Inpatient suicide: Who is liable, and how can we prevent it?
Dr. Jon Grant describes a 26-year-old Texas psychiatric inpatient who suffocated himself with cellophane wrap and a pillowcase (Malpractice Verdicts, Current Psychiatry, November 2005). As a forensic psychiatrist, let me offer some insights regarding this case.
A psychiatrist expects that hospitalization will prevent a patient’s suicide. Based on the facts Dr. Grant presented, however, the staff did not follow the standard of care and was obviously negligent:
- The patient was not adequately supervised, nor were the 15-minute checks properly documented.
- The rigor mortis is evidence that, contrary to the staff’s report, the patient could not have been checked 5 minutes before he was found dead.
The level of negligence appears clear enough not to require an expert witness to testify about the standard of care.
More information is needed before determining liability, however. Did the suicidality assessment contain factual errors? Did the patient reveal suicidal thoughts? Why wasn’t he assigned to onetoone observation? If the patient denied that he was suicidal and had not previously tried to kill himself, this case would be viewed differently.
Also, did lapses in the patient’s outpatient care lead to his hospitalization? In studying 481 suicides, Desai et al1 uncovered variables that increase suicide risk, including poor continuity of care and failure to readmit within 6 months. We need to be aware that borderline personality disorder or major depressive disorder enhances a patient’s ability to plan a suicide.2
As Dr. Grant notes, we can decrease suicide risk by identifying and minimizing risk factors, such as withholding potentially injurious material objects. Patients, however, can find many other ways to harm themselves. The patient Dr. Grant describes used a seemingly harmless object—a pillowcase—for his suicide.
Finally, as psychiatrists we find it fundamentally difficult to act on our suspiciousness, probably because of our positive countertransference toward patients and our trust in therapeutic alliances. We need to remember that acutely suicidal patients view us as obstacles to suicide, and that they probably will not give us reliable information.
Theodor Rais, MD
Assistant professor of psychiatry
Director, outpatient and partial hospitalization services
Medical University of Ohio at Toledo
1. Desai RA, Dausey RJ, Rosenbeck RA. Mental health services delivery and suicide risk: the role of individual patient and facility factors. Am J Psychiatry 2005;162:311-18.
2. Soloff PH, Lynch KG, Kelly TM, et al. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorders: a comparative study. Am J Psychiatry 2000;157:601-8.