A new system to investigate the deaths of people who died while subject to compulsory treatment under mental health legislation has been proposed by The Mental Welfare Commission for Scotland.

A public consultation will run from 8 December 2021 to 15 February 2022 to seek views on the proposals.

Scotland does not currently have a national unified system for investigating deaths of people who are subject to compulsory care and treatment. Different areas have different criteria and different timescales for undertaking investigations.

Following a review, the Scottish Government asked the Commission to propose a new system. The proposals and consultation come after working with external organisations and individuals including families and carers who have experience of the situation.

The new proposals 

In the revised process, the proposal is that the Mental Welfare Commission should take on responsibility for initiating, directing, and quality assuring the process of investigating all deaths during compulsory treatment. This would include cases where a person died within one month of having their compulsory treatment or detention order revoked. It would mean that the Commission would take an active role from the outset in every case. 

The Commission would have a role distilling the learning from these investigations; publishing an annual report to summarise the findings of the investigations; and sharing the main messages to the relevant audiences including local services, families and carers. 

The Commission would also have a role in ensuring that services implement follow-up actions from local investigations, and escalating cases where recommendations were not implemented satisfactorily.

Alison Thomson, executive director (nursing) at the Mental Welfare Commission, said: “We encourage all those with an interest in this important area of work to read our consultation and give us their views.”