Learning from cases of malpractice in psychiatry
Although the relationship between patient and care provider, such as psychiatrist, psychologist, psychiatric nurse or clinician is never intended to be anything but helpful, caring and hopefully healing, malpractice claims can be the undesirable end of this relationship.
A recent study investigated the lawsuits or medical board discipline of psychiatrists over almost 20 years, and discovered that psychiatrists are at increased risk of disciplinary actions, compared to other medical professions(1). It was however noted that most cases reach out of court settlements, and that psychiatric claims in total still only account for a small percentage of malpractice claims.
An interesting conclusion from this study was the fact that female board certified and newly practicing psychiatrists were at lower risk of board discipline than their colleagues.
One of the biggest controversies between professional psychiatric bodies and claimants (as well as the legislation) is the misperception that suicide is predictable, and therefore it should be possible for a psychiatric care provider to prevent it(2).
However, in contrast to a possible knowledge-based assessment of suicide risk and appropriate treatment of underlying psychological disorders, the ultimate choice and responsibility lies with the patient, unless there was a breach of duty of care.
A related lawsuit case against a consultant psychiatrist was filed last year, which led to a settlement between the claimant and the NHS Foundation Trust(3). The claimants were the parents of young man suffering from schizophrenia, whose medication was abruptly changed by a new consultant, leading to panic attacks, hallucinations and ultimate suicide.
In this case the psychiatrist in charge was found liable of medical negligence and clear breach of his duty of care by not following the NICE guidelines.
These clearly state that change of medication must be undertaken gradually following risk assessments, and should be continuously monitored for tolerance and effectiveness. Thus, in the background of disorders with suicidal associations, medical negligence can be fatal. This has been shown on a grander scale in the US by rulings against Pfizer, the manufacturer of the epilepsy drugs Lyrica and Neurontin.
Both drugs have been marketed for off-label uses, from pain relief to bipolar disorder, without added warnings about the potential side-effect of inducing suicidal thoughts and behaviours. Pfizer has so far pleaded guilty to misbranding, and has been ordered by the FDA to add warnings to the labels, but faces further lawsuits claiming the company knew that the agents pose a suicide risk(4).
Common injuries to psychiatric patients can include common medical mistakes such as misdiagnosis or false treatment, or failure of appropriate assessment of patient needs. More specific claims have been filed due to inappropriate restraint or premature discharge into the community.
In Lake County (IL, US) a case has been filed against the psychiatrist treating a patient with major depression, after he recommended voluntary admission to the psychiatric unit, but retreated the recommendations later, and the patient shot himself shortly after(5).
Ultimately, it lies with the claimant to prove that the healthcare provider has failed to meet the standard of care and to establish that this negligence has caused or contributed to the injuries alleged.
In addition, psychiatrists also have a duty of care towards third parties, if any relationship exists between them and the third party, if it is reasonably foreseeable that the third party could be endangered due to medical negligence of the practitioner.
In a pioneering case, the sister of Gilbert Kopernik-Steckel received compensation for loss of a future career after her brother, who had admitted himself to a psychiatric hospital days before the event but was not detained, killed his mother and himself in front of his sister(3).
The NHS Trust was found negligent in the care of the patient as well as of the third party. In conclusion, the above average risk of malpractice suits observed for mental health professionals is based on potential misperceptions about suicide risk and preventative care, as well as on additional duty of care towards third parties.
1 Reich JH and Maldonado J. Empirical findings on legal difficulties among practicing psychiatrists. Ann Clin Psychiatry. 2011 Nov;23(4):297-307.
2 Ho AO. Suicide: rationality and responsibility for life. Can J Psychiatry. 2014 Mar;59(3):141-7.
5 http://www.currentpsychiatry.com/the-publication/past-issue-single-view/liability-in-patient- suicide/0aca64944eb34e9314d1ee5300a3fe00.html