The Court of Appeals of Maryland (“Maryland Appellate Court”), which is Maryland’s highest appellate court, held in its opinion filed on July 12, 2018 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.”
In the case the Maryland Appellate Court was deciding, a 23-year-old man attempted to commit suicide in April 2011. He was taken to the defendant hospital pursuant to an application for involuntary admission certified by two doctors at another hospital, and came under the care of the defendant psychiatrist.
In accordance with the Maryland Mental Health Law, a hearing to determine whether the man should be admitted involuntarily or released was scheduled for 10 days later. In the interim, the man was confined at the defendant hospital where he was assessed and treated by the defendant psychiatrist. Two days before the scheduled hearing, the defendant psychiatrist decided that the man did not meet the statutory criteria required for involuntary admission and authorized his release. The day after he was released, the man committed suicide by jumping in front of a train.
The man’s mother subsequently filed her Maryland medical malpractice case alleging that the defendants were negligent in releasing her son. The Maryland medical malpractice jury found in her favor and awarded $6,112 for funeral expenses and $2.3 million for noneconomic damages. The jury’s total award was later reduced to $701,112 based on the statutory limit (cap) on noneconomic damages in Maryland. CJ §3-2A-09. The defendants appealed the verdict against them, arguing that they were immune from liability pursuant to the Maryland Mental Health Law.
Maryland Appellate Court Decision
The Maryland Appellate Court stated that under the Maryland Mental Health Law (Title 10 of the Health-General Article (“HG”)), a facility may not admit an individual involuntarily pursuant to an application filed by a person with a legitimate interest in the welfare of another individual 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.
Thus, in accepting such an individual as a patient, the facility must also assess whether the statutory criteria are met.
Regulations adopted by the Maryland Department of Health for involuntary admission 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. 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 Maryland Appellate Court stated that 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.
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. 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).
In a 2014 decision by the Maryland Appellate Court, the Court held 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 (the Maryland Appellate Court held in that case that the statutory immunity extended to the good faith decision to release the plaintiff’s son).
In the present case, the Maryland Appellate Court stated that the Maryland Mental Health Law does not consider an individual “admitted” as of the time the individual appears before the ALJ for the hearing. Rather, the confined individual is “proposed for involuntary admission”; involuntary admission is “sought” as opposed to already achieved; and the hearing will determine whether that individual is “to be admitted to a facility or released without being admitted.” Moreover, the ALJ is to release the individual unless the five criteria are satisfied at the time of the hearing. HG §10-632(e)(2).
Nonetheless, the Maryland Appellate Court stated “[t]o construe involuntary admission under Part III narrowly to encompass only the initial decision on an application for involuntary admission and not the period during which the individual is considered to be on “observation status” would conflict with the purpose of the immunity provision.” The purpose of the statutory immunity is to eliminate the incentive that a mental health facility or its physicians might otherwise have to err on the side of curtailing an individual’s liberty in order to protect themselves from liability. A narrow construction of the immunity statute would discourage a facility that made an initial decision that an individual be involuntarily admitted based on the statutory criteria from releasing that individual if, even a day later, it determined that those criteria were no longer met.
The Maryland Appellate Court continued: “It is thus evident that involuntary admission to a mental health facility is a process that includes at least an application accompanied by two certifications, the physical act of the individual entering the facility, and a hearing before an ALJ, after which the individual is either admitted or released without being admitted. Throughout that process, Part III of Subtitle 6 requires that the facility and the psychiatrist treating the patient ensure that the individual is confined against his or her will only if the criteria set forth in HG §10-617 remain satisfied. If they are not satisfied, the facility and the psychiatrist are obligated by Part III to release the individual. HG §10-617(a).”
The Maryland Appellate Court concluded: “In our view, the plain language of the immunity statutes – read in context, illuminated by their legislative history, and considered together with the agency regulations – extends immunity to every stage of the process by which an individual is involuntarily admitted to a mental health facility and at which the facility and its employees must apply the criteria set out in HG §10-617. That process begins with the individual’s initial confinement at the facility under an application for involuntary admission and ends with a hearing before an ALJ to determine whether the individual is to be admitted or released … a physician acting on behalf of the facility who determines, in good faith and with reasonable grounds, that a patient initially confined under an application for involuntary admission no longer fits the criteria of HG §10-617, and releases that patient, acts in compliance with Part III and is immune from civil or criminal liability. The assessment of those criteria need not be correct or done well. All that is required for immunity is that the assessment be done in good faith following the process and applying the criteria in the statute.”
The Maryland Appellate Court held: “the immunity statutes related to involuntary admission of an individual to a mental health facility apply to the entire process of involuntary admission from the initial application for admission to the mandatory ALJ hearing. If a psychiatrist employed by a facility applies the statutory criteria for involuntary admission in good faith and decides to release an individual prior to the ALJ hearing, the psychiatrist and the facility are immune from civil and criminal liability for that decision pursuant to HG §10-618 and CJ §5-623. Accordingly, a jury verdict of negligence may not be based upon an expert opinion that identifies such a decision as a breach of the standard of care.”
Source Bell v. Chance, No. 36 September Term, 2017.
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