Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_12-cv-05895/USCOURTS-cand-3_12-cv-05895-5/pdf.json

Nature of Suit Code: 555
Nature of Suit: Prisoner - Prison Condition
Cause of Action: 42:1983 Prisoner Civil Rights

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT 

NORTHERN DISTRICT OF CALIFORNIA 

RONALD DIAZ,

Plaintiff,

v.

CLAIRE WILLIAMS, et al.,

Defendants.

Case No. 12-cv-05895-WHO (PR) 

ORDER GRANTING DEFENDANTS' 

MOTION FOR SUMMARY 

JUDGMENT

INTRODUCTION 

Plaintiff Ronald Diaz claims that medical staff at Pelican Bay State Prison provided 

constitutionally inadequate medical care for his Hepatitis-C-infected liver in violation of 

42 U.S.C. § 1983. Having provided Diaz with the required warnings under Rand v. 

Rowland, 154 F.3d 952, 962–63 (9th Cir. 1998) (en banc), defendants move for summary 

judgment. (Docket No. 70.) The evidence necessary to establish deliberate indifference to 

serious medical needs is quite substantial. Diaz has not offered any evidence that would 

constitute a material disputed fact to show deliberate indifference. Accordingly, 

defendants’ motion for summary judgment is GRANTED. 

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STANDARD OF REVIEW 

Summary judgment is proper where the pleadings, discovery and affidavits 

demonstrate that there is “no genuine dispute as to any material fact and [that] the movant 

is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). Material facts are those 

which may affect the outcome of the case. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 

248 (1986). A dispute as to a material fact is genuine if there is sufficient evidence for a 

reasonable jury to return a verdict for the nonmoving party. Id. 

The party moving for summary judgment bears the initial burden of identifying 

those portions of the pleadings, discovery and affidavits which demonstrate the absence of 

a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). 

Where the moving party will have the burden of proof on an issue at trial, it must 

affirmatively demonstrate that no reasonable trier of fact could find other than for the 

moving party. On an issue for which the opposing party by contrast will have the burden 

of proof at trial, as is the case here, the moving party need only point out “that there is an 

absence of evidence to support the nonmoving party’s case.” Id. at 325. 

Once the moving party meets its initial burden, the nonmoving party must go 

beyond the pleadings and, by its own affidavits or discovery, set forth specific facts 

showing that there is a genuine issue for trial. Fed. R. Civ. P. 56(c). The Court is 

concerned only with disputes over material facts and “[f]actual disputes that are irrelevant 

or unnecessary will not be counted.” Anderson, 477 U.S. at 248. It is not the task of the 

court to scour the record in search of a genuine issue of triable fact. Keenan v. Allan, 91 

F.3d 1275, 1279 (9th Cir. 1996). The nonmoving party has the burden of identifying, with 

reasonable particularity, the evidence that precludes summary judgment. Id. If the 

nonmoving party fails to make this showing, “the moving party is entitled to a judgment as 

a matter of law.” Celotex, 477 U.S. at 323 (internal quotations omitted). 

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FACTUAL BACKGROUND 

In his amended complaint (Docket No. 8), Diaz alleges that defendants L. Thomas, 

M. Sayre, S. Risenhoover, C. Williams, M. Cook, G. Lewis, C. Tileston, and D. Foston 

violated his Eighth Amendment rights by failing to treat his Hepatitis-C-infected liver 

properly. He asserts that Sayre, the Chief Medical Officer at Pelican Bay, Risenhoover, a 

Pelican Bay physician, Williams, another physician, and Thomas, a third physician, were 

deliberately indifferent to his serious medical needs when they denied him (A) a liver 

biopsy, (B) combination therapy, (C) a hepatic diet, and (D) liver transplant consideration. 

He also contends that Cook, an associate warden, Lewis, the warden, Tileston, an 

administrative appeals examiner, and Foston, Chief Examiner of Pelican Bay’s Office of 

Appeals, were deliberately indifferent when they denied his requests to (A) receive the 

treatment the above defendants denied to him and (B) be transferred to a prison where he 

could receive better treatment. 

The following factual allegations are undisputed unless specifically noted 

otherwise. In January 1998, Diaz was tested for HIV and Hepatitis A, B, and C at Solano 

State Prison, but he was never informed of the results of the tests. (Compl. at 3; Opp. to 

Mot. for Summ J. (“Opp.”) at 9.) He arrived at Pelican Bay in February 2005. (Compl. at 

3.) In April 2006, he asked to see a doctor because he was losing weight and feeling ill. 

(Id.) That same month, he tested positive for the Hepatitis-C virus (“HCV”) antibody. 

(Id.) 

HCV is an infectious disease that can lead to cirrhosis of the liver. (Mot. for Summ. 

J. (“MSJ”), Sayre Decl. ¶ 11.) Standards for treating HCV (“Guidelines”) were approved 

in June 2004 by the Madrid court1, which held that the Guidelines were “an adequate HCV 

treatment program to address the problems with treatment of chronic disease.” (MSJ, Req. 

for Judicial Notice (“RJN”), Ex. B at 4.) The Guidelines allow for a liver biopsy and 

combination therapy (which is also called antiviral treatment, “AVT”) for certain patients. 

 

1 Madrid v. Woodford, No. 3:90cv3084-THE (N.D. Cal., filed Oct. 26, 1990). 

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(Id., Sayre Decl., Ex. C.) A biopsy is not a treatment, but rather a test to determine the 

amount of liver damage. (Id. ¶¶ 19, 21, 23.) It requires inserting a needle into the liver 

and removing a piece of it, can cause internal bleeding and death in patients prone to 

bleeding. (Id. ¶ 19.) Biopsies are not indicated for all patients with HCV--many HCV 

patients are prone to internal bleeding owing to varices, or bulging veins, and low platelets. 

(Id. ¶¶ 14, 18, 22.) 

Diaz’s doctors requested that Diaz be considered for a liver biopsy in May, 2006. 

(MSJ, Ex. A (PBSP-00957-PBSP-01125; PBSP-01118-PBSP-01120).)2 To see whether 

he could tolerate a biopsy, his platelet level was tested. (Id.) His July 2006 lab results 

showed that he had a condition diagnosed as thrombocytopenia, meaning that his platelet 

count was persistently below the range advised for a biopsy. (Id. ¶ 15, Ex. A (PBSP01063-PBSP-01066).) Owing to this condition and other safety concerns (occasional nose 

and gum bleeding), his biopsy was cancelled. (Id. (PBSP-01111-PBSP-01114).) 

Diaz contends that two of his blood tests showed a platelet count above 75,000 per 

milliliter, a level high enough that a biopsy could be performed safely. (Opp. at 9, ¶ 40.) 

At least seventeen other blood tests, however, resulted in an unacceptable platelet count. 

The platelet counts in the two tests Diaz identifies were not sustained over time. (MSJ, 

Sayre Decl. at p. 6, ¶ 29; Ex. C (HCV-000023).) 

In July 2007, Diaz was diagnosed with a large column of esophageal varices, which 

were treated with medications. (Id. (PBSP-01045).) Further testing in 2010 and in March, 

2011 also revealed possible esophageal varices. (Id. (PBSP-00792-PBSP-00793; PBSP00990-PBSP-00991, PSBP-00964).) 

After the testing in 2010 that showed the possible varices, Dr. N. Adam requested 

AVT, or combination treatment, for Diaz. Combination treatment is a course of antiviral 

drugs recommended under the Guidelines to treat HCV. (MSJ, Sayre Decl., Ex. C (HCV-

 

2 He was also enrolled in the prison’s chronic care program and signed a contract 

acknowledging that he was not guaranteed to be endorsed for HCV treatment. (Id. (PBSP1075-PBSP-1079; PSBP-01115-PBSP-01117).)

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000009-HCV-000015); RJN Ex. B.) The Madrid court found that this therapy “can result 

in a sustained virologic response in approximately one-half of the patients who undergo 

it.” (Id., RJN, Ex. B at 5.) The treatment is painful, time-consuming, and has many 

adverse effects, including anemia and a reduction in both white blood cell and platelet 

counts. (Id.; Sayre Decl. ¶ 26.) Because of its length and deleterious effects, combination 

therapy is given only to those patients who are likely to withstand it. (Id., RJN, Ex. B at 5; 

Sayre Decl. ¶¶ 26-29.) Dr. Adam’s request for combination therapy for Diaz was denied 

because Diaz did not meet the criteria for such treatment. (Id. (PBSP-00591-PBSP00593).) 

Liver transplant procedures were incorporated into the Guidelines in April 2008. 

(MSJ, Sayre Decl., Ex. F (HCV-000155).) The California Department of Corrections and 

Rehabilitation’s (CDCR’s) statewide Utilization Management/Medical Authorization 

Review (“UM/MAR”) committee identifies potential recipients of liver transplants, with 

ultimate approval coming from the outside transplant center being used. (Id. ¶ 37.) To be 

considered for a transplant, patients must have a certain MELD (Model for End-Stage 

Liver Disease) score, which is based on a calculation of various factors taken from blood 

analysis. (Id. ¶ 34.) In April 2008, the Guidelines required a score of 30 or more. (Id., 

Ex. F.) In September 2008, the MELD minimum was lowered to a score of 15 or more. 

(Id., Ex. G.) Diaz’s MELD scores were 8 (as of March 3, 2008), 11 (as of August 12, 

2008), and 12 (as of June 20, 2011). (Id. at ¶ 35, Ex. A (PBSP-00560-PBSP-00561, PBSP00773-PBSP-00774, PBSP-00779-PBSP-00781).) 

Diaz met with medical staff over thirty times in relation to his HCV infection 

between his transfer to Pelican Bay in February 2005 and November 2012, when he 

initiated the current proceedings. His treatment over this period included at least nineteen 

blood tests, appointments with a specialist, ultrasound scans, diet evaluation and 

modification, medication, and evaluations for a biopsy, liver transplant, and prison 

transfer. 

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DISCUSSION 

A prison official is deliberately indifferent if he knows that a prisoner faces a 

substantial risk of serious harm and disregards that risk by failing to take reasonable steps 

to abate it. Farmer v. Brennan, 511 U.S. 825, 837 (1994) (equating standard with that of 

criminal recklessness). The prison official must not only “be aware of facts from which 

the inference could be drawn that a substantial risk of serious harm exists,” but “must also 

draw the inference.” Id. Consequently, in order for deliberate indifference to be 

established, there must exist both a purposeful act or failure to act on the part of the 

defendant and harm resulting therefrom. See McGuckin, 974 F.2d at 1060. 

In order to prevail on a claim of deliberate indifference to medical needs, a plaintiff 

must establish that the course of treatment the doctors chose was “medically unacceptable 

under the circumstances” and that they embarked on this course in “conscious disregard of 

an excessive risk to [plaintiff’s] health.” Toguchi v. Chung, 391 F.3d 1051, 1058-60 (9th 

Cir. 2004). A claim of mere negligence related to medical problems, or “the inadvertent 

failure to provide medical care, or a difference of opinion between a prisoner patient and a 

medical doctor, is not enough to make out a violation of the Eighth Amendment. Id.; 

Franklin v. Oregon, 662 F.2d 1337, 1344 (9th Cir. 1981). The mere fact that a prisoner 

does not receive adequate medical care does not necessarily create a claim for “deliberate 

indifference” to serious medical needs for purposes of imposing liability under 42 U.S.C. 

Section 1983. Id. at 105-06. Mere negligence or “the inadvertent failure to provide 

medical care” will not sustain a Section 1983 claim. Id. at 105. 

I. Claims Against Sayre, Risenhoover, Williams, and Thomas 

Diaz claims that Sayre, Risenhoover, Williams, and Thomas were deliberately 

indifferent to his serious medical needs when they denied him (A) a liver biopsy, 

(B) combination therapy, (C) a hepatic diet, and (D) liver transplant consideration. He has 

not shown a genuine dispute on any issue that the defendants’ conduct was “medically 

unacceptable under the circumstances” and that they embarked on it in “conscious 

disregard of an excessive risk” to his health. Toguchi, 391 F.3d at 1058-60. His 

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disagreement with the course of treatment is not sufficient to show genuine dispute. Id. 

Defendants’ motion for summary judgment on these claims is GRANTED for the reasons 

explained in more detail below. 

A. Denial of Liver Biopsy 

Defendants declined to biopsy Diaz’s liver because of their serious medical 

concerns for his safety. Diaz’s platelet count was below normal levels and he had 

esophageal varices, making a biopsy dangerous. With such low platelets, a biopsy would 

likely cause internal bleeding that would not clot. This in turn could cause a rupture of 

esophageal varices, which is the most common cause of death in patients with cirrhosis or 

end-stage liver disease (“ESLD”). 

Diaz contends that medical staff were deliberately indifferent in delaying their 

diagnosis of HCV and that if he had been tested sooner, his platelet count would have been 

high enough to qualify for a biopsy. (Opp. at 22.) To support his claim that undue delay 

caused his platelet count to fall below the threshold for a biopsy, Diaz mistakenly points to 

a record that shows his platelet count at 210. While Diaz asserts that this was his platelet 

count when he arrived at PBSP in 2005, in fact the document on which he relies is a 

medical record from January 1998, some seven years before his transfer to Pelican Bay. 

(Id., Ex. A at 2.) There is no evidence of his platelet count when he was transferred to 

Pelican Bay in 2005 or of how much it may have dropped between the date he arrived at 

Pelican Bay and his diagnosis in 2006. 

Diaz made the request for HCV testing in March 2006. There is nothing in the 

record to indicate Diaz could not have requested testing sooner if he was concerned about 

potential risk of infection.3 Even if the medical staff’s failure to test Diaz for HCV sooner 

 

3 Diaz also alleges that defendants engaged in acts of fraudulent concealment of his 

medical records. (Opp. at 22.) In support of this claim, Diaz refers to PBSP-01091 in 

Exhibit A of Sayre’s Declaration. However, this page does not exist within the record so 

the Court is unable to evaluate this claim, and it would be unlikely to create a disputed 

material fact in any event. 

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could be found to constitute negligence or gross negligence (and on this record there is no 

evidence of fault at all), neither negligence nor gross negligence is actionable under section 

1983. Farmer, 511 U.S. 825, 835–36 & n.4 (1994). 

Diaz also claims that defendants ignored the recommendations of hematological 

specialist Dr. Bonis in favor of a biopsy. Contrary to Diaz’s assertions, Bonis did not 

recommend a biopsy. While Bonis wrote that there was “no absolute contraindication to 

having a biopsy of [Diaz’s] liver,” he concluded that, “Unfortunately [Diaz’s] platelet 

counts will remain a lifelong issue and one would need to weigh the risk/benefit ratio as to 

if a biopsy of the liver was obtained what would be done with that result more long term.” 

(MSJ, Sayre Decl., Ex. A (PBSP-00946).) Defendants did not allow a biopsy in an 

exercise of caution as a result of Diaz’s low platelet count and varices. That Diaz 

disagrees with their conclusion does not establish a genuine dispute of material fact that 

could show deliberate indifference. 

B. Denial of Combination Treatment 

Defendants denied the use of combination therapy for essentially the same serious 

medical reasons they denied the administration of a biopsy, that is, his low platelet count 

and his esophageal varices. The Guidelines for treatment of HCV state that if a patient has 

“decompensated cirrhosis,” which is marked by varices, acites, jaundice, or low platelets, 

he cannot safely receive combination therapy. As discussed above, a platelet count below 

75,000 per milliliter is also an absolute contraindication for combination therapy. Because 

administration of combination treatment was likely to cause harm to Diaz, defendants 

refrained from using it. Instead, they provided medication, reviewed his diet, made 

ultrasound observations, and continued to monitor his platelet count for improvement. 

(MSJ, Sayre Decl. Ex. A (PBSP-01291-PBSP-01292).) 

Diaz’s contention that two tests showed an acceptable platelet level is outweighed 

by the fact that those levels were not sustained. Seventeen other tests were below the 

minimum level required. Even if Diaz’s low platelet count was not an absolute 

contraindication for combination therapy, it would still have been reasonable for doctors to 

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deny combination therapy on the grounds that (i) Diaz had esophageal varices, (ii) he 

showed symptoms of decompensated cirrhosis, and (iii) combination therapy has serious 

adverse side effects, including a reduction in platelets. (MSJ, Sayre Decl. p. 6, ¶ 29; Ex. C 

(HCV-000023).) There is no genuine dispute that defendants’ decision to refuse 

combination therapy was “medically unacceptable under the circumstances” and that they 

embarked on this course in “conscious disregard of an excessive risk” to his health. 

Toguchi, 391 F.3d at 1058-60. 

C. Denial of Hepatic Diet

Diaz was originally recommended for and placed on a hepatic diet, the guidelines 

for which were revised in April 2008. (MSJ, Sayre Decl. ¶¶ 31-32.) The original 

guidelines for a hepatic diet were designed to restrict protein from the diet of patients 

suffering from frank hepatic encephalopathy, an accumulation of toxic substances derived 

from protein metabolism. (Id.) The April 2008 revisions encouraged protein in the diet 

for decompensated cirrhosis patients who did not show signs of encephalopathy and could 

thus tolerate higher levels of protein. (Id.) Since Diaz showed no signs of encephalopathy, 

Sayre disapproved the hepatic diet, keeping in line with the guidelines. (Id.) 

Diaz asserts that that the hepatic diet is the same as a low salt diet and contends that 

a low-salt diet would have alleviated episodic abnormalities of mental problems, breakouts 

in rashes, and itching that he was experiencing. (Am. Compl. at 14.) He again misreads 

the record on which he relies. The Chronic Care Program for Hepatitis C, Exhibit F of 

Sayre’s Declaration (HCV-000154), refers to two different diets: the “CDCR low-salt, low 

fat, ‘heart healthy’ diet,” and a “Low Protein Diet” for those who have symptoms of 

encephalopathy. It is the latter diet that is the hepatic diet, not the former. Diaz also 

mischaracterizes the qualification for being put on the hepatic diet as being “diagnosed 

with end-stage liver disease (ESLD).” (Id.) According to the revised diet guidelines 

implemented in April 2008, the hepatic diet was only necessary for ESLD patients 

suffering from hepatic encephalopathy, from which Diaz was not suffering. 

Diaz also claims that “counseling on nutrition and continuance on a heart healthy 

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diet was inadequate to reduce the pain and suffering [he] was forced to endure.” (Opp. at 

15.)4 While he describes his dissatisfaction with the efficacy of the treatment, he does not 

show a genuine dispute that defendants were deliberately indifferent. 

D. Denial of Liver Transplant Consideration

Defendants had no authority to place Diaz on a liver transplant list--that is done by 

the CDCR statewide UM/MAR committee. Diaz’s MELD scores were too low to require 

defendants to propose him for placement. Diaz nonetheless contends that defendants 

omitted “certain elements relevant to liver transplant evaluations, i.e., age/mental health 

instability/and other life threatening condition.” (Opp. at 15.) 

Again, Diaz may misunderstand the record on which he relies. It lists mental health 

instability and other life threatening conditions as contraindications for liver 

transplantation, not the reverse. (MSJ, Sayre Decl., Ex. F (HCV-000155).) 

Diaz’s assertions that defendants continuously refused or denied requests to see 

specialists has little bearing on the denial of his liver transplant, which is determined 

primarily by MELD score. (Id.) The MELD system is simply a formula used to calculate 

a score based on a patient’s date of birth, values for serum bilirubin, serum creatinine, and 

prothrombin time (“INR”), and whether the patient is undergoing dialysis. (MSJ, Sayre 

Decl., Ex. F (HCV-000155).) The September 2008 CDCR Guidelines provide 

transplantation evaluations for patients with a MELD score of 15 or higher. (Id., Ex. G 

(HCV-000195).) The United Network for Organ Sharing (“UNOS”), the single national 

database and waitlist for organ transplantation, uses MELD scores to rank a patient’s 

priority for liver transplantation, with a maximum score of 40 indicating the highest 

priority. 

Diaz’s claim that defendants “produce no evidence that they followed the MELD 

 

4

It is unclear from the record whether the CDCR’s standard diet is the heart healthy diet or 

whether, if not, Diaz ever requested the heart healthy diet. That is not material here, since 

Diaz’s claim concerned the hepatic diet and there is no evidence that the diet provided to 

him caused an excessive risk to his health that was medically unacceptable under the 

circumstances. 

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system to the letter” (Opp. at 15) is without merit. Diaz underwent repeated blood tests, 

which included measurements of these values that were used to calculate his MELD score. 

(Id., Ex. A (PBSP-00779-PBSP-00781, PBSP-00773-PBSP-00774, PBSP-00560-PBSP00561).) Diaz’s highest recorded MELD score was 12. (Id., Ex. A (PBSP-00779-PBSP00781).) Diaz’s MELD score precluded him from consideration for transplantation under 

the Guidelines. It indicated that he would be a relatively low priority even if he were 

referred to the UNOS waitlist. In short, it showed that his chances of receiving a transplant 

were slim. Diaz has not shown a genuine dispute that defendants’ decision to not 

recommend him for a transplant was “medically unacceptable under the circumstances” 

and that they embarked on this course in “conscious disregard of an excessive risk” to his 

health. Toguchi, 391 F.3d at 1058-60. 

II. Administrative Denials 

Defendants Cook and Tileston reviewed and rejected Diaz’s inmate appeals 

regarding his (A) treatment and (B) request for a transfer to another prison. Lewis and 

Foston are named as defendants because they supervised Cook and Tileston. None of 

Diaz’s claims against these defendants creates a disputed issue of material fact. 

A. Denial of Administrative Grievances for Treatment 

As determined above, Diaz has not shown a genuine issue of material fact that 

defendants Sayre, Risenhoover, Williams, and Thomas were deliberately indifferent to his 

serious medical needs. Since no genuine dispute of material fact exists as to their actions, 

Diaz cannot show a genuine dispute that those who reviewed his complaints about his 

treatment (Cook and Tileston) were deliberately indifferent. It follows that Diaz has not 

shown a genuine dispute as to the actions of Cook’s and Tileston’s supervisors, Lewis and 

Foston. Accordingly, defendants’ motion for summary judgment is GRANTED in favor of 

these defendants as to this claim. 

B. Denial of Transfer Request

In May 2011, Diaz appeared before the Institutional Classification Committee to 

review Diaz’s gang validation and housing in the Secured Housing Unit. The committee 

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noted a medical classification chrono that recommended a transfer to Sacramento State 

Prison owing to Pelican Bay being only a “basic care institution.” (MSJ, Townshend 

Decl., Ex. B at 2.) This transfer recommendation was denied because there was no 

indication that Diaz could not be cared for at Pelican Bay. Though his medical needs were 

deemed “High Risk,” he is also “deemed low-intensity nursing.” (Id.) The transfer was 

also denied because Diaz is a validated gang member who poses a security risk. (Id.) 

Diaz’s appeals regarding this matter were denied. (Id.) 

Diaz has supplied no specific medical reasons that Pelican Bay was not able to care 

for him such that the denial of transfer amounted to deliberate indifference. Nor has he 

shown that Sacramento offered a course of treatment so superior to Pelican Bay’s that the 

transfer denial was “medically unacceptable under the circumstances” and was embarked 

on in “conscious disregard of an excessive risk to [plaintiff’s] health.” Toguchi, 391 F.3d 

at 1051. There is no genuine issue that the transfer denial constituted deliberate 

indifference. Accordingly, defendants’ motion for summary judgment is GRANTED in 

favor of these defendants as to this claim. 

CONCLUSION 

Defendants’ motion for summary judgment (Docket No. 70) is GRANTED. The 

claims against M. Scott, Linda Rowe, and Dr. Wahidullah are DISMISSED because 

service of the complaint on them was never effected. The Clerk shall terminate Docket 

No. 70, enter judgment in favor of L. Thomas, M. Sayre, S. Risenhoover, C. Williams, M. 

Cook, G. Lewis, C. Tileston, and D. Foston as to all claims, and close the file. 

IT IS SO ORDERED.

Dated: March 27, 2015

_________________________ 

WILLIAM H. ORRICK 

United States District Judge

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