Failure to Implement Adequate Behavioral Health Safeguards a Factor in Patient Death

Allegation

The patient’s family alleged that staff failed to secure the suicidal patient during admission, allowing him to elope and enter traffic, resulting in his death.

Case Details

A 32 YOM was stating that he wanted to commit suicide. His family brought him to a local Crisis Center where he attempted to escape from his family before entering. He was stopped, and an ambulance was called to transport him to the local ED. The patient attempted to run away a second time on arrival to the ED and ran into traffic. He was stopped again and taken into the hospital by the ambulance crew. After an evaluation, it was decided to place an involuntary legal hold and transfer the patient to a behavioral health specialty hospital. Upon arrival the patient was placed in an unlocked, unmonitored room for triage. Approximately one hour later, after intake paperwork was completed by a staff member, the patient was left alone again in a triage room. He saw a staff member leaving the area through a locked door. He trailed out the exit door after the staff member and ran into traffic at a nearby highway. He was hit by a vehicle and died of his injuries.

Expert Testimony

Local, state, and federal reviews of the patient care were conducted. Plaintiff experts believed the patient should have been a direct admission to a locked unit instead of an unlocked triage area based on the extensive workup done by the crisis clinic and ED. They also opined that checking the patient every 15 minutes is not enough for someone on a legal hold for suicide ideation and a recent history of elopement attempts. They also felt that the patient should have been on 1:1 supervision.

Resolution

Despite a history of prior elopements and subsequent incidents, the facility failed to implement adequate safeguards to prevent patient elopement. Multiple external investigations identified significant lapses in care and found both the facility and staff negligent.

The case was resolved through settlement.

Risk Reduction Strategies

Ensure that proper intake and safety protocols are established and followed to create a safe environment for patients in a behavioral health setting:

• Conduct elopement risk screening at intake and maintain individualized alerts and care plans.
• Use structured tools such as SBAR I-PASS for handoffs with key risk history communicated.
• Perform regular simulation drills for elopement, self-harm, and violent threats or events.
• Evaluate triage decisions to determine when direct admission is more appropriate.
• Complete physical and environmental assessments to identify and mitigate safety risks.

---

If you have questions on this topic, please contact us at RiskAdvisor@ProAssurance.com or 844-223-9648.