Mental Welfare Commission, 2014

Mr EF died on 19 September 2011 in Community Unit B. It was reported to the Procurator Fiscal as a sudden death. The cause of death was subsequently confirmed at post-mortem examination as being due to bacterial endocarditis secondary to valvular heart disease. Four days previously, he had been reviewed urgently at General Hospital 1 by a consultant acute physician and sent back to Community Unit B. He was known to have a learning disability. He also had congenital heart disease affecting his aortic valve. He had been under the care of cardiologists for this.

He had a history of minor offences relating to poor social judgement as a result of his learning disability. These included assault, breach of the peace and making nuisance telephone calls. He had episodic hospital treatment during the 1990s for this

Mr EF was convicted of making threats to kill and was detained in the State Hospital in Scotland. He remained under a compulsion order with restriction order in terms of the Mental Health (Care and Treatment) (Scotland) Act 2003.

He was transferred in 2007 to Ward X at Psychiatric Hospital 1 and from there to Community Unit B to continue his rehabilitation.

Mr EF’s death was subject to a full and thorough internal review. The Commission was made aware of Mr EF’s death and received the internal review in October 2012. This was followed by a meeting between the Chief Executive and Chief Medical Officer of the Commission and the Medical Director of NHS Board A to discuss matters arising from the review.

This report outlines the main findings from this case and the steps taken by the Commission and NHS Board A to address the issues raised by Mr EF’s death.