This learning disabled man fully dependant on others to manage his welfare was administered a sedative by a carer and left unsupervised heavily sedated at the top of a flight of stairs. He is now paralysed as consequence of injury sustained when he fell. He had a right to be protected, and he has a right to a full investigation of this catastrophic care failure. The ability to fully investigate this extends beyond the legal locus of the Care Inspectorate as it requires investigation of the conduct of staff within a care service that has subsequently de-registered, investigation of the conduct of unregistered carers who continue to work with vulnerable people, and more significantly investigation of the conduct of SLC social work resource responsible for his care management.
The Social Work (Scotland) Act guidelines for a CSWO state it is a duty to call significant case reviews to investigate death or significant injury. Significant Case Reviews are more commonly used when children known to protective services are harmed. It applies equally to vulnerable adults known to lack capacity to manage their welfare. This CSWO is failing in his duty to vulnerable people.