Elizabeth Shin Chronology
On February 12, 1999, Ms. Shin took an overdose of Tylenol with Codeine. Ms. Shin was immediately transported to the Massachusetts General Hospital and to McLean Hospital, where she received in-patient psychiatric treatment for one week. Upon her release, she was referred to Dr. Kristine Girard, Associate Chief of MIT Mental Health Services.
Several MIT medical professionals and administrative staff learned of Ms. Shin’s suicide attempt, including Ms. Anna Maria Torianni, Ms. Shin’s Academic Advisor, Ms. Ayida Mthembu, the Associate Dean of Students, and Ms. Nina Davis-Millis, Ms. Shin’s Housemaster at Random Hall.
Ms. Shin was referred to Dr. Girard for treatment during the spring semester of 1999. During this time, Dr. Girard learned that Ms. Shin continued to express her intent to commit suicide and continued to suffer depression-related symptoms. Dr. Girard diagnosed Ms. Shin with “situational issues”, and did not advise her to seek psychotherapy or provide her with any medical referral during the summer semester break.
Upon her return to MIT for her Sophomore year, in October, 1999, Ms. Shin met with Dr. Leslie Egler and Dr. Kristine Girard at MIT Mental Health Services. Ms. Shin stated that she was going crazy, felt lonely and unloved, and was overwhelmed with negative thoughts. She was also eating poorly and not getting enough sleep. Dr. Egler and Dr. Girard concluded that she was confronting “situational issues” and encouraged her to come back to the clinic on a voluntary basis.
On November 9,1999, Ms. Shin met with Associate Dean Henderson and communicated to him that she had gotten upset and smashed a glass vase. She also told him that she had cut herself on her arms and wrists, but she was unclear if this was by accident or by a deliberate act.
That same day Associate Dean Henderson arranged for Ms. Shin to see Dr. Peter Reich, Chief of MIT Mental Health Services, who in turn assigned her to see Dr. Amy Brager. Ms. Shin called to sat that she would not attend the appointment. Neither Associate Dean Henderson nor Dr. Reich followed up with Ms. Shin, nor did they confirm whether anyone at MIT Mental Health Services had met with her.
On December 5, 1999, Ms. Shin sent an email to a faculty member, Riaz Shiraz Dhanani. She expressed that she was contemplating suicide by taking an overdose of sleeping pills. This email was forwarded to several MIT employees, including Associate Dean Henderson, who in turn informed Dr. Girard. No action was taken in response to the email message.
On March 18, 2000, at approximately 1:00 A.M., students that reside at Random Hall alerted Ms. Davis-Millis that Ms. Shin was cutting herself in her room. After finding Ms. Shin hysterical and out of control, Ms. Davis-Millis transported Elizabeth to MIT Mental Health Services.
Upon examination, an on-duty physician determined that Ms. Shin should be admitted to the MIT Infirmary for further observation. She was also seen by Dr. David Reisen, who concluded that Elizabeth suffered from depression and a and a potential borderline personality disorder. He observed that she feared for her safety, had suicidal thoughts, was unable to confront academic and social stress, and felt hopeless and worthless. Notwithstanding the foregoing, he discharged her the following day on March 19, 2000. On March 28, 2000, Dr. Peter Reich signed the discharge record.
On March 23, 2000, Ms. Shin sought treatment at the MIT Mental Health Services on a walk-in basis. She saw Dr. Linda Cunningham and told her that she had cut herself to get back to reality and had chronic suicidal thoughts. She felt alone, sad, angry, fearful, depressed, and had problems eating, sleeping, and concentrating. Dr. Cunningham prescribed an anti-depressant medication, but left it up to Ms. Shin to contact her parents about her diagnosed illness. Dr. Cunningham made no effort to place Ms. Shin in a more intensive therapy program.
On March 30, 2000, Dr. Cunningham saw Ms. Shin twice, by appointment and as a walk-in patient. Ms. Shin was having morbid thoughts about seeing herself bleed to death and wanting to hang herself. She seemed to be deteriorating and was not eating. Even though Dr. Cunningham diagnosed Ms. Shin with a major depressive disorder, with borderline traits, she did not seek to obtain inpatient care for Ms. Shin. Instead, Dr. Cunningham asked Ms. Shin to try to eat and to come to the walk-in clinic when she felt suicidal. She also asked Ms. Shin to return to the walk-in clinic at 3:00 P.M.
At 2:00 P.M. that same day, Dr. Cunningham communicated with Dean Henderson about Ms. Shin and her mental condition. Dean Henderson relayed that Ms. Nina Davis-Millis was concerned about Ms. Shin’s persistent self-mutilation and her morbid thoughts.
At 3:00 P.M. that same day, Ms. Shin met with Dr. Cunningham again. Dr. Cunningham increased Ms. Shin’s medication and referred her to an outpatient therapist, Eleanor Temelini, a Licensed Social Worker.
On March 31, 2000, Dean Henderson met again with Ms. Shin. During this meeting Ms. Shin informed him that she had not eaten for the last 48 hours and that she wondered why she worried about long-term plans when she might just end it all one day. Dean Henderson knew that Ms. Shin had been cutting herself at night in her dorm room and that she was seeing Dr. Cunningham. He was also aware that her dorm mates and Ms. Davis-Millis were very concerned about her and stayed up at night watching her. Dean Henderson, however, never shared these concerns or any medical diagnosis with Shin’s parents.
On April 4, 2000, Ms. Shin returned to MIT Mental Health Services on a walk-in basis, and met with a staff psychiatrist, Dr. Lili Gottfried. Ms. Shin stated to Gottfried that she “wondered why she is here” and “felt anxious in Spanish Class.” Even though Dr. Gottfried was aware that Dr. Cunningham has documented that Ms. Shin has suicidal ideation and cutting, she did not document a thorough assessment of Ms. Shin’s suicidal ideation, plan or intent.
On April 4, 2000, Ms. Shin saw an independent therapist, Eleanor Temelini, LICSW, who evaluated her. Ms. Shin agreed while meeting with Ms. Temelini that she would throw away any sharp objects she might use to cut herself, that she would try to distract herself from emotional pain, and that she would to to MIT Mental Health Services is she felt she might hurt herself.
On April 5, 2000, Ms. Shin purposely cut her wrists and arms again.
On April 6, 2000, Ms. Temelini communicated to Dr. Cunningham that Ms. Shin needed more services than she could provide, therefore, she recommended that Ms. Shin be admitted immediately into a 5-day, intensive program of Dialectic Behavior Therapy (“DBT”). Dr. Cunningham told Ms. Temelini that she would contact Ms. Shin and encourage her to make an intake appointment.
The same day, on April 6, 2000, Ms. Shin met again with Dr. Cunningham. During this meeting Dr. Cunningham learned that Ms. Shin had cut herself the night before. She discussed with Ms. Shin the option of hospitalization and participation in the DBT program, but left it up to Ms. Shin to decide what course to take.
On April 8, 2000, Ms. Shin told Jim Paris, a student who resides at Random Hall, that she wanted to kill herself that night by sticking a knife into her chest. Students contacted MIT Campus Police, who escorted Ms. Shin to MIT Mental Health Services. MIT staff physician Dr. Howard Heller saw her, and Elizabeth spoke by telephone to an on-call psychiatrist, Dr. Anthony Van Niel.
Dr. Van Niel was aware that Ms. Shin had expressed suicidal intentions earlier in the evening, and that she had a medical history which included depression and a prior suicide attempt with ongoing treatment. Notwithstanding the foregoing, Dr. Van Niel decided that he had no need to meet or evaluate Ms. Shin in person, and concluded that it was safe for her to return to her dorm room.
In the early morning hours of April 10, 2000, LeeAnn Henn Jim Paris, students at Random Hall, woke Ms. Davis-Millis and told her that Ms. Shin had said she was going to kill herself and had asked Mr. Paris to erase her computer files.
At 1:00 A.M., that same day, Ms. Davis-Millis contacted Dr. Van Niel about Ms. Shin’s suicidal intentions. Dr. Van Niel felt that Ms. Shin was not at risk and not the type of patient that should be involuntarily committed for mental health treatment. He encouraged Ms. Davis-Millis to speak to Ms. Shin. Ms. Davis-Millis contacted Dean Henderson and Dean Carol Orme-Johnson later that morning to express her concerns.
On April 10, 2000, at approximately 9:00 P.M., Andrew Thomas, a student who resided at Random Hall, heard the smoke detector in Ms. Shin’s room. He heard somebody moaning inside the room and tried to open the door, but it was locked. He called for Ms. Henn who confirmed that she too heard Ms. Shin crying and could smell smoke. As soon as Dispatcher Tirella notified the mobile units of the MIT Police, they went to Random Hall and found Ms. Shin engulfed in flames flailing on the floor in the middle of her room. Officer Munnelly entered the room and pulled Ms. Shin’s body out to the lobby area ... On April 11, 2000, Dr. Mangi informed Mr. and Mrs. Shin that their daughter had third degree burns over 65% of her body. Dr. Mangi also informed Mr. and Mrs. Shin of the grave nature of their daughter’s injuries, as well as the type of care that was being administered ... On April 14, 2000, Dr. Colleen Ryan met again with Mr. Shin to tell him that his daughter had died.