Two health boards, doctors, care staff and social workers were guilty of serious failings in the care of a woman who took her own life, a watchdog has ruled.

The Mental Welfare Commission launched an investigation into the care of Ms MN, a 44 year old woman who was placed in an independent specialist care which had expertise in the care of people with learning disabilities - even though she did not have one. The home was not told she had recently threatened suicide ans was not equipped to deal with her complex needs, which included a history of mental health problems and autistic spectrum disorders including an Aspberger's Syndrome diagnosis.

The MWC carried out the investigation and issued its highly critical findings after learning that the hospitals involved did not propose to carry out a critical incident review. This was despite the fact that significant communication breakdowns had occurred over the transfer of the woman - who has not been named - from a hospital stay to the care home.

The MWC report says that being placed in the home for people with learning disabilities had distressed the woman who suffered from long-standing mental health problems. She had multiple health and personal issues, was isolated and estranged from her family, and took a complicated combination of medications.

After several months in hospital, she was discharged to the care home on 8th November 2012, although was on a hospital based compulstory treatment order - which was suspended to allow the move. She hanged herself six weeks later in her room.

Care staff had withheld her medicine on the advice of a GP who had never met her. Workers had not been told of her many threats to her own life and in any case were inadequately trained to deal with suicidal thoughts.

Ms MN had made four previous recent attempts to kill herself but her consultant psychiatrist claimed she did not present a high risk of suicide, describing her threats to do so as a sign of distress, not a genuine intention to die.

However after she was moved, a fax from her consultant psychiatrist to the GP apologised for poor communication and promised a full discharge letter. This letter was later sent, by a junior pscyhiatrist: It arrived nearly a month after she had died.

The chief executive of the Mental Welfare Commission, Colin McKay, said there had been serious errors of judgement made in the case. He said the placement was not properly planned and that arrangements for managing Ms MN's care, and the risk of suicide, were confused and unsafe.

Mr McKay 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’.

All details of MWC investigations are anonymised but the findings of this report will be shared with all Scottish health boards. The Commission’s report contains calls for change from the Scottish Government, the Care Inspectorate, health boards, and joint health and social care bodies.

Key recommendations include more use of specialist assessments for people with autistic spectrum disorder and complex needs, better planning of discharges to ensure care homes and GPs have the information they need to manage patients in the community and a review of specialist services for people with autism who do not fit into mental health or learning disability provision.