CASES & REVIEWS
Public case reviews, safeguarding findings, and official reports highlighting failures in Power of Attorney oversight — including Mental Welfare Commission investigations and Adult Protection reviews.
Public findings and reporting on Power of Attorney and safeguarding in Scotland
This page brings together official reviews, statutory investigations, and reputable media reporting relating to Power of Attorney, safeguarding failures, and family exclusion in Scotland.
Everything below is drawn from publicly available sources.
We are not offering legal opinion — we are sharing what has already been recorded and published.
1. THE MCCULLOCH CASE
Highland Adult Protection Committee Learning Review (2024)
Summary (public record)
In 2024, the Highland Adult Protection Committee published a Learning Review into the case of three vulnerable brothers, referred to in the review as Mr A, Mr B and Mr C.
The review examined events following the granting of Power of Attorney and identified missed opportunities for protection.
Key findings (from the published review)
The review recorded that:
• concerns raised by family members were not acted upon in a timely way
• Adult Support and Protection procedures were not consistently used
• information from attorneys was accepted without sufficient challenge
• multi-agency coordination was limited
• opportunities to protect the adults were missed
The review concluded that earlier safeguarding action could have reduced the harm experienced.
Sources
• Highland Adult Protection Committee Learning Review (2024)
• BBC Scotland News (public reporting)
2. THE MR E CASE
Mental Welfare Commission for Scotland — Published Investigation (2024)
This page summarises the Mental Welfare Commission for Scotland’s published investigation into the care and treatment of “Mr E”.
Everything below is drawn from publicly available Mental Welfare Commission reports.
Background (from the MWC investigation)
Mr E was a man in his mid-50s with schizophrenia and diabetes.
He lived with family members and had a long history of limited engagement with services.
According to the Mental Welfare Commission:
• Mr E was not seen by any mental health professional between 2009 and 2015
• He received no care or treatment for physical or mental health conditions between 2017 and 2020
• During this period, he became severely unwell, largely bedbound, and suffered significant physical deterioration
• By the time services became aware again in 2020, Mr E had lost his sight and developed serious sores
• He was later detained under the Mental Health Act in August 2020
Mr E is now subject to a local authority welfare guardianship order and lives in a dementia unit receiving 24-hour care .
What the MWC investigated
The Mental Welfare Commission examined:
• The care, treatment and support provided to Mr E
• How safeguarding legislation was understood and applied
• Multi-agency working between health and social work
• Engagement with Mr E’s family
• Whether earlier protective action could have reduced harm
Key findings (from the MWC’s published findings)
The MWC found that:
• There was no evidence of assertive outreach or relationship-based practice
• No comprehensive social work or healthcare assessments were carried out
• There was no coordinated multi-disciplinary approach
• Safeguarding legislation was not implemented effectively
• Opportunities to prevent Mr E living a life “not of his choosing” were missed
• Reporting systems were not used with confidence
• Earlier coordinated action could have reduced the harm Mr E experienced
Wider learning identified by the MWC
The Commission stated that Mr E’s case highlighted broader issues, including:
• Poor communication between services
• Lack of clarity about safeguarding responsibilities
• Missed opportunities for Adult Support and Protection intervention
• Limited understanding of how key legislation interacts
• The absence of local learning reviews prior to serious harm
Why this case matters
The Mental Welfare Commission noted that the issues in Mr E’s case were not unique and reflected wider challenges in adult safeguarding across Scotland.
This case is shared here because many families report similar patterns — including delayed intervention, fragmented responsibility, and safeguarding concerns not being acted upon until serious harm has occurred.
Sources
• Mental Welfare Commission for Scotland — Investigation into the care and treatment of Mr E (2024)
• NHS Highland / MWC Summary Report (public document)
🌿 Important note
This page is based on public information and lived experience.
We are not lawyers — we’re families who learned the hard way.
Nothing here is legal advice.
Everything you share stays private unless you say otherwise.