Description

In their review, the Mental Hygiene Medical Review Board stated this unfortunate case was representative of "a series of errors back and forth...a problem of communication." The physicians on the Board noted that this case also raises questions about patients who decompensate frequently and postulated that, "treating them from a base in a hospital rather than returning them to the community" might prove to be more beneficial. This case depicts clinical chaos which culminated in a patient's falling through the cracks despite an overabundance of therapists and a variety of services.