Today, after weeks of testimony in the Lindsay Clancy trial, the evidence finally closed.
I was in the courtroom for the testimony, and although much of the legal debate centered on whether Lindsay had postpartum psychosis, bipolar disorder, depression, or another psychiatric condition, I kept coming back to the question that matters most in my work:
What can we learn from this case that could protect another mother and another child?
Cora, Dawson and Callan Clancy are the victims. Studying their mother’s healthcare does not change that.
My concern is the pathway that came before their deaths.
Lindsay Received a Lot of Care. But Was It Connected Care?
Lindsay had psychiatric appointments, medication changes, perinatal mental-health treatment, emergency evaluations and eventually an inpatient psychiatric hospitalization.
There was a quantity of healthcare.
But quality asks different questions:
Did her providers know about one another?
Did they know what medications the others were prescribing?
Were adverse reactions communicated?
Was anyone looking at the entire pattern instead of one appointment at a time?
And most importantly:
Was Lindsay actually getting better?
Those questions matter because a patient can touch the healthcare system many times without anyone having the complete picture.
But Patient Safety Is Also a Partnership
This trial has also forced me to look at something uncomfortable but important:
Lindsay had responsibilities in this pathway too.
Her healthcare professionals could not read her mind.
Testimony indicated that some extremely important information was shared with family members but apparently was not consistently shared with the clinicians treating her.
Thoughts involving harming the children were reportedly discussed with family. Yet treating clinicians testified that they did not know about some of those thoughts.
There were also questions about whether each provider knew about all of the other clinicians treating Lindsay and all of the medications being prescribed elsewhere.
That matters.
You cannot expect one psychiatrist to safely coordinate a treatment plan if that psychiatrist doesn’t know another provider is also treating you or prescribing medication.
And your family cannot substitute for your healthcare team.
Telling your husband or mother that something frightening is happening may be an important first step.
But they are not the people diagnosing you, prescribing your medication or determining your level of psychiatric care.
The healthcare professional needs to know too.
Patient safety requires partnership:
The provider has a responsibility to ask, listen, document, communicate and respond appropriately.
The patient has a responsibility to be as honest and complete as possible about symptoms, medications and other healthcare providers.
Families have a responsibility to communicate serious warning signs when the patient may not be doing so herself.
All three matter.
The Symptom You Are Afraid to Tell Them May Be the Most Important One
This may be one of the biggest lessons I take from the Clancy case.
If you recently had a baby and you’re experiencing something frightening, tell your provider what is actually happening.
Not the cleaned-up version.
If you are thinking about suicide, say it.
If you are thinking about hurting your baby or another child, say it.
If you hear something other people don’t hear, say it.
If you haven’t slept for an extraordinary amount of time, say it.
If a medication makes you feel dramatically different, tell them exactly how.
And tell every provider who else is treating you and what medications they have prescribed.
Do not assume that because healthcare professionals use electronic medical records, everybody automatically sees everything.
The 19 Days Still Trouble Me
Lindsay was discharged from McLean Hospital on January 5, 2023.
Her children died January 24.
Nineteen days.
That remains one of the biggest patient-safety questions for me.
What were the discharge instructions?
What warning signs were Lindsay and Patrick told to watch for?
Who followed her after discharge?
Who was monitoring sleep, medication response and suicidal thinking?
Did her outpatient providers receive everything they needed from the hospital?
And if she was continuing to deteriorate, what was supposed to trigger another emergency intervention?
Those are questions I will continue investigating.
This Is Not About Finding One Person to Blame
The healthcare system may have had gaps.
Providers may not always have had the complete picture.
Family members sometimes possessed information clinicians did not.
And Lindsay herself appears not to have communicated every critical symptom, provider and medication consistently across her treatment team.
All of those things can be true at the same time.
That is why patient-safety investigations should not begin by deciding who we want to blame.
We follow the pathway.
For another mother leaving the hospital after having a baby, the lesson is simple:
Know the warning signs. Tell the whole story. Make sure your providers know about one another. Bring your medication list. Include your family in the safety plan. And if you are getting worse instead of better, keep asking for help.
Healthcare professionals cannot read minds.
Patients cannot coordinate complex healthcare systems alone.
Families cannot be expected to diagnose psychiatric illness.
It has to be a partnership.
The jury will soon answer the legal questions in the Lindsay Clancy case.
My question will remain:
Where could this pathway have been interrupted before a mother’s psychiatric deterioration became a danger to herself and her children?
Because Cora, Dawson and Callan deserve for us to learn something that might protect the next family.
