The hospital advertised to the public it had available all the care anyone could need, on a twenty-four hour basis, including adult psychiatric services. The public were invited to call the hospital for a free assessment. The hospital advertised in addition that it had a twenty-four hour suicide crisis line.

   Nurses answering the crisis line received several phone calls from a despondent man. The man’s family phoned about his bizarre behavior. The family expressed concern he was a suicide risk. The man’s wife went to the hospital to speak with someone about her husband, and talked to one of the nurses in the emergency room.

   Soon the man was taken to the hospital emergency room in person. A nurse, who had spoken with the family on the crisis line, made no effort to get a physician to see the man for a suicide assessment or to have the man admitted for suicide precautions and inpatient psychiatric treatment. Instead, because the man had no job, no money and no insurance, the nurse gave him and the family the names of other facilities where they might want to go. The nurse also phoned around to see if some other facility would take him.

   The man was not seen by a physician, received no psychiatric assessment and was not admitted. He left the hospital in a highly agitated state. A few hours later he sat down in the middle of an interstate highway and was killed by a truck.