Opinion ID: 808047
Heading Depth: 3
Heading Rank: 1

Heading: sufficiency of evidence as to policy or custom

Text: To show that the government denied him medical care in violation of his Eighth Amendment rights, a prisoner must show an objectively serious medical need and show that “the prison official’s response to that need was poor enough to constitute an unnecessary and wanton infliction of pain.” Bingham v. Thomas, 654 F.3d 1171, 1176 (11th Cir. 2011) (per curiam) (internal quotation marks omitted). A medical need is 16 Case: 11-14594 Date Filed: 09/06/2012 Page: 17 of 28 serious if it “has been diagnosed by a physician as mandating treatment or one that is so obvious that even a lay person would easily recognize the necessity for a doctor’s attention.” Farrow v. West, 320 F.3d 1235, 1243 (11th Cir. 2003). The prisoner must additionally demonstrate that the prison official or municipality acted with deliberate indifference. See Taylor v. Adams, 221 F.3d 1254, 1258 (11th Cir. 2000). As noted above, a municipality or entity like Prison Health is liable only where its custom or policy causes the constitutional injury. See AFL-CIO v. City of Miami, 637 F.3d 1178, 1187 (11th Cir. 2011). “When a municipal policy itself violates federal law . . . resolving issues of fault and causation is straightforward.” Id. (internal quotation marks omitted). But, if the policy or custom is facially lawful, “the plaintiff must establish that the municipal action was taken with deliberate indifference as to its known or obvious consequences.” Id. Prison Health does not dispute that Mr. Fields had a serious medical need. Instead, Prison Health contends that Mr. Fields offered insufficient evidence to show that it had a policy or custom (1) that was deliberately indifferent to Mr. Fields’ medical needs, and (2) that violated Mr. Fields’ constitutional rights. After a review of the trial transcript and the exhibits, we disagree and conclude that the jury “reasonably could have resolved the matter the way it did.” Rodriguez, 518 F.3d at 1264. Prison Health is a private entity that provides medical services to prisoners in 17 Case: 11-14594 Date Filed: 09/06/2012 Page: 18 of 28 Lee County’s place, and so it can be held liable only if it had a “custom or policy that constituted deliberate indifference to [a] constitutional right.” McDowell, 392 F.3d at 1289. “A policy is a decision that is officially adopted by the municipality, or created by an official of such rank that he or she could be said to be acting on behalf of the municipality.” Goebert v. Lee Cnty., 510 F.3d 1312, 1332 (11th Cir. 2007). A policy may be deliberately indifferent if it is facially unconstitutional or where the policy is implemented with “deliberate indifference as to its known or obvious consequences.” McDowell, 392 F.3d at 1291. We have repeatedly held that “deliberate indifference” includes “the delay of treatment for obviously serious conditions where it is apparent that delay would detrimentally exacerbate the medical problem,” where “the delay does seriously exacerbate the medical problem,” and where “the delay is medically unjustified.” Harper v. Lawrence Cnty., 592 F.3d 1227, 1235 (11th Cir. 2010) (quoting Taylor, 221 F.3d at 1259–60). A delay of even hours may be deliberately indifferent given the “reason for the delay and the nature of the medical need.” McElligott v. Foley, 182 F.3d 1248, 1255 (11th Cir. 1999). The evidence at trial supports the jury’s determination that Prison Health had a policy that delayed treatment of serious medical problems. Both Ms. Allen and Prison Health’s corporate representative testified that Prison Health did not allow nurses or physician’s assistants to send inmates to hospitals, except 18 Case: 11-14594 Date Filed: 09/06/2012 Page: 19 of 28 in emergencies. See R. Vol. 8:118 at 70, 187. Prison Health’s representative defined “emergency” as a critical injury or life-threatening injury or illness, but the definition was not communicated to the medical staff, and the jury could have reasonably found that Ms. Allen and the rest of the staff defined “emergency” much more narrowly. According to Ms. Allen, under Prison Health’s definition, the word “emergency” was restricted to a life-or-death situation. Except for those life-or-death situations, it was for a doctor to send an inmate to the hospital. See R. Vol. 8:118 at 71. Given the failure of Prison Health to introduce its policy manual, the jury could have accepted Ms. Allen’s more-restrictive definition of emergency as the operative one. The evidence at trial, moreover, supports Ms. Allen’s definition over the corporate representative’s. The nurse’s reaction on the night that Mr. Fields hit the emergency button hundreds of time and the refusal of over a dozen Prison Health medical staff members to do anything in response to Mr. Fields’ pleas for help indicate that “emergency” meant only a life-or-death situation. After all, the nurse told Mr. Fields that he would have to wait until a doctor saw him, and the staff members who later saw Mr. Fields or heard his pleas for help did absolutely nothing. Critically, Ms. Allen further testified that the norm at Prison Health was to put inmates with partial paralysis in an observation room and wait for a doctor to see them. It is, in fact, what she had done the previous times that she had come across partially paralyzed inmates. See R. 19 Case: 11-14594 Date Filed: 09/06/2012 Page: 20 of 28 Vol. 8:118 at 86–87. And, as noted earlier, Prison Health never introduced a manual or policy guide at trial that described any other policy. Nor did Prison Health introduce anything in writing defining “emergency.” Despite not being a life-or-death situation, Mr. Fields’ situation undoubtedly constituted a serious medical need under the Constitution. For Eighth Amendment purposes, the “medical need of the prisoner need not be life threatening.” Washington v. Dugger, 860 F.2d 1018, 1021 (11th Cir. 1989). Accord Gayton v. McCoy, 593 F.3d 610, 620 (7th Cir. 2010) (“A medical condition need not be life threatening to be serious; rather, it could be a condition that would result in further significant injury or unnecessary and wanton infliction of pain if not treated.”). Thus, we have recognized that injuries like fractured hips and broken feet—which are unlikely to cause death and are far less serious than paralysis—constitute “serious medical needs.” See Brown v. Hughes, 894 F.2d 1533, 1538 (11th Cir. 1990) (per curiam); Mandel v. Doe, 888 F.2d 783, 790 (11th Cir. 1989). Constitutionally, paralysis is a serious medical need; medically, paralysis is a serious emergency. At trial, the doctors testified without contradiction that any form of paralysis, partial or total, or weakness of the legs constituted a medical emergency. Mr. Fields’ lack of reaction after being hit with a reflex hammer, Dr. Dominguez explained, was an emergency. See R. Vol. 8:118 at 161. And the doctors testified that delay in treatment 20 Case: 11-14594 Date Filed: 09/06/2012 Page: 21 of 28 would “detrimentally exacerbate” Mr. Fields’ medical problems. Treatment within 24 hours was critical to anyone in Mr. Fields’ situation. Plus, anyone with any medical training (and for that matter anyone without any medical training) should have realized that Mr. Fields’ paralysis required transportation to a hospital. See R. Vol. 8:118 at 34. Given Prison Health’s extremely narrow definition of “emergency,” and given the testimony presented at trial, the jury could reasonably conclude that Prison Health had a policy that improperly delayed treatment of serious medical needs, like paralysis, where such delay would detrimentally exacerbate an inmate’s condition. The jury could also have reasonably concluded that the delay here was medically unjustified. The doctors at trial testified that no medical justification existed for not sending Mr. Fields to a hospital and that any person with medical training would have known that Mr. Fields required medical help. See R. Vol. 7:117 at 111; R. Vol. 8:118 at 13–14, 24. And paralysis is such an uncommon, serious, and traumatic event that even someone without any medical training would have recognized the situation as requiring immediate care by a doctor. See Simmons v. Cook, 154 F.3d 805, 808 (8th Cir. 1998) (noting that being wheelchair bound is a serious medical need to which even laymen are aware); Blackmore v. Kalamazoo Cnty., 390 F.3d 890, 897 (6th Cir. 2004) (quoting Taylor v. Franklin Cnty., 104 F. App’x 531, 538 (6th Cir. 2004)) (“Such obvious signs of reoccurring incontinence and debilitating immobility were clear 21 Case: 11-14594 Date Filed: 09/06/2012 Page: 22 of 28 symptoms of a serious problem, even if Defendants did not choose to believe Plaintiff.”)). Mr. Fields’ objectively verified inability to walk, lack of reflexes, and incontinence so alarmed his fellow inmates that they begged Ms. Allen to take Mr. Fields to the hospital. Yet over a dozen Prison Health nurses ignored Mr. Fields’ pleas. Mr. Fields also testified that Mr. Richards examined his reflexes and sensation—just like Dr. Dominguez did—with a similar result. See R. Vol. 9:119 at 51–52. But, unlike Dr. Dominguez, Mr. Richards did nothing except give Mr. Fields Tylenol. Mr. Richards acknowledged that trauma, tumors, and spinal compression would cause partial paralysis—all of which are weighty medical problems. See R. Vol. 8:118 at 129. A reasonable jury could have concluded that no medical justification explained the delay. The evidence, in sum, sufficed to permit a finding of deliberate indifference: “[I]f necessary medical treatment has been delayed for non-medical reasons, a case of deliberate indifference has been made out.” Ancata, 769 F.2d at 704. See also Brown, 894 F.2d at 1538 (“[A]n unexplained delay of hours in treating a serious injury states a prima facie case of deliberate indifference.”). Plus, if the jury did ask itself why Prison Health delayed treatment for Mr. Fields’ paralysis, it could have concluded that it delayed treatment to save costs. Ms. Allen noted that the Prison Health supervisors yelled at nurses because the nurses sent inmates 22 Case: 11-14594 Date Filed: 09/06/2012 Page: 23 of 28 to hospital. See R. Vol. 8: 118 at 65. Although Ms. Allen mentioned that some nurses sent inmates to hospitals when the inmates had no medical problems—testimony, by the way, that the jury was free to reject given its lack of corroboration4—she also said that Prison Health underscored that it cost “so much money” every time an inmate went to the hospital. R. Vol. 8:118 at 70. Apparently, Ms. Allen heard this mantra from three different Prison Health supervisors. See R. Vol. 8:118 at 70–72. The jury could have thus concluded that Prison Health delayed treatment to save money, which is not a medical justification. Although an entity like Prison Health can generally include cost allocations in formulating its policies, see Craig v. Floyd Cnty., 643 F.3d 1306, 1312 (11th Cir. 2011), cost is not a factor which can justify the lack of timely medical treatment for something as serious as paralysis: “Lack of funds for facilities cannot justify an unconstitutional lack of competent medical care or treatment of inmates.” Ancata, 769 F.2d at 705. See also Anderson v. City of Atlanta, 778 F.2d 678, 688 n.14 (11th Cir. 1985) (noting that lack of funds cannot justify unconstitutional treatment of inmates). 4 Ms. Allen also testified that she acted properly because she did not believe Mr. Fields was really in medical trouble. But the jury was not required to believe this portion of her self-serving testimony. This is especially true because Ms. Allen requested that the corrections officers move Mr. Fields to the observation room. As the Seventh Circuit wrote about a similar case, “why put him in” an observation room “if this was all an act?” King v. Kramer, 680 F.3d 1013, 1019 (7th Cir. 2012). Ms. Allen further testified that she had placed partially paralyzed inmates in observation rooms before, and the jury could have found that this was how she dealt with such a serious medical problem. 23 Case: 11-14594 Date Filed: 09/06/2012 Page: 24 of 28 To hold Prison Health liable, Mr. Fields had to prove as well that Prison Health implemented its policy with “‘deliberate indifference’ as to [the policy’s] known or obvious consequences.” AFL-CIO, 637 F.3d at 1187. Three doctors testified that Mr. Fields faced dire consequences without timely medical treatment. Even Mr. Richards testified that only trauma, tumors, or compression to the spine, all of which are obvious dangers, would explain a healthy man’s inability to walk. Partial paralysis, according to the medical testimony, would be an obvious emergency that required at the very least an MRI. And yet Prison Health’s policy did not allow nurses to send inmates to hospitals in this very situation, as reflected not only by what happened to Mr. Fields but also by what Ms. Allen had done in prior cases of paralysis. Without prompt medical attention, the medical testimony indicated, the likelihood of paralysis skyrocketed. With this evidence, a jury could conclude that Prison Health implemented a policy while knowing that the policy would exacerbate inmate’s paralysis. Finally, a “plaintiff must prove causation by demonstrating that the municipality’s ‘deliberate conduct . . . was the “moving force” behind [his] injury.’” McDowell, 392 F.3d at 1292 (alterations in original) (emphasis omitted). See also Cuesta v. Sch. Bd. of Miami-Dade Cnty., 285 F.3d 962, 967 (11th Cir. 2002) (“A plaintiff must demonstrate a direct causal link between the municipal action and the deprivation of federal rights.”) (internal quotation marks omitted). Here, Mr. Fields had a serious medical need that 24 Case: 11-14594 Date Filed: 09/06/2012 Page: 25 of 28 Prison Health’s policy did not recognize as sufficient to warrant hospital care. And testimony at trial indicated that, had Prison Health sent Mr. Fields to the hospital earlier, paralysis could have been averted. A jury could therefore reasonably conclude that Prison Health’s policy restricting the transportation to hospitals of inmates with serious medical needs was a direct cause of Mr. Fields’ injuries.