Legal Review & Commentary

Patient suicide leads to $9 million Texas verdict

By Jon T. Gatto, Esq.

Blake J. Delaney, Esq.

Buchanan Ingersoll & Rooney, Tampa, FL

News: A man was admitted to the hospital complaining of anxiety and being under tremendous pressure at work. The man was seen by an internist and a neurologist, and antidepressant and anti-anxiety medications were administered. After a few days, the man's condition improved, and the results of a brain MRI came back normal. The next morning, the man asked his nurse for a razor so that he could shave. Three hours later, he was found dead, locked in the bathroom, having committed suicide with the razor. The man's family sued the hospital for the nurses' negligence in giving him a razor and leaving him unattended for more than three hours. A jury awarded the family $9 million in damages.

Background: A 41-year-old attorney visited a neurologist complaining of severe headaches and insomnia, and the neurologist ordered a brain MRI. Two days later, while the results of the test were still pending, the man went to the hospital, this time with principal complaints of anxiety, difficulty concentrating, and a sensation of his heart racing, particularly when he tried to sleep. He also reported being under tremendous pressure at work and feeling unable to think clearly or comprehend or concentrate on his work. He denied feeling depressed.

The man was admitted to the hospital primarily to see if he could sleep and to run tests. On the hospital's telemetry floor, the man was fitted with EKG leads on his chest for continuous monitoring of his heart activity. He was then evaluated by an internist, who prescribed an antidepressant, and by a neurologist, who diagnosed anxiety, depression with insomnia, difficulty in concentrating, and tension headaches. The neurologist recommended anti-anxiety medication and a psychiatric consult, at the discretion of the admitting physician. It is unclear whether a psychiatric consult was ever ordered.

The next day, the man claimed to be feeling better, with less dizziness and headache. The attending physician instructed the nursing staff to discontinue the IV and Hep-Lock, vital sign checks, and nighttime visitation. On the third day of the man's admission, the results of the brain MRI came back normal, indicating no physical or organic pathology to explain the symptoms.

At 5 a.m. the next morning, the man desired to take a shower and asked the nurse for toiletries, including a razor "to shave his chest because the EKG leads were hurting him." The nurse complied with the man's request, leaving a double-edge razor with him. Nurses did not check on the man again until 8:30 a.m. that morning, at which point they noticed that the man was not in his bed, his breakfast tray was undisturbed, and the bathroom door was locked. Hospital maintenance opened the bathroom door, and the man was found inside, dead. He had killed himself with the razor and had left a suicide note.

The man's estate and family sued the hospital for the nurses' negligence in leaving their decedent unattended with a razor for three hours. The man's wife of 13 years, sister, and mother gave very emotional testimony. The man's 5-year-old son, 7-year-old daughter, and 11-year-old daughter were introduced to the voir dire panel but did not attend the trial. The plaintiffs claimed unspecified damages for past and future mental anguish, loss of companionship and society, and loss of the decedent's wages. They also sought to recover damages for the man's conscious pain and suffering during the time leading up to his death.

The plaintiffs called expert witnesses in forensic psychiatry, economics, forensic pathology, and nursing. To support the plaintiffs' claim for damages relating to the man's conscious pain and suffering, the forensic pathologist opined that it took the man 2¾ hours to bleed to death from the cuts in his throat and arms.

The hospital denied negligence, principally arguing that the man was responsible for his own death. The hospital pointed out the man had denied depression when he went to the hospital and that even though he had asked for a razor on the morning of his death, he had requested and been provided with toiletries, including a razor, each of the previous days without incident. The defense also fought back in the battle of experts, entering into evidence the testimony of experts in hospital administration and procedures, pathology, psychiatry, and nursing.

A jury deliberated for two days, eventually returning a verdict in favor of the plaintiffs. The plaintiffs were awarded $9 million in damages.

What this means to you: "Clearly, this is a tragic case," says Ellen L. Barton, JD, CPCU, a risk management consultant in Phoenix, MD. "However, predicting suicide is not a science. There are only very rudimentary tools available to even the most skilled health care providers. When it is present, suicidal ideation and suicidal behavior is generally rather obvious. However, suicides often occur with little or no warning. Practitioners are left to their best judgment and, if the judgment turns out to be wrong, even the most exemplary assessment will not necessarily carry the day for the defense."

This patient was admitted to the hospital's telemetry unit, so that his heart activity could be monitored. He was seen by both an internist and a neurologist who, while suggesting a psychiatric consultation, left it to the discretion of the attending physician. Thus, in the opinion of the neurologist, who had seen the patient previously, and the internist, the patient did not present as suicidal. Under the circumstances, it is difficult to charge the facility with any knowledge, actual or constructive, that a suicide actually occurred. Nevertheless, that is just what the jury did, underscoring the need to be as careful as possible in preventing suicides in a health care facility.

If the patient had indicated "suicidal tendencies" to either health care professional, it would have been appropriate to conduct a full assessment to include:

• a full psychiatric evaluation of the patient;

• suicide risk assessment tools;

• trained staff capable of using screening mechanisms;

• suicide prevention strategies.

In addition, this patient did not at any time exhibit any behaviors that were observed by the nursing staff that would indicate he was "suicidal." Thus, there was nothing to indicate to the hospital's physician or nursing staff that an increased level of supervision and scrutiny was necessary. In fact, the patient had requested and safely used a razor on each of the three days prior to his suicide.

The patient was not in a psychiatric unit and was not being cared for by staff that was specially trained to recognize self-destructive behavior. The patient, in fact, appeared to be feeling better. The results of the MRI indicated that there was no organic pathology to explain his symptoms. We cannot know if a psychiatric evaluation would have made a difference. It does not appear that the staff were lulled into a sense of false complacency, as every indication was that the patient did not have underlying physical issues and, in fact, stated that he was feeling better. Further, there was no behavior that indicated that anything was amiss.

Under the circumstances presented, could the patient's suicide have been prevented? Some experts would certainly say no. That unfortunately is the dilemma that all suicide cases present. Given the facts in this case, it is understandable why the hospital chose to take this case to trial. And the fact that the jury deliberated for two days indicates that it was not an easy decision.

In spite of the fact that suicidal tendencies can be so difficult to detect and diagnose, the event of a suicide in a health care facility can have catastrophic consequences for the facility, including severe sanctions or termination by the Centers for Medicare & Medicaid Services or state agencies, not to mention the type of civil liability that occurred in this case. Suicides are treated as sentinel events that must be reported to federal and state agencies. Suicides committed at a health care facility also can be a lightning rod for unfavorable media coverage in the community in which the facility is situated. The risks posed by a suicide in a health care facility justify a substantial allocation of resources to training in prevention and assessment of suicides.

All that a facility can do is take every precaution to prevent suicides. Staff should be carefully trained in terms of how to identify, assess, and deal with suicidal ideation and suicidal behavior. Even then, suicides may occur where there are few or no real warning signs, as seems to be the case in this instance. Although the patient had mild psychiatric symptoms warranting a potential referral to a psychiatrist, there was no sign of suicidal ideation or suicidal behavior.

Another aspect of suicide by patients in health care facilities that often is overlooked is how painful it can be for staff who may feel that they should have intervened in some way or detected some sign of suicidal ideation or suicidal behavior. The health care facility should make counseling and pastoral services available to employees who may be in need of such services in the aftermath of a patient suicide.

Legally, this was a tough case for the facility to lose given the apparent lack of any warning signs with regard to the suicide. It seems potentially like an unfair result. It appears that the personal situation of the patient played heavily in the jury's determination. The fact that the patient left a widow and three minor children and a dependent mother would make him extremely sympathetic to any jury. The amount of the award was most likely also tied directly to the fact that he was a young attorney with significant earning capacity. In addition, the fact that the neurologist recommended a psychiatric consult, coupled with the fact that the consult was never ordered, would leave a question in the minds of jury as to liability. That is, if the consult had been ordered, the patient would have received the appropriate care and treatment. Thus, the fact that the psychiatric consult was not ordered and performed was viewed as negligence that led directly to the death of this patient. This is a far easier conclusion to reach than thinking that there was no way to prevent the patient's death. Sadly, such cases happen and seem to be almost impossible to defend. The best defense is prevention before the suicide occurs, which can only occur through appropriate training of staff in the detection, assessment, and handling of suicidal ideation and suicidal behavior.


• Case No. C-1900-06-H, Hidalgo County (TX) District Court.