Found 36 Results Sorted by Case Date
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California – Psychiatry – Improper Evaluation Of Patient With Psychiatric Disorder And Subtherapeutic Depakote Dosing



A psychiatrist saw a patient on 12/4/2007 and 6/6/2008.  The psychiatrist diagnosed the patient with having schizoaffective disorder and prescribed Depakote, mirtazapine, ziprasidone (an antipsychotic used in treating schizophrenia and bipolar disorder), and hydroxyzine (an antihistamine for treatment of allergies).

There is no documentation that the psychiatrist assessed the patient’s prior psychiatric functioning, any response to previous psychiatric treatment, nor did the psychiatrist conduct a comprehensive current assessment of the patient’s personal, interpersonal, social, and occupational functioning. The psychiatrist did not consider a differential diagnosis, which would include schizophrenia and mood disorder.

Although the psychiatrist did order appropriate chemistries on 12/4/2007, it does not appear that labs were drawn until five months later, on 5/29/2008.  The Depakote level at that time was 2.9, significantly subtherapeutic.  On the psychiatrist’s follow-up appointment with the patient on 6/6/2008, the Depakote level was not documented as being reviewed and the patient was kept on a significantly subtherapeutic dose.

For this allegation and others, the Board judged that the psychiatrist failed to provide appropriate care and treatment and failed to maintain appropriate medical records.  The Board ordered the psychiatrist to surrender his license.

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


Medical Error: Failure to examine or evaluate patient properly, Failure to follow up, Failure to properly monitor patient, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Psychiatry – Incomplete And Inadequate Mental Status Examination With Failure To Properly Prescribe Lithium



A psychiatrist evaluated a patient on one occasion on 10/13/2004.  The patient’s medications include Lithium Carbonate (used to treat mania and bipolar disorder), olanzapine (an antipsychotic drug used for treating schizophrenia and bipolar disorder), and fluoxetine (an antidepressant).  The patient died while in custody on 10/22/2004.

The psychiatrist’s 10/13/2004 progress note included a cursory summary of the patient’s subjective complaints, as well as an incomplete and inadequate mental status examination.  The psychiatrist also doubled the patient’s Lithium dose/level from 450 mg twice daily to 900 mg twice daily without knowing the patient’s prior Lithium dose/level.

There is also no documentation that the psychiatrist questioned the patient regarding side effects, assessed the patient’s subjective symptoms and level of psychosocial functioning, considered a possible differential diagnosis, a plan for psychiatric care, including medication adjustment as required, and appropriate ancillary services.

For this allegation and others, the Board judged that the psychiatrist failed to provide appropriate care and treatment and failed to maintain appropriate medical records.  The Board ordered the psychiatrist to surrender his license.

State: California


Date: July 2011


Specialty: Psychiatry


Symptom: N/A


Diagnosis: Psychiatric Disorder


Medical Error: Failure to examine or evaluate patient properly, Failure to properly monitor patient, Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Internal Medicine – Power Of Attorney Of A Patient With Intermittent Psychological And Cognitive Problems



On 11/11/2005, a 63-year-old woman with a history of multiple sclerosis, depression, and dementia presented to a skilled nursing facility after several falls at home.  She required a wheelchair.  During her stay, she exhibited exit-seeking behaviors.

In 05/2006, she had two unresponsive episodes, one of which caused her to fall and hit her head.  Afterward, she became increasingly agitated and became increasingly persistent in vocalizing her desire to go home.  She was difficult to redirect.  She also began experiencing delusions and hallucinations, saying she had to leave to care for the babies.

On 06/06/2006, a neuropsychological evaluation indicated that the patient had at least mild cognitive impairment, especially in the areas of memory and calculations and less so in visual-spatial constructions.  There was evidence of “at least moderate depression, which certainly may be reactive to her recent psychosocial stressors as well as her presenting problems.  She was, however, alert and well-oriented.”  Her attention and language abilities were within normal range.  Her reasoning abilities including abstraction and judgment were within normal range.  She was not diagnosed with dementia.  The neuropsychologist did not conclude that the patient was neither incompetent nor requiring a guardian.  On the day of testing, records from the nursing facility documented the patient saying, “I have to save the baby.  Is it wrapped?  It’s cold outside.  Please save the baby.”

Between 06/10/2006 and 06/20/2006, the cognitive and psychological status of the patient fluctuated.

On 06/08/2006, records documented that the patient’s mobility was compromised by weakness, balance problems, functional mobility limits, and cognitive deficits.  She required assistance for walking, transfers, positioning, and locomotion.

On 06/16/2006, the patient became agitated and combative, screaming that her legs were cut off and bleeding and that the staff was trying to kill her.

On 06/18/2006, the resident called 911 and reported that she had been kidnapped and was locked in a basement.  By 10 a.m., the patient had attempted to leave the facility at least five times.

The patient’s husband became concerned that the patient lacked the capacity to make her own medical decisions.

On 06/19/2006, the patient’s attending physician agreed.  Without personally examining the patient, he provided one of two signatures necessary to activate the patient’s medical power of attorney.

On 06/20/2006, after spending an hour talking with the resident and discussing her conduct with staff, the internal medicine physician noted that the patient had psychological and marital issues and required counseling.  However, he determined that the patient was capable of making her own health care decisions at the time of his interview.  The internal medicine physician declined to activate the patient’s medical power of attorney.  The husband requested a second opinion.

On 06/22/2006, the patient started having delusions and was released against medical advice.  That evening, her power of attorney for health care was activated.

According to the Board, the applicable standard of care requires that evaluations for the purposes of activation of a patient’s power of attorney for health care decisions are not limited exclusively to the period in which the physician actually sees the patient for the evaluative interview.  A patient who lacks the capacity to make healthcare decisions may have intermittent periods of lucidity.

The Board judged that the internal medicine physician provided care below the minimum standard of competence by failing to activate her medical power of attorney given periods of delusion and delirium.

He was ordered to complete multiple education activities regarding decision-making capacity and write a one page summary of how he would approach the case of the patient differently.

State: Wisconsin


Date: April 2011


Specialty: Internal Medicine, Family Medicine, Psychiatry


Symptom: Confusion, Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Psychiatry – Management Of A Patient Off Of Clozapine For More Than A Month



A patient had a long history of suffering from schizophrenia.  Prior to 1/10/2005, the patient lived in a board and care facility in Fresno.  Around December 2004, at the age of 35, the patient quit taking his medications, which included clozapine (Clozaril) for schizophrenia and propranolol for hypertension.

On 1/10/2005, the patient was evaluated at the Fresno County Psychiatric Assessment Center for Treatment (PACT) and admitted on a 5150 hold for danger to others and grave disability.  The 5150 report noted that the patient “refuses to takes meds, or have his lab work done.”  Psychiatrist A noted in the PACT report that the patient’s mother reported that the patient “was not taking his Clozaril or getting blood tests for more than a month.”  The patient had a history of almost ten years of maintenance on clozapine.

Psychiatrist B diagnosed undifferentiated schizophrenia by history and noted, “Recently decompensated due to medication noncompliance.”

At 4:35 p.m., on 1/12/2005, the patient was transferred to and admitted at the Community Behavioral Health Center (CBHC) in Fresno, California.

At 5:00 p.m. on 1/12/2005, the CBHC Nursing Admission Assessment filled by Nurse A, a registered nurse, noted, “Pt stopped Clorazil (sic) – now decompensated.”

At 5:30 p.m., Nurse A also noted in the nursing medication reconciliation that the patient had been on clozapine but had not taken it for one month according to his mother and that clozapine was not ordered by CBHC when the patient was admitted.

At 5:50 p.m. on 1/12/2005, Nurse A prepared the routine admitting orders on the patient.  She wrote everything on the page except for the following information written by others:

1) information regarding a clozapine order (which was filled out by another nurse)

2) information regarding the time, date, and signature starting with “8:45 p” (which was filled out by Psychiatrist C)

3) information written at the bottom of the page.

At 6:00 p.m. on 1/12/2055, Nurse A filled out the following on the Assessment of Ability to Function/Readiness for Discharge:

“Pt. admitted to 106 A from PACT.  Pt. Has stopped Clorazil (sic) – 1 mo ago.  now disorganized and has A/H, guarded, apprehensive..T/c with mom who reports pt. was living independently, driving to medical appts. himself.  About 1 mo. ago, pt. apparently stopped Clorazil (sic) because he was ‘tired of the labs.’…”

At 7:00 p.m. on 1/12/2005, the CBHC initial psychiatric screening noted the following:  “Pt. has been noncompliant w/meds for 1 month. Clorazil unk (sic) on dosage”

Psychiatrist B did not order clozapine for the patient.

On 1/12/2005, psychiatrist C had staff privileges at CBHC.  He performed a psychiatric evaluation of the patient.  At 8:45 p.m., Psychiatrist C signed the patient’s routine admitting orders, whereupon the patient became his patient.  The nurse told Psychiatrist C that the patient had been off of clozapine.

When Psychiatrist C initially evaluated the patient, several documents were in the patient’s chart and available to Psychiatrist C, including the following:

1) the Nursing Admission Assessment.

2) the Nursing Medication Reconciliation sheet.

3) the Assessment of Ability to Function/Readiness for Discharge.

The documents all indicated that the patient had discontinued taking clozapine.

At 8:46 p.m. on 1/12/2005, Psychiatrist C dictated a psychiatric evaluation on the patient, which noted the following:

1) He reportedly was noncompliant with medication

2) [C]ollateral information indicates that the mother who is the conservator for the patient states that the patient was not taking his Clorazil (sic) and was noncomplaint with blood draw…

3) Medications: Clorazil (sic), noncompliant, dose unk[n]own

4) [T]he patient is a 35-year-old Caucasion male with Schizophrenia, admitted for exacerbation of his condition. He was not taking his medication, non-compliant with blood draw, possibly resulting in decompensation of this condition requiring this hospitalization.

Psychiatrist C instructed Nurse B to find out how much clozapine the patient had been taking.  Nurse B called the board and care facility the patient lived at and was told the patient had not been taking clozapine for approximately one month.  Nurse B documented in the patient’s routine admitting orders the following: “Clorazil (sic) 125 mg in AM & 200 mg in PM.”  Thereafter, the supervisor told Nurse B that the patient could not have clozapine because of the length of time that had passed since the patient stopped taking it.  Based on the discussion with his supervisor, Nurse B crossed out the clozapine order on the routine admitting orders.  He then left a message for Psychiatrist C about the patient’s prior clozapine use and that the medication was not provided to the patient.

On 1/13/2005, Psychiatrist C ordered clozapine 200 mg orally every night for the patient.  A subsequent order noted the intention to withhold the clozapine until the whilte blood cell count (WBC) was taken and reviewed.  The patient received five doses of lorazepam 2 mg between 6:15 p.m. on 1/12/2005 and 8:10 p.m. on 1/14/2005.

At 9:00 p.m. on 1/14/2005, the patient was given the first and only dose of clozapine 300 mg, more than 48 hours after admission to CBHC and four days after his initial assessment at PACT.

At 6:25 a.m. on 1/15/2005, the patient was found without respiration and was shortly thereafter pronounced dead.

On 2/23/2007, Psychiatrist C made the following representations to the investigator:

1) that he was under the impression the patient had been taking clozapine but missed a dose here and there – once every couple of weeks for example

2) that he called the patient’s board and care manager who told him the patient was taking 400 mg of clozapine a day but that they failed to tell him that the patient had stopped taking clozapine

3) that the patient’s mother told him the patient did well on clozapine

4) that he would have started out giving the pateint 25 mg of clozapine had he known the patient had not taken the medication for a long time

5) that he was not aware that the patient had been off of clozapine for one week, two weeks, or a month

6) that Psychiatrist B had ordered clozapine for the patient, 125 mg in the morning and 200 mg at night

7) that Psychiatrist B’s clozapine order made him feel comfortable prescribing the medication

8) that he believed Nurse B crossed out the clozapine order on the routing admitting orders after the patient died

9) that the PACT report was not in the patient’s chart when he wrote the clozapine order on 1/13/2005.

The Board noted that the above statements were dishonest and were intentional misrepresentations to avoid responsibility and to place the blame on Psychiatrist B and CBHC.

The Board judged Psychiatrist C’s conduct as having fallen below the minimum level of competence given that he prescribed clozapine 300 mg to a patient who had been off of clozapine for an unknown period of time, failing to inquire from the patient’s mother whether the patient had discontinued clozapine, failing to review the patient’s chart which stated that the patient had discontinued clozapine, and providing misrepresentations to the investigator to avoid blame and responsibility.

The Board placed Psychiatrist C on probation for 3 years.  Stipulations included completing a continuing medical education course aimed at correcting areas of deficiency, completing an ethics course, and undergoing monitoring by another psychiatrist.

State: California


Date: June 2009


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder, Drug Overdose, Side Effects, or Withdrawal


Medical Error: Accidental Medication Error, Ethics violation, Failure of communication with other providers, Failure of communication with patient or patient relations


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Psychiatry – Reliance On Psychiatric Patient To Self-Report Psychiatric Symptoms In A Correctional Facility



A psychiatric patient in a correctional facility suffered from persistent and severe mental illness, for which he had been treated with psychotropic medications.  While he was taking his medications, his illness was in remission, but when he was not taking his medications he became psychotic.

His psychiatrist permitted his patient to discontinue his psychotropic medications on 3/26/1998, even though knew he that the patient was likely to become psychotic as a consequence.  The psychiatrist did not inform the correctional staff that the patient was no longer taking the psychotropic medications or that the patient was likely to relapse to a psychotic condition.

The psychiatrist’s treatment plan for the patient was to rely on the patient to recognize that he was becoming psychotic and to request psychiatric intervention and treatment when that happened, even though the psychiatrist knew that the patient could not be relied upon to recognize his deteriorating condition.

Between 3/26/1998 and 7/29/1998, the patient began to demonstrate self-destructive behaviors, including beating his head against his cell to the point that he required stitches to close the resulting wound.  On 7/29/1998, the patient committed suicide in his cell.

A civil and federal suit found that the psychiatrist was responsible and negligent for the patient’s death.  The psychiatrist asserted that he was not legally authorized to do anything but permit the patient to decide whether he needed treatment because the patient had not recently shown himself to be a danger to himself or others.  The legal standard for involuntary treatment of mentally ill persons who are already confined in prison does not require that the mentally ill person have a recent history of being a danger to himself or others, but only that the person be mentally ill, a proper subject for treatment, and in need of treatment.

The Board ordered that the psychiatrist pay the costs of the proceeding, be reprimanded, not practice in a correctional institution for a period of two years, and complete 20 hours of continuing education in the practice of psychiatry in correctional institutions, with particular emphasis on the prevention of suicide by mentally ill patients.

State: Wisconsin


Date: October 2005


Specialty: Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: Improper treatment


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Psychiatry – Internist Determines Psychiatric Consultation Not Necessary When Admitted Patient Threatens Suicide



On 9/10/1996, Patient A was admitted under an internist’s care after threatening suicide.  The internist determined that a psychiatric consultation was not necessary given Patient A’s history and physical assessment.  The internist cleared the Patient A for discharge on 9/12/1996.  The Committee determined that the internist’s care of Patient A was not optimal; however, they found his clinical judgment appropriate given his clinical findings.  Although Patient A committed suicide a week later, it was determined by the Committee that a different course of action by the internist would not have changed the outcome.

The internist provided a written statement dated 3/20/2003 to an Investigator for the Department of Health Professions in response to an investigation into his treatment of the patient.  The document contained a false statement in that the internist stated, “…this case had been thouroughly [sic] reviewed [by] my malpractice insurance company…thankfully, I had never had any malpractice case…”  This statement by the internist directly contradicted the evidence reviewed by the Committee in which a malpractice settlement had been reported to the National Practitioner Data Bank on 2/22/2002.

On 811/1999, a medical malpractice payment was made on his behalf to settle a claim of inadequate monitoring and treatment of Patient A.  Subsequent to the report, the internist failed to update within 30 days the change in the malpractice information on his Practitioner Profile as required by the Board’s General Regulations.  Further, the internist reported that “…this case is under peer review…”  This statement was misleading, as the case had already been settled.

He was issued a reprimand and a fine.

State: Virginia


Date: December 2003


Specialty: Internal Medicine, Psychiatry


Symptom: Psychiatric Symptoms


Diagnosis: Psychiatric Disorder


Medical Error: No error found


Significant Outcome: Death


Case Rating: 1


Link to Original Case File: Download PDF



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