Opinion ID: 215420
Heading Depth: 1
Heading Rank: 1

Heading: Deliberate IndifferenceEighth Amendment

Text: Although the panel majority discounts the importance of context with regard to VonWald's May 15 letter to the sentencing courtthat VonWald thought Schaub would remain on work release under the care of his own physiciansit claims for itself a pseudo context of facts and circumstances surrounding Schaub's return to full-time confinement and ADC-directed medical care upon loss of his employment. [19] But, even applying this pseudo context, I find the panel's analysis substantially wanting. The panel loosely weaves, evidence-wise, a tapestry adorned with factually and legally unsupportable breaches of duty and other transgressions by VonWald. Its panorama begins with VonWald becoming aware of Schaub's full-time return to the ADC on July 15. Although I do not disagree with the panel majority that Schaub had serious medical needs between July 15 and July 24needs Dr. Molella documented during her July 17 evaluationthere is little evidence to support the idea that VonWald personally became aware of or had a duty to become aware of such needs. For all VonWald knew, Schaub was returning to the ADC's work release program on July 15 after seventy-six days of recuperating from a broken leg and one edema-induced pressure sore. Nevertheless, the district court and the panel majority contend that VonWald had a duty, upon Schaub's return, to assume, as the Director of the ADC, immediate, personal, hands-on and continuing management of Schaub's medical treatment. For reasons outlined in more detail shortly, there is no precedent that supports the existence of such an Eighth Amendment duty based on the applicable facts and the ADC's routine course of operation. Additionally, assuming that VonWald was or should have become aware of Dr. Molella's July 17 evaluation of Schaub's condition, which noted his new, outside-acquired wounds and frailties, there is no precedent that required VonWaldwho had no reason to believe the highly trained ADC medical staff would fail or was failing to treat Schaubto pierce at least two levels of established subordinate supervision, Captain Sinner and Dr. Molella, to personally examine this particular prisoner's medical records and to then assume supervision management and responsibility for Schaub's serious medical needs. Even if, in the course of events, VonWald was negligent, or even grossly negligent, in carrying out his duties (which of course he was not) there is no Supreme Court or other federal court precedent that imposes such a constitutional requirement. To prevail on his Eighth Amendment deliberate indifference claim, Schaub bears the burden of proving that VonWald's mental state was akin to criminal recklessness: disregarding a known risk to the inmate's health. Vaughn v. Gray, 557 F.3d 904, 908 (8th Cir.2009) (quotation omitted). This rigorous standard is greater than gross negligence and VonWald may not be held liable unless he (1) recognized the existence of a substantial risk of harm to Schaub's health; and (2) knew that his conduct was inappropriate in light of that risk. Krout v. Goemmer, 583 F.3d 557, 567 (8th Cir.2009). But, supervisors such as VonWald cannot be held liable for an employee's unconstitutional actions under § 1983 on a theory of respondeat superior. Boyd v. Knox, 47 F.3d 966, 968 (8th Cir.1995). Rather, a supervisor incurs liability for an Eighth Amendment violation when the supervisor is personally involved in the violation or when the supervisor's corrective inaction constitutes deliberate indifference toward the violation. Id. Each step of the deliberate indifference inquiry is fact-intensive, and we review the district court's factual conclusions for clear error. Hartsfield v. Colburn, 491 F.3d 394, 397 (8th Cir.2007). Under clear error review, we may reverse the district court if its decision is not supported by substantial evidence, was based on an erroneous view of the law, or we are left with a firm conviction that a mistake has been made after reviewing the entire record. United States v. Fazio, 487 F.3d 646, 657 (8th Cir.2007). After reviewing the entire record, there is clearly a dearth of evidence regarding what VonWald knew, or was directly responsible for knowing, about Schaub's medical needs during the period at issue July 17 through July 24. As earlier noted, Schaub conceded at trial that he never (1) made any appeals to VonWald; (2) had any personal contact with VonWald during his confinement at the ADC; (3) requested special bedding accommodations beyond those provided by the ADC medical staff; or (4) requested to see a doctor between July 17 and July 24. Moreover, the evidence presented at trial shows that the ADC medical staff contacted VonWald just one time regarding Schaub's medical treatment between July 17 and July 24. On that occasion, VonWald approved Nurse Crandall's request for an outside agency to have access to Schaub. Simply put, between July 17 and July 24, there is no evidence that anyone notified VonWald that Schaub's bedding and wound-care needs were not being metnot Dr. Molella, not the ADC medical staff, not the ADC deputies, and not even Schaub. Absent such notice, there is certainly no basis for requiring the ADC director to essentially become a working member of the jail's medical unit. Despite the lack of evidence regarding VonWald's knowledge of Schaub's medical needs between July 17 and July 24, the panel majority charges VonWald with notice of such needs because (1) VonWald reviewed Dr. Stolp's April 7 letter; and (2) VonWald failed to make any inquires into Schaub's medical treatment between July 17 and July 24. Under established precedent, these facts are grossly insufficient to bridge the gap between the lack of evidence regarding VonWald's knowledge and the rigorous greater than gross negligence standard. It is not clear how Dr. Stolp's April 7 letter, written at a time when Schaub had one pressure sore, gave VonWald notice that Schaub would return to the ADC on July 15 with four pressure sores and a developing area of pressure on his sacral region. Similarly, it is not clear how Dr. Stolp's letter, written at a time when Schaub did not have access to the ADC medical staff and had not yet been provided with adaptive bedding accommodations, gave VonWald notice that the ADC medical staff could not meet Schaub's needs. Indeed, it was not until July 24 that Dr. Molella even became certain that the ADC medical staff could not meet Schaub's needs through adaptive measures and, at that point, she took the steps necessary to ensure that Schaub received treatment elsewhere. If it was not until July 24 that Dr. Molella, a Mayo Clinic physician, became certain that the ADC medical staff could not meet Schaub's needs through adaptive measures, it is not clear how VonWald, a non-medical prison official who had no contact with Schaub, could or should have known such information before that time. Th[e] [scienter] element of deliberate indifference must be viewed from [VonWald's] perspective at the time in question, not with hindsight's perfect vision. Jackson v. Everett, 140 F.3d 1149, 1152 (8th Cir.1998) (emphasis added). Also, in assuming that Dr. Stolp's April 7 letter sets forth the required course of treatment for Schaub between July 17 and July 24, the district court and the panel majority, without supporting medical evidence, improperly assume that the ADC medical staff's plan to meet Schaub's needs through adaptive measures was inappropriate under the circumstances. Ante at 915-16. While providing Schaub a pressure-relieving mattress may have represented the optimal course of treatment, [20] inmates are only entitled to adequate medical care, not the best care possible. Johnson v. Doughty, 433 F.3d 1001, 1013 (7th Cir.2006) (quotation omitted). Indeed, the Eighth Amendment does not require prisoners to receive unqualified access to health care, Hudson v. McMillian, 503 U.S. 1, 9, 112 S.Ct. 995, 117 L.Ed.2d 156 (1992), and prison doctors remain free to exercise their independent medical judgment. Dulany v. Carnahan, 132 F.3d 1234, 1239 (8th Cir.1997). While Dr. Stolp advocated a pressure-relieving mattress on April 7, Dr. Molella was not certain as of July 17 that a pressure-relieving mattress was the only way to adequately meet Schaub's medical needs. [21] This is significant because prison officials may be found free from liability if they responded reasonably to the risk, even if the harm ultimately was not averted. ... [And,] a showing of deliberate indifference ... requires more than mere disagreement with treatment decisions. Krout, 583 F.3d at 567 (quotations omitted). Under these circumstances, VonWald reasonably relied on the ADC's professional medical staff to accommodate Schaub. In an unconvincing attempt to impute the ADC medical staff's duties and knowledge of Schaub's condition between July 17 and July 24 to VonWald, the panel majority asserts that any inquiry into Schaub's treatment (or an examination of his medical file) would have revealed that his treatment was entirely insufficient. Ante at 918. This argument ignores the fact that, as discussed above, Schaub never made any appeals to VonWald and the ADC medical staff never told VonWald that Schaub's care, despite the implementation of an adaptive plan, was inadequate. The panel majority's notion thatabsent a reason to believe (or actual knowledge) that the ADC medical staff was mistreating SchaubVonWald had a legal duty to personally supervise Schaub's treatment between July 17 and July 24 ignores the division of labor present within correctional facilities. If a prisoner is under the care of medical experts ([Dr. Molella] in this case), a non-medical prison official will generally be justified in believing that the prisoner is in capable hands. This follows naturally from the division of labor within a prison. Inmate health and safety is promoted by dividing responsibility for various aspects of inmate life among guards, administrators, physicians, and so on. Holding a non-medical prison official liable in a case where a prisoner was under a physician's care would strain this division of labor. ... [A]bsent a reason to believe (or actual knowledge) that prison doctors or their assistants are mistreating (or not treating) a prisoner, a non-medical prison official like [VonWald] will not be chargeable with the Eighth Amendment scienter requirement of deliberate indifference. Spruill v. Gillis, 372 F.3d 218, 236 (3d Cir.2004); see also Johnson, 433 F.3d at 1010 n. 9. Surely, it was reasonable for VonWald, a non-medical prison official, to rely on a Mayo Clinic physician and the nurses she supervised to (1) meet Schaub's needs, and (2) notify him if such needs were not being met through adaptive measures between July 17 and July 24. The panel majority cites Langford v. Norris, 614 F.3d 445 (8th Cir.2010), to support its contention that VonWald had a duty to personally follow up with the ADC medical staff to determine whether Schaub's needs were in fact being met. But, Langford imposes no such duty under the facts of this case. Langford simply explains that  if [a supervisor] knew that [an inmate's] serious medical needs were not being adequately treated yet remained indifferent, he may be held personally liable. Id. at 460-61 (emphasis added). Here, unlike the supervisor in Langford, VonWald did not receive notice from Schaub (or anyone else) that the ADC medical staff was failing to meet Schaub's needs between July 17 and July 24. Cf. id. at 460-62 (holding that a supervisor who received inmates' complaints about receiving deficient medical care could be liable for his failure to ensure that the inmates received adequate treatment). Similarly, under the circumstances presented in this case, VonWald may not be held liable under a failure to supervise theory of liability. In Parrish v. Ball, 594 F.3d 993, 1002 (8th Cir.2010), we explained that to succeed on a failure to supervise theory under § 1983, the plaintiff must show that the supervisor: (1) [r]eceived notice of a pattern of unconstitutional acts committed by subordinates; (2) [d]emonstrated deliberate indifference to or tacit authorization of the offensive acts; (3) [f]ailed to take sufficient remedial action; and (4) [t]hat such failure proximately caused injury to [the plaintiff]. (emphasis added) (quotation omitted). Needless to say, there is no evidence that VonWald had any reason to believe the nursing staff would fail to bathe Schaub, change his dressings, or reposition him in bed. The panel majority recognizes that such treatment was well within the ken of the nursing staff, ante at 919, yet the majority faults VonWald for assuming, without follow-up, that the nursing staff would provide such care. In doing so, the panel ignores the fact that VonWald was entitled to rely on the ADC medical staff's professional training and ethical obligations to treat Schaub. Spruill, 372 F.3d at 236; cf. Connick v. Thompson, ___ U.S. ___, 131 S.Ct. 1350, 1363, ___ L.Ed.2d ___ (2011) (holding in the official liability context that a district attorney had no duty to train his prosecutors regarding the constitutional obligation at issue because [a] district attorney is entitled to rely on prosecutors' professional training and ethical obligations in the absence of specific reason, such as a pattern of violations, to believe that those tools are insufficient to prevent future constitutional violations). To be sure, VonWald knew that the nursing staff could not provide Schaub with a pressure-relieving mattress but the panel majority concedes the (non)provision of a pressure mattress was not the sine qua non of the Eighth Amendment violation found by the district court. Ante at 917 n. 5. The panel's requirements do not end there. Because, according to the majority, VonWald was untruthful with the sentencing judge about the quantity and quality of the ADC's medical capabilities and because he had the duty as director to become immediately aware of Schaub's serious medical needs, VonWald, not Schaub or his lawyer, had a duty to intercede sua sponte with Judge Williamson in support of Schaub being immediately placed on electronic-monitored home detention. Breach of the above-outlined duties, says the district court and the panel, constituted reckless indifference in violation of the Eighth Amendment. I very respectfully believe that this constitutes imagination unchecked. See, e.g., Michigan v. Bryant, ___ U.S. ___, 131 S.Ct. 1143, 1172, 179 L.Ed.2d 93 (2011) (Scalia, J., dissenting). I also disagree with the panel majority's conclusion that expert causation testimony was not required in this case because VonWald's deliberate indifference clearly exacerbated Schaub's wounds. Ante at 921. When an injury is sophisticated, proof of causation generally must be established by expert testimony. Robinson v. Hager, 292 F.3d 560, 564 (8th Cir.2002). Here, Schaub's failure to present any expert causation testimony is fatal to his claim because he clearly suffered from a sophisticated medical condition. Indeed, Dr. Molella testified at trial, without refutation by Schaub, that Schaub had very complicated health needs. Although the panel majority attempts to simplify Schaub's condition, causation in this case was simply not within the realm of lay understanding. Id. The total absence of any medical expert causation evidence makes it impossible to determine the extent of VonWald's damages liability, if any, for acts occurring between July 17 and July 24. And, the district court and the majority find no reckless indifference at any other time period. To be sure, the eggshell skull rulei.e., a tortfeasor takes his victim as he finds himapplies to a § 1983 case. Gibson v. County of Washoe, 290 F.3d 1175, 1193 (9th Cir.2002). However, the rule must not be applied in a way that obliterates the requirement that [a] defendant may be held liable only for the damages that [he] actually causes. Limone v. United States, 579 F.3d 79, 108 (1st Cir.2009). Indeed, notwithstanding the eggshell skull rule, a defendant ... is liable only for the extent to which the defendant's conduct has resulted in an aggravation of the pre-existing condition, and not for the condition as it was. Gibson, 290 F.3d at 1193 (emphasis added) (quotation omitted). A review of the district court's factual findings, the parties' stipulation of fact and other unrebutted portions of the record, highlights the evidentiary problems concerning causation. Without dispute, the first period of incarceration ended on April 29 when a fall at the ADC fractured Schaub's femur, resulting in a week's hospitalization. At that time, Schaub had one pressure sore on his left heel. The district court concluded that a deep thigh bruise resulted from Schaub's fall on April 29 and the bruise later developed into an open pressure sore on his ischial (lower buttock) region. Dr. Molella's July 17 evaluation indicated that Schaub returned to the ADC on July 15 with: (1) the previously undocumented 2.5 centimeter sore on his ischial region; (2) two (not one) separate ulcers on his left heel; (3) a new 2.5 centimeter sore on his right ankle bone; and (4) a new 4 × 5 centimeter area of pressure on his sacral region, which was appraised by Schaub's private physician on July 27 (three days after his discharge) as stage 1 (superficial). Moreover, at least two additional pressure sores developed after Schaub's final departure from the ADC. Against this evidentiary background, the district court and the panel majority assess damages against VonWald on the basis of Schaub's physical condition as it existed up to four years after he finally departed the ADC. This levy of damages includes the results of major surgery involving his fractured femur and the ischial region sore that developed from the thigh bruise that occurred at the time of the fracture. The district court specifically made no apportionment of physical damage that existed prior to July 17 or which was directly connected with the femur fracture of April 29 or incidents or medical care that occurred after July 24. The only causation testimony in any way related to the four-year period was Schaub's testimony concerning his health prior to incarceration and his view of the fateful eight-day period in July 2003. [22] Otherwise, the majority relies upon records kept by the ADC medical staff and testimony from Dr. Molella and three nurses that prove, it claims, that Schaub's wounds were exacerbated between July 17 through July 24. Exacerbated perhaps, but the record simply does not support the conclusion that this eight days of care was a sole proximate cause of every facet of damages Schaub allegedly incurred during the longer than four-year period at issue. VonWald had no responsibility for Schaub's femur fracture, or the heel sore that initiated during his original fifty-seven day stay. [23] Nor does the evidence support a finding that VonWald was responsible for the additional pressure sores Schaub brought along on July 15, or the surgery that developed from the leg fracture or the care that occurred while the two sores developed after July 24. [24] The panel majority cites Parrish, 594 F.3d 993, and Ricketts v. City of Columbia, 36 F.3d 775 (8th Cir.1994), as precedent for its unsupported conclusion that VonWald's deliberate indifference clearly caused Schaub's damages. Neither case supports the panel majority's position that specific causation evidence is not necessary in a case such as this. Indeed, both Parrish and Ricketts say only that if in a particular case relevant evidence of causation makes the issue free from doubt, the court may find causation as a matter of law, nothing more. Parrish, 594 F.3d at 1000 (quotation omitted); Ricketts, 36 F.3d at 779-80 (quotation omitted). Certainly, a finding of deliberate indifference does not come with self-executing proof of causation attached. With the naked statement that the care Schaub received from July 17 through July 24, exacerbated Schaub's wounds, ante at 921, the panel affirms the global damages imposed by the district court based upon an undifferentiated evaluation of Schaub's entire health travails extending from March 4, 2003, until at least four years later. Ante at 921. Without expert testimony, there is simply failure of proof. See Gibson v. Weber, 433 F.3d 642, 646 (8th Cir.2006) (holding that expert causation testimony was required to show that allegedly deficient treatment plan caused claimant's foot infection and subsequent amputation where the claimant's medical condition predisposed him to injuries of this nature and the foot wound worsened under claimant's own care).