Psychiatric Malpractice and the Standard of Care

Facts of the Case

On April 14, 2018, Terri Mattson started outpatient mental health treatment at the Idaho Department of Health and Welfare. On April 24, during her first appointment at the Department with a licensed professional counselor, Ms. Mattson reported symptoms of depression, anxiety, and alcohol relapse four months prior. Ms. Mattson informed the counselor of attempting suicide twice in the past but denied contemporaneous suicidal ideation. Her husband, however, reported that she had past and present suicidal thoughts. The counselor diagnosed Ms. Mattson with recurrent, severe major depressive disorder (MDD), assessed her risk of suicide as “moderate,” and recommended outpatient psychiatric pharmacological management, psychotherapy, and substance use treatment. Over the next three weeks, Ms. Mattson had three in-person and one phone appointment with her counselor. She reported worsening symptoms of depression, anxiety, and escalation of alcohol use that led to the loss of her employment.

On May 16, Ms. Mattson had her first and only appointment with a certified physician assistant (PA) for a psychiatric evaluation. She reported to the PA a history of over twenty years of depression and substance use. She denied current suicidality but stated that her symptoms included thoughts of suicide. The PA diagnosed Ms. Mattson with MDD and initiated fluoxetine that was dispensed by a nurse from a sample drawer. The PA scheduled a follow up appointment for two weeks later. Two days later, Ms. Mattson complained to her counselor about experiencing adverse effects from fluoxetine and no antidepressant effect. The counselor told Ms. Mattson that fluoxetine needed time to “build up in the body” (Mattson, p 736) and encouraged her to continue pharmacotherapy. On May 30, Ms. Mattson had her medication management follow-up appointment. She met with a nurse, to whom she reported increased anxiety and headaches since starting fluoxetine. The nurse recommended continuation of fluoxetine.

On June 21, the day of her next appointment at the clinic, Ms. Mattson retrieved a gun from her gun cabinet, bought a bottle of alcohol and consumed it on her way to the clinic. In the Department’s parking lot, she shot herself in the head. Ms. Mattson survived but suffered extensive head injuries with subsequent severe memory and behavioral impairments.

Later in 2018, Ms. Mattson and her husband sued the Idaho Department of Health and Welfare and its employee, a certified PA (the defendants), for medical malpractice and failure to obtain informed consent for fluoxetine. At deposition, several facts were disputed, including the duration of Ms. Mattson’s only appointment with the PA and the amount of information disclosed about fluoxetine. Ms. Mattson testified that she never received any written materials about fluoxetine, including the FDA’s “black box” warnings and manufacturer materials typically attached to a prescription bottle. She also testified that she was never warned by the PA that fluoxetine could increase her risk of suicide. Had she known this, she would have never consented to taking it.

The defendants moved for a summary judgment on both claims. In their argument, they relied on Idaho Tort Claims Act (ITCA), which states that government employees are liable for negligent and wrongful acts or omissions that happen within the course and scope of their employment if a private person would be liable for such acts. The ITCA also identifies limitations on governmental liability, stating that if a facility and its employees act “without malice or criminal intent, and without reckless, willful, and wanton conduct” (Idaho Code § 604A (2017)), they are immune from liability for any claims which, among others, arise out of injury “by or to a person receiving services from a mental health center, hospital, or similar facility” (Idaho Code Ann. § 6-904(A)(2) (2017)).

The defendants argued, first, that they were entitled to a summary judgment because they met the standard of care in treating Ms. Mattson and, second, that they were entitled to immunity under the ITCA because Ms. Mattson was injured while she was receiving services from a mental health center.

In response, the Mattsons argued that summary judgment was inappropriate because: first, the ITCA did not apply to claims brought by persons receiving noncustodial outpatient mental health services; and second, there was a triable jury question of whether the reckless, willful, and wanton conduct exception to immunity applied given evidence of the standard of care breach and causation for a malpractice trial. Each party supported its contentions with expert witness opinions.

The First Judicial District Court granted summary judgment in favor of the defendants on two grounds. First, the court interpreted the tort claims law to confer immunity from liability to the defendants because Ms. Mattson was injured while receiving services from a “mental health center.” Second, applying the standard of foreseeability, the court held that the defendants acted “in good faith” as no reasonable person could foresee that Ms. Mattson would obtain a firearm, consume alcohol, and shoot herself. Therefore, the defendants were immune from liability as their acts or omissions did not rise to the level of “reckless, willful, and wanton conduct” (Mattson, p 737). The Mattsons appealed the summary judgment on both grounds.

Rulings and Reasoning

The Idaho Supreme Court reviewed the district court’s summary judgment de novo. The court affirmed in part, reversed in part, and remanded the case for further proceedings.

The court determined that Ms. Mattson’s negligence claims fell within the purview of the tort claims law. The court disagreed with Ms. Mattson’s assertion that the ITCA’s mental health center, hospital, or similar facility clause did not apply to patients injured while receiving noncustodial outpatient mental health services. The court, however, held that even when the government and its employees qualify for immunity under the tort claim law, immunity from liability is not conferred when the degree of negligence amounts to reckless, willful, and wanton conduct. Based on Ms. Mattson’s expert witness testimony, the court concluded that sufficient facts were alleged to create a triable jury question on this exception to immunity. The court also held that the district court had misapplied the concept of foreseeability and improperly drew a “good faith” inference in favor of the defendants. The court clarified that the specific kind of harm, suicide, must be foreseeable, not the specific mechanisms of harm.