When making the 'right call' goes wrong: Lessons from a $4.2 million ED malpractice case
Industry Buzz
We as a society need to put forward plans and agree to fund mental health services. It will never be perfect or complete, but [it is] currently significantly underfunded and ignored by most.
—Joseph Mitros, MD, pathologist
Emergency physicians know the drill: A patient in florid psychosis escalates, staff safety becomes a concern, and all signs point toward physical restraint and rapid tranquilization.
But a $4.2 million settlement involving University of Iowa Health Care (UIHC) underscores just how narrow the margin for error can be—and how even appropriate-seeming actions can compound and cause catastrophic harm. []
This case isn’t about malice or reckless indifference—it’s about the real-world tension between safety, staffing, delays, and the clinical fog of crisis management.
About the lawsuit
According to the lawsuit, Conrad Colombo voluntarily sought help at the University of Iowa’s emergency department on April 10, 2022, reporting safety concerns and a history of bipolar and schizophrenic disorders. Psychotic features—hallucinations, paranoid delusions, and poor insight—were documented early. Colombo agreed to psychiatric admission.
There was just one problem: There were no beds available, and Colombo remained in the ED for 14 hours. Over the course of the morning, episodes of screaming, threatening language, and escalating agitation were noted. At one point, Colombo struck a hospital police officer after being told to lower his voice.
Multiple staff members subsequently restrained Colombo face down, and clinicians ordered parenteral sedation—two doses of droperidol and one dose of midazolam.
The lawsuit alleges that although Colombo was restrained prone on the floor, no staff member insisted that he be turned supine or positioned to monitor his vitals. For several minutes, staff continued to hold him face down while others prepared to restrain him.
By the time Colombo was rolled over for transfer, his lips were blue, and he was not breathing. Colombo experienced cardiac arrest and sustained permanent, catastrophic brain injuries.
The case argues that the combination of sedative medications, prone physical restraint, prolonged pressure, and lack of continuous assessment directly led to hypoxia, arrest, and irreversible neurologic damage. UIHC settled for $4.2 million.
Was this a product of underfunded mental healthcare?
Local Iowans took to Facebook to point out that this tragedy was a product of underfunded mental health services.
"We as a society need to put forward plans and agree to fund mental health services. It will never be perfect or complete, but [it is] currently significantly underfunded and ignored by most," wrote Joseph Mitros, MD in a Facebook comment.
This settlement is a reminder that the most dangerous moments in emergency medicine often occur not because clinicians don’t know what to do, but because high-risk decisions are made in compressed, chaotic conditions where small lapses have big consequences.
For ED teams, it’s a call to reexamine restraint workflows, clarify monitoring roles, and build systems that support real-time situational awareness, especially when patients are sedated, struggling, and prone.