Legal Review & Commentary

Patient under observation commits suicide: Verdict for the defense

By Jon T. Gatto, Esq. Barbara Reding, RN, LHCRM, PLNC

Buchanan, Ingersoll & Rooney, PC Citrus Memorial Health System

Tampa, FL Inverness, FL

News: A man with a history of suicidal ideation was involuntarily admitted to the hospital. The next day, the man was transferred to an acute care psychiatric facility and placed on 15-minute observation status by the on-call physician. The next day, the admitting psychiatrist interviewed the man, who denied suicidal ideation. An antipsychotic medication was prescribed. Later that same day, the shift RN interviewed the man, who appeared withdrawn and isolated but again denied suicidal ideation. A psychology technician ("PT") observed the man every 15 minutes from 3:15 p.m. until 4 p.m. and noted nothing of concern. At 4:15 p.m., the PT went to observe the man and found him hanging from the top of the bathroom door with a sheet. CPR was commenced and the man was transferred to an acute care hospital for further care. One week later, the family consented to removing the man from life support, and he was pronounced dead shortly thereafter. The jury found in favor of the psychiatric facility.

Background: A 27-year-old single male was admitted to an acute care hospital on an involuntary hold due to a possible danger to himself. Twenty-four hours later, he was transferred to another acute care hospital on a 14-day involuntary hold. Ten days later, he was discharged with a prescription for chlorapromazine and instructions to follow-up with outpatient psychology counseling.

About a week later, while on his way home from a bankruptcy hearing with his father, the man pulled a knife and threatened to commit suicide. The man's father was able to struggle with the man and retrieve the knife, thereby thwarting the suicide attempt. That same day, the man again tried to commit suicide with a knife in a locked bathroom. The father again intervened and was able to prevent the man from hurting himself. The man's father called the police, who took the man back to the original acute care hospital and placed him on involuntary hold. Twenty-four hours later, the man was transferred to an acute care psychiatric facility because of the lack of inpatient beds at the hospital.

Upon arrival at the psychiatric facility, the charge nurse obtained physician's orders to place the man on Q15 checks, suicide watch. The following morning, the man was examined by the attending psychiatrist, who found him to be calm and cooperative and without suicidal ideation. The physician's diagnosis ruled out paranoid schizophrenia and major depression. The physician ordered that olanzapine be administered. An unlicensed social worker also interviewed the man, and the social worker indicated that the patient was cooperative and denied suicidal ideation. Again that same day, the shift RN documented that the man, while withdrawn and isolated, denied suicidal ideation.

The PT was assigned to view the man every 15 minutes and did so four times between 3:15 p.m. and 4 p.m. At 3:50 p.m., the man exited his room and questioned a staff member about who had been assigned to room checks. At 4:15 p.m., just prior to completing her head counts, the PT went to the man's room and found him in the bathroom hanging from the inside of the door with a sheet tied around his neck. Staff members on the hall commenced CPR and called paramedics. The man was transferred to an acute care facility, where he remained on life support for six days. At the end of the six days, the family requested that he be removed from life support. The man died shortly thereafter.

The plaintiff, the man's father, brought suit against the psychiatric facility, alleging that the man was at high risk for suicide and that he should have been placed on one-to-one observation or line-of-sight observation. The father claimed that if either of these approaches had been implemented, the man would not have been able to hang himself. The plaintiff also argued that the man's denial of suicidal thoughts should have been ignored given the man's history of poor judgment.

The defendant contended that its actions were at all times appropriately within the standard of care and that a lapse in care was not the cause of the man's death.

At trial, the social worker who had interviewed the man testified that she had received a telephone call from one of the man's family members, who indicated that the man was hearing voices that were urging him to kill himself. The social worker recalled conveying this information to the charge nurse, though no notation was made. The charge nurse denied learning about this call.

Plaintiff's expert testified that the attending physician failed to adequately assess the man for suicide risk, and that he irresponsibly relied on the patient's denial of suicidal ideation. Other experts addressed facility issues related to the length of hallways, the existence of items that could be used for suicide, and the fact that patients slept on metal beds with wheels. The defendant's expert countered by testifying that not one risk factor or set of risk factors can be used to predict which patient will commit suicide. The fact that the man denied suicidal ideation, coupled with his overall demeanor, placed him at a low risk for imminent suicide. Given these facts, it was appropriate to place the patient on Q15 checks.

The jury agreed with the defense's argument and ultimately found in its favor.

What this means to you: According to the American Foundation for Suicide Prevention, more than 33,000 people in the United States die by suicide every year. Suicide is the fourth-leading cause of death in adults between the ages of 18 and 65. There are four male suicides for every female suicide and, every day, approximately 90 Americans take their own lives, while 2,300 more attempt to do so. A person dies by suicide approximately every 16 minutes in the United States. A suicide attempt is made approximately once per minute. Warning signs of suicide include observable signs of serious depression, increased alcohol and/or other drug use, recent impulsiveness and taking unnecessary risks, threatening suicide or expressing a strong wish to die, making a plan (giving away prized possessions, sudden or impulsive purchase of a firearm or obtaining poisons or medications), and unexpected rage or anger.

Given such statistics, The Joint Commission in its National Patient Safety Goal (NPSG) 15.01.01 requires an organization to identify patients at risk for suicide. This requirement only applies to psychiatric hospitals and patients being treated for emotional and behavioral disorders in general hospitals. The Elements of Performance for this NPSG state that: 1) the risk assessment is to include identification of specific patient factors and environmental features that may increase or decrease the risk for suicide; 2) the hospital is to address the patient's immediate safety needs and the most appropriate setting for treatment; and 3) the hospital is to provide information such as a crisis hotline to individuals at risk for suicide and their family members. The Joint Commission's rationale for this NPSG is: "Suicide of a care recipient while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event. Identification of individuals at risk for suicide while under the care of or following discharge from a health care organization is an important step in protecting these at-risk individuals." The Joint Commission recognizes the frequency of suicide even in staffed, round-the-clock organizations. The national statistics uphold the "success rate" of those who are determined to end their life by their own hand.

The 27-year-old in this case had a history of suicide attempts, including two attempts in one day using a knife. Upon transfer to an acute care psychiatric facility, the patient underwent several interviews by health care professionals over time, including a psychiatrist, a registered nurse, and a social worker. All interviews revealed a judgment based on assessment and a conclusion of no suicidal ideation by the patient at the time of each interview. The details of the risk assessment process are defined by the health care organization, according to The Joint Commission.

In accordance with Joint Commission requirements and recommendations, the acute psychiatric care facility assessed the patient within the above referenced Elements of Performance and placed the patient on every-15-minute suicidal watch checks. The Q15 checks were performed timely as ordered.

While arguments were made by both sides as to the precautions instituted or the lack thereof, there is no easy answer in this case or whenever a person chooses suicide. Based on the trial findings, it seems that the jury understood the difficulties of protection and prevention. What remains key to the defense of any organization caring for these at-risk individuals is the performance of a thorough initial assessment, appropriate diagnosis, reassessments on a consistent basis, timely and appropriate monitoring, and observation of each patient, and accurate, pertinent, and timely documentation. Monitoring closely for any change in patient status and immediate reporting of noted changes to the attending physician is critical. Evidence of ongoing staff education in the arena of risk factors for suicide is beneficial. Environmental rounds for safety and risk factors performed on a regular basis by different sets of eyes each time is required. And, when a patient commits suicide in a health care setting, emotional support must be provided for the staff.


• Los Angeles Superior Court/Pomona; Docket No. KC051107.