Criticism of care services after autistic woman's suicide
The Mental Welfare Commission (MWC) has called for a review of services for adults on the autistic spectrum after the suicide of a woman in a care home.
The 44-year-old woman, named only as 'Ms MN', took her own life after being sent to a home which did not have the specialist skills to care for her.
MWC said the "tragic case" contained lessons for all of Scotland.
The Scottish government said it was "absolutely committed" to improving the lives of people with autism.
Minister for mental health Jamie Hepbrun said: "Since this incident happened in 2012, new standards from Healthcare Improvement Scotland on investigating adverse events were put in place in 2013.
"We strongly support this and the MWC processes in place. However, we will look closely at the recommendations made and how we will take them forward."
MWC pointed out that people diagnosed with autism or Asperger Syndrome are often categorised as being the responsibility of mental health or learning disability services, when their needs are distinct.
"This is a desperately sad case of a vulnerable individual, who was struggling to deal with day-to-day life," said chief executive Colin McKay.
"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".
Ms MN had severe Asperger Syndrome and struggled with obsessional thoughts and ritualistic behaviour.
In 2012, after a period in a psychiatric hospital, she was admitted to a care home which claimed to specialise in people with challenging behaviour.
The Mental Welfare Commission said that in reality, it only had experience in learning disabilities and was struggling to recruit specialist staff.
No checks were made to see if the care home could provide the specialist service it advertised. The Mental Welfare Commission said Ms MN's psychiatrist suspected it wasn't good enough, but thought it was the best available option.
After Ms MN's admission to the care home, no local psychiatrist took responsibility for her.
The care home was left reliant on a local GP practice who had never met her and had not been given her full history, which stretched back to childhood. Ms MN took her own life in her room six weeks later.
Care home staff had not been told she had attempted suicide four times using the method which finally proved successful.
"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," said Mr MacKay.
"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."
The report points out that, following her death, there was no investigation until the Mental Welfare Commission intervened. Following this, an internal review was positive about her hospital care and did not identify any learning.
The MWC said the Care Inspectorate should review how it can be satisfied that specialist services are adequate.
A spokesperson for the Care Inspectorate said: "We expect to see that people's needs have been assessed correctly before they start using a care service and that services have sufficient, well-trained staff to be able to provide the right level of care and support, tailored to individual people's needs.
"We will consider this report very carefully to ensure that any learning from this case can be taken forward."
It added that it was currently reviewing its inspection methodology.
In 2011 the Scottish government announced a new 10-year strategy for autism, supported by £13.4m over the first four years.
However, the MWC said the implementation of the strategy appears to have been "piecemeal", with some areas of excellence and others where it has had less impact.
None of the funding was used in the health board where Ms MN was treated.
The MWC has recommended a review of specialist services for people with autistic spectrum disorders.