There is an interesting case in Detroit on the liability of hospitals for the actions of third parties — a case with striking similarities to the famous 1976 ruling in Tarasoff v. Regents of the University of California.
The Detroit case involves a woman murdered by her husband, Christopher Howard, 10 days after he was released by a Michigan hospital. The Sixth Circuit has ruled that the family of Marie Moses Irons can sue Providence Hospital under the Emergency Medical Treatment and Active Labor law requiring emergency treatment of patients by hospitals. The ruling by Judge Eric Clay (left) could have sweeping implications for hospitals across the country.
Writing for the majority, Judge Clay recognized that the ruling is likely to have seismic effects in the medical field: “We recognize that our interpretation … may have consequences for hospitals that Congress may or may not have considered or intended. However, our duty is only to read the statute as it is written.” The panel reversed U.S. District Judge Anna Diggs Taylor in her ruling in favor of the hospital
The facts are laid out by the Court suggest that a jury could find that this was an untreated emergency and link the failure to comply with the federal law factually and legally to the death. Indeed, the failure to perform a statutory duty is evidence of negligence per se. Here are the basic facts discussed by the Court:
On December 13, 2002, Moses-Irons took Howard to the emergency room of Providence Hospital in Southfield, Michigan because Howard was exhibiting signs of illness. Howard’s physical symptoms included severe headaches, muscle soreness, high blood pressure and vomiting. Howard was also experiencing slurred speech, disorientation, hallucinations and delusions. Moses-Irons reported these symptoms to the emergency room staff, and also informed them that Howard had “demonstrated threatening behavior, which made her fearful for her safety.” (Joint Appendix (“J.A.”) at 31-32.) The emergency room physicians decided to admit Howard to conduct more tests. Among the physicians who evaluated Howard during his stay at the hospital were
Mark Silverman (“Dr. Silverman”), a neurologist; Dr. Lessem, a psychiatrist; and Djeneba Mitchell (“Dr. Mitchell”), an internist. Dr. Silverman examined Howard on December 14, 2002. Dr. Silverman determined that Howard “was acting inappropriately” and “appeared to be somewhat obtunded,” but had “no overt outward signs of trauma.” (J.A. at 153.) In addition to informing Dr. Silverman of Howard’s symptoms, Moses-Irons also told him that Howard had told her that he “had bought caskets.” (J.A. at 150.) Dr. Silverman learned from Moses-Irons that Howard had recently tried to board a plane with a hunting knife. Dr. Silverman ordered a magnetic resonance imaging exam, though it is unclear from the record whether the exam ever took place. Dr. Silverman also “felt that a psychiatric evaluation would be warranted,” as well as a “lumbar puncture.” (J.A. at 154, 158.) His notes from the evaluation indicate his belief that “an acute psychotic episode [must] be ruled out.” (J.A. at 153, 158.) Dr. Lessem examined Howard several times during Howard’s stay at the hospital.On December 17, 2002, Dr. Lessem determined that Howard was not “medically stable from a psychiatric standpoint,” and decided that Howard should be transferred to the hospital’s psychiatric unit called “4 [E]ast” to “reassess him.” (J.A. at 165.) According to Dr. Lessem, 4 East is intended for patients “who are expected to be hospitalized and stabilized and who are acutely mentally ill.” (J.A. at 165.) Dr. Lessem felt Howard could be more closely observed at 4 East, and planned to conduct “reality testing” of Howard there to determine the extent of Howard’s delusions. (J.A. at 168.) Dr. Lessem’s order notes from December 17, 2002 state, “will accept [patient] to 4 [E]ast if [patient]’s insurance will accept criteria” and “please observe carefully for any indications of suicidal ideation or behavior.” (J.A. at 172.) Under the heading “orders for 4 [E]ast,” Dr. Lessem wrote, “suicide precautions.” (J.A. at 173.) The notes also indicate that Dr. Lessem believed Howard had an “atypical psychosis” and “depression.” (J.A. at 172.)
Howard was never transferred to the psychiatric unit, and instead was informed on December 18, 2002 that he would be released. A hospital clinical progress report signed by Dr. Mitchell that daystated that “[patient] declines 4 [E]ast, wants to go home. His affect is brighter. No physical symptoms now. [Patient] wishes to go home, wife fears him. Denies any suicidality.” (J.A. at 219.) Howard stated in a deposition that he never declined going to 4 East. In Howard’s discharge summary form filled out onDecember 18, 2002, the hospital’s “final diagnosis” of Howard, written by a resident, was that he had a “migraine headache” and an “atypical psychosis [with] delusional disorder.” (J.A. at 178.) A report dated December 19, 2002, signed by Dr. Mitchell, indicated that Howard would be “[discharged] home today . . . cannot stay as he is
medically stable and now does not need 4E.” (J.A. at 89.) Howard was released on December 19, 2002, and on December 29, 2002, Howard murdered Moses-Irons.
Howard killed his wife while she and their two-year-old son slept.
The case obviously draws instant comparison with the Tarasoff opinion. In that seminal 1974 case, Prosinjit Podder, an Indian Graduate student at Berkeley, fell in love with Tatiana Tarasoff. When she stated that she wanted to date other men, Podder went to counseling at the University Health Service and is treated by psychologist, Dr. Lawrence Moore. When he told Moore that he wanted to get a gun and kill Tarasoff, Moore sent a letter to campus police who interviewed Podder and decided that he was not a risk. Podder then went ahead and murdered Tarasoff.
In a controversial decision, Justice Mathew O. Tobriner held that “… the confidential character of patient-psychotherapist communications must yield to the extent that disclosure is essential to avert danger to others. The protective privilege ends where the public peril begins.” As a result, the hospital was held liable for the criminal actions of a third party — something that usually (but not always) cuts off proximate causation. It also rejects strong arguments made by doctors that such liability would create a chilling affect on counseling. A large number of patients often express their anger by focusing it on individuals and stating an intent to “kill that guy.” In the vast majority of such cases, the open disclosure is addressed and defused. However, if the patient knows that the doctor will have to tell authorities, such feelings are less likely to be expressed and addressed.
Picture of Tarasoff: 
For the Sixth Circuit decision, click here.
FYI, responding to Bron98’s comment, it pays to know the facts of the underlying case. The victim, Marie Moses Irons, in the underlying case did not just sit around waiting to determine whether her husband was crazy. She obtained a restraining order and removed him from the home, changed the locks and the police escorted the husband through the house upon his release to remove his belongings. The husband, unknown to the police, unlocked a basement window, and in the middle of the night, sneaked into the house and cut off Marie’s head with an ax while the couple’s toddler was asleep nearby. She did what she was supposed to do. It appears that the hospital was negligent in the excise of its duty.
Mespo/MikeA:
“So if we had government funded medicine there would be no case? I am no longer worried about whether there will be nationalized health care. Lawyers will not let it happen. Thank God for lawyers.”
I said that somewhat tongue in cheek, I have to get in what few licks I can.
Bron, BTW, the issue of liability under universal health care will provide for some very lively and interesting debate. Given the attitude toward med mal lawyers generated by years of advertising by the insurance industry and physician groups, I seriously doubt whether plaintiff’s lawyers will be cut any slack in what finally emerges. I am not a personal injury lawyer, however, and there are probably others who contribute here with better insight on that subject.
Bron, there are different statutes of limitation for different classes of claims. I suspect that this case was governed by a two-year professional negligence statute based on the timing of the filing. That is not unreasonable given the pre-suit requirements most states have adopted for medical malpractice claims. They typically include a requirement that the prospective patient obtain a written opinion from a qualified physician that the treatment at issue failed to comply with the standard of care in that jurisdiction. In addition, many statutes require pre-suit mediation.
I am confident the defense will raise all available defenses once it has to respond to the case on its merits. If the spouse did anything, or failed to do something, which increased the risk of injury to herself, that could be asserted as part of a contributory or comparative negligence defense. You may rest assured that the physicians and the hospital will not leave a stone unturned.
Bron98:
Even the most conservative lawyer would not argue that national health care would necessarily imply immunity from suit by health care providers. The law has always recognized some immunities arising from such things as an absence of a profit motive such as charitable immunity, or a desire to keep intact the family unit (you guessed intra-family tort immunity) or to insulate drivers from their guests (host immunity). Sovereign immunity was premised on the notion that the “king (or queen) can do no wrong,” (sort of the Bush attitude before there was a Bush) but was also defended on protecting the treasury. National health care won’t immunize corporate health care providers since they will still be in it for the profit–just not the exorbitant profits as is now the case.
http://www.pnhp.org/facts/single_payer_resources.php
MikeA:
I was curious about the time frame for the actual incident. How long after the hospital released the guy could they reasonably be held liable for his actions?
Dosent the wife have some responsibility? If my husband was threating me I would not hang around to see if he was sane or not, no matter what the doctors said. Although I dont have a very high opinion of the medical profession in general but there are some very good doctors and they need to be treated like gold.
Mespo:
“In this age of for-profit health care, to whom much is given much is expected.”
So if we had government funded medicine there would be no case? I am no longer worried about whether there will be nationalized health care. Lawyers will not let it happen. Thank God for lawyers.
Great point marie. The specialists usually are independent contractors so the hospital staff physicians get to make the calls on discharge. Caveat stupid!
Mike Appleton:
Like you, I think the statutory wording speaks for itself. I am amazed at the lengths these judges take to say, “Now, now, we are not making new law just enforcing the statute.” Hell judges make new law every day, and only the naive think otherwise. That’s why they are the third branch of government and not some bureaucrat (no offense to them either–they have saved the Republic twice by my count) robotically applying rules made by someone else. At least with this branch you can appeal and appeal. Try that with your local Congressman when he disagrees with you.
The problem seems to be that the specialist in this case, the psychiatrist, wanted the patient to be kept in the hospital for further observation and testing and this specialist was apparently overruled by an internist and a resident. If this hospital is so set up as to ignore its own specialists in favor of the opinions of comparatively unqualified doctors, then it is not surprising that that hospital’s policies and practices should be examined in this suit.
mespo, I read the opinion and I agree with you that there is nothing radical about the decision. The real dispute wasn’t over the causal relationship, but standing. The defense argued that the language of the statute should be construed to limit liability only to the patient, but the statute refers to “any individual” injured as a direct result of a breach of a statutory duty. The suit also included a common law negigence count. Had the summary judgment been upheld, the case would have been shipped to the state courts for further proceedings in any event. I expect there will now be efforts in Congress to amend EMTALA.
Bron, the case was filed less than two years after the incident, so there wasn’t an inordinate delay in pursuing it.
“As a result, the hospital was held liable for the criminal actions of a third party — something that usually (but not always) cuts off proximate causation.”
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I might say it slightly differently by holding that the hospital is liable for the harm resulting from the criminal acts of the third party (and along with the third party assuming he met the relatively low standard of M’Naghton’s Case ) that was reasonable foreseeable and likely to occur, coupled with the fact the hospital was in the best position to warn the public. I find it a logical extension of the duty the hospital owes to the public at large. May a medical provider, with superior and foreseeable knowledge of the harm a mental patient is likely to commit, release that patient on an unsuspecting family member that is the object of that patient’s ire, or a the public at large? I think a balancing test is in order and the standard for imposing liability should be relatively high given the inability of anyone to predict behavior. That said, there exists a special duty arising from the privilege the public grants to health care providers (including hospitals) to operate and that should be enforced at law. I would come down squarely on the side of the plaintiff be it controversial or not. I prefer to call the decision evolutionary rather than revolutionary. In this age of for-profit health care, to whom much is given much is expected.
My question is, was the guy a mental patient? He was not put on 4 east for observation.
How long can you extend the period for which the hospital is at fault.
It appears to be a case of residents screwing up yet again.
Is this a good opinion?