A Suicide Spurs Questions About What Hospitals Should Do

Brian Dunivan overdosed on alcohol and Klonopin in May 2016 but did not manage to take his life. He wound up in the hospital instead.

There, however, he broke out his window and fell to his death.

Dunivan’s parents laid out those events in a lawsuit suing the facility, Northside Hospital, for not taking adequate measures to prevent his death. Northside’s response in court denied negligence and said it complied with the standard of care in all respects. Citing ongoing litigation, the hospital declined to discuss the case with The Atlanta Journal-Constitution.

But in an age of rising suicides, the lawsuit raises questions about general medicine’s approach to mental health: Are institutions sufficiently inclined to see mental illness as a treatable health risk and act accordingly? And what do they owe patients who seem determined to defeat their efforts?

“It simply is an issue that has to be addressed by facilities,” said John Snook, the executive director of the Treatment Advocacy Center. “It’s like not being ready for heart attacks if you’re a cardiac center. It’s part of the illness.”

A sixth-floor window

Dunivan had a history of psychiatric problems. But like most patients, when he quelled his pain with chemicals, he had to go first to a general care hospital.

He arrived at Northside at about 2 a.m. May 7, and he was promptly placed on a psychiatric hold signed by a doctor. Another doctor admitted Dunivan to the medical floor, where he was kept under observation by a woman contracted to sit with him.

The next day, a counselor who specializes in depression and anxiety assessed him. According to the lawsuit, she noted that Dunivan had undergone four psychiatric hospitalizations and had a history of cutting himself to cope with emotional distress. She added that he was experiencing paranoia, the suit says, with a belief that he was being followed.

What apparently did not happen is the subject of the parents’ legal complaint. The lawsuit says the sitter or observer Northside provided was not able to physically restrain the 24-year-old man; that he was not administered appropriate antipsychotic medication; and, the lawsuit alleges, that Northside “failed to have a policy or procedure in place to allow a physician to be notified regarding a patient expressing paranoia,” leading to the lack of medication.

The family’s lawsuit has just been filed, and the story it tells is not complete.

The state Department of Community Health simply asks that hospitals have a plan to deal with suicidal patients. Northside declined to provide its general plan for suicidal patients for this story, saying it was proprietary and confidential. The hospital, created by a public health authority, recently lost an argument in the Georgia Supreme Court over whether its documents are subject to the state’s Open Records Act, but the litigation is ongoing.

Evening set on the day of Dunivan’s assessment, but he never saw dawn. In the middle of the night, just before 3 a.m., emergency calls came in to Sandy Springs police.

Police were told that Dunivan had “suddenly” jumped out of bed and grabbed the blood pressure cart. He broke out the window, then jumped. The emergency responder log said a nurse had tried to prevent him and had been injured.

By the time medical personnel reached Dunivan, he was dead.

A growing problem

A recent report by the Atlanta-based U.S. Centers for Disease Control and Prevention made waves recently with news that suicides have risen 30 percent nationwide since 2000. But patients who are known to be seriously mentally ill don’t just go to psychiatric hospitals; and even if they wanted to, there is a shortage of beds and trained workers. County jails have been called the nation’s largest psychiatric facilities. Experts say the vast delta in mental health between starting to get sick and winding up in crisis is not well recognized or addressed.

Dr. David Baker, the executive vice president of health care quality evaluation for the organization that accredits U.S. hospitals, the Joint Commission, said hospitals need to see mental health as just as important to their mission as any other branch of medicine.

A 2015 report by the American College of Emergency Physicians found that 8 percent of all adult patients in emergency rooms, regardless of why they show up, have recently had suicidal thoughts or behaviors.

“We have been slow” to address suicide as a public health issue like cardiac or nerve problems, said Roland Behm, the chairman of Georgia’s chapter of the American Foundation for Suicide Prevention. “The hospital has to be sure they are in a position of being able to address the individuals who come in seeking treatment. They take in individuals who are suicidal just like individuals who were in car wrecks or had heart attacks; they need to be able to address the needs of those individuals.”

No one keeps track of all suicides in hospitals or other health care facilities, said Baker of the Joint Commission. “There has never been a rigorous systematic analysis,” he said, though he and his colleagues are about to publish one.

“The patient doesn’t want to thwart you,” Baker said. “The patient’s goal is not to hurt the hospital. The patient’s goal, as sad as it is, is to end their suffering. And we need to do everything that we possibly can to eliminate suicides everywhere, but particularly in health care settings.”

The Joint Commission’s best estimates previously have been that about 80 hospital patients a year commit suicide.

The vast majority of in-hospital suicides are hangings or asphyxiations, Baker said. An expert panel convened by the Joint Commission last year recommended myriad ways to strengthen a hospital room, including looking for places a patient can hang a ligature. In addition, trained staff, including active one-on-one monitors, are key.

Skip Simpson, a Texas lawyer who has both sued hospitals and trained doctors on how to avoid malpractice liability, lays blame at the feet of a hospital that doesn’t do what it can to prevent death — such as suggestions by experts for shatter-proof glass for suicidal patients’ windows.

“They’re going to be thinking of every way they can to kill themselves,” Simpson said. “What the risk manager needs to do is lay in a bed and think of all the ways they could.”

The key is to realize that suicide is not an inevitable consequence of illnesses like depression, Baker said. Mental illness symptoms are treatable and can be conquered.

“The vast majority of people who attempt suicide and survive do not die of suicide,” Baker said. “That is the good news in this. We are able to treat these people and get them to be able to get restored at least, so they have the quality of life that allows them to keep on living.”