In the Matter of B.T.

Investigation into the death of a client of Riverbend Community Mental Health Center

December 2010

Disabilities Rights Center-NH investigated the untimely death of a 43 year old man who died of an acute diabetic crisis. Mr. M, who was a client of Riverbend and had been repeatedly hospitalized at New Hampshire Hospital , took psychotropic medications which had contributed to his substantial weight gain, metabolic syndrome, and adult onset diabetes.  He had not seen a primary care physician for the two years prior to his death despite his serious medical conditions. Just prior to his death, a neighbor had called Riverbend emergency services to try to get help for him due to changes in his mental state and complaints of excessive thirst, but Riverbend had not responded other than to tell the neighbor to keep an eye on him.

Changes in policies and procedures, both within the mental health center and within the Bureau of Behavioral Health, are recommended to avert similar tragedies. A more comprehensive, integrated and coordinated model for the delivery of both mental and physical healthcare is recommended, including the areas of informed consent, systems for measuring and monitoring medical risk, prevention strategies, integration of medical care, information transfer, assertiveness as to medical risk, and crisis response.

Read the Redacted report here: Review of the Circumstances Surrounding the Death of D.M., Former Client of NH’s Community Mental Health System

Summary of the NH Supreme Court Opinion in In the Matter of B.T.

Proof of Dangerousness Required in Involuntary Commitments to Conditional Discharge Status

The NH Supreme Court in a February 15, 2006 decision in The Matter of B.T., ruled that a person cannot be involuntarily committed to New Hampshire Hospital or other treatment facilities for purposes of conditional discharge unless it is demonstrated that the person meets the general involuntary admission standard. The general standard for involuntary admission is “whether the person is in such mental condition as a result of mental illness as to create a potentially serious likelihood of danger to himself or others.” The fact that conditional discharge status means that the person would not really be admitted to State Hospital does not relieve the petitioner (e.g. a mental health center) from having to prove dangerousness.

What constitutes “danger to himself or others?” Analogizing from the Involuntary Emergency Admission statute, the Court ruled that such a finding requires a threat of, a likelihood of, an attempt to inflict, or an actual infliction of serious bodily injury to oneself or another or a lack of capacity to care for one’s own welfare such that there is a likelihood of serious debilitation if admission is not ordered. The Court stated that this standard required that there be a finding by clear and convincing evidence that there are acts demonstrating “actual or likely serious bodily injury.”

The Court ruled that B.T. did not meet the dangerousness standard, and reversed the Probate’s Court decision to commit her to conditional discharge status, finding that:

• B.T’s status as an individual with a mental illness was clearly not enough to meet the standard.
• B.T.’s prior decisions to discontinue taking medication and the prior resulting manifestations of her illness such as being delusional were also insufficient to meet the standard.
• A past act involving an overdose, an isolated act of dangerousness, was not sufficiently recent and similar to the current allegations to be a reliable predictor of present dangerousness.
• “[A] psychiatrist’s finding of dangerous[ness]does not automatically …trigger commitment; without evidence of dangerous conduct.. .[E]ven the most persuasive psychiatrist’s report is insufficient…”

The Court concluded that it was reversing the lower court because “though B.T. might benefit from treatment for her illness, she cannot be deprived of her personal liberty by an involuntary commitment without clear and convincing proof of her dangerousness.” Thus, after recognizing the serious implications of depriving a person of personal liberty, the NH Supreme Court soundly rejected a more paternalistic approach in favor of an actual dangerousness standard.

NH Supreme Court Opinion in In the Matter of B.T