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 EvaluCare provides medical care reviews for hospitals using AI technology to identify gaps that providers can close. EvaluCare brings unmatched expertise to this challenging landscape to review care to ensure care met clinical guidelines, providing feedback more real time to adjust for issues before they lead to medical errors.

As the Board Chair for a mental health agency in Vermont, I support an organization at the forefront of suicide prevention.

It was part of the inspiration to create a software as a service to provide 100% evaluation of inpatient care to monitor whether proper screenings, assessment and treatment was conducted.

When records reveal missed opportunities, clear, actionable findings are communicated to clinicians.

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/

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

• 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:

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 Medical Care Review

Reviews can connect

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.

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.

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Eva, EvaluCare’s AI-powered SaaS, delivers quality review for inpatient care by checking adherence to thousands of evidence-based guidelines and protocols. It identifies care gaps, routes clear actions to the right clinicians, and accelerates improvement cycles, strengthening documentation and coding while reducing HACs, HAIs readmissions, length of stay and more. The result is an ROI, starting in the seven figures even for critical access hospitals. Learn more at evalucare.net or contact info@evalucare.net.

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About the Author

Jason Minor is a healthcare quality and transformation leader with nearly 30 years of continuous improvement experience. A Certified Lean Six Sigma Black Belt, Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, and Certified Utilization Review Professional, he has led thousands of end‑to‑end improvement projects, mentored dozens of quality professionals, and pioneered healthcare SaaS innovations.

As Board Chair of the Vermont Program for Quality in Health Care, Jason has partnered with hospitals, non‑profits, and state agencies to elevate patient safety and care quality statewide. Previously, as Network Vice President of Quality at the UVM Health Network and through the Jeffords Institute for Quality, he guided the redesign of a system‑wide quality framework and led initiatives that achieved a number‑one patient safety ranking among the nation’s top academic medical centers.

In 2020, Jason founded EvaluCare to help organizations shift from episodic improvement to a robust quality assurance approach.

EvaluCare’s Eva platform leverages AI‑powered natural language processing, machine learning, and agentic orchestration to analyze and improve inpatient care and support comprehensive quality, mortality, peer, and utilization reviews.

Jason Minor, EvaluCare Executive Director

Network Director Continuous Systems Improvement Jeffords Institute for Quality UVM Health

Board Chair Vermont Program for Quality in Health Care Inc.,

Vice Chair Northwestern Counseling & Support Services, Inc

Lecturer UVM College of Nursing & Health Sciences in Healthcare Quality

Quality Peer Reviewer Vermont Care Partners: Centers of Excellence

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.