Recommendations for change have been made to improve the care of vulnerable people by the Mental Welfare Commission, following the case of a woman with autism who took her own life.
The MWC’s report focused on the case of Ms MN, a 44-year-old woman with autism and complex needs, took her own life in a care home in Scotland in December 2012 soon after being transferred from hospital.
The circumstances of Ms MN's death, and the way in which her transfer to the care home had been managed, raised concerns at the MWC, which decided to conduct a full investigation.
MS MN had been in contact with mental health services since she was 18, and had experienced obsessional thoughts and ritualistic behaviour. She often self-harmed and regularly spoke about suicide. She had great difficulties with self-care and was vulnerable to exploitation. She had frequent admissions to a mental health ward in hospital.
She was prescribed a large amount of medication to deal mostly with anxiety, and became accustomed to receiving it 'as required', when in hospital.
Ms MN spent much of 2012 in hospital and was subject to a compulsory treatment order at the time of her death. In November 2012, she had been moved to the care home. Ms MN found that move extremely difficult, frequently talking to staff about self-harm and suicide. She was found dead in her room six weeks after her arrival at the home. The home was relying for medical advice on local GP services, who had not met Ms MN, and did not have full information on her case.
The MWC found that the placement was not properly planned and that arrangements for managing her care, and the risk of suicide, were confused and unsafe. Its resulting report contains recommendations for change for Scottish Government, the Care Inspectorate, health boards, and joint health and social care bodies. These include:
• A greater use of specialist assessments where people have autistic spectrum disorder and complex needs
• Better discharge planning, to ensure care homes and GPs have the right information and support to manage such people in community settings
• A review of the availability of specialist services for people with autistic spectrum disorders who do not fit into mental health or learning disability settings.
Colin McKay, chief executive of the MWC, said: "This is a desperately sad case of a vulnerable individual, who was struggling to deal with day-to-day life.
“Services tried, with varying levels of success, to support her. While there was certainly goodwill and a genuine caring attitude, there were also serious errors of judgement, and a lack of communication at key points. That resulted in her being in a home which was not able to meet her needs, and which did not have the appropriate support from specialist services when a crisis arose.
“This report is about one tragic case, but it contains lessons for all of Scotland. I hope it is read by all those involved in providing care and treatment for people with autistic spectrum disorder, and I hope all of our recommendations are acted upon.”