The sad tale of Mr G

“Personality disorder” – misdiagnosis and mismanagement?

The Commission’s duties under the Mental Health (Care and Treatment) (Scotland) Act 2003 include:

• Investigating if it appears to us that a person with mental disorder has suffered abuse, neglect or deficiency of care

• Bringing matters to the attention of various individuals and organisations if they may be able to rectify the situation

• Publishing our findings and recommendations

Mr G and the Commission – assessment in prison

• Removed from mental health care to prison in June 2004 due to assaults on staff:

• “This 61 year old man with anxious/avoidant personality disorder was admitted …….. doubly incontinent and disorientated for time and place”

• Assaulted staff when they tried to stop him eating sugar directly from the bowl.

• Prison staff and visiting psychiatrist alerted us and we decided to visit and intervene

Fact – Mr G had a life!

• Good employment record – librarian, factory jobs, latterly gardener/handyman at a school

• Married 1972 to 1988 when wife left for another man

• Enjoyed church activities, singing in choir, golf

• Moved to “area A” in 1998 due to discord with school employer

• GP – pleasant, genuine man but anxious and self-critical

Fact – Mr G had personality difficulties

• Parents separated early, close and intense relationship with mother

• Marriage never consummated

• Periods of individual and marital therapy in the 1970s. Hospital care in 1972 for depression and had ECT

• Admonished for indecent exposure once in 1979

• Coped badly with wife leaving and had OP and CPN contact 1988 to 1992

Event Our findings

Crisis at sporting event

GP referral – not coping at work

OP contact

07/00

Admission

02/01

Seen by junior doctors.

Depressed/anxious in the setting of inadequate

personality. Cognitive testing not performed

Event Our findings

9 month admission

Inappropriate sexual behaviour

Difficult rehab with odd behaviour

02/01

Discharge on CPA

11/01

RMO never wrote in notes

Behaviour assumed to be

“personality disorder”

Event Our findings

Sexual offences x2

Assaulted care worker

Removed from CPA and MH caseload

12/01

Prison

06/02

Court/forensic reports: PD. No

treatable disorder

No appropriate treatment and no

discharge summary

Event Our findings

Homeless acc. In area B on release from

prison

Behaviour worse

Emergency psychiatric reassessments

10/02

Prison

01/03

In the care of nuns – for one night!

“Consistent with previous diagnosis

of personality disorder”

Sexual offences, importuning

Event Our findings

Homeless acc. Sexual behaviour, self-harm

2 brief hospital reassessments

Incoherent, soiling self, further self-harm

03/03

Prison

10/03

Beh. programme devised. Not implemented

Forensic review – “baseline

investigations to exclude organic

pathology”

Cursory assessment – rapid

discharge

Event Our findings

Placed in care home in area C

Referred to MH services - paranoid

Assaulted staff in care home

11/03

Prison

02/04

No clear plan – somewhere to put

him

Psychiatrist looked at old notes and advised PF of

dangerousness

Poor availability of previous info

Event Our findings

Psych assessment and remand to hospital

3 month hospital assessment

Some response to behavioural approach

02/04

Prison

05/04

Range of diagnostic possibilities

RMO left. Short of cover. Court

reports – PD and no treatable illness

Normal plain CT scan but low BP

Event Our findings

Seriously abnormal behaviour in prison

Found not guilty and discharged to

homeless acc.

Admission to hospital and assaulted staff

05/04

Prison

07/04

“Not fit to be in halls let alone released”

Personality disorder still the

diagnosis

LA for area A withdrew

Event Our findings

Seen by MWC

Admitted to State Hospital

Transferred to unit for younger people with

dementia

08/04

Died04/06

Likely dementia. Advised urgent hospital care

Lost ability to swallow

Good care. Parkinsonism.

PSP?

Problem areas

1. Diagnostic assessment

2. Impact of diagnosis of personality disorder

3. Information sharing and continuity

4. Out-of-area specialist care

5. Management of challenging behaviour

Impact of diagnosis of PD

• Social skills training and behavioural exposure were never tried

• No psychologist ever involved

• Social care services given inadequate advice and support

• Diagnosis perceived as a “death-knell” and a “Get-out clause for mental health services”

• “We treated him for a broken arm when he had a broken leg”

Our findings

• Assumption of untreatability

• Contact with services “would worsen the situation”

• Assumption of capacity, choice and control with no attempt to help him modify behaviour

• On medication for much of the time without specialist review

• Diagnosis led to withdrawal of services

Our findings

• Once the diagnosis was made, his history changed to fit the diagnosis and all subsequent behaviour was explained away as “consistent with the diagnosis”

• Faced with the diagnosis, practitioners appeared to distance themselves from his care and nobody owned his case and offered an overall view of his care and treatment

What can the personality disorder network do?