The sad tale of Mr G

1. “Personality disorder” – misdiagnosis and mismanagement? The sad tale of Mr G

2. 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

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

6. 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

11. 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

12. 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

13. 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

15. Problem areas • Diagnostic assessment • Impact of diagnosis of personality disorder • Information sharing and continuity • Out-of-area specialist care • Management of challenging behaviour

16. 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”

17. 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

18. 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

19. What can the personality disorder network do?