Case Name: Ralph PARTRIDGE and Betty Partridge, Plaintiffs-Appellants, v. TWO UNKNOWN POLICE OFFICERS OF the CITY OF HOUSTON, TEXAS, et al., Defendants-Appellees
Court: United States Court of Appeals for the Fifth Circuit
Jurisdiction: United States
Decision Date: 1985-02-04
Citations: 751 F.2d 1448
Docket Number: No. 83-2615
Parties: Ralph PARTRIDGE and Betty Partridge, Plaintiffs-Appellants, v. TWO UNKNOWN POLICE OFFICERS OF the CITY OF HOUSTON, TEXAS, et al., Defendants-Appellees.
Judges: 
Reporter: Federal Reporter 2d Series
Volume: 751
Pages: 1448–1460

Head Matter:
Ralph PARTRIDGE and Betty Partridge, Plaintiffs-Appellants, v. TWO UNKNOWN POLICE OFFICERS OF the CITY OF HOUSTON, TEXAS, et al., Defendants-Appellees.
No. 83-2615.
United States Court of Appeals, Fifth Circuit.
Feb. 4, 1985.
E. Grady Jolly, Circuit Judge, filed dissenting opinion.
John P. Mustachio, Houston, Tex., for plaintiffs-appellants.
Mary Madigan Dinan, Asst. City Atty., Houston, Tex., for City of Houston and Houston Police.
D. Reid Walker, Houston, Tex., for Morris.
Before WISDOM, RANDALL and JOLLY, Circuit Judges.

Opinion:
WISDOM, Circuit Judge:
The question this case presents is whether the Eighth Amendment's prohibition against cruel and unusual punishment imposes a duty upon the state to protect prisoners (here detainees) from themselves. The parents of Michael Wayne Partridge brought suit under 42 U.S.C. § 1983 (1982) against the City of Houston, its police department, and various persons within the department after their son hanged himself in a solitary cell within a few hours of his arrest. The district court dismissed the suit under Fed.R.Civ.P. 12(b)(6) for failure to state a claim upon which relief could be granted. The Partridges appealed, claiming that their son's medical alert braclets, his aberrant behavior upon arrest, his record of an earlier attempted hanging, and his father's warning to the arresting and transporting officers that Michael was unstable should have alerted the jail's staff to their son's suicidal condition. The Partridges also alleged that inadequate training and staffing within the jail facility contributed to the jail staff's inattention to their son's suicidal behavior. Although the dismissal of the suit against James Morris, the transporting officer, was proper, we find that it was error to dismiss the claim and accordingly reverse.
I. FACTS AND PROCEEDINGS BELOW
The pleadings state the following facts. In February 1980, a Houston police officer arrested Michael Wayne Partridge on suspicion of burglary and theft. While the officer was investigating the scene of the alleged crime, Partridge became agitated and violent, and attempted to kick the doors and windows out of the car. The officer, who was working alone at the time, requested a two-man unit to transport Partridge to the jail. When the back-up unit arrived, Partridge was still kicking at the doors and windows. A sergeant at the scene asked Partridge's father if the boy had any "mental problems". Partridge's father told the officer that the boy had suffered a nervous breakdown.
The two transporting officers, one of whom was Morris, handcuffed Partridge and drove him to the jail. On the way to the jail, Partridge intentionally struck his head at least once against the plexiglass divider between the front and back seats. Morris was able to calm Partridge, and by the time they arrived at the jail, Partridge seemed composed. Neither of the two officers called anyone's attention to Partridge's aberrant behavior. Partridge was placed in solitary confinement. The jailor was unaware that Partridge's clinical record showed that Partridge had attempted suicide during an earlier confinement. The records were maintained four doors away from the booking desk. The jailor did see Partridge's two medical alert bracelets, and noted on Partridge's booking card "heart and mental". Three hours later Michael Partridge hanged himself.
The plaintiffs further alleged that suicide is a known risk at detention centers, that defendants knew or should have known of Partridge's suicidal tendencies, and that the defendants' policies and procedures inadequately protected detainees from the risk of suicide. The defendants filed a motion to dismiss under Fed.R.Civ.P. 12(b)(6) for failure to state a claim upon which relief could be granted, arguing that the complaint failed to allege unconstitutionally cruel and unusual conditions at the jail, and that the complaint failed to allege a legal deprivation or a pattern, practice, or policy that could have caused any deprivation.
Upon the defendants' motion to dismiss and the plaintiff's response, the district court held that the plaintiffs had failed to state a claim under the "deliberate indifference" standard of Estelle v. Gamble, 1976, 429 U.S. 97, 104, 97 S.Ct. 285, 291, 50 L.Ed.2d 251, 260. The court explained:
"In light of considerations established by the Court of Appeals for the Fifth Circuit in Woodall v. Foti, 648 F.2d 268 (5th Cir.1981), to determine whether the alleged denial amounts to deliberate indifference to the decedent's medical needs, it is the opinion of the Court that the plaintiffs' claim is insufficient to state a claim for relief under 42 U.S.C. 1983 (1976)."
This appeal followed.
II. DISCUSSION
A. The Standard of Review
The district court styled its action as a dismissal under Fed.R.Civ.P. 12(b)(6), although it stated in its dismissal that it had "reviewed the record". We therefore face at the outset the question of whether we should treat the court's action as in fact a grant of summary judgment. Carpenters Local v. Pratt-Farnsworth, 5 Cir.1982, 690 F.2d 489, 500 (Randall, J.), cert. denied, 1983, — U.S. -, 104 S.Ct. 335, 78 L.Ed.2d 305. (See also Carter v. Stanton, 1972, 405 U.S. 669, 671, 92 S.Ct. 1232, 1234, 31 L.Ed.2d 569, 572, in which, when the court considered matters outside the pleadings, a motion to dismiss was treated as a motion for summary judgment.) To the extent that the district court treated the motion to dismiss as a motion for summary judgment, we find that the ruling was premature. Such a motion is proper only if there are no matters open to factual dispute. In the present case, there are both material facts that are disputed and material facts that are unknown. The extent of Partridge's aberrant behavior during arrest and transport to the jail is uncertain. The record does not adequately reveal the jail's cell watch procedures and whether these procedures were followed. There is little discussion of policies at the jail or training of its staff. It is unclear if the jail took any precautions against suicide, such as removing an inmate's belt and shoelaces. Although we express no opinion on these issues or their relative weight, the failure to address them, together with the incomplete nature of the record before us and before the district court, makes summary judgment inappropriate.
To the extent that the district court confined itself to the pleadings, we treat the ruling as a response to a motion to dismiss under Fed.R.Civ.P. 12(b)(6). In reviewing such a dismissal, we may not go outside the pleadings. We accept all well pleaded facts as true and view them in the light most favorable to the plaintiff. Carpenters Local, 690 F.2d at 500. We cannot uphold the dismissal "unless it appears beyond doubt that the plaintiff can prove no set of facts in support of his claim which would entitle him to relief". Conley v. Gibson, 1957, 355 U.S. 41, 45-46, 78 S.Ct. 99, 101-02, 2 L.Ed.2d 80, 84; Cook & Nichol, Inc. v. Plimsoll Club, 5 Cir.1971, 451 F.2d 505, 506. Suicidal behavior evidences a serious medical need, and deliberate indifference to such behavior violates the Eighth Amendment's prohibition against cruel and unusual punishment. We find that the plaintiffs have alleged a cognizable claim under section 1983.
B. The Scope of Duty Under Section 1983
The Supreme Court has held that prison authorities have a duty under the Eighth Amendment to provide needed medical care for inmates, and that "deliberate indifference to serious medical needs of prisoners" violates the Constitution. Estelle v. Gamble, 1976, 429 U.S. 97, 104, 97 S.Ct. 285, 291, 50 L.Ed.2d 251, 260. Our Court has recently summarized the law on this point:
"The state has an 'obligation to provide medical care for those whom it is punishing by incarceration.' '[A]cts or omissions sufficiently harmful to evidence deliberate indifference to serious medical needs' of inmates constitute cruel and unusual punishment."
Ruiz v. Estelle, 5 Cir.1982, 679 F.2d 1115, 1149.
The defendants acknowledge that prison authorities have a constitutional duty to provide necessary medical care to inmates under Estelle, but contend that the duty does not extend to protecting inmates from themselves. We find, however, that the Eighth Amendment does reach some instances of deliberate self injury. This holding is consistent with the position taken by other courts of appeals and comports with our own precedents.
There is no sound underlying distinction between the right to medical care for physical ills and for psychological or psychiatric afflictions. See Woodall v. Foti, 5 Cir.1981, 648 F.2d 268, 272; Bowring v. Godwin, 4 Cir.1977, 551 F.2d 44, 47. Treatment of mentally disturbed inmates is a "serious medical need" under Estelle. Woodall, 648 F.2d at 272. The "deliberate indifference" standard of Estelle is therefore equally applicable to assessing the constitutional adequacy of treating psychological or psychiatric ailments at a prison.
Suicidal tendencies evidence a psychological or psychiatric condition that could be as serious as or more serious than any physical pathology or injury. And just as a failure to act to save a prisoner suffering from gangrene might constitute deliberate indifference, Bass v. Sullivan, 5 Cir. 1977, 550 F.2d 229, 231-32, cert. denied, 434 U.S. 864, 98 S.Ct. 195, 54 L.Ed.2d 138, failure to take any steps to save a suicidal prisoner from injuring himself may also constitute deliberate indifference to a serious medical need. Such indifference might be manifested by failure to search adequately a medically trained prisoner who had repeatedly threatened to smuggle poi son into jail or by failure to monitor adequately a prisoner who had twice before unsuccessfully attempted suicide.
Defendants contend that the state cannot be liable in a section 1983 action when the plaintiff died by his own hand rather than by the hand of another. We hold, however, that this distinction is not a bar to a section 1983 cause of action. In Scharfenberger v. Wingo, 6 Cir.1976, 542 F.2d 328, the plaintiff prisoner brought a section 1983 action alleging that he suffered two amputation operations to his right arm because he was injured by an injection with a drug provided by the prison's infirmary. The evidence was unclear whether the prisoner had injected himself or whether the injection had been made by one of the infirmary staff. The court held:
"Defendants expend considerable effort seeking to prove that Scharfenberger injured himself. We regard this issue as irrelevant because a prisoner's custodians cannot lawfully deny him adequate medical care even in instances of deliberate self injury."
Id. at 330.
Although Scharfenberger concerned the adequacy of treatment after the prisoner's arm began swelling rather than the propriety of injecting the substance into the inmate, subsequent courts have followed Scharfenberger to hold that liability under section 1983 "may be predicated upon inadequate custodial care of an inmate who might harm herself". Matje v. Leis, S.D. Ohio 1983, 571 F.Supp. 918, 930. Protecting inmates from themselves is "an aspect of the broader constitutional duty to provide medical care for inmates". Gugliel-moni v. Alexander, D.Conn.1984, 583 F.Supp. 821, 827.
Our own Court has not specifically addressed the question whether the Eighth Amendment in some instances protects prisoners who may harm themselves. In the closest case on point, Wright v. Wagner, 5 Cir.1981, 641 F.2d 239, the plaintiffs argued, after an inmate's suicide, that an alleged failure to comply with Tex.Rev.Civ. Stat.Ann. art. 5115 (Vernon Supp.1984) established as a matter of law a violation of the Eighth Amendment cognizable under section 1983. In affirming the district court's finding that there was no violation of article 5115, the Court intimated that an inmate's suicide could create section 1983 liability: "We think that a failure to place Mitchell in a padded cell or to otherwise deal with his violent behavior would not violate eighth amendment standards absent deliberate indifference to his condition and the likely consequences of that condition." Wright v. Wagner, 641 F.2d at 241-42 (emphasis added). Moreover, this Court has recently held that one .of the criteria for determining whether denial of psychiatric treatment for a prisoner violates the Eighth Amendment is "the extent to which the [mentally disturbed] prisoner presents a risk of danger to himself or other inmates". Woodall v. Foti, 5 Cir.1981, 648 F.2d 268, 272 (emphasis added). We now hold explicitly that deliberate indifference to a prisoner's suicidal behavior constitutes a violation of the Eighth Amendment under Estelle.
C. Assessing a Section 1983 Claim for Failure to Protect Against Self-Injury
A prisoner's or detainee's right under the Eighth Amendment to be protected from himself is not unlimited. The "deliberate indifference" standard is met only if there is a strong likelihood, rather than a mere possibility, that injury will occur.
First, a plaintiff must prove that deliberate indifference exists. Other courts have held, and we agree for present purposes, that deliberate indifference exists when action is not taken in the face of "a strong likelihood, rather than a mere possibility" that failure to provide care would result in harm to the prisoner. See State Bank v. Camic, 7 Cir.1983, 712 F.2d 1140, 1146, cert. denied, 1983, — U.S. -, 104 S.Ct. 491, 78 L.Ed.2d 686; Guglielmoni v. Alexander, D.Conn.1984, 583 F.Supp. 821, 826; Matje v. Leis, S.D.Ohio 1983, 571 F.Supp. 918, 930. As noted in Vun Cannon v. Breed, N.D.Cal.1975, 391 F.Supp. 1371, 1374-75, "a guard does not have to believe to a moral certainty that one inmate intends to attack another at a given place at a time certain before that officer is obligated to take steps to prevent such an assault. But, on the other hand, he must have more than a mere suspicion that an attack will occur."
A plaintiff might also show deliberate indifference by revealing a pattern of medical neglect. Although a delay or denial of medical care may be mere negligence, and thus not actionable under section 1983, repeated examples of such treatment would indicate a deliberate indifference by prison authorities. As the Second Circuit has held, "a series of incidents closely related in time . may disclose a pattern of conduct amounting to deliberate indifference to the medical needs of prisoners". Toda-ro v. Ward, 2 Cir.1977, 565 F.2d 48, 52.
The evaluation of medical care for inmates, however, is an area of special deference from the courts, for it is related to both prison administration and medical judgment, two areas where the courts have acknowledged their limited expertise. Procunier v. Martinez, 1974, 416 U.S. 396, 94 S.Ct. 1800, 40 L.Ed.2d 224; cf. Woodbury v. McKinnon, 5 Cir.1971, 447 F.2d 839. Mere negligence, neglect, dr medical malpractice is insufficient to state a claim for an Estelle violation. Fielder v. Bosshard, 5 Cir.1979, 590 F.2d 105. As this Court has recently held: "The Constitution does not command that inmates be given the kind of medical attention that judges would wish to have for themselves, nor the therapy that Medicare and Medicaid provide for the aged or the needy. It prohibits only 'deliberate indifference to serious medical needs'." Ruiz v. Estelle, 5 Cir.1982, 679 F.2d 1115, 1149, cert. denied, 1983, 460 U.S. 1042, 103 S.Ct. 1438, 75 L.Ed.2d 795.
D. Review of the Pleadings
Having established the standard to which the defendants must be held under Estelle, we return to the pleadings. The claim against Officer Morris, who transported Partridge to the jail, was properly dismissed under Rule 12(b)(6). The pleadings show, at worst, negligence. Morris's only offense was his failure to alert jail personnel to Partridge's aberrant behavior. This failure, without more, does not rise to the level of "deliberate indifference".
The pleadings against the remaining defendants present a different situation. The plaintiff alleged that the Houston Police had notice of Partridge's suicidal tendencies because of his aberrant behavior during his arrest and transport to the station, because of the warning in his wallet that he was under psychiatric care, because his father had informed the arresting officer that his son had suffered a nervous breakdown, and because the jail's records indicated that Partridge had attempted suicide during a detention just a few months before.
One means of establishing an Estelle claim is to prove state inaction in the face of a strong likelihood that harm will occur. Taken together, the allegations in the pleadings state a "strong likelihood" of harm sufficient to survive a motion to dismiss under 12(b)(6). It is also possible that the plaintiffs might be able to prove that the jailor's failure to consult the clinical records constituted "deliberate indifference".
Whether the defendants' failure to consult their medical records or to exercise special care in detaining Partridge given his aberrant behavior and the warnings constitute deliberate indifference are questions upon which we express no opinion. If the case reaches trial, these will be questions for the jury. We hold here merely that the pleadings allege a cause upon which relief might be granted. The district court's dismissal under Fed.R.Civ.P. 12(b)(6) is therefore REVERSED.
. There is no contention that the arrest was improper.
. The plaintiffs also claimed damages under the Texas Survival Statute and the Texas Wrongful Death Act.
. When the trial court considers matters outside the pleadings, the motion to dismiss must be treated as a motion for summary judgement, and the proceedings must comport with the hearing and notice requirements of Fed.R.Civ.P. 56(c). Underwood v. Hunter, 5 Cir.1979, 604 F.2d 367, 368, 369 (collecting cases).
. Pretrial detainees are often entitled to greater protection than convicted persons. See Bell v. Wolfish, 1979, 441 U.S. 520, 99 S.Ct. 1861, 60 L.Ed.2d 447; Jones v. Diamond, 5 Cir.1981, 636 F.2d 1364, 1368 ("The due process clause accords pretrial detainees rights not enjoyed by convicted inmates."). Although "[t]he standard by which to measure the medical attention that must be afforded pretrial detainees has never been spelled out," Jones v. Diamond, 636 F.2d at 1378, both this Circuit and other circuits have held that pretrial detainees are entitled to at least the level of medical care set forth in Estelle. See id.; Guglielmoni v. Alexander, D.Conn.1984, 583 F.Supp. 821; Matje v. Leis, S.D.Ohio 1983, 571 F.Supp. 918. We have been unable to find any case imposing a greater duty to provide medical care for pretrial detainees than for convicted persons, and decline to impose such an additional duty here.
. These examples are from cases in other circuits that have held that a prison is potentially liable for an inmate's suicide: Guglielmoni v. Alexander, D.Conn.1984, 583 F.Supp. 821, 826-27 (denying defendants' motion for summary judgment in suit alleging inadequate cell checking after victim had twice before attempted to kill himself); Matje v. Leis, S.D.Ohio 1983, 571 F.Supp. 918, 930-31 (denying defendants' motion for summary judgment after nurse committed suicide in county jail).
. Article 5115 outlines procedures for confinement of detainees suspected of insanity or who have been legally adjudged insane.