Three Children Died. Their Mother Was Already in Treatment.

By Mary Dobson, LMFT, CEDS

The very public Lindsay Clancy case is extraordinarily difficult to discuss responsibly. Unfathomably, a mother killed her three children. Worse, she had also been actively engaged in psychiatric care. 

The legal system is now deciding whether Clancy was criminally responsible for those killings. For behavioral health clinicians, the gutting question is this: How can a patient move through multiple psychiatric providers, medication changes, emergency evaluation, hospitalization and outpatient treatment without the treatment system developing a sufficiently integrated understanding of her deterioration?

This tragedy demands scrutiny of something I speak on often: fragmented care.

Now, I have every reason to believe Clancy’s providers cared. And she certainly had access to care. Yet, access does not imply comprehensiveness. A patient may have access to a therapist, psychiatrist, emergency evaluations and hospitalists, all without having anything close to a coherent treatment team.

Recent trial testimony makes this point painfully concrete. Reporting describes clinicians’ contrasting information about Clancy’s psychiatric progression, with no two providers sharing the same longitudinal picture.

To be clear, this does not establish individual negligence, but it does expose a structural vulnerability. Think about it: A therapist knows one part of the story / A psychiatrist knows another / The hospital knows what precipitated admission / A spouse knows what happens at home at 2 a.m. When each of these observations remain siloed, providers experience the illusion of comprehensive care while practicing in the dark.

Healthcare research has long identified transitions of care as high-risk periods. We say information gets “lost in translation,” but often it survives and loses its context instead. The medication remains on the list, but the reason it changed disappears. The diagnosis transfers, but the trajectory behind it is flattened. One clinician hears anxiety, while another has documented insomnia, racing thoughts, or suicidality.

Continuity of care requires preservation of clinical understanding, not simply transfer of records.

This Is Where Systemic Practice Matters

From my earliest training, I was taught to think systemically. That means, at the most fundamental level, that the identified patient never becomes the boundary of my clinical reasoning.

If I am treating a mother whose psychiatric condition is deteriorating, her children matter clinically. Her functioning at home matters. Sleep matters. Medication changes matter. What her spouse is observing matters. What happened during her hospitalization matters. What her family understands about risk matters.

Families possess information clinicians cannot possibly obtain during scheduled encounters. We see samples, where they see patterns.

This is why the question What did Patrick Clancy know? is grossly inadequate. I want to know what the treatment system told him. Did he understand the warning signs? Was he given guidance about supervision? Did he know when emergency reassessment was warranted? Was anyone regularly asking what he was seeing at home?

In best practices, families are expected to become part of the safety infrastructure after a psychiatric hospitalization. This also means we have to equip them accordingly.

This case illustrates why we built LiftWell around multiple levels of care within one clinical platform. Patients may change in acuity, but their clinical histories do not start over every time they do. This is also why we require LiftWell therapists to maintain regular consultation with outside providers. Patients cannot become the sole couriers of complicated psychiatric information between their clinicians. 

This case has demonstrated why, as providers, we must be relentlessly exacting about documentation and collaborative care. For example, at LiftWell, we reconcile medications repeatedly. “Takes Prozac” does not suffice as an adequate medication history. Who prescribed it? What dose? What changed? When? Why? Is she actually taking it? What happened afterward?

Multiple providers can reflect specialization and legitimate need; they can also reflect reassurance-seeking, ambivalence, splitting, shame, mistrust or selective disclosure. The pattern itself is data. Five siloed providers do not constitute a multidisciplinary team; they pose a danger to the same patient they aim to treat.

In training new clinicians, these lessons are often perceived as “needless paperwork,” or “over the top communication” – until they understand what these standards protect against.

Behavioral healthcare is increasingly delivered through compressed encounters, while many psychiatric illnesses become intelligible only across time. Telehealth has dramatically improved access, but a screen inevitably narrows observation and makes it remarkably easy to assemble disconnected providers across multiple platforms.

That does not make virtual treatment inferior. It means we have to ask whether the modality and frequency of treatment give us enough clinical information for the acuity of the patient.

Virtual treatment is a modality, not a level of care. This is especially the case for PHP, which provides a multidisciplinary team repeated opportunities to observe a patient, incorporate family information, monitor medication changes, consult outside providers and identify a trajectory.

In the case of the deaths of Cora, Dawson and Callan Clancy, hindsight makes warning signs appear obvious. Clinicians should resist that distortion. Even new behavioral health providers experience burnout and risk desensitization. We will never know whether standards of care would have made these losses preventable. 

The frightening reality is that while many people knew many things, no one had enough information to understand the totality of what any of it meant.

When we who supervise insist on collateral calls, outside-provider consultation, medication reconciliation, family involvement, careful documentation, multidisciplinary treatment and routine supervision, this headline is exactly what we are aiming to prevent. 

If a trainee inquires on the importance of any of these matters, this case will forever be a reference point of the worst that can go wrong when proper protocols are not employed. 

Most failures of fragmentation will not become national news. They look like medication errors, avoidable emergency visits, missed deterioration, unnecessary hospitalization, months spent treating the wrong formulation, and families who had no idea what they were supposed to be watching for.

Sometimes, the stakes are unimaginable.

We can’t and won’t eliminate all uncertainty from practice. We can and will build systems that make it less likely that clinically important information remains stranded. 

Being in treatment and being well cared for are not the same thing.

The Lindsay Clancy case should force our field to reckon with this difference.