Not my problem Investigation into deficiences in the care and treatment of Mr G by Mental Welfare Commission for Scotland Jim Grierson ; Practice Development Nurse

Mr G  61 year old man seen by the Commission in prison in July 2004  Prison health services and visiting psychiatrist concerned about condition  Charged with assault and thought to have a personality disorder  MWC disagreed and intervened to make sure he had hospital care  Mr G died in April 2006 in hospital care

Case Study  Several contacts with mental health services in the past  Relationship problems and spells of depression  Sexual difficulties and charged with indecent exposure in 1979  Apart from the above there was no reports of sexual aggressive or antisocial behaviour before 2000  Represented to mental health services in 2001 spending 9 months in hospital experiencing anxiety & depression

Case Study  Behaved in strange ways, inappropriate behaviour in public places  Behaviour attributed to personality disorder  Discharged to new accommodation banned from his local supermarket arrested for touching stranger on a bus & assaulted a care worker.  Psychiatrists still attributed this to personality disorder & discharged him from their care in spite of reports that he was defaecating & urinating in public  Evicted from his house in June 2002

Case Study  November 2003 he was either in prison or homeless accommodation  His local Authority had no accommodation so he moved to a neighbouring area  Still the responsibility of the social worker from his original area  Behaviour became more inappropriate masturbating undressing and jumping in front of buses  More convictions for lewd behaviour and indecent exposure  Seen by psychiatrists following emergency referral diagnosis of PD not questioned and no mental health service follow up

Case Study  Following another spell in prison Mr G was found a care home by his original Local Authority, charged with assaulting staff taken to prison and admitted to hospital  Despite a brain scan & brain function tests psychiatrists still thought a personality disorder. Mr G was sent back to prison  In prison he was found wandering,taking other peoples food & hallucinating  Prison staff were concerned no change to diagnosis  2004 he returned to homeless accommodation in another Local Authority  Admitted to hospital a week later under MHA disorientated and incontinent. Detention allowed to lapse assaulted staff returned top prison  Medical notes still recorded his diagnosis as personality disorder

Case Study  Original social worker kept in touch with Mr G’s situation however his managers denied any further responsibility for him  In prison he would only eat very sweet foods assaulted staff when they tried to help was incontinent and openly masturbated in public  Visiting psychiatrist contacted MWC

MWC doctor’s assessment  Depression could not be ruled out  Possible dementia with frontal lobe problems  Mr G was admitted to hospital further tests revealed dementia  Mr G developed signs resembling Parkinson’s disease  Treated for depression as mood was low with little success  Died in a unit for younger people with dementia when he became unable to swallow

Psychiatric Assessment & Diagnosis - aspects considered by MWC  Admission to hospital in 2001  Community follow up by Dr1  5 further hospital admissions  10 court reports  Independent forensic report  4 emergency psychiatric assessments  3 psychiatric assessments requested by prison staff

Cont’d  DR 1 did not keep good enough records during 9 months hospital admission  Too much reliance on dementia screening tests that are not accurate enough  Diagnosis of personality disorder was based on wrong or distorted information  Too many assessments accepted the previous diagnosis did not consider other possibilities  Psychiatrists were not up to date with most recent guidance on this type of dementia  Inconsistent practice among psychiatrists who visit prison in relation to their role in diagnosis and treatment

Impact of personality disorder diagnosis  Evidence suggests that people with PD get poor care from mental health services  Diagnosis seen as a “death knell” as it implied that the person was untreatable. Used as a “get–out” clause for services  Mr G was seen as untreatable specialist services not offered or withdrawn  No structured psychological treatments  Mental health services gave little help to alter his behaviour and accepted he was capable of choosing how to behave  Treated with anti depressants but not reviewed by psychiatrist  Once diagnosis of PD was made all future behaviour was regarded as consistent with his diagnosis

Information sharing & continuity  Mr G was removed from the Care Programme Approach despite evidence of significant problems and need for services on the basis that mental health services had nothing to offer. This resulted in the removal of clear lines of communication with the police  If all records had been examined they would have been less likely to make false assumptions about his past  Information in general practice and mental health records prior to 2000 which did not support assumptions made later about Mr G’s behaviour and social function

Cont’d  Discharged from consultants case load, and care from other practitioners within the mental health team without a discharge summary  No evidence of risk assessment and risk management plan shared between agencies on how to respond to problematic behaviour  Inappropriate placements with Nuns on one occasion  No multi agency case conference No contingency plans. No one operational or senior manager took full responsibility for coordinating care  No overall care manager appointed Local authority did not follow up written complaint about their actions  No access to prison social work records for visiting psychiatrists

Managing challenging behaviour  His diagnosis of PD appears to have resulted in assumptions about choice and control and impeded objective analysis of his behaviour  Evidenced based approaches in the management of challenging behaviour  Lack of knowledge in the NHS & private care homes in relation to behaviour management principles  No psychology input until July 2004

25 Recommendations in total  Recommendation No 2 Health Boards must ensure that staff working with pts over 18 are trained in use of behaviour management principles including education as to the ethical and legal issues involved and how to properly address issues of consent.