Liability in patient suicide
Cases were selected by CURRENT PSYCHIATRY’s editors from Medical Malpractice Verdicts, Settlements & Experts, with permission of its editor, Lewis Laska of Nashville, TN (www.verdictslaska.com). Information may be incomplete in some instances, but these cases represent clinical situations that typically result in litigation.
Clinical psychiatrists often find it hard to evaluate suicide risk and understand their potential legal liability. Prevalence of suicidality compounds this challenge: Up to one-third of the general population in the United States have suicidal thoughts at some point. 1 Although most people who consider suicide do not act on those thoughts, 51% of psychiatrists report having had a patient who committed suicide. 2
Because patient suicide risk is real, psychiatrists often worry about malpractice claims. Although post-suicide lawsuits account for the largest number of malpractice suits against psychiatrists, 3,4 a psychiatrist’s risk of being sued for malpractice is still quite low. 3 Even when sued, clinicians win up to 80% of cases. 3
Still, with malpractice claims increasing overall, clinicians should understand their potential liability in preventing suicide and the basic principles behind a malpractice claim.
Patient jumps from window after suicide watch is called off
Los Angeles County (CA) superior court
A 24-year-old man was hospitalized after attempting suicide by ingesting prescription pills and alcohol. He was admitted to the general medical floor with a 24-hour sitter to guard against additional suicide attempts. When the psychiatrist tried to evaluate him, he found the patient unresponsive because of the pills’ effects.
The next day, the psychiatrist evaluated the patient and recommended that the patient be transferred to the psychiatric unit and that the sitter be continued. Four hours later, without a further evaluation, the psychiatrist recommended moving the patient to another room and canceling the sitter.
The next day, the patient jumped from his sixth-floor hospital room window. He sustained traumatic brain injury.
The patient’s guardian ad litem argued that discontinuing the sitter was negligent. The defendant argued that discontinuation was within the parameters of proper care.
- The jury found for the defense.
Patient commits suicide hours after ER discharge
Lake County (IL) circuit court
A 36-year-old man was being treated by a psychiatrist for major depressive disorder. The patient owned several guns for hunting and target shooting and had a state-issued firearm owner’s identification card.
In October 2003, the patient presented to the emergency room and was examined by a mental health assessment staff. The psychiatrist recommended voluntary admission to the psychiatric unit for 23 hours.
The patient’s father discouraged the admission and stated that the patient could lose his gun owner’s card as a result. The patient was subsequently discharged. Within 24 hours after discharge, the patient shot himself in the chest and died.
The deceased’s estate argued that the psychiatrist should have admitted the patient involuntarily. The psychiatrist claimed no obligation to involuntary admission and argued that the patient did not meet criteria typically used for such admission.
- The jury found for the defense.
Doctor’s hanging attempt in hospital causes permanent brain damage
Morris County (NJ) district court
A cardiologist was admitted to the hospital’s psychiatric unit after decompensating. While hospitalized, he attempted suicide by hanging in a clinic bathroom. He suffered permanent brain injury as a result of the hanging. Because the injury left him in a childlike state, he required constant care.
The patient’s attorney argued that hospital personnel knew he was suicidal yet did not adequately supervise him. The attorney also argued that the injury cost his client $5 million in lost income.
The defense reported that the hospital had placed the patient on suicide watch and that staff checked him every 5 minutes. The defense also argued that the bathroom where the suicide was attempted was impossible to monitor.
- The jury found for the defense.
Dr. Grant’s observations
To win a malpractice claim, the injured party must show four things:
Duty to care for the patient existed based on the provider’s relationship with the patient. Whether on a hospital floor or in the emergency room, once a doctor-patient relationship has been established, the provider agrees to provide non-negligent care.
Negligence. The physician or hospital personnel acted negligently and violated the duty of care. This concept is based upon a “standard of care” —ie, what other psychiatrists would do in this situation.
Harm. Even if someone has acted negligently, a malpractice case cannot go forward if no harm has been suffered.
Causation. The negligent act caused the harm.
The defendants most likely won the cases cited above because the injured parties could not establish negligence. Clinicians are not negligent for merely failing to predict suicide, as the inability to predict suicide has been demonstrated. 5,6 Clinicians, however, must follow the profession’s standard of care, assess the relative degree of risk, and form a treatment and safety plan consistent with that risk. 4
Based on relevant case law, the following actions can decrease the risk of patient suicide—and a resultant malpractice claim:
- Conduct a comprehensive evaluation of the patient and his or her suicide risk. Ask about:
- Consider hospitalizing at-risk patients. If you decide against hospitalization, provide a comprehensive safety plan. In the gun owner’s case, such a plan would include arranging with the family to remove firearms. Implement additional anti-suicide precautions, such as more-intensive outpatient therapy or involving family members in treatment.
- Document suicide risk assessment and the reasons for your treatment decisions. Juries may interpret lack of documented information in the patient’s favor.
- Design a treatment plan for hospitalized patients to reduce suicide risk. Consider the patient’s reaction to constant surveillance. For example, checking a paranoid patient every 5 minutes may be more therapeutic than a constant watch while providing adequate safety. Thoroughly document your reasons behind the plan.
1. Hirschfeld RMA, Russell JM. Assessment and treatment of suicidal patients. N Engl J Med 1997;337:910-5.
2. Chemtob CM, Hamada RS, Bauer GB, et al. Patient suicide: frequency and impact on psychiatrists. Am J Psychiatry 1988;145:224-8.
3. Baerger DR. Risk management with the suicidal patient: lessons from case law. Prof Psychol Res Pract 2001;32:359-66.
4. Packman WL, O’Connor Pennuto T, Bongar B, Orthwein J. Legal issues of professional negligence in suicide cases. Behav Sci Law 2004;22:697-713.
5. Pokorny AD. Prediction of suicide in psychiatric patients. Arch Gen Psychiatry 1983;40:249-57.
6. Pokorny AD. Suicide prediction revisited. Suicide Life Threat Behav 1993;23:1-10.
7. Bell v. New York City Health and Hospitals Corp., 456 NYS 2d 787 (App. Div. 1982).
8. Simon RI. The suicidal patient. In: Lifson LE, Simon SI (eds). The mental health practitioner and the law: A comprehensive handbook. Cambridge, MA: Harvard University Press, 1998;166-86.