                     IN THE COURT OF APPEALS OF IOWA

                                    No. 18-0393
                              Filed November 7, 2018


IN THE MATTER OF T.K.,
Alleged to be Seriously Mentally Impaired,

T.K.,
     Respondent-Appellant.
________________________________________________________________


        Appeal from the Iowa District Court for Johnson County, Christopher L.

Bruns, Judge.



        T.K. appeals a district court order finding her seriously mentally impaired.

AFFIRMED.



        Sandra R. Hart of Hart Law, North Liberty, for appellant.

        Thomas J. Miller, Attorney General, and Gretchen Witte Kraemer, Special

Assistant Attorney General, for appellee State.



        Considered by Danilson, C.J., and Vogel and Tabor, JJ.
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TABOR, Judge.

       T.K.’s unsafe behavior during the “frigid weather” last winter prompted her

brother and her neighbor to seek mental health treatment on her behalf.                In

response to their affidavits and a psychiatric evaluation at the University of Iowa

Hospitals and Clinics (UIHC) in Iowa City, a judicial hospital referee committed T.K.

on an outpatient basis. The district court affirmed the involuntary commitment,

finding T.K. suffered from a serious mental impairment and was likely to physically

injure herself if she remained at liberty without treatment. On appeal, T.K. disputes

the district court’s finding she poses a threat to herself if allowed to remain at liberty

without treatment. Because we find substantial evidence supports the district

court’s findings, we affirm.

       I.      Facts and Prior Proceedings

       In late November 2017, T.K. made her monthly call to her brother Mark, who

lives out of state. During the call, T.K. made comments that worried her brother.

For example, she described being followed and having her communications

intercepted. She also disbelieved and misremembered recent and more distant

past events.     In December, T.K. performed demolition in her home and left

significant debris in her yard. In “bitterly cold” temperatures, T.K. walked to her

neighbor’s house barefoot and without a coat to apologize for yelling the day

before.     The neighbor contacted Mark with concerns about T.K.’s well-being.

Another neighbor contacted police, alleging T.K. had caused property damage.

T.K.’s long-time boyfriend, Michael, entered T.K.’s home to find the thermostat

removed and the heat left on high. T.K.’s dogs were not doing well, and Michael

was concerned the house had elevated levels of carbon monoxide.
                                              3


       On December 28, Mark filed an application alleging T.K. suffered from

serious mental impairment. His application asserted T.K. posed a danger to

herself or others and lacked judgmental capacity. In support, he provided an

affidavit detailing his observations, in addition to an affidavit from T.K.’s neighbor.

Under court order, UIHC admitted T.K. to its psychiatric ward. While there, T.K.

displayed symptoms of paranoia. She also refused to allow UIHC access to

medical records from institutions where she previously received mental-health and

substance-abuse treatment. Before T.K.’s admission, she was prescribed a high

dose of stimulants and a “modest prescription” for benzodiazepines. Doctors

evaluated T.K. twice during the in-patient commitment, seeing improvement in her

symptoms when she took her medication.

       At a January 5 hearing before the judicial hospitalization referee, T.K.

stipulated she met the elements necessary for a finding of serious mental

impairment:1 judgmental capacity, treatability, dangerousness, and mental illness.

The hearing was not reported, nor did the parties enter a written stipulation into the




1
               “Seriously mentally impaired” or “serious mental impairment”
      describes the condition of a person with mental illness and because of that
      illness lacks sufficient judgment to make responsible decisions with respect
      to the person’s hospitalization or treatment, and who because of that illness
      meets any of the following criteria:
               a. Is likely to physically injure the person’s self or others if allowed
               to remain at liberty without treatment.
               b. Is likely to inflict serious emotional injury on members of the
               person’s family or others who lack reasonable opportunity to avoid
               contact with the person with mental illness if the person with mental
               illness is allowed to remain at liberty without treatment.
               c. Is unable to satisfy the person’s needs for nourishment, clothing,
               essential medical care, or shelter so that it is likely that the person
               will suffer physical injury, physical debilitation, or death.
Iowa Code § 229.1(20) (2018).
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record. The referee ordered a complete psychiatric evaluation on an outpatient

basis and discharged T.K. to outpatient treatment.

       T.K. filed a handwritten notice of appeal on January 9 challenging the

finding of mental impairment. After filing the appeal, she filled one prescription on

January 11 but did not pursue refilling another prescription despite her primary

care physician’s direction she follow up with a psychiatrist. She also failed to

appear at her outpatient evaluation appointment scheduled for February 7.

       On February 8, the district court held a de novo hearing on T.K.’s appeal.

In its review, the district court considered Mark’s application and accompanying

affidavits, as well as three reports from the hospital’s chief medical officer

summarizing T.K.’s psychiatric examinations. The court also heard testimony from

T.K.’s attending psychiatrist, Dr. Judith Crossett, and T.K. herself.

       Dr. Crossett testified to gathering T.K.’s history from the “escalating report

of bizarre and dangerous behavior” from her brother.           Dr. Crossett likewise

incorporated the neighbor’s concerns about T.K. “yelling and screaming late into

the night” and “showing up at the neighbor’s door” with “no coat, no shoes” in late

December. The psychiatrist also considered information she received from T.K.’s

boyfriend that the house was in disarray and T.K. removed the thermostat from the

wall because “it was spying on her.” Michael found T.K. left the furnace “just full

on.” “The house was 90 degrees inside,” leaving Michael concerned about carbon

monoxide poisoning. Dr. Crossett described her impression of T.K. at the hospital

as “quite irritable” and “very guarded” about her condition.

       For her part, T.K. testified she was wearing a coat when she went to the

neighbor’s house but admitted going barefoot. T.K. claimed she had broken a toe
                                          5


and was unable to get her shoe on. She also testified she “wanted to freeze [the

toe] before [she] got into the shower.” She explained, “It’s just a sports thing to do.

I've broken it a couple times before and it helps.” T.K. attributed the disarray and

lack of thermostat to her renovations. She also said the debris on her lawn

included items former neighbors left at her house.

       The district court found the State proved T.K. had a serious mental

impairment by clear and convincing evidence “even absent the stipulation” in place

at the referee hearing. The court issued an order confirming T.K.’s placement in

outpatient commitment. T.K. appeals.

       II.    Scope and Standard of Review

       We review challenges to the sufficiency of the evidence in involuntary-

commitment proceedings for correction of legal error. In re B.B., 826 N.W.2d 425,

428 (Iowa 2013). We are bound by the factual findings when supported by

substantial evidence. In re L.H., 890 N.W.2d 333, 340 (Iowa Ct. App. 2016). “The

allegations made in the application for involuntary commitment must be supported

by clear and convincing evidence.” In re J.P., 574 N.W.2d 340, 342 (Iowa 1998).

We consider evidence “clear and convincing” when there is “no serious or

substantial doubt about the correctness of a particular conclusion drawn from the

evidence.” Id. (citation omitted).

       III.   Analysis

       Stipulation. The State argues T.K.’s stipulation to meeting the criteria for

serious mental impairment, referenced in the referee’s order, remains in force on

appeal. It is true we ordinarily enforce stipulations absent fraud, collusion, mistake,
                                            6

accident, or surprise. See In re Z.H., No. 15-1943, 2016 WL 4384363, at *2 (Iowa

Ct. App. Aug. 17, 2016). The trouble here is a deficient record.

       At the de novo hearing, Dr. Crossett testified it was her understanding T.K.

“chose to stipulate rather than have her brother called as a witness for the hearing”

with the judicial hospital referee. But no signed stipulation appears in the district

court record. And the State did not ask T.K. about her prior stipulation during the

district court hearing.

       Nor is there a record of the hearing before the judicial hospitalization

referee. The only evidence T.K. stipulated to the elements of serious mental

impairment is the referee’s findings of fact and order.2 Moreover, the district court

did not base its finding on the stipulation. See Iowa Code § 229.21(3)(c) (2018)

(“When appealed, the matter shall stand for trial de novo.”). For these reasons,

we do not rely on T.K.’s stipulation to serious mental impairment.

       Serious Mental Impairment.           Chapter 229 authorizes involuntary civil

commitment if a person “has a serious mental impairment.”                    Iowa Code

§ 229.13(1). The statutory definition of serious mental impairment includes three

elements. The person must: (1) have a mental illness; (2) as a result of the mental

illness, lack “sufficient judgment to make responsible decisions with respect to the

person’s hospitalization or treatment”; and (3) be likely, if allowed to remain at

liberty, to either inflict physical or serious emotional injury to themselves or another,

or be unable to satisfy their own basic physical needs. Id. § 229.1(20); see also


2
  In addition to the stipulated elements of serious mental impairment, the order stated,
“Respondent began the hearing, but decided prior to the close of the State’s case to
stipulate to the entry of the outpatient order requested by UIHC. Her stipulation was taken
on the record.”
                                             7

J.P., 574 N.W.2d at 343. Courts generally call the last element “dangerousness,”

as it requires a showing of danger posed to the person or others. See, e.g., B.A.A.

v. Chief Med. Officer, 421 N.W.2d 118, 123 (Iowa 1988) (examining

dangerousness as prerequisite to involuntary commitment). On appeal, T.K. does

not dispute the court’s finding of mental illness or lack of judgment. She challenges

only the sufficiency of the State’s proof of dangerousness.

         Dangerousness.       Dangerousness can manifest in three ways: (1) a

likelihood to physically injury one’s self or others; (2) a likelihood of inflicting serious

emotional injury on others; or (3) an inability to satisfy one’s own needs for

nourishment, clothing, essential medical care, or shelter, making physical injury,

debilitation, or death likely. Iowa Code § 229.1(20)(a)–(c).

         A finding of dangerousness under each means requires proof of a recent

overt act, attempt, or threat. L.H., 890 N.W.2d at 341. An overt act is aggressive

behavior or threats signaling “the probable commission of a dangerous act upon

[her]self or others” likely to result in injury. In re Foster, 426 N.W.2d 374, 378 (Iowa

1988).

         The court’s commitment order focused on the danger T.K. posed to herself.3

“In the context of a civil commitment proceeding, harm to oneself is defined in

terms of neglect or inability to care for oneself.” Id. at 379. In particular, T.K.

showed an inability to satisfy her needs for clothing against the elements, essential

medical care, and safe shelter—posing a likelihood her mental illness would lead

to physical injury.


3
 One of T.K.’s psychiatric evaluations also cited distress to neighbors and T.K.’s boyfriend
Michael as emotional injury to others resulting from T.K.’s mental illness.
                                           8


       At its core, the district court’s finding of dangerousness centered on the

likelihood T.K. would neglect her essential needs and injure herself. Substantial

evidence supported its finding. In its evaluation, the district court was free to reject

T.K.’s explanation of her late December behavior as simply an unconventional

treatment for a broken toe. Rather than seeking medical attention for her broken

toe, T.K. risked frostbite to both feet by walking barefoot outside in bitterly cold

temperatures. The district court was also entitled to give more weight to the

neighbor’s account T.K. was not wearing a coat, leaving her without protection

from the elements.

       As the district court noted, T.K. also revealed her inability to care for herself

by “disabling or not properly enabling her home heating system.” Like the excuse

for her barefoot walk, T.K.’s account of renovating her heating system in midwinter

without the funds to complete the repairs did not ring true with the district court.

Her actions demonstrated an inability to maintain safe shelter.

       In addition to her risky pre-commitment behavior, T.K. continued to

disregard her essential medical care after the referee ordered T.K. to engage in

outpatient treatment. T.K. did not attend scheduled treatment, filled a necessary

prescription late, and failed to seek a refill on another psychiatric medication.

These lapses evince T.K.’s continuing neglect of her mental health.

       In short, T.K.’s erratic behavior demonstrated her inability to meet the basic

needs of clothing and housing appropriate to the weather. She also failed to make

responsible decisions about her physical and mental health care. The record

supports the district court’s finding T.K. meets the “dangerousness” element of
                                    9


serious mental impairment. Accordingly, we affirm the outpatient commitment

order.

         AFFIRMED.
