On February 28, 2025, the Appellate Division of the Superior Court of New Jersey filed an opinion approved for publication in S.V. v. RWJ Barnabas Health. The court reversed the denial of a motion for summary judgment and ordered the dismissal of the psychiatric malpractice complaint. In an opinion written by Judge Sabatino, it held that the healthcare providers who had discharged a patient from a voluntary commitment did not have liability for a single car crash in which the passenger was injured when the recently discharged patient drove into oncoming traffic before losing control and crashing into a telephone pole. The court granted leave to appeal limited to the issue of whether the defendants had a legal duty to the non-patient passenger plaintiff who was the patient’s sister. Concluding that under the circumstances presented, the defendants “could not have reasonably foreseen that [the patient], shortly after her discharge, would cause a motor vehicle crash that would injure plaintiff.”

In dismissing the complaint because the defendants did not owe a duty of care to the third-party passenger, the court built upon a similar outcome in Vizzoni v. B.M.D. in which the Appellate Division affirmed summary judgment in favor of a psychiatrist whose co-defendant patient had killed a bicyclist while driving under the influence of psychotropic medications. The psychiatrist had not warned the patient that she should not drive while taking the medication. The court held that because the bicyclist was not the psychiatrist’s patient, he did not owe a duty of care to a third-party injured by the patient.

In Vizzoni, the court emphasized that foreseeability was “the foundational element in the determination of whether a duty exists” to provide a basis for imposing tort liability. It serves a dual purpose in determining both the existence of a duty of care and whether a breach of that duty is a proximate cause of the ultimate injury. In Hopkins v. Fox & Lazo Realtors, the New Jersey Supreme Court noted that this formulation arises out of the classic case of Palsgraf v. Long Island Railroad Company studied in law school. In various cases, the Supreme Court has repeatedly stated that the determination of the existence of a duty of care “is one of fairness and policy that implicates many factors” and “turns on whether the imposition of such a duty satisfies an abiding sense of basic fairness under all of the circumstances in light of considerations of public policy.” The factors to be identified, weighed, and balanced include the relationship of the parties, the nature of the risk, the opportunity and ability to exercise care, and the public interest in the proposed solution. 

In Vizzoni, the court noted the recognition in New Jersey judicial decisions that a mental health professional owes a duty to take reasonable steps to protect a readily identifiable victim put at risk by their patient. This duty of care arises from the context of a special relationship between physician and patient with the principal question being whether the defendant had a duty to act for the benefit of another but failed to do so. A special relationship can be the result of status, such as employer and employee, or it may emerge from some undertaking by the defendant to exercise care for the plaintiff, such as when a physician accepts a patient with an implicit promise to treat the patient with at least the skill and care customarily exercised by physicians in that field. In the absence of a special relationship a person has no duty to control the actions of another. The Appellate Division utilized Section 41 of the Restatement (Third) of Torts (2005) to support a distinction between where the practitioner is under an affirmative duty to act as opposed to when the practitioner’s conduct creates a foreseeable risk of harm. For example, when a practitioner prescribes either appropriate or inappropriate medication that impairs the patient, who in turn puts others at risk, the practitioner was under a duty to exercise reasonable care in making that decision to prescribe. The defendant psychiatrist in Vizzoni acted affirmatively by prescribing medication for his patient B.M.D. A risk to others may occur because of negligent treatment, such as prescribing inappropriate medication that impairs the patient, but it can also occur because of appropriate care of the patient, such as properly prescribing medication that impairs the patient. The Appellate Division stated: “Thus, the question is not whether the practitioner had a duty to act, but rather were the consequences of the act of prescribing medication foreseeable to the practitioner.” It then stated that “the issue in this case is properly framed as one of proximate cause, not the duty of care.” Based on its review of the record, the court found that the evidence did not show that the patient B.M.D. was impaired at the time of the crash. The plaintiff’s proofs that the patient was experiencing side effects of the medications such as dizziness, sleepiness, blurred vision and loss of coordination amounted to pure conjecture and speculation untethered to the observations of the police who had interviewed the driver at the scene of the accident and found no impairment.

While employing the Hopkins multi-factorial analysis for the determination of duty, in S.V. Judge Sabatino approached the question differently to reach the same conclusion as in Vizzoni. In contrast to focusing on proximate cause, he stated: “Breach or no breach, the injury must have been reasonably foreseeable to support liability.  In sum, there simply is no basis here to infer that this motor vehicle crash could reasonably have been foreseen by defendants when they discharged J.V. from their facility.” The patient was a middle-aged woman who began having psychiatric symptoms at the age of 18 with an eventual diagnosis of schizoaffective disorder and bipolar disorder. She received in-patient and out-patient treatment but had been without psychiatric episodes for about twenty years before the car crash incident. In August 2017, she threatened to kill herself which prompted a psychiatric evaluation. She agreed to a voluntary admission on the day of the evaluation.

While hospitalized, the patient received several anti-psychotic and other psychiatric medications. The medication doses and combinations were adjusted during her 14-day stay. She appeared to begin having delusions that other people were giving her cocaine and touching her belongings. Nonetheless, her condition seemed to improve during the hospitalization, and she asked to be discharged. She was attending group therapy, compliant with medication, and was eating and sleeping appropriately. She was referred to a psychiatric screening assessment with a note indicating some symptoms. However, the psychiatric screener and the psychiatrist who evaluated her both concluded that she did not meet the criteria for involuntary commitment. The statute requires proof the patient is dangerous to oneself or others in the “reasonably foreseeable” future.

The plaintiff’s expert criticized the decision to discharge as premature while her medications were being adjusted and that she was allegedly not sufficiently stabilized. There was no contention that the patient’s sister should have been warned that the patient was too unstable to drive a car or of any other dangers related to her condition. The plaintiff’s expert did not review the police report, the recorded statements obtained by the patient’s insurance investigator with contradictory versions of what happened in the crash, or the deposition of any of the fact witnesses. Significantly, in his deposition, the expert testified that he did not know what caused the patient to act in the way she did while driving. Proving that premature discharge is medical malpractice means not only proving that a doctor or hospital did not meet all standards of care in making the decision to discharge, but also that the premature discharge led to harm. Accordingly, Judge Sabatino concluded:

Given the absence of this critical element of foreseeability, we discern no grounds to impose a legal duty upon these defendants to protect third parties such as plaintiff who could have been passengers injured in a vehicle driven by J.V. after her discharge.  The sibling “relationship of the parties” did not make the crash foreseeable.  Nor did the “nature of the risk” or the “opportunity and ability to exercise care.”

He bolstered this conclusion by pointing out that the claim of a “premature discharge” of this voluntary mental health patient clashed with the terms of the civil commitment laws. The patient had requested that she be discharged after a 14-day hospitalization and, before being discharged, she was found to not be a danger to herself or others on an evaluation for involuntary commitment conducted in accordance with the statute. Invoking the fourth Hopkins factor of “the public interest” he stated that the premature discharge theory of liability actually ran counter to the civil commitment laws. By statute, a patient voluntarily admitted for psychiatric care “shall be discharged by the treatment team at the patient’s request” within 48 hours of the request unless the treatment team determined that there was a need for an involuntary commitment. Such an evaluation had been done but without finding an indication for the involuntary commitment because of danger to oneself or others “within the reasonably foreseeable future.” The theory of liability based on a supposed premature discharge was contrary to “these statutory requirements that are designed to honor a patient’s liberty and autonomy.” 

Use of foreseeability as a “crucial element” in deciding whether imposition of a duty on an alleged tortfeasor is appropriate and well engrained in New Jersey law. The Vizzoni court referred to both Section 41 and Section 7 of the Restatement (Third) of Torts. Section 7 presents an intriguing challenge.Comment j addresses the proper role for foreseeability in determining duty. It states:

Despite widespread use of foreseeability in no-duty determinations, this Restatement disapproves that practice and limits no-duty rulings to articulated policy or principle in order to facilitate more transparent explanations of the reasons for a no-duty ruling and to protect the traditional function of the jury as factfinder.

However, in Coleman v. Martinez, the Supreme Court noted that Vizzoni did not adopt Section 41 and commented that while the court typically gave “considerable weight” to views expressed in the Restatement, it concluded that “the particularized foreseeability test established in our jurisprudence readily covers whether a mental-health practitioner could be found to owe a duty of care for harm caused by a patient under a particular set of factual circumstances.” Similarly, in the more recent decision of Estate of Campbell v. Woodcliff Health & Rehabilitation Center, the Appellate Division stated that “no New Jersey published case … has looked to the Restatement to establish the existence and scope of a physician’s duty to a third party.” Thus, in the context of mental health malpractice claims, this will remain a fact-sensitive determination.