Opinion
No. COA15-1087
05-17-2016
IN THE MATTER OF: E.B.
Attorney General Roy Cooper, by Assistant Attorney General Josephine N. Tetteh, for the State. Parker Poe Adams & Bernstein LLP, by Matthew W. Wolfe, for Petitioner Holly Hill Hospital. Appellate Defender Glenn Gerding, by Assistant Appellate Defender Nicholas C. Woomer-Deters, for Respondent.
An unpublished opinion of the North Carolina Court of Appeals does not constitute controlling legal authority. Citation is disfavored, but may be permitted in accordance with the provisions of Rule 30(e)(3) of the North Carolina Rules of Appellate Procedure. Wake County, No. 15 SPC 0155 Appeal by Respondent from order entered 2 February 2015 by Judge Vince Rozier in Wake County District Court. Heard in the Court of Appeals 11 February 2016. Attorney General Roy Cooper, by Assistant Attorney General Josephine N. Tetteh, for the State. Parker Poe Adams & Bernstein LLP, by Matthew W. Wolfe, for Petitioner Holly Hill Hospital. Appellate Defender Glenn Gerding, by Assistant Appellate Defender Nicholas C. Woomer-Deters, for Respondent. STEPHENS, Judge.
Respondent E.B. appeals from an order of involuntary commitment and argues that the district court's findings of fact do not support its conclusion of law that E.B. was a danger to himself. We reverse the district court's order.
We refer to the Respondent by his initials throughout this opinion for the purpose of protecting his privacy.
Factual Background and Procedural History
E.B. is a 45-year-old male and was first admitted to Holly Hill Hospital on 7 January 2015. On 13 January 2015, Dr. Yizhe Wang filed an affidavit and petition in Wake County District Court seeking involuntary commitment of E.B. to Holly Hill Hospital based on E.B.'s "long history of schizophrenia"; E.B.'s refusal to take medication, eat, or bathe; and E.B.'s decreased ability to care for himself. The same day, a Wake County magistrate entered a custody order for E.B.'s involuntary commitment.
A hearing on E.B.'s involuntary commitment was held in Wake County District Court on 22 January 2015. During the hearing, Dr. Wang was admitted as an expert in psychiatry and testified that he had examined E.B. on a daily basis, excluding weekends, since his admission; that E.B. presented as paranoid schizophrenic with two major clusters of symptoms including severe paranoia and "avolition," meaning a lack of motivation to do anything related to his own self-care; that during his first few days at Holly Hill Hospital, E.B. appeared disheveled and refused to eat, drink, bathe, or take medications prescribed such as Zyprexa and Haloperidol; and that E.B.'s behavior had been hostile, agitated, and angry. Dr. Wang testified further that after he ordered that E.B. receive forced injections of an antipsychotic medication, E.B. had started to show signs of improvement but was not yet stable enough to return home because his medication dosages were still being adjusted and because E.B. continued to claim he did not need to take any medications at all. Dr. Wang opined that if E.B. did not take medication, "he could be continued decompensating in a state that's extremely paranoid, avolition (inaudible) called inactive symptoms schizophrenia. And he's not eating. You know, he's not eating and is not grooming, and he will feel so depressed he ends up committing suicide." Given his opinion that E.B. was "very severely in a very, very severe psychotic state," Dr. Wang opined that if released, E.B. "will not go to further treatment. He will continue getting worse." Dr. Wang therefore recommended that E.B. remain at Holly Hill Hospital for an additional 90 days of inpatient treatment so that the staff could continue to enforce his medication regimen, monitor E.B.'s compliance, and continue educating E.B. about how to treat his mental illness in a structured setting.
The court also heard testimony from E.B.'s mother, who testified that she had previously petitioned for her son's commitment because she was concerned E.B. was not eating or taking his medication, would not answer the phone or open the door when she went to visit him, and appeared to be confused about the date when she visited him for his birthday, Thanksgiving, and Christmas. E.B.'s mother testified further that she first noticed a change in E.B.'s behavior in July 2014 when, after his psychiatrist of nearly 20 years retired, E.B. decided he no longer needed medication and stopped attending therapy. According to E.B.'s mother, everything "started to go downhill" shortly thereafter, as E.B. stopped eating, bathing, paying his bills on time, and cleaning his residence. E.B.'s mother also testified that she had to shop for food for her son and that at some point, he smashed his guitar and the glass in his car. When asked whether her son had ever threatened to harm himself, E.B.'s mother explained that he "always said he was going to do away with himself, but he's done that for so many years," then clarified that E.B. had not recently made any threats of self-harm or suicide. Nevertheless, E.B.'s mother did not believe it would be safe for him to go home "[b]ecause he's not going to take care of himself, and he's going to . . . want me to take care of him . . . I'm gonna have to go over and get the food and do all the things for him."
E.B. testified during the hearing that prior to his involuntary commitment, he lived independently in a condo his parents had bought for him, which he acknowledged was messy and needed to be cleaned, but also stated that he regularly addressed various maintenance problems on his own. E.B. testified further that he had been doing "quite well" before his psychiatrist retired, that for years he carefully followed proper instructions for taking his medication, and that he "stopped taking the medication not just abrupt[ly,] I tapered off of it because I no longer needed it which [my psychiatrist] was okay with." E.B. also testified that he did not know why he was admitted to Holly Hill Hospital but believed it was because his mother got worried; that the glass his mother found in his car was broken by accident; that he never threatened to kill himself and never would; and that he was suffering from neither paranoia nor hallucinations. When asked about his course of treatment, E.B. testified that he had attended every group therapy session since his arrival at Holly Hill Hospital and had generally complied with staff requests and facility rules except for Dr. Wang's order that he take the medication Zyprexa because he believed it was too dangerous to start off at a dosage of 10 to 20 milligrams. E.B. stated that he wanted to be discharged; that he disagreed with Dr. Wang's approach; that his interactions and communications with Dr. Wang were very limited; and that he was willing to participate in outpatient therapy upon discharge but wanted treatment with a different psychiatrist and did not want to take the long-term injectable medications Dr. Wang had prescribed because he was unfamiliar and uncomfortable with them.
At the close of the hearing, E.B.'s counsel argued that he should be discharged because the criteria for involuntary commitment had not been met, while Holly Hill Hospital's counsel requested inpatient commitment for 90 days because the evidence was clear, cogent, and convincing that E.B. was mentally ill and a danger to himself. The district court agreed with E.B.'s counsel "in regards to 90 days not necessarily being required for [E.B.] to be safe and secure as far as ongoing treatment and back on a better path" but also raised concerns that E.B. might not follow through with his treatment plan if discharged immediately, which could lead him into a debilitating state. Ultimately, the court ruled that E.B. should remain in custody for at most 30 days, until outpatient treatment could be established, then set a 30-day review hearing for the matter.
On 2 February 2015, the court entered a written involuntary commitment order in which it found as facts that:
A. [E.B.] is a 45[-]year[-]old male. [E.B.] was admitted to Holly Hill Hospital on January 7, 2015.
B. Dr. Wang is [E.B.'s] treating physician at Holly Hill Hospital. Dr. Wang has examined the patient on a daily basis excepting weekends, beginning on January 7, 2015. [E.B.] stipulated at the hearing that Dr. Wang is an expert in the field of psychiatry.
C. [E.B.] presents to Dr. Wang as paranoid, agitated, hostile, and disheveled.
D. [E.B.] has a mental illness and a diagnosis of paranoid schizophrenia. Dr. Wang has prescribed [E.B.] medication, including Haloperidol, an antipsychotic medication. However, [E.B.] has refused medication. After [E.B.] refused medication for five days, Dr. Wang started a forced medication protocol. Dr. Wang testified that he needs time to adjust and stabilize [E.B.'s] mediation regimen.
E. [E.B.] presents a danger to himself as evidenced by his refusal to comply with his prescribed psychiatric medication regimen, his lack of insight into his illness, and his inability to care for himself.
F. [E.B.'s] mother also testified at the hearing. Prior to his admission, [E.B.] had stopped seeing his psychiatrist of 20 years and stopped taking his prescribed medication. [E.B.'s] mother testified that [E.B.] was not bathing, eating, answering his phone or door, or paying his bills. [E.B.'s] mother testified that it would not be safe for [E.B.]
to be discharged at this time.Based on these findings, the court concluded that E.B. was mentally ill and dangerous to himself and ordered 30 days of inpatient commitment followed by 60 days of outpatient commitment. E.B. gave notice of appeal to this Court on 20 February 2015.
G. [E.B.] is in need of further treatment at a 24-hour facility where hospital staff can ensure his compliance with [his] medication regimen. Inpatient commitment of 30 days is necessary to stabilize his medication followed by 60 days of outpatient treatment to monitor [E.B.'s] compliance with his medication regimen.
Analysis
E.B. argues that the district court erred in ordering his involuntary commitment because its determination that he was dangerous to himself was not supported by sufficient findings of fact. We agree.
As an initial matter, we note that even though E.B.'s period of involuntary commitment has ended, his appeal is properly before us because "a prior discharge will not render questions challenging the involuntary commitment proceeding moot." In re Booker, 193 N.C. App. 433, 436, 667 S.E.2d 302, 304 (2008) (citation omitted); see also In re Webber, 201 N.C. App. 212, 217, 689 S.E.2d 468, 472-73 (2009) ("When the challenged order may form the basis for future commitment or may cause other collateral legal consequences for the respondent, an appeal of that order is not moot.") (citation omitted), cert. denied, 364 N.C. 241, 699 S.E.2d 925 (2010).
On appeal of a commitment order, this Court's function is
to determine whether there was any competent evidence to support the "facts" recorded in the commitment order and whether the trial court's ultimate findings of mental illness and dangerous to self or others were supported by the "facts" recorded in the order. We do not consider whether the evidence of [the] respondent's mental illness and dangerousness was clear, cogent and convincing. It is for the trier of fact to determine whether the competent evidence offered in a particular case met the burden of proof.In re Collins, 49 N.C. App. 243, 246, 271 S.E.2d 72, 74 (1980) (citations omitted; emphasis in original).
Section 122C-268(j) of our General Statutes sets forth the criteria for involuntary commitment and provides that the district court "shall find by clear, cogent, and convincing evidence that the respondent is mentally ill and dangerous to self . . . or dangerous to others[.]" N.C. Gen. Stat. § 122C-268(j) (2015). The court must also record the facts that support its ultimate findings that the respondent is mentally ill and dangerous to himself or others. Id. Section 122C-3 of our General Statutes provides that a person is dangerous to himself if:
1. The individual has acted in such a way as to show:
I. That he would be unable, without care, supervision, and the continued assistance of others not otherwise available, to exercise self-control, judgment, and discretion in the conduct of his daily responsibilities and social relations, or to satisfy his need for nourishment, personal or medical care, shelter, or self-protection and safety; and
II. That there is a reasonable probability of his
suffering serious physical debilitation within the near future unless adequate treatment is given pursuant to this Chapter. A showing of behavior that is grossly irrational, of actions that the individual is unable to control, of behavior that is grossly inappropriate to the situation, or of other evidence of severely impaired insight and judgment shall create a prima facie inference that the individual is unable to care for himself; or
N.C. Gen. Stat. § 122C-3(11)(a) (emphasis added).
2. The individual has attempted suicide or threatened suicide and there is a reasonable probability of suicide unless adequate treatment is given pursuant to this Chapter; or
3. The individual has mutilated himself or attempted to mutilate himself and that there is a reasonable probability of serious self-mutilation unless adequate treatment is given pursuant to this Chapter.
This Court has held that a district court commits reversible error when its commitment order fails to include factual findings sufficient to demonstrate that, absent the commitment, there was "a reasonable probability" of the respondent suffering "serious physical debilitation within the near future," or of committing suicide or self-mutilation. See, e.g., In re Whatley, 224 N.C. App. 267, 736 S.E.2d 527 (2012). In Whatley, we reviewed an involuntary commitment order in which the district court determined the respondent was mentally ill and dangerous to herself based on its findings that she "was exhibiting psychotic behavior that endangered her and her newborn child" when initially committed and "continues to exhibit disorganized thinking that causes her not to be able to properly care for herself." Id. at 271, 736 S.E.2d at 530. The district court also incorporated the respondent's latest physician's report into its findings, which noted that she had a history of bipolar disorder, remained paranoid, disorganized, and intrusive, and did not plan to follow up with treatment as an outpatient or continue taking her prescribed medications. See id. at 272, 736 S.E.2d at 530. However, as we emphasized in reversing the commitment order, the court's conclusion that the respondent was a danger to herself was based only on findings pertaining "to either [the r]espondent's history of mental illness or her behavior prior to and leading up to the commitment hearing, but they do not indicate that these circumstances rendered [the r]espondent a danger to herself in the future." Id. at 273, 736 S.E.2d at 531. Thus, because none of the factual findings indicated that the respondent's "symptoms [would] persist and endanger her within the near future," as required by our General Statutes, we held that those findings were insufficient to support the district court's conclusion that the respondent was dangerous to herself. See id.; see also In re Thompson, ___ N.C. App. ___, 769 S.E.2d 423 (2015) (unpublished), available at 2015 WL 234521 at *3 (reversing commitment order because the district court's findings were insufficient to support its determination that the respondent was a danger to himself given that "[o]f the [district] court's findings, none address prospective concerns with regard to [the] respondent's future probability of physical debilitation"); In re Osteyee-Hoffman, ___ N.C. App. ___, 775 S.E.2d 36 (2015) (unpublished), available at 2015 WL 3490123 at *4 (reversing the district court's determination that the respondent was a danger to herself "due to the lack of findings drawing a nexus between [the] respondent's past behavior and the potential for future harm").
In the present case, as in Whatley, Thompson, and Osteyee-Hoffman, the district court's order includes no factual findings indicating that, absent E.B.'s commitment, there was a reasonable probability of serious physical debilitation in the near future. While the court found that E.B. "presents a danger to himself as evidenced by his refusal to comply with his prescribed psychiatric medication regimen, his lack of insight into his illness, and his inability to care for himself," our prior holdings demonstrate that, standing alone, neither a respondent's refusal of psychiatric medication nor his past inability to care for his diet, grooming, and general affairs are sufficient to support a determination that the respondent is a danger to himself. See, e.g., Thompson, 2015 WL 234521 at *3 (reversing commitment order while acknowledging that evidence supported the court's findings that the respondent lacked "self-control, judgment, and discretion in the conduct of his daily responsibilities," given testimony that the respondent refused medical treatment and psychiatric medication and that his father frequently saw burns on the respondent and his stove and found burned pots in the respondent's yard); Osteyee-Hoffman, 2015 WL 3490123 at *4 (holding that the district court's findings that the respondent "had made threats of violence, refused medication, and suffered from delusional thinking" were insufficient to support its determination that the respondent was a danger to himself without additional findings connecting those past behaviors to a threat of future harm absent treatment).
In light of our case law, we are unpersuaded by the State's argument that we should uphold the commitment order because the record supports the court's findings that E.B. failed to properly care for his medical needs, diet, and grooming. We are similarly unpersuaded by the State's attempt to analogize this case to In re Moore, 234 N.C. App. 37, 758 S.E.2d 33, disc. review denied, 367 N.C. 527, 762 S.E.2d 202 (2014). In Moore, the district court concluded that the respondent was a danger to himself and to others based on its factual findings that, inter alia, he had a diagnosis of schizoaffective disorder with psychotic and manic symptoms; that he had exhibited delusional thinking and aggressive tendencies; that he had a history of 27 prior psychiatric hospitalizations and his readmissions were becoming more frequent; and that he had a history of failing to take his medication, a high risk of decompensation without his medication, and his physician was concerned he would "relapse by the end of football season" if released without placement. See id. at 39-40, 758 S.E.2d at 35. On appeal, we upheld the district court's order and rejected the respondent's argument based on Whatley that "the possibility of relapse alone cannot satisfy the requirement of serious physical debilitation in the near future." Id. at 44, 758 S.E.2d at 38. As we explained, "[t]he Whatley court was concerned that the trial court's findings of fact were all focused on the respondent's past conduct and not about the respondent's potential future conduct," whereas in Moore, "[t]he facts before us are distinguishable from Whatley because, while the trial court did make findings of fact about [the] respondent's past conduct, the trial court also made findings about [the] respondent's likely future conduct" and the likelihood that he would relapse "by the end of football season." Id. While we concluded these findings were sufficient to support the court's conclusion in Moore, here, by contrast, the findings make no reference to the respondent's likely future conduct. We therefore conclude Moore is inapposite to the present facts. We also reject petitioner Holly Hill Hospital's suggestion that we should uphold the commitment order because the record includes ample evidence to support a prima facie inference that E.B. was unable to care for himself and that there was a reasonable probability E.B. would commit suicide absent continued treatment. As noted supra, when reviewing a commitment order, this Court's role is to review whether the district court's findings of fact and determinations of mental illness and dangerousness are sufficiently supported, not to make findings of its own. See Collins, 49 N.C. App. at 246, 271 S.E.2d at 74.
In summation, we hold that given the lack of any findings indicating there was a reasonable probability that absent commitment, E.B. would suffer serious physical debilitation in the near future, or commit suicide or self-mutilation, the district court failed to sufficiently support its determination that E.B. was a danger to himself. Consequently, the commitment order must be reversed. In light of our holding on this issue, we need not address E.B.'s additional argument that he received ineffective assistance of counsel during the 22 January 2015 hearing.
REVERSED.
Judges HUNTER, JR., and INMAN concur.
Report per Rule 30(e).