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Bell v. Chance

Court of Appeals of Maryland

July 12, 2018

Leroy C. Bell, Jr. and Bon Secours Hospital Baltimore, Inc.
v.
Patricia Chance, Individually and as Personal Representative of the Estate of Brandon Mackey

          Argument: January 5, 2018

          Circuit Court for Baltimore City Case No. 24-C-13-001083

          Barbera, C.J., Greene, Adkins, McDonald, Watts, Hotten, Getty, JJ.

          OPINION

          McDonald, J.

         Civil commitment of an individual to a mental institution against the individual's will may be sought when it appears necessary for treatment of the individual's mental disorder and for the safety of that individual or others. However, a decision on involuntary admission must take account not only of health and safety concerns, but also of the individual's right to liberty under the State and federal constitutions. Accordingly, under the Maryland Mental Health Law, an individual may not be admitted involuntarily unless the individual: (1) has a mental disorder; (2) needs inpatient care or treatment; (3) presents a danger to the life or safety of self or others; (4) will not or cannot be admitted voluntarily; and (5) could not receive a less restrictive form of intervention consistent with the individual's welfare and safety.

         An assessment of these criteria is made by a mental health facility when it considers whether to accept an individual presented for involuntary admission. A final decision as to whether the individual satisfies the criteria for involuntary admission is to be made within 10 days by an impartial hearing officer. Between the initial confinement of an individual and the ultimate review by the hearing officer, a physician caring for the individual at the facility must authorize release of the individual if the physician believes that the criteria for involuntary admission are no longer met. To encourage the appropriate exercise of that judgment, the Mental Health Law provides immunity from liability for a mental health facility, and its agents and employees, concerning decisions made in connection with the involuntary admission process.

         Brandon Mackey, the 23-year-old son of Respondent Patricia Chance, attempted to commit suicide in April 2011. He was eventually taken to Petitioner Bon Secours Hospital ("Bon Secours") pursuant to an application for involuntary admission certified by two doctors at another hospital, and came under the care of Petitioner Dr. Leroy Bell, a psychiatrist then employed by Bon Secours. In accordance with the Mental Health Law, a hearing to determine whether Mr. Mackey should be admitted involuntarily or released was scheduled for 10 days later. In the interim, Mr. Mackey was confined at Bon Secours where Dr. Bell assessed and treated him. Two days before the scheduled hearing, Dr. Bell decided that Mr. Mackey did not meet the statutory criteria required for involuntary admission and authorized his release. Tragically, the day after Mr. Mackey was released, he committed suicide.

         Litigation ensued in the Circuit Court for Baltimore City. Ms. Chance contended that Dr. Bell - and Bon Secours vicariously as his employer - were negligent in releasing her son. After a jury returned a verdict in Ms. Chance's favor, the Circuit Court vacated that judgment based in part on its understanding of the immunity statute. A divided Court of Special Appeals reversed the Circuit Court decision.

         We hold that the process of involuntary admission begins with the initial application for involuntary admission of an individual and ends upon the hearing officer's decision whether to admit or release that individual. During that process, if a physician applies the statutory criteria for involuntary admission and concludes in good faith that the individual no longer meets those criteria, the facility must release the individual. That decision is immune from civil liability and cannot be the basis of a jury verdict for medical malpractice.

         I Background

         A. Involuntary Admission to a Mental Health Facility

         To place the issues in this case in context, we first outline the relevant statutory provisions governing involuntary admissions to mental health facilities and summarize a key decision of this Court construing the immunity from liability provided for those involved in that process.

         Admission to a Mental Health Facility under the Mental Health Law

         The Maryland Mental Health Law comprises Title 10 of the Health-General Article ("HG") of the Maryland Code. HG §10-1101. Subtitle 6 of the Mental Health Law concerns admission of an individual to a mental health facility for treatment and is divided into five parts. The statute defines "admission" to a facility as "the process by which an individual is accepted as a resident in an inpatient facility[, ]" which process "includes the physical act of the individual entering the facility." HG §10-101(c)(1)-(2). The statute defines a "facility" as "any public or private clinic, hospital, or other institution that provides or purports to provide treatment or other services for individuals who have mental disorders." HG §10-101(g). Admission may happen voluntarily - i.e., with the patient's consent, or it may happen involuntarily - i.e., without the patient's consent.

         Particularly pertinent to this case are Part III of Subtitle 6 (HG §10-613 through §10-619), which concerns involuntary admission to a facility, and Part V (HG §10-631 through §10-633), which among other things concerns the hearing required for an involuntary admission.[1]

         Involuntary Admission - the Application and Certifications

         Any person with "a legitimate interest in the welfare of [another] individual" may apply for the involuntary admission of that individual to a facility. HG §10-614(a). The application must be made in writing, signed, and dated on a form required by the Behavioral Health Administration of the Department of Health, and state the relationship of the applicant to the individual for whom admission is sought. HG §10-615(1)-(5). Two certificates from health care providers must accompany that application.[2] HG §10-615(6). Those certificates must be based on each provider's personal examination of the individual and must include a diagnosis of a mental disorder, an opinion that the individual needs inpatient care or treatment, and "an opinion that admission to a facility … is needed for the protection of the individual or another." HG §10-616(a)(1)-(2). The Department of Health has provided in regulation that a certificate may not be used for an involuntary admission application if the examination on which it is based was done more than one week before the certificate was signed. COMAR 10.21.01.04B(4)(a), D(1)(a).[3]

         A facility presented with such an application may not admit the individual involuntarily unless five criteria are met:

(1) the individual has a mental disorder;
(2) the individual needs inpatient care or treatment;
(3) the individual presents a danger to the life and safety of the individual or of others;
(4) the individual is unable or unwilling to be admitted voluntarily; and
(5) there is no available, less restrictive form of intervention that is consistent with the welfare and safety of the individual.

HG §10-617(a)(1)-(5).[4] Thus, in accepting such an individual as a patient, the facility must also assess whether the statutory criteria are met.

         Involuntary Admission - Hearing as Prerequisite for Admission

         The statute entitles "any individual proposed for involuntary admission" to "a hearing to determine whether the individual is to be admitted to a facility … as an involuntary patient or released without being admitted." HG §10-632(a). The hearing is to be conducted within 10 days of the patient's "initial confinement" in the facility before an impartial hearing officer designated by the Secretary of Health. HG §10-632(b), (d). The Secretary of Health has designated the administrative law judges ("ALJs") of the Office of Administrative Hearings to serve as the impartial hearing officers contemplated by the statute. COMAR 10.21.01.02B(2).

         After considering all the evidence and testimony of record, the hearing officer is to order the release of the individual from the facility unless there is clear and convincing evidence of each of the five criteria required for involuntary admission. HG §10-632(e)(2)(i)-(v). Pursuant to a statutory directive, the Department of Health has adopted procedural regulations for such hearings. HG §10-632(d)(1); COMAR 10.21.01.09. The hearing officer's decision is subject to judicial review under the State Administrative Procedure Act. HG §10-633.

         Involuntary Admissions - Regulations Governing the Process

         The regulations adopted by the Department of Health for involuntary admission provide additional detail concerning the process of admission. COMAR 10.21.01. Those regulations refer to the individual as being in "observation status" during the time the individual is confined in a facility involuntarily on the basis of an application before "the individual is either admitted, voluntarily or involuntarily, to the inpatient facility or is released by a physician or by an ALJ from the inpatient facility without being admitted." COMAR 10.21.01.02B(18).[5] The regulations provide that an individual confined in a facility on observation status remains in that status unless (1) admitted voluntarily to the facility; (2) released upon a finding by a physician that the individual no longer meets the criteria for involuntary admission; or (3) either admitted to or released from the facility as a result of the hearing before the ALJ. COMAR 10.21.01.07F. The regulations thus contemplate that an individual confined in a facility as a result of an application for involuntary admission is considered admitted to the facility only if the individual consents (i.e., the admission becomes voluntary) or if involuntary admission is authorized by an ALJ.[6]

         Involuntary Admission - Statutory Immunity

         The Mental Health Law provides immunity from liability for those involved in the decision whether to admit an individual to a mental health facility against his or her will. HG §10-618; Maryland Code, Courts & Judicial Proceedings Article ("CJ"), §5-623. In particular, an applicant who acts "in good faith and with reasonable grounds" is immune from civil or criminal liability relating to the application. HG §10-618(a); CJ §5-623(b). Similarly, a mental health facility, as well as an agent or employee of a facility, that, in good faith and with reasonable grounds, acts in compliance with the provisions of Part III of Subtitle 6 is not civilly or criminally liable for those actions. HG §10-618(b)-(c); CJ §6-623(c)-(d).

         The Williams Case: Statutory Immunity Applies to Decision Not to Admit

         This Court construed the scope of the immunity granted in HG §10-618 and CJ §5-623 in Williams v. Peninsula Regional Medical Center, 440 Md. 573 (2014). In that case, a mother brought her son to the hospital because the son had been suffering from suicidal thoughts and hallucinations. 440 Md. at 575-76. After evaluating the son, the mental health care providers at the hospital decided to release him without admitting him to the hospital and directed him to "return if he felt that he would harm himself or others." Id. That same night, the son spent several hours wandering the streets, broke into a residence, and stood in the front yard wielding a knife. Id. When the police arrived, the son rushed the officers, who then shot and killed him. Id.

         The family sued the mental health care providers, asserting they were liable for their "failure to admit" the son which, the family alleged, proximately caused his death. The circuit court dismissed the complaint on the basis of statutory immunity - a decision affirmed by the Court of Special Appeals. 213 Md.App. 644 (2013).

         In this Court, the family argued that the statutory immunity provided by Mental Health Law applies only when a facility decides to admit an individual and not when it decides against admitting the individual. The Court reviewed the structure of Part III of Subtitle 6 and its legislative history. The Court noted that its purpose was to discourage excessive institutionalization and to protect the due process rights of individuals who are proposed for involuntary admission. Id. at 586. "That the General Assembly mandated a multi-step process before an individual's involuntary admission … suggests a legislative concern that individuals may be wrongfully admitted." Id. at 584. If a health care provider has immunity only when the provider admits an individual, the immunity provision would undermine the purpose of the statute, creating "an incentive to err on the side of involuntary admittance in order to receive statutory immunity and avoid liability." Id. at 587. The Court reasoned that applying the immunity provisions to the provider's decision on admission - regardless of whether that decision is to admit or to release the individual - ensures that no one will be held against his or her will out of a physician's fear of a lawsuit. Id. at 587. Accordingly, the Court held that the statutory immunity extended to the good faith decision to release the son.

         B. Facts

         While the parties differ on whether Dr. Bell was negligent or has immunity, the basic chronology of events appears to be undisputed.

         The Attempted Suicide of Brandon Mackey

         On March 13, 2011, after struggling for years with chronic mental illness, 23-year-old Brandon Mackey cut his wrists with a knife in an apparent attempt to commit suicide. At the time, Mr. Mackey lived at home with his mother and her husband, who witnessed the incident and called the police. An ambulance arrived and transported Mr. Mackey to Harbor Hospital.

         Mr. Mackey's First Stay at Bon Secours - Voluntary Admission

         Harbor Hospital referred Mr. Mackey to Bon Secours, where he was voluntarily admitted for psychiatric treatment the next day, March 14, 2011. Once at Bon Secours, Mr. Mackey came under the care of Dr. Bell, an attending psychiatrist at the hospital.

         Dr. Bell evaluated Mr. Mackey and gathered that Mr. Mackey was depressed. He prescribed an antidepressant, an antipsychotic (as the need might arise), and other medications for Mr. Mackey. Mr. Mackey remained at Bon Secours from March 14 until March 21, 2011, under Dr. Bell's care. At the time of Mr. Mackey's discharge, Dr. Bell diagnosed him as having "major depressive disorder." According to Dr. Bell, at that time he did not see symptoms of schizophrenia in Mr. Mackey, and the "psychotic behavior" that was apparent at the beginning of Mr. Mackey's time at Bon Secours "appeared to withdraw" by the time of his discharge. Dr. Bell also felt that the level of Mr. Mackey's depression had decreased over the course of his treatment at Bon Secours. In Dr. Bell's view, Mr. Mackey became more active, interacted more with others, and no longer communicated any suicidal thoughts. Dr. Bell decided to discharge Mr. Mackey on March 21, 2011, and move him to an aftercare program - a lower level of care that included partial hospitalization.[7]

         Mr. Mackey's Second Stay at Bon Secours - ...


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