Factors that Make Psych Lawsuit Easier to Defend

Patients with psychiatric illness who present to the ED "are frequently a challenge," according to Robert B. Takla, MD, FACEP, chief of the Emergency Center at St. John Hospital and Medical Center in Detroit, MI. "Trying to determine if a patient is truly suicidal or a real danger to themselves or others is not always straightforward."

With resources becoming scarcer, placing a patient into a facility is often very difficult, adds Takla. A large ED probably has psychiatric social workers that will see the patient and discuss the case by telephone with the psychiatrist on call, he says. "They will make recommendations, such as, 'This patient is OK to go and has an appointment in two days to see a psychiatrist,'" says Takla.

Smaller EDs, adds Takla, may not have a psychiatric social worker and physicians are making that assessment on their own. "Often they are so busy, that taking the time to do a good assessment may be difficult," he adds.

If you make the decision to let a patient go home and the patient injures him/herself or others, says Takla, "not only are you liable, but you will have to contend with the consequences of your decision."

"Obtaining a history and trying to put the picture together so you have an objective differential diagnosis is not always easy or without prejudice," says Takla. "It is well known that psychiatric patients have a higher mortality, and that is in part because physicians often dismiss their medical complaints as psychiatric."

Mental or Physical?

For example, an ED workup of a headache in a psychiatric patient may not include a CT or lumbar puncture, because the headache may be dismissed, or is attributed to the psychiatric complaint, says Takla. In some cases, he adds, EPs "just don't listen as seriously, and that is very unfortunate. This is especially true because about 50% of psychiatric illness that presents to the ER is dual diagnosis with substance abuse, either illegal drugs or alcohol."

Evaluating Suicidal Risk

Takla says that if a malpractice lawsuit is filed involving ED care of a psychiatric patient, these things would make the case easier to defend:

  • An appointment made for follow-up shortly after discharge;
  • A list of resources the patient has such as friends or family support;
  • A signed contract from the patient agreeing to not harm themselves;
  • A written explanation of the rationale that the patient is no longer interested in harming themselves or others because of ED interventions or an upcoming appointment;
  • Documentation that you have told the patient to return to the ED at any time if they feel like they want to harm themselves or others;
  • Documentation of an agreement from the family that the patient will not be left alone.

Inconsistent, incomplete documentation would undoubtedly make a lawsuit more difficult to defend, says Takla. He gives the example of a triage note stating that the patient is suicidal and wants to kill himself with a gun, a nursing assessment stating that the patient wants to end his life and says that he has nothing to live for, and then the ED physician sends the patient home without documenting the rationale behind this decision.

"The worst thing the plaintiff's attorney can find is documentation of suicidal or homicidal ideation, plans, and means, yet the patient is allowed to be discharged without documentation of the thought process as to why the patient was discharged," says Takla.


For more information, contact:

Edward Monico, MD, JD, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT. Phone: (203) 785-4710. E-mail: edward.monico@yale.edu

Tom Scaletta, MD, FAAEM, Chair, Emergency Department, Edward Hospital, Naperville, IL. Phone: (630) 527-3000. E-mail: tscaletta@edward.org.