Patient commits suicide after 15-minute checks are stopped
Honolulu County (HI) Circuit Court
A patient was brought to a hospital and interviewed by a psychiatrist. She was found to be at moderate risk for suicide, was admitted, and ordered to be monitored every 15 minutes. The patient attempted suicide 2 days later by closing a drawer on her neck. She died from the injuries the following day.
The patient’s family claimed that a hospital nurse misread the psychiatrist’s instructions and stopped the 15-minute checks on the morning of the incident, believing that the order was limited to 15-minute checks for the first 24 hours, even though they had been done for almost 2 days. The patient refused medication on the first day of admission, and the psychiatrist had started the procedure to obtain a court order committing the patient and allowing injection of necessary medication. The claims against the hospital were settled for a confidential amount.
The patient’s family claimed the psychiatrist diagnosed the patient with major depression with recurrent suicide ideation but failed to properly assess her for suicide monitoring. The family also said the patient should have been determined to be at least at high risk and required to be within sight of staff.
The psychiatrist claimed to be unaware the 15-minute monitoring had ceased. The psychiatrist saw the patient 30 minutes before she was found collapsed with her head in the drawer. The hospital staff checked the patient approximately 15 to 30 minutes before she was found.
- A defense verdict was returned
Reduced observation blamed for suicide by hanging
Kings County (NY) Supreme Court
A 45-year-old police lieutenant who suffered from alcohol abuse and depression was admitted to a psychiatric care facility. He was classiffied “Q15,” a category assigned to patients who must be visually inspected every 15 minutes, cannot have access to sharp objects or any other material or object they can use to inflict bodily harm, and must request permission to use restrooms. The next day the psychiatrist examined the patient and moved him to a “Q30” status, which halved the frequency of visual inspections, gave him unrestricted access to restrooms, and allowed him to have a bathrobe with a belt. The patient hanged himself the next day, using a restroom door to support a noose he made from the bathrobe belt.
The patient’s family faulted the hospital and psychiatrist for prematurely advancing the patient to “Q30” status. The hospital and psychiatrist claimed the suicide could not have been predicted and argued that given his background as a police lieutenant, the patient would have interpreted more stringent restrictions as incarceration. The psychiatrist argued that such a perception would have impeded the patient’s progress.
- A $71,989 verdict was returned, apportioning fault 65% to the hospital and 35% to the psychiatrist
Constant patient observation—such as one-to-one staffing or 15-minute checks—is used to protect patients from harming themselves or others. One study of a psychiatric hospital1 reported that 13% of psychiatric inpatients required constant observation.
Even 15 minutes is sufficient time to complete a suicide.3 Common methods of inpatient suicide include hanging, overdosing, and jumping from high places.4,5 One study found that 73% of inpatient suicides in a psychiatric ward occurred after 28 days of admission.5
The cost of constant observation may account for as much as 20% of the total nursing budget at a psychiatric hospital and up to 10% at a long-term care facility or general hospital.6 The annual cost of constant observation can exceed $500,000, depending on the hospital’s size and monitoring frequency.6
Determining responsibility
The outcomes of these 2 cases may appear inconsistent. In the first, the psychiatrist who assessed the patient as a moderate suicide risk was not negligent, even though the family claimed the patient was at high risk. In the second case, the psychiatrist was found partly liable for not maintaining a higher vigilance of suicide risk assessment.
Physicians cannot put every patient on one-to-one monitoring or 15-minute checks because of fear of suicide and malpractice litigation. These 2 cases demonstrate that if a suicide occurs, the courts will look for clinical reasons for the level of observation. The level of suicide precautions—one-to-one vs 15-minute checks—should be based on the patient’s clinical presentation and supported by clinical rationale.7