Few outcomes weigh on clinicians like losing a patient to suicide. In Episode 2 of Scrubs and Subpoenas: Tales from the Witness Stand, Dr. Sally Miller presents a case she reviewed as an expert witness. Dr. Wendy Wright, Fitzgerald faculty member, joins her.
The case centers on a family nurse practitioner managing a young man on an inpatient psychiatric unit. It raises tough questions about how far assessment should go, what documentation must show, and where scope of practice ends.
The Case: From Acute Psychosis to a Depression Diagnosis
A 21-year-old man living on his own called his mother at night. He couldn’t sleep, was having nightmares, and said he was seeing the devil. Over the next 36 hours, he believed people were chasing him, didn’t recognize his mother, and feared his stepfather would kill the family. He was hospitalized for a week with acute psychosis of unknown cause and treated with antipsychotics. His history included marijuana, mushrooms, and occasional alcohol.
At discharge, his speech was pressured and he talked about the devil. The next day he ran into traffic trying to reach the airport and threw away clothes he said were “demonized.” He was hospitalized again and transferred to a second psychiatric facility.
At the new facility, a psychiatrist completed an overnight telehealth intake. The diagnosis was major depressive disorder, severe, without psychotic features, with passive suicidal ideation. The note did not mention the psychosis. The patient agreed to a voluntary admission, and an FNP took over as his inpatient provider.
Over seven days, nursing, therapy, and the NP documented a withdrawn, depressed patient. There were no hallucinations or delusions. Ideation was passive at most and never active. Repeated suicide screenings were completed. The patient was discharged with a follow-up appointment three days out, written instructions, and crisis resources. He died by suicide two days later.
The NP, the psychiatrist, and the facility were sued, and the case settled. Sally, who worked on the defense, believes the NP’s care met the standard.
The Clinical Lesson: Depression or First-Episode Psychosis?
In hindsight, interviews with the family, his brother, and an ex-girlfriend described years of withdrawal, low mood, and isolation since high school. Sally believes this was most likely a first psychotic break of schizophrenia. Onset of schizophrenia in young men typically falls in the late teens to early twenties.
Sally’s teaching point applies to any NP treating depression. A depressive episode in a young adult calls for ruling out bipolar disorder and a psychotic disorder. Explore the trajectory and timeline of the depression, and ask directly about any past psychotic symptoms. A depressed 21-year-old with a recent history of hallucinations deserves a broader differential than MDD alone.
Language Can Hide the History
Midway through the stay, a therapist held a session in Spanish. That’s when the team learned the patient grew up in Mexico and moved to the U.S. at 18. In his first language, he opened up about family conflict and feeling unwanted, which he hadn’t shared in English. Assess language preference early and use an interpreter or language-concordant clinician when you can. A gap in communication can look like a gap in symptoms.
Suicide Risk Assessment and Discharge Documentation
The plaintiff’s allegations show where suicide care is most exposed. Here’s what NPs can take from each one.
- Assessment is more than “denies SI.” This team used structured screening, the ASQ, and documented risk factors, protective factors, and passive versus active ideation. That depth was central to the defense.
- “Not suicidal at discharge” is not “no risk.” The complaint said the NP rated his risk as “none.” The record actually documented no current ideation. Chart what you assessed, not a blanket conclusion. Involuntary holds require imminent danger to self or others, and passive ideation alone usually doesn’t meet that bar.
- Know your duty to seek history and collateral. The NP was faulted for not obtaining prior records and not calling the family. The patient had signed a form declining family contact. Psychiatric records may take up to 30 days to arrive. Document what you requested, what the patient consented to, and why.
- Treat the patient in front of you. Wendy’s view is that you assess the patient as he presents today, with or without old records.
- Build a concrete aftercare plan. The discharge included an appointment within three days, a named contact, written instructions, and crisis resources. The weeks after psychiatric discharge are a high-risk period for suicide, so a specific, near-term follow-up matters.
Sally writes every note as if “three or four experts are going to be looking at it with a magnifying glass three years down the line.”
Scope of Practice: FNPs in Mental Health
The NP in this case was an FNP who was also enrolled in a psychiatric mental health NP program. Sally notes that FNPs currently provide more mental health care than PMHNPs, often because no one else is available, especially in rural areas. That makes the role common, and common practice shapes the standard of care.
Scope still matters, and Wendy says attorneys are raising it more often in malpractice cases. Sally described a Nevada FNP who worked in a psych NP role. She was disciplined by the board and can no longer practice in mental health there without PMHNP certification. It didn’t matter that she was very good at the work.
Sally offers a two-step decision tree:
- Does your state’s nurse practice act permit it?
- If so, are you qualified, both educationally and experientially?
Wendy adds that an employer can limit your scope but can never expand it. If you’re unsure, contact your board of nursing.
Listen to the Full Episode
Hear Dr. Sally Miller and Dr. Wendy Wright discuss this case on Scrubs and Subpoenas: Tales from the Witness Stand. Subscribe for new Season 2 episodes, and visit FHEA.com for more NP resources and continuing education.
If you or someone you know is in crisis, call or text 988 to reach the 988 Suicide & Crisis Lifeline.
