As the San Diego Tribune recently reported, suicide rates are high among veterans who have served in combat since the attacks on 9/11/01. Unfortunately, research into veteran suicides reveals that both the VA and civilian health institutions are not doing enough to help when veterans appear to be giving up on treatment or experiencing despair. In some cases, veterans in inpatient care are not even being provided with the minimum level of assistance they need.

When someone is in a VA hospital or other treatment facility and there is a risk of death by suicide, steps need to be taken to ensure the person is properly monitored and an effective treatment plan is in place. When this does not happen and inpatient suicide occurs, the family members of the victim need to hold the institution and mental health professionals working at the institution accountable for their failures. This is especially true in situations where professionals who work with veterans regularly should be aware of signs of suicidal ideation and should ensure the proper healthcare is provided for patients who are receiving inpatient psychiatric care.

Veterans at Risk of Inpatient Suicide

According to the San Diego Tribune, one case which has spurred the VA to try to make some changes involved a 37-year-old Air Force Veteran who died by suicide at a local hospital within days of being released from a lockdown psychiatric hold. He had been released from lockdown even though he clearly was not yet ready for release, as he was still experiencing suicidal ideation. He was admitted to a drug rehabilitation program at the same hospital with the belief he would get further help in the rehab program. Unfortunately, he hanged himself in his room.

Following this veteran’s death, the hospital decided to formalize the process of handoffs among inpatient units so staff members in different units would document that they had reviewed the patient’s case together and were aware of the risks. This is certainly a positive change: If veterans are to be released from one inpatient program to a different one when still at risk of suicide, extra precautions will need to be taken by new care providers to be watchful for continuing signs of suicidal ideation.

Unfortunately, changing the process of handoffs may not be enough to stop the epidemic of veteran suicides. Paul Rieckhoff, the executive director of Iraq and Afghanistan Veterans of America believes the government is downplaying the severity of the suicide crisis, which is a major public health issue more resources are needed to address. He compared the failures to provide appropriate care to suicidal veterans to the lack of response in the early days of the AIDS crisis.

The government has a responsibility to veterans, and the VA in particular has an obligation to make sure veterans are getting the care they need. Most importantly, facilities treating veterans must take seriously their duties to monitor and protect those who served, especially as suicide rates remain high.

Zero Suicide represents a commitment to identify, protect, and treat people who are at risk of suicide. Central to this commitment is the ability to record and properly share accurate information about a patient’s history and treatment. Without this information, each clinician that treats a patient must start from scratch — an inefficiency that will frustrate health care providers and patients, as well as affect the quality of care. Careful documentation also allows us to understand how health care systems can be improved and patient care made more effective.

The documentation essential to Zero Suicide has another benefit. It can protect clinicians and institutions from malpractice suits. Suicide is the most common cause of legal action against mental health care professionals. The central issues in most suicide malpractice cases are whether the clinician should have anticipated the risk of suicide and whether he or she provided care appropriate to this risk. Showing that a clinician met the standard of care appropriate for suicide risk can stop a malpractice suit in its tracks. Patient care should be documented in real time. Juries may suspect that medical records created after the fact rather than during treatment are inaccurate or self-serving.

Assessments of suicide risk should be carefully documented. It is a fundamental principle of good practice that risk assessment is more than simply using a screening instrument—clinical observation and judgment are also essential. These observations should be documented in the patient’s medical record. Patient responses to questions about suicide and self-harm should be recorded in their own words, and quotation marks used to clearly distinguish which statements represent clinical judgments and which are verbatim reports of what a patient said.

Embarrassment and anxiety can make patients reluctant to admit they are thinking about suicide. They may want to protect family secrets about substance abuse, mental health disorders, sexual abuse, or family violence. They may be in denial or afraid of being institutionalized or feel that no one can help. Involving family members can be crucial to accurately assessing a patient’s risk and making care decisions. Family members can provide information that the patient can’t—or won’t—and this information should be carefully recorded. It should also be noted if family members cannot be reached or are uncooperative. If a suicide results in a malpractice suit, it is the family that will sue. Accurate information about the family’s involvement—or lack of involvement—in patient care can be critical to the outcome.

The clinician should also document the decisions made while developing a patient care plan, how this care plan was implemented, and the criteria used to decide the steps needed to preserve the patient’s safety (such as whether the patient admitted to actively planning his or her suicide and whether the patient has access to firearms).

It is also important for the clinician to document his or her review of medical records and consultations with other service providers. If medical records or prior providers are not available, all attempts to obtain records and reach providers should be documented.

Focusing on the possibility of malpractice lawsuits turns the clinician’s attention away from the patient to him- or herself. Thoroughly and accurately documenting the assessment and care of patients who may be at risk of suicide will help deter malpractice lawsuits as well as contribute to quality care, patient safety, and the ability of clinicians and the health care system to work toward the goal of zero suicides.

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Virginia governor Terry McAuliffe’s plan to close Catawba Hospital, a 110-bed psychiatric facility located near Roanoke, is the latest blow to the state’s underfunded and uncoordinated mental health system.

Over the past four decades, Virginia has already lost nearly 80 percent of its psychiatric hospital beds, leaving fewer than 1,500 statewide. Compounding the problem is the lack of community-based services, such as counseling, housing and treatment, needed for people struggling with mental illness to get the care they need outside an inpatient facility.

Due to the state’s failure to invest in those services, hundreds of discharge-ready patients are crowded into a limited number of beds, stuck at a hospital level of care because there is no plan for them to step down. This leaves little room for those who are most at risk.

As a result, people suffering from mental illness and substance disorders are left in a place that is ill-equipped to care for them: the criminal justice system. Nearly 7,000 Virginians with mental illness are currently incarcerated, more than four times the number in psychiatric hospitals.

Lack of Services Leads to Tragedy

Without the dedicated care they need, inmates with mental illnesses are at increased risk of abuse, neglect and suicide. In one recent tragedy, Jamycheal Mitchell, a mentally ill 24-year-old man, was arrested after shoplifting $5 worth of snacks from a convenience store. He wasted away and died after four months of neglect in jail.

A judge repeatedly ordered that Mitchell be transferred to a psychiatric hospital, but no beds were available. Meanwhile, at Eastern State Hospital, the nearest state psychiatric facility, some two dozen patients had been designated ready for discharge but remained in their beds due to a lack of community-based services.

Even when beds are available, failures to effectively coordinate care can be deadly. In November 2013, Austin “Gus” Deeds, a 24-year-old college student with bipolar disorder, stabbed and slashed his father, R. Creigh Deeds, 13 times before dying by suicide.

That night, the Deeds family had gotten a court order that gave the state six hours to place Gus in an inpatient treatment facility. Mental health evaluator Michael Gentry claimed he called 10 facilities that could care for Gus, but phone records show that he only called seven. Tragically, two of the three facilities that were not called had space available.

The elder Deeds, a Virginia state senator, survived the attack and has been a vocal advocate for mental health reform since. He is also pursuing a $6 million wrongful death suit against the state.

A Nationwide Trend

Virginia’s issues with mental health are far from unique. Rather, the lack of psychiatric beds is a result of a nationwide initiative in the 1970s to downsize psychiatric hospitals in favor of community-based care. While well-intentioned, this initiative ultimately led to cuts across the mental health system, as funding did not follow the patients into the community.

As such, people suffering from mental illness and their loved ones are left to deal with confusing bureaucracy, long wait times for services, overcrowded facilities and overworked care providers. In such environments, patients are commonly neglected and even abused, leaving them at elevated risk for inpatient suicide.

Mental health facilities have obligations to psychiatric patients to keep them safe, particularly when patients are on suicide watch and there is a risk of death by suicide.  One of the duties in most facilities is simply to monitor patients who are at great risk to ensure they do not try to self-harm.  If a hospital has failed in any of its obligations to patients and inpatient suicide occurs as a result of this failure, it is possible to take legal action against the facility.

Hospitals can be held responsible for negligence in policies which lead to patients dying by suicide. If staff members fail to fulfill the obligations imposed upon them by their jobs, mental health facilities can also be held accountable due to these on-duty errors or the negligence of staff members in fulfilling work tasks.

Hospital records and other internal evidence from mental health facilities can prove invaluable in determining if the facility has lived up to its obligations or not.  An experienced inpatient suicide lawyer can assist family members of patients who died by suicide in obtaining necessary records to help prove negligence.

Video Surveillance Footage Helps to Show Staff Failure in Mental Health Facility

Naples News reported on one tragic case which illustrates how information a hospital collects can be used to help prove negligence after inpatient suicide occurs.  The case involved the suicide of a 51-year-old man who was in a psychiatric inpatient hospital. The man had been admitted because of feelings of paranoia, hopelessness, and depression. His admissions paperwork indicated he had been having suicidal thoughts.

During the time he was in the 103-bed facility, the 51-year-old man was quiet and didn’t participate in any activities or therapy sessions. Two days prior to his death, he asked to talk to a social worker and requested forms for a living will. The social worker didn’t ask the reason for this request, and did not report the request to anyone.   The patient’s doctor indicates he would have put the patient on immediate suicide watch if he had been aware a request for a living will was made.

Even though the patient was not on suicide watch, he was still supposed to be checked on every 15-minutes.  Unfortunately, though written paperwork indicated these checks had happened, surveillance footage from the hospital shows there were two checks missed in a row. Neither a 9:15 and a 9:30 check happened. By 9:45, when the 51-year-old patient was finally checked on, the patient had gone into the bathroom and hanged himself with a tied-up hospital gown.

There were numerous situations in this case where the hospital facility dropped the ball, from the social worker not reporting the living will to the 15-minute checks not being made. The surveillance evidence and the patient records including the living will help to show how the hospital facility fell short of its obligations.  A suicide lawyer can help family members to obtain this type of evidence to prove a mental health facility should be held accountable for lapses.

Facilities that provide inpatient care to patients experiencing mental health issues have a strong obligation to make sure patients are carefully monitored and appropriately treated to prevent an attempted suicide. When patients are depressed and experiencing suicidal ideation, it is especially imperative the institutions in charge of them take active steps to protect them.

Sometimes, however, institutions fall short. One such institution, which tells patients to “expect a miracle” is considered one of the foremost rehabilitation centers in the country. The strong reputation and appealing promises made by the institution led one family to pay $64,800 to get care for a 55-year-old man who had been struggling with chronic depression. The man’s admission to the rehabilitation facility was his first time in a residential treatment center, although he had previously been hospitalized for mental health issues. Unfortunately, Tucson.com reports the man died by suicide while under the care of the rehabilitation center.

In cases like this one, serious questions arise regarding whether the inpatient treatment center did enough to protect the residential patient or whether the center fell short. In this case, a lawsuit has been filed in response to the inpatient suicide, with family members claiming they were misled into thinking the patient would be safe and arguing the facility was negligent because staff members failed to notice the patient had not shown up for scheduled activities.

Responsibility for Inpatient Suicides

Despite its promises of miracle cures, the facility has faced trouble in the past with actually living up to its promises.  Five patients have died in the care of the facility since 2011, all of whom were men between the ages of 20 and 71. Three of the patients died of suicide, two hanging themselves with a shoelace and one hanging himself with a belt.

Because of problems with the provision of patient care, the state Department of Health Services has been heavily monitoring its operations. The monitoring requirement was imposed because the rehab center was not following its own policies on keeping track of where its patients were. In the case of the 55-year-old suicide victim, for example, the man did not show up for any of the five activities he was scheduled to attend. He also missed appointments.

When patients are 15 minutes late for an activity, staff members are supposed to look for them.  Interviews with staff members, however, revealed no one looked for this man for hours, until it was too late. Staff members also confirmed they did not know who was responsible for taking attendance of patients, reporting when a patient was absent, and calling for the initiation of a search to locate the patient.

It was especially important for the facility to take action here, as records show the suicide victim had described feelings of total helplessness and thoughts of suicide.  Inpatient facilities are supposed to be operated specifically to protect patients like this when they offer care to those experiencing thoughts of suicide and they need to be held accountable when they fail in fulfilling obligations.

Approximately six percent of deaths by suicide in the United States occur when patients are under care in a psychiatric hospital, a mental health facility, or a mental health unit of a hospital.  According to Psychiatric Times: “Inpatient suicides are viewed as the most avoidable and preventable because they occur in close proximity to staff.”

Understanding when and how these suicides occur is key to successful prevention of death by suicide. When psychiatric health professionals fail in effective monitoring and prevention, the facility where the patient was receiving treatment may be held accountable.

Understanding Death by Suicide in an Inpatient Setting

Psychiatric nurses in an inpatient facility generally experience a completed suicide every 2.5 years on average, although these suicides are widely considered the most preventable due to staff-member control of the environment and due to the greater control exercised over inpatients versus outpatients.  Why? See the end of this blog.

The greatest danger to patients of death by suicide occurs in unsupervised areas, and patients are most at risk at night or during hand-offs when one staff member leaves a shift and care transfers to another healthcare worker.  However, patients may die by suicide at any time when staff members fail to fulfill obligations to keep them safe.

The majority of deaths by suicide in psychiatric hospitals occur because of hanging, and 75 percent of the deaths occur in closets, bedrooms, or bathrooms of patient rooms—those hidden areas all nurses and hospital techs know about.  While suicide watch protocols are aimed at preventing these fatalities, they are failing. Why? The observation period is too long.  It takes approximately two minutes of hanging to have irreversible brain damage and five to six more minutes to die—either on the unit or on a respirator a few days later in another hospital where the patient has been transferred due to the emergency.   When the suicide watch protocol involves checking on the patient every 15 minutes (the time interval often selected), this allows sufficient time for the patient to successfully complete a suicide. More frequent monitoring of patients at risk for suicide is called for-usually one to one (where a staff member is within arm’s length) or line of sight monitoring.   In one study of patients who died by suicide in an inpatient facility, 51 percent of patients were being monitored on a 15-minute suicide observation protocol.

Inpatient facilities can also eliminate threats to patients by reducing patient access to tools and conditions which could facilitate death by suicide. For example, grab bars in showers and plumbing fixtures can be used by patients in an attempt to die by suicide.  Adding plates to grab bars and putting safeguards around plumbing fixtures, like stainless steel boxes, can help to eliminate environmental risks.

Staff members must also be able to recognize when patients are at the greatest danger of death by suicide.  Studies suggest in 60 percent of suicides among inpatients, the patient’s level of risk was not adequately determined by psychiatric professionals or the appropriate precautions were not taken based on the risk level identified.  Professional psychiatric staff must be accurate in diagnosing the level of suicide risk posed by each patient in an inpatient facility, and appropriate protocols must be followed to protect patients from harm based on their specific risk levels.

Skip Simpson says: “In a nut shell hospitals must stop providing suicidal patients with the means, time and opportunity to kill themselves. Patient safety is not the goal for these hospitals; it is profits. Simple patient safety rules will stop the suicides if greed is put to the side.”

In 2012, the National Action Alliance for Suicide Prevention and the Suicide Prevention Resource Center (SPRC) came together to develop a plan called “Zero Suicide.”

Zero Suicide was outlined in the 2012 National Strategy for Suicide Prevention, and the website for Zero Suicide indicates the “foundational belief” of the project is: “that suicide deaths for individuals under care within health and behavioral health systems are preventable.” Essentially, this means individuals should not be falling through the cracks and the healthcare system should take a systematic approach to patient care to prevent death by suicide – all of them.

Mental health care providers play a key role in Zero Suicide, because as National Council magazine indicates: “serious mental illnesses and addictions elevate suicide risk by 6-12 times over the general population’s.”

When people with mental health issues seek treatment, care providers must recognize the dangers, be alert to signs of suicidal ideation, and take necessary steps to offer services designed to eliminate risk. If a mental health care provider fails in obligations and a patient dies by suicide, the care provider may be held legally liable for mental health malpractice for deciding not to follow the standard of care which contributed directly to the patient’s attempted suicide and/or death.

Zero Suicide Can Be Effective at Reducing Suicide Risks

States throughout the country are embracing the systematic approach of Zero Suicide, including New York. New York’s view is when suicide deaths occur, the fatalities are because of systemic failures- which are precisely the type of failures Zero Suicide is intended to stop from occurring. As part of a Suicide Prevention Initiative in NY, a plan has been put in place to improve the quality of behavioral healthcare and put an end to these systemic failures.

New York is putting a systems approach into place in higher risk communities and among higher risk demographic groups. Steps being taken include:

• Improving inpatient and outpatient care to reduce or eliminate suicide deaths in state-operated psychiatric service systems.
• Involving multiple parties and institutions, including local county leadership, residential care providers, inpatient and outpatient care providers, mental health professionals, and substance use care providers, in developing a comprehensive care and support network.
• Embedding suicide care in the major organizations serving youth across the state.
• Raising levels of staff support and surveying staff members in mental health facilities on their readiness to provide effective suicide prevention care.
• Assisting organizations in creating effective management practices aimed at achieving Zero Suicides through team-based care.

In Zero Suicide approaches, suicide protocols should be incorporated within policies and procedures of healthcare facilities, and the suicide risk of all patients should be assessed. Suicide should be treated not as a symptom of a mental health disorder or substance abuse disorder but instead as a condition for which a patient receives direct treatment.

When a suicide risk is identified in patients, a safety plan should be developed and regularly reviewed to reduce the risk of death by suicide and to ensure patients are provided with necessary support.

Above all, clinical staff must be appropriately trained, must follow up with patients, and must ensure they are providing the level of care patients need to reduce risks.

Nationally-recognized suicide attorney Skip Simpson of the Law Offices of Skip Simpson has been appointed to the Board of Directors for the American Association of Suicidology, a non-profit organization devoted to educating the public about suicide and working to prevent future suicides.

“I am honored to be chosen to serve on the board for this important organization,” Simpson said. “I believe I can bring a wealth of knowledge to this charitable group about the legal implications of suicide, particularly for cases involving the wrongful death of someone by suicide. I also hope I can do my part for the American Association of Suicidology to bring more awareness to this extremely important issue.”

According to the American Association of Suicidology’s website, the “AAS is a charitable non-profit membership organization for all those involved in suicide prevention and intervention, or touched by suicide.  AAS is a leader in the advancement of scientific and programmatic efforts in suicide prevention through research, education and training, the development of standards and resources, and survivor support services.”

The AAS’s goals match attorney Simpson’s focus at the Law Offices of Skip Simpson. As an attorney, Simpson focuses on teaching suicide prevention and prosecuting suicide malpractice cases throughout the country.

Death by suicide remains one of the leading causes of death for certain age groups in the United States. Among young people 15 to 24 years old, suicide is the second leading cause of death, according to the AAS. Overall, an estimated 41,100 people of all ages die each year due to suicide, according to the AAS.

In most cases, more can be done to prevent suicides, according to Simpson. “Most people considering suicide give clear warning signs before they act on such thoughts,” Simpson said. “That’s why it’s critical that doctors properly diagnose someone seriously considering suicide. There’s no room error when it comes to such cases. That’s why I’m honored to work with families dealing with the loss of a loved one and proud to serve on the board of at the American Association of Suicidology.”

In 2014, a college student died by suicide following his first year at the University of Texas at Austin. Following his death, his parents began to advocate for legislation that would increase awareness of mental health resources on college campuses. College students are particularly vulnerable to the risk of suicidal ideation because they are often facing tremendous academic pressure and are away from family and support systems for the first time.

While colleges have counselors available, students may be unaware of the mental health services that can be provided to them. Counselors may also fail to notice signs of suicidal ideation among their patients, which can result in accusations of clinician malpractice. Protecting young people during a vulnerable time in their life is of the utmost importance and two new laws have passed that could make a substantial difference in saving lives.

A closer look at Texas college suicide rates

In Texas, suicide is the second leading cause of death for college-aged kids. Around a third of all college students in Texas are reportedly dealing with depression.

Senate Bill 1624 was championed by the parents of the University of Texas at Austin student who died by suicide. The Bill was signed into law and took effect recently. The law requires universities to provide students with information on suicide prevention services and mental health services during their orientation period.

The bill mandates the information be provided to students during either a live presentation or a video. The information may not be provided in paper form. The purpose of requiring a video is to ensure students actually receive the information. Dallas News reports the director of the Counseling and Mental Health Center at UT-Austin is making a video that schools statewide can use in order to fulfill the new legal requirement.

Senate Bill 1624 was one of two laws that recently took effect to try to reduce the risk of death by suicide among college students. The other law requires local universities create a web page providing information to students about how to contact the local health authority in the university community.

The purpose of the new laws is to make it easier for students to access information they need and to reach out for help.  The lawmaker who authored the legislation stated: “College students in particular are at an age or an environment [where it’s] even more difficult for them, to seek out help.”  Now, by providing the information at orientation and on an easy-to-access website, hopefully more students will reach out.

The strong push should be “zero suicide.” This concept is realistic—several organizations have drastically reduced suicides and others have reached the goal of zero.  If zero is not the right number, what is?

Once students do seek mental health services, it is up to counselors to recognize signs of suicidal ideation and to take action to help vulnerable students. The counselor may be the only source of support a student who is far from home has, and the counselor must live up to the professional obligation he has to provide appropriate care and take action to help stop an attempted suicide or a suicide.

A new school year is starting and kids will soon be heading back to college campuses nationwide. For many of these students, the new school year is not something to look forward to this fall. Instead, returning to college mean means a return to the tremendous pressures to be perfect in a competitive college setting. High expectations and intense stress to succeed often contribute to high rates of campus depression and suicidal thoughts among young people.

New York Times reported the rate of death by suicide among 15 to 24 year olds has steadily increased since 2007. And college students may be among the most vulnerable segment of society. A recent survey of college counseling centers found that more than half of clients seeking counseling have “severe psychological problems.” College students, who may have limited parental supervision and distant support networks while away at school, face an especially significant risk. College counselors may be the only ones who can determine when a student is considering death by suicide and the only ones available to take action to help the student. That’s why counselors and academic institutions may be held accountable when these warning signs are missed.

Warning signs are missed by clinicians because of lack of training on taking a systematic suicide assessment.  With training a clinician has no excuse for deciding not to take the time to properly assess and document the assessment.  If the student is at risk for suicide then appropriate interventions need to be taken to protect the patient.

College Students and Risks of Death by Suicide

In 2007, there were 9.6 deaths by suicide per 100,000 individuals age 15 to 24. In 2013, that figure had risen to 11.1 suicides per 100,000 individuals within the same demographic group. Among college students seeking counseling, chances a student would be diagnosed with a severe mental condition increased 13 percent over a period of just two years. Anxiety and depression are the two most common mental health diagnoses among college students.

Female students may be especially at risk of suffering from anxiety and depression because reports have shown many feel a pressure to be effortlessly and relentlessly perfect. This means not only excelling academically and in social endeavors, but also putting forth a persona of being happy and self-assured all the time.

Women afraid to fail may hide mental issues they are facing until it is too late for friends and family to help them. College counselors need to be trained to identify when a student is masking deep-seated depression or anxiety so they can provide the mental health assistance students need when coping with the very real pressures they face.

The Times notes there has been several high profile suicides among both college and high school students in recent years attributed to the culture of high expectations and overachievement. In just 13-months, six students from University of Pennsylvania died by suicide. Tulane University lost four students to death by suicide in a single academic year, and there were three deaths by suicide at Appalachian State. From 2009 to 2010, there were also six students at Cornell University who died by suicide. Most of these students appeared to have everything going for them, and were active in campus groups. However, many were likely responding to pressures to act self-assured and mask doubts they had about their futures.

As college students head back to campus this year, schools need to be aware of the toll of the pressure to be perfect can have on students. That’s why colleges and universities need to make sure students receive the support they need to deal with mental health issues before it’s too late.

A suicide attorney at the Law Offices of Skip Simpson can help. Call (214) 618-8222 or visit http://www.skipsimpson.com to schedule a free case consultation.