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ProAssurance Risk ManagementDecember 20233 min read

Failure to Identify Risks Alleged in Patient Suicide


Hospital and psychiatrist in the behavioral health unit failed to appreciate patient’s suicide risk and failed to implement appropriate preventions.

Case Details

A 60 YOM with a history of depression and anxiety voluntarily presented to the emergency department (ED) after suffering suicidal ideations. The patient was evaluated by an ED physician, who then contacted a psychiatrist for admission to the Behavioral Health Unit (BHU). The patient was transferred to the BHU at approximately 4:50 p.m.

A behavioral assessment performed upon the patient’s arrival at the BHU noted that the patient was not demonstrating signs of psychosis and no longer reported active suicidal ideations. The treating psychiatrist’s admitting orders instructed that the patient be checked every fifteen minutes and that suicide precautions be implemented. He also ordered the administration of the patient’s “normal” bedtime medication and a dose of olanzapine for sedation.

The psychiatrist then briefly met with the patient but did not perform a complete assessment of him. Following this interaction, the psychiatrist notified the charge nurse that he wanted to give the patient an additional dose of olanzapine to facilitate sleep that evening. This order was not documented in the medical record, and no nighttime medications were given.

During the patient’s routine check at 9:30 p.m., he was found hanging from a shower curtain in the bathroom in his room. A Code Blue was called, and the patient was transferred to the ICU, where he remained comatose until care was withdrawn the following day.

A wrongful death lawsuit was filed against the hospital and psychiatrist, alleging both defendants negligently failed to implement one-to-one observation of the patient, failed to keep the patient’s room free of items that could be used to inflict self-harm, and failed to consider psychotic features of the patient’s condition. The complaint also alleged that the psychiatrist failed to perform an adequate psychiatric evaluation.

Expert Testimony

The plaintiff’s case argued that the defendants failed to appreciate that the patient was actively suicidal when he presented to the BHU, warranting one-to-one observation. In support of this position, the plaintiff pointed to the patient’s suicidal ideations and his self-reported plan to jump off a parking garage. Defense experts for the psychiatrist noted that one-to-one observation was not required since the patient was calm and cooperative during his initial assessment in the BHU. However, the psychiatrist’s experts also advised that there is literature to support the implementation of one-to-one observation when suicidal ideations are paired with a plan for carrying out said ideations.

As discovery proceeded, it became evident that the defendants would ultimately be pitted against one another on several key issues. The order to sedate the patient was never carried out, never documented, and the charge nurse denied it ever happened. Similarly, there was ambiguity in the order to implement suicide precautions. No specific precautions were outlined and it was anticipated that the defendants would be at odds regarding who was ultimately responsible for these unspecified precautions.


The case was settled.

Risk Reduction Strategies

  • Develop clear protocols for one-to-one observation, including documentation, observations at regular intervals assessing the patient’s emotional state, and reporting any changes or concerns to the healthcare team.
  • Ensure that trained staff members are available to provide continuous one-to-one observation for at-risk patients, particularly during periods of heightened risk or crisis. Identify patients at high risk of suicide through a thorough risk assessment and establish criteria for when one-to-one observation is needed.
  • Continuously evaluate the need for one-to-one observation and adjust the level of observation based on changes in the patient’s condition and risk factors.
  • Conduct a comprehensive environment of risk assessment. Modify the physical environment to reduce risk, including removing or securing items that could be used for self-harm.
  • Implement a strict medication monitoring protocol, including regular assessments of medication side effects and effectiveness.

ProAssurance Risk Management

The ProAssurance Risk Management department is here to help you promote patient safety, minimize risk, and improve defensibility of claims by providing comprehensive assessment and training resources that are relevant and easy to share. If you have a question you would like to discuss with a risk consultant, email or call 844-223-9648.