Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_16-cv-01412/USCOURTS-casd-3_16-cv-01412-11/pdf.json

Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 42:1983cv Civil Rights Act - Civil Action for Deprivation of Rights

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

THE ESTATE OF RUBEN NUNEZ by 

and through its successor-in-interest 

LYDIA NUNEZ, ALBERT NUNEZ, and 

LYDIA NUNEZ,

Plaintiffs,

v.

COUNTY OF SAN DIEGO, et al,

Defendants.

Case No.: 3:16-cv-01412-BEN-MDD

ORDER GRANTING PLAINTIFFS’ 

MOTION TO RECONSIDER

[Doc. 392]

Pending before the Court is Plaintiffs’ motion to reconsider the Court’s summary 

judgment order as to Defendant Correctional Physicians Medical Group (“CPMG”) in light 

of newly discovered evidence. Because Plaintiffs’ newly discovered evidence raises 

genuine issues of material fact, the motion is GRANTED, and Plaintiffs’ claims for failure 

to train and failure to supervise under 42 U.S.C. § 1983, as well as Plaintiffs’ prayer for 

punitive damages, are hereby reinstated against CPMG.

BACKGROUND

On January 2, 2019, through pleadings and exhibits filed in another case, Nishimoto 

v. County of San Diego, et al., 16-cv-01974-BEN-LL, Plaintiffs became aware of various 

documents that Defendants had not produced, including correspondence between the 

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County of San Diego and CPMG regarding Mr. Nunez. In response, on January 7, 2019, 

Plaintiffs moved the Court to vacate under Federal Rule of Civil Procedure 54(b) the 

portions of its November 5, 2018 summary judgment order, [Doc. 322], which granted 

CPMG’s motion for summary judgment on Counts 5 and 6 and Plaintiffs’ prayer for 

punitive damages. Plaintiffs further requested that the Court refer the motion to the 

Magistrate Judge for an evidentiary hearing to determine the scope of withheld evidence 

and to determine what sanctions, if any, were appropriate. Subsequently, Defendant 

CPMG produced approximately 100 pages of inadvertently withheld discovery. 

The Court denied Plaintiffs’ motion to vacate but ordered that “Plaintiffs may seek 

leave to re-assert a motion to vacate later, if substantial relevant evidence is newly 

discovered.” [Doc. 343.] The Court did, however, grant Plaintiffs’ request for a referral 

to the Magistrate Judge, who found the late-produced documents were not withheld

willfully or in bad faith. [Doc. 374.] Nonetheless, the Magistrate Judge determined there 

was time for corrective action and permitted Plaintiffs to depose Dr. Mannis, Dr. Rao, and 

Dr. Badre about the contents of the newly discovered evidence. [Doc. 374.] Following 

those depositions, Plaintiffs again move to vacate the Court’s summary judgment order as 

to CPMG, arguing that substantial newly discovered evidence regarding CPMG’s failure 

to train and supervise creates genuine issues of material fact as to Counts 5 and 6 and 

Plaintiffs’ prayer for punitive damages. 

DISCUSSION

In its November 5, 2018 order, the Court granted summary judgment in favor of 

CPMG on Count 5 for Failure to Train because of a lack of evidence, finding “the 

connection between CPMG’s alleged failure to train and the alleged constitutional 

violations are both unsupported and are far too tenuous to satisfy the high Monellstandard.” 

[Doc. 322, p. 31.] As to Count 6 for Failure to Supervise and Discipline, the Court again

found Plaintiffs’ evidence was “virtually nonexistent” and that Plaintiffs “ma[d]e a variety 

of unsupported arguments based on assumptions, rather than facts.” [Id. at 31.] For 

example, “Plaintiffs rel[ied] on an alleged ‘prior incident in which Naranjo failed to enter 

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information in JIMS and failed to coordinate a patient’s care with the nursing staff,” but 

Plaintiffs failed to support that allegation with any evidence. [Id.] Regarding Count 10’s 

prayer for punitive damages as to the state law negligence claim, the Court held that based 

on the minimal evidence offered, no reasonable jury could find CPMG’s conduct, 

“however negligent, rose to a level of sufficient deliberate disregard . . . that their conduct 

may be called willful or wanton.” [Id. at 37.] At present, Plaintiffs’ Count 10 for 

negligence is the only remaining claim against CPMG, which is set for a jury trial on June 

4, 2019.

A. Reconsideration Is Warranted

Reconsideration is an “extraordinary remedy, to be used sparingly in the interests of 

finality and conservation of judicial resources.” Kona Enterprises, Inc. v. Estate of Bishop, 

229 F.3d 877, 890 (9th Cir. 2000). Indeed, “a motion for reconsideration should not be 

granted, absent highly unusual circumstances, unless the district court is presented with 

newly discovered evidence, committed clear error, or if there is an intervening change in 

the controlling law.” Id. “A motion for reconsideration may not be used to raise arguments 

or present evidence for the first time when they could reasonably have been raised earlier 

in the litigation.” Life Techs. Corp. v. Illumina, Inc., 2012 WL 10933209, at *1 (S.D. Cal. 

June 11, 2012) (quoting Kona Enters., 229 F.3d at 890)). Moreover, motions to reconsider 

are not a platform to relitigate arguments and facts previously considered and rejected. See 

Harrison v. Sofamor/Danek Grp., Inc., 1998 WL 1166044, at *3 (S.D. Cal. Sept. 15, 1998).

This is one of those unusual cases. Here, the Court is satisfied that the evidence 

proffered by Plaintiffs is newly discovered and could not reasonably have been discovered

earlier. CPMG does not argue otherwise. Indeed, Plaintiffs properly requested the lateproduced evidence, which was both discoverable and inadvertently withheld until after the 

Court issued its summary judgment order. The record reflects that Plaintiffs relied upon 

CPMG’s discovery responses that all such evidence had been produced. Thus, the Court 

cannot find that Plaintiffs reasonably could have known of the evidence earlier. 

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B. The Newly Discovered Evidence Raises Genuine Issues of Material Fact

The Court next evaluates whether Plaintiffs’ newly discovered evidence warrants 

vacating the Court’s summary judgment order in favor of CPMG. 

1. Evidentiary Objections1

The Court considers the parties’ evidentiary objections before turning to the 

undisputed facts. CPMG objects to Dr. Gage’s supplemental expert report, arguing (1) it 

has not been properly authenticated through an affidavit and (2) Dr. Gage’s opinion relies 

upon inadmissible evidence in the form of CPMG’s subsequent remedial measures. In 

response to CPMG’s first argument, Plaintiffs submitted Dr. Gage’s affidavit to 

authenticate his supplemental expert report, which is sworn under penalty of perjury and 

offers information reflecting his competence to offer his expert opinions. [Doc. 401-2.] 

The Court is satisfied that Plaintiffs’ subsequently filed sworn statements adequately 

remedy the procedural deficiencies of Dr. Gage’s report. See, e.g., Liebling v. Novartis 

Pharm. Corp., 2014 WL 12576619, at *2 (C.D. Cal. Mar. 24, 2014) (“Courts have held, 

however, that a party can ‘cure’ the defect of an unsworn expert’s report by proffering the 

sworn deposition or declaration of the expert.”). In addition, the Court finds Dr. Gage 

timely supplemented his expert report, having done so more than 30 days before trial. 

Next, CPMG argues Dr. Gage’s opinions are inadmissible because they rely upon 

“subsequent remedial measures,” as prohibited by Federal Rule of Evidence 407. In a 

related argument, CPMG additionally objects to “the majority of” Plaintiffs’ newly 

discovered evidence as constituting inadmissible subsequent remedial measures. [Doc. 

398, p. 21.] It is true that “[w]hen measures are taken that would have made an earlier 

injury or harm less likely to occur, evidence of the subsequent measures is not admissible 

to prove” either “negligence” or “culpable conduct.” Fed. R. Evid. 407. Contrary to 

 

1 As to CPMG’s request that the Court take judicial notice of the pleadings and its 

prior Orders, the request is GRANTED. See Shuttlesworth v. Birmingham, 394 U.S. 147, 

157 (1969) (A court is permitted to take judicial notice of its own court records and files.).

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CPMG’s argument, however, internal quality assurance discussions and peer review used 

to determine the necessity of implementing subsequent remedial measures are not, 

themselves, “subsequent remedial measures” excluded by Fed. R. Evid. 407. Put another 

way, a defendant’s internal investigations and reviews might constitute the initial step 

toward identifying the need for particular remedial action, but “they are not themselves 

excluded under Rule 407.” Aranda v. City of McMinnville, 942 F. Supp. 2d 1096, 1103 

(D. Or. 2013) (“By its terms, this rule is limited to measures that would have made the 

harm less likely to occur; it does not extend to post-incident investigations into what did 

occur.”).2 Id. Accordingly, CPMG’s objections on these grounds are OVERRULED.3 

2. Factual Background4

The Court assumes familiarity with the facts of this case. On September 4, 2014, 

CPMG contracted with the County to “provide psychiatric clinical services which include 

but [were] not limited to initial psychiatric/medical evaluation, diagnosis, treatment, 

emergency medication orders, medication evaluation and prescription.” [Ex. 1 at p. 22.] 

Dr. Steven Mannis is the sole owner of CPMG. Dr. Nicholas Badre became the “Lead 

Physician” at the Central Jail one day after completing his residency. Dr. Sanjay Rao was 

 

2 The Court need not address the remaining argument about evidence concerning the 

removal of a psychiatrist, Dr. B, because it does not rely upon that evidence in this order.

3 Further, to the extent CPMG again asserts California’s peer review privilege, the 

Court again finds that federal privilege law, not state privilege law, governs here. As 

Magistrate Judge Dembin held, “[The self-criticial analysis privilege] is not recognized by 

the Ninth Circuit in this context of the instant case . . . State privilege law applies to purely 

state law claims brought in federal court pursuant to diversity jurisdiction; however, state 

law claims that are pendent to federal question cases are governed by federal privilege 

law.” [Doc. 189 at p. 7:14-8:16, 9:7-14.] 

4 The factual background is drawn from the relevant admissible evidence submitted 

by the parties. The Court’s reference to certain pieces of evidence is not an indication that 

it is the only pertinent evidence relied upon or considered. The Court has reviewed and 

considered all relevant admissible evidence submitted by the parties. Where properly 

supported disputes of material fact exist, they are construed in the light most favorable to 

Plaintiffs, as the non-movants on summary judgment.

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named the Medical Director of Psychiatry for all CPMG providers. According to CPMG 

and the County’s contract, neither party would supervise the other party’s employees, and 

thus, CPMG was responsible for supervising and training its own employees. [Ex. 1 at 21.] 

The contract further required CPMG to designate a “Lead Psychiatrist” to “[p]erform 

Quality Assurance/Quality Inspections (QA/QI) on new residents’ charts, as well as 

performing a quarterly review of charts of all assigned physicians; keep the Sheriff’s CMO 

and/or his designee apprised of QA/QI results.” [Id. at 24.] 

Every month, between 12 and 20 patients were transferred from Patton State 

Hospital to the Central Jail. In August 2015, Mr. Ruben Nunez, who suffered from serious 

medical conditions of schizophrenia and psychogenic polydipsia (water intoxication), was 

one such patient. Mr. Nunez died from these conditions at the Central Jail on August 13, 

2015. 

Construing the disputed facts in the light most favorable to Plaintiffs, as the nonmovants, the following is true about CPMG’s training efforts during the time period 

leading up to Mr. Nunez’s death. For new physicians, CPMG conducted an orientation 

consisting of (1) one day of job shadowing and (2) a packet of orientation information 

about “correctional psychiatry jargon,” general information about the Psychiatric Security 

Unit (“PSU”), facility security, safety cell clearance, psychiatric sick call, psychotropic 

medications, and writing orders. [Ex. E.] CPMG did not have a Director of Training. 

Although Dr. Mannis testified that Dr. Rao was in charge of training and educating CPMG

physicians, Dr. Rao did not know this was his responsibility and had not been so informed 

by Dr. Mannis. Dr. Rao did not know how many employees worked at CPMG in 2015, 

including whether it was less than 25 or more than 40. During 2015, approximately 30 

physicians and four nurse practitioners worked for CPMG. 

CPMG’s training efforts consisted of (1) disseminating educational information to 

physicians on an “as needed” basis, as determined by Drs. Mannis, Rao, and Badre and (2) 

holding “journal club meetings” approximately twice a year for providers to meet and 

discuss any issues, review procedures, and assess how practices could be improved, among 

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other topics. CPMG providers were encouraged but not required to attend the journal club 

meetings. Dr. Rao could not recall if there had been even one journal club meeting in 2015. 

As for its supervision efforts, CPMG did not conduct a single performance review 

of its providers. Dr. Rao, the individual in charge of conducting chart reviews, did not 

counsel any individual providers and could not identify any doctor with whom he spoke 

about a deficiency in the charts. Although Dr. Rao conducted at least some audits of 

psychiatric provider charts, he did not believe any CPMG doctor ever received a copy of 

his reviews. Dr. Rao could not identify any physicians who received retraining. CPMG 

did not conduct any formal in-person reviews of its physicians. Dr. Naranjo testified that 

he was never audited or received a performance review and had never seen any audits or 

reviews of his performance. Dr. Badre recommended the termination of one provider for 

poor documentation accompanied with poor response to feedback given. Howeve, prior to 

Mr. Nunez’s death, Dr. Mannis did not terminate the contracts of any CPMG providers for 

poor performance. 

At the Central Jail, the Psychiatric Security Unit (“PSU”) functions to treat mentally 

ill patients who need hospitalization, and in the PSU, jail staff are permitted to administer 

medication involuntarily to patients. Importantly, the PSU is also the only location in the 

Central Jail where psychiatric patients’ water intake can be regulated. At the beginning of 

the parties’ contractual relationship in November 2014, Dr. Alfred Joshua, Chief Medical 

Officer for the Sheriff’s Department, emailed CPMG regarding various action items, 

including noting that the policy on admissions to the PSU would be drafted by December 

15, 2014. He summarized the policy on “Admission into PSU” as providing that Nurse 

Practitioners could not admit patients to the PSU; only a psychiatrist could ultimately 

evaluate and admit inmate-patients into the PSU. [Ex. 5, p. 1.] Likewise, Dr. Mannis, 

CPMG’s owner, understood that it was psychiatrists who ultimately evaluated and admitted

patients to the PSU. When Mr. Nunez was transferred to the Central Jail, Patton State 

Hospital sent along the court order authorizing “San Diego County Jail’s Psychiatric 

Security Unit and Patton State Hospital to involuntarily administer antipsychotic 

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medication” to Mr. Nunez. [Ex. 3 at 5.] Mr. Nunez, however, was not placed in the PSU 

and had unrestricted access to water.

Dr. Sara Hansen, a CPMG psychiatrist, knew Mr. Nunez’s water needed to be 

restricted. CPMG did not train Dr. Hansen that, to restrict a patient’s water, she had to 

order his placement in the PSU. Similarly, Dr. Badre did not receive training on where 

patients’ water could be restricted. Dr. Badre also did not know physicians were 

responsible for housing determinations and testified that CPMG staff could not affect 

housing. Dr. Rao, in charge of CPMG’s training and supervision, did not understand the 

process for admitting an inmate patient who had been transferred from a state hospital. 

Dr. Joshua testified that Dr. Jorge Naranjo was the psychiatrist responsible for 

inmates coming from state hospitals and was in charge of the PSU. He also testified that 

the initial psychiatrist who evaluated an incoming inmate would determine where that 

inmate was housed. Dr. Naranjo, however, testified that he had nothing to do with housing 

determinations and did not have the authority to decide whether patients were admitted into 

the PSU or the psychiatric floor. Further, Dr. Naranjo testified that he would not review a 

new inmate-patient’s chart and would only review the medication list. Similarly, Dr. 

Hansen testified that she had a habit of not reviewing the nurse’s discharge summary for 

transferred patients. She did not review Mr. Nunez’s record from the Central Jail where a 

Jail nurse noted that she told Mr. Nunez “to drink plenty of water.” 

After Mr. Nunez’s death, Drs. Badre and Rao found Dr. Hansen failed to properly 

document Mr. Nunez’s medical history, failed to request reasonable follow up, and did not 

document an alert for water restriction in the Jail’s computerized medical record system 

(“JIMS”) for Mr. Nunez. Prior to Mr. Nunez’s death, Dr. Mannis knew some providers 

had difficulty with JIMS. Dr. Hansen testified she did not know how to use JIMS medical 

alerts. Meanwhile, Dr. Rao, who was in charge of training CPMG providers, believed 

CPMG physicians were not responsible for updating a patient’s medical alerts in JIMS. 

Similarly, Dr. Badre testified he had never been trained on how to use the JIMS alerts. 

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3. Failure to Train and Supervise Claims

For purposes of Plaintiffs’ § 1983 claims for failure to train and failure to supervise, 

private entities like CPMG are treated like municipalities under Monell v. Dept. of Soc. 

Servs., 436 U.S. 658 (1978). See Tsao v. Desert Palace, Inc., 698 F.3d 1128, 1139 (9th 

Cir. 2012). “Under Monell, [CPMG] can be held liable under § 1983 for policies of 

inaction as well as policies of action.” Jackson v. Barnes, 749 F.3d 755 (9th Cir. 2014). 

Because neither state officials nor municipalities are vicariously liable for their employees’ 

deprivations of others’ constitutional rights, Flores v. City of Los Angeles, 758 F.3d 1154, 

1158 (9th Cir. 2014) (citing Monell, 436 U.S. at 694)), it is also true that, under § 1983,

CPMG cannot be held liable under a respondeat superior theory.5 Rather, to bring Monell

claims against CPMG based on CPMG’s alleged failure to train and supervise its 

employees, Plaintiffs must show (1) CPMG acted under color of state law,6(2) CPMG’s 

training and/or supervision policies were not adequate to prevent violations of law by its 

employees and/or were not adequate to train its employees to handle the usual and recurring 

situations with which they must deal, (3) CPMG was deliberately indifferent to the 

substantial risk its policies were inadequate, and (4) CPMG’s failure to provide adequate 

training and/or supervision was so closely related to the deprivation of Mr. Nunez’s rights 

as to be the moving force that caused his death. See, e.g., Ninth Cir. Model Jury Instruction 

9.8; see also, e.g., Kirkpatrick v. County of Washoe, 843 F.3d 784, 793 (9th Cir. 2016).

Plaintiffs argue their newly discovered evidence shows the following training and 

supervision failures by CPMG: (1) failure to train physicians to understand that they, alone, 

could order patients to be housed in the PSU; (2) failure to train physicians on the 

 

5 Despite Plaintiffs’ repeated reliance on Starr v. Baca, 652 F.3d 1202 (2011), 

CPMG cannot be held liable under a supervisory liability theory because Plaintiffs do not 

individually name any CPMG supervisors as defendants. Cf. Starr, 652 F.3d at 1207-1208 

(considering defendant Sheriff Baca’s supervisory liability under § 1983 and Monell where 

Baca was a supervisor who plaintiff sued in his individual capacity).

6 As before, the parties do not dispute this element. [Doc. 322, p. 30.]

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Department of State Hospitals terminology; (3) failure to train physicians on how to 

communicate critical medical information through the Central Jail’s computerized system, 

JIMS; (4) failure to train physicians to read patients’ medical records and discharge 

summaries; (5) failure to train physicians on where water can be restricted and monitored; 

(6) failure to conduct quality assurance by reviewing its physicians’ performance; and (7) 

failure to take corrective action when deficiencies were found. [Doc. 389, p. 22.] 

In opposition, CPMG argues the Court’s summary judgment order must stand 

because despite Plaintiffs’ new evidence, a reasonable jury could not find CPMG’s alleged 

failures to train and supervise amounted to “deliberate indifference” or that they caused 

Mr. Nunez’s death. For the following reasons, the Court finds Plaintiffs have carried their 

burden to raise a triable issue as to both elements, defeating CPMG’s motion for summary 

judgment. 

a. Plaintiffs Raise a Triable Issue of Fact as to CPMG’s Deliberate Indifference

First, CPMG argues that Plaintiffs’ § 1983 claims must fail because they do not offer 

evidence of a pattern of constitutional violations similar to the one Mr. Nunez experienced. 

To show deliberate indifference supporting a failure to train claim, Plaintiffs must offer 

evidence showing CPMG “disregarded a known or obvious consequence . . . that a 

particular omission in [its] training program [or lack of supervision] [would] cause[] 

[CPMG] employees to violate citizens’ constitutional rights.” Connick v. Thompson, 563 

U.S. 51 (2011). As Defendants correctly argue, a “pattern of similar constitutional 

violations by untrained employees is ordinarily necessary to demonstrate deliberate 

indifference for purposes of failure to train.” Connick, 563 U.S. at 62 (emphasis added). 

The Supreme Court further explained:

Policymakers’ continued adherence to an approach that they know or should 

know has failed to prevent tortious conduct by employees may establish the 

conscious disregard for the consequences of their action—the ‘deliberate 

indifference’—necessary to trigger municipal liability. Without notice that a 

course of training is deficient in a particular respect, decisionmakers can 

hardly be said to have deliberately chosen a training program that will cause 

violations of constitutional rights.

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Id. at 62.

Although Plaintiffs do not offer evidence showing a pattern, the analysis does not 

end there. [Doc. 401 at 4.] The Supreme Court also “left open the possibility that, in a 

narrow range of circumstances, a pattern of similar violations might not be necessary to 

show deliberate indifference.” Connick v. Thompson, 563 U.S. 51, 63 (2011) (citing City 

of Canton v. Harris, 489 U.S. 378, 390 at n.10 (1989)). For instance, a plaintiff may 

succeed in proving a failure to train claim without showing a pattern where “a violation of 

federal rights may be a highly predictable consequence of a failure to equip [the employees]

with specific tools to handle recurring situations.” Bd. of Cnty. Commissioners v. Brown, 

520 U.S. 397, 409 (1997).

As an example of such “a narrow range of circumstances,” the Supreme Court 

offered the hypothetical of a city that deploys its police force with firearms into the public 

to capture fleeing felons without training the officers in the constitutional limitation on the 

use of deadly force. Id. In its hypothetical, the Court “sought not to foreclose the 

possibility, however rare, that the unconstitutional consequences of failing to train could 

be so patently obvious that a city could be liable under § 1983 without proof of a preexisting pattern of violations.” Id. The Court explained that its hypothetical recognized 

“[t]here is no reason to assume that police academy applicants are familiar with the 

constitutional constraints of the use of deadly force.” Id. 

Here, the Court is persuaded that a reasonable jury could find Plaintiffs’ failure to 

train and supervise claims fall within the narrow range of circumstances sufficient to 

support a deliberate indifference finding. First, Plaintiffs’ evidence suggests more than a 

missing policy or a lack of training specific to a unique situation. Instead, Plaintiffs’ 

evidence suggests that CPMG’s training and supervision efforts were so minimal that their 

inadequacy would have been patently obvious to CPMG. Moreover, the circumstances 

surrounding Mr. Nunez’s transfer to and need for increased monitoring at the Central Jail 

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were not unusual in several respects.

7

 It is undisputed that inmate-patients transferred from 

state hospitals to the Central Jail generally require medical alerts in the JIMS system and 

housing in the PSU. It is also undisputed that between 12 and 20 of those state hospital

patients are transferred to the Central Jail every month. In other words, Mr. Nunez’s 

transfer from a state mental hospital to the Central Jail was not a unique circumstance; it 

was a “recurring situation.” Bd. of Cnty. Commissioners v. Brown, 520 U.S. 397, 409 

(1997). Where not one CPMG individual accepts responsibility for training CPMG’s 

providers and where multiple providers, including CPMG directors, have no understanding 

that only psychiatrists can place transferred inmate-patients in the PSU, Plaintiffs have 

raised a triable issue on whether Mr. Nunez’s death was “a highly predictable consequence 

of fail[ing] to equip [CPMG providers] with specific tools to handle recurring situations.” 

Brown, 520 U.S. at 409. The “highly predictable consequence” of failing to equip CPMG 

doctors with knowledge about how to place critically ill patients in the PSU or that it was 

their responsibility to order transferred patients’ housing in the PSU, is that critically ill 

transferred patients would not be placed in the PSU and would not receive the level of 

psychiatric care and monitoring required by the U.S. Constitution. 

Moreover, much like the Supreme Court’s hypothetical in Canton, there is no reason 

to assume that CPMG physicians would innately know—without CPMG’s training—that 

it was their responsibility to place patients into the PSU, how to place patients in the PSU, 

or how to communicate critical medical alerts about patients through the Central Jail’s 

computerized system. Cf. Flores v. Cnty of Los Angeles, 758 F.3d 1154, 1160 (9th Cir. 

2014) (without pattern of similar constitutional violations, “[t]here [wa]s no basis from 

which to conclude that the unconstitutional consequences of failing to train police officers 

 

7 To be sure, Mr. Nunez’s need for a cell with water restrictions appears to be an 

unusual circumstance. Without a pattern of similar violations, however, the Court cannot

find CPMG’s failure to train its providers on how to restrict patients’ water rises to the 

level of deliberate indifference under Monell. Nonetheless, the other circumstances 

surrounding Mr. Nunez’s treatment at the Central Jail are not unusual. 

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not to commit sexual assault are so patently obvious that the [defendants] were deliberately 

indifferent” where “[t]here [wa]s . . . every reason to assume that police academy applicants 

are familiar with the criminal prohibition on sexual assault, as everyone is presumed to 

know the law.”). This is particularly so within the overall context of CPMG’s training 

efforts. Plaintiffs offer evidence depicting CPMG’s training process as both ineffective 

and virtually nonexistent. With only a single day of job shadowing and an orientation 

packet that did not address the PSU housing placement process, CPMG physicians 

managed the medical and psychological needs of a complex population, including

transferred inmate-patients so mentally ill that they were not competent to stand trial and 

often required additional medical care in the PSU. At the same time, there was 

organization-wide confusion about who oversaw the training and supervision of CPMG 

physicians and whose responsibility it was to order a patient’s placement in the PSU.

Indeed, Dr. Naranjo, the very physician in charge of both CPMG’s psychiatric unit and the 

initial evaluation and placement of all transferred patients, did not know he could order a 

housing placement in the PSU and believed his role was limited to reviewing a patient’s

medication list. At minimum, the new evidence raises a triable issue as to whether CPMG’s 

training failures were “so patently obvious that [CPMG] w[as] deliberately indifferent.” 

CPMG responds by arguing that its “journal club meetings” covered the majority of 

CPMG’s training needs. The evidence also shows, however, that these journal club 

meetings were held approximately twice a year and were voluntary, not mandatory. Dr. 

Rao, the individual tasked with training and supervising all CPMG providers, could not 

recall if he conducted even one of those journal club meetings in the year prior to Mr. 

Nunez’s death. In essence, the new evidence raises a genuine issue as to whether CPMG’s 

training was so inadequate that a jury could reasonably find deliberate indifference.

The Court is similarly not persuaded by CPMG’s contention that it had no notice of

Dr. Hansen and Dr. Naranjo’s training deficiencies and continuity of care problems. The 

new evidence raises a genuine issue upon which a reasonable jury could find that CPMG 

chose not to know about Dr. Hansen and Dr. Naranjo’s training needs because it chose not 

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to implement a systematic and regular auditing system to monitor the performance of its 

30 physicians. Prior to Mr. Nunez’s death, CPMG neglected to review the performance of 

either Dr. Naranjo, who was in charge of the psychiatric unit, or Dr. Hansen. Indeed, 

CPMG did not audit either provider’s charting practices even once. 

Further, the new evidence suggests deliberate indifference by CPMG and that 

deliberate indifference may have caused Mr. Nunez’s death. For example, a review of both 

physicians’ practices reflected serious deficiencies that CPMG likely would have identified 

had it conducted regular reviews of its physicians’ charting or practices. Dr. Naranjo 

testified he never reviewed patients’ charts and would only review their medication lists, 

despite other testimony that Dr. Naranjo was responsible for all inmates transferred from 

state hospitals. Similarly, Dr. Hansen testified that she did not review nurse discharge 

summaries for transferred patients. Had CPMG audited Dr. Hansen and Dr. Naranjo’s 

charts, it may have learned that neither doctor was placing critically ill patients into the 

PSU for needed treatment and neither doctor was writing treatment plans or coordinating 

continuity of care. Thus, the Court finds Plaintiffs’ new evidence “raises more than a 

spectre of deliberate indifference” by CPMG. Kirkpatrick v. Cty. of Washoe, 843 F.3d 784, 

796 (9th Cir. 2016) (denying summary judgment on plaintiff’s failure to train claim, despite 

lack of evidence showing pattern of similar constitutional violations, where evidence 

showed a complete failure by agency to train its social workers on the procedures for 

obtaining a warrant and when a warrant is required before taking a child from a parent). 

Despite the many challenges posed to CPMG physicians at the Central Jail, 

including having to manage the psychological needs of inmate-patients coming and going 

from state hospitals within a complicated corrections facility environment, Plaintiffs’ new 

evidence further suggests that CPMG’s supervision efforts were constitutionally 

inadequate. The new evidence raises genuine issues as to whether CPMG formally 

reviewed a single physician, provided audits to its physicians, or had a methodical system 

for conducting audits of its physicians’ charting and treatment practices. In light of the

newly discovered evidence, a reasonable jury could find that had CPMG conducted even 

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the most basic of oversight, it would have conducted additional training after (1) 

recognizing its physicians lacked an understanding of the housing placement process for

patients so vulnerable that they required admission to the PSU, and (2) recognizing its 

physicians lacked an understanding of how to use the medical alerts in the Central Jail’s 

electronic system. Put another way, a jury could reasonably find that the need for 

additional training and supervision was “so patently obvious” that serious risks to patients’

medical care was the likely consequence. Plaintiffs have carried their burden to raise a 

triable issue as to whether CPMG’s alleged failures amounted to deliberate indifference. 

b. Plaintiffs Raise a Triable Issue of Fact as to Causation 

CPMG acknowledges the widespread confusion about how to place patients in the 

PSU. Still, CPMG contends that Plaintiffs cannot show causation because, even if Mr. 

Nunez had been admitted to the PSU, he still would have had access to water, unless a 

provider ordered water restriction. [Doc. 398, p. 25.] CPMG further argues that Plaintiffs’ 

argument about the need for training on PSU housing placement “presupposes that Dr. 

Naranjo and Dr. Hansen understood they were responsible for monitoring Mr. Nunez’s 

medical conditions and knew Mr. Nunez needed immediate water restriction.” Id. 

CPMG’s theory is not persuasive, particularly because it evinces the inadequacy of 

CPMG’s training: why did neither Dr. Naranjo nor Dr. Hansen know they were responsible 

for monitoring Mr. Nunez’s medical conditions? Moreover, the evidence shows that 

patients in the PSU were subject to greater monitoring, and thus, a fact question exists as 

to whether PSU staff would have been more likely to notice and react to Mr. Nunez’s dire 

condition before it was too late. Accordingly, Plaintiffs’ new evidence raises a triable issue 

on causation—whether CPMG’s training and/or supervision failures were so closely 

related to the deliberate indifference to Mr. Nunez’s serious medical needs as to be the 

moving force that caused his death.

4. Punitive Damages

In its summary judgment order, the Court found that no reasonable jury could find 

CPMG’s conduct rose to the level of “deliberate disregard of the interests of others that 

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[its] conduct may be called willful and wanton.” [Doc. 322, p. 37.] For the same reasons 

that Plaintiffs’ newly discovered evidence raises genuine issues of material fact as to 

CPMG’s deliberate indifference, Plaintiffs have likewise raised genuine issues of material 

fact as to the appropriateness of punitive damages. Based on the record, a reasonable jury 

could find CPMG’s recklessness in failing to train and/or supervise its providers rose to a 

level of deliberate disregard sufficient to support punitive damages. 

CONCLUSION

For the previous reasons, Plaintiffs’ motion is GRANTED. It is further ordered that 

the parties re-submit their proposed joint pretrial order and their proposed jury instructions 

to include Counts 5 and 6 and punitive damages against CPMG within 7 days of this order. 

As before, the parties’ proposed jury instructions must comply with the Court’s prior order 

as to format, and the parties are ordered to again meet and confer about the additional jury 

instructions before submitting them to the Court. 

IT IS SO ORDERED.

DATED: May 17, 2019 _______________________________

HON. ROGER T. BENITEZ 

United States District Judge

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