Current situation
There are approximately eight hundred deaths per year due to suicide in Scotland – two every day! - and many of these deaths occur in people who are under the care of mental health services, either in hospital or in the community.
Under the present system, the Procurator Fiscal decides whether a Fatal Accident Inquiry should be held to establish the facts surrounding these deaths and to look at whether improvements should be made to systems or processes to try to prevent similar situations occurring in the future. This is a lengthy process, with relatives of the deceased often waiting for many years before a decision is even made about whether the suicide of their loved one will be the subject of a Fatal Accident Inquiry or not. This places an undue burden on the relatives of the deceased and can have a seriously detrimental impact on the already traumatic grief experienced by those who suffer from such a tragic loss.
I have personal experience of the shortcomings of the current system, as I have been attempting to get NHS Tayside to make improvements to their services and systems since the death of my son by suicide in November, 2012. But NHS Tayside, it seems (despite being criticised by the Scottish Public Services Ombudsman in 2013 for failings in their provision of care in the community and involvement of relatives in its review of an earlier death by suicide: www.spso.org.uk/investigation-reports/2013/april/tayside-nhs-board), is accountable to no-one for their actions.
The NHS has not even carried out a full and accurate report, as they promised, on their final episode of care for my son, even though I have obtained and paid for the services of a solicitor and I have obtained an independent report, which found the NHS to be negligent in their care of my son. I have also been liaising with the Procurator Fiscal Service, for over three years now, but I seem to be no closer to reaching a decision on whether or not a Fatal Accident Inquiry will be held into his death when he was on release from hospital under the terms of a Compulsory Treatment Order and subject to continuing NHS care.
Section 37 Review
The Scottish Parliament did not include suicide (even for those detained in hospital or people receiving care under Compulsory Treatment Orders in the community) as mandatory for investigation by Fatal Accident Inquiry in the recently passed Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016.
However, the Scottish Government will conduct a review of the arrangements for investigating the deaths of patients in hospital in accordance with the terms of Section 37 of the Mental Health (Care and Treatment) (Scotland) Act 2015. I think the remit of this review should be expanded to include the terms called for by this petition.
I believe there is a need for a separate inquest system for all suicides in Scotland, which should be led by an independent body and should incorporate a system of mandatory actions to be taken where failure of mental health care systems or individuals operating within these systems is established. Relatives of the deceased should be able to participate in this process and should be kept fully informed of all proceedings and investigation results. An inquest system would also enable the facts to be fully reported and this would, perhaps, lead to an increase in suicide prevention and a more transparent, accountable system for dealing with these tragic losses. The need for this system and recommendations for how it could operate should therefore be incorporated into the forthcoming Section 37 review.
I also believe it is imperative that the systems for investigating the suicide of patients who were either released from hospital, or receiving care in the community under Compulsory Treatment Orders, should be incorporated into the review. These patients are under the care of the NHS, which owes them a duty of care. It is important that this is properly investigated to ensure lessons are learned and better care is provided for patients in future.