Legal Review & Commentary

$5 million awarded to family of suicidal man hit by a car before discharge from hospital

News: This case involves a 24-year-old single father who was involuntarily committed to the hospital for severe depression, including suicidal and homicidal ideations. Following his presentation, the patient remained in the emergency department and was placed in an examination room, where he remained for 18 hours until he left the hospital through an unguarded exit. About 10 hours later, he was hit by a car and sustained multiple injuries including catastrophic brain damage and multiple fractures, which resulted in his death. It was alleged that the hospital’s failure to properly monitor and supervise the patient was the proximate cause of his death. A jury awarded the patient’s estate $5 million.

Background: On April 5, 2011, the patient presented to the emergency department concerned about his thoughts of hurting himself and others. According to hospital records, the patient had a history of drug abuse, depression, and paranoid delusions. A psychiatric evaluation of the patient was performed, which included an evaluation of his degree of dangerousness and depression. Following the evaluation, the patient was involuntarily committed to the hospital until a bed became available at a 24-hour facility for temporary custody. In the interim, the hospital staff kept the patient in a corner examination room at the back of the emergency department. The room was adjacent to an unlocked and unguarded exit. Hospital staff allegedly checked on him every 15 minutes. The morning of April 6, 2011, the patient walked out of the hospital through the unlocked exit. The hospital alerted law enforcement, and a silver alert was issued, which commonly broadcasts information about missing persons, especially persons with mental disabilities. About 10 hours later, the patient walked in front of a car and suffered a massive brain injury and leg fractures. He died the following day.

A few months later, the patient’s estate commenced a medical malpractice and wrongful death action against the hospital. Plaintiff alleged that the hospital was negligent in failing to adequately assess the degree of the patient’s depression, failing to properly monitor and supervise the patient, and failing to prevent the patient from leaving the hospital. To prove their allegations, plaintiff introduced expert testimony from a psychiatrist that revealed that the initial assessment form that was utilized by the hospital to evaluate the patient’s degree of depression and dangerousness failed to include that the patient was excessively abusing drugs and had PCP (phencyclidine) in his system, despite the fact that the drug screen performed in the emergency department revealed this information. Had the form included the patient’s suicide risk as demonstrated by his suicidal thoughts and potentially increased by his use of a dissociative drug, the patient would have been placed on one-to-one observation, which should have prevented him from leaving.

Plaintiff showed the jury a surveillance tape of the nurse’s station at the hospital that demonstrated one instance in which the nurse was absent from the nurse’s station for only 13 seconds when she went to check on the patient. This length of time, combined with the fact that the patient had been gone for 10 hours before the car accident, made the jury question whether anyone at the hospital was regularly checking on the patient or actually looking for the patient after he left the hospital.

The hospital attempted to defuse plaintiff’s allegations by arguing that the staff acted in accordance with hospital policy as soon as the patient’s absence was recognized. However, plaintiff’s objective was to prove that the hospital’s policy was inadequate and was able to do so by telling the jury a story of another man who was involuntarily committed to the same hospital and was able to leave in the same manner as this patient. The jury was convinced that additional safety measures needed to be taken to avoid any future incidents.

After a six-day trial and only two hours of deliberation, the jury awarded $5 million to the patient’s estate. The award went to the patient’s daughter, who was 5 years old at the time of trial.

What this means to you: Due to state and federal budget cuts relating to inpatient and community resource treatment centers for people with mental illness, a general emergency department often is the only or most accessible healthcare setting for people who are experiencing an acute psychiatric condition. The lack of alternative healthcare settings has increased the frequency and length of time in which psychiatric patients are being held in an emergency department while waiting placement in an appropriate inpatient psychiatric setting. During this extensive boarding time, patients might not receive the specialized psychiatric monitoring and treatment that is needed, which appears to have been true in the above described case scenario.

The psychiatrist’s evaluation resulted in the patient being involuntarily committed to an inpatient setting for further evaluation and treatment due to his suicidal and homicidal thoughts. Although it does not appear that plaintiff’s counsel had cause to argue against the appropriateness of the involuntary commitment, it does appear that plaintiff’s counsel had legitimate arguments about the subsequent care as well as the physical environment safety elements that were in place in the emergency department.

A patient who has been involuntarily committed for inpatient psychiatric care should be automatically considered a flight risk. Couple this situation with the fact that this patient was determined to have suicidal or homicidal thoughts — this patient would have benefited from direct one-to-one observation by a staff person who remains in close proximity to the patient at all times. From the case scenario, the patient allegedly was being monitored by a staff member every 15 minutes, and plaintiff’s counsel proved that this level of patient monitoring was a deviation from the standard of care. It is unclear if this deviation from the standard was due to inadequacy of hospital policy or was a workaround because of emergency department staffing. Whatever the reason, a more thorough review of internal policies for monitoring psychiatric patients in the emergency department against best practices is warranted.

Emergency department physicians often are uncomfortable with ordering psychiatric medications, and they rely on the consulting psychiatrist for these orders. It is unclear from the case scenario whether the psychiatrist wrote covering orders while the patient was waiting for transfer to an inpatient setting. However, it appears that this patient was in the emergency department for 18 hours without the benefit of any psychotropic medications or other therapeutic interventions he might have needed while waiting for transfer to an inpatient unit. We would suggest that a patient who is being monitored in the emergency department for a cardiac condition should receive routine cardiac meds while waiting for disposition. Why should it be any different for a psychiatric patient waiting transfer to an inpatient unit? As psychiatric hold patients are becoming more common, it is in the best interest of the patient, healthcare provider, and hospital to review current policies and practices to ensure the therapeutic interventions are continued in the emergency department.

It is generally acknowledged that the emergency department is not the ideal therapeutic environment for psychiatric patients. The department often doesn’t have an area specifically dedicated to a psychiatric patient, especially a patient who is actively suicidal or homicidal. Since emergency departments generally are very busy environments that might exacerbate a psychiatric patient’s condition, psychiatric patients typically are placed in rooms that are not in the center of all the activity. These rooms often are at the end of the hall by an exit, which appears to have been the room of choice in this case. If it is necessary to use the room furthest from the hub of the emergency department for boarded patients, precautions should be taken to ensure that a patient cannot easily leave without being noticed. The hospital should consider some type of monitoring system that can be used, i.e. alarms, exit buttons, or wander guards, that would alert staff that the patient is leaving the room and/or building while ensuring that these egress alerts do not interfere with building egress safety requirements.

Although the hospital tried to defend the staff’s actions after it was discovered that the patient eloped, the video surveillance camera evidence did not support actions that might have been taken after the silver alert was called. There might have been a reasonable explanation for why the emergency department nurse left the nursing station for only 13 seconds, but there is no description of other documentation the hospital had to demonstrate that its internal silver alert policy was carried out. Once an elopement alert has been called, it is important to document in the patient’s medical record all activities undertaken by the hospital staff, including who, what, when, and where. Who performed the internal house rounds, and when was the internal search completed? Who notified the police department, and when did they respond? Who contacted the patient’s family, and what was their response? An elopement, especially an elopement by a patient who has voiced suicidal and homicidal thoughts, is a serious event that can result in tragedy and heartbreak for many people.

As an increasing number of psychiatric patients are boarded in the emergency department, nursing protocols should be established to meet the special needs associated with these patients. These needs include ongoing and proactive behavior assessments to identify escalation of symptoms, identification and fulfillment of basic patient needs, such as nutrition, toileting, and hygiene, as well as the provision of diversionary activities, such as television and newspapers, to keep patients calm and comfortable while waiting transfer. These often are overlooked issues because these diversionary activities are not needed or appropriate for the typical emergency department patient.

This case describes a very unfortunate event that might have been prevented had appropriate policies and practices been in place for psychiatric patients who are boarded in the emergency department. Patients who remain in the emergency department without the benefit of psychotropic and therapeutic interventions are at higher risk for elopement and escalation of unwanted behaviors. Appropriate physician-to-physician and physician-to-nurse communication is essential to ensure appropriate evaluation and monitoring of the patient’s condition. Nursing protocols for the identification and fulfillment of the special needs associated with boarding psychiatric patients are required. If the trend with decreasing inpatient and outpatient services for patients with mental illness continues, emergency departments will see a corresponding increase in risk exposure if these safety nets are not put in place.

Reference

JAS NC Ref. No. 271033 WL (N.C. Super.), 2012 WL 5506957.