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

Method

16. The Review has sought the advice of professional experts, organisations and people with lived experience in order to fully understand the current arrangements for investigating deaths. The membership of the Review Group included representatives from a range of organisations with expertise in the review of deaths and in care or treatment for mental disorder. A list of Review Group members is provided at Annex A

17. At the first meeting of the Review Group it was agreed that evidence gathering in three main areas was needed: organisational views on current arrangements; staff experiences of those arrangements; and the experiences of carers and families of those arrangements.

18. The Review Group agreed that, given the importance of recognising the experiences of carers and families across the country, a Carers and Families Sub-Group would be created to take forward the work to engage with the experiences of carers and families on the issues within the scope of this review. The Sub-Group membership is provided at Annex B

19. To obtain details on corporate governance arrangements in respect of investigation of deaths, a questionnaire was sent to NHS board chief executives; local authority chief executives; chief social work officers; independent hospitals; integration joint board officers; the Crown Office and Procurator Fiscal Service (COPFS); the Health and Safety Executive; the Mental Welfare Commission for Scotland ('the Commission'); and Police Scotland.

20. The questionnaire sought information on: the role that the organisation plays in reviewing deaths; the statutory powers available to it; the resources and policies it has it place; the triggers for initiating an investigation; how it works with other organisations and shares information; how it involves families and carers; and how it uses the findings from investigations. A list of respondents is provided at Annex C. The Review Group Chair undertook a series of visits to organisations to speak to staff face to face about their processes for investigating deaths.

21. The Carers and Families Sub-Group developed a survey to enable families and carers to provide their experiences of the arrangements for investigating deaths. The survey ran from 2 July to 24 September 2018 (12 weeks) on the Scottish Government's consultation website.^[5] A total of 42 responses were received. A summary report of the responses received (quantitative questions only) is provided at Annex D

22. The survey for carers and families was followed up with the offer to meet for one-to-one discussions. This was facilitated by members of the Carers and Families Sub-Group and the organisations they represented. At these meetings, carers and families had an opportunity to discuss their experiences and put forward what would have improved things for them. Additionally, the Chair of the Review Group met with several family members in separate meetings to hear from them about their experiences of investigation.

23. A survey for staff was also produced and ran from 2 July to 24 September 2018 (12 weeks) on the Scottish Government's consultation website.^[6] The survey received 172 responses. A summary report of the responses (quantitative questions only) is provided at Annex E

24. Both surveys were publicised using social media channels and were available to anyone visiting the Scottish Government's consultation website. Links to the surveys were widely disseminated through stakeholder networks, NHS boards, local authorities and members of the Review Group. Printed copies of the leaflet to accompany the carers and families survey were sent to main libraries across Scotland.

25. The Scottish Government and the Review Group are grateful to everyone who took the time to tell us about their experiences of how deaths are investigated. Especially so to those carers and families who responded to the survey or met face to face to speak about the impact of these processes on their adjustment to the tragic deaths of the people they loved.