Slow Healthcare Transformation: Increasing Suicide Risk & Malpractice

Death by suicide is a growing national epidemic. Our health system is slow to keep up, as regulatory bodies scramble to put regulations in place to build the systems needed for prevention and treatment. The gap between system transformation puts many at risk of receiving negligent care.

On average, over 130 Americans die by suicide every day, with more than 48,000 lives lost annually VA Research. Suicide rates climbed 37% from 2000 to 2018, dipped slightly in 2019–2020, and surged again in 2022 CDC. Yet the tragedy is not only the numbers—it’s that most people who die by suicide have recently interacted with the healthcare system. In fact, approximately:

• 80% saw a physician within the year before their death

• 45%–66% saw a physician within the month before their death

• 45% saw a primary care provider within one month of suicide PMC

Equally concerning, 67% of U.S. military suicide decedents had a primary care encounter in the 90 days before their death Defense Security Cooperation Agency.

These statistics point to a critical window of opportunity—across primary care, urgent care, emergency departments, and inpatient settings—to screen, assess, and treat suicidal ideation. Failure to seize this opportunity can, and sometimes does, cross the line into medical malpractice.

This blog explores not only the suicide crisis in the US, but also how EvaluCare that can help find answers. EvaluCare brings unmatched expertise to this challenging landscape. EvaluCare's executive director in mental health and behavioral health have decades of experience implementing and overseeing suicide prevention programs across the system. We meticulously review medical records to determine whether proper screenings were conducted, whether positive screens received the mandated assessments, whether appropriate treatment was provided and whether a safety plan was in place and communicated at discharge.

Our experts cross‑reference Joint Commission standards, national guidelines, and institutional policies to identify deviations from accepted practice. When records reveal missed opportunities, such as missing PHQ‑9 scores, undocumented risk interviews, or absent follow‑up appointments, we compile clear, actionable findings that families and attorneys can use to pursue accountability and systemic improvement.

For patients and families who have lost loved ones under these circumstances, EvaluCare offers direct support even if no attorney is yet involved. We provide an initial case assessment, explain potential care deficiencies, and recommend next steps, whether that is filing a complaint with regulatory agencies, pursuing accountability through direct settlement negociations, or engaging a qualified malpractice attorney. If legal representation is needed, we refer families to trusted attorneys who specialize in medical negligence. Our goal is to ensure that every affected individual has access to the clinical expertise required to uncover the truth and secure justice.

A National Patient Safety Goal: Suicide Risk Assessment

Recognizing this urgent need, The Joint Commission established National Patient Safety Goal 15.01.01: “Identify patients at risk for suicide”

Accredited hospitals and behavioral health settings must:

1. Screen all patients for suicide risk using a validated tool (e.g., PHQ‑9, Columbia‑Suicide Severity Rating Scale).

2. Assess those who screen positive with a comprehensive evaluation of ideation, intent, plan, and lethality.

3. Create a care and safety plan, including means restriction, outpatient follow‑up, and crisis resources.

4. Document all screening, assessments, and interventions in the medical record.

This framework is backed by the U.S. Surgeon General, American Foundation for Suicide Prevention (AFSP), and Substance Abuse and Mental Health Services Administration (SAMHSA), all of which emphasize universal screening as a cornerstone of prevention WikipediaMedCentral.

Why Early Screening Matters

Capturing a Critical Window

Patients often present with non‑psychiatric complaints, fatigue, insomnia, pain, that mask underlying distress. Universal screening ensures that suicidal thoughts are not overlooked simply because the visit is for hypertension or a sprained ankle.

Reducing Missed Opportunities

• Primary Care: Up to 77% of decedents saw a PCP within a year; 45% within a month PMC.

• Emergency Departments: Nearly 30% of suicide decedents visited an ED in the week before their death ScienceDirect.

• Inpatient & Urgent Care: Acute settings often lack standardized mental health screening, leading to silent risks during transitions of care.

Challenges Across Care Settings

Primary Care

• Time Constraints: Busy clinics may lack the 10–15 minutes needed for thorough suicide screening and safety planning.

• Training Gaps: Many PCPs report low confidence in assessing lethal ideation and crafting safety plans MedCentral.

Urgent Care

• Focus on Physical Injuries: Urgent care providers may not see mental health screening as within their scope, missing crucial signs.

• Lack of Follow‑Up: Walk‑in visits rarely include structured linkage to psychiatric services.

Emergency Departments

• High Acuity: EDs manage life‑threatening physical conditions, with mental health screening often de‑prioritized.

• Boarding & Crowding: Wait times and boarding of psychiatric patients can exacerbate distress and limit privacy for honest disclosure.

Inpatient Settings

• Variable Protocols: General medical floors may lack behavioral health expertise and standardized suicide precautions.

• Transition Risks: Discharges without clear outpatient follow‑up or safety planning see elevated post‑discharge suicide risk.

Evidence & Best Practices

• PHQ‑9: A nine‑item depression screen with a specific item on self‑harm ideation. A score ≥1 on item 9 flags the need for immediate assessment Wikipedia.

• C‑SSRS: Endorsed by the FDA and Joint Commission for its predictive validity across age groups.

• Safety Planning Intervention: A brief, collaborative tool shown to reduce suicidal behavior by up to 45% over 6 months CAMS-Care.

When Screening Fails: Malpractice Cases

Case 1: $1.5 Million Settlement for Failure to Treat Suicidal Patient

A Pittsburgh‐area man presented to primary care with depression but was neither screened nor referred. Weeks later, he died by suicide. His family secured a $1.5 million settlement, with the court finding failure to assess suicidal ideation constituted negligence.

Case 2: $1 Million Psychiatric Malpractice Settlement

In Virginia, a patient under outpatient psychiatric care denied suicidal thoughts on an unstructured interview. No standardized tool was used. Two weeks later, he completed suicide. The practice settled for $1 million, noting that deviation from accepted screening standards was a breach of the standard of care.

Case 3: $225,000 Settlement Against Mental Health Provider

A regional provider failed to document any suicide risk assessment in the medical record for a patient with known self‑harm history. After discharge, the patient died by suicide; the estate received $225,000 for negligent mental health support.

In each case, plaintiffs showed that absent or inadequate screening, assessment, and safety planning directly contributed to harm—meeting the legal threshold for malpractice.

National Organizations Leading the Charge

• American Foundation for Suicide Prevention (AFSP): Champions screening and lethal means counseling in healthcare settings.

• Suicide Prevention Resource Center (SPRC): Provides toolkits for integrating screening into primary care.

• Zero Suicide: A systems‐based approach for behavioral health care emphasizing routine screening and follow‐up.

• The Joint Commission: Mandates NPSG 15.01.01 for accredited hospitals and behavioral health programs

EvaluCare: Your Expert Partner in Seeking Justice

When a loved one dies by suicide after a care gap, families need rigorous, compassionate review to determine if malpractice occurred. EvaluCare’s executive directors in Mental Health and Behavioral Health, each with decades of experience, offer:

1. Comprehensive Medical Care Review: Identify missing screens, incomplete assessments, and absent safety plans.

2. Policy & Guideline Mapping: Correlate chart findings with Joint Commission, VA/DoD, USPSTF, and Zero Suicide standards.

3. Expert Reports: Detailed analysis by quality leaders and mental and behavioral health leaders.

4. Attorney Referrals: If legal action is needed, we connect families to top malpractice counsel.

5. Direct Support: For those without attorneys, we guide next steps, whether appeal to the hospital, regulatory complaints, or malpractice claims.

Our goal: help families uncover the truth, hold providers accountable, and drive system changes that save lives.

Conclusion: Screening Is Not Optional

Suicide is preventable. Every healthcare encounter—whether at a family practice, urgent care, ED, or inpatient unit—is a chance to ask, listen, and intervene. As The Joint Commission and national experts affirm, routine, validated suicide screening followed by thorough assessment and safety planning saves lives—and prevents malpractice liability.

If your loved one died by suicide after a care gap, reach out to EvaluCare. Our mental health and behavioral health experts will review every record, map the deviations, and empower you with the evidence needed for justice—and for safer care for others.

You don’t have to face this alone. Contact EvaluCare today to begin your path to answers and accountability.

For more information on how EvaluCare can review your case or support your organization’s quality initiatives, visit EvaluCare Medical Care Review Services.

Learn more at www.EvaluCare.net or email info@EvaluCare.net

References

1. The Joint Commission. National Patient Safety Goal 15.01.01: Identify patients at risk for suicide. Feldman Shepherd

2. Stone DM, et al. “Vital Signs: Trends in State Suicide Rates … ” MMWR. 2018. CDC

3. Bertling Law Group. “Negligent Medical Care & Mental Health Support Resulting in Suicide.” Bertling Law Group

4. Feldman + Shepherd. “$1.5 Million Settlement for Failure to Treat Suicidal Patient.” Feldman Shepherd

5. WawLaw. “Psychiatric Malpractice/Suicide Case Settled for $1 Million.” wawlaw.com

6. SPRC. “Safety Planning Intervention.” CAMS-Care

7. MedCentral. “Suicide Must Be Discussed in Primary Care.” MedCentralVeuillez note, sources correspond to in‑text citations.