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

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 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

7. 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”

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Event Our findings Seen by MWC Admitted to State Hospital Transferred to unit for younger people with dementia 08/04 Died 04/06 Likely dementia. Advised urgent hospital care Lost ability to swallow Good care. Parkinsonism. PSP?

15. 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

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?