Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-3_07-cv-08129/USCOURTS-azd-3_07-cv-08129-2/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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A fourth Defendant, Nurse Betty, was dismissed for failure to serve (see Doc. #20).

 JDN

WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Barry C. Beckhum, 

Plaintiff, 

vs.

Lisa Hirsch, et al.,

Defendants. 

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No. CV 07-8129-PCT-DGC (BPV)

ORDER

Plaintiff Barry C. Beckhum brought this civil rights action under 42 U.S.C. § 1983

against medical personnel at the Coconino County Jail: Head Nurse Lisa Hirsch, Nurse

Elizabeth Broadwell, and Dr. Paul Fader (Doc. #8).1

 Before the Court is Defendants’ Motion

for Summary Judgment (Doc. #36), which is fully briefed (Doc. ##55, 58). Also before the

Court are Defendants’ Motion to Strike (Doc. #57), Plaintiff’s Motion for Extension of Time

(Doc. #59), and Plaintiff’s Motion for Leave to File Sur-Reply/Motion to Strike (Doc. #60).

The Court will deny the motions to strike, the motion for extension, and the motion for leave

to file a sur-reply, and grant Defendants’ summary judgment motion.

I. Background

Plaintiff’s claim arose in 2007 during his confinement at the Coconino County Jail

(Doc. #8 at 1). Plaintiff’s First Amended Complaint set forth two claims for relief. In

Count I, Plaintiff alleged that Defendants acted with deliberate indifference to his serious

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Defendants’ affidavits are supported by various exhibits that make up Exhibits A-Y.

As a result, many exhibits are submitted twice; once as an attachment to an affidavit, and

again as a stand-alone exhibit. For example, Hirsch’s affidavit is Exhibit F, which includes

16 attached exhibits – all identified by letters but not in alphabetical order (Doc. #37, Ex. F,

Attachs.). One attached exhibit is Exhibit S – Plaintiff’s medical records from another

detention center (id., Ex. S). Exhibit S is also found in Document #39, Ex. S. In short,

Defendants’ exhibits are confusing and difficult to navigate, so where Plaintiff has submitted

the same document, the Court cites to Plaintiff’s exhibit. 

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medical needs in treating his diabetes (id. at 3). He claimed that they continued to administer

the incorrect insulin – instead of the type prescribed by Plaintiff’s physician – for about a

month despite adverse effects (id.). Plaintiff further claimed that Defendants routinely

delayed provision of time-sensitive medication and meals to manage his diabetes (id. at 3A).

In Count II, Plaintiff alleged that the administration of blood glucose tests and insulin

injections through the food trap door by Hirsch and Broadwell was unsanitary (id. at 4).

Defendants filed an Answer (Doc. #18), and the Court issued a Scheduling Order

(Doc. #19). Defendants have now filed a Motion for Summary Judgment (Doc. #36).

II. Motion for Summary Judgment

A. Facts

The parties each submit a separate Statement of Facts (Doc. #37, Defs.’ Statement of

Facts (DSOF); Doc. #56, Pl.’s Statement of Facts (PSOF)). DSOF is supported by 220 pages

of exhibits, identified as Exhibits A-Y (Doc. ##37-39). Included in these exhibits are

Defendants’ affidavits (Doc. #37, Exs. E-F; Doc. #38, Ex. H),2

 Plaintiff’s responses to

Requests for Admissions (Doc. #37, Ex. C), copies of Plaintiff’s Inmate Request Forms

(Doc. #37, Ex. F, Attachs.; Doc. #38, Ex. I), excerpts from Plaintiff’s deposition (Doc. #38,

Ex. G), jail policies and records (within Doc. ##37-39), and copies of Plaintiff’s medical

records (id.). PSOF is supported by 121 pages of exhibits that include Plaintiff’s own

declaration with attachments (Doc. #56, Ex. A, Attachs.), Defendants’ responses to Requests

for Admissions and Interrogatories (id., Exs. B-G, K-M), articles on diabetes management

and treatment guidelines (id., Exs. H-J), Plaintiff’s formal grievance and the response thereto

(id., Exs. –O), and copies of e-mail and letter correspondence (id., Ex. P). 

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The parties’ respective Statements of Facts set out the following facts. Plaintiff was

confined in the Coconino County Jail from July 31, 2007, through January 18, 2008 (DSOF

¶ 1; PSOF ¶ 1). When he was booked into the jail, Plaintiff informed medical staff that he

had Type 1 diabetes, asthma, and schizophrenia and bi-polar disorder (DSOF ¶ 3; PSOF ¶ 2).

As a Type 1 diabetic, Plaintiff’s body does not produce insulin, so he requires a consistent

insulin dose to maintain a healthy blood glucose level and avoid the risks of serious and lifethreatening complications (PSOF ¶¶ 5-6, 22). Plaintiff states that he informed medical staff

that he required daily injections of Lantus insulin (a long-lasting insulin), which he had been

taking prior to his incarceration (PSOF ¶ 27). Defendants state that after Plaintiff was

booked into jail, his blood glucose levels were checked and he received an injunction of

regular insulin (DSOF ¶ 4). 

Defendants state that from July 31 to August 28, 2007, Plaintiff was on a medical

regimen of 70/30 insulin (a combination of a medium to long-lasting insulin and regular

insulin) and as-needed regular insulin, his blood glucose levels were checked three to four

times daily, and he received a diabetic diet (DSOF ¶ 6 & Ex. F, Fader Aff. ¶ 14; PSOF ¶ 29).

On August 28, 2007, Fader changed Plaintiff’s insulin prescription from the 70/30 insulin

to Lantus insulin and as-needed regular insulin (DSOF ¶ 7). 

Also on August 28, 2007, Plaintiff submitted an Inmate Request Form (informal

grievance) that complained about the overall care he was receiving for his diabetes (PSOF

¶ 31; DSOF ¶ 10). Inmate Relations Officer Waldren responded that same day. He directed

Plaintiff to the grievance process and forwarded Plaintiff’s Inmate Request Form to the

medical department (DSOF ¶ 11; PSOF ¶ 32). On August 30, Plaintiff completed another

Inmate Request Form to complain about his diabetes treatment (PSOF ¶ 33). On

September 3, Hirsch delivered a response to Plaintiff’s August 28 and 30 informal

grievances. The response documented her conversation with Plaintiff about the timing of

blood sugar tests and the effect of his diet on his condition (DSOF ¶ 12; PSOF ¶ 34; see

Doc. #56, Ex. A, Ex. 2).

On September 6, Plaintiff submitted two more Inmate Request Forms complaining

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about delays in receiving his insulin (DSOF ¶¶ 13-14; PSOF ¶ 35). On September 8, he

submitted another Inmate Request Form to complain that his insulin was administered late,

which caused his blood sugar level to rise to 300 (PSOF ¶ 36; DSOF ¶ 15). On September 9,

Plaintiff filed more Inmate Request Forms: one made the same complaint about receiving

insulin late; two others complained that in the previous days, Hirsch and Broadwell had

performed glucose finger-stick tests without gloves (PSOF ¶ 37; DSOF ¶¶ 16-17).

On September 10, Plaintiff filed a formal grievance regarding his treatment complaints

(DSOF ¶ 18; PSOF ¶ 38). On September 13, Hirsch issued a written response to Plaintiff’s

formal grievance. The response explained medical staff procedures and the reasons for those

procedures, and indicated that blood glucose tests were not to be done without gloves and

injections were not to be administered through the trap doors (DSOF ¶ 19; PSOF ¶ 39). This

written response from Hirsch was delivered to Plaintiff on September 14, by Officers

Waldren and Glenn (DSOF ¶ 23; PSOF ¶ 41). Plaintiff states that at that time, he advised

the officers that his treatment was improving, but he still had concerns that he wanted the jail

commander to address (PSOF ¶ 41). Plaintiff states that Waldren told him he could appeal

the grievance to the jail commander, but Waldren had no grievance forms with him at that

time. Waldren assured Plaintiff that he would be provided with one (PSOF ¶ 41). Defendants

state that Plaintiff did not express a desire to appeal Hirsch’s response (DSOF ¶ 23).

 By September 16, Plaintiff had not received a grievance form from Waldren, so he

requested the form from the housing unit staff. He was told that only the Inmate Relations

Officer (Waldren) could provide the form (PSOF ¶ 43). That same day, Plaintiff submitted

an Inmate Request Form addressed to Waldren requesting a grievance form so he could file

an appeal. There was no response to this Inmate Request Form (PSOF ¶ 44). On October 15,

Plaintiff sent a second Inmate Request Form to Waldren requesting a grievance form so that

he could file an appeal. There was no response (PSOF ¶ 45). 

Meanwhile, Plaintiff had begun to complain to his attorney and his mother about his

treatment (PSOF ¶ 47). Plaintiff’s attorney was put in touch with Mikkel Jordahl, a civil

rights advisor who began to work with the Coconino County Jail in an attempt to resolve

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A normal blood glucose level is between 50 and 350 mg/dl (PSOF ¶ 23).

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Plaintiff’s complaints about medical care (DSOF ¶ 48). Plaintiff states that Jordahl told him

that he need not file any additional grievances because Jordahl would intercede on his behalf

(PSOF ¶ 49). In September 2007, Jordahl met with Hirsch to discuss Plaintiff’s treatment

(PSOF ¶ 53).

Beginning on October 3, Plaintiff’s blood glucose levels were fluctuating greatly

(DSOF ¶¶ 27-28).3

 At 5:30 a.m., his blood glucose levels were 199; they dropped to 40 by

11:30 a.m., at which time Plaintiff was given insulin and a meal (DSOF ¶ 27). Later that day,

at 5:53 p.m., his levels were at 160 (DSOF ¶ 27). Also on October 3, Plaintiff was moved

to the medical housing unit so that his dietary intake could be observed. He returned to his

general population housing unit the next day (DSOF ¶ 29; PSOF ¶ 56). On October 5, at

4:35 p.m., Plaintiff’s blood glucose levels were 56. He was not given insulin (DSOF ¶ 28).

Later that day, at 8:00 p.m., he was given Lantus insulin (DSOF ¶ 28). 

In January 2008, Plaintiff was transferred from the jail to the Arizona Department of

Corrections (PSOF ¶ 61).

B. Parties’ Contentions

1. Defendants’ Motion

Defendants seek summary judgment on the grounds that (1) Plaintiff failed to exhaust

his administrative remedies, (2) Plaintiff cannot show that Defendants were deliberately

indifferent to his serious medical condition, and (3) Hirsch and Broadwell are entitled to

qualified immunity (id.). 

Defendants first argue that Plaintiff failed to exhaust the available administrative

remedies as required under the Prison Litigation Reform Act (PLRA), 42 U.S.C. § 1997e(a)

(id. at 3-4). They submit a copy of the Inmate Rules and Regulations Handbook, which sets

out the steps in the grievances process: (1) first attempt to resolve the complaint informally;

(2) if not resolved, file an Inmate Request Form with the Inmate Relations Officer; (3) if still

not resolved, file a formal grievance to the supervisor on an inmate grievance form; and (4) if

not satisfied with the supervisor’s response, file an appeal – also on an inmate grievance form

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– to the jail commander, whose decision is final (id. at 3; Doc. #39, Ex. X). 

Defendants contend that although Plaintiff filed a formal grievance to the nursing

supervisor (Hirsch) regarding his complaints about treatment, he failed to appeal Hirsch’s

response to the jail commander (Doc. #36 at 3). Defendants maintain that Plaintiff’s failure

to complete the last step of the grievance process requires dismissal of his claim (id. at 5).

Defendants next argue that the care provided to Plaintiff did not amount to deliberate

indifference. Defendants do not dispute that Plaintiff’s diabetes constituted a serious medical

condition (id. at 10). They note that immediately upon his arrival at the jail, they learned of

his condition and began regular blood-glucose-level checks and administration of two types

of insulin (id. at 11). With regard to Plaintiff’s complaint about receiving the 70/30 insulin

instead of Lantus insulin, Defendants assert that the medication formulary established for the

jail medical staff at the time prescribed 70/30 insulin as the long-duration insulin to be used

for those with Type 1 diabetes (id.; Doc. #37, Ex. F, Hirsh Aff. ¶ 18). According to Fader,

70/30 insulin is an accepted and effective long-duration insulin for Type 1 diabetes that is

used in several medical arenas (id., Ex. E, Fader Aff. ¶ 14). 

Defendants argue that Plaintiff’s diabetes was not well controlled before his

incarceration and, even after he was switched to the Lantus insulin, his condition remained

unstable (Doc. #36 at 11). Defendants submit that this is because Plaintiff was a “brittle

diabetic,” meaning that even with consistent doses of insulin and a prescribed diet, he

produces highly variable responses within short periods of time (Doc. #37, Ex. E, Fader Aff.

¶ 6). They contend that Plaintiff’s blood glucose would vary highly regardless of efforts to

control it (Doc. #36 at 12). As to those instances where Plaintiff alleges that his blood

glucose levels were low, Defendants claim that the medical records show the instances were

of short duration (id.). 

Defendants assert that administration of blood glucose tests and injections through the

trap door were isolated occurrences and at least one incident was necessitated by a security

issue (id. at 12-13). Defendants argue that episodic acts do not amount to a constitutional

violation without a showing that the official acted with deliberate indifference (id. at 13).

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The Court issued the Notice required under Rand v. Rowland, 154 F.3d 952, 962 (9th

Cir. 1998), informing Plaintiff of his obligation to respond to Defendants’ motion (Doc. #40).

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They maintain that the few number of instances and the fact that the practiced ceased show

that neither Broadwell nor Hirsch acted with deliberate indifference (id.).

Finally, Defendants contend that because Hirsch and Broadwell were operating

pursuant the jail’s policies, the jail’s established formulary, and physician’s orders when they

administered medication to Plaintiff, claims against them are barred (id. at 13). Defendants

submit that at all times, these two Defendants followed the proper medical protocol and

standing physician’s order and thus did not violate a clearly established law (id. at 13-14).

2. Plaintiff’s Response4

Plaintiff opposes Defendants’ motion (Doc. #55). He explains Type 1 diabetes and

the importance of glycemic control in management his disease (id. at 2-3). He submits that

during his incarceration, he did not receive fundamental lab tests and physical exams that are

vital to treating his conditions (id.). Plaintiff states that although it is essential that

medication and nutrition/diet therapy be continued without interruption to avoid

hyperglycemia or hypoglycemia, when he entered the jail, Defendants changed his insulin

medication from Lantus to 70/30 (id. at 4).

Regarding his grievances, Plaintiff argues that the law recognizes that it is possible

for a prisoner to exhaust administrative remedies without completing the highest level of

administrative review (id. at 10). He cites cases where courts have found exhaustion despite

failure to fully complete the grievance process when an inmate was denied grievance forms,

where officials lost grievances, where officials failed to timely respond to grievances, where

an inmate received relief at an intermediate level, where injury prevented an inmate from

timely filing a grievance, and where officials give a favorable decision in response to a

grievance but then failed to implement the promised relief (id.). 

Plaintiff argues that the grievance procedures were not available to him when jail

officials refused to provide him with a grievance form for an appeal despite his repeated

requests (id. at 11). Thus, he contends that he exhausted the procedure that were available

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to him. 

In the alternative, he submits that the failure to comply with administrative procedures

constitutes a “special circumstances” because he was advised by Jordahl, the civil rights

advisor, not to file any further grievances (id. at 11-12). Plaintiff alleges that he should not

be penalized for relying on the advice of an attorney (id., citing Hemphill v. New York, 380

F.3d 680 (2d Cir. 2004)). Plaintiff’s third argument for exhaustion is that he received a

favorable response to his formal grievance—Hirsch promised that certain adjustments to his

treatment would be made, that his injections would be timely administered, and that he would

no longer receive injections and blood glucose checks through the trap door (id. at 12).

Plaintiff argues that the fact that Hirsch did not implement those promised changes should

not require him to file additional grievances (id., citing Abney v. McGinnis, 380 F.3d 663,

669 (2d Cir. 2004)). 

As to Defendants’ claim that there was no deliberate indifference on the part of

Defendants, Plaintiff relies on the guidelines established by the American Diabetes

Association, the National Commission on Correctional Health Care, and the National

Clearinghouse Guidelines (id. at 16). He submits that these guidelines call for diabetic

inmates to receive specific diagnostic testing and examinations upon an initial medical

evaluation; however, the record shows that Plaintiff never received some of these tests, such

as a urine microalbumine test, an exam of the feet, and a retinal examination (id.) He states

that he likewise never received nutritional therapy in the form of an individualized meal plan

(id. at 16-17). Further, Plaintiff contends that although the guidelines urge institutions to

implement policies that require staff to notify a physician when an inmates’ blood glucose

levels are outside a certain range, when Plaintiff’s blood glucose levels fell outside of the

normal range on multiple occasions, the results were reported to Fader on just one occasion

(id. at 17). 

Plaintiff argues that from this record, a reasonable jury could conclude that

Defendants’ failure to adhere to well-known treatment guidelines led to severe fluctuations

in Plaintiff’ blood sugar levels and exposed him to unnecessary risks (id.). 

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Plaintiff also presents an argument for municipal liability and contends that the

Coconino County Jail maintained a policy of omission by failing to obtain accreditation,

which in turn led to jail employees’ unlawful conduct (id. at 18-19). He notes that

Defendants admit that the jail is not accredited but that they look to the national guidelines

to establish treatment programs (id. at 19). Plaintiff argues that this omission—the failure

to obtain state-required accreditation—was the moving force behind Defendants’ unlawful

conduct and had the jail obtained accreditation, Plaintiff’s rights would not have been

violated (id. at 20). 

Lastly, Plaintiff asserts that there is a material question of fact whether Defendants

violated Plaintiff’s rights and it is clearly established that he had a right to adequate treatment

for his diabetes; therefore, qualified immunity does not apply (id. at 21).

3. Defendants’ Reply

In reply, Defendants first argue that Plaintiff failed to file a separate statement of

contravening facts as required under the Rules of Procedure (Doc. #58 at 2). Defendants

next reassert that with regard to exhaustion, Plaintiff expressed no desire to appeal Hirsch’s

response to the formal grievance (id. at 3). They note that one of the Inmate Request Forms

Plaintiff proffers to show that he requested a grievance form does not contain an

acknowledgment that it was received by a staff member, and the other form does not mention

a request to file an appeal (id.). As to Plaintiff’s assertion that Jordahl’s involvement and

advice not to file further grievances constitutes an special circumstance excusing exhaustion,

Defendants note that after Jordahl’s participation and meeting with jail staff, Plaintiff failed

to file an appeal (id.).

In support of summary judgment, Defendants point out that the parties agree on a

substantial number of facts; namely, that Plaintiff was screened upon his arrival at the jail

and immediately started on treatment for his condition, he was started on insulin and his

blood glucose levels were monitored 3-4 times a day, he was a brittle diabetic, and when his

blood glucose levels were high or low the medical staff responded to bring the levels closer

to a normal range (id.). Defendants assert that 70/30 insulin given to Plaintiff is effective and

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commonly used to treat diabetes and, regardless, Plaintiff was switched back to his preferred

insulin after just 26 days (id. at 5). 

Defendants contend that the national guidelines Plaintiff’s relies on to demonstrate

the standard of care are merely guidelines and that the guidelines themselves emphasize that

they are general in nature and not meant to be a management manual (id. at 7). Defendants

also note that many of the tests Plaintiff refers to are required annually and were not due

during his time at the jail (id.). And the record shows that Plaintiff was provided dietary

counseling (id. at 8). Defendants explain that the state statute Plaintiff cites in reference to

accreditation provides that accreditation is not the only means of complying with the statute

(id. at 8, citing Ariz. Rev. Stat. § 36-402(A)). Defendants argue that Plaintiff presents no

evidence to show that he was harmed by either the absence of certain tests or the lack of

accreditation exams (id. at 7-9). 

As to the claims pertaining to blood tests and injections administered in an unsanitary

manner, Defendants dispute Plaintiff’s claims but contend that even assuming they are true,

the few instances of improper administration not rise to a constitutional violation (id. at 8-9).

III. Other Motions

A. Defendants’ Motion to Strike/Plaintiff’s Motion for Extension

Defendants move to strike two documents submitted by Plaintiff with his response:

(1) the Inmate Request Form dated September 16, 2007, which asks for a grievance form to

file an appeal, and (2) the Inmate Request Form dated October 15, 2007, which requests a

grievance form (Doc. #57 at 2, referring to Doc. #56, Ex. A, Ex. 4). Defendants argue that

Plaintiff failed to disclose these two documents as required under Federal Rule of Civil

Procedure 26 and the Court’s Scheduling Order (Doc. #57 at 2). For this reason, they

maintain that pursuant to Rule 37(c)(1), the documents and any references to them must be

excluded (id. at 3).

Plaintiff filed a Motion for Extension of Time to respond to Defendants’ Motion to

Strike, and he lodged a proposed response (Doc. ##59, 61).

The Court will deny Defendants’ Motion to Strike and, because it need not consider

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Plaintiff’s response in its determination, it will also deny Plaintiff’s Motion for Extension of

Time. Pro se prisoner actions are exempt from Rule 26 initial disclosure requirements.

Fed. R. Civ. P. 26(a)(1)(B)(iv). The Court’s Scheduling Order specified only that the parties

provide witness lists, including experts, as required under Rule 26(a)(2) and (3). To the

extent that Plaintiff failed to proffer these two exhibits in response to Defendants’ request for

documents, the Court finds that failure to be harmless because these Inmate Request Forms

are Defendants’ records to which they had access. See Fonseca v. Sysco Food Servs. of

Ariz., Inc., 374 F.3d 840, 846 (9th Cir. 2004) (late disclosure of evidence was harmless

because the defendant had knowledge of the evidence). In addressing disclosure issues, the

Ninth Circuit has instructed that “[d]istrict courts must take care to insure that pro se litigants

are provided with proper notice regarding the complex procedural issues involved in

summary judgment.” Id. Further, the Ninth Circuit has given “particularly wide latitude to

the district court’s discretion to issue sanctions under Rule 37(c)(1).” Yeti by Molly, Ltd.

v. Deckers Outdoor Corp., 259 F.3d 1101, 1106 (9th Cir. 2001). Here, in exercising its

discretion, the Court declines to exclude Plaintiff’s evidence.

B. Plaintiff’s Motion for Leave to File Sur-Reply

Plaintiff seeks to strike and to file a response to Defendants’ Reply on the ground that

it raises arguments and issues that were not presented in the summary judgment motion

(Doc. #60). Specifically, Plaintiff refers to Defendants’ assertions regarding the opinion of

one of Plaintiff’s previous unnamed physicians and Defendants’ arguments regarding the role

of national guidelines and accreditation of correctional facilities’ medical care regimens (id.

at 2-5). Defendants oppose Plaintiff’s motion to strike and to file a sur-reply (Doc. #62).

The Court will deny Plaintiff’s motion as unnecessary. Any arguments raised for the

first time in Defendants’ reply brief will not be consider by the Court. See Cedano-Viera v.

Ashcroft, 324 F.3d 1062, 1066 n. 5 (9th Cir. 2003). The Court notes, however, that

Defendants’ “guidelines” and “accreditation” arguments are in response to Plaintiff’s claims

set forth in his opposition brief. Thus, Defendants’ arguments are not new; they are rebuttal

arguments, which are permitted in a reply brief. See EEOC v. Creative Networks, LLC and

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Res-Care, Inc., 2008 WL 5225807, *2 (D.Ariz. 2008).

IV. Exhaustion

A. Legal Standard

When an exhaustion issue is raised in a motion for summary judgment, the court

should treat it as a matter of abatement in an unenumerated motion under Rule 12(b). Wyatt

v. Terhune, 315 F.3d 1108, 1119 (9th Cir. 2003); Ritza v. Int’l Longshoremen’s &

Warehousemen’s Union, 837 F.2d 365, 368-69 (9th Cir. 1988). The Court will construe

Defendant’s exhaustion argument as unenumerated Rule 12(b) motion.

The PLRA requires a prisoner to exhaust available administrative remedies before

bringing a federal action concerning prison conditions. See 42 U.S.C. § 1997e(a); Griffin

v. Arpaio, 557 F.3d 1117, 1119 (9th Cir. 2009). He must complete the administrative review

process in accordance with the applicable rules. See Woodford v. Ngo, 548 U.S. 81, 92

(2006). 

Exhaustion is an affirmative defense. Jones v. Bock, 549 U.S. 199, 212 (2007). Thus,

the defendant bears the burden of raising and proving the absence of exhaustion. Wyatt, 315

F.3d at 1119. Because exhaustion is a matter of abatement in an unenumerated Rule 12(b)

motion, a court may look beyond the pleadings to decide disputed issues of fact. Id. at

1119-20. Further, a court has broad discretion as to the method to be used in resolving the

factual dispute. Ritza, 837 F.2d at 369 (quotation omitted).

B. Analysis

There is no dispute that the final step in the jail’s grievance procedures is an appeal

to the jail commander and that Plaintiff filed a formal grievance but did not thereafter appeal

to the jail commander. The Court must determine (1) whether Plaintiff had remedies

available to him after Hirsch’s response to his formal grievance or (2) whether Plaintiff was

required to appeal in light of the circumstances or the substance of Hirsch’s response.

1. Available Remedies

There is no obligation to exhaust a remedy that is not “available.” See Brown v.

Valoff, 422 F.3d 926, 935 (9th Cir. 2005). “If prison employees refuse to provide inmates

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with those [grievance] forms when requested, it is difficult to understand how the inmate has

any available remedies.” Dale v. Lappin, 376 F.3d 652, 656 (7th Cir. 2004) (per curiam)

(administrative remedy not available where officials refuse to provide inmates with forms

when requested); Mitchell v. Horn, 318 F.3d 523, 529 (3d Cir. 2003); Brown v. Croak, 312

F.3d 109, 113 (3d Cir. 2002) (where officials thwarted the plaintiff’s efforts to exhaust his

remedies, the grievance procedure was not “available” within the meaning of § 1997e(a));

Miller v. Norris, 247 F.3d 736, 740 (8th Cir. 2001) (a remedy that prison officials prevent

a prisoner from utilizing is not an “available” remedy under § 1997e(a)). 

Plaintiff presents evidence that he requested a grievance form to file an appeal of

Hirsch’s response but that his requests were not responded to and, thus, an appeal was not

available (Doc. #56, Ex. A, Pl. Decl. ¶¶ 25-28; Ex. 4). In his affidavit, Walden states that

Plaintiff did not indicate that he wanted to appeal and that Walden received “no written

requests for a grievance form from [Plaintiff], and no appeals to the jail commander were

presented to [Walden]” Doc. #38, Ex. P., Walden Aff.). That no request for a grievance form

was “received” by Walden is not proof that a request for a form was not submitted. Although

Defendants argue that one of the two Inmate Request Forms Plaintiff submitted was not

signed as “received” by an officer, the other form clearly indicates that it was “received” by

an officer, who is identified by badge number (Doc. #56, Ex. A, Ex. 4). Notably, Defendants

do not present any alternatives available to Plaintiff if he did not receive a response to an

Inmate Request Form or if he was unable to secure a grievance form for filing an appeal. On

this record, the Court finds that Defendants have not met their burden to demonstrate that

administrative remedies were available after Plaintiff received no forms or responses to his

requests.

2. Appeal Requirement 

The Court rejects Plaintiff’s suggestion that his reliance on Jordahl’s advice not to file

further grievances constitutes a “special circumstance” justifying his failure to exhaust. See

Hemphill, 380 F.3d at 689 (“special circumstance” exists where an inmate’s failure to

exhaust stems from ambiguous grievance procedures and the inmate’s reasonable

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interpretation of those procedures). Jordahl is not a jail official. His advice to Plaintiff does

not amount to “reliable information” from an administrator that no additional relief is

available though the grievance process. See Brown, 422 F.3d at 935 (an inmate need not

continue to exhaust additional levels of review if he has “been reliably informed by an

administrator that no remedies are available”). 

But Plaintiff’s assertion that he was not required to file additional grievances after

receipt of Hirsch’s response is tenable. Hirsch’s thorough, three-page response found many

of Plaintiff’s concerns to be legitimate and included assurances that adjustments to his

treatment would be made, that injections would be administered timely, and that there would

be no more injections and blood glucose checks through the trap door (Doc. #55 at 12; Doc.

#56, Ex. O). The response did not include any language informing Plaintiff that he could

appeal the response or what further steps to take in the grievance process (see Doc. #56, Ex.

O). The Court finds that it was reasonable for Plaintiff to infer from this response that the

issues were addressed or resolved and that no further appeal was necessary. This situation

is similar to Abney v. McGinnis, where the prisoner repeatedly obtained favorable rulings

on his grievances but the defendants failed to implement the rulings. 380 F.3d at 669. The

prisoner’s only available remedy was to file another grievance, which he did, and those

grievances were resolved, but again not implemented. Id. The Second Circuit found that to

require a prisoner who wins in principle to file another grievance to win in fact could lead

to a never-ending cycle of grievances. Id. (citing Dixon v. Page, 291 F.3d 485, 490 (7th Cir.

2002)). In this case, once Hirsch confirmed to Plaintiff that adjustments would be made to

address his treatment concerns, Plaintiff essentially won in principle. He was not required

to wait to see if Hirsch followed through on her promises and, if she did not, file another

grievance or appeal.

In sum, Defendants have failed to demonstrate that administrative remedies were

available to Plaintiff after he received Hirsch’s response to his formal grievance. In the

alternative, Plaintiff was not required to appeal Hirsch’s response in light of the assurances

that his complaints were addressed and resolved. Defendants’ request for dismissal based

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on nonexhaustion will be denied.

V. Summary Judgment

Defendants’ remaining arguments – that they were not deliberately indifferent to

Plaintiff’s serious medical need and, nonetheless, they are entitled to qualified immunity –

are addressed in the summary judgment analysis. 

A. Legal Standards

1. Summary Judgment

A court must grant summary judgment “if the pleadings, the discovery and disclosure

materials on file, and any affidavits show that there is no genuine issue as to any material fact

and that the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(c); see

also Celotex Corp. v. Catrett, 477 U.S. 317, 322-23 (1986). Under summary judgment

practice, the movant bears the initial responsibility of presenting the basis for its motion and

identifying those portions of the record, together with affidavits, that it believes demonstrate

the absence of a genuine issue of material fact. Celotex, 477 U.S. at 323; Devereaux v.

Abbey, 263 F.3d 1070, 1076 (9th Cir. 2001) (en banc). 

If the movant meets its burden with a properly supported motion, the burden then

shifts to the nonmovant to present specific facts that show there is a genuine issue for trial.

Fed. R. Civ. P. 56(e); Auvil v. CBS “60 Minutes”, 67 F.3d 816, 819 (9th Cir. 1995); see

Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). The nonmovant need not

establish a material issue of fact conclusively in its favor; it is sufficient that “the claimed

factual dispute be shown to require a jury or judge to resolve the parties’ differing versions

of the truth at trial.” First Nat’l Bank of Ariz. v. Cities Serv. Co., 391 U.S. 253, 288-89

(1968). By affidavit or as otherwise provided by Rule 56, the nonmovant must designate

specific facts that show there is a genuine issue for trial. Anderson, 477 U.S. at 249;

Devereaux, 263 F.3d at 1076. The nonmovant may not rest upon the pleadings’ mere

allegations and denials, but must present evidence of specific disputed facts. See Anderson,

477 U.S. at 248. 

At summary judgment, the judge’s function is not to weigh the evidence and

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determine the truth but to determine whether there is a genuine issue for trial. Id. at 249. In

its analysis, the court must believe the nonmovant’s evidence, and draw all inferences in the

nonmovant’s favor. Id. at 255. 

 2. Fourteenth Amendment

As a pretrial detainee, Plaintiff is protected by the Fourteenth Amendment’s Due

Process Clause, which establishes that “detainees have a right against jail conditions or

restrictions that ‘amount to punishment.’” Pierce v. County of Orange, 526 F.3d 1190, 1205

(9th Cir. 2008). The Fourteenth Amendment standard is more protective than the Eighth

Amendment. “This standard differs significantly from the standard relevant to convicted

prisoners, who may be subject to punishment so long as it does not violate the Eighth

Amendment’s bar against cruel and unusual punishment.” Id.; Jones v. Blanas, 393 F.3d

918, 931 (9th Cir. 2004). Although a pretrial detainee’s right to receive adequate medical

care derives from the Due Process Clause of the Fourteenth Amendment, Gibson v. County

of Washoe, 290 F.3d 1175, 1187 (9th Cir. 2002) (citing Bell v. Wolfish, 441 U.S. 520, 535

(1979)), it is difficult to apply the “punishment” standard to medical care claims in the same

manner it is applied to conditions-of-confinement claims. See Pierce, 526 F.3d at 1206-1213

(addressing detainees’ claims regarding reading materials, telephone access, holding cells,

exercise, and other conditions at the county’s jail facilities). Under the Due Process Clause,

however, a detainee is protected against conditions or conduct – including conduct related

to medical treatment – that is arbitrary or purposeless. See id. at 1205 (if a particular

condition or restriction is arbitrary or purposeless, a court may infer that the purpose of the

action is punishment that may not be inflicted on pretrial detainees) (citing Bell, 441 U.S. at

539).

At a minimum, the Due Process Clause imposes the same duty to provide adequate

medical care to those incarcerated as is imposed by the Eighth Amendment. Gibson, 290

F.3d at 1187. Therefore, the Eighth Amendment standards governing medical care may be

applied. See Frost v. Agnos, 152 F.3d 1124, 1128 (9th Cir. 1998); Jones v. Johnson, 781

F.2d 769, 771 (9th Cir. 1986) (“the eighth amendment guarantees provide a minimum

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standard of care for determining [the plaintiff’s] rights as a pretrial detainee, including his

right to medical care”). 

To establish a § 1983 claim for violation of the Eighth Amendment based on

inadequate medical care, a plaintiff must demonstrate “acts or omissions sufficiently harmful

to evidence deliberate indifference to serious medical needs.” Estelle v. Gamble, 429 U.S.

97, 106 (1976). This requires the plaintiff to make two showings: (1) that he suffered a

serious medical need and (2) that the defendant’s response to that serious medical need was

deliberately indifferent. Jett v. Penner, 439 F.3d 1091, 1096 (9th Cir. 2006). 

To act with deliberate indifference, a prison official must both know of and disregard

an excessive risk to inmate health. The official must both be aware of facts from which the

inference could be drawn that a substantial risk of serious harm exists, and he must also draw

the inference. Farmer v. Brennan, 511 U.S. 825, 837 (1994). In the medical context,

deliberate indifference may be shown by a purposeful act or failure to respond to a prisoner’s

pain or possible medical need, and harm caused by the indifference. Jett, 439 F.3d at 1096.

Prison officials are deliberately indifferent to a prisoner’s serious medical needs if they deny,

delay, or intentionally interfere with medical treatment. Wood v. Housewright, 900 F.2d

1332, 1334 (9th Cir. 1990). But a delay in providing medical treatment does not constitute

an Eighth Amendment violation unless the delay was harmful. Hunt v. Dental Dep’t, 865

F.2d 198, 200 (9th Cir. 1989) (citing Shapley v. Nevada Bd. of State Prison Comm’rs, 766

F.2d 404, 407 (9th Cir. 1985) (per curiam)). Thus, to establish deliberate indifference, a

prisoner must show that the delay led to further injury. See Hallett v. Morgan, 296 F.3d 732,

746 (9th Cir. 2002). 

“[A] mere ‘difference of medical opinion . . . [is] insufficient, as a matter of law, to

establish deliberate indifference.’” Toguchi v. Chung, 391 F.3d 1051, 1058 (9th Cir. 2004)

(citation omitted). Therefore, to prevail on a claim involving choices between alternative

courses of treatment, a prisoner must show that the course of treatment the doctors chose was

medically unacceptable in light of the circumstances and that it was chosen in conscious

disregard of an excessive risk to the prisoner’s health. Jackson v. McIntosh, 90 F.3d 330,

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332 (9th Cir. 1996).

B. Analysis

The Court rejects Defendants’ contention that Plaintiff failed to comply with the

Rules of Procedure because he failed to file a separate statement of contravening facts

(Doc. #58 at 2). Although the PSOF does not set forth numbered paragraphs directly

corresponding to each of Defendants’ numbered paragraphs, it more than sufficiently

establishes disputes with the DSOF. In light of Plaintiff’s pro se status and the requirement

to construe his pleadings liberally, the Court will consider his response and the PSOF.

Karim-Panahi v. Los Angeles Police Dep’t, 839 F.2d 621, 623 (9th Cir. 1988); see also

Haines v. Kerner, 404 U.S. 519, 520-21 (1972). 

Turning to the merits, the parties do not dispute that Plaintiff suffered from a serious

medical need, thereby satisfying the first prong of the deliberate-indifference test. Estelle,

429 U.S. at 104. The summary judgment analysis thus turns on whether Defendants’

response to Plaintiff’s serious medical need was deliberately indifferent. See Jett, 439 F.3d

at 1096.

To meet their burden on summary judgment, Defendants must come forward with

evidence that establishes the absence of a triable issue of fact; in other words, evidence that

they did not deny or delay treatment for Plaintiff’s diabetes knowing that such treatment was

medically appropriate. The gravamen of Plaintiff’s complaint is that the lack of initial

diagnostic testing, the delay in obtaining Lantus insulin, delays in administering injections,

and injections and blood glucose checks through the trap door exemplify deliberately

indifferent medical care.

1. Initial testing

The parties dispute whether Defendants were required to provide a battery of

diagnostic tests when Plaintiff arrived at the jail. Defendants submit a copy of the Coconino

County Policy governing treatment of diabetic inmates (Doc. #37, Exs. F, V). This policy

requires that an initial medical questionnaire on the inmate’s diabetic history be completed,

that medical staff be notified of the inmate’s condition, that nursing staff conduct a medical

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screening, and that nursing staff ensure a medically approved diabetic diet for the inmate and

daily insulin treatment (id.). Finally, the policy requires a physician to review medications

given to diabetic inmates at the earliest opportune time (id.). The record shows that upon his

arrival at the jail, an initial evaluation and medical screening were performed, Plaintiff was

immediately placed on a protocol of regular blood glucose monitoring and prescribed

insulin, and he was provided a diabetic diet (Doc. #37, DSOF ¶ 6; Ex. B; Ex. F, Hirsch Aff.

¶¶ 5-6). According to Defendants’ evidence, they adhered to the jail’s policy requiring

specific and immediate treatment for incoming diabetic inmates. 

In response, Plaintiff proffers articles regarding the treatment of diabetes in the

correctional setting and that suggest that certain tests be performed, such as a Hemoglobin

A1C blood test, a fasting blood lipid test, a urine test, as well as eye and foot exams (Doc.

#56, Exs. H-J). Although Plaintiff presents these articles as establishing the standard for

diabetes treatment, none of the articles makes such a claim, and Plaintiff presents no medical

expert who makes that claim. The American Diabetes Association article specifically states

“[t]his document provides a general set of guideline for diabetes care . . . . It is not designed

to be a diabetes management manual” (id., Ex. H at S73). The National Commission on

Correctional Health Care describes its published guidelines as tools to help correctional

health care professionals manage diseases, but notes that its “guidelines cannot and do not

substitute for individual clinical professional judgment” (id., Ex. I at 8, citing

http://www.ncchc.org/resources/guidelines.html). The National Guidelines article states that

it “provides a general set of guidelines for diabetes care in correctional institutions. It is not

designed to be a diabetes management manual” (id., Ex. J at 9). Thus, Plaintiff’s evidence

consists of various recommendations. There is nothing to show that Defendants’ failure to

adhere to these recommendations amounted to deliberate indifference. 

Moreover, there is no dispute that when he arrived at the jail, Plaintiff was medically

screened, immediately received insulin, and was placed on a protocol to treat his diabetes

(see Doc. #37, Ex. F; Doc. #56, PSOF ¶¶ 27, 29). Plaintiff also received a Hemoglobin A1C

blood test during his confinement at the jail (Doc. #56, PSOF ¶ 10). Finally, Plaintiff makes

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no allegations that he suffered eye or foot problems that could have been avoided with an

initial eye or comprehensive foot exam. See Hunt, 865 F.2d at 200 (any delay in care must

be harmful to implicate the Eighth Amendment).

 Plaintiff’s claim that Defendants were deliberately different because the jail facility

was not accredited represents an official-capacity claim, or a claim against the county, and

such a claim was not raised in Plaintiff’s First Amended Complaint (see Doc. #8, setting

forth only individual-capacity claims against the named Defendants). Regardless, Plaintiff

cites no legal authority holding that the lack of accreditation, standing alone, gives rise to an

Eighth Amendment violation. As noted by Defendants, state law does not require

accreditation. It only requires some type of annual inspection by an outside agency

(Doc. #58 at 8, citing Ariz. Rev. Stat. § 36-402(A)(11)). 

The Court concludes, on the basis of undisputed facts and as a matter of law, that

neither the failure to perform various medical and diagnostic tests at booking nor that lack

of accreditation amounts to deliberate indifference.

2. Insulin

Plaintiff immediately was placed on a regimen of insulin treatment when he arrived

at the jail. Defendants administered 70/30 insulin along with regular insulin (Doc. #37, Ex.

F, Hirsch Aff. ¶ 15). Hirsch attested that the 70/30 insulin was the long-acting insulin on the

Coconino’s Jail’s formulary at the time (id. ¶ 18). Nonetheless, Fader switched Plaintiff from

the 70/30 insulin to Lantus insulin on August 28, 2007, less than month after Plaintiff arrived

at the jail (id. ¶ 19). Plaintiff’s medical records reflect that his blood glucose levels

continued to fluctuate and his condition remained difficult to manage even after the switch

to Lantus insulin (id. ¶ 20). 

Plaintiff provides few allegations regarding how he was harmed from the initial use

of 70/30 insulin. In his pleading, he stated that he began to get very sick, that his glucose

levels rose extremely high, which in turn harmed his pancreas (Doc. #8 at 3). In his response

and PSOF, however, he makes no additional or specific allegations regarding the harm that

resulted from the use of a different type of insulin. See Celotex, 477 U.S. at 324 (nonmovant

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must “go beyond the pleadings . . . and designate specific facts showing” a material factual

dispute). Plaintiff did not respond to Defendants’ evidence showing that Plaintiff’s glucose

levels continued to fluctuate after the switch to Lantus, nor did he dispute Defendants’

diagnosis of Plaintiff as a “brittle diabetic” with highly variable responses to consistent doses

of insulin and a managed diet (see Doc. #37, DSOF ¶ 5). As a result, there is nothing to

suggest that the use of 70/30 insulin was medically unacceptable, used in disregard of a risk

to Plaintiff’s health, or damaging to Plaintiff. See Jackson, 90 F.3d at 332. 

Plaintiff may have disagreed with Defendants’ initial decision to use 70/30 insulin,

but mere disagreements between an inmate and medical personnel over the course of medical

treatment does not establish deliberate indifference. See Toguchi, 391 F.3d at 1058. Plaintiff

has not presented evidence from which a reasonable jury could conclude that the use of 70/30

insulin for approximately one month amounted to deliberate indifference.

3. Injection delays

The record shows that Plaintiff received late insulin injections twice on September 6,

once on September 8, and again on September 9 (Doc. #56, Ex. A, Pl. Decl. ¶¶ 20-22). On

September 10, Plaintiff file his formal grievance in which he complained generally about

untimely injections (id. ¶ 23). Hirsch’s response acknowledged that Plaintiff may have

received some untimely injections, but noted that the majority of his injections have been

within an hour of his meal times, which is standard practice (id., Ex. O at 2).

Plaintiff does not present specific facts or evidence showing harm caused by a few late

injections. Nor does Plaintiff aver that the late injections continued after Hirsch’s response

to the formal grievance (see id., Ex. A, Pl. Decl. ¶ 24 (stating only that injections and blood

glucose checks through the trap door continued after Hirsch issued her response)).

Moreover, the record shows that Defendants responded to Plaintiff’s concerns about the

timeliness of injections. Plaintiff has not presented evidence from which a reasonable jury

could conclude that Defendants acted with deliberate indifference concerning the timing of

Plaintiff’s injections.

4. Injections and blood glucose tests through trap door

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In his formal grievance to Hirsch, Plaintiff complained that he received blood glucose

tests and insulin injections through the trap door (Doc. #56, Ex. N). In the September 13,

2007 response to this complaint, Hirsch acknowledged that it was not an ideal way to

administer injections, stated that she discussed this issue with the nurses, and assured

Plaintiff that it would not happen again (id., Ex. O). In his deposition, Plaintiff confirmed

that Hirsch had agreed to change the practice of administering injections through the trap

door, but that “[i]t happened maybe two more – one or two more occasions” (Doc. #38, Ex.

G, part 2, Pl. Dep. 145:10-17). Plaintiff averred that in all, he received injections through the

trap door 4 or 5 times during his confinement at the jail (id., Ex. G, part 3, Pl. Dep. 161:22-

162:3).

Plaintiff received blood glucose checks 3-4 times a day, and after most of these

checks, he received insulin injections (Doc. #37, Ex. F, Hirsch Aff. ¶¶ 7, 15-16). Therefore,

during his 5 and 1/2-month jail confinement, Plaintiff received at least 500 or more blood

glucose checks and insulin injections. His admission that just 4 or 5 of these injections were

improperly administered through the trap door fails to establish deliberately indifferent care.

If the neglect is an “isolated occurrence” or an “isolated exception” to the overall treatment

of the prisoner, it “militates against a finding of deliberate indifference.” McGuckin v.

Smith, 974 F.2d 1050, 1060 (9th Cir. 1991), overruled on other grounds by WMX Techs.,

Inc. v. Miller, 104 F.3d 1133 (9th Cir. 1997) (en banc). Although Plaintiff’s concerns about

the unsanitary practice of administering injections through the trap door were valid, he has

failed to show that he contracted an infection or suffered any harm as a result of those

isolated occurrences (see Doc. #38, Ex. G, part 4, Pl. Dep., 158:4-159:16). His assertion that

he may have contracted an infection or disease that has not yet presented is purely

speculative (see id.). 

Finally, as stated, Hirsch responded to Plaintiff’s concern about use of the trap door

and assured him that this practice would not continue (Doc. #56, Ex. O at 3). Shortly after

issuing this response, Hirsch held a medical staff meeting and posted the meeting’s agenda,

which specifically addressed insulin administration and directed that blood glucose checks

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and insulin injections are “NEVER to be done thru the trap (unless of course there is some

oddity). Gloves are to be worn at all time during this procedure!” (Doc. #39, Ex. U (meeting

agenda dated 10/16/07)). This demonstrates that Defendants did not disregard Plaintiff’s

complaints or the risk to his health. Again, Plaintiff has failed to provide evidence from

which a reasonable jury could find that the few instances of trap-door injections amounted

to deliberate indifference.

In conclusion, the Court finds that there exists no genuine issue of material fact

precluding summary judgment. The record reflects that Defendants provided treatment that

was medically appropriate for Plaintiff’s condition. See Wood, 900 F.2d at 1334.

Defendants’ Motion for Summary Judgment will therefore be granted, and the Court need

not address qualified immunity.

IT IS ORDERED:

1. The reference to the Magistrate Judge is withdrawn as to Defendants’ Motion

for Summary Judgment (Doc. #36) and Motion to Strike (Doc. #57 ), and

Plaintiff’s Motion for Extension of Time (Doc. #59) and Motion for Leave to

File Sur-Reply/Motion to Strike (Doc. #60).

2. Defendants’ Motion to Strike (Doc. #57) is denied.

3. Plaintiff’s Motion for Extension of Time (Doc. #59) and Motion for Leave to

file Sur-Reply/Motion to Strike (Doc. #60) are denied.

4. Defendants’ Motion for Summary Judgment (Doc. #36) is granted.

5. The Clerk of Court shall terminate this action.

DATED this 17th day of February, 2010.

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