August 2017

    The patient died in an exam room in the hospital’s emergency department from injuries sustained in a struggle with a police officer who was keeping the patient from leaving the hospital.  

    The patient’s prior psychiatric diagnoses included paranoid schizophrenia, PTSD and major depressive disorder.  This time she was in the emergency department for treatment of a head laceration.  After she was sutured the nurses asked the patient to wait until a ride home could be arranged.  While the patient waited several hours at the hospital a nurse contacted the local mental health professional for an involuntary mental health hold, but before a deci-sion was made by the mental health professional the patient left by herself.

    A second nurse phoned the local police to report that the patient had walked away from the hospital against medical advice while they were getting a mental health hold order to keep her.   Minutes later the mental health professional called back and told the nurse the hold order was being denied on the grounds that no proof had been provided of likelihood of harm to self or others.  Nevertheless the police dispatcher sent out a call that a patient for whom there was a hold order had eloped from the hospital.    

    An officer apprehended the patient and brought her back to the hospital.  An emergency department nurse put them together in an exam room.  The patient started acting out with only the officer present.  While trying to restrain the patient himself the officer suffocated her. The autopsy revealed numerous broken ribs.

    The US District Court for the Southern District of West Virginia ruled it was negligent for the nurse who called the police not to clarify explicitly that no mental health hold order existed at the time.   The nurse was negligent for implying to the police that such an order was going to be issued for the patient who the nurse should have known did not qualify for such an order, due to lack of evidence of likelihood of harm to self or others.    In fact, the patient was at the hospital voluntarily.  She had voluntarily agreed to wait a while after treatment for her head laceration so that a ride home could be arranged, but at no time was she not free to leave on her own volition.  The Court also questioned the wisdom of leaving the patient in an exam room with just a police officer after she was re-turned to the hospital.