This month we look at a case that highlights a very important issue – what duty do clinicians have to warn potential victims about a dangerous patient? The facts of this case are particularly tragic and disturbing.
The case primarily deals with events that took place over an approximately 1-month period from early December to early January. The first time the patient, Mr Z, a 24-year-old man, was brought into the emergency department (ED) of his local hospital it was by his mother. She brought him in after he had threatened to strangle her. He presented with suicidal ideation, agitation, and depression, and his symptoms were noted as being severe. His mother mentioned to the attending physician that her son ‘believed the TV was talking to him.’ A behavioral health consult was ordered, and the patient was diagnosed with major depression, but was discharged home with instructions to follow up with behavioral health.
The patient would return to the emergency department 4 more times over the course of a month and would see various clinicians. He was prescribed medication, but it was unclear whether he was compliant with taking it and/or whether it was working for him.
Two days after his first visit to the ED, Mr Z returned on his own, reporting suicidal thoughts and a belief that he needed to be hospitalized. After some hours, he was again discharged home with instructions to follow up.
Five days after that, Mr Z’s grandfather called the police after his grandson kicked him, threatened to kill him, and expressed a belief that ‘the Illuminati’ were telling him to do things. Mr Z presented in the ED with delusional thoughts, angry, and agitated. His mother reported that he had been talking about harming his family and himself. On this occasion, the decision was made to admit Mr Z for psychiatric care. He remained in the hospital for 3 days, at which point he was discharged.
In the hospital report from that day, it was noted that Mr Z thought everyone was out to get him, and he admitted to threatening and pushing his grandfather whom he felt was withholding information from him.
Two weeks later, Mr Z was again brought to the emergency department by the police. He had threatened to kill his mother, kicked his grandfather for a second time, and killed the family dog. A mental health consult indicated that Mr Z’s mood was angry and irritable, and that his judgment and impulse control were poor. After several hours he was discharged with instructions to follow up with the behavioral health department.
Finally, a week later, Mr Z returned to the emergency department for a final time. On this occasion he came alone, acting anxious and agitated, asking to be admitted. He was seen by a physician assistant and a physician. A behavioral health consult was ordered, during which Mr Z talked about not being able to control his thoughts and needing something to keep him from thinking so much. It was determined that inpatient treatment was not medically necessary, and Mr Z was discharged that night.
Several hours later, he went to his grandfather’s home and brutally attacked him – hitting the grandfather in the head with his fist and a frying pan, stomping on him, choking him, and finally cutting his wrist with a steak knife, after which he calmly called 911. His grandfather died 2 days later.
Mr Z would be charged with murder, but eventually pled guilty but mentally ill to voluntary manslaughter.
Two years after her husband was killed, Mr Z’s grandmother sued several of the hospital’s physicians, claiming that they should have taken action to have Mr Z admitted to the hospital, involuntarily committed, and provided adequate warnings to potential victims of his violent nature as evidenced by his presentations in the emergency department.
The defendants moved to have the case dismissed, claiming they were not required to take such action.
The Court Decides
The defendants pointed out that the state code provides immunity for providers for failing to warn about a patient’s violent behavior unless the patient has communicated a specific threat of actual violence against an identifiable victim, or if the patient is an imminent danger. The physician defendants argued that Mr Z did not communicate an actual specific threat to them about the grandfather, and that even if he did – his family was already aware of the danger he posed and thus the providers were not required to “re-warn” them.
The court agreed that there was no actual threat expressed. It pointed out that Mr Z, when speaking to various providers acknowledged making earlier threats against his grandfather. But acknowledging an earlier threat – “Yes, doctor, last night (or last month, or last year) I threatened to kill John” – is not the same as communicating an actual threat – “Doctor, I’m going to kill John.” The court held that no actual threat communication took place here.
However, the court held that when looked at as a whole, the totality of Mr Z’s statements and conduct during that month-long period could support a finding that he was an imminent danger, and thus the court refused to dismiss the case against the physicians.
The court also disagreed with the defense’s argument that it had no duty to “re-warn” the family because they already knew that Mr Z was a danger. “Nothing in [the statute] indicated that the duty to warn or take precautions is owed only to those potential victims who are completely unaware of the danger posed,” noted the court in its decision. “Furthermore,” continued the court, “requiring a provider to take protective measures even when a potential victim is aware of some danger makes practical sense. Being warned by a trained professional may very well cause a potential victim to take extra precautions to avoid violence.” The court denied the defense’s motion to dismiss the case, and the case is currently continuing.
In this particular case, the duty to warn would have been satisfied had the healthcare providers taken 1 or more of the following actions:
- A reasonable attempt to warn the potential victim.
- A reasonable attempt to contact police or law enforcement.
- Seek civil commitment of the patient.
- Take steps to prevent the patient from using violence until law enforcement can be summoned.
Whether these steps would have prevented the tragedy which occurred in this case is unclear, but they might have at least protected the clinicians from liability.
We will be following this case as it gets closer to trial.