Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_07-cv-01476/USCOURTS-azd-2_07-cv-01476-5/pdf.json

Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 42:1983 Civil Rights Act

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1

 Aaron committed suicide by stuffing a wad of toilet paper down his throat. He

received the toilet paper after requesting it from a night correctional officer who was no

longer on duty at the time Aaron was found unresponsive.

2 In her Complaint, Plaintiff named the following defendants: Correctional Officer II

Matthew Shaw, Sergeant Ronald Carlson, Correctional Officer II Gavino Lechuga, Deputy

WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Barbara Patterson,

Plaintiff, 

v.

Dora Schriro, et al.,

Defendants. 

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) 

 No. CV 07-1476-PHX-PGR

ORDER

On May 15, 2007, Barbara Patterson (“Plaintiff” or “Patterson”) filed a 42 U.S.C. §

1983 civil rights Complaint on behalf of her son and herself in Superior Court. Therein she

alleged violations under the Eighth and Fourteenth Amendments of the United States

Constitution.

Patterson’s son Aaron committed suicide on May 12, 2005 at the Arizona Department

of Corrections (“ADC”).1

 Subsequent to finding Aaron unresponsive, ADC security staff

performed a cell extraction and Aaron was taken to the Health Unit where he was

pronounced dead at 0843 hours. Patterson contends that the “deliberate indifference” of the

named Defendants2

 resulted in the death of her son Aaron in violation of the Eighth

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Warden Johnny Tucker, Sergeant McClaine, Psychology Associate Jeanie Cooper, Director

of the Arizona Department of Corrections Dora Schriro, Licensed Practicing Nurse Jesus

Gutierrez, Licensed Practicing Nurse Maroni, Correctional Officer Betty Esterline, and

Correctional Officer Bryant Millwee. The Defendants remaining in this case are Officers

Matthew Shaw and Gavino Lechuga, Sergeants John McClaine and Ronald Carlson, Nurse

Jesus Gutierrez, and Psychology Associate Jeanie Cooper. Cooper’s motion for summary

judgment will be addressed in a separate order. All Defendants addressed in this Order are

referred to collectively throughout as “Defendants.”

3

 Section 1441, 28 U.S.C. provides in relevant part: 

(a) Except as otherwise expressly provided by Act of Congress, any civil action brought in

a State court of which the district courts of the United States have original jurisdiction, may

be removed by the defendant or the defendants, to the district court of the United States for

the district and division embracing the place where such action is pending.

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Amendment. She further asserts that the Defendants’ conduct “shocks the conscience” in

violation of Aaron’s substantive due process rights under the Fourteenth Amendment.

Finally, Plaintiff alleges substantive due process claims against the Defendants under the

Fourteenth Amendment on her own behalf based on the loss of the life of her child and for

the continued loss of her child’s association.

The Defendants filed a “Notice of Removal” pursuant to 28 U.S.C. §1441 to remove

the case from state court and bring it before the federal court.3

 Specifically, 28 U.S.C. §1331,

provides that district courts have original jurisdiction over all civil actions arising under the

Constitution and laws of the United States. See also City of Chicago v. International College

of Surgeons, 522 U.S. 156 (1997). Plaintiff’s claims of Eighth and Fourteenth Amendment

violations clearly fall within the jurisdictional parameters of 28 U.S.C. §1331. Accordingly,

original jurisdiction in federal court is proper. On August 2, 2007, this case was properly

removed to the United States District Court for the District of Arizona.

After removal, Licensed Practicing Nurse Jesus Gutierrez filed his pending motion

for summary judgment on all charges filed against him by Plaintiff. (Doc. 71.) Thereafter,

Correctional Officers Matthew Shaw and Gavino Lechuga, as well as Sergeants John

McClaine and Ronald Carlson together filed a separate motion for summary judgment on all

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4The following facts are ascertained directly from the parties’ statements of facts and

corresponding exhibits.

5

 Aaron denied the following: ever being admitted to a psychiatric hospital; seeing

a psychiatrist or other mental health professional; taking medication for emotional problems,

mental illness or nerves; having serious head injury; experiencing auditory or visual

hallucinations; experiencing perceptions of thought insertion, broadcasting, or mind control;

experiencing beliefs of paranoia; experiencing any episodes of mania (when not using drugs

or alcohol); ever having attempted suicide; being a victim of sexual or physical abuse; having

a history of violent or aggressive behavior; having a history of emotional problems while

previously being in jail or incarcerated; any current suicidal ideation; or having any serious

episodes of depression while admitting to the heavy use of marijuana and alcohol since the

age of thirteen (13). 

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charges filed against them by Plaintiff (Doc. 72.) The Court will address both of the motions

as follows.

I. Factual Background4

Aaron’s Mental Health History Prior to and During his Stay at ADC

On June 8, 2001, Aaron stabbed his stepfather Troy Steven Longley to death at his

residence in Bisbee, Arizona. On September 19, 2002, Aaron pled guilty to manslaughter in

Cochise County, Superior Court. Aaron also plead guilty to first-degree burglary. He was

sentenced to a term of four (4) years imprisonment at the ADC on Count I (manslaughter)

and seven (7) years intensive probation to begin immediately upon release from ADC on

Count II (first degree burglary). On October 3, 2002, Aaron was transferred from Cochise

County to the Arizona State Prison Complex, Phoenix, Alhambra Unit for processing into

the Arizona prison system.

The ADC administered a routine battery of tests designed to provide a reference point

to evaluate Aaron’s medical and mental health needs as well as Institutional and Public risk

factors for appropriate placement within the prison population. Aaron provided a substantial

amount of information related to his medical and mental health history.5

 Based on the

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6

 A Mental Health Care Needs Scoring Criteria of 1 means that the inmate does not

require placement in an institution that has regular psychological and psychiatric staffing and

services. This occurs when the inmate has no known history of mental health problems or

treatment. 

7

 The drugs he admitted to using were: marijuana, alcohol, sniff glue, paint, gas,

cocaine, crack, methamphetamines, LSD, mushrooms, PCP.

8 Suicide and mental health watches are ordered by the psychology staff when there

is a possibility of an inmate hurting himself. The watches require security staff to monitor

the inmate by checking on him every 10 or 30 minutes, respectively, to ensure that he is

alive. Security is also responsible to keep track of the inmate’s behavior in an observation

log. An inmate on a mental health watch is placed in a holding cell and any item of clothing

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information provided, Aaron was assigned a mental health score of 1.6 On October 3, 2002,

Aaron executed a mail waiver and stated that he wanted no one notified in the event he

sustained a serious illness, accident, or death. 

On October 9, 2002 Aaron completed his initial inmate intake process and was

transferred from Alhambra processing facility to the Arizona State Prison Complex in

Tucson. Aaron was placed in general population. Psychologist Brautigam assessed Aaron

with “major depression.” 

On December 3, 2002, Aaron provided a significantly different history of mental

health than he had provided upon intake. Aaron revealed a history of depression and having

been in and out of a mental health center while taking the medication Paxil. Aaron also

revealed a suicide attempt in 1997 or 1998, at which time he cut his arm while in a drug

rehabilitation center. He stated that both his mother and father have a history of psychiatric

illness. Aaron conveyed that he began using drugs at age nine.7

 An “Institutional Need

Consultation Referral” was ordered for reclassification and a response was prepared by Dr.

Taylor. He recommended that Aaron’s mental health score be raised and he be assigned to

a mental health unit. Aaron was transferred and he consented to the administration of

psychotropic medication. He was then placed on his first 10 minute suicide watch.

Thereafter, Aaron was placed on and off suicide and mental health watch8

 until his suicide

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or personal property that could be used by the inmate to harm himself is confiscated pursuant

to psychology staff orders. Security staff is not authorized to make any independent

determination as to what an inmate on mental health watch is allowed to possess. The

observation log contains a code with lower-case letters representing various behaviors that

has commonly exhibited.

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on May 12, 2005. 

On January 2, 2003, Aaron grabbed the crotch of a female correctional officer which

resulted in Aaron being charged with assaulting staff. He was disciplined therefor. While in

the holding cell, Aaron took his sheet and tied it to the “cage” to form a noose. Aaron was

found by security staff standing with a sheet knotted around his neck. 

Aaron was taken for crisis contact. He denied suicidal intent and admitted that he had

not taken his medication for two days because he didn’t think he needed it. He believed that

people constantly picked on him. He admitted that when he thought about killing people, it

made him feel better. Aaron then cried when he was told he was being put on suicide watch.

He became aggravated and verbally abusive to the psychology associate. He also became

belligerent and reported to Dr. Kaz that he didn’t know if he intended to kill himself. Later

that afternoon, Dr. Kaz again met with Aaron. Dr. Kaz advised members of security that if

necessary, they should remove Aaron’s clothing for security purposes. Suicide watch was

continued. 

Throughout January, the record reflects that Aaron had poor coping skills. He

admitted to having used the knotted sheet in autoerotic strangulation/asphyxiation and he was

found guilty of sexual assault on another staff member on January 16, 2003. Staff noted his

behavior as manipulative with sexual innuendos and expressions. Staff further noted that

while on suicide watch, Aaron was most frequently observed sleeping or resting quietly

without acknowledging the staff during observations. 

On January 21, 2003, Dr. Kaz discussed with Aaron that he was being moved to

SMU-II Mental Health Unit. Aaron was amenable to that move. Dr. Kaz again noted that

Aaron had poor coping skills and that he needed regular “psych” follow up. Dr. Kaz

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9 SMU I and II generally house aggressive inmates, some who feign or exaggerate

their medical symptoms for increased attention from staff or in attempts to assault members

of the staff.

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removed Aaron from suicide watch and placed him on 30 minute mental health watch. Aaron

remained on 30 minute mental health watch until January 30, 2003. At that time, he told

security staff that he was going to kill himself and that his mother told him he would kill

himself. He also stated that the devil was coming and that in his dreams, his parents are

dead. Aaron also kicked the door into Dr. Kaz. The assessment was major depression,

psychosis, and violent behavior. He was placed on 10 minute suicide watch.

Throughout February, records indicate that he spent much of his time on suicide and

mental health watch. The observation logs reveal that he was observed quietly lying down,

resting, or sleeping while members of the staff did their rounds.

Upon his arrival at SMU II9

 Mental Health Unit on February 7, 2003, Aaron was

interviewed by Dr. Backlund. Aaron discussed his history of drug use and the rush he got

from tying a sheet around his neck. He denied wanting to die and admitted wanting to visit

Disneyland. Aaron admitted to wanting more attention and to hearing voices. Dr. Backlund

opined that Aaron’s risk to himself was low and discontinued his suicide watch. 

On February 17, 2003 Aaron exposed his genitals to a correctional officer when she

opened the food trap. A few hours later, Aaron assaulted an ADC staff officer by grabbing

the officer’s arm and key set as the officer attempted to remove handcuffs from Aaron.

Aaron was subsequently charged with assault for both occurrences. He was disciplined

therefor. Aaron’s suicide watch continued. He was then seen by Dr. Herron who

recommended that Aaron be transferred to Phoenix Complex, Baker Ward Mental Health

Facility (“Baker”). He further recommended an adjustment be made to his medications. 

 Aaron’s treatment plan at Baker included addressing: the fact that Aaron’s

adolescence and early adulthood was largely spent incarcerated; Aaron lied profusely and

had done a significant amount of drugs; Aaron’s manipulative conduct; his denial of

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hallucinations, delusions, obsessions/compulsions; and his denial of pre-admission or present

suicidal feelings.

In March 2003, Aaron became disruptive during pill call and required lock-down. Dr.

Clearly noticed fresh bruises on Aaron’s neck where he had applied pressure in a sexually

motivated attempt at partial-asphyxiation consistent with previous behavior. On March 5,

2003, Aaron was placed back on suicide watch after reporting that his dead stepfather told

him to kill himself. The following morning, Aaron again made a determined suicide attempt.

Suicide watch was continued. The next day, Aaron refused medication. The following day,

Aaron opened sutures on his head. Later that day, Aaron confided in Dr. Tee that he wanted

to shoot himself. Suicide watch was continued.

 At Baker, Aaron received continuous mental health care from February 18, 2003 until

the middle of August 2003. On August 7, 2003, he was determined to be stable on

psychotropic medications. Therefore, on August 19, 2003, Aaron was transferred to SMU

I. Over the next several months, Aaron’s psychological logs document improvement with

his moods. They show that he had no homicidal or suicidal ideation and that Aaron appeared

generally stable. The reports note that he was receiving the necessary treatment.

From approximately December 1, 2003 to January 29, 2004, Aaron’s mental health

cell-front logs denote that he was observed primarily sleeping with no significant problems.

On February 3, 2004, Aaron was seen by Dr. Herron for mental health treatment. Aaron

stated that he believed he was improving. Dr. Herron noted that Aaron spent the majority

of time sleeping, but Aaron did not seem to mind because it helped his depression. 

Until March 30, 2004, Aaron was observed sleeping the majority of the day with no

significant changes. Aaron’s mental health treatment was continued. Aaron’s conduct

remained consistent until July 2004 when he refused his medication and refused to sign a

refusal form. Throughout the summer, the mental health team met to create a plan for

Aaron’s major depression, mood disturbance, and psychotic symptoms. The team noted that

overall, Aaron remained stable and cooperative.

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On November 2, 2004, Aaron was seen by Dr. Herron. Aaron stated that he was

sleeping all day until dinner, he denied hallucinations, had a little depression, and had no

suicidal ideation or current suicidal plans or intent. On February 16, 2005, Aaron again met

with Dr. Herron. Aaron complained that his medication was no longer working, he was

depressed, hearing voices, and having feelings of hopelessness. Dr. Herron ordered

medications and notified staff about Aaron’s thoughts of self harm. 

On March 4, 2005, Aaron had in his possession what appeared to be a homemade

stinger wrapped in a washcloth. The following day, Aaron pulled a telephone out of the wall.

A few days later, Aaron denied any suicidal ideation. Security noted that he had slept all

day. Dr. Herron restarted Aaron on Haldol, a medication Aaron had previously taken, and

referred Aaron to psychology. Later that week, Aaron denied any suicidal intention or plans

and reported no current depression. Aaron’s cell-front logs from March 1, 2005 to March

31, 2005 note that he was “generally stable and cooperative.”

On April 10, 2005, Aaron was transferred from SMU II Mental Health Wing to SMU

I Mental Health Wing. At 0945 hours, Aaron notified Nurse Myers (“Myers”) that he was

going to kill himself. He began banging his head, kicking the door, demanding to be

transferred to Baker. Aaron was placed on 10 minute suicide watch by Dr. Arnold. Later

that afternoon, Aaron was observed by Myers to be singing, sitting quietly, smiling at passing

staff, cooperative with medication, and having a good appetite. However, the next day, at

1000 hours, Aaron again complained that he wanted to return to Baker. He threatened that

if he couldn’t go to Baker, he would again bang his head. He refused his medication and

complained of depression. Six hours later, Aaron said he was feeling better, he wanted a

book to read, and was trying not to “do anything stupid” so he could come off watch the next

day. His suicide watch was continued. On April 13, 2005, Aaron was transferred back to

SMU II Mental Health Unit. Documents reflect that Aaron had not been taking his

medication since April 5, 2005. 

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On April 26, 2005, Aaron requested an HIV/Hep. C test. He indicated that he was

bleeding from his rectum due to a razor blade he had swallowed. On April 28, 2005, Aaron

told mental health staff that he was not taking any of his medication because he did not need

them and they did not work. He only wanted medication to sleep. He denied having

hallucinations. The medical staff advised Aaron to continue taking his medication until he

met with Dr. Herron. The medical staff also advised Aaron that his depression and psychosis

increases when he doesn’t take his medication. 

On May 2, 2005, at 1000 hours Aaron was seen by staff with a bleeding scalp and

wrist. He admitted to banging his head and cutting his wrist with a “spork.” He stated that

unless he was given something that would calm him down, he would continue to hurt

himself. Aaron was placed on a 10 minute suicide watch. Nurse Dixon noted that she

responded ten minutes later to an IMS of Aaron self-abusing. She observed a one and a half

inch laceration to his forehead and a superficial laceration to his left wrist. Suicide watch was

continued.

On May 3, 2005, Aaron told mental health staff that he hadn’t heard from his mother

in over a month and that made him sad. He also said he had not heard voices for four days

and he didn’t want to hurt himself. Suicide watch was changed to a 30 minute mental health

watch.

On May 4, 2005, mental health staff cancelled the mental health watch. Later that

day, Aaron told Nurse Grant that he had been pacing around and had passed out because he

was dizzy. He stated that he had started his new “psych meds” that day which may have

caused the dizziness. On or about May 5, 2005 was Mother’s Day. Plaintiff came to visit

Aaron, but he refused her visit, stating “she just makes it worse” because she was “mean to

him.”

On May 6, 2005, Aaron was seen by mental health staff Jeanie Cooper (“Cooper”)

at his cell front. He complained that he needed to go to Baker. He also stated that he wanted

to go to Heaven because it is a better place. Cooper did not have the authority to transfer him

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10 There are two exceptions, on May 2, 2005, at 1750 hours and 1800 hours Aaron was

threatening and standing still, respectively, and subsequently he was quiet and confused. On

May 3, 2005, Aaron was observed “briefly yelling.”

11 In this opinion, correctional officers are referred to as security officers or security

staff. At the ADC, members of the security staff, such as officers Shaw and Lechuga, are

responsible for securing the inmates in their cells to ensure the safety of the inmates and staff.

Security staff is not authorized to diagnose or treat inmates for medical/mental health

problems. With respect to medical issues, the responsibility of security staff is limited to

securing the inmate for examination by medical staff. Security staff is not privy to the exact

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to Baker. She relayed to her superiors his request to be transferred to Baker and discussed

the encounter with her teammates. Consequently, Aaron was placed back on a 30 minute

mental health watch. 

Over the course of the next few days, mental health watch was continued. The logs

indicate that Aaron spent much of his time lying down quietly with no distress. Therefore,

on May 9, 2005, mental health watch was discontinued. On May 10, 2005, Aaron was again

seen by Cooper at his cell front because he was lying in bed requesting a diaper. He had

been urinating and making bowel movements in his sheet. Despite appearing calm, Aaron

refused to answer Cooper’s questions. After the meeting with Aaron, Cooper discussed

Aaron’s treatment plan with her teammates. Cooper placed Aaron on a 30 minute mental

health watch. 

The following day, Aaron was quiet through the night shift. The next morning, he

was again seen by Cooper. He told her that he was doing well, just “kicking back” and that

he would be good if given another chance. He asked to go to his room. Mental health watch

was continued.

SMU I Mental Health Unit and the Staff During the Final Hours of Aaron’s Life

According to the observation logs from May 2, 2005 through May 12, 2005, members

of security staff noted that during their checks, Aaron was primarily quiet and sleeping, either

lying down in the cell or sitting quietly.10 On May 12, 2005 the day Aaron committed

suicide, Correctional Officer11 Shaffer (“Shaffer” is not a defendant) recorded at

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diagnoses of the inmates or the medications taken by the inmates.

12 The next scheduled check would have been performed no later than 0820 hours,

thus this occurred sometime after 0750 hours and prior to 0820 hours.

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approximately 0600 hours that Aaron was lying or sitting quietly in the holding cell. At

approximately the same period of time, Correctional Officers Matthew Shaw (“Shaw”) and

Gavino Lechuga (“Lechuga”) began their day shifts as the house officer and escort officer,

respectively, for Aaron’s area of APSC-Eyman SMU I. 

Shortly after their arrival, they attended their morning briefing where they were

informed that Aaron was in the holding cell for a 30 minute mental health watch.

Immediately after the briefing, they reported to their posts. According to the observation log

Shaffer had last checked on Aaron and signed the log at 0620 hours. He recorded that Aaron

was quietly lying or sitting in the cell in the same position in which Shaw later observed

Aaron.

At approximately 0650 hours, Shaw checked on Aaron and believed he observed

Aaron’s chest rising and falling, that Aaron was breathing and still resting quietly. Shaw

filled out the log to that effect. At 0720 hours and 0750 hours, Shaw checked on Aaron and

logged that he was lying down quietly in approximately the same position he had been in

during the previous checks. Shaw believed that Aaron continued to be breathing and was

resting quietly. During one of his checks, Shaw thought he observed Aaron move his finger

or his hand in what he believed to be a direct and purposeful response to Shaw knocking on

the door and calling Aaron’s name. Shaw did not observe anything during any of his checks

that caused him to believe that Aaron was in medical distress.

Prior to Shaw’s next scheduled check on Aaron, psychology associate William Memo

Grassman (“Grassman”) came into the unit and stopped at the holding cell.12 Grassman

called to Shaw and Lechuga and informed them that he was having trouble getting a response

from Aaron. Lechuga went to the holding cell to perform a check while Shaw went to inform

Correctional Officer Betty Esterline, a more senior security staff member on duty that day.

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13 This is the lying position referred to throughout this order.

14 Some prisoners take medications that can put them in a catatonic-like state. 

15 According to the record, water is used because it has been demonstrated to be an

effective tool to determine whether an inmate is feigning maladies. 

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At approximately 0810 hours, Sergeant John McClaine (“Sergeant McClaine”) was

conducting a walk through of the wing and noticed Lechuga and Shaw attempting to get the

attention of Aaron. Sergeant McClaine approached the holding cell and observed Aaron lying

down in the corner of the holding cell with his head propped up against the bench.13 Sergeant

McClaine also believed that Aaron was sleeping. Nevertheless, he tried to get his attention.

He tried to sprinkle water on Aaron, but to no avail. Sergeant McClaine had no specific

knowledge regarding the medication Aaron was taking.14 Furthermore, Sergeant McClaine

testified that despite not getting an immediate response from Aaron, he did not observe

anything that caused him to believe that there was an emergency situation or that Aaron was

in any serious medical distress. Sergeant McClaine then reviewed the observation logs for

the previous several security checks on Aaron that day and entered a notation stating that

nothing seemed peculiar about the observations. 

At 0815 hours, Sergeant Ronald Carlson (“Sergeant Carlson”) heard over the radio

broadcast that he had a telephone call. He walked toward the pod office to use the phone

across the hall from Aaron’s holding cell. Sergeant Carlson noticed Lechuga and Sergeant

McClaine attempting to get the attention of Aaron. He looked into the holding cell and he

too thought he saw Aaron breathing. He did not observe any signs that Aaron was in serious

medical distress.15 Nevertheless, Sergeant Carlson attempted to get a water cannon from the

fire hatch to elicit a response from Aaron, but the key for that cannon did not function. 

The staff had not received a response from Aaron after exhausting protocol efforts

such as calling out his name, banging on the cell, spraying him with water in an attempt to

elicit a physiological response, etc. Therefore, at 0822 hours, Sergeant McClaine activated

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16 The Incident Management System is utilized to provide an organized and prompt

response to emergent situations that arise at prison complexes. When an IMS is activated,

a recorder at the control station records in writing all radio broadcasts in order to keep as

accurate a record of the timeline of the incident as possible. During this IMS, a video

recording was taken. Unfortunately, the majority of the recording was inaudible, thus

overall, the Court was unable to decipher what and by whom things were being said.

Furthermore, the camera focused primarily on Aaron, thus anyone viewing the recording is,

for the most part, unable to identify the individuals on the scene. The caveat, however, is

Sergeant McClaine’s report made directly to the camera, which is discussed throughout this

order.

17 IMS procedures call for various individuals to be assigned to different teams. “ATeam” responders are the first responders in a given situation. If additional responders are

necessary, the incident commander will activate the “B-Team” and so forth and so on. 

18 See FN 15.

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an Incident Management System16 (“IMS”) and ordered the A-Team17 and medical staff to

respond to Aaron’s holding cell. As the officer who activated the IMS, Sergeant McClaine

was considered the incident commander. At approximately 0823 hours, Sergeant Carlson

found a plastic cup that he filled with water.18 He attempted to throw the water onto Aaron

through the food trap of the cell door. Aaron did not respond. Sergeant Carlson ordered

Shaw to retrieve a different water cannon so he could spray Aaron to get a response.

Sergeants McClaine and Carlson continued to attempt to elicit a response from Aaron. 

At 0826 hours, Correctional Officer Sanchez arrived on the scene with the IMS video

camera and Nurse Gutierrez (“Gutierrez”) arrived on the scene in response to the call for

medical staff. According to testimony, Gutierrez observed Aaron through the trap door and

opined that he believed that Aaron was breathing. Medical staff is not permitted to

physically examine prisoners until after the prisoner has been extracted from the cell. During

the same period of time, Lieutenant York (“York”) arrived on scene and called Deputy

Warden Tucker to advise him of the situation. Based on the phone call, York instructed

Sergeant McClaine that Deputy Warden ordered the extraction team to wait for his arrival

before entering the holding cell. Sergeant McClaine was then under the impression that

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19 As noted, inmates have feigned unconsciousness or unconscious-like conduct in

order to commence fights with staff. Furthermore, Aaron had a history and of aggressive and

violent behavior toward the staff and had previously been found with a homemade weapon.

20 Sergeant McClaine's report to the camera occurred prior to the cell extraction and

was audible on the IMS video. His statements supported his as well as the other officers’

testimony that they believed Aaron was alive and breathing.

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Deputy Warden Tucker had more information about Aaron than the information to which he

was privy. The foregoing events, such as the phone call and Gutierrez’s observation were not

shown on video because the video was focused on the inside of the holding cell. However,

the events are supported by testimony in the record.

At 0828 hours, Shaw returned to the holding cell area with a water cannon which

Lechuga used on Aaron. This was recorded on the IMS video. There was still no response

from Aaron. He remained lying down in the same position. The IMS video then focused on

Aaron’s upper body while the A-Team responders went to the staging area down the hall

from the holding cell to suit up with elbow and knee pads, a stab vest, helmet and visor, and

a shield-all pursuant to ADC policy.19

At 0835 hours, the IMS video shows that the A-Team was suited up and briefed. At

approximately the same time, Sergeant McClaine reported the status of the events directly

to the camera.20 At 0836 hours, Deputy Warden Tucker arrived on the scene and authorized

the A-Team to enter the holding cell for the removal of Aaron. The IMS recording supports

the testimony of the officers that at 0836, the A-Team entered the holding cell, and pursuant

to ADC policy, they restrained Aaron and removed him from the cell. Aaron was then

placed on a gurney for immediate medical examination. This was all recorded on the IMS

video. Nurses Gutierrez and Maroni performed the medical evaluation immediately after the

extraction was complete. The video also shows one of the officers placing a blanket over

what appears to be Aaron’s mid-section. Lead nurse Maroni reports finding agonal carotid

pulse. At the direction of Maroni, Aaron was taken to the Health Unit at 0839 hours. Upon

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21 The health care provider is believed to be Dr. Strubeck.

22 An electrocardiogram is a test that detects and records the heart's electrical activity.

U.S. Dep’t of Health and Human Services, National Institute of Health.(Nov. 2008).

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arrival at the Health Unit, the health care provider21 noted that Aaron was nonresponsive, had

no heartbeat, and no respiration. According to the video, he checked Aaron and ordered an

electrocardiogram (EKG)22. Maroni prepared the EKG. The health care provider then

ordered the lights to be turned off to administer the test. After the outcome of the test, at

0843, Aaron was pronounced dead.

The Criminal Investigation Unit

Criminal Investigations Unit (“CIU”) Investigator Russell Brodeur (“Brodeur”) is

currently employed as a Special Investigator at the ADC. Brodeur has attended many classes

pertaining to examining corpses to recognize physiological changes resulting from death,

including lividity. Brodeur understands the importance of the absence or presence of lividity

at the time of initial observation of a deceased body in determining the time of death.

On May 12, 2005, Brodeur received a call at 0837 hours reporting a nonresponsive

inmate at SMU I. He was assigned as lead investigator and while preparing to leave for

SMU I, he received a call advising him that the inmate had died. At approximately 0859

hours, Brodeur arrived at SMU I Health Unit accompanied by special investigators Abe

Kakar (“Kakar”) and Pablo Hernandez (“Hernandez”). Brodeur briefed them on Aaron’s

suicide and the events surrounding the suicide. Brodeur took the blanket from Aaron’s body

and visually observed lividity on the right side of Aaron’s chest, on his stomach, and on his

leg. All of this information was noted in his written report. Simultaneously, Kakar used a

35mm camera to photograph Aaron’s body. According to the undisputed evidence, the

photographic process took no more than ten minutes. Brodeur subsequently reviewed the

photographs and found them to be true and accurate depictions of his observations of Aaron’s

body at approximately 0900 hours on May 12, 2005. 

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23 Dr. Spitz defined rigor mortis as “the stiffening of muscles after death.” He

explained that rigor mortis occurs faster in smaller muscle groups than larger ones and the

typical time for onset of rigor mortis is thirty minutes to an hour after death. 

24 Dr. Spitz speculated that Aaron could have had a partial occlusion at some point

in time. However, he provided no evidence to that effect. It amounted to mere conjecture.

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At approximately 0931 hours, Brodeur arrived at the holding cell and concluded that

the position of Aaron’s body in the cell was consistent with the location of lividity he had

observed on Aaron’s body. While at the holding cell, Brodeur confiscated the observation

record logs as evidence. He took the logs to the evidence room where they have remained.

Aaron’s body was transported to Pima County Medical Examiner’s Office for an autopsy.

The Medical Examiner’s Findings and Dr. Spitz’s Opinions

The autopsy revealed that Aaron had committed suicide by “shoving toilet paper into

his mouth.” Dr. Diane Karluk (“Dr. Karluk”), the medical examiner, concluded, “[t]he death

of this man is due to complete occlusion of his upper airway by a large wad of toilet paper.

He was apparently suicidal and had been placed in a single cell under suicide watch. The

manner of death is suicide.” (Emphasis added). Dr. Karluk found that the toilet paper wad

was located in the larynx area (upper airway) and explained that a person looking into

another person’s mouth would not be able to see the larynx without a tool such as a

laryngoscope. It is undisputed that the ADC medical staff was not equipped with a

laryngoscope and had no experience using such a tool.

Plaintiff retained Daniel J. Spitz, M.D., (“Dr. Spitz”) a pathologist and medical

examiner as an expert in this matter to formulate opinions regarding the cause of Aaron’s

death and to evaluate the circumstances under which he died. Specifically, Dr. Spitz testified

that rigor mortis23 would appear faster in smaller muscles, such as Aaron’s jaw muscles, than

it would in other areas. Dr. Spitz agreed with Dr. Karluk that the cause of death was

asphyxiation secondary to the obstruction of the upper airway by toilet paper.24 Dr. Spitz

also agreed with Dr. Karluk’s conclusion that the toilet paper wad was located in the larynx

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25 Dr. Spitz defined livor mortis, or lividity, as the “pooling of blood after death.” He

explained that it occurs in the dependent portions of the body essentially affected by gravity.

Lividity manifests as reddish, purple discoloration of the skin. The onset of lividity is similar

to rigor mortis and may occur as soon as 30 minutes after the time of death. 

26 The purpose of an AIU investigation is to determine whether any staff misconduct

occurred and to make recommendations for review and disposition by the approving

authorities. 

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area and that a person looking into another person’s mouth would not be able to see the

larynx without a tool such as a laryngoscope. He acknowledged that when evaluating Aaron,

Maroni was unable to open Aaron’s jaw. Dr. Spitz opined that it would take approximately

one hour for rigidity to set in to the point when someone would be unable to open Aaron’s

jaw. 

Dr. Spitz further acknowledged that Dr. Strubeck found dependent lividity25 on

Aaron’s buttocks including streaks or lines of red discoloration. Based on Dr. Strubeck’s

observation of lividity at 0843 hours, and Dr. Spitz’s opinion that lividity takes

approximately an hour to appear, Dr. Spitz testified that Aaron had to have been deceased

for longer than forty-five minutes at the time of observation. During his October 20, 2008

deposition, Dr. Spitz reviewed for the first time photographs taken of Aaron’s body at 0900

hours on May 12, 2005. He testified that the photographs depicted reddish discoloration

consistent with lividity that would occur within about an hour of the time of death. He then

agreed that based on that evidence, Aaron most likely died between 0800 hours and 0815

hours, if not earlier. 

The Administrative Investigation Unit

The ADC’s Administrative Investigation Unit (“AIU”) conducted an internal

investigation of the foregoing events.26 During the course of the investigation and pursuant

to standard policy, all relevant documents, including correctional officers’ logs, were seized

and maintained as evidence. On May 3, 2007, the AIU completed its investigation and

issued a final Administrative Investigation Report. The AIU determined that the allegations

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of policy violations against Officers Lechuga and Shaw, and Sergeants McClaine and

Carlson were unsustained.

II. LEGAL STANDARD AND ANALYSIS 

The standard for summary judgment is set forth in Rule 56(c) of the Federal Rules of

Civil Procedure. Under this rule, summary judgment is properly granted when, after viewing

the evidence in the light most favorable to the non-moving party, no genuine issues of

material fact remain for trial. Fed. R. Civ. P. 56; Celotex Corp. v. Catrett, 477 U.S. 317, 322-

23 (1986); Eisenberg v. Ins. Co. of N. Am., 815 F.2d 1285, 1288-89 (9th Cir. 1987).

The moving party bears the burden of demonstrating that it is entitled to summary

judgment. Mur-ray Mgmt. Corp. v. Founders Title Co., 819 P.2d 1003, 1005 (Ariz. Ct. App.

1991). If the moving party makes a prima facie case showing that no genuine issue of

material fact exists, the burden shifts to the opposing party to produce sufficient competent

evidence to show that a triable issue of fact does remain. Ancell v. United Station Assocs.,

Inc., 803 P.2d 450, 452 (Ariz. Ct. App. 1990). The Court must regard as true the non-moving

party's evidence, if it is supported by affidavits or other evidentiary material. Celotex, 477

U.S. at 324. However, the non-moving party may not merely rest on its pleadings, it must

produce some significant probative evidence tending to contradict the moving party's

allegations and thereby creating a material question of fact. Anderson v. Liberty Lobby,

Inc., 477 U.S. 242, 256-57(1986)(holding that the plaintiff must present affirmative evidence

in order to defeat a properly supported motion for summary judgment); First Nat'l Bank of

Ariz. v. Cities Serv. Co., 391 U.S. 253, 289 (1968).

A. Eighth Amendment Claims on Behalf of Aaron and Barbara Patterson

In determining the existence of deliberate indifference, a court must consider the

seriousness of the prisoner’s medical need and the nature of the specific defendant’s response

to that need.” McGuckin v. Smith, 974 F.2d 1050, 1059 (9th Cir. 1992), overruled on other

grounds by WMX Techs, Inc. v. Miller, 104 F.3d 1133, 1136 (9th Cir 1997). Plaintiff must

show that a defendant “purposefully ignored or failed to respond to his pain or possible

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medical need.” Id. at 1060. In Farmer v. Brennan, 511 U.S. 825, 837 (1994), the Supreme

Court instructs that the state of mind of the defendant is to be viewed from a subjective,

rather than objective viewpoint. (Emphasis added.) Based upon the Farmer standard, the

Ninth Circuit explained, “[o]nly if the person 'knows of and disregards an excessive risk to

inmate health and safety.' . . . it is not enough that the person merely 'be aware of facts from

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

draw that inference.' If a person should have been aware of the risk, but was not, then the

person has not violated the Eighth Amendment, no matter how severe the risk.” See Gibson

v. County of Washoe, 290 F.3d 1175, 1187-88 (9th Cir. 2002) (quoting Farmer, 511 U.S. at

837, citing Jeffers v. Gomez, 267 F.3d 895, 914 (9th Cir. 2001))(emphasis added). 

Furthermore, in civil rights actions, the Ninth Circuit requires proof of causation. “A

person deprives another of a constitutional right within the meaning of Section 1983 if he

does an affirmative act, participates in another’s affirmative acts, or omits to perform an act

which he is legally required to do that causes the deprivation of which [the plaintiff

complains].” Leer v. Murphy, 844 F.2d 628, 633 (9th Cir. 1988) (quoting Johnson v. Duffy,

588 F.2d 40, 743 (9th Cir. 1978))(emphasis added). For a prisoner to prevail on a civil rights

claim under 42 U.S.C. § 1983 based on the allegation of inadequate medical care in violation

of the Eighth Amendment, the prisoner must establish that the individual defendant caused

“acts or omissions sufficiently harmful to evidence deliberate indifference to serious medical

needs.” Estelle v. Gamble, 429 U.S. 97, 106 (1976). Moreover, the court must focus on

whether the individual defendant was in a position to take steps to avert additional harm, but

failed to do so intentionally or with deliberate indifference. Leer, 844 F.2d at 633-34

(internal citations omitted). The Court will now address Plaintiff’s specific claims against

each individual defendant.

1. Nurse Gutierrez

Plaintiff alleges that Gutierrez, a licensed practical nurse employed by ADC, was

deliberately indifferent to the serious medical needs of Aaron in violation of his Eighth

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27 The other Defendants on the scene also believed Aaron was breathing while he was

in the holding cell. Moreover, Nurse Maroni, an experienced nurse, opined that she had

detected an agonal pulse.

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Amendment rights. To prevail on her Eighth Amendment claims, Plaintiff must establish that

Gutierrez was deliberately indifferent to Aaron’s medical needs and that such deliberate

indifference was the cause of Aaron’s death.

Plaintiff contends that more timely intervention by Gutierrez could have prevented

Aaron’s death. As the record reflects, Gutierrez testified that immediately upon arriving at

the scene and observing Aaron, he opined that Aaron was alive and breathing.27 Based on

this belief, he did not perceive a medical emergency existed. Plaintiff has failed to proffer

evidence to raise a genuine issue of material fact contradicting Gutierrez’s belief that Aaron

was not in serious medical distress. Moreover, in the factual narrative provided by Plaintiff,

she concedes that shortly after arriving at the scene, Gutierrez is heard saying, “[h]e’s

breathing” followed by the statement “[t]hat’s a good sign.” While poor medical treatment

may at some point rise to the level of a constitutional violation, malpractice, or even gross

negligence does not suffice for a claim of deliberate indifference. Estelle, 429 U.S. at 106;

see also Hallett v. Morgan, 296 F.3d 732, 744 (9th Cir. 2002) (“Mere medical malpractice

does not constitute cruel and unusual punishment.”)(citation omitted); see also Wood v.

Housewright, 900 F.2d 1332, 1334 (9th Cir.1990). Plaintiff has failed to satisfy her burden

of establishing that Gutierrez was deliberately indifferent to Aaron’s medical needs based on

the timing of his intervention. Based upon Gutierrez’s subjective state of mind, he cannot

be held liable for a violation of Aaron’s Eighth Amendment rights based upon on this

particular allegation. Farmer, 511 U.S. at 837; Leer, 844 F.2d at 633. 

Plaintiff’s next argument is that Gutierrez should have known there was a substantial

risk to Aaron’s health at the time he arrived on the scene merely by virtue of being called to

the scene. However, this is not the standard promulgated by Farmer, 511 U.S. at 837, nor

is it the standard set forth by the Ninth Circuit in Gibson, 290 F.3d at 1187-88 (Even if a

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28 An example of Gutierrez not being in a position to avert any alleged further injury

to Aaron. Leer, 844 F.2d at 634.

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person should have been aware of the risk, but was not, the person was not in violation of the

Eighth Amendment.) Consequently, Patterson’s argument fails. Gutierrez cannot, as a

matter of law, be liable under the Eighth Amendment for not knowing the risk. Id. 

Next, Plaintiff avers that Gutierrez was deliberately indifferent to Aaron’s medical

needs by not attempting to resuscitate Aaron. This Court disagrees. It is undisputed that it

is the policy of the ADC that medical staff may not physically examine an inmate, including

efforts to resuscitate, until the inmate has been extracted from the cell. According to the

undisputed testimony of both Gutierrez and Sergeant McClaine, as well as footage from the

IMS video, Gutierrez examined Aaron immediately upon his removal from the holding cell.

Nurses Gutierrez and Maroni checked for a heart beat and respiration. Gutierrez testified that

he then prepared to begin CPR. However, immediately after the initial examination, Maroni

directed that Aaron be taken to the Health Unit. Maroni had the higher nursing license and

was the appropriate nurse to make that decision. The undisputed testimony provided by

Gutierrez’s nursing expert confirmed that his deference to Maroni under those circumstances

is consistent with the applicable standard of care. This supports the conclusion that

Gutierrez was not in the position to avert any alleged further injury to Aaron. Leer, 844 F.2d

at 634. Therefore, he could not, as a matter of law, have been the cause of injury to or death

of Aaron. Id. Likewise, he cannot be held liable for an Eighth Amendment violation for

deliberate indifference to Aaron’s medical needs for not attempting to resuscitate Aaron.

Plaintiff further argues that Gutierrez was deliberately indifferent to Aaron’s medical

needs by not acting with more of a sense of urgency. As the Court has previously addressed,

medical staff is not permitted to physically examine inmates until after they have been

extracted from the cell by security officers. Pursuant to the order of the Deputy Warden, the

extraction was not permitted until he arrived on the scene.28 According to the Supreme

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Court, prison administrators should be accorded wide-ranging deference in the adoption and

execution of policies and practices that in their judgment, are necessary to preserve internal

order and discipline, and to maintain institutional security. Whitley v. Albers, 475 U.S. 312,

321-22 (1986). Gutierrez did not have the authority to physically examine Aaron any sooner

than he did and hence was not in a position to avert injury to Aaron. Leer, 844 F.2d at 633-

34. Therefore, Gutierrez’s alleged failure to act with more urgency could not have been the

legal cause of any alleged further injury to or death of Aaron. Id. Thus, he cannot be held

liable for an Eighth Amendment violation for deliberate indifference for failure to act with

more urgency.

Plaintiff was unable to satisfy the subjective component of the deliberate indifference

standard. Moreover, she was unable to establish that Gutierrez’s actions or inactions were

the cause of death or injury to Aaron. Therefore, Gutierrez is entitled to summary judgment

in his favor as to all allegations of Eighth Amendment violations.

2. The Officers

The Court will not reiterate the specific components of the deliberate indifference

standard or the requirement for individual causation for each defendant. However, for the

sake of clarity, the Court will briefly set forth what is necessary for a plaintiff to successfully

establish a 42 U.S.C. § 1983 civil rights claim against individual state officials. State

officials are not subject to suit under 42 U.S.C. § 1983 unless they are alleged to have played

an affirmative part in depriving a plaintiff of his constitutional rights. Rizzo v. Goode, 423

U.S. 362, 377. Furthermore, the inquiry into causation must be individualized and focus on

the responsibilities of each defendant whose acts or omissions are alleged to have caused a

constitutional deprivation. Rizzo, 423 U.S. at 377; Leer, 844 F.2d at 633; King v. Atiyeh,

814 F.2d 565, 568 (9th Cir. 1987). A plaintiff must prove that each individual official acted

with deliberate indifference and that this deliberate indifference was the legal cause of the

deprivation of the inmate’s Eighth Amendment right to be free from cruel and unusual

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29 For a more detailed analysis of the deliberate indifference standard, see supra.

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punishment. Leer, 844 F.2d at 634.29 

In Gibson v. County of Washoe, Nev., the Ninth Circuit agreed that the subjective

component of Farmer’s deliberate indifference standard could be met if the risk involved was

obvious, but determined that Gibson’s condition was not so obvious that the security officers

involved could be found liable. Gibson, 290 F.3d at 1196-97. Inmate Gibson died of a heart

attack after struggling with officers who were trying to restrain him. Id. at 1183. Gibson was

seriously mentally ill and took medication for manic depressive order. Id. at 1180. His

widow alleged that the officers were deliberately indifferent to her husband’s mental state.

Id. Despite evidence of extreme mood swings and dramatic shifts from compliance and

combatance, the Ninth Circuit found that the security officers did not have actual knowledge

of the prisoner’s specific mental condition and that with no training regarding the diagnosis

and treatment of mental illness, a jury could not find that the prisoner was so obviously

mentally ill that the officers could be held liable under the deliberate indifference standard.

Id. at 1197. In the instant case, like in Gibson, the Defendants are not trained regarding the

mental health, diagnoses, medications, treatment plans, or the specific mental illness of the

prisoners. Accordingly, a jury could not find that the officers could know that Aaron was so

obviously mentally ill that he would commit suicide by shoving toilet paper down his throat.

Therefore, as in Gibson, a jury could not find that the officers and sergeants could be held

liable under a deliberate indifference standard for violations of the Eighth Amendment. Id.

at 1197. Notwithstanding, this Court will take a more individualized approach to come to

its decision. 

a. Officer Shaw

Plaintiff claims that Shaw violated Aaron’s rights under the Eighth Amendment

because he was deliberately indifferent to Aaron’s medical needs by not recognizing sooner

that Aaron was in serious medical distress. It is undisputed that Shaw first observed Aaron

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30Even assuming Shaw should have known there was something particularly different

about Aaron that day, the law dictates that he cannot be held liable for an Eighth Amendment

violation. Gibson, 290 F.3d 1187-88. As unfortunate as the circumstances are, and the Court

acknowledges that this is an extremely sad situation for Patterson, the Court is bound by the

standards set forth by the Supreme Court and the Ninth Circuit.

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at approximately 0650 hours, at which time he stated unequivocally that he believed Aaron

was breathing. He did not believe that Aaron was in any medical distress. Based on Shaw’s

subjective belief, and pursuant to the law set forth in Farmer and its progeny, Shaw cannot

be held liable for not responding earlier to Aaron. See Farmer, 511 U.S. at 837; Gibson, 290

F.3d at 1196-97. 

Next, Plaintiff argues that Shaw has no “reasonable” explanation as to how he could

“fail to be concerned with an inmate naked on the cement floor who is virtually motionless.”

First, the Court reminds Plaintiff that it is not she who decides whether Shaw’s conduct is

reasonable. Second, deliberate indifference is not comprised of a reasonableness standard.

As previously articulated by this Court, to establish deliberate indifference, Plaintiff must

demonstrate that Shaw’s “failure to be concerned” was intentional, purposeful, and

deliberate, and was the actual and proximate cause of the deprivation of his Eighth

Amendment right. In other words, Plaintiff must satisfy the test for deliberate indifference,

beginning with the subjective component set forth in Farmer. See Farmer, 511 U.S. at 837.

As stated, Shaw believed Aaron was alive and breathing, hence his steadfast belief that

Aaron was not in medical distress. Plaintiff has failed to present evidence to establish that

Shaw knew Aaron was dying and intentionally left him to suffer. To the contrary, the

evidence demonstrates the Shaw had no reason to believe that Aaron’s conduct on May 12,

2005 was any different to Aaron’s conduct any other day he spent lying in the same or

similar position in the holding cell.30 Having established Shaw’s subjective belief, the

Court could essentially stop its inquiry. However, it will briefly address the issue of

causation. Plaintiff has failed to proffer evidence establishing that any specific action or

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31 Similarly, Patterson concludes that shooting water at Aaron was done for security

purposes as opposed to addressing Aaron’s “serious medical needs.” Testimony establishes

that none of the Defendants believed that Aaron had any serious medical needs.

Furthermore, the officers’ attempt at trying to elicit a response via calling out Aaron’s name,

knocking on the door, and spraying the water cannon prior to suiting up and performing a cell

extraction is ADC protocol. Therefore, this is an issue that Plaintiff has with the ADC, not

with the individual Defendants.

32 It seems evident that based on Plaintiff’s argument, she summarily concludes that

an IMS should be initiated whenever an inmate is nonresponsive. This is not an issue

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inaction on the part of Shaw observing Aaron lying naked on the floor of the holding cell

caused the death of Aaron. Leer, 844 F.2d at 633.

Plaintiff’s next allegation against Shaw is that immediately upon realizing that Aaron

was not responding to him, Shaw should have initiated an IMS. She contends that such a

delay in medical treatment amounted to deliberate indifference in violation of his Eighth

Amendment rights. Prison officials are deliberately indifferent to a prisoner's serious medical

needs when they delay or intentionally interfere with medical treatment and such delay

caused substantial harm. Wood, 900 F.2d at1334-35 (citing Hutchinson v. United States, 838

F.2d 390, 394 (9th Cir.1988)). Here, Plaintiff has not provided evidence establishing that

Shaw, as an individual, denied, delayed, or intentionally interfered with medical treatment

for Aaron. The assertion that the IMS should have been initiated earlier is an argument that

is essentially directed at the ADC’s policies. It appears that it is Plaintiff’s position that the

ADC policies in effect at the relevant times were insufficient. However, Plaintiff’s specific

claim is against Shaw, not against the ADC.31 The premise of her argument is that Shaw

should not have retrieved the water cannon or tried to elicit a response from Aaron in any

manner. Without any evidentiary support, she concludes that Shaw should have immediately

initiated an IMS. After a review of the record, there is no deposition testimony by anyone

at the scene stating that they believed Aaron was in medical distress. No one observed Aaron

attempt to place or actually place anything in his mouth. There were no signs that he had

been choking or struggling for breath.32 It is undisputed that Shaw first became aware of

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currently before the Court. Furthermore, it is not a claim to be alleged against the individual

Defendants, rather, this pertains to her underlying issues with the ADC policies as they relate

to the IMS process. 

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Aaron’s nonresponsiveness when Grassman stopped at the holding cell at approximately

0810 hours. Furthermore, Grassman testified that as soon as Shaw (and Lechuga) were

alerted by him, both officers immediately “opened the food trap, and they both got down and

looked in, and yeah, they were right on it.” He further stated that they opened the food trap

“faster than within a half a minute.” 

Based on the aforementioned, the Court finds that Patterson has failed to present

evidence establishing that Shaw’s individual actions or inactions “den[ied], delay[ed], or

intentionally interfere[d] with [Aaron’s] medical treatment.” Hallett, 296 F.3d at 744

(citation omitted); Wood, 900 F.2d 1334. Moreover, critical to the outcome of Patterson’s

allegation that Shaw “delayed medical treatment for her son” by not initiating an earlier IMS

is Deputy Warden’s order prohibiting Aaron’s extraction from the holding cell until he

arrived on the scene. Regardless of when an IMS was called, the extraction would not have

occurred until the arrival of the Deputy Warden. 

 Possibly most significant regarding initiating an earlier IMS is the following, which

applies to all Defendants. The medical examiner’s findings established that the ADC

medical staff would not have been equipped to extract the occlusion from Aaron’s airway

despite an earlier extraction from his holding cell. Based on this evidence, none of the

medical staff nor security staff could have done anything to prevent further injury or harm

to Aaron. Thus, none of the Defendants were in a position to take steps to avert additional

harm, yet failed to do so intentionally or with deliberate indifference. Leer, 844 F.2d at 633-

34 (internal citations omitted). Accordingly, Plaintiff’s assertions that Shaw’s failure to

initiate an IMS caused Aaron’s death or additional injury to Aaron must fail as a matter of

law. Id. Thus, Shaw cannot be held liable for an Eighth Amendment violation for deliberate

indifference for failing to initiate an IMS.

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b. Officer Lechuga

Plaintiff’s claims against Lechuga are strikingly similar and often overlap with her

claims against Shaw. Plaintiff argues that Lechuga also violated Aaron’s Eighth Amendment

rights by denying Aaron more timely medical care. It is undisputed that Lechuga believed

that Aaron was not in medical distress during the time that he and Shaw were attempting to

elicit a response from Aaron. Such undisputed testimony clearly establishes Lechuga’s state

of mind, a necessary component of the deliberate indifference standard. Farmer, 511 U.S.

at 837.

Plaintiff further argues that Lechuga should have known that something was wrong

with Aaron because he (and Shaw) spent a lot of time with the inmates. Based on the clear

legal authority set forth above, the Court could summarily dismiss this argument, as it was

directed at both Shaw and Lechuga, without an individualized focus. Instead, the Court will

dispose of the argument on its merits. One can deduce from the cell-front logs that Lechuga

was in fact quite familiar with Aaron’s propensity to lie down quietly in the holding cellparticularly in the position in which he was found. He was also familiar with Aaron’s prior

inclination to sleep through the day until dinner. All of this, however, supports the finding

that Lechuga’s action or inaction did not amount to deliberate indifference to Aaron’s

medical health. As established, the deliberate indifference standard is not comprised of a

“should have known” component. See supra. The Court recognizes the sensitive nature of

the pending issues, however, it is bound by the standard of the law, and deliberate

indifference requires that the defendant knew of and intentionally disregarded the excessive

risk to the inmate’s health and safety. See Farmer, 511 U.S. at 837; See also Gibson, 290

F.3d at1187-88.

Another argument set forth by Plaintiff is that Lechuga, like the other officers, should

have initiated an IMS as soon as he knew that Aaron was unresponsive. Without being

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33 The Court is mindful that it has previously found that none of the Defendants are

liable for deliberate indifference for failing to initiate an earlier IMS based upon the medical

examiner’s finding that the ADC medical staff would not have been equipped to extract the

occlusion from Aaron’s airway despite an earlier removal of Aaron from his holding cell.

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redundant, the Court will briefly address this issue.33 By the time that it was established that

Aaron was unresponsive, there were several officers and sergeants on the scene. Thus, as a

correctional officer surrounded by superior officers, Lechuga would not have initiated an

IMS in lieu of a higher ranking officer initiating the IMS. Furthermore, there are ADC

policies in place to ensure that initiating an IMS is appropriate, including, but not limited to,

first calling out to an inmate, banging on the cell door, throwing water into the cell, and

spraying a water cannon into the cell. Such attempts at eliciting a response are not arbitrary

at the ADC. Specifically with regard to Lechuga, he made constant attempts at eliciting a

response from Aaron beginning from the time he was aware that Aaron was not responding

to Grassman. See Supra. However, Lechuga was not in a position to take steps to avoid

injury to Aaron. Lechuga was not permitted to enter Aaron’s cell until the arrival of Deputy

Warden Tucker. Therefore, an earlier IMS would have proven futile.

Finally, Plaintiff makes a sweeping conclusion, with no evidence to support it, that

Lechuga (as well as others) knew that Aaron was unresponsive, had no weapon, and that

immediate extraction was necessary. Again, this could be summarily disposed of because

of the lack of individualized focus as to each individual defendant. Leer, 844 F.2d at 633-34.

Patterson maintains that such inaction amounted to deliberate indifference. The record

establishes the contrary. Aaron had a history of aggressive behavior, had a disciplinary

history of assaults against security staff, and had been found with a homemade weapon on

a previous occasion. Furthermore, “[s]weeping conclusory allegations will not suffice to

prevent summary judgment. The prisoner must set forth specific facts as to each individual

defendant's deliberate indifference.” Leer, 844 F.2d at 633-34. Plaintiff has failed to

demonstrate that Lechuga knew that an immediate extraction was necessary and intentionally

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34 See FN 33.

35 Whether his statement was accurate is irrelevant under the deliberate indifference

standard, as it is based on his subjective belief that Aaron was breathing at the time. 

Farmer, 511 U.S. at 837.

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failed to act there upon.

c. Sergeant McClaine

Plaintiff claims that Defendant McClaine also violated Aaron’s rights under the Eighth

Amendment by denying him timely medical care by virtue of not initiating an earlier IMS.34

Upon arriving on the scene, Sergeant McClaine noticed Officers Shaw and Lechuga

attempting to get a response from Aaron. Sergeant McClaine called out Aaron’s name,

banged on the cell, and directed Lechuga to spray Aaron with a water cannon. This was all

part of a routine course of action meant to achieve an intended result from a nonresponsive

inmate. After not receiving a response to any of their attempts, Sergeant McClaine initiated

an IMS. The IMS video clearly shows Sergeant McClaine reporting to the camera that

Aaron was breathing.35 During his deposition, Sergeant McClaine testified that upon

observing Aaron in the holding cell, he believed that Aaron was breathing. Plaintiff has

failed to proffer evidence to the contrary. Therefore she is unable to satisfy her burden set

forth by the Supreme Court and the Ninth Circuit. Farmer, 511 U.S. at 837; Gibson, 290

F.3d at 1187-88. Accordingly, based on Sergeant McClaine’s subjective belief, he cannot

be held liable under the Eighth Amendment for deliberate indifference for failure to provide

timely medical care by failing to initiate an earlier IMS. 

Plaintiff’s next point of contention is that as incident commander, Sergeant McClaine

should have recognized the medical emergency and disregarded Deputy Warden Tucker’s

order prohibiting the cell extraction until his arrival. In particular, she argues that Sergeant

McClaine knew or should have known that pursuant to General Order No. A08-100-10

regarding suicide prevention in SMU I, he had the ability to override the Deputy Warden in

certain situations. General Order No. A08-100-10 states in pertinent part, “...when obvious

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signs of suicide paraphernalia are present in conjunction with an unresponsive inmate, staff

must immediately change tactics...” Significantly, the Court notes that Plaintiff has failed

to articulate any “obvious signs of suicide paraphernalia.” To the contrary, no one knew that

Aaron was provided with the toilet paper he had used to commit suicide. He had no clothing,

sheets, toilet paper, or any other “paraphernalia” near or around him that could be used to

alert any of the officers of such a situation. The Court finds that Sergeant McClaine would

have had no reason to override an order from his superior when (1) his subjective belief was

that Aaron was not in serious medical distress; (2) the circumstances did not fit within the

parameters of those enumerated in the General Order; and (3) as testified to, Sergeant

McClaine believed that based upon Deputy Warden Tucker’s order, the Warden had more

information regarding Aaron than the information to which he was privy. Based upon the

foregoing, Plaintiff has failed to establish that Sergeant McClaine’s decision not to override

Deputy Warden’s order and his action or inaction as incident commander caused further

injury to or the death of Aaron. Leer, 844 F.2d at 633.

d. Sergeant Carlson

Plaintiff’s arguments against Sergeant Carlson were primarily a melange of arguments

asserted against the “officers” in general. However, there is an exception. Plaintiff

specifically argues that “it strains belief that an individual could have such shallow breathing

that Carlson imagined it without ‘any obvious signs [of] medical distress.’” As previously

articulated, such conclusory statements are without merit. Leer, 844 F.2d at 633-34.

(Conclusory allegations are not sufficient to prevent summary judgment. A prisoner must set

forth specific facts as to each individual defendant's deliberate indifference.) Id. As

established, Sergeant Carlson and other officers all testified that they believed that Aaron was

alive and breathing when they observed him in the holding cell. They did not believe that

there was an emergency situation or that Aaron was in medical distress. Plaintiff has

proffered no evidence to contradict their testimony nor has she alleged any specific conduct

on the part of Sergeant Carlson amounting to deliberate indifference. Plaintiff has further

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failed to establish that Sergeant Carlson’s actions or inaction were the cause of injury to or

the death of Aaron.

B. Aaron Patterson’s Fourteenth Amendment Claim

In her Complaint, Plaintiff claims that “[a]s a direct result of Defendants’ deliberate

and unconstitutional conduct, Aaron Patterson died.” Specifically regarding her Fourteenth

Amendment claim on behalf of Aaron, Plaintiff contends only that “Defendants’ conduct,

including that of literally standing and watching Aaron die, ‘shocks the conscience’ and as

such, violates substantive due process.” The Court has determined that the conduct of the

officials did not reach the level of deliberate indifference. Pursuant to the Ninth Circuit, the

“deliberate difference” standard is a subset of the “shocks the conscience” standard. Porter

v. Osborn, 546 F.3d 1131, 1137 (2008). Furthermore, the Supreme Court has expressly

stated that only official conduct that “shocks the conscience” is cognizable as a due process

violation. Lewis, 523 U.S. at 846, 118 S.Ct. 1708 (citing Rochin v. California, 342 U.S. 165,

172-73, 72 S.Ct. 205, 96 L.Ed. 183 (1952)). Having found that Plaintiff has failed to

establish that any of the individual Defendants’ conduct amounted to deliberate indifference,

a ‘shocks the conscience’ claim against any of them must fail as a matter of law. 

The Court acknowledges that the instant circumstances are well beyond the realm of

unfortunate. It is without any question, far beyond the normal course of nature for a parent

to cope with her own child’s death. However, it is both the role and the duty of this Court

to base it’s decisions strictly on the law. In the instant matter, none of the Defendants had

the requisite state of mind to satisfy the subjective component of the deliberate indifference

standard set forth by the United Stated Supreme Court and the Ninth Circuit Court of

Appeals. Furthermore, Plaintiff was unable to satisfy the Ninth Circuit’s causation

requirement for any and all individual defendants in 42 U.S.C. § 1983 civil rights actions.

Accordingly, the Defendants are entitled to summary judgment in their favor on all claims

alleged under the Eighth Amendment on behalf of Aaron and Plaintiff and all claims alleged

under the Fourteenth Amendment on behalf of Aaron. 

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36 Although the Court does not “elect to break new legal ground,” the Court does find

said response to lack any substance whatsoever. Plaintiff’s counsel presumes that this Court

is responsible for (1) briefing the issue for Plaintiff, including the relevant law and factual

analysis necessary to determine the outcome or (2) deciding the issue without adequate

briefing. Such bare allegations and presumptuous expectations do not reach the standard that

is acceptable to this Court. 

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C. Barbara Patterson’s Fourteenth Amendment Claim

Patterson alleges that the conduct of the Defendants “violated (her) rights under the

Fourteenth Amendment to a continued familial relationship” with Aaron. Defendants argue

that Patterson’s claim should be dismissed because relief for a claim such as this “should be

limited to situations in which the child involved is a minor.” Plaintiff’s response, in its

entirety, consists of the following36: 

Defendants also seek dismissal of Ms. Patterson’s personal claim under the

14th Amendment. As Defendants have acknowledged, this Court is bound by

the Ninth Circuit authority to the contrary. Therefore, Plaintiff will not address

the merits of the argument. Should the Court elect to break new legal ground,

Plaintiff requests the opportunity to brief the merits.

“It is well established that a parent has a fundamental liberty interest in the

companionship and society of his or her child and that the state's interference with that liberty

interest without due process of law is remediable under 42 U.S.C. § 1983.” Lee v. City of

Los Angeles, 250 F.3d 668, 685 (9th Cir.2001) (citation, alterations, and internal quotation

marks omitted). However, for the same reasons that Plaintiff’s Eighth Amendment deliberate

indifference claims fail, her due process claims must also fail. “[L]iability for negligently

inflicted harm is categorically beneath the threshold of constitutional due process.” County

of Sacramento v. Lewis, 523 U.S. 833, 849(1998)(citations omitted)(emphasis added);

Daniels v. Williams, 474 U.S. 327 (1986)(The Supreme Court ruled that the “Due Process

Clause is simply not implicated by a negligent act of an official causing unintended loss of

or injury to life, liberty or property.” A due process claim requires a showing of more than

negligence. Toguchi v. Chung, 391 F.3d 1051, 1060 (9th Cir. 2004)(emphasis added). The

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Court finds that Plaintiff has failed to satisfy the necessary threshold to establish a Fourteenth

Amendment due process claim based upon the violation of a parent's liberty interest in the

companionship of her child. Defendants are entitled to summary judgment in their favor as

to Patterson’s Fourteenth Amendment Claim.

Accordingly,

IT IS HEREBY ORDERED GRANTING Summary Judgment on all claims in favor

of Jesus Gutierrez. (Doc. 71.)

IT IS FURTHER ORDERED GRANTING Summary Judgment on all claims in favor

of Defendants Matthew Shaw, Gavino Lechuga, John McClaine, and Ronald Carlson. (Doc.

72.)

DATED this 21st day of September, 2009.

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