Legal Review & Commentary

Denial to hospital admittance results in a suicide; $242,500 settlement in Texas

By Jan J. Gorrie, Esq., Buchanan Ingersoll PC, Tampa, FL

News: A man diagnosed with bipolar disorder became extremely depressed. Believing that he required full-time professional care, his family physician arranged for admittance to a psychiatric hospital. The hospital, however, refused to admit the patient because the admissions staff did not think that he met the criteria for institutionalization. The man killed himself the following day. After filing a lawsuit against the hospital and its individual employees involved in the decision to turn away the decedent, the plaintiffs settled with the defendants' insurance carriers for $242,500.

Background: A widower had become extremely depressed over the one-year anniversary of the death of his wife of 41 years. Realizing that the man already had been diagnosed with bipolar disorder, a brain disorder causing unusual shifts in mood, energy, and the ability to function, the man's family physician determined that her patient posed a significant risk for suicide. The doctor decided that the man needed full-time professional care and she monitored him in her office until he could be transferred directly to a psychiatric hospital.

When he arrived at the psychiatric hospital, a nurse and a physician assistant assessed his condition. Subsequently, the doctor in charge of psychiatric admissions determined that the man did not meet the criteria for institutionalization and declined to admit the patient. Fewer than 18 hours later, the man killed himself.

On behalf of their deceased father, the man's son and daughter filed suit against the hospital, the nurse, the physician assistant, the physician assistant's employer, and the doctor in charge of admitting. The plaintiffs alleged that the defendants negligently refused to provide psychiatric care to their father, even though he posed a significant risk of killing himself. The plaintiffs further contended that this conduct directly and proximately caused their father's subsequent death. The defendants denied that they acted negligently, arguing that the decedent failed to meet the criteria for admission to the psychiatric hospital. The defendants recognized that the man had exhibited some suicidal ideation, but they determined that he did not have a plan or the ready means to commit suicide. Furthermore, the defendants contended that the decedent, upon being denied admission to the psychiatric hospital, had agreed to return to his family physician to undergo outpatient therapy. Because the patient willingly entered this contract for safety, the man's subsequent suicide was beyond the defendants' control.

To prepare for trial, each party retained three expert witnesses in the fields of psychiatry, psychiatric nursing, and hospital administration and procedures. Nevertheless, all parties, fearing the unpredictability of a jury, entered into settlement agreements before the trial began. The insurance carrier of the doctor, the physician assistant, and the physician assistant's employer agreed to pay the plaintiffs $85,000; the hospital settled for $157,500.

What this means to you: The leading cause of a sentinel event, as reported by the JCAHO, is patient suicide. Root-cause analysis shows the leading contributory cause is environmental safety and security, which was a factor in more than 85% of the cases. But it is followed closely by patient assessment, which was present in four out of five cases.

"Clearly, this is a tragic case. However, predicting suicide is not a science. There are only very rudimentary assessment tools available to even the most skilled health care providers. And, if the judgment regarding psychiatric treatment turns out to be wrong, even the most exemplary assessment will not necessarily carry the day for the defense," notes Ellen L. Barton, JD, CPCU, a risk management consultant in Phoenix, MD.

There are several important facts about this case that should be noted.

"First, the concern regarding the patient's suicidal tendencies was made by a medical professional — not a layperson. Second, the hospital involved was not a community hospital that had a psychiatric service but rather a psychiatric hospital where one would presume a higher level of expertise in the evaluation and assessment of a potential psychiatric patient. Third, the patient had a serious, previously diagnosed underlying mental illness of which the admissions staff was aware. Thus, one would assume that these three factors would have argued strongly for the admission of this patient — the fact that a medical professional had concerns, the fact that the facility was a psychiatric facility, and the fact that the patient had a significant brain disorder. Unfortunately, the interplay of these factors seems to have had the opposite effect. The heightened scrutiny that one would expect based on the three factors outlined above led not one, but three mental health professionals to assess the patient as not meeting the criteria for admission," says Barton.

"From the brief facts provided, it appears that the psychiatric hospital followed an established protocol whereby the patient was assessed initially by a nurse and a physician assistant with a final assessment and determination by the physician in charge of admissions and a professional judgment was made that although there was clearly suicidal ideation, the patient lacked a plan and the ready means to follow through. Perhaps, however, given the fact that the patient's personal physician had made the referral, the psychiatrist should have had a follow-up call with her to gain additional perspective on this patient. In addition, while it might be suggested that given the underlying mental illness, this patient's family should have been notified, that course of action would be fraught with HIPAA [Health Insurance Portability and Accountabilty Act] hurdles," she adds.

"The hospital is left with reviewing the clinical standards used to assess patients to see if they meet the criteria for admission. In this context, it would seem most important to take into account the patient's personal history — particularly the death of his wife after 41 years of marriage — as well as his medical history, which in this case was a serious underlying mental illness. It also would seem to be prudent that where another health care provider is involved, as the patient's personal physician was in this case, that discussions with that health care provider be considered mandatory prior to admission determinations," notes Barton.

"The personal situation of the patient also plays heavily in the determination of whether to settle or try a case. The fact that the patient was a recent widower and the fact that he had an underlying mental illness would make him extremely sympathetic to any jury. The very fact that this individual harmed himself may be viewed as proof of negligence;" she says, "sadly, such cases happen and seem to be among the most difficult to defend.

"The JCAHO sentinel event policy provides that suicide 'of any individual receiving care, treatment or services in a staffed around-the-clock care setting or within 72 hours of discharge' is a reportable sentinel event. So, presuming that the psychiatric hospital is JCAHO-accredited, this case could go either way. However, the patient was screened by facility staff and even though he was not admitted, since his suicide fell within the prescribed 72-hour period, whether reported or not, the facility would do well to perform a root-cause analysis of the case with particular focus on their screening and admission criteria," notes Barton.