Medical Provider Liability under the Mental Health Procedures Act for Failure to Voluntarily Admit Patient
Estate of Frederick v. Geisinger Med. Ctr., 291 A.3d 899 (Pa. Super. 2023), allocatur granted Oct. 6, 2023, appeal dockets 93 & 94 MAP 2023
This case arises from Westley Wise’s murder of his girlfriend, Jessica Frederick, following a history of mental health issues for which Wise was allegedly refused treatment by Geisinger Medical Center and Alley Medical Center. Stephen Matos, administrator of Jessica Frederick’s estate, filed suit against Geisinger and Alley under the Mental Health Procedures Act (“MHPA”), 50 P.S. §§ 7101–7503 alleging that Geisinger and Alley were liable under the MHPA for gross negligence and/or willful misconduct in failing to diagnose Wise’s condition and failing to initiate inpatient treatment. Superior Court summarized the factual background as follows:
The evidence, construed in the light most favorable to Matos, demonstrates that Wise suffered a traumatic brain injury at the age of six when he was thrown from the back of an ATV while riding without a helmet. He was in a coma at Geisinger for days but eventually regained consciousness and then required extensive hospitalization thereafter. The accident left Wise with ongoing cognitive and behavioral issues throughout his childhood and adolescence, including poor judgment and lack of impulse control.
In May 2000, Wise was heavily abusing alcohol and street drugs and had acute psychological problems. He checked himself into Geisinger for psychiatric treatment and was placed into an inpatient treatment center for what he described as a nervous breakdown. He was released after 28 days of treatment.
Between 2005 and 2007, Wise treated with Alley for mental health issues, including bipolar disorder. In 2007, while living with Jennifer Karns, the mother of two of his children, Wise again abused drugs and alcohol and had significant employment issues. During an argument with Jennifer, Wise “blacked out” and “snapped,” R.R. 565, and cut Jennifer’s throat with a knife. Wise was convicted of simple assault and served 21 months in county jail.
In January 2011, Wise again was using street drugs and was having employment problems and ongoing problems with his live-in girlfriend, Jessica Frederick. In addition, his best friend died in a drunk driving automobile accident. On January 21, 2011, Wise reacted to these events by calling for an ambulance to take him to Geisinger’s emergency room. Wise testified that he went to Geisinger because he previously had been admitted there for voluntary psychiatric treatment and was familiar with its admission process. Wise’s father received a call that night that Wise was going to the hospital for psychiatric treatment. Wise’s father drove from Pottstown to Geisinger to be with Wise.
Wise submitted himself for examination and requested inpatient treatment, stating to Geisinger personnel that he was “suicidal, like I was going to snap,” Wise Deposition at 64, that he felt “suicidal or homicidal,” id. at 65, and that he “felt like I was going to snap. I didn’t feel mentally right at the time.” Id. Wise recounted his conversation with the psychiatric physician assistant, Appellant Davies, as follows:
Q. What did you tell him?
A. Just told I felt like I was going to snap. I told him I wasn’t mentally right, that I wanted to stay there.
Q. You asked him to stay there?
A. Yeah.
Q. Why did you want to stay there?
A. I just wasn’t feeling safe, wasn’t feeling okay.
Q. And how long were you with this … physician[ ] assistant, Mr. Davies?
A. Maybe 15, 20 minutes.
Q. Did you ask him if you could stay at the hospital?
A. Yeah.
Q. What did he say?
A. He said no.
Q. Did he explain to you why?
A. Basically he was saying I wasn’t bad enough to stay there, more or less.
Id. at 69.
Geisinger discharged Wise without admitting him as an inpatient and without administering any treatment. According to Geisinger’s medical records, the plan for Wise merely advised him to stop alcohol and street drugs, take daily vitamins, contact the area Service Unit for psychiatrist supervision and call Tapline if he was suicidal or homicidal or felt worse.
Wise’s father, Barry, informed Geisinger that Wise stated he feared he would harm himself or another person:
Q. Okay. What did you observe during this interaction?
A. Well, … he introduced himself. And I don’t know what his name was … I don’t know.
Q. Okay.
A. [ ] I asked him, … what was going on. And I said, I know he … when I come there, too, I had asked Wes, too. And he said, I need to stay here. I need to stay here, you know. And I asked him, I said … he wants to be committed and stuff. And he says, well, he’s not bad enough. And I says, what do you mean, not bad enough? … I said, if a person … calls 911 and come here because … they are afraid of doing something or hurting themselves or somebody, I mean – – and they said, well, you know, we don’t feel he’s bad enough….
Barry Wise Deposition at 86.
On January 24, 2011, three days after his discharge from Geisinger, Wise, accompanied by his father, presented for examination and inpatient treatment at Alley. Wise’s father told physician assistant Maza that Wise needed help because he feared hurting himself or someone else, “And you know, I said, you know, I think he needs to be put somewhere so … he needs help. Some help.” Id. at 110. Wise’s father elaborated:
Q. Okay. Did you tell … Mr. Maza … that you believed that Wes was either a danger to himself or someone else?
A. I said – – this is what I remember saying when we sat there: You know, I told him about the Geisinger thing. You know, he called to get help, you know, because he felt he was going to hurt himself or somebody….
Id. at 113. Wise testified that he told Maza he had been having hallucinations and delusions, that he was suicidal or homicidal, and that he felt as if he were going to snap. Wise Deposition at 81-83. Nevertheless, Alley discharged Wise without further treatment.
Wise returned home to his apartment, where his girlfriend, Jessica Frederick, asked him to stay the night because he was planning to go to his father’s residence for the foreseeable future. Wise killed Frederick that night and attempted unsuccessfully to kill himself. Wise later pled guilty to third-degree murder and is now serving a sentence of imprisonment.
Slip op. at 3-7. Geisinger and Alley moved for summary judgement on the estate’s claims contending that they are immune from suit under Section 7114(a) of the MHPA, which provides:
(a) In the absence of willful misconduct or gross negligence, a county administrator, a director of a facility, a physician, a peace officer or any other authorized person who participates in a decision that a person be examined or treated under this act, or that a person be discharged, or placed under partial hospitalization, outpatient care or leave of absence, or that the restraint upon such person be otherwise reduced, or a county administrator or other authorized person who denies an application for voluntary treatment or for involuntary emergency examination and treatment, shall not be civilly or criminally liable for such decision or for any of its consequences.
Slip op. at 10, quoting 50 P.S. § 7114 (emphasis added by Commonwealth Court). Relying on Leight v. University of Pittsburgh Physicians, 243 A.3d 126 (Pa. 2020), which held that medical providers were not liable under the MHPA for refusing to initiate involuntary commitment procedures against a patient who subsequently committed murders, Geisinger and Alley argued they could not be liable under the MHPA because no written application was ever made to admit Wise for voluntary inpatient treatment. Geisinger and Alley each filed motions for summary judgment, which the trial court denied. Superior Court granted Geisinger and Alley’s requests for interlocutory appeal.
Superior Court held that genuine issues of material fact existed as to whether centers were immune from civil liability or their refusal constituted willful misconduct or gross negligence. While Superior Court agreed that “Leight‘s logic applies with equal force to this case,” the court nonetheless reached a different result “because the prerequisites for involuntary examination are not the same as those for voluntary inpatient examination and treatment.” Slip op. at 15. Superior Court reasoned:
…whereas a written application is a prerequisite to initiating the involuntary inpatient examination process, no such prerequisite exists to commence voluntary inpatient examination and treatment.
An involuntary inpatient examination is not the patient’s own choice; he “is made subject to” examination, 50 P.S. § 7301, when a third person such as a physician requests examination and treatment, 50 P.S. § 7302. The applicant is a third person such as a physician, peace officer or other responsible party. See 50 P.S. § 7302(1) (physician or other responsible party must file a “written application” for emergency examination); 50 P.S. § 7302(2) (physician, peace officer or person authorized by the county administrator must file a “written statement” articulating the grounds for an emergency examination). Under the involuntary inpatient examination provisions medical providers are deemed immune from liability until “written” application is filed requesting an involuntary emergency inpatient examination, as a written application is the prerequisite to initiating this process. Leight, 243 A.3d at 141. Only after a written application is made may a medical provider be liable for denying an involuntary inpatient examination if denial constitutes willful misconduct or gross negligence. Id.
In contrast, in the case of voluntary inpatient examination and treatment under Section 201, 50 P.S. § 7201, entitled “[p]ersons who may authorize voluntary treatment”, a person may submit himself for voluntary inpatient examination and treatment. A person typically does so by taking himself to an emergency room for an evaluation to determine the level of treatment needed. There are no hearings required for admission. Voluntary admission to a facility may occur after the person is examined and the evaluating provider and person agree that he would benefit from hospitalization. If the person is to be admitted, he is then required to sign a consent form that documents his rights and describes the proposed inpatient treatment plan. In short, the prerequisite for triggering voluntary inpatient examination and treatment is when a person “submit[s] himself” to a facility requesting examination for inpatient treatment.5 Thus, while we apply Leight’s rationale that a prerequisite to treatment under the MHPA first be satisfied before liability may be asserted against a provider under the MHPA, the prerequisites are different for involuntary inpatient examination and voluntary inpatient examination and treatment. The only prerequisite necessary to trigger the MHPA’s process for voluntary inpatient examination and treatment is a person submitting himself to an approved facility requesting examination and admission for inpatient treatment. Nowhere does the MHPA require that a written application first be made before the person submits himself to a facility for examination and treatment. While the involuntary inpatient examination provisions require a “written” application for examination and treatment, the term “written” is conspicuously absent from the MHPA’s voluntary inpatient examination and treatment provisions. The inclusion of “written” in the involuntary inpatient examination provisions and its omission from the voluntary inpatient examination and treatment provisions demonstrates that the legislature did not intend to require written applications for voluntary inpatient examination and treatment. See Fonner v. Shandon, Inc., 555 Pa. 370, 724 A.2d 903, 907 (1999) (where “unless” language was in one section of Workers’ Compensation Act but not in second section, legislature had different intent in drafting second section; “where a section of a statute contains a given provision, the omission of such a provision from a similar section is significant to show a different legislative intent”). Because of this difference, the point at which liability may attach under the MHPA differs as between the involuntary examination and voluntary inpatient examination and treatment processes. If a facility refuses to examine a person who presents himself for voluntary inpatient examination and treatment, or after examination refuses to admit the person for treatment, liability may attach if the refusal constitutes willful misconduct or gross negligence.
The record here reflects that Wise, an individual with a history of acute psychological problems and a criminal record for assault, visited Geisinger and verbally requested inpatient treatment, claiming that he was homicidal and suicidal and about to snap. Geisinger’s medical providers performed an initial evaluation examination on Wise but declined his request for inpatient treatment. Three days later, Wise visited Alley and verbally requested inpatient treatment upon the same bases. Alley’s medical providers performed an examination but declined Wise’s request for inpatient treatment. That night, Wise murdered Frederick.
Construed in the light most favorable to Matos, the trial court properly denied summary judgment to Geisinger and Alley on the narrow question that was before the court. A prerequisite for liability under the voluntary inpatient examination and treatment provisions of the MHPA was satisfied when Wise submitted himself to approved facilities, Geisinger and Alley, for voluntary inpatient examination and treatment. Geisinger and Alley examined Wise but denied inpatient treatment. Under Section 7114, Geisinger and Alley participated in decisions concerning whether to treat Wise for voluntary inpatient treatment. Therefore, they may be subject to liability if their conduct constituted willful misconduct or gross negligence.
Slip op. at 17-20. Superior Court concluded:
Geisinger and Alley urge that this case will open the floodgates for lawsuits against medical providers unless we find them immune from suit under the MHPA. Our job, however, is to apply the law as written. It is up to our legislature to decide policy issues as to when and under what circumstances medical providers may be liable for harm. Here, the legislature has drawn that line only to impose liability if the refusal to treat a person constitutes willful misconduct or gross negligence. This demanding standard reflects the legislature’s attempt to strike a balance between the rights of patients and the ability of medical providers to provide adequate mental health services. We find our conclusion also to be consistent with the legislature’s intent to assure the availability of adequate treatment to those who are mentally ill and where the need is great and its absence could result in serious harm to the mentally ill person or to others. Leight, 243 A.3d at 130 (citing 50 P.S. § 7102).
Slip op. at 22.
The Supreme Court granted allocatur to consider the following issues:
(1) Whether the Superior Court of Pennsylvania erred when it found that a third party had a viable cause of action under Section 7114 of the Mental Health Procedures Act for failing to seek voluntary commitment, when in Leight, this Court expressly limited liability under the Act to decisions made after evaluation and treatment had been formally initiated under the Act, which did not occur here.
(2) Whether, in an issue of first impression and significant statewide importance, this Court’s holding in Leight v. University of Pittsburgh Physicians, 243 A.3d 126, 130 (Pa. 2020), requiring— as a condition precedent to the attachment of liability under Section 7114 of the Mental Health Procedures Act in involuntary inpatient treatment cases—evidence that treatment has been formally initiated (as opposed to merely ‘contemplated’ or ‘considered), applies with equal force to requests for voluntary inpatient examination and treatment.
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