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When Failed Mental Health Assessments End in Tragedy

Sufficient access to care helps individuals with mental health challenges proactively manage their conditions, which can lead to positive long-term health outcomes. But given lingering social stigmas and scarcity of services, those with mental health impairment tend to be complex patients, which may convolute delivery of services. This Case of the Month highlights the unfortunate scenario when a patient with mental health issues fell through the cracks within the healthcare system.¹

On January 6, 2015, a 22-year-old male patient was brought into a New York hospital’s ED for an evaluation after he reportedly attacked his uncle and beat the family dog. The patient’s family members and friends reported that the patient began exhibiting signs of a mental break that day. According to the doctors, the patient believed himself to be the god of war, and that a world war was coming. Among many other delusions, he was also convinced that the government was spying on him through electronics, and that the local sanitation employees were going to kill him. The patient was released from the ED the same day. Several hours after being released, police reported he killed his adoptive mother, uncle, and stepsister.

According to the evidence, the patient stabbed his stepsister 178 times and ultimately beheaded her, stabbed his adoptive mother 187 times, and stabbed his uncle 40 times. When police arrived at the residence, they found the bodies mutilated. A dagger-like weapon with a bent blade and a glass nativity set was found on the uncle's stomach because the patient said he thought it would get rid of the devil. Mirrors had been placed around the bodies “because [he] thought the devil couldn't see in the mirror.”²

The patient was charged with the murders of his three family members. In the criminal court proceeding, the patient’s plea that he was not responsible for the crimes by reason of mental illness at the time he killed his family members was accepted by the criminal court. Subsequently, the patient filed a civil action against the hospital, the emergency physician group (“ED group”), and other parties for negligence and medical malpractice. He alleged that the treating physician, who was a member of the ED group, failed to perform a proper psychiatric examination and failed to diagnose and treat the patient's acute mental illness, ongoing psychiatric condition, and violent propensities. He also alleged the physician, with other members of the healthcare team, caused him to be discharged the same day of the murders. It was noted that police asked to be alerted of the patient’s discharge, but were not notified of the patient’s release. The patient sought compensatory damages due to the psychological trauma he experienced after committing the murders, his loss of freedom, and the stigma of a psychiatric admission.

The ED group filed a motion to dismiss the lawsuit, arguing that under New York state case law a plaintiff may not take advantage of their own serious violation of the law by basing a claim on the direct results of that wrong. The ED group contended the patient was attempting to do just that. The trial court denied the motion and the ED group appealed the ruling.

Ultimately, the appellate court affirmed the trial court’s denial of the ED group’s motion to dismiss. (Bumbolo v. Faxton St. Luke’s Healthcare, 196 A.D.3d 1119 [N.Y. App. Div. July 16, 2021]). The basis of this decision was that by accepting the patient’s pleas, the criminal court upheld that the patient lacked substantial capacity to understand and recognize the nature and outcomes of his conduct. Since the patient was found to lack criminal responsibility by reason of mental disease, he lacked substantial capacity to know or appreciate the nature and consequences of his conduct or that his conduct was wrong.¹

Outside of the criminal and civil cases, state inspectors on behalf of the Centers for Medicare and Medicaid Services completed an inspection of the hospital in response to an unspecified complaint. The inspectors reviewed medical records of patients with potential psychiatric conditions and found several inadequacies in the ED records for its handling of six of eight patients. Three of the patients did not receive mental health evaluations by a licensed clinical social worker, and two patients were released. According to their report, “The facility failed to ensure ED services were provided in accordance with generally accepted standards.” It was also observed that the hospital did not have a written policy and procedure for performing suicidal and/or homicidal assessments.³

Healthcare organizations and professionals need to assess their current strengths and opportunities for improvement in addressing the behavioral health needs of patients, especially when providing adequate mental health assessments and medical clearance for discharge. This can be done by evaluating patient flow within the health system and collaborating with behavioral health providers to map available resources, identify opportunities, and facilitate coordinated care. It is important for the organization to define the necessary competencies for staff members who directly interact with patients with behavioral health needs, identify any gaps in those competencies, and provide training to bridge those gaps. Additionally, the organization should establish protocols, care plans, or other tools to handle specific patient situations. An organization's plans and protocols should consider interactions with law enforcement, intake, admission, evaluation, treatment, response to escalating needs, and care coordination. The processes and tools used to assess behavioral health needs should be tailored to the patient population and the specific unit. Furthermore, healthcare organizations should consider expanding behavioral health support in nonpsychiatric acute care units, emergency departments, and other outpatient settings.1,4,5

While it is true that even the best emergency psychiatric care can only estimate risk, and not predict violence, physicians play a vital role in the safe and comprehensive care of patients requiring admission for psychiatric services.   

Monica Ludwick is a Senior Risk & Patient Safety Specialist. Questions or comments related to this article should be directed to



¹Patient Who Killed Three Family Members May Sue Emergency Physician Group That Discharged Him. Emergency Care Research Institute (ECRI). /hrcalerts011222_patient/. Accessed 8/20/2023.

²Thomas, Cara. "Doctors: Utica Murder Suspect Suffered Psychiatric Break Night of Stabbings." December 1, 2015.…. Accessed 8/15/2023.

³Thrasher TW, Rolli M, Redwood RS, Peterson MJ, Schneider J, Maurer L, Repplinger MD. 'Medical Clearance' of Patients With Acute Mental Health Needs in the Emergency Department: A Literature Review and Practice Recommendations. WMJ. 2019 Dec;118(4):156-163. PMID: 31978283; PMCID: PMC7215859. Accessed 8/22/2023.

4Coombs NC, Meriwether WE, Caringi J, Newcomer SR. Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study. SSM Popul Health. 2021 Jun 15;15:100847. doi: 10.1016/j.ssmph.2021.100847. PMID: 34179332; PMCID: PMC8214217. Accessed 8/15/2023.

5Hospital Inspection Report: Faxton-St. Luke’s Healthcare. January 12, 2015. Accessed 8/22/2023