Dawn Martin was admitted to the ED in April after a suicide attempt. She later left the ED unnoticed and committed suicide. The state Department of Health investigated her death and found that eight other people in mental health crises left the hospital’s ED without being immediately noticed between January and April.
The department fined the hospital $26,000 for failing to adequately supervise potentially suicidal patients and failing to follow up on mental health patients who “eloped” from the hospital, according to the report. The department required the hospital to institute a corrective action plan and to keep detailed records of mental health ED patients.
In response, Holy Spirit has made policy changes, including continual supervision of potentially suicidal ED patients, immediate involvement of a specialized crisis worker in the case and increased staff training.
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