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Avoiding Malpractice Lawsuits by Following

Risk Assessment and Suicide Prevention

Guidelines

Albert R. Roberts, PhD

Ianna Monferrari, BA

Kenneth R. Yeager, PhD

Every 17 min, someone in the United States commits suicide. This equates to 83 suicides

every day throughout the year (A. R. Roberts & K. Yeager, 2005). Suicide results in

approximately 30,000 reported deaths annually. The loss of a patient to suicide is often

a feared outcome among psychiatrists, psychologists, social workers, and crisis counselors,

especially because the law assumes that in most situations suicide is preventable. Suicide

accounts for many of the largest monetary settlements and judgments as well as a large

proportion of malpractice lawsuits filed against mental health clinicians. Yet, clinicians

often lack sufficient education on the legal aspects of malpractice associated with patient

suicide. This article reviews several legal cases in which psychiatrists and/or social workers

failed to protect patients. This includes failure to conduct a comprehensive biopsychosocial

and lethality assessment, failure towarn of imminent risk of suicide, and/or breach of duty to

care standards. Each case presentation concludes with recommendations for actions. Next,

the article identifies common allegations made in suicide malpractice lawsuits. Conditions

necessary to meet the criteria for a malpractice suit are laid out. The article concludes with

the authors guideline (FIKKE) for managing malpractice risk along with a decision-making

flowchart designed to reduce a patients risk of suicide during the treatment process. [Brief

Treatment and Crisis Intervention 8:514 (2008)]

KEY WORDS: suicide, malpractice lawsuits, duty to care, lethality assessment, risk factors.

Suicide lethality assessment and risk manage-ment of suicidal patients are growing concernsof mental health professionals throughoutNorth America. In fact, a patients suicidaldeath and the accompanying malpractice liabil-

ity can have devastating consequences to amen-tal health professionals career. Regrettably,little, if any, training is currently being pro-vided by graduate schools (White, 2002). Thisarticle begins with a review of case examples. Ithighlights some actions that should be taken(DOs), such as conducting an all-inclusive riskassessment. This is followed by a discussion ofthe key legal issues surrounding malpractice/negligence lawsuits. The article concludes withthe introduction of the FIKKE guideline toavoid a malpractice/negligence lawsuit.

From the Rutgers University (Roberts, Monferrari) and the

Ohio State University School of Medicine (Yeager).

Contact author: Albert R. Roberts, Professor of CriminalJusticeandSocialWork,RutgersUniversity,LivingstonCampus,

Lucy Stone Hall, B-261, 54 Joyce Kilmer Avenue, Piscataway,

NJ 08854. E-mail: [email protected].

doi:10.1093/brief-treatment/mhm029

Advance Access publication February 7, 2008

The Author 2008. Published by Oxford University Press. All rights reserved. For permissions, please e-mail:[email protected].

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Risk Assessment/Management

What exactly is risk assessment for suicide andwhat is its importance? Risk assessmentexamines a persons suicide potential and waysto effectively manage such peril (Berman, 2006).There are so many well-known suicide assess-

ment instruments such as the BeckHopelessnessScale, Beck Depression Inventory, Scale for Sui-cide IdeationWorst Point, Lifetime Parasuici-dal Count, SADPERSON Scale, Linehan Reasonsfor Living Scale, Suicide Potential LethalityScale, and many others. One would think thatassessment of suicidalitywould be a simple task.This simply is not the case. Dr. Douglas Jacobs(American Psychiatric Association [APA],2003), formerchairof theAPApracticeguidelineon treatment of patientswith suicidal behaviors,reports: Data indicate that 50% of individualswho complete suicide are in psychiatric treat-ment at the time, 10% are inpatients, and5%10% are posthospital discharge. Douglasalso reports that with regard to an analysis ofrecords of 100 patients who committed suicidein a hospital, 77%denied suicidal intent in theirlast communication with staff. One possible ex-planation of the patients change is the frequentambivalence expressedbypatients.At intakeas-sessment, patients or their family members fre-quently report suicidal thoughts, threats, and/orgestures. However, because we often have twodifferent or paradoxical thoughts at almost thesame time, many patients decide after severalhours in a busy hospital emergency room thatthey would be more comfortable going homeand controlling their own decisions and/or theywant to live for an upcoming family event. Forexample, a close family members high school orcollege graduation may only be 6 months away.Inadequate lethality assessments and other con-cerns related to patient assessment, reassess-ment, orientation of staff regarding suicidalrisk measures combined with inadequate staff-ing levels, and infrequent patient observations

contribute to inpatient psychiatric patient sui-cides. Additionally, the Joint Commission onAccreditation of Hospital Organizations reportsthat there are a significant number of suicides ingeneral hospital settings. Despite all the riskmeasures, it is necessary to develop a PracticeGuideline for the Risk Assessment and Treat-ment of Patients with Suicidal Behaviors thatcombines practice knowledge, experience, andevidence and takes into account patient rights.Psychiatrists, social workers, and psycholo-

gists sometimes lack the training in assessingthe degree of suicidality and conducting a le-thality assessment. According to the APA(2003, p. 23) Practice Guideline for patientswith suicidal behaviors:

If the patient has developed a suicide plan, itis important to assess its lethality. The lethal-ity of the plan can be ascertained throughquestions about the method, the patientsknowledge and skill concerning its use,and the absence of intervening persons orprotective circumstances . . . .

We build on the APA (2003) Practice Guide-line which is not intended to serve as a standardof care. The APA guidelines have been devel-oped by psychiatrists who are highly experi-enced clinical practitioners, combined withresearchers and academicians. The guidelineconsists of three parts (Parts A, B, and C). PartA addresses Assessment, Treatment, and RiskManagement Recommendations. This includeskey recommendations of the guideline andcodes each recommendation according to thedegree of clinical confidence associated withthe recommendations. Additionally, there isa discussion of assessment of the patient includ-ing consideration of factors that may impactsuicidal risk. Recommendations are made withregard to psychiatric management, treatmentmodalities, as well as for documentation of careand potential risk management issues. Part B, of

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6 Brief Treatment and Crisis Intervention / 8:1 February 2008

the guideline outlines background information,for example, natural history, epidemiology,and course, as well as a review of currentlyavailable evidence. Part C of the guideline isdedicated to drawing from the previous sec-tions, summarizing recommendations, and out-lining areas where additional research isrequired to advance the data, knowledge, andpractice approaches in addressing high-riskbehaviors. We support and build upon theAPA guideline and are not trying to replace it.The suicide ideation and assessment flowchart

in this article takes into account several criticalwarning signs (Figure 1). The following warn-ing signs are adapted from the chapter in thethird edition of the Crisis Intervention Handbookby Roberts and Yeager (2005, pp. 41 and 45):

family member reports on drastic behaviorchange in patient (e.g. banging his headagainst the wall, or barricading himself inhis room for an extended period and not com-ing out for meals or the bathroom);family member reports on patients suicidalstatement;patient gives away prized possessions;patient indicates that they have a firearm intheir home and they exhibit poor judgement;patient indicates depression symptoms;patient expresses suicide ideation;patient has a suicide plan;patient is agitated and exhibits imminentdanger to self or others;psychotic patient exhibits command halluci-nations related to harming self or others;patient is intoxicated or high on illegal drugsand acting in an impulsive manner.

It is the goal of this article to address issuesrelated to risk assessment and managementmeasures while devising ways to instruct men-tal health professionals that would safeguardthem against malpractice suits. The authorsof this article chose a unique and innovative ap-

proach. We developed specific actions to do.How is it unique and innovative? What does itdo that the APA guideline does not do? The fol-lowing section answers these two questions bypresenting concise summaries of cases fromwhich a list of practical DOs will be derived.

Case Examples

1. Hanging by a Thread (Roberts & Jennings,2005)After watching her husbandexpress hallucinations (thought that histesticles were disappearing), sudden majorchanges in behavior, such as banging hishead against the wall, heavy pacingaround in underwear, as well asenunciating a suicide threat of wanting toend his life through hanging, a concernedwife takes her husband to the emergencyroom of a private hospital. The patient issoon transferred to the nearest cityhospital with a mental health intake unit,and the mental health technicianscompleted form is faxed ahead of time tothe city hospitals intake unit. This formnotes that Mr. Banach was a danger tohimself because he mentioned the desire toend his life through hanging. The patientwas then examined and interviewed at thecity hospital by an attending physician,Dr. Dang, and later interviewed on thephone via a 20-min translated phoneconversation with a social worker, ChesterScott.Within 1 hr, the attending physicianand social worker allow the family to takethe patient home, stating that he wassexually dysfunctional due to drinkingproblem (Roberts & Jennings, 2005, p. 2),further advising that he should receivefollow-up treatment at an outpatientcommunity clinic. Unfortunately, thesocial worker and physician failed to makea proper diagnosis of psychosis,depression, and high suicide risk; failed to

Risk Assessment/Suicide Prevention

Brief Treatment and Crisis Intervention / 8:1 February 2008 7

give the family proper warning of risk ofsuicide; as well as ensure the patientssafety once he left the hospital. The patienthung himself at approximately 2 a.m. a fewhours after his midnight discharge fromthe hospital (Roberts & Jennings, 2005).The social worker attempted to defend

himself by negating his liability due to hisposition as a social worker, passing it on tothe doctor. The court denied his defense,explaining how the social worker anddoctor worked as team, having equal sharein the responsibility. Both, doctor andsocial worker were found liable (Roberts &Jennings, 2005).

U DO: diagnose properly (adequateassessmentespecially suicide).

+ Gain an understanding of clients hopesand plans for the future, levels ofdepression and anxiety, psychotic anddelusional thoughts, and family membersreports of suicidal threats or gestures(Roberts & Jennings, 2005, p. 4).

U Evaluate properly (please refer to flowchart).

U Be aware of the nine most serious warningsigns for suicide (these are listed earlier inthis article).

U Be knowledgeable on the standard of care(provide a translator to inform not onlythe patient, but the family of importantinformation).

U Become aware of your role in the team.

U Take appropriate action to inform thefamily of patients status.

U Dont take familys concerns lightly.

U Be suspicious of highly unusual behavior.

U Take higher precautions if patientdemonstrates an active suicide plan.

2. Gaido v. Weiser (1988/1989)a patientwith a history of severe depression and

anxiety, previously diagnosed as havingmultiple sclerosis, and having attemptedsuicide was released from his inpatienttreatment, being required that hecontinued psychiatric treatment. Theappointment tomeetwith a newdoctorwasscheduled for 6 days after his release; in themeantime, the patient begandemonstrating anxiety symptoms thatwere very similar to what he hadexperienced in the past, prior tohospitalization, including a very unusualone: excessive drinking. Concerned, thewife called the new doctor (Dr.Weiser) andasked that he sees her husband that sameday. The doctor refused the wifes request,given that the patient continued taking hismedicationeven though he did not checkwhat medication had been previouslyprescribed. The wife continued trying toschedule an earlier appointment, at onepoint, the Dr. agreed to prescribesomething to take the edge off (p. 15)while he maintained his position of notbeing able to see the patient before thescheduled appointment. Patients bodywas found on a riverbank, the autopsyfound a large amount of water in hisstomach, and a 0.23% alcohol in his blood,it was then concluded that the patientdrowned, and the cause of death wasaccident. The wife expressed that thedoctor did not meet the appropriatestandards of care and was negligent inprescribing the drug Tranxene to herhusband, proximately causing decedentsdeath. The doctor denied (Gaido v.Weiser,1989) breach[ing] the proper duty of care:

legal obligation imposed on an individual re-quiring that they exercise a reasonable stan-dard of care while performing any acts thatcould foreseeably harm others (APA, PracticeGuideline, 2003)

ROBERTS ET AL.


further stating that if his behavior was found tobe negligent, it would not be the proximatecausean event that is legally sufficient todocument liability resulting from a legallyrecognizable injury to be held the cause of thatinjury (Black, 1999, p. 234) of decedents death(Gaido v. Weiser, 1989). According to BlacksLaw Dictionary, negligence is defined as anact or omission that is considered in law to re-sult in a consequence so that liability can be im-posed on the actor (Black, 1999, p. 234). Thecourt found negligence on the part of the psy-chiatrist due to his failure to acquire thepatients medical history and the fact that heprescribed a medication in its absence. Thecourt found the doctor negligent based onthe failure to obtain the patients hospitalrecords, as well as his failure to ascertain whatmedication the patient had previously beenprescribed (Baergar, 2001). One would do:

U DO: Obtain the patients history (hospitalrecords, medications previouslyprescribed, current medications, etc.)before making judgments, especiallyprior to prescribing medication.

Abille v. United States (1980)after beingprescribed Reserpinea drug for the controlof high blood pressurethe patient began ex-periencing depressive symptoms (often a sideeffect of Reserpine) and suicidal thoughts anddecided to admit himself into a hospital. Hismedical history was taken during intake bya psychiatrist, who noted psychomotor retarda-tion, suicidal ideation, and sleep disturbances(Abille v. United States, 1980).He later concluded that the patient was suf-

fering from depressive neurosis, hyperten-sion, and reactive depression to Reserpine(Abille v. United States, p. 2). All patients weregiven status levels. New patients were usuallygranted S1 statusthe most highly restric-tiveonly allowingpatients tomovewith anac-companying staff member. Four days after his

admission, Abille was allowed to attend mass,shave, and go to mass unattendedgrantinghim S2 status, which was generally given topatients who were not thought to be of suicidalrisk. He was found dead shortly after he wasgiven the razor. According to the autopsy re-port, he took his own life (Abille v. United States,1980).Although Dr. Hipolito testified that he did

change Abilles status to S2, there was no writ-ten record of it. The nurses acted based onthe assumption of this presumed change. Thus,the court had to decide if the defendant met theprinciples of due care in his attempt to safe-guard Abille against his own self-injurious be-havior (Abille v. United States, 1980). In order tosustain the burden of proof, in other words, toprove the allegations enunciated by the court(for full list refer to Abille v. United States,p. 3), three questions were raised:

Did. Dr. Hipolito in fact change Abilles sta-tus?If he did change it, did he exercise due care indoing so?If he failed to exercise due care, was his neg-ligence a proximate cause of Abilles death?(Abille v. United States, pp. 34).

The court found that by allowing the patientto leave the ward by himself, the nurses actedbelow the standard of care. Court furthernoted that the psychiatrists decision tochange Abilles level was within the standardof care; however, the way through which hedid so was not. There were no notes or anyrecords that could serve as a documentationof his decision-making process. Dr. Hipolitowas found liable for his failure to describe ac-curately and fully in his report of the eventsand medical orders everything of consequencethat he did and which his trained eye observedduring the inpatient stay (Abille v. UnitedStates, p. 8).



U DO: keep an all-inclusive record, from thepatients status to reasons behindchoosing a certain decision.

U Avoid making assumptionsmake surethere are documented reasons and notesprior to following an order.

Stepakoff v. Kantar (19841985)The wife ofa patient diagnosed as manic-depressive psy-chotic (Stepakoff, p. 2) alleged that her hus-bands psychiatric doctor failed to let herknow of his suicidal status and to implementadequate arrangements for her husbandssafety (Stepakoff v. Kantar, 19841985).Experiencing some marital difficulty, the wife

goes away letting the patientMr. Stepakoffknow that he must be out of the house when shegets back and also informing the doctor of thesituationthe doctor tranquilizes the wife stat-ing that her husband should be fine. The psy-chiatrist was aware of his patients suicidaltendencies, but believed that the patient hadstrong coping mechanisms and because hehad been treating the patient for 15 months,he also thought that he had established a closeand strong therapeutic relationship with the pa-tient, which would deter Mr. Stepakoff fromattempting suicide or from making any majordecisions without contacting him first (Stepakoffv. Kantar, 19841985).The psychiatrist had plans to go on aweekend

vacation 2 days after the patients wife had lefthim. He made arrangements for the patient tocontinue treatment with another psychiatristwhile he was away and agreed to give him a fol-low-up call every night (Stepakoff v. Kantar,19841985).Prior to going on vacation, he had an emer-

gency meeting with the patient, during whichhe noted, a question of whether he will makeit over the weekend (Stepakoff v. Kantar,19841985, p. 2). During his statement to thecourt, he explained this question as not beinga suicidal concern, but rather,

Whether he would be able to carry out theactivities that he and I outlined, or whetherthe type of thing that happened to him justpreceding his psychiatric admission toNewton-Wellesley [in 1974] would occur . . .it was that type of regression and inabilityto function that I was questioning (Stepakoffv. Kantar, 19841985, p. 2).

The court stated how the psychiatrist hasa duty to his patient, not to third parties. Thus,the psychiatrist was not found negligent due tothe cautious treatment plan he developed inconjunction with the patient, as well as the factthat the patient did not meet the legal criteria tobe hospitalized involuntarily at the time(Stepakoff v. Kantar, 19841985).

U DO: Be familiar with the legal criteria forinvoluntary commitment.

U If you need to be absent, make properarrangements for patient to continuetreatment.

U Follow through with plans/stand behinddecisions (if you tell the patient youllcall, than do so).

U Document thoughts.

U Reread notesexplain/document certainincriminating remarks.

Bates v. Denny (1990)Mr. Bates, a 33-year-old male was brought to the emergency room ofa hospital, complaining of pain in his ribs due tofalling from a flight of stairs. Several cuts andscratches were found on his wrist during exam-ination, which he explained as being catscratches (Bates v. Denny, 1990, p. 1). Thepatients mother, Irene Bates, was a relativeof the emergency room physician and elabo-rated on her sons psychiatric and hospitaliza-tion history, including two recent suicideattemptsoverdose on sleeping pills and

ROBERTS ET AL.


shooting himself in the abdomenconcernedthat her son was suicidal, she asked for his hos-pitalization. She further stated that Mr. Bateshad stopped taking his medication andexpressed a desire to kill himself through usageof a gun. However, when questioned, hecontested being suicidal and did not agree tobeing hospitalized (Bates v. Denny, 1990).Assessment and TestingDr. Newman did perform a mental status eval-

uation on the patient, and other than noting hisslurred speech and discontent with familysinsistence on hospitalizing him, his behaviorwas rather normal. The decision to send thepatient home was made based on the phoneconversation he had with the patients most re-cent psychiatrist, also the patient was notthought to be depressed or psychotic, and thefamily was to keep close watch, ascertainingthat he did not obtain access to a weapon, fur-ther stating that involuntarily hospitalizing thepatient, would perhaps be counterproductive(Bates v. Denny, 1990, p. 3). Mr. Bates diedthe next morning from a self inflicted contactgunshot wound to the right temple (Bates v.Denny, 1990, p. 1).Three psychiatrists provided expert testi-

mony. To summarize arguments that foundthe psychiatrist negligent were based on thepatients chronically suicidal (Bates v.Denny, 1990, p. 4) status. During the testi-mony, one of the experts stated that becausethe patient posed a serious threat to himself,the best way to safeguard him was to keephim under a close watch within the safe andhighly monitored atmosphere of a hospital.He further stated that if the patient does notdemonstrate suicidal ideation, it is up to themental health professional to make a judgmentcall as to the truthfulness of the patientsword, perhaps alluding to the doctors im-proper judgment (Bates v. Denny, 1990).Arguments against assigning culpability to

the psychiatrist were slightly similar, also rely-

ing on the elaboration of the patients chroni-cally suicidal status.

A chronically suicidal person is one who hasasuicidepotentialoveralongperiodoftimewithperiods of remission alternating with acutelysuicidal states (Bates v. Denny, 1990, p. 4).

Expert testimony as well as the court notedthat the patient was in his remission state,not acutely suicidal, and did not express anypsychotic or suicidal signs; thus, it was withinthe standard of care to allow him to leave. Inother words, one cannot maintain a chronicallysuicidal patient locked up indefinitely. Further-more, the doctors actions did not demonstratea breach in the standard of care due to the factthat the doctor scheduled a follow-up appoint-ment, was aware of the patients family andclinical history, and also made arrangementsto inform the family of the patients needs.Also, because the patient had a history of beingresistant to treatment, involuntarily retaininghim would also make his treatment worse.And finally, in expressing the conditions for in-voluntary hospitalization whether the patientis suicidal, homicidal or gravely disabled(Bates v. Denny, 1990, p. 5), because the patientdid not demonstrate any of these signs, the ruleof the least restrictive judgment comes intoplay. Thus, the psychiatrist was found to haveacted within the standard of care.

U DO: obtain patients clinical and familyhistory.

U Make arrangements for follow-upappointments.

U Be knowledgeable on the necessaryconditions for involuntaryhospitalization.

U Be aware of the rule of the leastrestrictive environment.

U Think decisions through thoroughly.



FIGURE 1

From Lethality Assessments and Crisis Intervention with Persons Presenting with Suicidal Ideation, by A. R. Roberts

and K. Yeager, 2005, in A. R. Roberts (Ed.), Crisis Intervention Handbook: Assessment, Treatment and Research (3rd

ed.). New York: Oxford University Press.

ROBERTS ET AL.


Malpractice and Negligence

In legal terminology, malpractice is classified asa tort action. Tort is a civil wrong committedby one individual (the defendant) that causedsome injury to another individual (the plaintiff)(Packman and Harris, 1998, pp. 150186).Negligence is the failure to exercise the stan-

dard of care that a reasonably prudent personwould have exercised in the same situation(Black, 1996, p. 1405). The standard of careis the degree of care that a reasonable personshould exercise, thus differing from situationto situation (Black, 1996, p. 589). Malpractice isfrequently described as professional negli-gence, referring to negligence or incompetenceon the part of the professional; specifically, anegligent act committed by a professional thatharms another (Roberts and Jennings, 2005,p. 5). There are two primary areas of focus:an act of commission (i.e., mental health profes-sional doing something that should not havebeen done) and an act of omission (i.e., mentalhealth professional not taking appropriate ac-tion given presenting risk factors) (Robertsand Jennings, 2005, pp. 110).In regards to malpractice suits, the plaintiff

must demonstrate that their case against the de-fendant meets these conditions:

Action Based Elements of Proof Duty of care was owed by the professionalto the plaintiff;

The professional violated the applicablestandard of carebreach of duty;

The plaintiff suffered a compensableinjury; and

Causation, that the plaintiffs injury wascaused in fact and proximately caused bythe defendants substandard conduct.(Roberts and Jennings, 2005, pp. 110)

In addition to knowing the conditions thatmust be met in a malpractice suit, it is also im-

portant for a practitioner to be familiar with thetypical allegations made in a malpractice suitfiled in a case of suicide.

Top Eight Complaint Allegations

Extracted from the work of Packman, Pennuto,Bongar, and Orthwein (2004)

n Failure to predict or diagnose the suicide.

n Failure to control, supervise or restrain.

n Failure to take proper tests and evaluationsof the patient to establish suicidal intent.

n Failure to medicate properly.

n Failure to observe the patient continuously,(24 hrs.) or on a frequent enough basis (e.g.every 15 minutes).

n Failure to take an adequate history.

n Inadequate supervision or failure to removedangerous objects, such as a patients belt.

n Failure to place the patient in a secure area.

Guidelines to Avoiding Malpractice/Negligence Lawsuits (FIKKE Model)

In order to obtain a more in-depth understand-ing of the issues, as well as employ the best pre-cautionary actions against a malpractice/liability suit, the authors offer the followingguidelines.

FIKKE Model of Malpractice Suits.

Familiarize yourself with the common allega-tions in negligence/malpractice suits.Implement an all-inclusive Risk Assessment

Strategyplease refer to Roberts and Yeagersflowchart (reprinted in this article).Know suicide warning signs and legal termi-

nologies and their meanings (meanings of im-portant terms such as proximate cause,burden of proof, negligence, malpractice).Keep the Dos in mind.



Enhance understanding through caseexamples.

Conclusion

The overriding goal of our suicide preventionwork is to save lives. However, even the mostcompetent professional cannot always preventa patients suicide, especially in the smallnumber of cases where there are no warningsigns. Cases proceed to court only if the suicidewas reasonably foreseeable and preventable(VandeCreek & Knapp, 1989). This article hopesto decrease the odds of being found negligent orliable for a patients suicide while also prevent-ing suicides by providing clinicians with a Doschecklist and decision flowchart, for improvingassessment and patient management. It identi-fies specific suicide risk practices and familiar-izes clinicians with the malpractice aspectsof their fiduciary duty to protect those undertheir care.

Acknowledgment

Conflict of Interest: None declared.

References

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Berman, Alan L. (2006). Risk management withsuicidal patients. Journal of Clinical Psychology,

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