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

Introduction

7. The Scottish Government recognises the importance of people being able to get the right help at the right time, expect recovery, and fully enjoy their rights, free from discrimination and stigma. Mental health legislation plays a part in this by promoting rights and providing safeguards for patients. The 2015 Act strengthened measures in the 2003 Act that promote support for decision making, including those for independent advocacy, advance statements and named persons.

8. People in Scotland receive care and treatment for mental disorder in an array of settings. When people die in hospital there may be a review of their death in some circumstances. The type and complexity of investigation of any particular death depends on a number of factors, including whether the death was unexpected or unexplained; staff action (or inaction) which may have contributed to the death; as well as organisational policies, procedures or practices which may have contributed to the death.

9. According to the Inpatient Census 2018 (Part 1: Mental Health & Learning Disability Inpatient Bed Census) there were 3443 patients occupying a psychiatric, addiction, or learning disability inpatient bed in an NHS Scotland facility at the point of the 2018 Census. A total of 1460 of those patients were subject to an order under either the 2003 Act or part VI of the 1995 Act.^[4] These figures do not include independent hospitals but give an indication of the number of people being treated for mental disorder. The Census also tells us that a total of 1196 patients had been admitted to hospital for at least one year or more with 366 of those having dates of admission of 5 years or more.

10. Healthcare providers are required to notify the Mental Welfare Commission for Scotland of the revocation or termination of any order under either the 2003 Act or part VI of the 1995 Act (with the patient's death being one of several reasons for revocation or termination). In 2017-18 the Commission received 100 reports of deaths of people subject to an order. Table (i) provides the number of deaths reported to the Commission since 2014-15.

11. The information and data currently available to describe systems and processes of investigation are not sufficient to provide assurance of timely and effective delivery. Further action will be required to identify a broader range of process and outcome measurements that more explicitly inform scrutiny, assurance, and improvement support.

*source: Mental Welfare Commission for Scotland