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