Unmonitored suicidal man suffocates himself
Tarrant County (TX) District Court
A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.
For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.
The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.
At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.
- A settlement of $1.1 million was reached.
Dr. Grant’s observations
Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective7 and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.7 Frequently document the patient’s location, activities, and behavior.
To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.8 For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.