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

Background

1. The 2015 Act sets out a requirement for Scottish Ministers to undertake a review of the arrangements for investigating deaths of patients in hospital for treatment of mental disorder. This report gives the findings of the Scottish Ministers' Review and the actions that will be taken to address those findings.

2. In response to an investigation report by the Mental Welfare Commission for Scotland and a petition before the Scottish Parliament, Ministers agreed that the Review would look at two additional circumstances.

3. The Mental Welfare Commission for Scotland published a report, in January 2016, on its investigation into the death of Ms MN, a person with complex needs.^[2] Ms MN was subject to a hospital-based compulsory treatment order (CTO) and subject to suspension of detention when she died by suicide in 2012. The investigation report made a recommendation to the Scottish Government that the Review should also consider deaths by suicide of patients subject to suspension of detention. This recommendation was accepted.

4. In response to petition PE1604, submitted to the Scottish Parliament by Catherine Matheson, the Minister for Mental Health agreed that the Review should also include the arrangements for investigating the deaths of people being treated in the community while subject to an order under the 2003 Act or part VI of the 1995 Act.^[3]

5. Once the remit of the review had been finalised, the Minister for Mental Health asked Professor Craig White, Divisional Clinical Lead, Scottish Government Directorate for Healthcare Quality and Improvement to chair a group to review existing arrangements and develop a series of actions for improvement. Policy support to the Review Group was provided by the Law and Protection of Rights Team, Scottish Government Directorate for Mental Health.

6. The Review Group met for the first time in October 2017 and subsequently in April, June, August, and October 2018. A list of group members is provided at Annex A.