The medicolegal implications of the suicidal patient in psychiatric practice

Each year, over 5,000 people in the UK die by suicide. However, it is very likely that this figure underestimates the true picture. While women attempt suicide more frequently than men, men are more likely to be successful. Suicide may be precipitated by a number of factors, including illness, which is not necessarily psychiatric in nature; loss of social support leading to isolation; relationship breakdown; economic catastrophe; and underlying personality traits. 

The loss of a family member by suicide is often extremely traumatic for those left behind and litigation in these circumstances is very common. Around 50% of families have considered consulting a lawyer following the suicide of a loved one, and 25% have actually done so. Should a lawsuit be successful, financial settlements can be substantial. However, as with every medicolegal case, it is necessary to prove that the treating psychiatrist and/or hospital staff were negligent and it was this negligence that led to the patient’s death. 

The reasons cited for pursuing a claim for medical negligence following a patient suicide differ slightly depending on whether the suicide took place in a hospital or outpatient setting.

Issues relating to suicide in a hospital setting

In hospital situations, the key management points are an assessment of suicide potential at the time of admission, the precautions taken or systems used to minimise suicide attempts while an inpatient, and any changes made in the management of the patient in accordance with their perceived suicide risk. The usual accusations are that the psychiatrist failed to use appropriate clinical judgement or to conform to appropriate medical practice, while the hospital staff may be charged with failure to carry out medical orders, not following hospital policy or not reporting significant events to the medical staff. 

Issues relating to outpatient suicide

Common allegations following an outpatient suicide include failure to adequately assess the patient’s mental state and evaluate for suicide risk, correctly diagnose the patient’s symptoms, establish a formal treatment plan, properly evaluate the need for psychological or pharmacological intervention, maintain adequate observation and supervision of the patient, or to initiate hospitalisation if necessary. 

The challenge of determining mode of death

Before a lawsuit can be launched, it must be established that the patient’s death really was suicide. Therefore, as well as determining the cause of death, the mode of death, which relates specifically to the patient’s state of mind at the time of their demise, must be investigated. In the absence of a note, the motive of suicide can be difficult to prove. In some circumstances, including cases involving hanging or firearms, the intent is clear but this is often less true for scenarios such as single car accidents, falls and cases involving alcohol or drugs. Thus, distinguishing between suicide, accident, homicide or natural causes presents a challenge. 

In this respect, a psychological autopsy can be helpful in determining the mode of death. This procedure attempts to determine the state of mind of the patient at the time of their death through in-depth interviews with family and friends and close scrutiny of relevant records, including medical and employment records, personal journals and computer hard drives, and legal documents, such as wills and life insurance policies. In this way, a picture of the patient’s own and family psychiatric history, personality and lifestyle characteristics, recent stressors or conflicts and the patient’s reaction to them, quality of interpersonal relationships and plans for the future can be built up, and an overall assessment of suicidal intention can be made. 

A criticism of the psychological autopsy procedure is that it lacks reliability and validity. To address these concerns, the Empirical Criteria for Determination of Suicide screening instrument has been developed to directly assess the patient’s mental state at the time of their death. It assesses the pathological, toxicological, investigatory and psychological evidence indicative of self-inflicted death and has proved to be remarkably accurate at distinguishing between a suicide and an accident. 

Conclusion

Clearly, litigation could be avoided entirely if every suicide could be prevented. In reality, this is almost impossible to achieve. Many patients who die by suicide are successful on their first attempt, and many have not expressed any suicidal ideation or sought any type of psychiatric help before they die. Therefore, even if all those who have previously attempted suicide could be prevented from doing so again, many suicides would still occur. Attempts to develop screening tools to identify those at risk of suicide have proved unsuccessful. Most lack both sensitivity and specificity, meaning that the rates of both false-positive and false-negative results are high. Furthermore, without the correct resources in place, patients with positive screening results will remain untreated. During their career, around half of psychiatrists will lose a patient to suicide and there is a high chance that litigation will follow. In order to successfully defend a case, the defendant must show that they provided adequate, rather than perfect, care. Thus, comprehensive medical records, precise documentation of every decision taken, particularly those involving patient privileges, and adherence to clear hospital policies and procedures are vital. The best strategy is prevention but this is difficult to achieve as no universal screening tool exists. In addition, psychiatrists should be particularly careful when encountering patients who do not fit the typical profile not to dismiss the risk of suicide completely.