Anne Allen was admitted to Norristown State Hospital for treatment of mental retardation and psychosis following an adverse reaction to medication. Three months later, she was transferred to Montgomery Hospital for treatment of dehydration and a fever. The two hospitals had a contractual agreement wherein the Montgomery facility would provide treatment for mentally ill patients from the state hospital.
The attending physician removed Ms. Allen from all but one of her psychotropic drugs. The young woman was kept in a posey restraint—a vest-like shirt that enabled her to move her extremities and sit up while being tied to her bed. The purpose of a posey restraint is to prevent a patient from falling out of bed.
Ms. Allen's condition improved and she was scheduled to be transferred back to Norristown. On the day before the transfer, a nurse found her hanging about six inches above the floor between the side-rails with the posey restraint around her neck. She had been attempting to get out of bed. Cardiopulmonary resuscitation was administered and Ms. Allen survived, but with permanent brain damage due to lack of oxygen.
Her parents filed a complaint for negligence against Montgomery Hospital and the attending physician. The trial judge instructed the jury that, pursuant to the Mental Health Procedures Act [hereinafter MHPA], the defendants were immune from liability unless they were found to be grossly negligent [see glossary]. The jury vindicated the defendants.
The Mental Health Procedures Act, Section 114 provides in part that, [I]n the absence of willful misconduct or gross negligence, a county administrator, a director of a facility, a physician... or any other authorized person who participates in a decision that a person be examined or treated under this act, or that the person be discharged, or placed under partial hospitalization. shall not be civilly or criminally liable for such decision or for any of its consequences.
On appeal, Ms. Allen argued that the immunity provisions of the MHPA did not apply for physicians who provided medical care for the physical ailments of psychiatric patients. The Superior Court agreed, and the case was remanded for a new trial.
The Pennsylvania Supreme Court intervened and conducted a statutory review to determine if the legislature intended for the heightened immunity provisions of the MHPA to apply to hospitals and doctors providing medical care to mentally ill patients pursuant to a contract. Ms. Allen's attorneys argued that to single out the mentally ill and apply a higher standard of negligence was a constitutional denial of equal protection. They asserted that a vulnerable population's access to the courts would be unfairly and unequally, curtailed.
Holding: The MHPA provided the defendants with immunity from the negligence claim. The court found that the legislature intended to extend immunity to physicians who provided physical care as well as psychiatric services to persons with mental illness. Without this extension of heightened legal immunity, physicians may choose to limit their liability by placing the patient in a more restrictive environment or adopt other measures that would increase the costs of medical care. This result, said the Court, would thwart the MHPA's purpose of providing adequate treatment to the mentally ill within the least restrictive environment.
Editor's Note: Ms. Allen's attorneys hope to carry their equal protection argument to the U.S. Supreme Court. A petition for certiorari has been filed and the Court will decide whether to hear the case.
 | Michael Welner, M.D. Chairman The Forensic Panel |
Dr. Welner comments: Transferring a severely disturbed patient from a psychiatric ward to a medical unit is fraught with unforeseen complications. The acute nature of the illness necessitates a higher level of observation, especially warranted because the medical staff is less trained in psychiatric nursing care. A psychiatric presence is needed to assuage medical staff fears that the psychotic patient will terrorize their unit. Daily follow up visits provide for quick and clinically appropriate problem solving, and are just as useful to advise the staff about helpful non-medication approaches.
The short cut to behavioral control is the posey, a physical restraint that should not allow the kind of movement that contributed to the near-death of this patient. In this sense, res ipsa loquitur, i.e. the thing speaks for itself, may apply. A patient given a nursing intervention that severely restricts egress from the bed should not be found hanging and asphyxiated.
Use of the posey for longer than a few hours smacks of a myopic cost-consciousness. After all, why tie up a nurse's aide when you can tie down the patient? Providing continuous observation of the patient might have prevented the outcome, which could not have been anticipated. Such management is not at all overcautious. Even though the patient warranted treatment on a locked unit in the first place to ensure the safety of her and others, what is to guarantee safety on the open medical unit? For this reason, a recommended standard is to provide continuous observation for any patient who will require housing on a psychiatric unit once their medical condition stabilizes.
Why tie up a nurse's aide when you can tie down the patient?
The debate in this case is over a standard of gross negligence. Not to be forgotten is the protection afforded to the patient by the specter of liability for bad care. A unit whose psychiatric approach is to lighten the load for the staff by tying up one patient is tying somebody else down, too. Liability for this pacifier approach to patient care will not make the nurses tie the knots tighter, but pressure their vacant supervisors to encourage a good old-fashioned hands on approach. Believe it or not, good can emerge from malpractice suits.
