yes all right me please the court i think that the facts are agreed upon in the case the issue is going to be it seems to me the law to briefly summarize i think everyone agrees that mr thomas was in a intervene is lasix no twenty four hour medical care no radiologist no x ray so obviously something had to be done to make sure that patients who were not in a medically stable condition had to be seen by a doctor and identified everyone also agrees that a doctor was necessary a transfer of patient that medical approval was was needed and that appellee agrees with that to but dr warner's information which is contained in the excerpt to record beginning of page nineteen shows is a pattern of indifference which is documented by dr warner and documented in the records and briefly without going into a lot of talk about th policy so what is the county now the policy you are alleging was responsible for the injuries ok here's the here's the issue it it's either a policy or the absence of a policy and what i found here to be absent was that there was no systematic first of all there were no guidelines on when a doctor would see a patient no guidelines no policy on when a doctor would be contacted that's why dr war telling all these indicia of serious medical needs and no doctor is contacted no one telling the nurses you must contact a doctor how do you answer the other side's complaint that to do that they'd have to micromanage every response to that is to say that when a patient is not in a medically stable condition you must contact the doctor must a doctor must see the doctor in that event not on a place on a doctor's line of broad guidelines just saying that that policy must be enforced and then people must be trained to adhere to that these nurses were not trained when you see dr warner's declaration it's devastating because of all the indicia of failure ultimately what was what was the proof the putting was that you're a patient falls and is in the foot on the floor of a cell in his own feces and no doctor is required to see that patient so the policy to answer question is any time number one any time a patient is not liability under section one thousand and three well there are two two basic areas one is i think the canton when you have a failure to train it's another another adjunct to the failure to have a policy in canton they left a woman and over what you see is that you know the facts of oh yeah i know but what you have there is a situation where you know that people should be released and there's absolutely no way of keeping they have no way of keeping track so they they didn't make any effort to keep track so they would know that people were away so that if there was a need to release they had no organized way of keeping track this is the same thing it's monitoring the serious medical condition of an inmate in a vulnerable position they s that many of the people the detainees were illiterate or unable to cure themselves they were in a vulnerable situation that's what they said and over yet here is well if you have people who suffer from hypoxia where the oxygen is reduced and they fall out that their disoriented they can i get their own medical care in fact he asked for medical care on the twentieth of march and was denied medical care for days after that so what you have is number one of failure to failure to have a policy to immediately again vulnerable people a person comes in with mental illness that person is vulnerable and what they said at page eleven eighty nine of the gibson was there was a failure to respond to the need that is it the failure to respond to the need this person in suffering from serious ailments and it wasn't the one hour in canton that they feel to respond in canton this was eighteen days when they failed to respond eighteen days it wasn't one incident it was n medical judgment of whether he did or did not need to see him and if he decided that he didn't live that medical malpractise well i think it's a difference i think it's i think the failure de ferry to require a doctor see a patient and this is i think a jury trial it's our two experts dr rosenfeld and dr warner concluded that and they're experienced experts that the ferry to have a policy in this situation demonstrates deliberate indifference because what you have to do is you have to say the doctor telephone therapy is not enough here you have to go and examine the patient and see the patient because only a doctor can transfer the person to u s c to the hospital only doctor can make that call a nurse can't do it so what do you do he did everything in conformity w a policy of the doctors and nurses can basically fend for themselves that it is all up to the doctors and nurses with no guidelines in gifts and as you as you know there was a nurse there that was involved in gibson but that nurse at page eleven ninety five they said that the deficiency was not requiring that nurse to act that was what the gibson court said that nurse was not required to act and here the same thing a doctor is involved that doctor was not required to act and that was the problem with what they did in the district court's opinion she really found that there was neglect and you have just about a minute do you wan say this minute yes thank you policy of hiring licensed doctors and nurses to take care of its patients and on the doctors and that's about what else could they do that's not a policy that's a basic minimum requirement of l it has some policies about how to transfer patients but the most important thing here is that the county has to be found to be deliberately indifferent and here is what it did was it hired license starters and nurses to provide patient care and what we're talking about is asking the doctors and nurses to determine when a patient is medically unstable often doctors knew all doctors and nurses knew the limitations of the medical services bureau they knew that if a patient was unstable the patient would have to be transferred to the hospital the issue as well the issue according to mr burke is whether or not they did it but the real issue is was there the real issue is that the county hire these doctors and nurses and asked them to basically follow the standard of care and if the doctors didn't follow the standard of care the not might the amount practice too but it doesn't show that the county was deliberately indifferent unless the county had some reason to believe that the them what to do with respect to their practice or training and very well you might have to provide them some sort of training but here we're talking about training the doctors when to how to recognize when a patient is medically unstable and that's something that they would learn in medical school the county can't really train them to determine when a patient is medically unstable because that's part of the healing aren't that they learn in medical school they would the county would have to have a lu balloon years and years of training to replicate what the doctors and nurses would learn in medical school to be able to tell the doctors how to recognize when a patient is medically unstable in other words there wasn't a simple policy that the public defender's office had a policy of assigning the least experienced lawyers i think the miranda you're talking oh i'm sorry yes you're right it is miranda the public in miranda the public defender's office had a policy of assigning least experienced lawyers in the office to death penalty cases and the court there actually said that this was deliberate indifference because it was not merely an isolated assignment of an experienced lawyer but a deliberate policy of refusing to train lawyers for death penalty cases that the administrators knew it was very unusual demands on attorneys so in that particular case the county public defender's office knew or had reason to know that that these particular types of cases would require especially experienced lawyers and yet they fail to do anything about it but here we're not talking about asking a dermatologist to do brain surgery or a general practitioner to do something like brain surgery or in other words to deal with a type of situation that they should know would be unusually demanding and that an inexperienced doctor couldn't do here we  had the county delegating the responsibly to doctors and in fact one of the doctors here had sixteen years of experience with the county and then a county doctor for sixteen years and basically the county was relying on these doctors  to determine when a patient is medically unstable that's not comparable to hiring to lead to assigning i'm a lawyer fresh out of law school to try and death penalty case which the county public defender's office knows is an especially difficult case here we're talking about something pretty basic just determining when a patient is medically unstable kind of had a couple of expert witness doctors nurses here didn't follow the standard of care they didn't do what they should have done and they saw particular symptoms and they didn't realize them and they didn't act on the knowledge that the patient was medically unstable so if anything  of medical malpractise or whether the doctors in this particular situation failed to provide adequate care it doesn't speak to whether the county had a policy of providing adequate care and the fear of failing to train the question that his doctor experts can't can't opine on they can opine on the standard of care they can opine as to whether the doctors and nurses should have done something but i don't think they can opine on whether the authority are you relying upon to support your argument that experts cannot opine on the ultimate question of law i don't have authority for that proposition your honor but even if they knew my my larger point is that the question of deliberate indifference vs a question for the jury or if there is no evidence that a jury could return a verdict on then it's a question for your honour's so expert states the opinion that this was deliberate indifference it's still up to the jury or the court to determine whether there actually was a point the point is why isn't that enough to take this case to a jury asonable person would recognize the need and i don't think the expert d and if not what kind of policies are required is there a policy required here telling doctors how they should react when they get calls that people  the here's what the hospital provides some of the ways they might have to train the doctors as to the particular facility but that's different from saying you have to train the doctors to recognize when someone's unstable because here all the doctors and nurses testified that they knew that if a patient became unstable they had to transfer them to the hospital they knew that there wasn't understood transferred and only the doctor could transfer them and there was nothing to say that the doctor had to see them in order to decide whether the well well that's true but the county was remind on the nurses to know when i don't or had to be summoned and that's actually common practice in hospitals so for instance if someone's a patient in a hospital and they not the nurses force and she did what you supposed to do call the doctor told them what was going on question is do you need a policy that requires doctors to go to the jails or kitty i vaguely remember just your act over the telephone i'm not sure the person well in this case the issue there seems to be that well that the nurse did notify the doctor but the doctor didn't come it's up to the doctor's independent professional judgment to determine whether they county had a policy i would assume so yes regardless of whether in his independent judgment he felt he should come or should not come if there were a policy regardless the county field independently he'd have to come with the right that's true but it sounds like what your honor is saying is that the county should have had a backup policy in case the doctors failed to follow the standard of care but it seems that when plaintiffs experts here are saying is that the doctors didn't follow the standard of care it's not there was it's not deliberate indifference for the county not have a policy requiring the doctors to follow the standard of care unless there was some reason for the county to know that doctors no no i won't i didn't i know your time is important i'll just say very briefly and try to get the points first of all i think that it's a jury question as to whether this reflects deliberate indifference and the experts say that it does and the experts look at everything look at the oxygen situation the patient refuses oxygen and at x or to record seventy seven the only policy dr johnson says when you refuse oxygen you give a patient a release of reliability form well they can have a policy to get a patient release from liability form shouldn't a jury be permitted to conclude that that would indicate that this entity has prepared in advance and knows that they face libeling which means there could be no harm and they should have had a policy to also require a to fall yes this and only the second fall the first fall no doctor was contacted in the first fall a patient fell and we know from the medical evidence that that is also a potentially traumatic incident no doctor was called i don't see anything in the record saying that medical schools or nursing schools would teach prison medicine or other types of medicine the way in miranda you would say that there's a certain protocol that you could call someone to to follow  a patient in a vulnerable medical condition i think that's the that's the key and then that can indicate instability that can indicate hypoxia that's the the evidence from the experts that can indicate disorientation and so a nurse should call a doctor to make that judgment and that's what the experts believe and if that's too much then they should transfer that person to a place they can get the monitors the twenty four hour care that they that they need or they shouldn't take patients like this at  s b unit because this person died eighteen days after having them received because of the fact that he was steadily deteriorating in the experts views of a person slips on a bar and you think that the doctor has that pa t if a persian slips on a bar of soap and there is nothing indicating any any possibility of anything worse maybe not but if there is an incident where a patient is a bone in a vulnerable medical condition because of in this situation what they said a host of serious medical problems such that any instability even shortness of breath would lead and should lead to an immediate transfer where you can be monitored yes that's the difficulty with having a you're saying that because i think the job may be tough but that doesn't mean they can't and shouldn't do it they should define what instability what patients what to what patients instabilities important cardiac patients patients who have a host of medical problems district court found and the district court's opinion at eleven thirty two was exact i'm sorry page one thirty one of the yesterday record was and one thirty two it was that the counties poss the only policy was to leave it to the doctors i think the jury be able to conclude assess the evidence listen to the experts and conclude that more was needed here and that they had noticed that people with serious medical problems come into the jail and that more had to be provided in the way of definition protocol and policy and very ok thank you very much i'm sorry for going