Opinion ID: 170853
Heading Depth: 5
Heading Rank: 1

Heading: Failure to supply a qualified medical provider

Text: Plaintiffs have not shown how any individual officer or nurse failed to supply a qualified medical provider to Boyett. As a preliminary matter, there is no per se requirement that a jail provide its inmates around-the-clock access to a medical doctor. While jailers are ultimately responsible for their inmates’ medical needs, Farmer v. Brennan, 511 U.S. at 833–34, they can provide that care in a variety of ways, including access to trained personnel such as guards in the first instance, nurses, and physicians’ assistants. The Eighth Amendment requires nothing more as a general matter. See, e.g., Hoptowit v. Ray, 682 F.2d 1237, 1253 (9th Cir. 1982) (en banc) (reversing lower court’s order that a penitentiary must hire two medical doctors to meet minimum standards of prison medical care under the Eighth Amendment); McCord v. Maggio, 910 F.2d 1248, 1250 (5th Cir. 1990) (noting state prison officials retain “wide discretion in the operation of prison facilities”). While access to a medical doctor may be necessary in certain situations, e.g., Sealock, 218 F.3d at 1210–11, no constitutional violation occurs unless medical care is intentionally or recklessly denied. E.g., Estelle, 429 U.S. at 104–05 (discussing prison guards “intentionally denying or delaying access to medical care or intentionally interfering with the treatment once prescribed”). Here, Washington County supplied qualified nurses, a licensed clinical social worker, and a licensed physician’s assistant to provide immediate medical -12- care to inmates. All of these individuals acted in accordance with the dictates of the Eighth Amendment by promptly and diligently assessing Boyett’s medical condition and taking reasonable steps in light of their evaluations. The record is replete with examples of correctional officers notifying the nursing staff about Boyett’s medical needs in a timely manner. Those nurses promptly responded to the calls and treated Boyett in a professional way. Physician’s Assistant Steele and Licensed Clinical Social Worker Worlton also supplied timely medical care to Boyett. In fact, over a six-day period (August 31 to September 5), Boyett was examined by at least six different staffers with medical training on no less than eight separate occasions. These officials conducted examinations, treated wounds, and administered medications based on their diagnoses. In short, Plaintiffs have not demonstrated the existence of a genuine issue of material fact pointing to deliberate indifference by any Defendant in failing to provide a qualified medical provider to Boyett. b. Failure to provide the medicine and care prescribed by Boyett’s treating physicians prior to incarceration Plaintiffs contend the decision by Washington County officials to take away Boyett’s prescription Methadone when he entered the facility violated his rights. 3 Boyett’s doctor had prescribed the Methadone to treat his alcohol 3 Boyett was also taking Celexa and Xanax before he entered the Washington County facility. Plaintiffs have failed to show whether these were prescribed by Boyett’s doctor and, if so, whether they were taken away by (continued...) -13- withdrawal symptoms, but because Methadone is a narcotic, he was not allowed to keep it in the jail. To replace the Methadone, Physician’s Assistant Steele prescribed 0.1 mg of Clonidine to be taken twice daily. Steele’s prescription of substitute medication for Boyett does not demonstrate deliberate indifference. See Callahan v. Poppell, 471 F.3d 1155, 1160 (10th Cir. 2006) (“[A] prison doctor remains free to exercise his or her independent professional judgment and an inmate is not entitled to any particular course of treatment.” (quoting Dulany v. Carnahan, 132 F.3d 1234, 1240 (8th Cir. 1997))); Perkins v. Kansas Dep’t of Corrs., 165 F.3d 803, 811 (10th Cir. 1999) (“[A] prisoner who merely disagrees with a diagnosis or a prescribed course of treatment does not state a constitutional violation.”). Plaintiffs also complain officials inadequately treated Boyett’s hernia repair. On August 20, Boyett’s outside doctor told Washington County officials Boyett had undergone surgery to repair a hernia about one month before entering the facility. Boyett also informed officers and nurses of this fact. When Physician’s Assistant Steele conducted a physical examination of Boyett on September 1, she determined he was healed. Even if we assume the diagnosis was both negligent and harmful, Steele’s conduct would not rise to the level of a constitutional violation because there is no evidence she acted with the requisite 3 (...continued) Washington County officials. Plaintiffs have therefore waived review of any claim with regard to these drugs. -14- culpable state of mind. See Farmer, 511 U.S. at 835 (“[D]eliberate indifference describes a state of mind more blameworthy than negligence.”). Plaintiffs have failed to put forth evidence Steele knew of “a substantial risk of serious harm,” and “consciously disregard[ed]” it. Self, 439 F.3d at 1231. c. Failure to respond to symptoms and complaints regarding internal bleeding On August 31, at 12:49 p.m., Boyett told Officer Pitcher he thought he was bleeding internally. Pitcher alerted Nurse McKinnon, but neither McKinnon nor any other nurse responded. Three hours later, Boyett told Officer Ence he thought he was hemorrhaging. Soon thereafter, Nurses McKinnon and Hanson responded and Boyett told them he was going comatose and had spit-up blood. After conducting a thorough examination of Boyett, McKinnon and Hanson concluded Boyett was not lapsing into a coma or suffering from internal bleeding. The nurses instructed Boyett to drink six to eight glasses of water per day. Although the three-hour delay in responding to Boyett’s claims of internal bleeding is troubling, it does not constitute deliberate indifference to a serious medical need because the delay caused Boyett no harm. “[D]elay in medical care can only constitute an Eighth Amendment violation if there has been deliberate indifference which results in substantial harm.” Olson v. Stotts, 9 F.3d 1475, 1477 (10th Cir. 1993) (quotation omitted); see also Mata, 427 F.3d at 753 (noting prisoner’s injury must be “sufficiently serious” to constitute deliberate -15- indifference). Boyett was not experiencing internal bleeding or any other medical problem at that time. The autopsy performed after Boyett’s death showed no evidence of internal bleeding or related ailments arising from this incident. d. Failure to respond to falls and seizures on September 3 In treating Boyett after his fall on September 3, Washington County officials did not violate Boyett’s constitutional rights. Nurse McCoy evaluated Boyett soon after the fall and did not discover any serious injuries. Officer Keil, who was also on the scene, did not notice any bleeding or other injuries. Because officials thought the fall was due to a seizure or other medical condition, they transferred Boyett to a medical observation cell for continued monitoring. After Boyett was moved to the observation cell, nurses determined no additional treatment was necessary. The Purgatory staffers’ considered medical judgments did not violate Boyett’s constitutional rights. No Eighth Amendment violation can arise from a situation where “a doctor merely exercises his considered medical judgment” and “resolves the question whether additional diagnostic techniques or forms of treatment” are required. Self, 439 F.3d at 1232; see also Estelle v. Gamble, 429 U.S. 97, 107 (1976) (“A medical decision not to order an X-ray, or like measures, does not represent cruel and unusual punishment. At most it is medical malpractice and as such the proper forum is the state court.”). None of the officials involved in the decisions to move Boyett to a special cell and refrain -16- from pursuing additional treatment evidenced deliberate indifference to his medical needs. Indeed, the decision to move Boyett to a medical observation cell evidenced concern for—not deliberate indifference to—Boyett’s health and wellbeing. e. Failure to treat Boyett’s head laceration Officers Kounalis and Redford observed Boyett’s head laceration the evening of September 5. The laceration likely stemmed from Boyett banging his head against the door of his cell during the prior day’s swing shift (3:00 p.m. – 11:00 p.m.). Nurse Hanson treated Boyett’s laceration by washing it with clean water, and determining sutures were not needed. Social worker Worlton also evaluated Boyett at that time, and determined Boyett appeared psychotic and should be given antipsychotic medication. Although the Plaintiffs now complain Boyett should have been treated by a doctor or given sutures for his head injury, these post-hoc opinions do not prove Hanson and Worlton violated the Constitution. Because the injury was not so serious that “even a lay person would easily recognize the necessity for a doctor’s attention,” Sealock, 218 F.3d at 1209, Hanson and Worlton were not reckless in their treatment. Hanson made an on-the-spot determination that the laceration did not require sutures. “[T]he subjective component [of deliberate indifference] is not satisfied, absent an extraordinary degree of neglect, where a [prison] doctor merely exercises his considered medical judgment.” Self, 439 F.3d at 1232. -17- f. Improper injection of antipsychotic medication The prison’s use of the antipsychotic drug Thorazine did not violate Boyett’s constitutional rights. Washington County officials injected Boyett with this antipsychotic on three occasions. Nurse Hanson administered the first 100 mg injection on September 4, after Hanson concluded Boyett appeared dangerous. Hanson administered a second 100 mg dose on September 5 after he and Worlton jointly determined Boyett appeared psychotic and was a danger to himself and others. Nurse Hummer gave Boyett a third 100 mg injection of Thorazine a few hours later on the evening of September 5. Each of the three Thorazine injections were made pursuant to a doctor’s standing order. While the standing order is not part of the record, Nurse Hummer testified as to the policy’s contours. According to Hummer, Purgatory medical staff had a standing order to inject an inmate with Thorazine when the following three conditions were met: (1) the inmate was dangerous or threatening; (2) injecting Thorazine was the best alternative available; and (3) an individualized assessment of the inmate’s medical history weighed in favor of Thorazine treatment. R., Vol. 2 at 524. The Thorazine policy exists primarily to prevent inmates from harming themselves. The policy provides Washington County officials the ability to quickly respond to a dangerous situation, and is administered under the supervision of medical personnel and only given to inmates showing signs of serious mental disturbance. -18- That the policy allows Thorazine to be administered without inmate consent does not by itself present a constitutional problem. First of all, the record does not suggest that Boyett objected to the drug treatment or that it was administered against his will. Moreover, as the Supreme Court has held, “given the requirements of the prison environment, the Due Process Clause permits the State to treat a prison inmate who has a serious mental illness with antipsychotic drugs against his will, if the inmate is dangerous to himself or others and the treatment is in the inmate’s medical interest.” Washington v. Harper, 494 U.S. 210, 227 (1990). This makes good sense, for where an inmate is a danger to himself or others, an involuntary medication policy may be considerably more humane than a policy disallowing the practice altogether. 4 Prison officials have a duty to care for their inmate population, and using antipsychotic medications is an appropriate medical response in certain situations. Cf. Hogan v. Carter, 85 F.3d 1113, 1118 (4th Cir. 1996) (concluding medical personnel, “acting in accordance with sound medical judgment and with the prisoner’s best interests in mind,” may order an emergency injection of Thorazine); Harper, 494 U.S. at 231 (“Though it cannot be 4 We note that if prison officials had not given Boyett the Thorazine injections after witnessing his self-destructive behavior, Plaintiffs may have alleged Defendants were deliberately indifferent in failing to protect Boyett from himself. See Hogan v. Carter, 85 F.3d 1113, 1118 (4th Cir. 1996) (concluding if prison doctor “had not ordered the single dose of Thorazine” to mentally deteriorating prisoner “it is not unlikely that [doctor] would now be facing a lawsuit by [prisoner] claiming that he was deliberately indifferent to his serious medical needs”). -19- doubted that the decision to medicate has societal and legal implications, the Constitution does not prohibit the State from permitting medical personnel to make the decision under fair procedural mechanisms.”). The jail’s Thorazine policy alone does not demonstrate deliberate indifference. Although Plaintiffs argue a medical doctor should have made the Thorazine decision, they have not shown how this is constitutionally compelled. As we have noted, a prison need not have physicians on site around-the-clock. See Hoptowit, 682 F.2d at 1253; Perkins, 165 F.3d at 811. It is enough that a prison make medical personnel, including doctors, available to help with ongoing medical needs, or meet emergencies. In light of this reality, Washington County’s policy provides for prompt action by on-site medical staff, including nurses, licensed clinical social workers, and physicians’ assistants. Other medical personnel, including doctors, are available as necessary. See R., Vol. 5 at 1481 (Physician’s Assistant Steele testifying her supervising doctor “was available by phone twentyfour hours a day if I had a question”). Nor do we see a constitutional violation based on the manner in which the Thorazine was administered. Boyett’s three Thorazine injections were given in accordance with the standing order, which required (1) a determination of dangerousness, (2) Thorazine being the best course of action, and (3) an individualized assessment of the inmate. There is no dispute Nurse Hanson administered the first injection after determining Boyett posed a danger to himself. -20- It also appears Hanson determined Thorazine was the best method of treatment and an individualized assessment of Boyett’s medical history weighed in favor of Thorazine treatment. Although strapping Boyett down to a bed or engaging in some other treatment may also have been helpful, there is no indication Thorazine was not the best treatment option. 5 The second and third injections also complied with the policy. The second Thorazine injection was given by Nurse Hanson on September 5. This injection came after consultation with Licensed Clinical Social Worker Worlton. Worlton had spoken with Boyett’s wife regarding Boyett’s medical history and consulted Boyett’s medical charts before determining Thorazine was the best course of treatment. Nurse Hummer gave Boyett a third shot of Thorazine later that night. Plaintiffs point to no record evidence sufficient to carry their burden of showing Nurse Hummer ran afoul of the standing order. Again, nothing in the record suggests that Boyett objected to any of the injections. Thorazine is used in institutional settings and accepted by mentally 5 See Steven K. Erickson, The Myth of Mental Disorder: Transsubstantive Behavior and Taxometric Psychiatry, 41 Akron L. Rev. 67, 101–02 (2008) (describing “[t]he introduction of Thorazine” as “monumental to psychiatry” because “it brought hope to the severely mentally ill in a manner that was manifestly obvious”); Thomas G. Gutheil, M.D. and Paul S. Appelbaum, M.D., “Mind Control,” “Synthetic Sanity,” “Artificial Competence,” and Genuine Confusion: Legally Relevant Effects of Antipsychotic Medication, 12 Hofstra L. Rev. 77, 93–97 (Fall 1983) (noting cases in which a defendant was given Thorazine to regain cognitive functionality, sanity, and/or competency to stand trial). -21- unstable individuals in precisely Boyett’s circumstances. In fact, Plaintiffs concede that, at least for the third treatment, “Boyett was not offensive or combative, and in fact, he complied with the order of the jailers to sit still and allow himself to be injected.” Aplt. Br. 22–23. In sum, Plaintiffs have not shown how Washington County’s antipsychotic injections policy or the injections in this case evidenced deliberate indifference to Boyett’s medical needs. Plaintiffs have pointed to nothing in the record suggesting Boyett objected to the medication or that the nurses unreasonably believed that Thorazine was an inappropriate means of addressing Boyett’s indications of mental illness. g. Failure to prevent Boyett’s death Finally, Plaintiffs contend prison officials deliberately failed to prevent Boyett’s death. Purgatory officials found Boyett dead in his cell on the morning of September 6. We have outlined above the steps taken by prison officials to address Boyett’s medical ailments and complaints during the preceding week. On this record, it is obvious jail officials responded reasonably to Boyett’s medical condition prior to his death, and therefore did not violate Boyett’s constitutional rights. “[P]rison officials who act reasonably cannot be found liable under the Cruel and Unusual Punishments Clause.” Farmer, 511 U.S. at 844–45. Dr. Leis, the medical examiner, concluded Boyett died of occlusive coronary artery disease. There is no reason to believe any prison official should have been -22- aware of this medical risk. Boyett had not documented the disease on his medical history paperwork, nor had he shown any symptoms of the disease before he died. Even if Boyett’s other medical conditions somehow contributed to his death, Plaintiffs point to no evidence in the record that prison officials: (1) recklessly misdiagnosed or ignored medical problems; (2) delayed providing medical treatment; or (3) denied altogether access to medical personnel or medication. See Self, 439 F.3d at 1232; Mata, 427 F.3d at 753. While Plaintiffs ask us to surmise Boyett was not treated after a cell room assault perpetuated by either prison officials or other inmates, there is no evidence of an assault or that prison officials were aware of these injuries and failed to treat them.