Physician Legal Review & Commentary

$1.5 million award in suicide malpractice case

News: A jury awarded a 51-year-old man’s family $1.5 million following a finding that the defendant primary care physician was negligent and committed malpractice in treating the patient with antidepressants. The defendant primary care physician reportedly repeatedly renewed the patient’s prescription for the antidepressant paroxetine without having seen or examined the patient in approximately 10 years. The patient, a teacher and assistant principal, committed suicide and left behind a widow and three daughters. The jury found the defendant primary care physician 100% responsible for the patient’s death.

Background: The patient, a 51-year-old basketball coach, physical education teacher, and assistant principal, committed suicide while under the effects of antidepressants. The patient’s widow filed suit against the patient’s primary care physician alleging negligence and medical malpractice. Specifically, the plaintiff claimed that the physician was negligent in reportedly prescribing paroxetine for years without seeing the patient, in failing to warn the patient and his wife about the serious risks associated with paroxetine, in doubling the paroxetine dose and adding olanzapine, an antipsychotic drug, by telephone, and then in abandoning the patient during his decline.

The patient, a long-time patient of the defendant primary care physician, was prescribed paroxetine, an anti-depressant, by the defendant physician. Despite the longstanding physician-patient relationship between the patient and defendant physician, the defendant physician had not seen or examined the patient in approximately 10 years. The plaintiff claimed the defendant physician repeatedly renewed the prescription for paroxetine without examining or meeting with the patient.

In August 2009, the physician, via telephone order, put the patient on olanzapine and doubled his dosage of paroxetine following an anxiety attack. The plaintiff claimed this increase in the patient’s drugs via telephone, without an in-person consultation, began an escalating decline in the patient’s medical condition, which ended a little more than month later with his suicide.

Soon after the telephone order, the patient went to a local hospital with what he thought was a heart attack. At the hospital, a heart attack was ruled out, though the hospital physician put the patient on a lower dose of paroxetine.

Following the hospitalization, the patient was seen by the defendant primary care physician for their first office visit in 10 years. The plaintiff claimed that the defendant physician was furious that the patient had gone to the hospital and “exposed his treatment.” The patient reportedly was thrown out of the defendant physician’s office without further treatment.

The patient then was seen at another local hospital, where the hospital physician switched him from paroxetine to three other medications but failed to schedule any follow-up visits upon discharge from the hospital. The plaintiff claimed that after the second hospitalization, the patient got worse. She claimed he was feeling the side effects of the medication, including burning in his head and feelings like hot poison was going through his veins. The patient committed suicide shortly thereafter, and he left behind a wife and three daughters.

In February 2012, the state health department charged the physician with practicing with negligence for prescribing drugs to patients for many years without seeing them in his office. He was placed on probation for three years. In September 2012, the state disciplined the physician for abusing drugs and alcohol himself. His probation was extended to five years.

Following the two-week trial, the jury deliberated over two days. Ultimately, the jury found the defendant primary care physician 100% responsible for the patient’s death. The jury awarded $800,000 to the plaintiff for the loss of her husband’s income. The jury also awarded $200,000 to the patient’s youngest daughter and $100,000 to each of his two oldest daughters for their loss of his support, guidance, and nurturing. An additional $324,000 in interest will be added to the verdict, which brings the total to $1.5 million.

What this means to you: Clearly nothing went right with this case. The physician caring for the patient committed outright malpractice and in addition to the adverse result of the suit, the physician was cited by the Office of Professional Medical Conduct for treatment failures and personal addiction issues.

The main areas of danger are clearly the failure to maintain appropriate oversight over the patient and his condition, the prescribing of drugs inappropriately by telephone, the failure to engage when presented with a clear issue, and the competency of this practitioner treating this condition.

Obviously, there is no arguing with the failure to see the patient on a routine basis. There is a tendency among some practitioners to consider “a little depression” as a small issue that can be dealt with in the office of a primary care physician. While that might be the case in mild cases of short duration, this particular patient had a problem for years. The failure of the family doctor to see the patient on a regular basis creates instant liability.

When the patient got into trouble, the family appropriately took him to a hospital for evaluation. Upon being advised of this action, the family doctor became angry and essentially discharged the patient from care. This step resulted in a new physician seeing the patient without the benefit of knowing the full history and the patient’s prior response to medication. This case was clearly one of abandonment and subjected the physician to further liability.

The doctor routinely prescribed antidepressant medication over the phone without seeing the patient. One short renewal until the next office visit might have been acceptable, but not prescribing for years without the benefit of the ability to see the patient, examine him, and take a history. This statement is especially relevant for these particular medications that have been identified as not so innocuous and contain explicit warnings from the Food and Drug Administration (FDA). In 2007, the FDA ordered makers of paroxetine and other anti-depressants to add warnings to their packaging saying the drugs increased the risk of suicidal thinking. As such, in this case, especially given the nature of the medication, the physician erred in routinely renewing the patient’s prescription without examining or considering his history.

The other issue in this case is the propriety of this type of physician treating a patient such as this one with these types of drugs for an extended time. From a risk management perspective, the use of drugs that alter the brain chemistry and which have the potential for devastating side effects should probably be under the control of a psychiatrist or other trained practitioner. A short course prescribed by a family doctor or an internist to get the patient over a psychological bump in their lives is common. This particular patient had a long history of anxiety disorder and likely would have benefited from an evaluation by a specialist physician. The length of time that a medication is used does increase the risk.

Just as a primary doctor may prescribe antibiotics for a simple infection but will turn to an infectious disease specialist when the infection becomes chronic, patients on long-term selective serotonin reuptake inhibitors (SSRIs) such as this patient create medical legal risk and should be seen by the highest level of provider credentialed to prescribe the medication.

This case is an unfortunate one, and given that the treating physician was cited for his own use of alcohol and medication use, it might be that the root cause is the physician’s own loss of reasoning ability. This brings up yet another risk management issue. We must be vigilant in monitoring providers for any hint of inability to perform at the appropriate level and intervene. This step is easier done in a hospital setting where the provider is out in the open, but any sign of compromise in a provider’s status should be taken seriously before harm ensues.