Clancy trial: Whose job is it to coordinate care?

Then what?

What happens once a patient is referred to the mental health system has taken on new urgency during the trial of Lindsay Clancy, the Duxbury mother who killed her three young children in January 2023.

Her defense attorney, Kevin Reddington, has argued the mental health system failed Clancy, that she put her postpartum struggles in the hands of a half-dozen specialists, but they failed to coordinate with each other while showering her with some 30 prescriptions over four months.

During their testimony, Reddington repeatedly asked the clinicians why they did not follow up with each other or even seek access to Clancy’s full medical records as she entered hospitals or sought other psychiatric treatment.

The testimony underscored what some experts said is a clear failing with the medical system.

“I wish I could say there was one person responsible for coordinating that kind of care. … Right now, that doesn’t exist within our systems,” said Dr. Nancy Byatt, a perinatal psychiatrist and professor at UMass Chan Medical School in Worcester. “We’ve heard from perinatal and postpartum individuals who feel like they need someone to help broker all these relationships. It takes a village.”

The problem isn’t limited to behavioral health, experts say.

“The reality is, these gaps exist in the entire health system,” said Dr. Jennifer Payne, professor of psychiatry, neurobehavioral sciences, and vice chair of research at the University of Virginia School of Medicine.

“Anybody who’s prescribing a medication should follow up with that patient,” Payne said. But patients can seek care elsewhere, she added, “and nobody’s tracking that.”

In Franklin, Martha Jean “MJ” Gouveia is a conduit for various providers for her son, Sam, 13, who has ADHD, disruptive mood dysregulation disorder, and depression. Those providers all talk separately to the health insurance company, she said, and she is left to pick up the pieces.

Martha Jean “MJ” Gouveia her son Sam, 13, organized medications for an upcoming trip to New Hampshire.Barry Chin/Globe Staff

She estimates she spends at least 15 hours a week managing his care.

She keeps track of diagnoses, monitors medications and refills, and handles prior authorizations. She chases referrals, decides which records should go to which providers, and checks clinical notes for accuracy.

“I’m not the only parent that does this,” Gouveia said. “The system is built to fail people.”

Under a 2024 law addressing maternal health issues , primary care providers, obstetricians, gynecologists, midwives, and pediatricians in Massachusetts must offer patients screening for postpartum depression. If the results indicate the patient is experiencing such depression or another major depressive disorder, the clinician must discuss treatment and refer the patient to a mental health expert.

The statute does not spell out who owns the patient’s care after that handoff.

That distinction matters because mental illness, unlike diabetes or high blood pressure, does not present in a predictable way.

“Postpartum psychosis is a fluctuating condition, and diagnoses are not always a snapshot,” said Dr. Suzan Song, a Harvard- and Stanford-trained psychiatrist based in Washington, D.C. In psychiatry, she said, a diagnosis can be a “working formulation” that changes as a clinician sees a patient over time. That’s not a bad thing, she said, but those providers may be seeing only pieces.

“It’s all the blind men touching different parts of the elephant,” Song said. A psychiatrist managing medication may hear one history, and a therapist will hear another.

“What we need is a medical home,” she said. “It’s actually a good thing that people see different providers and consultations, but you need some home,” such as a single provider or guardian, “to manage or make sense of all of it.”

In an ideal system, Song said, a clinician or team would be explicitly responsible for coordinating care. “Until then, families should ask who is overseeing communication among providers, receiving records, and tracking medication changes. If no clinician can take that on, then unfortunately a family member may need to hold the pieces together.”

Obtaining records for mental health treatment adds additional complications.

Federal privacy law generally treats mental health information like other medical records, but notes from psychotherapy receive additional protection and generally require patient authorization before they can be shared with another provider.

“I can refer a patient to a specialist, and I never hear back from them again, or patients are referred to me, but they don’t have any medical history whatsoever,” said Song. “I’ll ask for medical records from past providers, but mental health is treated very differently in medical documentation, and records vary on the system the practitioner is using.”

Still, providers should request records, and patients have the choice whether to provide or decline access, she said. The Clancy trial has demonstrated how difficult that can become.

Defense attorney Kevin Reddington questioned Rebecca Jollotta, one of Clancy’s providers, about what happened after Clancy voluntarily entered McLean Hospital in early January 2023, weeks before the killings.

Jollotta testified that she did not have access to Clancy’s McLean records.

Reddington asked whether anyone had asked Clancy to sign a release allowing her providers to obtain those records.

“I did not,” Jollotta replied.

In pressing murder charges against Clancy, prosecutors argue she closely managed her own treatment and did not always take medications as prescribed. Clancy, meanwhile has admitted to killing her children, but asserts she should not be held criminally responsible because she was in the throes of postpartum psychosis.

In sorting responsibility for a patient’s care, technology can bridge some divides. Shared electronic-record systems can allow clinicians to see records from other institutions. But if the patient sees a provider who doesn’t use a shared system — some mental health providers in private practice do not use the electronic medical record system EPIC — it won’t appear in the patient’s file.

“It is very difficult to get psychiatry medical records anywhere in this country,” Payne said.

And tracking them down takes time and resources that are not reimbursed by insurance.

“There are no requirements,” Payne said of follow-up. “It’s very much left to the individual practice and practitioner.”

There are legitimate reasons mental health information is handled carefully. For example, Gouveia, the Franklin woman whose son has multiple clinicians, is selective about sharing his complete medical records with every one of them; in some cases, it’s because she wants a new clinician to assess him with fresh eyes.

But absent Gouveia’s intense involvement, it’s not clear who else would bear the burden of reconciling all his competing needs: a psychiatrist, primary care doctor, case manager?

“Nobody talks,” she said. “I give the info and they run with it.”

After the birth of her first son, Gouveia said, she struggled with postpartum depression and was later diagnosed with bipolar disorder. She’s had the same counselor for 18 years but multiple psychiatric providers. But for her three sons, she said, navigating their mental health care has been far harder.

From a provider standpoint, Payne said, “Most practices will have a nurse or somebody who will try to track down people who are supposed to be following up or supposed to be filling their medication, but people fall through the cracks.”

Clancy’s treatment history was unusually extensive.

To Gouveia, the number of different medications Clancy was prescribed was difficult to comprehend. She said, in her experience, pharmacists are often the only checkpoint.

“They break everything down for the patient, and talk to the provider, insurance companies, or question if treatment is going to work,” she said.

When it comes to coordinating care solutions, “There’s no easy fix,” Song said.

“Because the American health care system is so fragmented and it’s hard for patients to get care,” she said. “It’s completely appropriate to refer out, but someone has to be the guardian and oversee all of it, and that’s more than likely up to the patient.”

Globe correspondent Chloe Craft contributed to this report.

Sarah Rahal can be reached at sarah.rahal@globe.com. Follow her on X @SarahRahal_ or Instagram @sarah.rahal.