Thanks for the case
@bbc586 , I especially liked the Expert Witness source you posted and will be perusing that later. I think there's a few things to take from the case that haven't been mentioned much or were missed.
Edit: Sorry for the essay/word vomit, I'm just really interested in forensics and don't really get much exposure/conversation about it where I'm at
😳
The biggest one being that accurate documentation is key and the idea of "if' it's not documented, it never happened" should reinforced in the medical setting. We don't have access to the actual medical records, but from the expert witnesses' reports it sounds like no collateral was obtained. We do know that the patient contracted for safety and was picked up by her step-brother and step-father and taken to her mother's house. Was any collateral obtained from the family who picked her up? Did the family agree to monitor her closely and ensure she would be safe? Was the family in contact with the boyfriend and to what extent was the family aware of the events? Imo, all of those points would matter in my decision to admit or discharge her, and if the family was present to pick her up, likely would not be all that difficult to obtain. Additionally, the ER doc actually quoted the patient as saying "I'm going to kill myself". That line alone is probably enough to show negligence in this case even though it wasn't consistent with earlier reports which quoted a statement of conditional suicidality which was "If you don't let me out of this car, I'm going to kill myself"; which actually makes the exit from the car sound
less like a suicide attempt. The most egregious mistake though, was that no one documented that she actually attempted to exit a moving vehicle. The paramedics should get the most responsibility on this one, as the testimony makes it clear that they were directly told this. The lack of this information likely would have held significant weight in the ER staff's decision to hold or discharge her (though that doesn't excuse the lack of collateral).
Another is the importance of communication between healthcare professionals. Even if it was documented by the paramedics, I have a hard time believing no one informed the ER doc or any ER staff that this girl tried to jump out of a moving vehicle and it's probably the most attention-grabbing part of this whole case before she was discharged. Regardless, there was clearly a breakdown in communication somewhere as neither the ER doc nor the psych tech/SW documented this, and I have a hard time believing they'd intentionally omit this unless they knew it was an inappropriate d/c. I know that sometimes patient handoffs can be annoying or excessive, but this is a prime example of what can happen when communication breaks down within the team.
The last point is that just "contracting for safety" isn't good enough, even if the patient is going to stay with others. If there were clear documentation that the patient would be discharging to her mother's house, that there would be a family member watching her 24/7 until she improved, and that the family was in agreement with the safety plan and that she didn't need hospitalization, it would be hard for the plaintiffs put liability to the point of negligence or malpractice on these professionals even without collateral from the boyfriend. I've seen a few other examples (the neurologist in NYC, one of my attendings in med school) who had similar experiences where they let a patient leave under the care of family and then were sued and either lost or endured years of litigation because of this, and those were cases where the documentation was pretty solid. I think the fault here probably goes beyond just the lack of collateral, and possibly to the point that the dispo plan was minimally documented which made this a much easier case for the plaintiffs. I see "patient contracted for safety" in quite a few notes, but often don't see adequate details after this to tell me what the actual safety plan was, which can not only cause results like the one in this case but can be problematic for future physicians trying to figure out if certain parts of a safety plan may be adequate or if they need to change the plan d/t failures in the past.
Very few psychiatrist would discharge a patient who attempted suicide without contacting collaterals. This shows relying on midlevels is a liability for a hospital system.
For legitimate confirmed attempts I agree, but I can think of plenty of situations where this happens. The homeless guy who is been to the ER 4 times this month after "attempts" who is otherwise obviously stable, the borderline patient who brings herself in after "overdosing" on 4 Hydroxyzines or 600mg of Seroquel, the patient who was so intoxicated they couldn't even speak when brought in but completely denies SI or even depression with congruent affect when sober, any of the aforementioned and some others who have been in the ER for 12 hours of the day and the 5 contacts they gave you for collateral continually don't respond, even the girl who seems fine now but 8 hours ago tried to jump out of her boyfriends car after he breaks up with her while she was significantly intoxicated. I don't think this is as uncommon as you're making it seem.
I agree and note above I've seen many EDs work like this. I am just trying to ascertain which states have laws that prevent this non-authorized collateral collection in psychiatric emergencies (and I could honestly guess some states that would). It's a bit astonishing to me, but also very believable as an American.
In my previous state, it would depend on the emergency. I've had one or two patients who accepted voluntary admission without any of their contacts knowing for "really bad SI", then demand to leave the following day stating they're no longer suicidal and refusing to sign an ROI. We legally could not contact collateral because then the contacts would know the patient was on our unit which would violate his privacy rights. I've dealt with that situation more than once, and the final decision by the attending(s) as to whether to file the involuntary was very situational. Now if someone knew the patient was already there, we could call and gather collateral and just not provide any information about the care he was receiving. I'm honestly not 100% sure on the specific legal rulings of this in the state, but one of our attendings teaches a lot about the involuntary laws and what is and isn't legal for us to do.
