 IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON


In re the Detention of A.H.,              )      No. 72508-4-1

STATE OF WASHINGTON,

                     Respondent,          ]
                                                 DIVISION ONE                     ^
          v.                              ;

A.H.,                                     ]      UNPUBLISHED OPINION              -'
                     Appellant.           )      FILED: September 28. 2015

        Spearman, C.J. — A.H. appeals his 14-day involuntary commitment at

Harborview Medical Center. He contends the trial court's finding that he suffered

from a grave disability was not supported by sufficient evidence. We disagree

and affirm.


        According to a Seattle Police report dated August 29, 2014, A.H.'s mother

called 911 that day and said her son was "in a state of [c]risis" and running in the

street. Clerk's Papers (CP) at 7. When police arrived, they found A.H. standing

shirtless outside the family home. He "did not seem to be mentally present while

speaking to Seattle Police Officers, or his immediate family." CP at 8. He stared

up into the sky, speaking to "Allah." Id. He went into a rage, swinging his hands

wildly and telling an officer, "Tm going to take that gun, and shoot you in the

face.'" Id. Police transported A.H. to Harborview Medical Center for evaluation.
No. 72508-4-1/2



       On August 30, 2014, a designated mental health professional for King

County filed a petition for A.H.'s initial 72-hour detention. The petition alleged

that A.H. suffered from a mental disorder and as a result presented "a likelihood

of serious harm to him/herself or others or that he/she is gravely disabled." CP at

1. The petition recounted facts alleged in the police report, noting in particular

that A.H. had been running in the street without regard for traffic and had not

been eating or drinking.

       On September 3, 2014, Harborview Medical Center filed a petition for a

14-day involuntary commitment. The petition alleged, among other things, that
A.H. was "gravely disabled," that he exhibited symptoms of psychosis, and that
he "reportedly decompensated over the last three weeks, resulting in refusal to
eat and drink, poor sleep, aggressive behavior and unsafe behavior [.]" CP at

16.

       On September 4, 2014, the superior court held a hearing on the petition
for a 14-day commitment. The sole witness at the hearing was Dr. Joyce
Shaffer, a licensed clinical psychologist and licensed, registered nurse. Defense
counsel stipulated to Dr. Shaffer's professional qualifications, and the court

qualified her as an expert.

       Dr. Shaffer testified that she had evaluated A.H. and concluded that he

suffered from psychosis. This condition had "a substantial adverse effect on his
cognitive and emotional competence." Verbatim Report of Proceedings (VRP) at
No. 72508-4-1/3



6. It caused "severe deterioration in routine functioning, evidenced by repeated

and escalating loss of cognitive and volitional control over his actions such that,

outside the hospital setting, he would not receive care essential for his needs of

health and safety." jd. She concluded he was gravely disabled and "in danger of

serious physical harm from the failure or inability to provide for his essential

needs of health and safety." Id.

       In forming her opinion, Dr. Shaffer relied on several sources, including her

interview with A.H. She testified that A.H. was "very disorganized" during their

interview and appeared to be having visual and auditory hallucinations. VRP at

7. A.H. was "very, very thin" and told Dr. Shaffer he had "stopped eating" and

was "ready to die." VRP at 6-7. He also said he attended medical school in

China and was considering enrolling at Bellevue College. Dr. Shaffer concluded

that A.H. was "a young man of formerly very high functioning who is, at this point,

incapable of self-care because of the psychosis." VRP at 9. Dr. Shaffer

described this as a "remarkable decline for an individual." VRP at 8.

       Dr. Shaffer also relied on various statements in the previously mentioned

police report. Although the court admitted the report, it admitted it solely as the

basis of Dr. Shaffer's opinion and not as substantive evidence.

       Dr. Shaffer also considered, and the court also admitted, A.H.'s hospital

medical chart. The court admitted several portions of the chart solely as the

basis for Dr. Shaffer's opinion and not as substantive evidence. They included
No. 72508-4-1/4



A.H.'s father's statements that A.H. went to medical school in China until early

2014, showed no signs of deterioration until approximately one month prior to his

admission to Harborview, had become uncommunicative, distrustful, and

uncooperative, and had decreased appetite.

       The court admitted other portions of the chart as substantive evidence,

including a number of chart notes. A chart note from August 29, 2014 stated that

A.H. had ketones in his urine at admission and a low level of potassium. Dr.

Shaffer testified that these lab results were consistent with A.H.'s statement that

he had stopped eating.

       Chart notes from September 2, 2014, stated that A.H. refused to talk to his

parents when they visited him and that he was placed in seclusion after entering
other patients' rooms and refusing to leave. Another note said "[u]pon interview,
patient under blanket and refuses to speak with team. Interview ended
secondary to the patient being uncooperative, re-approached 30 minutes later....
And he continued to not respond to the team." VRP at 24.

       A chart note from September 3, 2014 stated that "on interview, patient

continues to refuse to speak with the team [.]" VRP at 18. Another note from

that day states "patient refused dinner and any foods or drinks," and "[c]ontinues
to respond to internal stimuli and is positive for auditory hallucinations and visual
hallucinations." VRP at 24-25. The chart indicated that his "nutrition needs"

were "not met," and that he was not free from restraint or seclusion. VRP at 25.
No. 72508-4-1/5



       Dr. Shaffer testified that the chart notes, A.H.'s statement that he had

stopped eating, his very thin condition, and the fact that he was not cooperating

with his family or staff, supported a conclusion that he was suffering from a grave

disability. She stated:

       . . . this is a very, very thin man. And the fact that his labs are
       indicating that he's had inadequate oral intake is very concerning
       and place that in [the] context of this man being more responsive to
       auditory and visual hallucinations than he is to the environment
       around him and to him refusing assistance, for him to refuse to be
       interviewed by the caregivers that are trying to be helpful and trying
       to understand more of what he's experiencing. This is a man
       whose psychosis intervenes in such a way that he's not. .. able to
       manage his own care, nor can he cooperate with healthcare
       providers that are attempting to evaluate and treat his psychosis.

VRP at 26. Dr. Shaffer concluded that A.H. "is an individual who can't give

himself adequate oral intake and he can't cooperate with those who would

provide it for him." VRP at 29. When asked what "harmful consequences" she

foresaw if A.H. were not committed, Dr. Shaffer said "[h]e will continue to put

himself at risk either in traffic again or. .. with inadequate oral intake." Id.

       On cross-examination, Dr. Shaffer conceded that chart notes indicated

that A.H. had good food intake on August 30, 2014 and September 1, 2014.

Other notes indicated periods of improvement in his attitude and behavior.

       On redirect examination, Dr. Shaffer testified that A.H. did not meet his

nutritional needs after September 1, 2014. She also noted that any improvement

he experienced was likely due to compelled medication, and that he would

deteriorate when he had the right to refuse medication.
No. 72508-4-1/6



      The court granted the commitment petition, finding A.H. "gravely disabled"

under RCW 71.05.020(17)(b). In its oral ruling, the court found that A.H. suffered

from a mental disorder that was "having a substantial effect on his cognitive or

volitional functions." VRP at 61. Although the court noted there was relatively

little evidence of A.H.'s baseline functioning, it concluded that A.H.'s admission

that he attended medical school in China established a sufficient baseline and

supported findings of severe deterioration and grave disability.
       The court later entered the following pertinent supplemental findings and

conclusions:

       23. After hearing from both sides, the Court began to issue its oral ruling.
           The Court noted that at that very moment Respondent was looking up
       at the ceiling, holding his hands in somewhat ofan open prayer method,
       not responding to his attorney who was talking to him, shaking his head
       and staring at the wall a few feet from where he was seated.
       24. [T]he Court noted that Respondent began to chant and bend over with
       his head in his lap. The Court also noted that Respondent continued to
       chant despite his attorney's and nurse's efforts to get him to stop

       27. [T]he evidence supports a finding by a preponderance of the evidence
       that Respondent manifests a serious deterioration in routine functioning
       evidenced by loss of cognitive or volitional control over actions. This Court
       also found that he is not receiving care essential for his health and safety
       outside the hospital setting, and he is unable to make rational decisions
       regarding his need for treatment.



       35. In reaching the finding that he was gravely disabled, this Court
       considered his baseline to be that of a medical student in comparison to
        Dr. Shaffer's testimony regarding his current state in which he exhibited
       auditory and visual hallucinations, he was unresponsive, he acknowledged
No. 72508-4-1/7



       he was "crazy," which he later retracted, and was "ready to die." This
       Court also considered that he stopped eating and was not meeting his
       nutritional needs. These actions are consistent with deterioration under
       Prong B (of Gravely Disabled Allegation), in routine functioning and a loss
       of cognitive and volitional control over his actions and that harmful
       consequences will follow if involuntary treatment is not ordered. This Court
       does not find any evidence that the respondent can make a rational
       decision about need for treatment.

       36. In short, the Court finds under Prong B that the Respondent is Gravely
       Disabled.


                               CONCLUSIONS OF LAW

       4. The Petitioner proved by a preponderance of the evidence that the
       Respondent has a mental disorder, and as a result of that mental disorder
       presents as Gravely Disabled. Petitioner also proved a less restrictive
       alternative was not appropriate at this time.

CP 88-92 (Footnote omitted).

       A.H. appeals.

                                        DECISION


       The sole issue on appeal is whether the State presented sufficient

evidence to prove that A.H. was gravely disabled.1 Our review is limited to

determining whether substantial evidence supports the court's findings of fact

and, if so, whether the findings in turn support the trial court's conclusions of law

and judgment. In re Detention of LaBelle. 107 Wn.2d 196, 209, 728 P.2d 138
(1986); In re Detention of Clark, 187 Wn. App. 303, 313, 348 P.3d 1231 (2015).


        1Although A.H.'s commitment concluded long ago, A.H. contends, and the State does
not dispute, that his appeal is not moot because an involuntary commitment order may have
adverse consequences in future commitment proceedings. See RCW 71.05.245(1); In re
Detention of M.K.. 168 Wn. App. 621, 625-30, 279 P.3d 897 (2012).
No. 72508-4-1/8



When, as in this case, a court erroneously includes its grave disability

determination in its findings of fact, we treat the finding as a conclusion of law. in

re Detention of M.K.. 168 Wn. App. 621, 623 n.3, 279 P.3d 897 (2012).

       Under chapter 71.05 RCW, individuals may be involuntarily committed for

up to 14 days ifthe State demonstrates by a preponderance of the evidence that,

as a result of a mental disorder, they present a likelihood of serious harm or are

"gravely disabled." RCW 71.05.240(3). "Gravely disabled" means a person, as a

result of a mental disorder,

       (a) Is in danger of serious physical harm resulting from a failure to
           provide for his or her essential human needs of health or
           safety; or
       (b) manifests severe deterioration in routine functioning
           evidenced by repeated and escalating loss of cognitive or
           volitional control over his or her actions and is not
           receiving such care as is essential for his or her health or
           safety.

RCW 71.05.020(17) (emphasis added). When, as here, the State proceeds

under the definition of gravely disabled in subsection (b), it must present proof of
significant loss ofcognitive or volitional control and a factual basis for concluding
that the individual is not receiving or would not receive, if released, the care

essential for his or her health or safety. In re LaBelle, 107 Wn.2d at 208.

       A.H. contends "the State failed to introduce sufficient substantive evidence

that [he] manifested severe deterioration in routine functioning." Brief of
Appellant at 15. He correctly points out that evidence admitted to show the basis
of an expert opinion, but not as substantive evidence, cannot be used to
No. 72508-4-1/9



establish necessary facts. See Group Health Co-op. of Puaet Sound, Inc. v.

Dep't. of Revenue. 106 Wn.2d 391, 399-400, 722 P.2d 787 (1986); Allen v.

Asbestos Corp.. 138 Wn. App. 564, 579, 157 P.3d 406 (2007). A.H. contends

there was insufficient substantive evidence establishing his baseline functioning;

therefore, there was insufficient evidence supporting the finding that he

"manifests a serious deterioration in routine functioning evidenced by loss of

cognitive or volitional control over actions." CP at 89.

       Although admittedly thin, the evidence was sufficient to support the court's

finding by a preponderance of the evidence. Dr. Shaffer testified that 21 year old

A.H. told her he was in medical school in China and had considered enrolling at

Bellevue College. This substantive evidence supported an inference of recent

high functioning and a finding that A.H.'s present condition showed severe

deterioration in that functioning.

       A.H. also contends there was insufficient substantive evidence supporting

the court's finding that "he is not receiving care essential for his health and safety

outside the hospital setting." CP at 89. Again, we disagree. To demonstrate

that a person "is not receiving such care as is essential for his or her health or

safety" as required by RCW 71.05.020(17)(b), there must be "a factual basis for

concluding that the individual is not receiving or would not receive, if

released, such care as is essential for his or her health or safety." (Emphasis
No. 72508-4-1/10



added). In re LaBelle. 107 Wn.2d at 208; In re Detention of A.S.. 91 Wn. App.

146, 164, 955 P.2d 836 (1998).

       Contrary to A.H.'s assertions, there was sufficient substantive evidence

that his essential nutritional and mental health needs were not being met prior to

his admission to Harborview, and would not likely be met if he were released.

A.H.'s lab results, his statement that he had stopped eating, and his "very, very

thin" appearance, all support the finding that he was not receiving care essential

to his health prior to admission. His severely deteriorated mental state upon

admission also supported an inference that he had not been receiving essential

mental health care prior to admission.

       Substantive evidence also supported the court's finding "that harmful

consequences will follow if involuntary treatment is not ordered." CP at 91. Dr.

Shaffer testified that A.H. would not be able to care for his nutritional needs or

physical safety if released, and would not cooperate with those who would try to

help him with his issues. She concluded that A.H. was "incapable of self-care

because of the psychosis and more responsive to the psychosis than he is to the

environment around him." VRP at 9. Dr. Shaffer's conclusions, and the court's

finding of likely future harm, were supported by substantive evidence that A.H.

had not met nutritional needs even while hospitalized, that he was suffering from

hallucinations, impaired judgment, and lack of impulse control, and that he had




                                         10
No. 72508-4-1/11



generally been unable or unwilling to communicate or cooperate with those trying

to help him.

        In short, the court's findings are supported by substantial evidence, and

those findings support the court's conclusion that A.H. suffered from a grave

disability.

        Affirmed.



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WE CONCUR:




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