MH4A: Personality Disorder - Major Failings in Care Part 2

Recently, in Part 1, I wrote about the failings in medical care afforded to Mr G whose case was the subject of an investigation by the Mental Welfare Commission for Scotland [download the full report here].  Today, in Part 2 which is another massively long post, I detail major failings in other areas.  I should make clear, as does the WMC report, that:

"The [WMC investigation] team were struck by the considerable efforts made by front-line care staff, often in very challenging circumstances, to provide proper care and treatment for Mr G.   They appear, in most instances, to have been let down by the same system failings that Mr G himself was subject to.  It is our hope that these individuals do not feel criticised by the content of this report."

Before I list more failings it is interesting to detail how different carers perceived the effect of a diagnosis of personality disorder on the level of a patient's care.

"3.2.9 When we interviewed a variety of individuals and groups involved in Mr G’s care, we were struck by the different perceptions of the impact of a diagnosis of personality disorder on the care and treatment a person receives. For example:
• Dr1 told us that he did not think it made a huge difference to the quality and quantity of care;
• CMHN1 [Community Mental Health Nurse 1] however, who was part of the same team as Dr1, told us that the effect of the diagnosis was for Mr G to be viewed as “untreatable,” leading to the rejection of subsequent approaches for assistance by social care agencies;
• CCSW2 [Community Care Social Worker 1] said that the diagnosis could be a “death-knell”, suggesting imperviousness to treatment or any investment of time;
• Staff from homeless services commented that the diagnosis was an obstacle to obtaining healthcare care and often used as a “get out clause” in managing difficult people."

Only Dr 1 is out of line with the other three respondents.  Did he not know the truth? Was he incompetent?
Did he know the truth but did not tell the truth?  Was he lying?
From the report there is no doubt that the front-line staff knew and told the truth about the effect of the diagnosis on Mr G's care.  Where does that leave Dr 1? 
The report highlights examples of information held in one system which is not available to those from other disciplines.  For example,

"We found that information about Mr G’s presentation in prison was held in separate records held by the health care team and the social work team. Some of the information held in the social work records could have been valuable to visiting psychiatrists but was not available to them."

It is inconceivable that the recorded problems occurred only in the case of Mr G and in those geographical locations.  With goodwill problems such as these could be resolved quite easily but, and it is a big "but", organisations can only resolve if they are aware that there is a problem.  However, as we shall see goodwill towards Mr G was lacking and between Local Authorities.

The rest of this post will concentrate on the following faults:
•  recommendations made but not fulfilled
•  prejudice towards Mr G by Local Authority A
•  bare-faced refusal by Local Authority A to act in Mr G's interest
•  deliberate flaunting of guidelines by Local Authority A


Recommendations Made But Not Fulfilled
There are several examples where Mr G would have been helped had recommendations been carried out. A typical example is:

"2.4.20    Prison staff struggled to manage Mr G but tried to ensure that proper discharge arrangements were made.  Despite being invited, no-one from Local Authority A attended the pre-discharge meeting and support workers and the Homeless Team were left to manage him.  The Homeless Team contacted the MWC advice line on 30th October 2003. It was suggested that Mr G may have an underlying psychiatric illness and that another psychiatric assessment would be required to determine if that was the case. Again, this appeared not to have taken place."

Prejudice Towards Mr G by Local Authority A
The very end of Section 3.2 carries the following two points which summarise terrible prejudice within Local Authority A:

"When Local Authority A decided to withdraw from accepting any responsibility for Mr G’s care, they stated the lack of an identified mental disorder as one of the major reasons for this.  Had a person with another mental health diagnosis displayed the same level of apparent need, we do not think that the authority would have made such a decision. [Calum's emphasis]
Overall, we were left with the impression of a man who was seen as difficult and challenging. Faced with this, many practitioners and services appeared keen to accept any opportunity to distance themselves from his care." [Calum's emphasis]

Local Authority A was not in the least concerned about Mr G's well-being.  All that was important was to shift the responsibility for his care to another body, any body.  Isn't this just typical.  The more needy one is the less chance there is of receiving appropriate care.
The next point highlights how frontline services were denied access to full information about Mr G.

"3.3.5 Mr G was removed from the CPA [Care Plan Approach] despite evidence of significant problems and needs for services. This was on the basis that mental health services believed that they had nothing to offer Mr G.  The effects of this included removal of clear lines of communication with the Police and Local Authority A left to try to support Mr G without psychiatric assistance."

Talk about being cast adrift?  Agencies and Mr G struggling because of my two favourite words at the moment - "incompetence" and/or "prejudice".


Bare-faced Refusal by Local Authority A to Act in Mr G's Interest
Local Authority A comes in for stick in the report and this post mirrors that.  Ddespite its length, I believe it is worthwhile to quote the next paragraph in full. 

"3.3.7 We found no Community Care Assessment, no risk assessment or risk management plan in the community care notes from Local Authority A. We also found no risk of harm assessment or risk of sexual harm assessment in Local Authority A’s criminal justice records. These are serious omissions." [Calum's emphasis]

Why were so many assessments and plans missed?

3.3.7 [continues] The housing agency in Local Authority A requested a case conference as they had community safety concerns when Mr G was described as a ‘paedophile’ by neighbours.  This never took place as he was remanded in prison. Local Authority A still had responsibility for his care and CCSW1 [Community Care Social Worker 1] informed the service manager that “The problem is simply being shifted and not dealt with.”  There was no response to this memo in the case records, no multi-agency vulnerable adults care conference convened and the police were not part of any formal discussions despite their increasing involvement.

It's become clearer now. Mr G is not wanted and Authority A is ignoring him.  The same paragraph continues again:

"3.3.7 [continues again] There is insufficient evidence that anyone at an operational or senior management level in Local Authority A took charge of the situation. One of the operational managers told us that we were incorrect in assuming that the above memo [i.e. of the problem being simply shifted] required a response. There was no evidence of a shared approach between agencies as to how to respond when Mr G presented problematic behaviour."

I believe the report is partially correct when it suggests that no senior person took charge. No one took charge to help Mr G but someone did take charge to deny help to Mr G and to shift the responsibility onto another Local Authority.
Even the police were left unhelped by services.

"3.3.13 Prior to his move to the care home, Mr G came to the attention of the Police on several occasions. The Police passed on their concerns to social work colleagues, but no Vulnerable Adult’s case conference was ever held. The Police Constable identified that “no-one wanted to take responsibility for Mr G, either social services or health, leaving the police to deal with an ill man.” This was another missed opportunity for all the agencies concerned to share information and make management/contingency plans for Mr G."

Whilst talking about Local Authority A the report states:

"3.3.9 The homeless provider made a formal complaint in December 2002 to the Social Work Director of Local Authority A. The letter stated, “I wish to make a formal complaint about the inappropriate manner in which Mr G has been treated by your department. It became rapidly apparent that the current accommodation was unacceptable for Mr G’s care. This was immediately brought to the attention of your staff and a case conference was requested to deal with the inappropriate behaviour of Mr G and to consider how we could access something more acceptable. We were constantly given assurances … ‘we accept responsibility for Mr G’. Unfortunately this did not materialise. In essence we believe that an extremely vulnerable man was off-loaded by your department because they were unable to address Mr G’s complex needs.”  This complaint was never formally answered and no senior manager took responsibility for the situation."

Dumped and then when a complaint was made they ignored it.  We know we're in the wrong but if we forget about it possibly it will go away and it did go away ..... until the MWC came in.
Is there no shame?  When does a patient cease to be a person and become a "thing" to be flushed out of their system?
Shameful!!  Shocking!!  I believe that the MWC was much too weak in its criticisms of Authority A but there are two more examples of their inhuman treatment.

"3.3.18 When Mr G was placed in Local Authority C, background information was requested from Local Authority A.  They took over three months to reply. Following receipt of the request, a first line manager contacted the senior manager asking if existing information should be sent. The response given was: “No. I have spoken to … who is preparing a report for them. In the meantime, least said the better as I have encouraged … to take these issues of home authority up with the Scottish Executive as our duties have been discharged under criminal justice legislation”.  It is our view that this response was unacceptable.  No one was thinking of Mr G’s social care needs: he had needs other than those served by Criminal Justice services." [Calum's emphasis]
"3.3.19 While Mr G was in the State Hospital, their social work department invited representatives from Local Authority A to attend case conferences and sent a copy of a social circumstance report for information, to assist with future care planning requirements for Mr G.  A senior manager from Local Authority A replied, “I appreciate that you have kept staff … advised of Mr G’s progress. This was not invited as (we) continue to dispute any responsibility for him.”  We find this response inappropriate as it, yet again, did not focus on the needs of Mr G." [Calum's emphasis]

Of course, it didn't!  They were far beyond the point of seeing Mr G as a human.  This is where so many of us find ourselves; a problem to be avoided, a dog turd to be scraped off a shoe!  Why?  Because we are needy.  Because our problems are complex.  Because it is simply easier not to have to deal with us!
This post is so long now that there is much damning material which I cannot include but I must include more.


Deliberate Flaunting of Guidelines by Local Authority A

"3.4.6 An email from the Director of Local Authority A was forwarded to Local Authority C. It stated, “I understand that Mr G has been assessed by medical professionals as not having a mental health problem. When previously resident in Local Authority A, his behaviour resulted in eviction and he has exhausted the services that the Council is able to provide. In these circumstances he is considered to be responsible for the consequences of his actions … If he presents at any Council offices in Local Authority A, he should be advised that the Council will not take responsibility for his accommodation and that he must make his own arrangements.”   We formed the view that, by this juncture, it was highly unlikely that Mr G had the capacity to make decisions about where he wanted to live or the capacity to arrange accommodation for himself. We found no evidence that formal consideration of capacity issues had ever been undertaken. In any event, we believe that Local Authority A acted in breach of the Homeless Persons Advice and Assistance (Scotland) Regulations 2002." [Calum's emphasis]

But Local Authority A did more (or should it be "less"?

"3.4.9 Mr G was effectively left with no Local Authority prepared to accept on-going responsibility for his care and treatment.  The State Hospital social worker stated that he could think of no other similarly protracted case or one without resolution.  CCSW2 [Community Care Social Worker 2] also stated that, he was “aghast at the way his (Mr G’s) case bounced around the Local Authorities at a senior management level.”  He sensed that energies were being spent in “passing the buck, rather than dealing with the situation.”
3.4.10 We concur with this statement and find that Local Authority A eventually reached a point where they failed to accept ongoing responsibility for this vulnerable man, with complex health and social care needs. In our view, Local Authority C accepted appropriate responsibility for assessment and care management as the “authority of the moment”. Local Authority A was responsible for Mr G’s placement in NH1 [Nursing Home 1] but acted in breach of paragraphs 11 and 12 of Scottish Office Circular No: SWSG 1/96. They neither accepted any ongoing responsibility for Mr G nor had they informed Local Authority C of his placement. Mr G did not “subsequently move without Local Authority involvement” – the placement broke down as a result of NH1 and primary health services being unable to meet his needs."

This is really just more of the same but it demonstrates how easy it is for a patient to be not only abandoned by many of those who should be caring but to be no longer human - a problem to be dealt with.
I apologise for including so much material from the report but I feel that it is hard to understand just how badly treated was Mr G without putting in vast amounts of detail.
Why have I written these posts?  Most of us who are fighting the systems for ourselves, for loved ones or for those unable to fight for themselves will have experienced similar actions and attitudes from the so-called caring services but to see these actions and attitudes described in an official report validates our own issues.
Mr G's case may be more extreme than most but I have no doubt that other health boards and Local Authorities have acted, are acting, and will continue to act in similar ways.  His is the case which has been scrutinised.  If only all our cases were subject to the same level of detailed scrutiny.
Before I finish there is one more paragraph to copy.

"2.7.10    The Mental Welfare Commission were contacted by Dr8 and, independently, by the Healthcare team at HMP B over the first few weeks of July 2004. They expressed concerns that Mr G appeared to be suffering from mental illness but had been rejected by mental health services."

At last, here were people with the gumption, honesty and the caring to raise their concerns with an appropriate body. 
If only the others had acted in a similar way.
Too many knew the problems but did not pursue them. 
Too many knew the problems but did not care.
If only those with whom we are dealing / fighting would respond with honesty and caring.
A big bloody IF ONLY


We must stand together .
We must shout together.
We must fight together.
If we do not then all we will be left is "If Only".
But I am not prepared to accept "If Only"

I will accept only:

MENTAL HEALTH 4 ALL

Please stand and shout and fight with me.