Opinion
23-0758
03-27-2024
IN THE MATTER OF S.P., Alleged to Be Seriously Mentally Impaired, S.P., Respondent-Appellant.
Janice B. Binder, Martelle, for appellant. Brenna Bird, Attorney General, and Sarah Jennings, Assistant Attorney General, for appellee State.
Appeal from the Iowa District Court for Johnson County, Paul D. Miller, Judge.
S.P. appeals the district court's finding he suffered from a serious mental impairment and his commitment was proper. AFFIRMED.
Janice B. Binder, Martelle, for appellant.
Brenna Bird, Attorney General, and Sarah Jennings, Assistant Attorney General, for appellee State.
Considered by Bower, C.J., Greer, J., and Vogel, S.J. [*]
BOWER, CHIEF JUDGE.
S.P. appeals a finding he suffered from a serious mental impairment and his commitment was proper. He claims there were less restrictive alternatives available because a guardianship was in place. He also claims the State did not meet its burden to show he suffered from a serious mental impairment. Because we find each conclusion was supported by substantial evidence, we affirm.
I. Background Facts and Proceedings
S.P.'s initial contact with the University of Iowa Hospitals and Clinics (UIHC) was in November 2022, on a voluntary basis. He presented with extreme malnutrition and severely low body mass index (BMI), and he was at risk for a potentially life-threatening condition known as refeeding syndrome. At the same time, his family reported he had been engaging in disorganized, disruptive, and self-injurious behavior. The UIHC team also had concerns he was psychotic at the time.
On December 29, 2022, S.P. returned to the hospital on an emergency basis after his mother called 911. He presented similar symptoms as before: severely low weight and malnutrition, psychotic behavior, hallucinations, inability to speak at times, lack of awareness, self-injurious and assaultive behaviors, and disorientation. At this time, S.P. was also seen engaging in dangerous behaviors by staff and family members. He hit his head on a wall repeatedly, urinated on another patient's floor, and tried climbing out of a locked seventh-floor window. Additionally, medical professionals noted S.P. had discontinued the use of his antipsychotic medication since leaving the hospital in November.
UIHC filed an application for commitment under Iowa Code chapter 229 (2022). A commitment hearing was held on January 6, 2023, after which S.P. was committed. The hospitalization referee found S.P. to be a danger to himself due to his low weight and BMI. S.P. was ordered to inpatient care, diagnosed with schizophreniform disorder, and again placed on medication. This decision was appealed on January 16, 2023. An appeal hearing was set for May 3, 2023.
UIHC also reported to the Iowa Department of Health and Human Services (HHS) it believed that S.P. was a victim of adult dependent abuse under Iowa Code chapter 235B.
An order was entered on January 19, 2023, setting a hearing for February 8, 2023, but was continued due to lack of judicial resources and to allow time for the State time to respond to a motion to dismiss.
S.P. was released from UIHC to Vita Health Services, a residential care facility in Polk County, Iowa, on March 15, 2023. Though there had been improvements with the use of medication, S.P. still "demonstrate[d] poor insight into his illness and negative symptoms." The Broadlawns outpatient mental status exam, performed on April 17, 2023, showed S.P. had fair insight and his judgment was intact. No abnormalities were noted.
On May 3, 2023, an appeal hearing was held in Johnson County District Court, after which the commitment was affirmed. S.P. now appeals.
Dr. Strong, a psychiatrist employed by UIHC, testified to S.P.'s mental condition at the time of hospitalization.
Additionally, the venue of the commitment was transferred to Polk County.
II. Standard of Review
Iowa Code chapter 229 involuntary commitments for serious mental illness are reviewed for corrections of errors at law. In re B.B., 826 N.W.2d 425, 428 (Iowa 2013). A district court's findings or fact are binding if they are supported by substantial evidence. In re J.P., 574 N.W.2d 340, 342 (Iowa 1998). Evidence is substantial if a reasonable trier of fact could conclude the findings were established by clear and convincing evidence. Id.
III. Analysis
A. Mootness
The State claims this matter is moot because S.P. has been discharged from his involuntary commitment.
An issue is moot if it "becomes nonexistent or academic and, consequently, no longer involves a justiciable controversy." State v. Hernandez-Lopez, 639 N.W.2d 226, 234 (Iowa 2002). Courts generally decline to review moot matters; however certain exceptions are widely recognized. Such exceptions include a party who has been adjudicated seriously mentally impaired and involuntarily committed because it is presumed they have suffered collateral consequences justifying appellate review. B.B., 826 N.W.2d at 429. "Because a person's liberty interests are at stake, it is imperative that the statutory requirements and procedures be followed." In re M.T., 625 N.W.2d 702, 706 (Iowa 2001). Another factor to consider is whether the matter will frequently be moot before it reaches the appellate level. Id. S.P. was involuntarily committed after being adjudicated seriously mentally impaired. Additionally, there may be lasting collateral consequences because of this decision. Finally, a matter such as this has the potential to frequently be moot before it reaches appellate review. For these reasons, we determine this matter is not moot.
B. S.P.'s Condition
The purpose of an appeal is for the fact finder to review evidence available at the time a ruling was made. At the time S.P. was committed, there was testimony by Dr. Strong as well as the results of a neuropsychological exam that had been administered. These were the mechanisms the hospital referee used to determine S.P. to be a danger to himself due to his low weight and BMI. It was appropriate, not outrageous as the appellant claims, for the district court to rely on this evidence to reach its conclusion. As the State points out, "Chapter 229 provides avenues for discharge and termination of a proceeding when a patient subjected to an involuntary committal is no longer seriously mentally impaired." To adopt S.P.'s argument could result in future appeals where the respondents would simply introduce their subsequent improvements as evidence to undermine the initial committal order.
C . Serious Mental Impairment
To be found seriously mentally impaired, a person must: (1) have a mental illness; (2) because of that illness, lack sufficient judgment to make responsible decisions with respect to hospitalization or treatment; and (3) because of that illness meet any of the following four criteria:
a. Is likely to physically injure the person's self or others if allowed to remain at liberty without treatment.
b. Is likely to inflict serious emotional injury on members of the person's family or others who lack reasonable opportunity to avoid contact with the person with mental illness if the person with mental illness is allowed to remain at liberty without treatment.
c. Is unable to satisfy the person's needs for nourishment, clothing, essential medical care, or shelter so it is likely the person will suffer physical injury, physical debilitation, or death.
d. Has a history of lack of compliance with treatment and any of the following applies:
(1) Lack of compliance has been a significant factor in the need for emergency hospitalization;
(2) Lack of compliance has resulted in one or more acts of causing serious physical injury to the person's self or others or an attempt to physically injure the person's self or others.Iowa Code § 229.1(22).
It is undisputed S.P. has a mental illness, as his diagnosis of schizophreniform disorder is classified as a mental illness under the diagnostic and statistical manual. This type of diagnosis is deemed sufficient evidence by the court. In re S.S., No. 15-0494, 2015 WL 6508809, at *4 (Iowa Ct. App. Oct. 28, 2015).
Additionally, there is ample evidence in the record to indicate S.P. lacked sufficient judgment to make responsible decisions regarding his hospitalization or treatment. S.P. was admitted to UIHC in November due to concerns for S.P. being very thin, possibly malnourished, and exhibiting psychotic behavior. He was treated and subsequently discharged. Less than a month later, S.P. was readmitted to UIHC for the same concerns. He experienced hallucinations, was disorganized, had paranoia and confusion, and lacked awareness of his circumstances. S.P.'s behaviors, consistent with that of his mental illness and lack of judgmental capacity, included urinating on the floor of another patient's room, attempting to climb out of the seventh-floor window of the hospital, and hitting his head against a wall outside the hospital. This hospital stay was the result of S.P. failing to be compliant in taking his medication when living at home with his parents and his inability to meet his physical and mental-health needs. There was clear and convincing evidence S.P. lacked the judgmental capacity to make responsible decisions with respect to hospitalization or treatment.
A recent overt act is required to prove the dangerousness element of civil commitment. O'Connor v. Donaldson, 422 U.S. 563, 576 (1976) (requiring proof of dangerousness); In re Foster, 426 N.W.2d 374, 377 (Iowa 1988) (requiring proof of a recent overt act). "Stringent proof under the dangerousness standard is necessary because predicting dangerousness is difficult and, at best, speculative." Id.
For the dangerousness standard to be met, the State must show S.P. satisfies one of the standards laid out in Iowa Code section 229.1(22). It is clear from the record; he has met at least one of the standards.
S.P.'s second admission to UIHC came under the duress of a 911 call by his mother when the family observed him harming himself. At the time he was committed, S.P. was "severely malnourished." The physician treating him wrote "[he] was at risk of serious injury and death if he [was] not treated and left to manage his illness on his own." The medical team also stated he need to be "closely monitored to avoid worsening of malnutrition and possible refeeding syndrome." Lastly, the staff at UIHC reported S.P. climbing onto the windowsill of a locked window on the seventh floor of the building in what "appeared to the staff to be an attempt to leave the unit." This is overwhelming evidence to show S.P. to be a danger to himself.
However, as further evidence, the State points out in its brief S.P. also satisfies two other grounds for dangerousness. When S.P. was first committed, he was at "high risk" for death due to starvation. His team noted "while on the unit, he demonstrated poor understanding of how to care for himself and [had] stolen another patient's clothing." S.P. also showed he had a lack of compliance with treatment by his need for multiple hospitalizations. While we do not discredit S.P. was able to initiate his own care after placement at Vita, this comes after he had just undergone hospital care and treatment for several months, not before.
D. Guardianship
"It is not only the customary procedure, but the constitutionally and statutorily mandated requirement, to treat even seriously mentally impaired persons in the least restrictive environment medically possible." Leonard v. State, 491 N.W.2d 508, 512 (Iowa 1992). The "least restrictive environment" being referred to is the placement of the individual under the committal. Id. Additionally, as the State points out, Iowa Code chapters 229 and 235B "serve different purposes and bestow the substitute decision-maker with different powers." "Chapter 229 protects a seriously mentally impaired person from harming themselves or others." Accord Iowa Code § 229.1(22). Chapter 235B, while also providing for the "acts or omissions of the dependent adult" himself, primarily aims to stop others from harming a dependent adult. Accord id. § 235B.2(5)(a).
Chapter 229 gave UIHC the clear and necessary power to ensure administered medication over S.P.'s objections in order to best treat him, in the condition he arrived. Based on the above arguments, there was clear and convincing evidence for the district court to find the guardianship did not render the commitment improper.
IV. Conclusion
For the foregoing reasons, we affirm the district court's finding of clear and convincing evidence S.P. suffered from a serious mental impairment and commitment of S.P. was proper.
AFFIRMED.
[*]Senior judge assigned by order pursuant to Iowa Code section 602.9206 (2024).