Court Opinion

ID: 9693809
Source: CourtListenerOpinion
Date Created: 2023-08-25 17:01:19.487279+00
Date Added: 2024-06-11T12:08:18.521232
License: Public Domain

FOR PUBLICATION

     UNITED STATES COURT OF APPEALS
          FOR THE NINTH CIRCUIT

SURIE ALEXANDER,                                  No. 22-55588

                 Plaintiff-Appellant,               D.C. No.
                                                 5:19-cv-01359-
    v.                                              DSF-SP

DAU V. NGUYEN, M.D., in his
individual capacity,                                OPINION

                 Defendant-Appellee.

         Appeal from the United States District Court
            for the Central District of California
          Dale S. Fischer, District Judge, Presiding

              Argued and Submitted June 5, 2023
                    Pasadena, California

                     Filed August 25, 2023

     Before: Milan D. Smith, Jr., David F. Hamilton, * and
              Daniel P. Collins, Circuit Judges.

             Opinion by Judge David F. Hamilton

*
 The Honorable David F. Hamilton, United States Circuit Judge for the
U.S. Court of Appeals for the Seventh Circuit, sitting by designation.
2                      ALEXANDER V. NGUYEN

                          SUMMARY **

        Pretrial Detainees/Substantive Due Process

    The panel affirmed, on the merits rather than based on
the defense of qualified immunity, the district court’s
summary judgment in favor of Dr. Dau Nguyen, a
psychiatrist at Patton State Hospital in California, in Surie
Alexander’s 42 U.S.C. § 1983 action alleging that he was
twice attacked by a fellow patient while he was a pretrial
detainee and a patient at the Hospital.
    Alexander sued Nguyen for injuries from the second
attack, alleging that Dr. Nguyen violated his Fourteenth
Amendment right to substantive due process. Alexander
argued that Dr. Nguyen denied him appropriate medical care
in violation of his Fourteenth Amendment rights under
Gordon v. County of Orange, 888 F.3d 1118 (9th Cir. 2018),
which requires a plaintiff to “prove more than negligence but
less than subjective intent—something akin to reckless
disregard,” while Dr. Nguyen argued that the proper inquiry
was whether Alexander was deprived of safe conditions
under Youngberg v. Romeo, 457 U.S. 307 (1982), which
requires a finding of conscious indifference amounting to
gross negligence.
    The panel determined that both tests ask whether Dr.
Nguyen’s conduct was reasonable, and both require
Alexander to show that Dr. Nguyen’s conduct was worse
than negligent. The panel held that under either test,
Alexander offered no evidence that Dr. Nguyen failed to act

**
  This summary constitutes no part of the opinion of the court. It has
been prepared by court staff for the convenience of the reader.
                    ALEXANDER V. NGUYEN                      3

reasonably, let alone that he was “more than negligent” in
not transferring Alexander or the other patient after the first
attack. Although Alexander was attacked a second time, the
evidence showed that Dr. Nguyen’s responses to both
incidents were thorough and careful. Accordingly, the panel
found no violation of Alexander’s constitutional rights.

                         COUNSEL

Zulu Ali (argued), Law Office of Zulu Ali, Riverside,
California, for Plaintiff-Appellant.
Thomas M. McMahon (argued), Deputy Attorney General;
Donna M. Dean, Supervising Deputy Attorney General;
Pamela L. Holmes, Acting Senior Assistant Attorney
General; Rob Bonta, California Attorney General; California
Attorney General’s Office, Los Angeles, California, for
Defendant-Appellee.
4                   ALEXANDER V. NGUYEN

                         OPINION

HAMILTON, Circuit Judge:

    While plaintiff Surie Alexander was a pretrial detainee
and a patient at Patton State Hospital in California, he was
twice attacked by a fellow patient. He sued Dr. Dau Nguyen,
the psychiatrist in charge of his unit, under 42 U.S.C. § 1983
for injuries from the second attack, alleging that Dr. Nguyen
violated his Fourteenth Amendment right to substantive due
process. The district court granted Dr. Nguyen’s motion for
summary judgment based on the defense of qualified
immunity. We affirm summary judgment on Alexander’s
claim, basing our decision on the merits of the claim rather
than qualified immunity.
I. Factual and Procedural Background
    We state the facts relevant for purposes of summary
judgment, giving Alexander as the non-moving party the
benefit of conflicts in the evidence and reasonable inferences
that can be drawn from the evidence. Nehad v. Browder, 929
F.3d 1125, 1132 (9th Cir. 2019). On February 7, 2017,
Alexander was admitted to Patton State Hospital to
determine whether he was competent to stand trial on a
criminal charge. He was assigned to Unit 72, where he was
treated by Dr. Nguyen, the unit psychiatrist. Hospital staff
diagnosed Alexander with aphasia, which is the loss of the
ability to understand or express speech due to brain damage.
Alexander was initially deemed incompetent to stand trial,
and staff in Unit 72 began working with him to restore his
competency.
   On April 29, 2017, another patient in Unit 72 struck
Alexander twice on the left side of the head with his fist.
                    ALEXANDER V. NGUYEN                      5

Alexander was treated by nursing staff, who noted redness
on the left side of his face but observed no bleeding,
bruising, swelling, or adverse neurological impacts.
    A special incident report was prepared, and the
professional staff of Unit 72 met to discuss what action
should be taken to prevent further violence between
Alexander and the patient who attacked him. When patient-
on-patient violence occurs in a state hospital, the standard of
care does not require automatic transfer of one of the patients
to a different unit. The undisputed evidence in this record
shows instead that providers must carefully weigh several
factors to determine the best course of action for the patients
and the hospital. These factors include the severity of the
assault, whether there were prior assaults or threats between
the two patients, whether the patients can be counseled to
avoid further violence, whether the victim feels safe
remaining in his current unit, and whether the victim would
enjoy greater well-being in a different unit.
    Dr. Nguyen initially recommended that Alexander be
transferred to a unit for fragile patients, but Alexander did
not meet the requirements. After consulting with other
members of the Unit 72 staff, Dr. Nguyen ultimately decided
that Alexander should not be moved to a different unit. Dr.
Nguyen’s decision was based on his conclusions that (1) the
assault was not particularly severe, (2) there had been no
prior incidents between the two patients, (3) Alexander and
the other patient were counseled on the need to refrain from
further violence and both agreed, (4) when asked, Alexander
said that he felt safe in Unit 72 and did not want to be
transferred, and (5) there was no reasonable likelihood that
Alexander’s well-being would be improved by transfer to a
different unit. Dr. Nguyen and the staff also decided to
adjust the medication of the patient who attacked Alexander
6                    ALEXANDER V. NGUYEN

and altered that patient’s access to the dining room to limit
his interactions with Alexander.
    On May 10, 2017, however, the same patient struck
Alexander with his fists again, this time on the right side of
his head. Alexander was immediately treated by staff, who
noted slight discoloration and swelling near his lower right
eyelid and a superficial scratch. He did not suffer any
neurological damage, and an x-ray showed no break or
fracture.    Eight days after the incident, Alexander
complained of intermittent pain in his right eye. He was
evaluated by an ophthalmologist, who prescribed an
ointment for eyelid abrasion and Motrin for pain and
recommended further monitoring by hospital staff.
     After the May 10 attack, another special incident report
was prepared, and in consultation with the staff in Unit 72,
Dr. Nguyen again weighed relevant factors to determine the
best course of action. Immediately after the attack, staff had
placed the aggressor patient in restraints and assigned a staff
member to supervise him one-on-one, but the staff did not
consider these to be feasible, long-term solutions. The staff
also did not believe that adjusting the patient’s medication
or limiting his access to the dining room would prevent
further acts of violence. Alexander continued to say that he
felt safe in Unit 72 and that he did not want to be transferred.
Nevertheless, based principally on the fact that the patient
had attacked Alexander twice, Dr. Nguyen and the staff in
Unit 72, with the agreement of Alexander’s wife, decided to
transfer him to a different unit.
    Alexander was transferred to Unit 71 on May 17, 2017.
Hospital records indicate no further violence between
Alexander and the aggressor patient or any other patient or
staff member. Alexander was released from Patton State
                     ALEXANDER V. NGUYEN                      7

Hospital in late February 2018 after staff determined he was
competent to stand trial.
   Alexander then filed this suit against Dr. Nguyen under
42 U.S.C. § 1983 alleging a violation of his Fourteenth
Amendment right to substantive due process. Dr. Nguyen
moved for summary judgment, arguing (a) that the
undisputed facts showed no violation of Alexander’s
constitutional rights, and (b) that in any event Dr. Nguyen
was entitled to qualified immunity.
    Dr. Patricia Tyler, a licensed psychiatrist with substantial
experience treating patients within the California State
Hospital system, provided an affidavit in support of Dr.
Nguyen’s motion. Dr. Tyler is familiar with the standard of
care applicable to hospitals and medical providers
responding to incidents of patient-on-patient violence.
According to Dr. Tyler, the reasonable and customary
standard of care in such cases is to conduct a timely review
of the incident, to perform a risk assessment to determine
what caused the incident, and to consider and coordinate
reasonable actions to prevent further violence, while
considering the impact of any action on patient care. This
decision process requires providers to weigh various factors,
including the severity of the incident, any prior incidents of
violence against patients or staff involving the aggressor
patient, whether medication or schedule changes could
prevent further acts of violence, whether the patients
involved could be counseled to avoid retaliation and further
violence, the availability of appropriate treatment beds in
other units and the level of aggression or risk of aggression
in those units, and victim and family preferences. Dr. Tyler
opined that Dr. Nguyen met and exceeded the standard of
care for responding to patient-on-patient aggression after
8                     ALEXANDER V. NGUYEN

both incidents. Plaintiff Alexander has not offered any
evidence disputing this evidence of the standard of care.
    The district court granted Dr. Nguyen’s motion for
summary judgment. The court did not decide whether
Alexander’s constitutional rights were violated but
concluded that Dr. Nguyen was entitled to qualified
immunity because it was not clearly established that his
actions violated the Constitution.
II. Jurisdiction and Standard of Review
    We have jurisdiction over this appeal pursuant to 28
U.S.C. § 1291. We review de novo the district court’s grant
of summary judgment. Nehad, 929 F.3d at 1132. As noted,
in reviewing a grant of summary judgment, we view all facts
and draw all reasonable inferences in the light most
favorable to the non-moving party. Id. Summary judgment
is appropriate where the movant shows there is no genuine
dispute as to any material fact and the movant is entitled to
judgment as a matter of law. Fed. R. Civ. P. 56(a); Rice v.
Morehouse, 989 F.3d 1112, 1120 (9th Cir. 2021).
III. Analysis
    A government official is entitled to qualified immunity
“unless the plaintiff raises a genuine issue of fact showing
(1) ‘a violation of a constitutional right,’ and (2) that the right
was ‘clearly established at the time of [the] defendant’s
alleged misconduct.’” Evans v. Skolnik, 997 F.3d 1060,
1064 (9th Cir. 2021) (quoting Pearson v. Callahan, 555 U.S.
223, 232 (2009)). The court may address these issues in
either order. Id. at 1064–66.
   This court tends “to address both prongs of qualified
immunity where the two-step procedure promotes the
development of constitutional precedent in an area where
                    ALEXANDER V. NGUYEN                     9

this court’s guidance is … needed.” Martinez v. City of
Clovis, 943 F.3d 1260, 1270 (9th Cir. 2019) (quoting Horton
by Horton v. City of Santa Maria, 915 F.3d 592, 602 (9th
Cir. 2019) (internal quotation marks omitted)). Because the
law governing pretrial detainees’ claims of inadequate
medical care and other dangerous conditions of confinement
is still developing in the wake of the Supreme Court’s
decision in Kingsley v. Hendrickson, 576 U.S. 389 (2015),
we address the first prong, which is decisive here. We need
not discuss qualified immunity separately.
    Alexander argues that he can prove that Dr. Nguyen
denied him appropriate medical care in violation of his
Fourteenth Amendment rights under the test set forth in
Gordon v. County of Orange, 888 F.3d 1118 (9th Cir. 2018).
Dr. Nguyen argues that the proper inquiry is whether
Alexander was deprived of safe conditions under the test in
Youngberg v. Romeo, 457 U.S. 307 (1982). These tests
differ only slightly. Both ask whether Dr. Nguyen’s conduct
was reasonable, and both require Alexander to show that Dr.
Nguyen’s conduct was worse than negligent.             The
undisputed facts show that Alexander cannot meet this
burden under either phrasing.
     Gordon followed Kingsley and held that claims for
violations of the right to adequate medical care brought by
pretrial detainees are to be evaluated under an objective
deliberate indifference standard. 888 F.3d at 1124–25. To
prevail on such a claim, the pretrial detainee must prove:
“(i) the defendant made an intentional decision with respect
to the conditions under which the plaintiff was confined;
(ii) those conditions put the plaintiff at substantial risk of
suffering serious harm; (iii) the defendant did not take
reasonable available measures to abate that risk, even though
a reasonable official in the circumstances would have
10                  ALEXANDER V. NGUYEN

appreciated the high degree of risk involved—making the
consequences of the defendant’s conduct obvious; and
(iv) by not taking such measures, the defendant caused the
plaintiff’s injuries.” Id. at 1125. Gordon made a significant
point regarding the third element: “mere lack of due care by
a state official” is not enough to show a constitutional
violation. Id. (quoting Castro v. County of Los Angeles, 833
F.3d 1060, 1071 (9th Cir. 2016) (en banc) (internal quotation
marks omitted)). The plaintiff must “prove more than
negligence but less than subjective intent—something akin
to reckless disregard.” Id. (quoting Castro, 833 F.3d at
1071).
    In Youngberg, the Supreme Court held that patients
committed involuntarily to state hospitals have a
constitutional right to safe conditions. 457 U.S. at 315–16.
Claims alleging violations of that right are evaluated under a
professional judgment standard. Under this standard,
decisions made by appropriate professionals are
“presumptively valid,” and liability “may be imposed only
when the decision by the professional is such a substantial
departure from accepted professional judgment, practice, or
standards as to demonstrate that the person responsible
actually did not base the decision on such a judgment.” Id.
at 323. The standard from Youngberg thus considers
whether a hospital official’s conduct “diverges from that of
a reasonable professional.” Ammons v. Washington Dep’t of
Social & Health Servs., 648 F.3d 1020, 1027 (9th Cir. 2011).
To impose liability, the professional judgment standard
requires a “finding of conscious indifference amounting to
gross negligence.” Estate of Conners by Meredith v.
O’Connor, 846 F.2d 1205, 1208 (9th Cir. 1988).
   This case does not depend on any nuanced differences
between these standards. Alexander has offered no evidence
                    ALEXANDER V. NGUYEN                     11

that Dr. Nguyen failed to act reasonably, let alone that he
was “more than negligent” when he decided not to transfer
Alexander or the other patient after the April 29 incident.
Undisputed evidence shows that Dr. Nguyen’s response to
the first attack on Alexander was reasonable (as was his
response to the second).          Though Alexander was,
regrettably, attacked a second time, the evidence shows that
Dr. Nguyen’s responses to both incidents were thorough and
careful.
    After each incident, hospital staff investigated and
memorialized their findings in a report. Dr. Nguyen
consulted with other professionals to determine the best
course of action. He considered relevant factors and
evaluated the risk of future violence against Alexander, as
well as the effect of a transfer on Alexander’s treatment. Dr.
Nguyen and his staff also implemented measures to reduce
the likelihood of future incidents, including adjusting the
aggressor’s medication and his access to the dining room
when Alexander would be there. The declaration of Dr.
Tyler, who has substantial experience treating patients in
state hospitals and is familiar with the standard of care for
responding to patient-on-patient violence, confirmed that
Dr. Nguyen’s conduct complied with, and in fact exceeded,
accepted professional standards. Whether evaluated under
Gordon or under Youngberg, Dr. Nguyen’s conduct was
reasonable and did not violate Alexander’s constitutional
rights.
    Alexander’s arguments to the contrary do not establish a
genuine dispute of material fact. He criticizes Dr. Nguyen’s
decision to keep him in Unit 72 after the first attack, but the
benefit of hindsight from the fact that Alexander was
attacked a second time does not show that Dr. Nguyen’s
original decision was unreasonable. Alexander is arguing,
12                 ALEXANDER V. NGUYEN

in effect, for a standard of strict liability for a second
incident. That would not be consistent with the law in
Youngberg or Gordon, or Kingsley, for that matter. The
undisputed facts show that Dr. Nguyen based his decision on
relevant factors, including whether a transfer would be
conducive to Alexander’s treatment, and he took several
measures to reduce the likelihood of further aggression.
Alexander also argues that Dr. Nguyen should not have
relied on Alexander’s stated desire to stay in Unit 72 given
his aphasia, but even assuming that Alexander was unable to
express his wishes clearly, his stated preference was only
one of several factors that Dr. Nguyen considered. Nothing
in the record would allow a reasonable jury to find that Dr.
Nguyen unreasonably relied solely—or even principally—
on Alexander’s stated preference when deciding not to
transfer him after the first attack. Because the undisputed
facts show that Dr. Nguyen acted reasonably in response to
the April 29 incident, we find no violation of Alexander’s
constitutional rights.
  Accordingly, the judgment of the district court is
AFFIRMED.