MH4A: Personality Disorder - Major Failings in Care Part 1

At the end of July, having read an article in the Glasgow Herald, I posted about the prejudices experienced by sufferers of Borderline Personality Disorder (BPD). The article referred to the case of a Mr G whose case was investigated by the Mental Welfare Commission for Scotland (MWC) which is ".... an independent organisation set up by Parliament with the responsibility of protecting the welfare of people with mental disorder (including learning disabilities and dementia) in Scotland. We have a duty to anyone with a mental disorder whether they are in hospital, in local authority, voluntary run or private accommodation or in their own homes."
The Herald article was a powerful condemnation of the way in which the services had failed Mr G and I was drawn to read the MWC report into Mr G's treatment. [The full report can be downloaded from here] Despite knowing the basics of his case - from the Herald - I was shocked - not surprised though - to see the detail. To those fighting The System, the report will not be surprising because it confirms many of the points which we have been making.
That the failings have been made in an official investigation lends them massive credibility. Too often the NHS, Social Services and other Local Authority Services act as though they are the absolute fonts of knowledge and are unchallengeable. This MWC report shows just how disastrously poor these services can be and how they can act in their own, rather than patients', interests.
In this post - Part 1 - I highlight many of the medical failings because it is very important that they be more widely known. Part 2 - now published here - will deal with failings elsewhere. Unfortunately, this is a very long post but, hopefully, others can dip into these posts rather than having to read the 75 page MWC report.
I realise that the length and detailed content of this post is likely to be of interest to only a few of my visitors but the issues raised are so important that I am prepared to "turn off" some visitors.
The basics of the case are that Mr G, who did have some very challenging behaviours, was diagnosed as having a personality disorder when, in fact, he was suffering from dementia. Much of his mistreatment followed on from the mis-diagnosis of Personality Disorder but medical and Local Authority incompetence and buck-passing were crucial failings.
Interestingly the report is entitled,

"Not My Problem - The Care and Treatment of Mr G"

and there follow two quotations:

“Instead of responding to the person, we typically react to the behaviour”
(Herb Lovett) [Clinical psychologist died 1998]

"We want the facts to fit the preconceptions. When they don't, it is easier to ignore the facts than to change the preconceptions."
(Jessamyn West) [American writer 1902 – 1984]

The report found 5 problem areas. One of them is very common to those who are fighting the NHS: Mr G's History was distorted to fit the diagnosis of personality disorder.
The report states in Paragraph 3.1.6:

• Five incorrect accounts of his forensic history, with statements such as “long history of anxiety and sexual offending” (Court report 2001), “displays aggression and sexual disinhibition in keeping with his behaviour over several years” (hospital admission February 2004) and “numerous convictions dating back to 1979” (Court report February 2004) distort the truth as Mr G was actually admonished in 1979 and never prosecuted or convicted again until 2002;
• A significant error in his personal history. From around April 2004, the account of his previous history recorded that his wife left in 1998. This was used as an explanation for his decline since then. She actually left in 1988;
• Distorted accounts of his previous psychiatric history. Most Court reports contained accurate accounts of his previous psychiatric contact. A significant exception is a report that alleged “extensive contact with the psychiatric services over the last forty years.” It stated that this contact “has not brought about any modification in his behaviour. There is a danger that further treatment will just foster dependence and encourage further sexual deviance” (Court report 2002). This report also referred to abnormal sexual behaviour in 1972 to support the claim that such problems were longstanding. This behaviour occurred once in the context of a brief spell of disturbance immediately following treatment with electroconvulsive therapy and was not a feature of his behaviour at any other time prior to 2001.

If the MWC can uncover the true background one must ask why so many mistakes were made. Were the distortions deliberate or due to simple incompetence?
Paragraph 3.1.7 summarises the position:

3.1.7 It was therefore evident that the lack of a complete and consistent longitudinal account of Mr G’s life and previous mental health contacts seriously impeded the process of accurate diagnosis. During our investigation, we found that the account of his history became distorted to become consistent with the accepted diagnosis of personality disorder. [Calum's emphasis]

Many will not be surprised to read this. Get a negatively viewed diagnosis or label and you've got it ... forever!
The incorrect diagnosis could have been picked up but

3.1.1 We examined the process of diagnosis when Mr G came to the attention of mental health services in NHS Board A. Following this, there were numerous opportunities to reassess the diagnosis during contacts with mental health practitioners in various services, including practitioners providing Court reports.

Paragraph 3.1.5. details those opportunities:

Subsequent contacts with mental health services included:
• A seven month period of community follow-up by Dr 1
• Five further hospital admissions
• Ten Court reports
• An independent forensic mental health report requested as a “second opinion”
• At least four emergency psychiatric assessments
• Three psychiatric assessments at the request of prison staff

Seven months under Dr 1 - I'll come back to Dr 1 later - AND twenty-three separate opportunities not taken. Not only were these opportunities to reassess not taken but at the very end of Section 3.1 the report states:

There was evidence that the diagnostic process was based on inaccurate and unsubstantiated information and assumptions that lacked corroborative evidence from a careful analysis of previous case records and/or information from informants.
In many cases, there was a failure to consider and document a differential diagnosis that would have been useful as a guide to the need for further investigations and interpretation of their results. This includes an apparent failure to consider a second diagnosis in a person with pre-existing personality difficulties.

This is important because

3.1.11 The diagnosis of personality disorder is notoriously unstable and many people can have other co-existing mental disorders (Ref 10)[Calum's emphasis]. In Mr G’s case, we found evidence that diagnostic statements appeared to accept the previous diagnosis of personality disorder too readily and without proper consideration of other possibilities. Further, insufficient consideration was given to the possibility of co-morbid disorders.

Again this will be very familiar to many. There is a "story" and, by God, everything will be made to fit. Nothing else will be considered.
Worse was to follow. Not only was the history distorted and the diagnosis not reassessed but once the diagnosis of personality disorder was made all symptoms were ascribed to this disorder.

3.2.6.This unquestioning acceptance of a diagnosis of personality disorder was also evident in further forensic assessments from April to June 2004 and on his admission to hospital in June 2004 and subsequent arrest and return to prison.

3.2.7 The last of these is of particular concern. Mr G was described as being disorientated for time and place, incontinent of urine and manually evacuating faeces which he offered to staff. This behaviour was new and had not been a feature of his previous admission yet it was explained as another feature of his personality disorder. We are confident, had it not been for his previous diagnosis of personality disorder, that the emergence of these features would have aroused a high level of suspicion of an organic brain disorder. [Calum's emphasis] Unfortunately, we were not able to interview Dr 9 to explore this further.

Well Dr 9, whoever you are, I hope you have learned but, more importantly, I hope that you are hurting over your mistreatment of Mr G. More examples of the personality disorder diagnosis over-riding everything else are given:

3.2.2 In June 2002, psychiatric services withdrew from his care ....... We found no discharge summary by the mental health services, no clear statement as to why he was discharged and no detailing of what circumstances could lead to re-referral. It appears that there was a decision that Mr G was “untreatable.” [Calum's emphasis]
3.2.3 Around this time, two psychiatric reports stated that he did not suffer from a mental disorder (within the meaning of the 1984 Act). Here, and subsequently, we found statements that providing services to Mr G was likely to foster dependence and increase his offending behaviour.
3.2.4 Following his release from prison in October 2002, Mr G was seen on two occasions by psychiatric emergency services. Despite the fact that he was on medication and some suggestions were made as to the dosage, no psychiatric follow up was organised. Given that follow-up would have been organised if the diagnosis had been, for example, schizophrenia or bipolar disorder, we consider that the diagnosis of personality disorder was a major factor in denying Mr G the benefit of psychiatric follow up. [Calum's emphasis]
3.2.5 From this time until his placement in NH1 [nursing home 1], there were several brief contacts with mental health services. Mr G had two brief admissions to hospital in the summer of 2003 and an assessment in prison in October 2003. He presented with self-harm and inappropriate behaviour that showed clear lack of social judgement. However, all assessments commented on his diagnosis of personality disorder and that further mental health contact was unlikely to help. We consider that, had such behaviours occurred in the absence of such a diagnosis, Mr G would likely have received further assessment and treatment. [Calum's emphasis]

Not only did all of this follow on from the initial diagnosis but that initial diagnosis of personality disorder was incorrect and incompetent.
MMSE tests which ruled out the possibility of dementia were inappropriate. Clinicians were unaware of the limitations to the test's usefulness! [The details of this test are unnecessary here]. Paragraph 2.3.6 states, for example, that:

A good score was obtained on the MMSE and this was taken to indicate that he was “certainly not dementing”.

WRONG!!

3.1.9 The MMSE (ref 1) is a much-used screening and assessment tool. However, it has its limitations and is a poor diagnostic instrument(ref 5). It is only useful once its limitations are understood (ref 6). In the case of Mr G, we found extensive evidence of psychiatrists using the MMSE without realising its limitations. [Calum's emphasis]

Not just one psychiatrist but "extensive evidence that psychiatrists". We put our trusts in the "hands" of so-called experts like these and, as the report shows, they didn't know what they were doing.
And we're meant to have confidence in them.
And we're not meant to question them.
And we're not meant to challenge them.
And we're not meant to complain about them.
It is important to point out that not all clinicians displayed incompetence. One report did flag up a suitably wide range of possible diagnoses but at subsequent hospital admissions these possibilities were not considered [paragraph 3.1.11]. More incompetence or the personality disorder effect again!

I said that I would came back to Dr 1. Well, Dr 1, you're a cracker aren't you!.

3.1.4 .... Unfortunately, during this important period of time, there was a nine month period when Dr1 made no direct entries in the case record and entries by junior medical staff made no reference to Dr1 actually examining Mr G. This clearly falls below acceptable standards of professional practice. [Calum's emphasis] The case record contains no explanation for either Mr G’s behaviour or any consideration of differential diagnoses. In the absence of a clear record of the diagnostic process and any differential diagnosis that was considered, we therefore find evidence that the diagnoses of “depression and anxiety” and “dependent personality” given at the point of discharge were insufficient to explain all the behaviour that Mr G displayed during this admission.

Nine months without seeing a patient!
Not worthy of your time!
Not worthy of your "knowledge"!
Well, given the state of knowledge displayed, perhaps it's better that you didn't see him!
Dr 1, you're incompetent, aren't you! Did you suffer as a consequence of your inactions and lack of knowledge? I hope so.


The WMC report highlights a catalogue of failings - incompetences and prejudices - from members of a profession which holds itself in the highest regard. Just as well they do because I'm damned if I ever will again. Individuals possibly but as a profession NEVER.
I repeat here a variant of what I wrote a few lines above:
We put our trust in the "hands" of so-called experts like these and, as the report shows, they didn't know what they were doing. They were incompetent and prejudiced.
And we're meant to have confidence in them.
And we're not meant to question them.
And we're not meant to challenge them.
And we're not meant to complain about them.
And if we do any of the above we're shunned and labelled as being difficult.
I say, "Doctors, get yourselves and your own houses in order first before you dare to criticise those who suffer and come to you for help. Your job is to help us. If you can't do your job because you are incompetent or prejudiced then, for God's sake, get out and do something else where you will do less harm!"
Part 2 will follow in a few days.

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