Clarifying the Voluntary-Inpatient Threshold under Pennsylvania’s MHPA

Introduction

In Estate of Frederick v. Geisinger Medical Center, the Pennsylvania Supreme Court addressed whether a patient’s mere request for inpatient psychiatric care transforms a voluntary outpatient into a “voluntary inpatient” under the Mental Health Procedures Act (MHPA), thereby triggering Section 114’s liability scheme. The case arose after Westley Wise walked into two emergency departments, asked for voluntary psychiatric admission, was turned away, and then fatally shot Jessica Frederick. Frederick’s estate sued for gross negligence under Section 114 of the MHPA. A 4–3 majority held that Wise’s “volitional act” of requesting inpatient admission commenced the MHPA’s voluntary inpatient process. Chief Justice Todd’s dissent (Justice Wecht writing) vigorously contends that the MHPA prescribes numerous written-application and acceptance steps before any “voluntary inpatient” status can exist—and that none occurred here.

Summary of the Judgment

The majority concluded that:

• The MHPA defines a voluntary inpatient not by written forms or facility acceptances, but by the patient’s own voluntary request for inpatient treatment at a psychiatric facility.
• Once Wise asked twice—first at Geisinger, then at Alley Medical Center—for admission, he “commenced” the voluntary inpatient treatment process under the Act.
• Because Wise’s requests triggered the MHPA’s examination-and-treatment framework, the health-care providers could be liable for gross negligence in refusing admission or failing to perform a full MHPA evaluation before discharge.

The dissent, however, would have reversed. It reasons that the Act itself (and the Department’s implementing regulations) mandates a multi-step, written application and acceptance procedure—none of which took place—so Wise remained a voluntary outpatient, beyond Section 114’s scope.

Analysis

Precedents Cited

• Leight v. Univ. of Pittsburgh Physicians (Pa. 2020): Held that a mental-health professional is only “participat[ing] in a decision that a person be examined” under Section 114 once the formal prerequisites for involuntary emergency examination (written application under Section 302) are satisfied.
• Fogg v. Paoli Memorial Hospital (Pa. Super. 1996): Concluded that a patient’s mere presence in an ER seeking psychiatric care does not invoke MHPA immunity—because informal ER triage is not “treatment under the Act.”
• O’Connor v. Donaldson (U.S. 1975) and Humphrey v. Cady (U.S. 1972): Established the modern constitutional standard that involuntary commitment must rest on both mental illness and dangerousness, safeguarding individual liberty.

Legal Reasoning

1. Statutory Scope of the MHPA:
   • Voluntary outpatient care is expressly outside the MHPA (50 P.S. § 7103).
   • Article II (Sections 201–205) governs only voluntary inpatient treatment; Article III governs involuntary procedures.
2. Written Application Requirement:
   • Section 202 requires any prospective voluntary inpatient to submit an application to an approved facility or county administrator.
   • Section 110(a) mandates that “all applications” under the Act be in writing, verified, and carry a notice of criminal penalties for falsification.
   • Department Regulation 5100.72(a) prescribes Form MH-781 as the mandatory “written application for voluntary inpatient treatment.”
3. Prerequisites to Inpatient Acceptance: Before a facility may accept a voluntary inpatient application, the Act and regulations require:
   • Delivery of an explanation of possible treatments and any restrictions (50 P.S. § 7203).
   • Provision of the patient’s Bill of Rights (50 P.S. § 7203; 55 Pa. Code § 5100.73).
   • Written consent on a department-adopted form (Form MH-781).
   • Preliminary evaluation (55 Pa. Code § 5100.72(c)–(d)) to assess medical necessity and least-restrictive-setting requirements (50 P.S. § 7102).
4. Section 114 Liability: Civil/criminal liability for willful misconduct or gross negligence attaches only to those who “participate in a decision that a person be examined or treated under this Act.” Without written application and formal acceptance, no such decision occurs under Article II.

Impact on Future Cases

• Affirming the majority’s “volitional request” rule could expand MHPA exposure to any ER triage, outpatient appointment, or written request, creating enormous uncertainty for providers.
• Rejecting the dissent’s formal-process approach risks incentivizing over-commitment—providers admitting borderline cases voluntarily to avoid potential malpractice suits—conflicting with the Act’s “least restrictive setting” policy.
• This decision will shape how hospitals, psychiatrists, and county administrators design intake protocols and train staff to distinguish outpatient inquiries from formal applications under the MHPA.

Complex Concepts Simplified

• Voluntary Outpatient vs. Voluntary Inpatient:
  • Outpatient—patient lives at home, can seek therapy or medication without being governed by MHPA procedures.
  • Inpatient—patient resides (full- or part-time) in a psychiatric facility and must go through MHPA’s written application, evaluation, consent, and acceptance steps.
• Section 114 Immunity and Liability: Health-care workers and administrators are immune from suit for MHPA decisions—unless they act with gross negligence or willful misconduct in a formal MHPA admission, examination, treatment, discharge, or partial-hospitalization process.
• Due Process Protections: The MHPA balances patient liberty with access to care by requiring clear written steps—notification of rights, opportunity to consent, ability to withdraw—before restricting freedom of movement.

Conclusion

Estate of Frederick sharpens the line between informal outpatient inquiries and formal MHPA inpatient proceedings. The robust dissent reminds us that the legislature deliberately constructed a multi-step, written framework to protect patient autonomy, ensure due process, and mandate the least restrictive treatment setting. As Pennsylvania courts and providers interpret this ruling, they must decide whether a simple plea for help indeed invokes the full weight of the MHPA’s procedural safeguards, or whether—consistent with prior authority—the Act’s protections and liabilities remain tethered to its statutory written-application and acceptance requirements.