In the Matter of the Commitment of E.F., E.F. v. Health and Hospital Corporation d/b/a Sandra Eskenazi Mental Health Center (mem. dec.) ( 2021 )

MEMORANDUM DECISION
Pursuant to Ind. Appellate Rule 65(D),
this Memorandum Decision shall not be FILED
regarded as precedent or cited before any Jan 22 2021, 9:28 am
court except for the purpose of establishing CLERK
the defense of res judicata, collateral Indiana Supreme Court
Court of Appeals
and Tax Court
estoppel, or the law of the case.
ATTORNEYS FOR APPELLANT ATTORNEYS FOR APPELLEE
Valerie K. Boots Bryan H. Babb
Deborah Markisohn Sarah T. Parks
Marion County Public Defender Agency Bose McKinney & Evans, LLP
– Appellate Division Indianapolis, Indiana
Indianapolis, Indiana
IN THE
COURT OF APPEALS OF INDIANA
In the Matter of the January 22, 2021
Commitment of E.F., Court of Appeals Case No.
20A-MH-1103
E.F.
Appeal from the Marion Superior
Appellant-Respondent, Court
v. The Honorable Kelly M. Scanlan,
Judge Pro Tempore
Health and Hospital Corporation Trial Court Cause No.
d/b/a Sandra Eskenazi Mental 49D08-2005-MH-15959
Health Center,
Appellee-Petitioner.
Mathias, Judge.
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 1 of 14
[1] E.F. appeals the Marion Superior Court’s order temporarily committing her to
Eskenazi Mental Health Center (“Eskenazi”). E.F. argues that the trial court’s
finding that she is gravely disabled is not supported by clear and convincing
evidence.
[2] Concluding that Eskenazi failed to prove that E.F. is gravely disabled, we
reverse.
Facts and Procedural History
[3] E.F. is a thirty-three-year-old woman who has been diagnosed with
schizophrenia and lives with her mother. E.F. has been hospitalized on several
occasions over the past five years as a result of her mental illness. Most recently,
she was hospitalized from February 26, 2020 to March 9, 2020, and from April
2, 2020 to April 4, 2020. When she was discharged from those hospitalizations,
she was prescribed oral medications, which she did not maintain.
[4] On May 13, 2020, law enforcement officers transported E.F. to Eskenazi for an
immediate detention following allegations that she was not taking her
prescribed medication and had threatened to kill her mother. She also
threatened to break the windows in her mother’s house. When she was
admitted, E.F. “described a delusion that her mother was in some kind of . . .
gang bang with the place [she] used to work, and a guy named Bill for ninety
billion dollars.” Tr. p. 7.
[5] The next day, Eskenazi filed in Marion Superior Court a “Report Following
Emergency Detention.” Appellant’s App. p. 19. Dr. Halimah Oral (“Dr.
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 2 of 14
Oral”), the treating physician, opined that E.F. suffers from schizophrenia and
is gravely disabled. Eskenazi recommended that E.F. be detained in its facility
pending a hearing. Dr. Oral believed that E.F. needed custody, care, or
treatment in an appropriate facility and stated that E.F. refused to begin
voluntary treatment. Id. at 24–25. Dr. Oral recommended a temporary
commitment not to exceed ninety days.
[6] The trial court held a commitment hearing on May 20, 2020. Eskenazi only
presented evidence from Dr. Oral who testified that she had examined E.F. on
numerous occasions during the emergency detention. Dr. Oral stated that E.F.
suffers from schizophrenia, hallucinations, delusions, and impaired thinking
and judgment. Dr. Oral expressed her opinion that E.F. would not take
medication as prescribed if she were released from Eskenazi. Dr. Oral was
concerned that if E.F. refused to take medications, her delusions would worsen
and E.F. might become a danger to herself and/or others. Dr. Oral also testified
that during the emergency detention, she has not observed that E.F. was a
danger to herself or others, only that she possibly could be. Tr. pp. 9, 13.
[7] E.F. testified and, on multiple occasions, denied suffering from schizophrenia.
Tr. pp. 15, 20. Yet, she stated she would take her prescribed medications. While
she did not deny prior hospitalizations, she did not agree that she was
hospitalized as a result of her mental illness. E.F. was able to care for her basic
needs during the emergency detention. And, Eskenazi did not present any
evidence that she acted dangerously or aggressively toward hospital staff.
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 3 of 14
[8] The trial court found that E.F. suffers from schizophrenia. The court also found
that E.F.
is currently gravely disabled in that she is demonstrating a
substantial impairment and obvious deterioration in her
judgment and reasoning and behavior that has resulted in her
inability to function independently at this point in time. The
court basis [sic] that on all of the testimony including Dr. Oral’s
testimony - that of the delusions that [E.F.] reported and as well
as her significant disorganized thought processes. . . . [H]er
thoughts are not logical and goal directed, per Dr. Oral and her
reasoning is significantly impaired which prevents her from
reaching logical conclusions about what is going on around or
what she should do which would certainly put her at risk for
harm in the community. Furthermore, [E.F.] has . . .
demonstrated no insight into her mental illness. She denies . . .
having schizophrenia and it sounds as though . . . that she is not
in agreement with taking medications once she is released from
the hospital. . . . I will point out that the court is as well
concerned with the multiple admissions since the end of
February so [E.F.] has established a pattern of not following
through with what has been prescribed and return to the hospital
and she is a high risk of returning again if not on commitment.
Tr. pp. 21–22. For these reasons, the trial court granted Eskenazi’s request to
temporarily commit E.F. until August 18, 2020, unless discharged prior to that
date.
[9] E.F. now appeals. Additional facts are provided below.
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 4 of 14
Discussion and Decision
[10] E.F. contends that there was insufficient evidence to support her involuntary
regular commitment because Eskenazi did not prove by clear and convincing
evidence that she is gravely disabled. First, we observe that E.F.’s appeal is
arguably moot because ninety days have elapsed since the trial court issued its
order and she has likely been released from her involuntary commitment.
“When a court is unable to render effective relief to a party, the case is deemed
moot and usually dismissed.” In re Commitment of J.M., 62 N.E.3d 1208, 1210
(Ind. Ct. App. 2016) (quoting In re J.B., 766 N.E.2d 795, 798 (Ind. Ct. App.
2002)). However, “Indiana recognizes a public interest exception to the
mootness doctrine, which may be invoked when the issue involves a question of
great public importance which is likely to recur.” T.W. v. St. Vincent Hosp. &
Health Care Ctr., Inc., 121 N.E.3d 1039, 1042 (Ind. 2019) (quoting Matter of Tina
T., 579 N.E.2d 48, 54 (Ind. 1991)). “[A]n involuntary commitment is of great
public interest and involves issues which are likely to recur, so we generally
choose to address the merits of such appeals, despite the mootness of the case.”
B.D. v. Ind. Univ. Health Bloomington Hosp., 121 N.E.3d 1044, 1048 (Ind. Ct.
App. 2019).
[11] “’[T]he purpose of civil commitment proceedings is dual: to protect the public
and to ensure the rights of the person whose liberty is at stake.’” T.K. v. Dep’t of
Veterans Affs., 27 N.E.3d 271, 273 (Ind. 2015) (quoting In re Commitment of
Roberts, 723 N.E.2d 474, 476 (Ind. Ct. App. 2000)). “The liberty interest at stake
in a civil commitment proceeding goes beyond a loss of one’s physical freedom,
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 5 of 14
and given the serious stigma and adverse social consequences that accompany
such physical confinement, a proceeding for an involuntary civil commitment is
subject to due process requirements.” Id.[12] To satisfy due process, the facts justifying an involuntary commitment must be
proved by clear and convincing evidence. In re Commitment of G.M., 743 N.E.2d
1148, 1151 (Ind. Ct. App. 2001). Clear and convincing evidence is defined as an
intermediate standard of proof greater than a preponderance of the evidence
and less than proof beyond a reasonable doubt. T.D. v. Eskenazi Midtown Cmty.
Mental Health Ctr., 40 N.E.3d 507, 510 (Ind. Ct. App. 2015). In order to be clear
and convincing, the existence of a fact must be highly probable. Id. When we
review the sufficiency of the evidence supporting an involuntary commitment,
we will affirm if, “considering only the probative evidence and the reasonable
inferences supporting it, without weighing evidence or assessing witness
credibility, a reasonable trier of fact could find [the necessary elements] proven
by clear and convincing evidence.” T.K., 27 N.E.3d at 273 (citation omitted).
[13] To obtain an involuntary commitment, the petitioner is “required to prove by
clear and convincing evidence that: (1) the individual is mentally ill and either
dangerous or gravely disabled; and (2) detention or commitment of that
individual is appropriate.” Ind. Code § 12-26-2-5(e). Here, the trial court found
that E.F. is mentally ill and gravely disabled. E.F. does not dispute that she is
mentally ill. Her sole challenge to the sufficiency of the evidence revolves
around the trial court’s finding that she is gravely disabled.
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 6 of 14
[14] Gravely disabled is defined as:
a condition in which an individual, as a result of mental illness, is
in danger of coming to harm because the individual:
(1) is unable to provide for that individual’s food, clothing,
shelter, or other essential human needs; or
(2) has a substantial impairment or an obvious deterioration of
that individual’s judgment, reasoning, or behavior that results in
the individual’s inability to function independently.
Ind. Code § 12-7-2-96. Because this definition is written in the disjunctive, it is
not necessary to prove both prongs to establish grave disability. W.S. v. Eskenazi
Health, Midtown Cmty. Mental Health, 23 N.E.3d 29, 34 (Ind. Ct. App. 2014),
trans. denied. In this case, the trial court concluded that E.F. was gravely
disabled as defined by Section 12-7-2-96(2).
[15] E.F. lives with her mother. She has physically harmed her mother in the past.
On May 13, 2020, the date E.F. was admitted to Eskenazi, she threatened to
kill her mother and destroy the windows of their home. E.F.’s medical records
from past hospitalizations document E.F.’s delusions that her mother is trying
to harm her. Tr. p. 7. But Eskenazi did not present any evidence that E.F. made
additional threats towards her Mother during her emergency detention in this
case. And, very importantly, Eskenazi never alleged that she was a danger to
herself or others.
[16] Dr. Oral reviewed E.F.’s medical records and treated her when she was
admitted to Eskenazi. Dr. Oral testified that E.F’s “symptoms have been
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 7 of 14
present for well over six months[.]” Id. E.F. suffers from delusions,
hallucinations and “significant thought disorganization.” Id. Dr. Oral
personally observed E.F. suffering from hallucinations and disorganized
thoughts. E.F. was previously hospitalized with similar symptoms from
February 26 to March 9, 2020 and from April 2 to April 4, 2020. E.F. also has a
history of several temporary commitments within the last five years. Dr. Oral’s
testimony focused on E.F.’s prior commitments and medical records. While
relevant, E.F.’s prior medical history and past treatment of her mental illness is
not clear and convincing evidence that would support the conclusion that E.F.
was gravely disabled on the date of the commitment hearing.
[17] Eskenazi proved that E.F. lacks insight into her mental illness. E.F. struggles to
understand the importance of taking her medications as prescribed. Tr. p. 11.
E.F. describes pills as “yucky,” and she has stated that she will give her
medication to someone who needs it. Id. E.F. also does not believe that she
suffers from schizophrenia. Tr. pp. 11, 15, 20. She also denied suffering from
delusions. Tr. p. 17. E.F. was hospitalized as a result of her mental illness on
three separate occasions in less than three months in 2020. Dr. Oral does not
believe that E.F. will continue to take prescribed medication if she is discharged
and she would likely be re-hospitalized “very soon.” Tr. p. 11.
[18] However, E.F. correctly observes that her refusal to acknowledge her mental
illness or to take recommended medication “standing alone, are insufficient to
establish grave disability because they do not establish, by clear and convincing
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 8 of 14
evidence, that such behavior ‘results in the individual’s inability to function
independently.’” 1 T.K., 27 N.E.3d at 276 (quoting I.C. § 12-7-2-96(2)).
[19] After examining E.F. and considering her medical history, Dr. Oral concluded
that E.F. “has decompensated due to noncompliance with medication.” Tr. p.
9. Dr. Oral opined that if E.F. continues to refuse medication, “her delusions
will worsen” and she will “have conflicts with the people that she is living with
and possibly other individuals as well.” Id. Ultimately, Dr. Oral concluded that
E.F. is gravely disabled because
[S]he has severe thought disorganization that prevents her from
being based in reality and knowing what needs to be done or . . .
having a real picture of what is going on around her. And I think
that the delusions also contribute to that. Yesterday when I spoke
to her, she was still jumping from topic to topic. . . . [H]er
thoughts were not logical or goal directed. . . . [E.F.’s] reasoning
is significantly impaired because she is not able to sort of follow it
out through to its conclusion and she is also bothered by these
delusions that prevent her from having a real picture of what is
1
In T.K., our supreme court disapproved of cases from this court applying a too-deferential standard of
review, which affirmed civil commitment orders merely if a reasonable person could have drawn the
conclusion that commitment was necessary, even if other reasonable conclusions were possible. 27 N.E.3d at
274 (disapproving M.L. v. Meridian Servs., Inc., 956 N.E.2d 752 (Ind. Ct. App. 2011); S.T. v. Cmty. Hosp. N.,
930 N.E.2d 684 (Ind. Ct. App. 2010); K.F. v. St. Vincent Hosp. & Health Care Ctr., 909 N.E.2d 1063 (Ind. Ct.
App. 2009); J.S. v. Ctr. for Behavioral Health, 846 N.E.2d 1106 (Ind. Ct. App. 2006), trans. denied). The T.K.
Court did not list every case from this court that contained the disapproved language.
Cases T.K. did not include, but which contain the disapproved standard of review, are A.L. v. Wishard Health
Services, 934 N.E.2d 755 (Ind. Ct. App. 2010), trans. denied, and In re Involuntary Commitment of A.M., 959
N.E.2d 832, 835 (Ind. Ct. App. 2011). Eskenazi relies heavily on these cases in arguing that E.F.’s
commitment was supported by sufficient evidence. However, both cases were decided before T.K. disapproved
of the standard of review employed in A.L. and A.M.; therefore, Eskenazi’s citations to A.L. and A.M. do not
persuasively support its argument. If an appellate case applied an incorrect and too-deferential standard of
review, it is difficult if not impossible to assess whether that case’s ultimate determination of the sufficiency
of the evidence is still valid. Both A.L. and A.M. were implicitly, if not expressly, disapproved of by T.K.
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 9 of 14
going on. And because of that she cannot reach logical
conclusions about what is going on around her or what she needs
to do. So I think that constitutes an impairment in her reasoning.
Tr. pp. 10–11. Dr. Oral believed that E.F. was capable of performing activities
of daily living, i.e. showering and eating. But the doctor was concerned that
E.F.’s mental illness could cause her harm because she was likely to become
distracted by her delusions, which presents safety concerns. Dr. Oral was also
concerned that E.F. was likely to be involved in conflicts with strangers.
[20] But E.F.’s hypothetical mental state in the future cannot support a finding of
grave disability. See In the Matter of the Civil Commitment of B.J., 67 N.E.3d 1034,
1040 (Ind. Ct. App. 2016) (noting that Indiana Code section 12-7-2-96 requires
the trier of fact to assess the individual’s state at the time of the hearing prior to
ordering a commitment). In T.K., our supreme court concluded that threats to
other individuals combined with a failure to medicate and denial of mental
illness is not clear and convincing evidence that an individual is gravely
disabled. 27 N.E.3d at 277.
[21] In B.J., the treating physician believed that B.J. was gravely disabled because
his delusions made B.J. believe that he was being watched, causing him to
anger easily. 67 N.E.3d at 1037. The doctor also believed that if B.J. did not
continue with his treatment plan there was a risk that he would harm himself or
others because his symptoms would escalate. Id. Like E.F., B.J. lived with his
parents and relied on them for support, and he was able to meet his basic
human needs. Id. The trial court concluded that B.J. was gravely disabled
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 10 of 14
because he both lacked insight into his mental illness and behavior and suffered
from delusions. Our court reversed the commitment order after concluding that
the evidence only supported the conclusion that B.J. might become a danger to
himself or others in the future. Id. at 1040.
The only other evidence supporting B.J.’s commitment was Dr.
Salama’s testimony and reports that B.J. had threatened other
individuals, Dr. Salama’s testimony that B.J. had missed two
treatment appointments, and B.J.’s behavior that led the trial
court to determine that he was in denial of his mental illness.
However, the supreme court held in T.K. that threats such as
those made by T.K. and B.J., failure to medicate, and a denial of
mental illness are not sufficient to prove that an individual is
gravely disabled. Accordingly, we must conclude that there also
was insufficient evidence here for the trial court to conclude that
B.J. was gravely disabled. We are not holding that evidence of
threats may never be sufficient evidence of a grave disability, but
there was no evidence that B.J. destroyed property or put himself
or others in actual danger after he began his treatment. Those
were two factors that the T.K. Court found significant in
determining whether T.K. was gravely disabled. See T.K., 27
N.E.3d at 277.
Id.
[22] Our court addressed similar circumstances in P.B. v. Evansville State Hospital, 90
N.E.3d 1199 (Ind. Ct. App. 2017). In that case, P.B. was hospitalized because
she suffered from paranoid delusions and believed that individuals were
breaking into her apartment and threatening her harm. Id. at 1200–01. She had
frequent conflicts with neighbors and called the police department multiple
times per day. Id. She was not compliant with therapy or recommended
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 11 of 14
medication. Id. at 1201. While hospitalized, P.B. engaged in unpleasant and
aggressive behavior and was resistant to being medicated. Id. at 1204. However,
there was no evidence that P.B.’s delusions caused her to destroy property or
cause harm to herself or any other person. Id. And there was no evidence that
she was unable to feed, shelter, or cloth herself. Id. We concluded that the
hospital did not present clear and convincing evidence of grave disability after
observing that
Dr. Vatel’s recommendation in favor of P.B.’s continued
involuntary commitment was based on her unpleasantness and
inability to get along with other people, her paranoid delusions,
and her failure to fully cooperate with treatment. None of this is
untrue, and there is no doubt that P.B. suffers from severe mental
illness. However, the statutory definition of “gravely disabled” is
very specific, and it has not been met here. There is a lack of
clear and convincing evidence that P.B. was unable to function
independently or that she was in danger of not providing for her
own needs.
Id. at 1204–05.
[23] Here, Dr. Oral testified that E.F. was able to take care of her basic needs.
Eskenazi did not present any evidence that E.F. would be unable to return to
her mother’s home when released from her hospitalization. E.F.’s testimony
that she has a job was not disputed. Dr. Oral testified that E.F. suffered from
hallucinations and delusions while hospitalized, but there was no evidence that
E.F. threatened harm to herself or others or engaged in any harmful behavior to
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 12 of 14
any person or property during her hospitalization. 2 E.F. did not refuse
medication while hospitalized. Tr. p. 14. Dr. Oral’s concerns that E.F. would
likely suffer harm if she does not continue to take her medication were
speculative. And although Dr. Oral believed that E.F. suffers from impairment
in her reasoning, she did not testify how that impairment rendered E.F. unable
to function independently on the date of the commitment hearing. Tr. p. 10.
Importantly, Dr. Oral testified she had not observed that E.F. was a danger to
herself or others, only that she possibly could be. Tr. pp. 9, 13.
[24] Eskenazi proved that E.F. suffers from schizophrenia affecting her ability to
function independently. But Eskenazi was required to prove by clear and
convincing evidence that E.F. was gravely disabled, i.e. in danger of coming to
harm because she is unable to function independently. See I.C. § 12-7-2-96(2).
Dr. Oral’s testimony is this case was simply too vague and speculative to
support the trial court’s finding of grave disability. For these reasons, we
conclude that the trial court’s temporary commitment order was not supported
by clear and convincing evidence.
2
Dr. Oral testified that E.F. had physical altercations with her mother that led to prior hospitalizations. The
incident that led to E.F.’s emergency detention in this case was an oral threat to kill her mother and destroy
the windows of their home. E.F.’s mother dealt with the threats appropriately and called the police, who
transported E.F. to Eskenazi. There is no evidence in the record that E.F. made any additional threats during
her hospitalization.
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 13 of 14
Conclusion
[25] Eskenazi failed to establish, by clear and convincing evidence, that E.F. was
gravely disabled, as defined by statute. Thus, the trial court’s order for E.F.’s
involuntary commitment was not supported by sufficient evidence and must be
reversed.
[26] Reversed.
Altice, J., and Weissmann, J., concur.
Court of Appeals of Indiana | Memorandum Decision 20A-MH-1103 | January 22, 2021 Page 14 of 14