JUDY LYNN PRINCE, administrator of the estate of Wayne Bowker, deceased v. SHERIFF OF CARTER COUNTY, in his official capacity; MILTON ANTHONY, in his individual capacity; DANNY RENKEN, Deputy; CHESTER CARTER, Deputy; JESSE MCDANIELS, Sergeant; KIMBERLY MILLER; JOHN DOES 1-10, Doctors; JOHN DOES 1-10, Nurses
No. 20-7056
United States Court of Appeals, Tenth Circuit
March 14, 2022
PUBLISH
Appeal from the United States District Court for the Eastern District of Oklahoma (D.C. No. 6:18-CV-00201-RAW)
Robert M. Blakemore (Daniel Smolen and Byron D. Helm, with him on the briefs), Smolen & Roytman, Tulsa, OK, for Plaintiff - Appellant.
Wellon B. Poe, Jr. (Ambre C. Gooch and Jamison Whitson, with him on the briefs), Collins, Zorn & Wagner, P.C., Oklahoma City, OK, for Defendant - Appellee Sheriff of Carter County.
James L. Gibbs, II (Seth D. Coldiron, with him on the briefs), Goolsby, Proctor, Heefner & Gibbs, P.C., Oklahoma City, OK, for Defendant - Appellee Kimberly Miller.
Before TYMKOVICH, Chief Judge, LUCERO, Senior Circuit Judge, and MORITZ, Circuit Judge.
Wayne Bowker died at the Carter County Jail on June 30, 2016, while awaiting trial for a drug possession charge. In the days and weeks preceding his death, Bowker did not receive several of his prescribed medications, experienced fecal incontinence
This appeal considers whether the district court properly granted summary judgment on qualified immunity grounds to jail nurse Kimberlee Miller in her individual capacity and whether it properly granted summary judgment to the Sheriff of Carter County in his official capacity. We conclude that a reasonable jury could determine that Miller violated Bowker‘s clearly established constitutional right by acting with deliberate indifference toward his psychosis, fecal incontinence, and catatonia. In addition, a reasonable jury could conclude that Carter County‘s failure to medically train jail employees, adequately staff the jail, and provide timely medical attention caused Bowker‘s death. Thus, exercising jurisdiction under
I
A
Wayne Bowker was booked into the Carter County Jail (“CCJ“) on March 23, 2016, for possession of cocaine.1 During the booking process, he informed jail staff that he suffered from numerous serious medical conditions, including asthma, congestive heart failure, high blood pressure, bipolar disorder, anxiety disorder, seizures, shortness of breath, and thyroid problems. Bowker‘s medical intake questionnaire also indicated that he was prescribed medication for his cholesterol and blood pressure. Pursuant to jail policy, officers reviewed this questionnaire with Bowker, without further health assessment at the time of his booking.2 Although
Miller worked as a nurse at CCJ five days a week from 8:00 a.m. to 4:00 p.m. If medical problems occurred when Miller was not at work, corrections officers were instructed to ask dispatch employees to contact her by text message. Occasionally, it took two or three calls before she would respond. Miller was known to yell at staff when contacted outside of work hours, a problem so pervasive that even the Sheriff was aware that officers were hesitant to contact Miller when she was off duty. The record reflects that, when finally reached, Miller would call the jail and make a health assessment by phone without seeing the inmate experiencing the health issue. If an inmate required emergency medical treatment when communication with Miller was infeasible, detention officers with no medical training were expected to rely on their “common sense” to determine whether an inmate should be transferred to the emergency room. Even when on site, Miller testified that, as a nurse, she was unqualified to make medical diagnoses. She had no specific mental health training, and CCJ did not employ any mental health staff. Miller testified that she did not regularly conduct “rounds” to check on inmates, even among those housed in the medical unit. According to Miller, she had conversations with the Sheriff‘s office about whether it would be helpful to have a licensed physician “come in.” Despite the lack of trained medical staff at CCJ, the Sheriff‘s office made limited efforts to employ a licensed physician even though it was required to do so in order to be in accord with its policies.
B
Bowker submitted his first medical request to Miller on April 13, 2016. He complained that his breathing was stopping at night and his hands and feet were swelling, that he had suffered from these ailments his whole life, and that he did not have his medication or a continuous positive airway pressure (“CPAP“) machine. An attached note from Bowker‘s cellmate emphasized the severity of the situation—“we are afraid he is going to die on us.” Miller did not review this request until two days later, at which point she indicated on the request form that she would call Bowker‘s family to procure a CPAP machine. She did not conduct a health assessment of Bowker at the time.
On April 16, 2016, Bowker‘s mother delivered the CPAP machine and prescription medications to the jail. Yet, jail staff refused to accept the medication because CCJ had a policy of refusing any medication that was not packaged in bubble packs. If an inmate‘s family did not provide medication in this specific type of packaging, an inmate could only obtain medication through a visit to the emergency room, which resulted in a $100 transport fee deducted from the inmate‘s commissary account pursuant to a policy created by the Sheriff‘s office. These policies applied to all prescriptions even though CCJ‘s policies required the jail to
Between May 18 and June 11, 2016, Bowker was transported to the emergency room three times. On May 18, Bowker was admitted to Mercy Hospital on account of a rash. Hospital staff recommended follow-up care within one week, noting “of course [Bowker needs] a primary care physician for complete care and evaluation.” The record does not reflect that CCJ ever arranged follow up care for Bowker with a primary care physician. On May 28, Bowker submitted his second medical request to Miller, complaining of a broken toe and difficulty balancing. She did not review this request until June 6, nine days later. This delay was not uncommon. Miller regularly took one or two weeks to respond to inmate medical requests, and a former jail employee testified that the Sheriff was aware of these delays. Having received no response to his May 28 request, Bowker submitted another request on June 3. He reiterated his balancing problems, noting that he was experiencing dizzy spells and had fallen twice, resulting in a back injury. Again, jail paperwork reflects this request was not reviewed until June 6. Bowker was transported to the emergency room for a second time on June 5, more than a week after submitting his initial medical request and before either request was reviewed by Miller. When medics arrived at CCJ, Bowker was in a wheelchair and unable to stand due to weakness in his legs. At the hospital, a doctor concluded Bowker‘s symptoms were likely a side effect of his medication and directed a reduced Zyprexa dosage. In the discharge paperwork, Bowker‘s treating physician emphasized the need for follow-up care outside of the emergency room—“I have explained that if [Bowker does] not have routine and prompt follow up, then [he] may suffer permanent disability, pain and possibly death“—and specifically recommended seeing a psychiatrist.
Bowker was returned to the emergency room for a third time on June 11, after reporting leg pain and difficulty walking. The doctor who saw Bowker indicated in his notes that he was confused by his condition and it was possible that the observed symptoms were psychosomatic. Emergency room records reflect that hospital staff were under the mistaken impression that Bowker would be released within ten days. It appears from the record that jail employees did not advise hospital staff of this error. Bowker‘s discharge papers directed that he be seen by a neurologist as soon as he was released from jail, and the hospital provided contact information for a neurologist with directions to call in one day. His after-visit summary paperwork listed three medications that Bowker should continue taking: Levothyroxine, Metoprolol Tartrate, and Olanzapine.
Despite clear instructions from the hospital to obtain follow-up neurology care and continue Bowker‘s course of medications, CCJ provided no further medical care to Bowker after his June 11 hospital visit. Moreover, CCJ‘s medication logs reflect that he received three prescribed medications for the last time on June 11 and June 12, including Levothyroxine and Metoprolol prescriptions that were specifically listed in his hospital discharge paperwork. Bowker‘s condition rapidly deteriorated
Jail medical records for this period are sparse, but deposition testimony and later reports indicate that Bowker‘s behavior became abnormal and alarming. He defecated on himself daily for at least a week. Officers relocated Bowker to H Block, a wing of the jail designated for inmates with special needs, because he was “laying around and defecating on himself.” In H Block, Bowker slept on a concrete slab without benefit of a bed or mat. On either June 28 or 29, he began to stand in place and stare catatonically at guards. During this period, he refused to eat or move, failed to respond to verbal communications, and kept repeating “I can‘t” when asked to sit down.
Miller was on vacation during some of this period. It is unclear from the record precisely when she left, but it is clear that Bowker was in H Block on her return. She spoke to Bowker on June 29 and asked why he had been defecating on himself and refused to eat and move. Bowker responded, “I can‘t. I can‘t.” At this point, Bowker had been laying in one place for so long that he had bruising on his shoulder.3 An officer gave Bowker a shower, and Bowker repeated the phrase, “I can‘t. I‘m stuck, I‘m scared.” When Miller provided a toothbrush, he refused to brush his teeth, stating, “Water is going to run over. Water is going to run over.” Guards then carried Bowker to a different jail block where he was placed in a cell by himself. According to Prince‘s expert medical witness, a prudent layperson should have recognized Bowker‘s state of mental derangement based on these unusual behaviors.4
According to CCJ‘s Emergency Medical Care Plan, a sudden onset of bizarre behavior is deemed an emergency. Yet at no point on June 28 or 29 did CCJ staff transport Bowker to an emergency room or otherwise provide medical care. Rather than contacting a physician or taking Bowker‘s vital signs, Miller called the judge assigned to his criminal case. Miller testified that she decided to call the judge because Bowker “needed to be someplace besides in our jail,” neglecting to recognize her authority—and obligation under CCJ‘s own emergency policies—to have Bowker transported to the emergency room or another medical treatment facility. The judge told Miller that Bowker appeared normal at a court proceeding on June 21. Miller took no additional action to treat Bowker or seek emergent care following this conversation.
At 1:02 a.m. on June 30, an officer conducting a site check observed Bowker sitting on the toilet in his cell. By the next site check at 2:09 a.m., Bowker was found collapsed on the floor unresponsive. Officers performed CPR and called an ambulance, but it was too late. Emergency room doctors pronounced Bowker dead at 2:55 a.m. The pathology by the Office of the Chief Medical Examiner declared his immediate cause of death as cardiomegaly, or enlarged heart. Prince‘s expert medical witness opined that Bowker‘s cause of death was multifactorial, with severe acute psychosis causing an acute encephalopathy, or brain disease.
C
As relevant to Prince‘s unofficial policy or custom claim, we are pointed to incidents
In the second, Bradley Weaver, another diabetic inmate, suffered a hyperglycemic episode and died in custody in April 2014. Three days prior to his death, Weaver submitted a medical request to Miller complaining that he had been vomiting and dry heaving. According to the request, Weaver was not receiving his diabetes medication. The only action taken by Miller in response was calling Weaver‘s mother to request that she bring his medication in bubble packaging. Weaver was not taken to the emergency room until days later, after he urinated on himself, repeatedly fell, and stopped breathing.
Finally, Michael Manos, an inmate with bipolar disorder and high blood pressure, died in custody in November 2015 under circumstances similar to Bowker‘s death. About a week after arriving at the jail, Manos began refusing medication and food and was moved to a medical cell. In his new cell, Manos experienced fecal incontinence and smeared feces on himself and his cell. Jail staff called an ambulance after Manos began eating his feces, but the EMTs determined Manos was faking his mental illness and decided not to transport him. Three days later, Manos was discovered dead in his cell, covered in feces. The Sheriff at the time of Manos’ death testified that he could not remember whether he investigated Manos’ passing and that he took no steps to determine whether the jail had an adequate medical delivery system. In the seven months that passed between Manos’ and Bowker‘s deaths, the only action the Sheriff took with respect to the CCJ medical system was asking the jail administrator to direct Miller to monitor inmate medication logs more closely. Miller testified she was not asked to do anything different following Manos’ death.5
D
Prince sued several defendants, including Miller in her individual capacity and the Sheriff of Carter County in his official capacity, under
II
We review the grant of summary judgment on qualified immunity grounds de novo. Lance v. Morris, 985 F.3d 787, 793 (10th Cir. 2021). Summary judgment is only appropriate when, viewing the evidence in the light most favorable to the non-moving party and drawing all reasonable inferences in their favor, the movant establishes that there is no genuine dispute of material fact and that the movant is entitled to judgment as a matter of law. Sawyers v. Norton, 962 F.3d 1270, 1282 (10th Cir. 2020);
A
We begin by addressing Prince‘s claims against Miller. In a defendant‘s assertion of a defense of qualified immunity, the burden shifts to the plaintiff to show: (1) a violation of a constitutional right, and (2) that the right was clearly established. Lance, 985 F.3d at 793 (citation omitted). The district court granted summary judgment to Miller on the grounds that Prince failed to meet her burden with respect to both prongs of the qualified immunity test. We disagree.
In the first prong of qualified immunity, we ask whether Prince has raised a genuine dispute of material fact such that a reasonable jury could find a violation of her son‘s constitutional rights. Specifically, Prince asserts that Miller violated Bowker‘s rights under the Eighth and Fourteenth Amendments. Courts have long held that a prison official‘s deliberate indifference to a convicted prisoner‘s serious medical needs constitutes cruel and unusual punishment in violation of the Eighth Amendment. Estelle v. Gamble, 429 U.S. 97, 104 (1976); Strain v. Regalado, 977 F.3d 984, 989 (10th Cir. 2020). Pretrial detainees like Bowker are entitled to the same standard of medical care under the Due Process Clause of the Fourteenth Amendment. Bell v. Wolfish, 441 U.S. 520, 535 n.16 (1979); Strain, 977 F.3d at 989 (citing Garcia v. Salt Lake County, 768 F.2d 303, 307 (10th Cir. 1985)). Therefore, Miller violated Bowker‘s constitutional rights if she acted with deliberate indifference toward his medical conditions.
In considering whether the plaintiff was treated with deliberate indifference, we consider the objective severity of the harm suffered as well as the subjective
1
The objective component inquiry is whether Prince alleges a “sufficiently serious” harm. A medical condition is “sufficiently serious” when “the condition has been diagnosed by a physician as mandating treatment or is so obvious that even a lay person would easily recognize the necessity for a doctor‘s attention.” Al-Turki v. Robinson, 762 F.3d 1188, 1192-93 (10th Cir. 2014) (quotation omitted). Deliberate indifference toward an inmate‘s risk of death certainly satisfies this standard. Martinez, 563 F.3d at 1088-89. The district court concluded that:
the objective component is satisfied, but with caveats. This prong is satisfied if the defined harm (as claimed by plaintiff) is death, which is “sufficiently serious” to satisfy this prong... The court finds plaintiff has not satisfied the objective component under the “intermediate harm” analysis because the symptoms Mr. Bowker presented upon initial booking and during his incarceration did not put jail employees on notice that Mr. Bowker would suffer death.
Prince, 2020 WL 5638819, at *6.8
Bowker‘s psychosis, fecal incontinence, and catatonia, all of which were raised in the complaint, rise to a level of seriousness sufficient to satisfy the objective prong of the deliberate indifference standard. See Mata, 427 F.3d at 753 (“Of course, a prisoner must be careful in selecting what harm to claim. The prisoner may be better off claiming some intermediate harm rather than the last untoward event to befall her.“). Viewing the evidence in the light most favorable to the plaintiff, Bowker‘s symptoms were sufficiently serious that a layperson could have easily recognized his need for medical attention. See Al-Turki, 762 F.3d at 1192-93.9 Clearly, some jail employees recognized exactly that. Bowker was relocated to an isolated cell in the days leading up to his death, defecated on himself, and needed to be cleaned by guards. When Miller and other jail staff attempted to speak with Bowker, he responded with strange phrases instead of communicating normally. He stayed in
The district court determined that these harms were insufficiently serious because it would not have been obvious to a layperson that his symptoms could lead to death. Yet because we conclude that Bowker‘s earlier symptoms should prompt a layperson to seek immediate medical attention, the risk of death was an incorrect inquiry. See Al-Turki, 762 F.3d at 1192-93 (“A medical need is considered sufficiently serious to satisfy the objective prong if the condition has been diagnosed by a physician as mandating treatment or is so obvious that even a lay person would easily recognize the necessity for a doctor‘s attention.” (quotation omitted)); Lance, 985 F.3d at 800 (This court has “not required a life-threatening condition to trigger a constitutional duty to provide adequate medical care.” (citing McCowan v. Morales, 945 F.3d 1276, 1293-94 (10th Cir. 2019))); see also Foelker v. Outagamie County, 394 F.3d 510, 513 (7th Cir. 2004) (determining that prisoner experiencing hallucinations and defecating on himself presented evidence of a serious medical need). Bowker‘s symptoms were sufficiently serious to satisfy the objective component of deliberate indifference.
Even if we considered Bowker‘s psychosis, fecal incontinence, and catatonia as insufficiently serious harms, his condition would yet meet the objective component of the deliberate indifference standard under the “intermediate harm” analysis. We have said that the determination of whether a medical need is sufficiently serious need not be exclusively based on the symptoms observed by prison officials. Mata, 427 F.3d at 753. For purposes of meeting the objective inquiry, the detainee may claim to have suffered a resulting harm (such as heart damage) as a consequence of an intermediate harm or symptoms (such as chest pains). Id. Under this approach, the focus of the objective prong is the resulting harm. As long as the resulting harm is sufficiently serious and prison officials ignored the intermediate symptoms, the objective prong is satisfied. Id. It is undisputed that Bowker‘s ultimate harm of death was sufficiently serious for purposes of the objective component of deliberate indifference. See Martinez, 563 F.3d at 1088-89. Additionally, Prince has presented expert evidence indicating that Bowker‘s symptoms (the intermediate harms which were ignored by Miller) became lethal as a result of the delay in providing medical attention. See Mata, 427 F.3d at 754. Therefore, a jury could find that Prince also prevails under the “immediate harm” theory of the objective analysis.
In sum, viewing the evidence in the light most favorable to the plaintiff, Miller has not established that she is entitled to judgment as a matter of law with respect to whether Bowker‘s symptoms of psychosis, fecal incontinence, and catatonia satisfy the objective component. A reasonable jury could certainly determine that Bowker‘s symptoms were sufficiently serious both on their own and when considered as an intermediate harm that ultimately resulted in Bowker‘s death.
2
In analyzing the subjective component of deliberate indifference, we consider “evidence of the prison official‘s culpable state of mind,” and are satisfied when the record evidence establishes that the “official knows of and disregards an excessive risk to inmate health or safety.” Id. at 751 (quotation omitted). An official‘s state of mind can be inferred from circumstantial evidence. DeSpain v. Uphoff, 264 F.3d 965, 975 (10th Cir. 2001). “[I]n some cases a factfinder may conclude that a prison official knew of a substantial risk from the very fact that the risk was obvious.” Id. (quotation omitted). The district court concluded below that the subjective prong was not satisfied because Miller believed Bowker‘s symptoms were consistent with his bipolar disorder and therefore not serious.
However, viewing the evidence in the light most favorable to the plaintiff, as we must, the record reflects that Miller both knew of and disregarded a serious risk to Bowker‘s health. As we have explained, Bowker‘s symptoms were so obvious that even a layperson would have recognized his need for medical treatment, even disregarding the discharge instructions of the treating physicians.
When Miller spoke to Bowker on June 29, he communicated using only incoherent phrases. He had been moved to an isolated cell due to his fecal incontinence, the evidence of which was all around him, and Miller could not have concluded that his symptoms were merely the result of bipolar disorder or that he was malingering. She knew she was unqualified to render psychiatric diagnoses, and she knew that Bowker had submitted multiple medical requests and been taken to the emergency room three times since arriving at the jail. One of the medical requests reflected another inmate‘s concern that Bowker might die. Bowker‘s records placed Miller on notice that follow-up medical treatment was urgent. She received doctors’ orders that he see a neurologist, a psychiatrist, and a primary care physician. One emergency room doctor even noted that Bowker risked death if he was not provided follow-up medical treatment. Miller knew that a previous inmate, Michael Manos, had died in confinement seven months earlier upon exhibiting similar symptoms.
Despite being on notice of the severity of Bowker‘s symptoms, Miller made no effort to order that Bowker be transported to a hospital. She failed to follow the jail‘s Emergency Medical Care Plan, which classified a sudden onset of bizarre behavior as a medical emergency. See Mata, 427 F.3d at 757 (violations of internal prison procedures “certainly provide circumstantial evidence that a prison health care gatekeeper knew of a substantial risk of serious harm“). The only action Miller took following her interaction with Bowker was to call his criminal court judge. She testified that she made this phone call because she believed Bowker needed to be removed from the jail, but proceeded under the mistaken impression that the pending legal proceedings bore on her responsibility as a medical professional to provide lifesaving care. Upon our review of the record as a whole, we entertain no doubt that Miller disregarded a serious risk to Bowker‘s health.
As the administrator of Bowker‘s estate, Prince has presented sufficient evidence to allow a reasonable fact finder to consider the objective and subjective components of deliberate indifference. Prince has carried her burden of proof on both components and the district court should not have granted summary judgment to Miller.
3
Our next inquiry in the qualified immunity analysis with respect to Miller is whether the constitutional right at issue was clearly established. Lance, 985 F.3d at 798-99. “A constitutional right is clearly established if all reasonable jail [officials] would have understood that their conduct had violated the Constitution.” Id. “[T]he salient question is whether the state
Several Tenth Circuit cases clearly establish that deliberate indifference to symptoms such as those described above violates the Constitution. In Sealock v. Colorado, 218 F.3d 1205, 1211-12 (10th Cir. 2000), we reversed summary judgment in favor of a physician‘s assistant at a prison who failed to transport an inmate experiencing chest pains to the hospital. We held that the inmate‘s chest pain, which ultimately resulted in a heart attack, was sufficiently serious to satisfy the objective prong of the deliberate indifference standard. Id. at 1210. In addition, the subjective prong was satisfied because the physician‘s assistant failed to fulfill his role as a gatekeeper to other medical personnel by exhibiting deliberate indifference toward the inmate‘s condition. Id. at 1211-12. The physician‘s assistant knew that his role in the prison was to connect inmates to medical professionals who could provide additional medical attention, just as Miller understood in the present case. See id.
Two years later, in Olsen v. Layton Halls Mall, 312 F.3d 1304 (10th Cir. 2002), we held that a police officer who allegedly ignored an arrested man‘s panic attack was not entitled to qualified immunity on the arrestee‘s deliberate indifference claim. Id. at 1315-17. Like Bowker, the plaintiff in Olsen suffered from a mental health condition—in that case, obsessive-compulsive disorder (“OCD“)—and required medication for this condition. Id. at 1310-11. Olsen alleged that he experienced a panic attack while being transported to a jail, and an officer ignored his need for medical attention. Id. In affirming denial of summary judgment on qualified immunity grounds, we emphasized that a jury could certainly determine that an OCD-related panic attack was sufficiently serious under the objective prong of deliberate indifference. Id. at 1316. Because the record contained conflicting evidence with respect to the officer‘s subjective awareness of the plaintiff‘s condition, summary judgment was precluded. Id. at 1317.
In Al-Turki, 762 F.3d 1188, we affirmed denial of qualified immunity to a prison nurse who failed to provide medical attention to a diabetic inmate suffering from abdominal pain and nausea that resulted in kidney stones. Id. at 1194. Our decision specifically rejected the nurse‘s argument that the law was not clearly established because previous Tenth Circuit deliberate indifference cases involved longer periods of delay and more serious conditions than kidney stones. Id. We held “that a deliberate indifference claim will arise when ‘a medical professional completely denies care although presented with recognizable symptoms which potentially create a medical emergency.‘” Id. (quoting Self v. Crum, 439 F.3d 1127, 1232 (10th Cir. 2006)).
Finally, in McCowan, 945 F.3d 1276, we affirmed the denial of qualified immunity on a deliberate indifference claim to a police officer who delayed an arrestee‘s access to medical care for shoulder pain. Id. at 1291-93. The plaintiff in that case was offered no treatment despite suffering significant pain as a result of re-injuring a hurt shoulder while being tossed around unbuckled in a police vehicle. Id. at 1280-81. We relied on Olsen (and Sealock, to a lesser extent) to hold that the officer‘s deliberate indifference to McCowan‘s
The facts of these four cases are sufficiently analogous to Bowker‘s situation to have placed all reasonable jail officials on notice that disregarding his severe symptoms amounted to a constitutional violation.10 Each case involved the denial of medical attention to an individual in custody, and three of the plaintiffs had pre-existing medical conditions like Bowker. Olsen, 312 F.3d at 1310-11; Al-Turki, 762 F.3d at 1191; McCowan, 945 F.3d at 1280-81. Further, the medical conditions at issue in Olsen and McCowan, panic attacks and shoulder pain, were not nearly as severe as the symptoms Bowker suffered in the days leading up to his death. Given that it was clearly established in 2015 that ignoring an arrestee‘s shoulder pain violated the Fourteenth Amendment, Miller had notice that her deliberate indifference to Bowker‘s far more serious symptoms did as well. See McCowan, 945 F.3d at 1292-93.11
We therefore conclude that the district court erred as a matter of law in concluding that Miller did not violate a clearly established constitutional right. The district court did not consider Sealock, Olsen, or McCowan. Rather, it explained only its view that Miller did not completely deny medical care as did the defendant in Al-Turki, because she sent Bowker to the emergency room on three occasions. However, the district court failed to consider the complete denial of medical attention to Bowker‘s serious symptoms from June 12 until his death on June 30. The record reflects that during this period Bowker never received a medical evaluation and was not provided three of his medications, at least two of which were life-sustaining. Thus, the district court erred in determining that Miller‘s actions did not amount to a complete denial of medical care under Al-Turki. Bowker‘s constitutional right to be free from deliberate indifference to his serious medical conditions while in custody was clearly established at the time of the relevant events, and as noted above, the district court should not have granted summary judgment.
B
We turn next to Prince‘s claim against the Sheriff of Carter County in his official capacity. She alleges three distinct theories of municipal liability: failure to adequately train jail employees, failure to hire adequate medical personnel at the jail in accordance with the County‘s own written policy, and failure to provide timely medical services to inmates at CCJ.
An official capacity suit “is, in all respects other than name, to be treated as a suit against the entity.” Kentucky v. Graham, 473 U.S. 159, 166 (1985) (citation omitted). Municipalities are liable under
The district court determined that its grant of summary judgment in favor of the individually named defendants on qualified immunity grounds precluded the imposition of municipal liability. However, as we have explained, the district court erred in granting summary judgment to Miller in her individual capacity. Thus, the question before us is whether the Sheriff has established that there are no genuine disputes of material fact and that he is entitled to judgment as a matter of law with respect to whether Carter County‘s policies or customs caused the violation of Bowker‘s constitutional rights.12
We conclude that he has not. Viewing the evidence in the light most favorable to Prince, a reasonable jury could find that Carter County had unofficial policies or customs of failing to medically train jail employees, inadequately staffing the jail, and delaying inmate medical attention. Further, a reasonable jury could conclude that the municipality acted with deliberate indifference to these failures and that these policies caused Bowker‘s death. We address each of Prince‘s theories of municipal liability in turn.
First, with respect to CCJ training, multiple employees testified that they received no meaningful medical training. To the extent that employees participated in training, they were administered tests on which they were encouraged to cheat using provided answer keys. Untrained staff completed booking of new inmates, meaning employees with no medical training were tasked with identifying medical conditions. Miller, the only CCJ employee with any medical background, testified that she had no training on mental health issues and was not qualified to diagnose medical conditions. According to jail employees, the Sheriff was aware of these serious deficiencies in training.
Second, the county failed to employ any medical staff other than Miller. CCJ did not employ a licensed physician, despite written policies requiring the county to do so. Although the Sheriff attributed the lack of a physician to the county‘s inability to locate qualified candidates, the
Third, the record reflects that inmate medical attention at CCJ was routinely plagued by delays. The jail‘s medication policy prohibited inmates from receiving life-sustaining medications unless they were provided in specific packaging or the inmate was transported to the emergency room, at a personal cost of $100 for the transport alone. As a result of this policy, Bowker received no medication for close to two months after arriving at CCJ, and two life-sustaining medications were withheld from him in the days leading up to his death. Miller, the only medical employee at the jail, regularly took at least several days to review inmate medical requests, allowing serious medical concerns to go untreated. Testimony of a former jail employee demonstrates that the Sheriff was aware of these delays. Against this backdrop, it is hard to avoid the conclusion that at CCJ, delay in the provision of medical services is the rule rather than the exception.
Viewing the evidence in the light most favorable to the plaintiff, a reasonable jury could conclude that CCJ maintained unofficial policies or customs of inadequate training, inadequate staffing, and delays in medical attention, often in violation of its own written policies, all as alleged in the complaint. The next inquiry is whether a reasonable jury could conclude that the municipality acted with deliberate indifference. “The deliberate indifference standard may be satisfied when the municipality has actual or constructive notice that its action or failure to act is substantially certain to result in a constitutional violation, and it consciously or deliberately chooses to disregard the risk of harm.” Barney v. Pulsipher, 143 F.3d 1299, 1307 (10th Cir. 1998) (citation omitted).
The record below reflects that the Sheriff had actual knowledge of the numerous and systemic problems with CCJ‘s health care system. In particular, he was aware that CCJ did not employ a licensed physician in violation of its written policy. See Tafoya v. Salazar, 516 F.3d 912, 919 (10th Cir. 2008) (“The knowing failure to enforce policies necessary to the safety of inmates may rise to the level of deliberate indifference.” (citations omitted)). Moreover, three other CCJ inmates died in the three years prior to Bowker‘s death after seemingly receiving inadequate medical attention. See Barney, 143 F.3d at 1307 (“In most instances, notice can be established by proving the existence of a pattern of tortious conduct.“). The Sheriff testified that the only action he took in response to Manos’ death, which took place seven months prior to Bowker‘s death and under similar circumstances, was directing the jail administrator to ask Miller to better monitor medication logs. Former jail administrator Michael Armstrong agreed during a deposition that requiring staff without medical training to make inmate medical decisions left CCJ‘s health care system “destined to fail.” Given the Sheriff‘s
Finally, a reasonable jury could conclude that CCJ‘s deliberate indifference caused Bowker‘s death. As a result of CCJ‘s customs and policies, Bowker failed to receive medication, experienced delays in medical treatment, and untrained staff failed to timely transport him to the emergency room in his final days. According to Prince‘s medical expert, there is a reasonable probability that CCJ‘s failure to provide continuous medical care to Bowker caused his death. We have recently held that a Sheriff‘s “continuous neglect” of medical conditions similar to those in this case could lead a reasonable fact finder to infer causation of a plaintiff‘s injury sufficient to defeat summary judgment. Burke v. Regalado, 935 F.3d 960, 1001 (10th Cir. 2019). Prince has therefore established a genuine dispute of material fact as to the Sheriff‘s liability. Accordingly, the Sheriff is not entitled to judgment as a matter of law.
III
In summary, a reasonable fact finder could conclude that Wayne Bowker‘s tragic death resulted from both Miller‘s abdication of her medical duties and the Sheriff‘s systemic failure to address deficiencies in the provision of medical services at CCJ. To the extent that both defendants acted with deliberate indifference, they violated Bowker‘s constitutional right to have his medical conditions addressed urgently as a pre-trial detainee. Because this right is clearly established in the context of Bowker‘s specific conditions, Miller is not entitled to summary judgment on qualified immunity grounds.
The district court‘s grants of summary judgment in favor of Miller in her individual capacity and the Sheriff of Carter County in his official capacity are REVERSED.
CARLOS F. LUCERO
UNITED STATES CIRCUIT JUDGE