Not my problem

1
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

2
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

3
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

4
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

5
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

6
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

7
Case Study

• Original social worker kept in touch with Mr Gs
  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

8
MWC doctors 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 Parkinsons
  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

9
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

10
Contd

• 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

11
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
  getout 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

12
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 Gs behaviour and
  social function

13
Contd

• 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

14
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

15
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.