On April 1, 1965, a 51-year-old depressed woman asphyxiated herself by tying a plastic bag over her head. The suicide occurred on a relatively open ward at the Psychosomatic and Psychiatric Institute (hereafter known as P&PI) of Michael Reese Hospital and Medical Center.
The patient had been admitted to a closed ward in late February 1965 with a psychotic depression. On the eve of her admission she began having grand mal seizures which evolved into status epilepticus. She was then transferred emergently to the intensive care unit at the main hospital, where chemotherapeutic control was established. Upon her return to P&PI on March 5, she was placed on the maximum security ward. She remained extremely depressed, withdrawn, and querulous; however, after several weeks she became more communicative and overtly angry. Transfer to a more open ward was effected on April 1, without administrative hesitation despite the open protestations of the