ER Psych: Crise v. MGH
The Baltimore Medical Malpractice Lawyer Blog examines issue in Maryland medical malpractice cases. In this post, I look at the issue of what duty of care an emergency room (ER) owes to a psychiatric patient. The case a reported opinion by the Court of Special Appeals of Maryland (now the Appellate Court of Maryland). The case is Crise v. Md. Gen. Hosp., 212 Md. App. 492 (2013). The opinion addresses the intersection of professional standards of care, psychiatric emergencies, and procedural mechanics. The appellate court tackled the question: Can a hospital be liable for medical malpractice when a psychiatric patient elopes from an emergency room and subsequently injures themselves, even if the hospital lacked formal legal authority to involuntarily detain them?
In an opinion that protects a patient’s right to a jury trial, the court held that the existence of a medical provider-patient relationship triggers a duty of care that is not dictated solely by statutory detention powers.
Factual Background
On December 31, 2008, a 25-year-old patient arrived at the emergency room of the hospital. He was accompanied by his mother and sister. The patient had an extensive, documented history of severe mental illness, including diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia. The hospital was familiar with his psychiatric history. It had admitted him to their specialized psychiatric unit at least four times previously. The most recent was just six months prior.
Upon arrival, the patient complained of chest pains and heart palpitations. However, his mother alerted the nursing staff that he was undergoing a severe psychiatric crisis. She informed them that the patient had been non-compliant with his psychiatric medications for five days. He had not eaten, drank, or slept during that time. Also, he was actively excited, delusional, and hearing voices. Furthermore, a patient care technician overheard the mother begging staff to watch her son closely. She knew he would attempt to flee the emergency room if left unmonitored. This would be a key fact in the issue of the ER’s psychiatric duty of care.
The emergency room doctor evaluated the patient. They ruled out acute cardiac distress. Then they formally ordered an evaluation by a crisis counselor to initiate a psychiatric admission. While awaiting this evaluation, the patient grew increasingly restless, pacing his room and stepping out into the hallways. The staff administered a sedative, Ativan, to calm him down. Shortly thereafter, the patient went to the bathroom, ripped out his IV line, and emerged bleeding.
No Sitter
Despite these warning signs of escalating agitation and a clear flight risk, the hospital did not assign a “sitter.” That is, a hospital employee dedicated to monitoring a high-risk patient one-on-one. They claimed they were short-staffed. Instead, the charge nurse attempted to monitor him visually from the nurses’ station. At approximately 6:15 p.m., the patient slipped out of his room unnoticed. He exited through an alarmed rear door clad only in a hospital gown. Then he walked into the freezing winter night toward his home.
When the police—alerted by the hospital—spotted the patient on a bridge, the suspicious and delusional patient attempted to evade them. Believing in his psychotic state that “it wouldn’t be such a big deal,” he jumped over the side of the bridge. He plummeted 30 to 40 feet onto concrete, fracturing his pelvis, wrist, and both legs.
The plaintiff subsequently filed a medical malpractice lawsuit against the hospital in the Circuit Court for Baltimore City, alleging that the facility breached the standard of care by failing to properly monitor and secure a known, vulnerable psychiatric patient.
The Parties’ Arguments on ER Psychiatric Duty of Care
The Hospital’s Defense
The hospital moved for summary judgment, raising a multi-pronged defense. First, they argued a lack of proximate causation. They claimed that even if they had assigned a sitter, that employee would have lacked the physical authority to stop the patient from walking out. They asserted that the arrival of the police broke the chain of causation, and that the patient chose to leave because he felt “nothing was happening”. Additionally, the hospital argued that the plaintiff’s claims were barred under the doctrines of contributory negligence and assumption of risk, asserting that a reasonably prudent person would not jump off a bridge.
The Plaintiff’s Response
The plaintiff counter-argued that a standard medical malpractice duty of care arose directly from the established provider-patient relationship. Supported by emergency medicine and psychiatric expert witnesses, the plaintiff argued that the applicable standard of care required the hospital to place him in a safe and secure environment—via a one-on-one sitter, appropriate chemical sedation, or a locked room—until the crisis evaluation took place. The plaintiff noted that he had been easily redirected by verbal commands earlier in the day, meaning a sitter could have easily intervened without force. Furthermore, the plaintiff contended that under Maryland Health-General § 10-625, the hospital did have the emergency authority to involuntarily detain an individual who posed a clear danger to themselves.
The Court’s Ruling
The procedural path to the appellate court was unusual. On the second morning of the trial, after a jury had already been selected, the trial judge took action on his own initiative. Invoking Maryland Rule 2-502—a rule meant to allow judges to decide discrete legal questions that fall solely within the court’s province—the trial judge dismissed the case. The trial court ruled as a matter of law that because the patient was voluntarily present, the hospital lacked the legal authority to detain him against his will, and therefore owed him no duty to prevent him from leaving.
On appeal, the Court of Special Appeals reversed this ruling, remanding the case for a trial. The court clarified that the trial court committed two errors:
- Misapplication of Duty vs. Scope: The appellate court held that because a provider-patient relationship indisputably existed, the hospital did owe the patient a legal duty of care. The true dispute centered on the nature and scope of that duty (i.e., the standard of care). That is a fact-dependent question driven by expert testimony and reserved entirely for the jury.
- Procedural Violations of Rule 2-502: Rule 2-502 is reserved for purely legal, preliminary issues. For example, statutes of limitations or res judicata. By resolving disputed facts regarding the patient’s mental competency and standard of care requirements without giving the parties advance notice or an opportunity to argue, the trial court stripped the plaintiff of his right to a trial by jury.
Commentary by Baltimore Medical Malpractice Lawyer Mark Kopec on ER Psychiatric Duty of Care
The Court of Special Appeals’ ruling prevents medical facilities from using a patient’s “voluntary” admission status as a shield against operational negligence.
The trial court’s logic was flawed. It conflated a state-sanctioned involuntary hold with a medical provider’s foundational standard of care. A hospital’s duty to keep a patient safe does not suddenly vanish simply because formal, involuntary commitment paperwork has not been stamped. When an emergency department accepts a patient who is actively psychotic, delusional, and unmedicated, it assumes the responsibility to manage that vulnerability competently.
As the appellate court rightly highlighted, the hospital’s defense that a sitter could not “legally restrain” the patient is a red herring. The standard of care asserted by the plaintiff’s experts did not call for immediate physical combat. It called for basic, vigilant monitoring. A dedicated sitter would have noticed the patient moving toward a back exit. They could have used verbal redirection, called for immediate medical re-evaluation, or requested an adjustment in sedation.
Furthermore, the trial judge’s dismissal ignored the reality of medical emergency laws. Maryland law explicitly provides mechanisms to temporarily detain individuals experiencing severe psychiatric crises to prevent self-harm. By ruling that the hospital was powerless to act, the trial court created a dangerous incentive for emergency rooms to simply look the other way when high-risk psychiatric patients wander out into dangerous conditions.
ER Psychiatric Duty of Care Reaffirmed
By restoring this case to a jury, the appellate court reaffirmed a principle of Maryland medical malpractice law. When a hospital undertakes the treatment of a mentally incapacitated patient, it must exercise the degree of care and skill that a reasonably competent hospital would provide under similar circumstances. Fact-finding belongs to the jury, and this ruling ensures that vulnerable patients receive their day in court. This does not mean that the plaintiff wins. merely, that he got to go to the jury.
The trial court docket reveals that this case was dismissed on remand. This likely means that the parties reached a settlement.
Mark Kopec is a top-rated Baltimore medical malpractice lawyer. Contact us at 800-604-0704 to speak directly with Attorney Kopec in a free consultation. The Kopec Law Firm is in Baltimore and helps clients throughout Maryland and Washington, D.C. Thank you for reading the Baltimore Medical Malpractice Lawyer Blog.