I saw a patient recently who was in crisis, truly suicidal. He opened up to me about it. I assessed the risk, took it seriously, and did everything we’re trained to do. I even called ahead to the hospital, spoke to the charge nurse directly, made it very clear: this man is not safe to be alone.

He told me, “I don’t want to do it. I just can’t get the thoughts out of my head.”

That was his plea. Not a threat. Not a performance. A human being asking for help.

He was evaluated.

And then discharged.
No inpatient stay.
No follow-up care.
No safety net.

This morning, I found out he did the very thing he didn’t want to do. What we tried so hard to prevent.

I can’t even describe the weight of that moment, the sick feeling in my gut, the anger, the helplessness, the grief. And yet, none of it surprised me.

Because this is what our system does.
It fails people.

It fails them in emergency rooms with impossible intake quotas and burned-out staff. It fails them with insurance companies that decide who gets to live or die based on billing codes. It fails them by treating psychiatric crisis like an inconvenience instead of the emergency it is. It fails primary care providers like me who try to get our patients the help they need, only to be blocked at every turn.

We say things like “mental health matters” and “we need to break the stigma,” but when it comes time to actually care for people in crisis, our system shrugs.

He should’ve been admitted.
He should’ve had care.
He should still be alive.

I don’t want to write this post. I don’t want to make this political. I don’t want to turn a human tragedy into content.

But I also refuse to be silent while this continues to happen, to my patients, to your family, to our communities.

We need a system that doesn’t just check boxes.
We need a system that shows up when it matters most.
We need to do better.

Because right now? We’re not even close.