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In Scotland, following the closure of long stay learning disability hospitals in 2005, focus has shifted on to developing robust community services/resources to cater for the healthcare needs of people with learning disabilities. In the absence of robust in‐patient services, a small number of individuals with learning disabilities and associated severe challenging behaviours, despite not being regarded as “forensic” cases, do inappropriately get referred and sometimes admitted to forensic learning disability services. This study aims to explore this area of clinical practice in the context of referrals to the high secure forensic setting of The State Hospital, Carstairs, Scotland and in light of key UK and Scottish Government policies.

All referrals made to the State Hospital's forensic learning disability service between August 2005 and July 2010, which met the criteria, were reviewed (n=5) and common determinants leading to these referrals identified and thematically analysed.

The identified determinants leading to the making of these referrals were broadly classifiable into psychiatric, environmental and staffing themes.

In Scotland, there does appear to be a requirement for a specialist in‐patient service to meet the needs of this complex and challenging group of patients. There is a need for effective supra‐regional planning to meet the needs of similar “high cost, low volume” patient groups.

This study highlights the wider issue of “gaps” within services in Scotland for individuals with severe challenging behaviours and autism and the requirement for a national specialist service.