Case Study: A Disastrous Outcome Despite Appropriate Treatment

Repurposed from The Scope, Medical Edition, First Quarter 2023.

Facts of the Case

A 38-year-old male with a history of depression, violent behavior, assault and alcohol and drug abuse was brought to the emergency department (ED) of a MLMIC-insured hospital after his wife called the police when she suspected he might be suicidal due to the break-up of their marriage. She had an Order of Protection in place against him, which had recently expired. The patient was evaluated by the ED psychiatric social worker who determined that, while he was anxious, he did not seem to be suicidal or in need of inpatient treatment. As such, the patient was discharged with instructions to be seen by the MLMIC-insured psychiatrist.

The psychiatrist saw the patient one week later and found him depressed and filled with despair, hopelessness and jealousy. He expressed anger about his custody issues and the loss of his job when police questioned him at work regarding a prior assault on his wife. Although the patient admitted to chemical dependency, he appeared to be sober and denied suicidal or homicidal ideation. Our insured diagnosed him with chemical dependency and anti-social and narcissistic traits. He prescribed Lexapro and Seroquel and referred the patient to a social worker.

Two weeks later, the patient returned to the ED with extreme depression and advised that he could not afford his medication and therefore had never started it. He was admitted to the hospital and seen by another physician, who noted his anxiety, poor hygiene and lack of sleep. While the patient had no homicidal ideation, he was found to suffer from suicidal ideation as he expressed his plan to shoot, hang or stab himself to death. During his admission, a family meeting was held with the patient, his wife, the hospital social worker and a nurse. It was recommended that the couple live apart and undergo marital therapy.

The following day, the patient was again seen by our insured psychiatrist who noted that he was now taking Lexapro and Seroquel for depression and anxiety. The patient was discharged, though his prognosis was guarded as he did not exhibit much insight into his relationships, including his interactions and behavior with his wife and children. At the time of the discharge, the patient was not deemed suicidal or homicidal.

The patient was seen by the psychiatrist one week later as an outpatient. The physician felt the patient was compliant with his medications, provided him with sufficient refills and referred him to a therapist to continue outpatient therapy. By this point, the patient was diagnosed with bipolar disorder.

The patient was subsequently seen by his new therapist and believed that his diagnosis of bipolar disease, as well as a prior failed marriage and problems in his current marriage, explained his prior behavior. At this point, it appeared that his wife wished to move on with her life without him, and he advised him of his suspicion that she was dating. At this meeting, he willingly discussed his problems and expressed hope for the future. Although the future of his marriage was uncertain, the therapist’s plan was to aid the patient in dealing with his depression, set employment goals and encourage him to be more social and involved with his children. She believed the patient was compliant with his medications at that time.

The patient returned for another session one week later and appeared enthusiastic about his future with his wife and children. He denied any suicidal or homicidal ideation at that visit. The therapist felt that he was compliant with his medications. An appointment was made for the patient and his wife to return in two days; however, the appointment was canceled when the patient’s wife did not confirm.

The day prior to the patient’s next scheduled appointment, the patient went to the family home where he stabbed his wife to death. He next went to their babysitter’s home, where he raped her. The babysitter then went to a friend’s home while the patient sat outside in his truck, asking for a gun. The friend provided the patient with a rifle, which he later used to kill himself.

The Lawsuit

An action was brought on behalf of the deceased husband and wife for their two minor children alleging failure to formulate an appropriate discharge plan for the plaintiff-decedent; discharging him with prescriptions for Lexapro and Seroquel despite his history of being noncompliant with his medications; discharging the plaintiff-decedent despite the fact that his prognosis was guarded in light of his recent history of suicidal and homicidal ideation and failing to refer him for outpatient treatment and evaluation to assure his compliance with his medications.

This case was reviewed by the MLMIC claims department, as well as expert psychiatrists, who concluded that the case was defensible as the plaintiff-decedent had agreed to a discharge plan and, following his discharge, kept his appointments with the psychiatric social worker who noted that he was doing well. The psychiatrist had insight into the patient’s problems and agreed to continued psychiatric care on an outpatient basis. The murder/suicide occurred three weeks after his hospital discharge, and there was nothing in his outpatient treatment indicating that he would commit this crime. In addition, the patient’s wife had participated in a family meeting, at which time she agreed to work on the marital issues and did not object to the discharge plan. The case was tried to conclusion, and a swift verdict was rendered in favor of the MLMIC-insured psychiatrist and hospital. The jury unanimously found that it was not a deviation from good and accepted standards of psychiatric practice to discharge the patient following an approximately six-day admission for depressive/bipolar disorder. The plaintiff’s counsel did not pursue an appeal of this matter, and the case was closed upon entering the judgment.

MLMIC policyholders can reach out to our legal department for questions regarding documentation, discharge instructions or to ask any other healthcare law inquiries by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here.

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This document is for general purposes only and should not be construed as dental or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, dental or professional obligations, the applicable state or federal laws or other professional questions.