not my problem investigation into deficiences in the care and treatment of mr g by mental welfare...
TRANSCRIPT
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.