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

Chair's foreword

I would like to thank everyone who has contributed to the work of this Review. I would particularly like to acknowledge the contribution of the people who, through their own direct experiences, shared their views on what works well and what needs to be improved.

I heard first-hand from staff, families and carers about the importance to them of compassionate, timely and thorough investigation following the deaths of people they have cared for.

I heard of the way in which investigations can be helpful for all those affected, in supportively considering factors that contributed to individual circumstances, recognising through action the importance of communication, information, involvement and, when the investigation has been completed – ensuring that requirements for change and improvement can be described clearly.

Support to make the necessary improvements and provide transparent public assurance that this has happened was consistently raised as the hallmark of best practice in this area.

I also heard of the distress that insensitive, defensive and unresponsive actions can cause to people who were already finding it difficult to makes sense of what had happened.

Organisations told me how they were taking steps to continuously learn and improve the way they investigate deaths and their commitment to do what is required to address the findings of this review.

This review has confirmed that there is widespread recognition across the country that there is a pressing need to ensure consistently high standards of investigation, that this is accompanied by timely scrutiny of the quality of that investigation and that greater transparency in the way in which changes and improvements are being effectively delivered is prioritised.

Although the review identified several areas of improving practice in the investigation of deaths, staff, families and carers were united in identifying a need for further focus, resource and support to undertake what is often complex, difficult and distressing work.

All those who were engaged with this work agreed that our collective response to this report, its findings and proposed actions will be vital in creating the conditions for change that everyone we spoke to wants to see.

I look forward to supporting the further work that is needed, involving people whose lives have been changed forever following deaths of the sort our review has focused on.

All members of the Review Group have expressed their willingness to contribute to the further work that will be required through responses to this Review and other commitments, building on what works well and in identifying new nationally supported systems and processes.

Professor Craig White
Divisional Clinical Lead,
Directorate for Healthcare Quality and Improvement, Scottish Government