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September 16, 2008

Duty to warn - Is a psychiatrist to blame for failing to warn a woman murdered by his patient?

Rene Cissell did not want to hurt his girlfriend, but he admitted to a social worker at University of Louisville Hospital that he just could not control his violent outbursts. 

Earlier that morning, on July 19, 1995, Cissell held a serrated knife to Kenneitha Crady’s throat, causing a minor laceration. A week before, he attempted to run his girlfriend off the road, ramming her vehicle while driving nearly 90 miles per hour. The patient recounted these attacks to his psychiatrist in detail, saying he did not want to continue hurting the woman he loved. 

Beating his legs with his fists and speaking with clenched teeth, Cissell asked to be admitted to the hospital to receive emergency psychiatric treatment and “straighten himself out.” Because he had expressed homicidal thoughts, emergency room personnel classified the patient as a high priority and placed him on an “involuntary hold,” meaning he could not leave the hospital until a doctor released him.

That would take only a few hours.

After a brief evaluation, Dr. William James determined Cissell was not dangerous, releasing him from University Hospital that afternoon and urging him to continue receiving outpatient substance abuse and psychological treatment. Although a social worker and triage nurse noted in their reports that the potentially homicidal patient had assaulted his girlfriend that morning, the psychiatrist assured the woman — who was present at the hospital — that Cissell did not pose a threat.

The next day, Cissell killed Kenneitha Crady in a brutal rampage, stabbing her more than 40 times.

“Rene Cissell relayed a compulsion to commit violence and he said he needed to be hospitalized because he couldn’t help himself,” Christopher Bates, lawyer for the victim’s family, argued before the Kentucky Supreme Court last week in a lawsuit that’s dragged on for more than a decade. The convoluted case raises questions about how far Kentucky mental healthcare providers must go in protecting a potential victim from a violent patient.

Arguing state law required the psychiatrist in this case to warn the victim and notify police of a threat, Bates said the doctor failed to do both.

The victim’s family filed a civil suit in Jefferson County Circuit Court in 1996, claiming Dr. James — along with other healthcare providers who either settled or were dismissed from the claim — failed to comply with a law requiring mental health professionals to inform a clearly identifiable victim of a threat of violence, and to contact police.

Although a jury unanimously agreed Cissell threatened violence, the jurors ruled in the psychiatrist’s favor, deciding his failure to act was not a substantial factor in causing the victim’s death.

In a 2-1 decision, the state court of appeals upheld the verdict last year, declaring a patient must communicate a threat “directly” to a medical professional, noting Cissell did not threaten his girlfriend in front of James. The threats, however, were relayed to the doctor via notes taken by his staff.

Appellate Judge Rick Johnson cast the dissenting vote, and in a separate opinion suggested the majority had essentially rewritten the law by inappropriately adding the word “directly:” “An indirect communication of an actual threat by the staff to a qualified mental health professional would meet the requirements of the statute.”

But the psychiatrist’s lawyer disagrees with that view, asserting his client is not responsible for the tragedy.

“They (mental health professionals) don’t have a proverbial crystal ball to predict what their patients are going to do in the future,” lawyer Walter King said during his argument before the high court. “It is inherently unfair to put them in a position of having to predict the future.”

The panel of seven judges — who traveled to Louisville last week to hear several cases — challenged both lawyers with questions.

Justice Mary King asked, “If you have reason to believe there is risk, we aren’t going to come after you if you get it wrong by taking precautions … isn’t that true under the statute?”

To that, the psychiatrist’s lawyer pointed out Kenneitha Crady was present when his client interviewed Cissell, saying the couple was affectionate and that the patient did not threaten to hurt anyone during the session.

Justice Lisabeth Hughes Abramson said the fact that the victim was present during Cissell’s evaluation adds “a very unique wrinkle to this case.” 

It could take the court several months to render a decision.