ER Scenario 3: Inappropriate Discharge

[Sender Name and Address]

[Recipient Name, Title]
[Hospital name and address]

[Date of Letter]

Re: Patient [Patient Name], DOB: [Patient Date of Birth]

Dear Recipient Name],

You were the attending [Physician Specialty] who treated my [Relationship to Patient, e.g., son/daughter/partner], [Patient Name], during [his/her/their] admission to [Hospital Name] between [Admission Date] and [Discharge Date]. I am writing in the hope of better understanding the clinical reasoning on which you based your decision to discharge [Patient Name] on [Discharge Date].

You will recall that [Patient Name] was admitted after [he/she/they] was brought to the emergency room at [Hospital Name] by [Arriving Agency, e.g., police/ambulance] on [Admission Date]. [Patient Name] had been [Briefly describe circumstances leading to admission, e.g., sleeping on the streets] and had developed [Secondary physical symptoms or injuries, if applicable]. [Patient Name] suffers from [Primary Diagnosis/Mental Health Condition]. [He/She/They] had been [Describe immediate housing/living history and any prior evictions or disruptions]. Following this, [he/she/they] [Describe situation ; ie intermediate housing , details of departure]. [Patient Name] was [Describe psychological state upon initial assessment] when assessed in the emergency room and the decision was made to admit [him/her/them] to the [Unit Name, e.g., psychiatric unit] at [Hospital Name] for further assessment and treatment.

While in hospital you administered [Describe treatment or medication regimen given in hospital] that [Patient Name] had been [Describe history with this treatment/medication]. After [Number of days] days you discharged [Patient Name], referring [him/her/them] back to [Discharge Destination/Housing] and [if appliable] gave [him/her/them] an appointment to see Dr. [Follow-up Provider Name], a [Provider Specialty] whom [he/she/they] had never met, in the outpatient department on [Follow-up Appointment Date].

[Describe any subsequent incidents and consequences of these incidents for example:]

[Patient Name] did not attend the appointment on [Follow-up Appointment Date], and, as a result, did not receive the [Medication/Treatment] on that date, nor apparently since then. [Patient Name] was [Describe subsequent legal, medical, or safety incident, e.g., arrested] on [Incident Date], when [he/she/they] [Specific actions during the incident]. [He/She/They] is now in the [Current Facility/Location].

Can you please explain to me:

1. Why you decided to discharge [Patient Name] on [Discharge Date], without a comprehensive plan to manage [his/her/their] [Primary Diagnosis/Mental Health Condition]? [Patient Name] had previously [Restate critical risk factor/past behavior, e.g., left the shelter] and there was nothing to prevent [him/her/them] doing so again.
2. Why did you not arrange for some type of case management in the community? A case manager could have followed up with [Patient Name] when [he/she/they] failed to attend the appointment on [Follow-up Appointment Date] and ensured that [he/she/they] received the prescribed [Medication/Treatment].
3. Did you consider placing [Patient Name] on a [Alternative Legal/Clinical Framework, e.g., community treatment order], which is an option under the Involuntary Psychiatric Treatment Act?

From my perspective [Patient Name] needed [Describe desired living/clinical arrangement, e.g., a stable residence where staff with clinical training could monitor him closely and ensure that he received his prescribed medication]. Furthermore, [Patient Name] needs assistance to [Describe specific functional/cognitive support needed, e.g., remember dates of appointments and needs to be prompted to take medication].

I would be happy to meet with you to discuss your answers to the above questions. Failing that, please respond to my questions in writing before [Deadline Date]. I want to better understand your clinical reasoning and determine how this type of scenario can be avoided in the future, both for my [Relationship to Patient] and for others. Hopefully, we can do this without unnecessarily having to involve hospital administrative staff.

Sincerely,

[Sender Name]

[Your Name and Address]

[Recipient Name and Title]
[Hospital Name and Address]

[Date of Letter]

Re: Concerns about the discharge of my [Relationship, e.g., son], [Patient Full Name], on [Discharge Date].

Dear [Recipient Name],

I am writing to request your opinion about the standard of clinical care and the discharge planning provided to my [Relationship], [Patient Name], during [his/her/their] admission to the [Unit Name, e.g., psychiatric unit] at [Hospital Name] from [Admission Date] to [Discharge Date].

On [Date of Initial Inquiry Letter], I sent a formal inquiry to [his/her/their] attending [Physician Speciality, e.g., psychiatrist], [Doctor's Full Name], requesting clarification of [Doctor's Name]’s clinical reasoning and in particular what appeared to have been the absence of a comprehensive discharge plan. To date, I have not received a response from [Doctor's Last Name]. From my perspective, [Patient's First Name]’s discharge without a comprehensive plan for [his/her/their] care and ongoing treatment in the community resulted in [his/her/their] predictable [Consequence, e.g., medical relapse and subsequent incarceration]. I am now bringing this matter to your office for a formal administrative review.

Background of Admission and Discharge

[Patient's First Name] suffers from [Medical/Mental Health Diagnosis]. [He/She/They] was brought to the Emergency Room by [Bringing Party, e.g., police] on [Admission Date], after [Circumstances leading to admission, e.g., sleeping rough in subzero temperatures and developing frostbite due to severe psychosis]. At the time of admission, [he/she/they] was [Housing status at admission, e.g., unhoused, having recently been evicted from a group home].

Despite [his/her/their] [Clinical symptoms/risk factors, e.g., poor judgement, persistent psychotic symptoms, lack of housing, and history of non-adherence to treatment], [Doctor's Last Name] discharged [Patient's First Name] after just [Number] days on [Discharge Date]. [He/She/They] was [Discharge location details, e.g., referred back to the same homeless shelter he had previously fled], and was given a routine outpatient appointment for [Follow-up Appointment Date], with a physician [he/she/they] had never met.

[Patient's First Name] did not attend the appointment on [Follow-up Appointment Date], and, as a result, did not receive [Clinical consequence of missed appointment, e.g., the injection of antipsychotic medication on that date, nor apparently since then]. [Patient's First Name] was [Subsequent event, e.g., arrested, harmed someone, etc]. [He/She/They] is now in the [ie correctional facility, another psych unit, etc].

Key Areas for Review

Can you please tell me if you think it was appropriate for [Doctor's Last Name]:

1. To discharge my [Relationship] on [Discharge Date] without [Crucial resource, e.g., stable housing]? A [Discharge environment, e.g., homeless shelter] does not seem to be a suitable place to send an individual suffering from [Condition, e.g., a psychotic illness], especially given [Patient's First Name]'s specific history of [Relevant past behavior, e.g., fleeing the shelter].
2. Not to have arranged for some type of [Support service, e.g., case management] in the community? A [Support role, e.g., case manager] could have followed up with [Patient's First Name] when [he/she/they] failed to attend the appointment on [Follow-up Appointment Date], and ensured that [he/she/they] received the prescribed [Treatment/Medication, e.g., antipsychotic medication].
3. Not to have considered placing [Patient's First Name] on a [Legal/Clinical mechanism, e.g., community treatment order], which is an option under the Involuntary Psychiatric Treatment Act?

I look forward to hearing from you before [Response Deadline Date] and hope that we can resolve this matter without having to take it to the hospital’s administration.

Sincerely,

[Your Name]

[Your Name and Address

[Recipient Name and Title]
[Hospital Address]

Re: [Patient Full Name] DOB: [Patient Date of Birth]

Dear [Recipient Name],

I am writing to formally ask your opinion on the standard of clinical care, risk management, and failed discharge planning provided to my [relationship, e.g., son], [Patient Name], during [his/her/their] involuntary psychiatric admission this past [Month of admission].

This issue was previously raised with [his/her] attending psychiatrist, [Attending Doctor Name], on [Date of first contact], and, when [Attending Doctor Name] did not respond, to the [Second Recipient Title an name] on [Date of second contact]. To date, neither [Dr. Last Name 1] or [Dr. Last Name 2] have responded to the questions I posed about the sequence of events that led directly to my [relationship]’s predictable medical relapse and subsequent [outcome, e.g., incarceration]. As the [Recipient Title, e.g., Chief Executive Officer], I am now looking to your office to initiate a review and provide formal, written responses to the questions outlined below.

Background of the Systemic Failure

[Patient First Name] lives with [Medical Condition, e.g., schizophrenia]. On [Admission Date], [he/she] was brought to your Emergency Department by [bringing agency, e.g., police], suffering from [acute symptoms, e.g., severe psychosis and frostbite] after [circumstances of admission, e.g., sleeping rough in subzero temperatures]. [He/She] was [housing status, e.g., unhoused, having been evicted from supportive housing and unable to maintain residency at a local shelter].

Despite [his/her] acute vulnerability, [list of vulnerabilities, e.g., lack of stable housing, persistent psychotic symptoms, and a documented history of treatment non-adherence], [Attending Doctor Name] discharged [Patient First Name] after only [number] days on [Discharge Date]. [He/She] was directed back to [discharge location, e.g., the homeless shelter he had previously fled], and given a routine community appointment for [Follow-up Appointment Date], with [details of appointment, e.g., an unfamiliar physician].

From my perspective it is not surprising that, without a robust community transition plan or dedicated oversight, [Patient First Name] missed this appointment, missed [his/her/their] critical [medical treatment, e.g., long-acting antipsychotic injection], and destabilized completely. On [Relapse/Incident Date]—less than [timeframe] post-discharge—[he/she/they] was/were [consequence, e.g., arrested during a psychiatric crisis and remains detained at the [Name of Facility].

To help prevent such catastrophic outcomes for other vulnerable patients, can you provide a written response to the following specific questions:

1. Does [Hospital Name] consider discharging a [patient clinical status, e.g., psychotic, non-adherent] patient directly to a [discharge environment, e.g., transient homeless shelter] to be a safe, compliant, and acceptable standard of medical discharge planning?
2. Should [Attending Doctor Name] have assigned my [relationship] a [clinical support person, e.g., case manager] before [he/she/they] was/were discharged?
3. Why did the clinical team fail to follow-up when [Patient First Name] missed [his/her] [Date] [missed event, e.g., medication appointment]?
4. Why was a [Legal/Clinical Mechanism, e.g., Community Treatment Order (CTO)] under the Involuntary Psychiatric Treatment Act (IPTA)] not utilized or even evaluated as a legal mechanism to mandate and support [Patient First Name]’s [clinical goals, e.g., medication adherence and stability] in the community?
5. Why have my previous requests for answers to these questions not been answered?

I look forward to your detailed response to these five questions. I expect a reply by [Deadline Date], and trust that we can resolve this issue without involving others outside of the hospital.

Sincerely,

[Your Signature]
[Your Printed Name]

CC: [Name and Title; e.g. Chief of Staff], [Hospital Name]