To reach a suicide prevention hotline, call 888-568-1112 or 800-273-TALK (8255), or visit suicidepreventionlifeline.org.
Staff at a Waterville hospital sent a patient home last summer after he made suicidal statements and had a bandaged wrist, only for the patient to return the next day with a self-inflicted gunshot wound from which he later died.
The case at Northern Light Inland Hospital drew a citation from state and federal regulators following a fall 2021 review, prompting the hospital to make changes around staff training, event reporting and medical records.
The patient, who was not identified, first called Inland Hospital on Aug. 2 to report that he was considering suicide and then appeared at his primary care physician’s office at the hospital the next morning at 9:30 a.m. to report that he had slashed his left wrist in an attempt to end his life and wanted to see a doctor. He was referred to a physician assistant that afternoon.
The patient had previously gone to an outpatient clinic three times on June 6, June 13 and July 23, and said he was suicidal on those three occasions. He was held for three days on an involuntary psychiatric hold at a different hospital a week before he cut his wrist and went to Inland Hospital, according to a report from the federal Centers for Medicare and Medicaid Services.
The report, which was published on the agency’s website, said that the physician assistant failed to document the patient’s suicidal statements or examine his injury when he returned on Aug. 3 for his 3:15 p.m. appointment, though a receptionist noted that the patient had been having difficulty sleeping and that he said that if he had a gun, he would shoot himself with it.
“There was no evidence in the patient’s medical record that [the physician assistant] discussed and assessed the patient’s suicidal ideation or that a physical exam was completed to assess [his] bandaged wrist before the patient left the office,” the report said.
The physician assistant later said in an interview with inspectors on Oct. 6 that the patient had been agitated about the delay in being seen, and that the assistant had done a general assessment but not a physical examination. The physician assistant didn’t note any bandages, and wasn’t aware that the patient had formulated a plan for suicide, according to the interview. The receptionist had noted the patient’s plan in an email to a nurse.
After the patient’s “mood and agitation had lifted, I was under the assessment that he was doing really good,” the assistant said, adding that the patient’s behavior was not abnormal in light of his mental health history. “I had very little to no concerns. I never looped back to ask about his mood.”
The patient was then sent home, after which he returned to the hospital the next day on Aug. 4 around 11:50 a.m. via ambulance after he shot himself in the head. He died a week later, on Aug. 11, at another hospital after being assessed and treated at Inland Hospital and flown to the other hospital.
A hospital administrator, who is also the patient’s primary care physician, said that there were “pretty major” documentation problems with the case.
“I was a bit shocked that the patient was allowed to leave in the morning with suicidal ideation…and that the suicidal intent was not addressed at the [afternoon] appointment,” the physician told interviewers.
The federal agency said that documents and interviews showed that the hospital had failed to conduct required reviews of the case, including one that examined its causes so the hospital could take steps to prevent a similar case.
Inland Hospital took the citation seriously and immediately acted upon it to ensure a similar event didn’t happen again, as is the standard for every hospital the Centers for Medicare and Medicaid Services cite, said Suzanne Spruce, a spokesperson for Northern Light Health. The agency reported that the hospital’s governing body had corrected deficiencies on Dec. 15.
“We addressed every aspect identified by CMS and implemented appropriate changes,” Spruce said. “In this case that included education, training, improved event reporting processes, and changes to our electronic health records.”