The sad tale of Mr G

1
The sad tale of Mr G

• Personality disorder misdiagnosis and
  mismanagement?

2
The Commissions 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

3
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

4
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

5
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

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Event Our
findings
07/00
Crisis at sporting event
GP referral not coping at work
Seen by junior doctors. Depressed/anxious in the
setting of inadequate personality. Cognitive
testing not performed
OP contact
Admission
02/01
7
Event Our
findings
02/01
9 month admission
Inappropriate sexual behaviour
RMO never wrote in notes
Behaviour assumed to be personality disorder
Difficult rehab with odd behaviour
Discharge on CPA
11/01
8
Event Our
findings
12/01
Sexual offences x2
Court/forensic reports PD. No treatable disorder
Assaulted care worker
No appropriate treatment and no discharge summary
Removed from CPA and MH caseload
Prison
06/02
9
Event Our
findings
10/02
Homeless acc. In area B on release from prison
In the care of nuns for one night!
Sexual offences, importuning
Behaviour worse
Emergency psychiatric reassessments
Consistent with previous diagnosis of
personality disorder
Prison
01/03
10
Event Our
findings
03/03
Homeless acc. Sexual behaviour, self-harm
Beh. programme devised. Not implemented
2 brief hospital reassessments
Cursory assessment rapid discharge
Incoherent, soiling self, further self-harm
Forensic review baseline investigations to
exclude organic pathology
Prison
10/03
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Event Our
findings
11/03
Placed in care home in area C
No clear plan somewhere to put him
Referred to MH services - paranoid
Poor availability of previous info
Assaulted staff in care home
Psychiatrist looked at old notes and advised PF
of dangerousness
Prison
02/04
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Event Our
findings
02/04
Psych assessment and remand to hospital
Range of diagnostic possibilities
3 month hospital assessment
Normal plain CT scan but low BP
Some response to behavioural approach
RMO left. Short of cover. Court reports PD and
no treatable illness
Prison
05/04
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Event Our
findings
05/04
Seriously abnormal behaviour in prison
Not fit to be in halls let alone released
Found not guilty and discharged to homeless acc.
LA for area A withdrew
Admission to hospital and assaulted staff
Personality disorder still the diagnosis
Prison
07/04
14
Event Our
findings
08/04
Likely dementia. Advised urgent hospital care
Seen by MWC
Admitted to State Hospital
Good care. Parkinsonism. PSP?
Transferred to unit for younger people with
dementia
Lost ability to swallow
Died
04/06
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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

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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

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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

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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

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What can the personality disorder network do?