News: The Georgia Court of Appeals recently upheld a trial court’s decision granting summary judgment to the defendants in a medical malpractice suit following the accidental drowning death of a patient after he was discharged from the hospital. The patient, diagnosed with multiple mental health disorders, was discharged from emergency mental healthcare by physicians at the defendant hospital. Three days after discharge, he was discovered to have died from accidental drowning in a nearby lake.
The plaintiffs, his parents, sued the hospital and physicians for medical negligence. They alleged that the hospital and its staff were at fault for failing to reassess the decedent’s mental health condition on the day of discharge and that this failure led to his accidental drowning. However, the trial court found — and the appeals court agreed — that the alleged negligence in discharging the patient was not the proximate cause of his death, emphasizing the remoteness of the discharge from the subsequent drowning and the lack of evidence tying the defendants’ actions directly to the outcome.
Background: The patient, who suffered from schizophrenia, bipolar disorder, and oppositional defiance disorder, was found dead from accidental drowning. The patient had stopped taking his medication before a family trip, leading to a deterioration in his mental state. This culminated in a series of events where the patient was eventually admitted to a hospital in Augusta, GA, for psychiatric evaluation. His death occurred shortly after his discharge from emergency mental healthcare provided by several physicians at the hospital.
During his hospital stay, the patient exhibited signs of acute psychosis, leading to an involuntary hold. Despite attempts to secure inpatient treatment, logistical challenges prevented his admission to a facility. One physician, in consultation with a counselor and another emergency physician, decided to discharge the patient into his parents’ care, believing he posed no danger to himself or others. This decision was based on their assessment of the patient’s condition at the time, including his cooperation and alertness, and the difficulty in securing inpatient care across state lines due to residency and insurance complications.
The decision to discharge him was contested by his parents only after his death. They filed a medical malpractice suit, arguing that the defendants were negligent in discharging him without a final reassessment. The parents supported their claim with expert testimony that the patient’s ongoing psychosis made him incapable of self-care.
The defendants moved for summary judgment, arguing there was no proximate cause linking their alleged negligence to the patient’s death. Proximate cause requires that the defendant’s actions are connected closely enough to the plaintiff’s injury to justify holding the defendant liable. The defendants argued that the remoteness of the patient’s discharge from his death, combined with the absence of direct evidence linking the discharge to the drowning, broke the chain of causation.
The trial court agreed, finding that as a matter of law, the record merely established “but for” causation or “cause in fact.” However, the court found that the record did not demonstrate that releasing him proximately caused this outcome. It found that there was no expert testimony or other evidence in the record that explained what caused the patient’s drowning death. The plaintiffs’ experts also conceded that they lacked sufficient information to form any specific conclusion about what caused the patient to drown. Without establishing proximate causation, the parents could not prove an essential element of their negligence case. The appellate court affirmed the trial court’s summary judgment in favor of the defendants.
What this means for you: Every medical negligence requires a plaintiff to prove four elements:
- the defendants owed a duty to the plaintiff;
- the defendants breached that duty by failing to meet the recognized standard of care in their profession;
- the breach of that duty to the plaintiff caused plaintiff’s injury;
- the plaintiff was harmed.
As to the causation element, courts apply a two-part analysis. The first part, as the appellate court in this case noted, is called “but for” causation. Would the plaintiff have suffered an injury but for the defendant’s action or inaction? To establish causation, the answer to this question must be “no,” as it was here. The decedent in this case would not have drowned if the defendant physicians had not discharged him from the hospital. Or, in other words, “but for” the patient’s discharge, the plaintiff would not have been injured. However, “but for” causation is only the first part of the causation analysis.
The second part of the causation analysis is called “proximate cause.” Proximate cause requires that the defendant’s actions or inactions are connected closely enough to the plaintiff’s injury to justify holding the defendant liable. Proximate cause requires a closer look at whether the breach of duty was the primary cause of the defendant’s injury. If it is not, then the defendant cannot be liable for negligence. A defendant may argue, as they did in this case, that the “chain of causation” was broken by the acts of an intermediary and that there is no proximate cause. Here, the defendants argued that after the patient fled the hospital, a deputy encountered him trespassing, yet the deputy failed to detain the patient. The deputy’s actions were an intervening cause and broke the “chain of causation” between the hospital discharging the patient and the patient drowning.
The defendants also argued that the chain of causation was broken by both the remoteness in time and space between the patient’s discharge and his subsequent death. Especially in cases where the injury may occur several days after the defendant’s actions, the defendant may argue that the “remoteness in time and space” serves essentially as an intervening cause, breaking the chain of causation. At least in cases such as this, where the plaintiff claims that the hospital wrongfully or precipitously discharged a patient, the more time that passes from the alleged breach of the hospital’s duty, the more difficult it can be to show that the breach proximately caused the injury.
In medical malpractice cases, expert testimony on causation is required. In this case, the plaintiffs presented two experts to testify that the hospital discharging the patient led to his demise days later. However, the court found that this expert testimony established nothing more than “but for” causation, not proximate causation. Even with their status as experts, the court found their testimony lacking enough that it refused to let the issue of causation be determined by a jury, despite that it is commonplace for judges to allow juries to determine whether causation existed. To that end, practitioners should be aware that retaining an expert and getting that expert’s testimony occasionally is not enough to get the issue in front of a jury. Judges still serve as the gatekeepers of what the jury sees.
From a practical perspective, the court’s ruling underscores the importance of comprehensive discharge planning for providers, especially for patients with significant mental health challenges. While the defendants believed that discharging the patient to his parents was the best option under the circumstances, and despite that the parents of the patient also requested the discharge, the tragic outcome highlights the potential risks involved in discharging mentally ill patients without secure follow-up care or reassessments on the day of discharge. Although the plaintiffs were not successful in holding the physicians liable, the case still made it to summary judgment, with an appeal following.
The ruling also demonstrates that not all unfortunate outcomes are attributable to medical negligence. The court acknowledged the tragic nature of the patient’s death, with sympathy for the patient’s parents. But it also made clear that legal liability requires more than a temporal sequence of events. It emphasized the need for specific evidence that directly links a defendant’s actions to the harm suffered. That was lacking here, even with expert witnesses.
Dealing with mental health patients has challenged hospitals in general and emergency physicians in particular. Despite their best intentions, there is no possibility of getting inpatient psychiatric care for most of those who desperately need it. Funding has all but disappeared, and while some states are trying desperately to build up existing or find new resources for funding inpatient care, there are no new paths to explore. The public myth is that it is just too expensive to hospitalize mental health patients, there are not enough hospital beds, and patients can just take a few pills every day to get well. These unfortunate misconceptions are obstacles to change and an open invitation to tragic outcomes.
REFERENCE
- Decided March 14, 2024, in the Court of Appeals of Georgia, Case Number A23A1715.
The Georgia Court of Appeals recently upheld a trial court’s decision granting summary judgment to the defendants in a medical malpractice suit following the accidental drowning death of a patient after he was discharged from the hospital.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content