Summary
In Johnson, the court held that "[a] hospital owes a duty to its patients to exercise such reasonable care for their safety as their known mental and physical condition may require * * *."
Summary of this case from Millhoff v. Ohio Dept. of Mental HealthOpinion
No. 72-288
Decided December 15, 1972.
Negligence — Hospital — Care of patients — Patient committing suicide — General hospital not liable, when — Protective measures directed by physician taken — Evidence.
A hospital owes a duty to its patients to exercise such reasonable care for their safety as their known mental and physical condition may require; however, a general hospital is not liable for the death of a patient who voluntarily jumps from a hospital windoe, where the hospital staff provides the protective measures directed by the attending physician to prevent such act of self-destruction.
APPEAL from the Court of Appeals for Franklin County.
Plaintiff-appellee, Irvin R. Johnson, administrator of the estate of Mildred Johnson, deceased, brought an action for wrongful death against defendant-appellant, Grant Hospital, alleging in his petition that:
"3. On the 27th day of May, 1968, defendant undertook for good and valuable consideration to keep and provide safely and carefully for the custody and maintenance of plaintiff's decedent at and upon the premises of the defendant as hereinbefore described and to provide the plaintiff's decedent with treatment and care for her illness diagnosed as schizophrenic reaction or acute anxiety reaction.
"4. Upon admission to defendant's hospital, defendant knew, or in the exercise of ordinary care should have known, plaintiff was depressed, delusional and despondent with memory lapses. Following the admission of plaintiff's decedent to defendant's hospital, plaintiff's decedent became increasingly depressed, disturbed and delusional, all of which was known to the defendant. At approximately 9:00 p.m. on May 31, 1968, plaintiff's decedent attempted to leap from the window of her room on the 9th floor of defendant's hospital and at approximately 10:00 p.m. on May 31, 1968 attempted to leap from another room on the 9th floor of defendant's hospital, all of which was observed by and known to defendant hospital. Plaintiff was thereafter placed by defendant hospital in a security room in defendant hospital.
"5. On the following morning, June 1, 1968, plaintiff's decedent left her security room and made her way to the 9th floor solarium room where she jumped from the window to the ground, causing her death."
At trial, the deceased's attending physician testified as follows:
"Q. Doctor, does the term mentally ill lend itself to a specific mental definition that would have any application to this lady's case?
"A. In a concise concept of being mentally ill, she does not fit. She fits the emotionally disturbed category.
"* * *
"Q. * * * Can you say whether or not with medical certainty — reasonable medical certainty that this lady was or was not mentally ill, insane or deranged at the time she took her life?
"A. She was not mentally ill, deranged or insane at the time she took her life is my concept for this reason: I had a conversation with Mrs. Johnson approximately four or five hours prior to her demise, and she was very clear, concise, rational, and went along with my recommendation for her to wait till I saw her in the morning, then we will make some changes, et cetera. I have four notes that Mrs. Johnson wrote which were written deliberately and carefully and in excellent language and thinking clear thoughts which is not the pattern of a schizophrenic or a person that is deranged. The letters she wrote were evidently why she had planned to take her life sometime that morning, whenever it was, but I am saying that the contents of these notes were so precise and in excellent language and thought plus what I have spoken to her four to five hours prior to that, in no way indicate her to be deranged.
"Q. * * * you just mentioned that you talked with her four or five hours before she took her life. How did this conversation take place? * * *
"A. This was telephone. It originated when Mrs. Johnson called me from her room. She was upset over my asking them to have her locked in for the night, and I received a call from the family, she was disturbed at my having done this, and then shortly after, Mrs. Johnson herself called me and I spoke to her at length and told her that tomorrow we will make some changes and she was quiet — her anger became subdued and we spoke rationally like we always do after we get in conversation, and I felt then that she had remained in good contact.
"Q. Did you indicate in that answer, Doctor, that members of the family had also complained about the locked door?
"A. Yes.
"Q. That evening?
"A. Yes, sir.
"Q. The question of whether or not the door would be locked, did you consider this a medical question within your control?
"A. Yes. I am so responsible for the ordering whether the door is locked or not since I am in charge of the patient's care.
"Q. * * * This is a medically important decision in regard to handling this kind of patient?
"A. Yes, I think it is. The judgment of the physician if he feels his patient may be a particular problem to the nurses and personnel in the ward, or the patient may be unpredictable at a specific time, or three, if the patient is emotionally disturbed and may cause problems to the other patients on the floor, or five, if the patient himself needs to be isolated from others. There are a variety of things that go into a decision like this by the attending physician.
"Q. At the time you made that decision, Doctor, were you in a position to know all of the facts and circumstances of your patient's case?
"A. Yes, I think the nurse and supervisor in charge had briefed me on the patient. * * *
"Q. Doctor, you do have the hospital chart before you, do you not. * * *
"A. These are the physician's orders * * *.
"Q. * * * May 31, 1968, it says, `Lock door at night.' Was that an order you gave?
"A. Yes. That is a telephone order I gave to the nurse in charge the night of the 31st.
"Q. The order right above that says, would you read the order right above.
"A. I earlier said, `Please transfer to security room, however, leave door open.'
"Q. So the position of the door either open or closed was a very conscious problem in your opinion?
"A. Yes, sir, in my opinion, yes, sir.
"Q. Now, the `lock door at night,' Doctor, would you explain what that order means as far as the following morning is concerned, whether the door was to be opened or closed.
"A. It meant that the door was to be opened in the morning at 8:00 o'clock. This is in keeping with hospital practices that activity started at 8:00 o'clock in the morning for the patient, so from 12:00 to 8:00 when we say, `Lock at night,' is what we are speaking about.
"* * *
"Q. So if A.M. care was given at 5 minutes to 8:00, that wouldn't make it wrong under your order?
"A. No.
"Q. Or at 7:30?
"A. No.
"* * *
"Q. In the course of your conversation you had with the patient, wasn't her family — the night before there was a specific reference by them, an objection, to this locked door, is that not true?
"A. Yes, sir.
"Q. And you at that time assured them that the door would be opened the next morning?
"A. That's correct.
"Q. Now, under all the circumstances, Doctor, would you expect the nurses to overrule your judgment on whether that door should be locked or unlocked?
"A. In hospital practice or medical practice the nurses only act on specific orders given by the attending physician.
"Q. Doctor, in further keeping with the open door question, permitting the door to be opened, you would anticipate that possibly the patient would walk out into the hall, would you not?
"A. Yes, sir.
"Q. This was permissible as far as you were concerned?
"A. Yes, sir.
"Q. You do not imply or tell the hospital even though the door is open, keep her in her room?
"A. No. Once we open her door, it is meant that the patient has the freedom to walk in the aisle or walk in the corridors.
"Q. Again, Doctor, in keeping with your total knowledge and treatment of this patient, you never contemplated or ordered that the hospital stand guard over this patient as though she were being confined, did you?
"A. No.
"* * *
"Q. Is it not true, Doctor, that she was in fact admitted to Grant Hospital on your service because of her physical problems, not her mental problem?
"A. Yes, sir.
"Q. In the course of your practice as a psychiatric specialist, Doctor, do you have occasion to admit patients to other than general hospitals?
"A. Yes, sir.
"Q. Where would that be?
"A. That would be Upham Hall at University or Harding Hospital or to the State Hospital or to Mt. Carmel.
"Q. Is this where you would put a patient that you consider to be deranged or insane?
"* * *
"Q. In one of these other hospital instead of in Grant?
"A. Yes, sir.
"Q. In your professional opinion and in your experience does Grant hold itself out as a hospital for the treatment of insane or deranged or mentally ill patients?
"A. No. The policy of Grant and the same is true of other hospitals in our area are general hospitals and it is felt that the patients who have psychiatric problems would not be admitted. Arrangements are made if necessary before admission to elsewhere. If they become disturbed within the confines of the hospital, they are transferred to a psychiatric setting.
"Q. As a matter of fact, Doctor, isn't it a well known fact within the medical profession that Grant Hospital and these other hospitals for that matter are not equipped to take care of mentally ill and insane patients?
"A. You are asking me my concept of the hospitals, they usually serve the total needs of the patient in general. They do not have facilities for the person that is deranged.
"* * *
"Q. Doctor, in your professional opinion did the Grant Hospital nursing staff follow your orders to the letter?
"A. Yes, it did.
"Q. Again in your professional opinion and based on your total knowledge of this case, did the Grant nursing staff violate any of its duties to your patient, Mrs. Johnson?
"A. No, they did not."
At the conclusion of plaintiff's case, the trial court granted defendant's motion for a directed verdict, stating for its reason that "* * * reasonable minds could come to no other conclusion than that the evidence shows that the decedent was not insane, was not mentally deranged, was not mentally incompetent and that * * * [death resulted from] her voluntary act."
Upon appeal, the Court of Appeals reversed the judgment and remanded the cause to the Court of Common Pleas for further proceedings.
The cause is now before this court pursuant to the allowance of a motion to certify the record.
Messrs. Barkan, Barkan Neff and Mr. Frank J. Neff, for appellee.
Messrs. Ginger Christensen, Mr. Richard J. Brentlinger and Mr. Bradley Hummel, for appellant.
For reversal of the judgment of the Court of Appeals appellant advances two propositions of law: (1) "In an action for wrongful death based upon a breach of a specific duty of care owed by the defendant to a person committing suicide, the act of suicide is an intervening cause of death unless the decedent was mentally incompetent at the time he killed himself"; (2) "Where a patient in a general hospital indicates an intention to commit suicide and attempts to jump from a hospital window, is then locked in a security room on the order of her attending physician, a psychiatrist, with the provision that the door be opened the following morning, expert opinion evidence is required to establish the standard of care the hospital must exercise in following or disregarding the physician's order."
It is obvious that, if it is determined that the defendant hospital is not liable as a matter of law for the voluntary act of the patient in committing suicide, there is no necessity to pass upon all the issues raised in appellant's propositions of law. Consequently, this opinion will focus upon the question of defendant's liability on the facts presented.
In an annotation, entitled "Liability of hospital or sanitarium for injury or death of patient as result of his escape or attempted escape," 70 A.L.R. 2d 347, 348, it is said that as a general rule "* * * the duty of a hospital toward its patients is to exercise such reasonable care for their safety as their known mental and physical condition may require, and that in a proper case this duty may extend to affording reasonable protection against self-inflicted injury * * *."
The Court of Appeals, in its opinion, noted that hospitals have a duty "* * * in caring for a patient to take steps to prevent the patient from injuring himself under circumstances where the danger is apparent," citing Jones v Hawkes Hospital of Mt. Carmel (1964), 175 Ohio St. 503, and Burks v. Christ Hospital (1969), 19 Ohio St.2d 128.
Paragraph two of the syllabus in Jones reads:
"Where an expectant mother is in a labor room of the obstetrical department of a hospital, is under sedation and is extremely restless, endeavoring repeatedly to climb over the raised guardrails of her bed, and the nurse or nurses assigned to the care of such patient by the hospital leave the room and are absent for a period of from two to five minutes on a matter unrelated to the care of the patient, and during such absence of the nurse or nurses the patient falls out of her bed and is injured, expert opinion evidence is not necessary to aid the trier of the facts to ascertain whether the conduct of the nurse or nurses constituted negligence."
In Burks, the syllabus reads:
"1. Where a short, obese hospital patient, who is in severe pain, is placed in a hospital bed with rollers and without side rails and sedated to the point where she is foggy, drowsy and disoriented, and while under the effects of sedation she falls from her bed and is injured, it is a jury question as to whether the hospital was negligent in not applying raised side rails to the bed, and, if the jury finds that the hospital was negligent, it is then a question for the jury to determine whether that negligence was the proximate cause of the injury which the patient suffered.
"2. In such case, in considering the question of the negligence of the hospital, the jury must also determine whether the hospital exercised reasonable care in promulgating and enforcing rules to protect the patient against the dangers incident to the patient's condition."
It is noteworthy that in both Jones and Burks the hospitals provided the type of care for which the patients were admitted, and that their liability stemmed from injuries connected with alleged negligence in that care. On the other hand, the record here shows that the defendant hospital was a general hospital which did not provide care for mental patients and that the death resulted from deceased's own voluntary act.
In the case of Clements v. Swedish Hospital (1958), 252 Minn. 1, 89 N.W.2d 162, plaintiff was admitted to a general hospital for treatment of injuries sustained in an automobile accident. After her admission, plaintiff "exhibited depression and possible hallucinatory ideas." This was known to the hospital staff and to her attending physician; however, the physician did not order any special treatment because of that knowledge. On the day plaintiff was to be discharged from the hospital she jumped out of a window, and subsequently she brought an action against the hospital for the injuries thereby sustained. The trial court directed a verdict for the hospital and the Supreme Court of Minnesota affirmed.
After observing that the defendant hospital was a general hospital not equipped for the care of mental patients and that there was nothing to indicate that plaintiff was contemplating suicide, the court concluded, at page 7:
"* * * To hold that under such circumstances the failure of the hospital attendants to apply restraints or to take other steps to restrict or confine her upon their own responsibility constituted negligence would place too heavy and dangerous a burden upon the attendants employed by a general hospital. Hospitals for the treatment of mental patients are specially equipped and are staffed with employees trained in the field of mental disorders. If such a hospital were involved here, it might well be determined that the failure of its employees to restrain a patient confined for mental disorders or developing mental disturbances and manifesting suicidal tendencies after confinement constituted negligence. See, Mounds Park Hospital v. Von Eye (8 Cir.), 245 F.2d 756. But where, as in the instant case, a patient is admitted to a general hospital merely for the treatment of injuries sustained in an accident and nothing is said as to any mental disorders afflicting such patients; and where, after an incident such as described here, the patient manifested such improvement as to eliminate any evidence of peculiarity or tendency to suicide and the hospital attendants abide by the orders of the patient's physician, it can scarcely be said that a fact question is present as to the hospital's negligence. See, Mesedahl v. St. Luke's Hospital Assn., 194 Minn. 198, 259 N.W. 819."
A general hospital, which ordinarily does not and is not equipped to treat mental patients, should not be held to the same standard of care as a hospital which is operated and equipped to provide care for a patient who has displayed a tendency to commit suicide.
With this principle in mind, the court turns to the question of whether, in the circumstances presented, the defendant hospital exercised reasonable care to protect the deceased against self-inflicted injury.
The record shows that defendant's staff had "briefed" the attending physician "on the patient" and that the physician ordered that the patient's door be locked at night. There was no order that the door be locked during the day, or that the patient be otherwise restrained. In fact, the physician testified that the deceased was "not mentally ill, deranged or insane at the time she took her life," and that in a telephone conversation with the patient after he had ordered her locked in for the night "her anger became subdued and we spoke rationally." The physician testified further that: "In hospital practices or medical practice the nurses only act on specific orders given by the attending physician."
The foregoing indicates that the staff of defendant hospital followed the instructions of deceased's attending physician to the letter. Inasmuch as defendant hospital is a general hospital, this court is of the opinion that it was required to do no more to protect deceased from self-inflicted injury than was ordered by deceased's physician. Thus, by caring for deceased in the manner directed by her attending physician, defendant's staff exercised reasonable care in the circumstances. To require more would be to impose a standard of care which, as this court has determined, would extend beyond that required of a general hospital.
A hospital owes a duty to its patients to exercise such reasonable care for their safety as their known mental and physical condition may require; however, a general hospital is not liable for the death of a patient who voluntarily jumps from a hospital window, where the hospital staff provides the protective measures directed by the attending physician to prevent such act of self-destruction.
From the principles expressed herein, it follows that the trial court properly granted defendant's motion for a directed verdict.
Therefore, the judgment of the Court of Appeals is reversed.
Judgment reversed.
SCHNEIDER, CORRIGAN, STERN and LEACH, JJ., concur.
HERBERT, J., concurs in the judgment.
BROWN, J., dissents.
Under the facts of this case, a finding against the hospital would amount to a requirement that its employees have disobeyed the direct orders of decedent's attending physician. The instant record may come close, but does not reach a fact pattern justifying such unorthodox conduct by the hospital's personnel.
However, my quarrel with the syllabus and opinion in this case is that it removes from general hospitals all responsibility, save the obedience of orders from an attending physician. I can readily foresee special cases in which hospital personnel should exert an independent judgment, in the patient's interest, and should be required to do so as a part of their duty to exercise reasonable care for his safety.