the Scottish Government's 'Suicide prevention action plan' to review every death by suicide and ensure the importance of clarity, alignment and integration of review and investigation processes for maximum impact.

4 The Scottish Government will work with the Mental Welfare Commission for Scotland, Healthcare Improvement Scotland, and NHS National Services Scotland to identify an appropriate set of publicly reportable measures that reflect best practice in the investigation of deaths and can be used to identify where improvement is required.

5 The Scottish Government will ask Healthcare Improvement Scotland to make changes to its Suicide Reporting and Learning System to immediately reintroduce the suicide notification requirement and scrutiny of NHS boards' suicide reviews. Healthcare Improvement Scotland will also be asked to describe how it will support boards to continuously improve the quality of the suicide review reports. There should be a clearer link between the scrutiny of these reports and specific improvement support that is directly designed and targeted around the common contributory processes identified in suicide review reports. This will be aligned to the new investigation process referred to in action 1.

6 The Scottish Government will work with partner organisations to produce resources for carers and families which provide information on how deaths are reviewed.

7 The Scottish Government will work with partner organisations to improve the co-ordination of support available for families and carers. This will include the creation
of a single point of contact for families and carers in relation to all investigations and reviews. It will also include investigation of any barriers that need to be addressed in order to ensure that co-ordination of support is able to operate effectively across the various organisations involved.

8 The Scottish Government will establish an implementation group to oversee the implementation of actions arising from this report. This group will include equal representation from carers and families.

9 The Scottish Government will work with partner organisations to consider what support and advice staff need to involve families and carers in a meaningful way.

10 The Scottish Government will work with the Mental Welfare Commission for Scotland and Healthcare Improvement Scotland to improve the ways in which investigation findings and recommendations are disseminated, and explore options to support healthcare providers to use this information to commission improvement support. The new system of investigations referred to in action 1 should include a mechanism for transparent follow up and public assurance of changes.


Email: Dan Curran

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