By EMILY JOHNSON

Imagine you’re an executive at a large health system in a major metropolitan area. One morning, you wake up to a missed call and a voicemail from your PR leader. It’s urgent: one of your employees–who was also a patient and a member of the organization–has unexpectedly died by suicide.  Their family is furious.

You follow up and learn that this wasn’t just any employee. It was a young leader you had worked with only a few months ago. You had regular meetings with them and had been serving as a mentor. You had been impressed by this young person’s drive, enthusiasm, analytical skills, and ability to build relationships. You believed they were on the path to being a strong leader in health care. But not anymore. Now, seemingly out of nowhere, they are gone.

You’re shocked. You’re devastated. You’re confused. You demand an immediate safety review to understand what happened and why.

The patient safety team moves quickly to investigate, and they discover that the patient was a young woman who had given birth to her first child just two weeks ago at one of your hospitals.

During her pregnancy she had disclosed to her primary OB that she was beginning to have panic attacks. The OB offered to start her on an antidepressant, but the patient declined. No referrals were placed. Red flag.

She delivered her baby after a 30+ hour labor culminating in postpartum hemorrhage. Anxiety was noted several times throughout her hospital stay. Her notes from labor say “patient acutely anxious and requesting “to be done.” Her discharge notes state “Difficulty coping with anxiety for past 1-2 weeks. Has been affecting her ability to bond with baby.” Red flag.

She was seen by a social worker, who shared with her a packet of information about postpartum depression. This person recalls the patient asking her “which of the numbers should I call if I need help immediately?” Red flag.

She presented back at the ED the day after her initial discharge with additional hemorrhage concerns. Her notes say “Patient is anxious, tearful, arriving in the ED hypertensive at 140/90, tachycardic in the 120s.” She was discharged with blood pressure medication. Red flag.

You learn that her husband tried calling the behavioral health department to make his wife an appointment, only to be told that the soonest they could get her in would be 6 weeks. He pressed and asked if there were exceptions for urgent OB patients and was told no. Red flag.

In the week leading up to her death this patient had been in contact with 3 OBs, a pediatrician, and a lactation consultant, saying things like “I am afraid of everything” and “I can’t eat or drink.” She had a positive EPDS flagging thoughts of self-harm. Big, bright, unmistakable red flag.

Phone records show that one night she tried calling the behavioral health appointment scheduling line, which was given to her by multiple providers as a 24/7 crisis line, at 2am. Red flag.

Her notes from the last time she was seen in the clinic state “she is not eating, vomits any food she eats and has diarrhea. She reports sleeping at most 4 hours a day.” She walked out of that appointment with only a prescription for hydroxyzine, which is similar to Benadryl. Red flag.

At 5:30am the next morning, her husband woke up and found that she was not in the bed. He looked over and saw that the baby was still sleeping peacefully in the bassinet. He panicked. He knew in his gut that something was wrong.