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A.H. v. St. Louis County

United States District Court, E.D. Missouri, Eastern Division

January 25, 2017

A.H., et al., Plaintiffs,
ST. LOUIS COUNTY, MISSOURI, et al., Defendants.



         This matter is before the court on defendants' motion for summary judgment [Doc. #1');">11');">12');">2');">2');">2');">2');">2');">2');">2], pursuant to Fed.R.Civ.P. 56(a). The issues are fully briefed.

         I. Background

         On November 1');">1, 2');">2');">2');">2');">2');">2');">2');">201');">12');">2');">2');">2');">2');">2');">2');">2, Jereme Hartwig was confined in the St. Louis County jail for a probation violation. As part of the jail's intake procedure, Mr. Hartwig was assessed by a nurse who filled out an intake medical history form. [Doc. #1');">11');">13, ¶31');">1]. According to the form, Mr. Hartwig reported that his chief complaints at that time were asthma and depression, conditions for which he had previously received treatment. [Doc. #1');">11');">13, ¶32');">2');">2');">2');">2');">2');">2');">2]. He denied being suicidal and denied any use of alcohol or drugs. [Doc. #1');">11');">13, ¶31');">1]. On September 1');">1, 2');">2');">2');">2');">2');">2');">2');">201');">11');">1, one year prior to his detention in the jail, Mr. Hartwig had attempted suicide by hanging himself in the garage of his mother's residence. At some point during Mr. Hartwig's confinement jail staff became aware of his previous suicide attempt. [Doc. #1');">11');">13, ¶35].

         On December 1');">11');">1, 2');">2');">2');">2');">2');">2');">2');">201');">12');">2');">2');">2');">2');">2');">2');">2, Mr. Hartwig was referred to the jail's mental health division due to his history of suicide attempts. [Doc. #1');">11');">13, ¶37]. On January 1');">14, 2');">2');">2');">2');">2');">2');">2');">201');">13, Mr. Hartwig saw a psychiatrist who found no indications of suicidal intent and that Mr. Hartwig had received medication because he was depressed and having problems adjusting to incarceration. [Doc. #1');">11');">13, ¶38]. The psychiatrist also noted that Mr. Hartwig had a history of substance abuse and that he was facing charges for failure to pay child support. [Doc. #1');">11');">13, ¶38]. The psychiatrist determined that Mr. Hartwig needed no medication at the time and he did not enter an order of designation of suicide risk status for Mr. Hartwig. [Doc. #1');">11');">13, ¶38].

         On January 2');">2');">2');">2');">2');">2');">2');">28, 2');">2');">2');">2');">2');">2');">2');">201');">13, Mr. Hartwig had a personal visit with Savannah Cobb, the mother of his child. [Doc. #1');">11');">13, ¶39]. During the visit, Ms. Cobb told Mr. Hartwig that she was ending their relationship. [Doc. #1');">11');">13, ¶39]. Mr. Hartwig then starting hitting himself on the head with the telephone receiver. [Doc. #1');">11');">13, ¶39]. He was taken to the jail infirmary where sutures were placed to close the wound. [Doc. #1');">11');">15');">1');">11');">15');">1');">11');">15');">1');">11');">15, p1');">14');">p. 1');">14-1');">15]. Although he was observed to be visibly upset, Mr. Hartwig “[c]ontinue[d] to insist to staff that he's ‘not suicidal'.” [Doc. 1');">11');">15');">1');">11');">15');">1');">11');">15');">1');">11');">15, 1');">15');">p. 1');">15].

         On January 2');">2');">2');">2');">2');">2');">2');">29, 2');">2');">2');">2');">2');">2');">2');">201');">13, Mr. Hartwig saw defendant Wendy Magnoli, Ph.D., a clinical psychologist, for a psychological evaluation. [Doc. #1');">11');">15');">1');">11');">15');">1');">11');">15');">1');">11');">15, pp. 1');">11');">1-1');">12');">2');">2');">2');">2');">2');">2');">2]. He told Dr. Magnoli about his prior suicide attempt in 2');">2');">2');">2');">2');">2');">2');">201');">11');">1, but stated that he had had no suicidal ideation since that time. [Doc. #1');">11');">13, ¶¶63-64]. Mr. Hartwig identified a number of stressors, including that he had been in prison off and on for 1');">15 years for nonpayment of child support, that he was currently incarcerated for a drug case, and that he was in significant debt due to legal fees and accumulated child support. After conducting an assessment, Magnoli concluded that Mr. Hartwig presented a “low risk of harm” to himself and to others. [Doc. #1');">11');">15');">1');">11');">15');">1');">11');">15');">1');">11');">15, 1');">12');">2');">2');">2');">2');">2');">2');">2');">p. 1');">12');">2');">2');">2');">2');">2');">2');">2]. She directed that he be placed on precautionary status, discharged from the infirmary, and referred to a social worker for supportive follow-up. [Doc. #1');">11');">13, ¶78]. Magnoli did not recommend further treatment from a psychiatrist because she believed Mr. Hartwig's risk of suicide was low. [Doc. #1');">11');">13, ¶78-79].

         In 2');">2');">2');">2');">2');">2');">2');">201');">12');">2');">2');">2');">2');">2');">2');">2 and 2');">2');">2');">2');">2');">2');">2');">201');">13, St. Louis County had in place a written suicide prevention policy, Policy 906. [Doc. #1');">11');">13, ¶2');">2');">2');">2');">2');">2');">2');">26]. According to the policy, inmates at risk for suicide are classified as high, medium, and precautionary, based on the degree of risk they present. [Doc. #1');">11');">13, ¶2');">2');">2');">2');">2');">2');">2');">27]. High and medium risk inmates are housed in one-person cells in the psychiatric infirmary. [Doc. #1');">11');">13, ¶2');">2');">2');">2');">2');">2');">2');">28-2');">2');">2');">2');">2');">2');">2');">29; Doc. #1');">170, ¶1');">199]. High risk inmates are not allowed to have regular bedsheets, and they are to be observed every five minutes on an irregular schedule. [Doc. # 1');">170, ¶2');">2');">2');">2');">2');">2');">2');">262');">2');">2');">2');">2');">2');">2');">2; Doc. #1');">170-2');">2');">2');">2');">2');">2');">2');">2, p. 8]. Medium risk inmates are to be observed every 1');">15 minutes on an irregular schedule. [Doc. #1');">170-2');">2');">2');">2');">2');">2');">2');">2, p. 9]. The suicide prevention policy requires an initial screening of inmates for suicide risk at intake to the jail, and a follow-up with a more comprehensive medical assessment within fourteen days of the initial screening. [Doc. #1');">11');">13, ¶30].

         Mr. Hartwig was placed on precautionary status under Policy 906, a decision made by Magnoli. [Doc. #1');">11');">13, ¶2');">2');">2');">2');">2');">2');">2');">26]. Inmates classified as precautionary are housed in the general population. [Doc. # 1');">11');">13, ¶2');">2');">2');">2');">2');">2');">2');">29]. The policy requires that they be “housed with a cellmate at all times.” [Doc. # 1');">170-2');">2');">2');">2');">2');">2');">2');">2, 1');">13');">p. 1');">13 (italics in original)]. The policy, however, does not require that the cellmate be present in the cell with the precautionary status inmate at all times. Precautionary status inmates in general population are to be observed at least once an hour during the first and second shifts, and at least once every 40 minutes during the third shift. [Doc. #1');">170-2');">2');">2');">2');">2');">2');">2');">2, 1');">13');">p. 1');">13]. If a precautionary status inmate is in the infirmary, however, the monitoring is done every 30 minutes. [Doc. #1');">170-2');">2');">2');">2');">2');">2');">2');">2, 1');">13');">p. 1');">13]. Precautionary risk inmates are to be re-evaluated by the mental health staff every three weeks in order to determine whether any change should be made to their status. [Doc. # 1');">170-2');">2');">2');">2');">2');">2');">2');">2, 1');">14');">p. 1');">14] to After Mr. Hartwig was discharged from the infirmary, he returned to general population. [Doc. #1');">11');">13, ¶93]. At approximately 7:2');">2');">2');">2');">2');">2');">2');">25 p.m. on February 5, 2');">2');">2');">2');">2');">2');">2');">201');">13, defendant Lauren Abate, a corrections officer, was conducting her tour of the general population cellblock. [Doc. #1');">11');">13, ¶1');">134]. At the time of her tour, inmates in the cellblock were allowed to leave their cells and go to the day room. [Doc. #1');">11');">13-1');">1, ¶31');">1]. In her deposition, Abate testified the she did not “specifically recall noticing” Mr. Hartwig. [Doc. #1');">159-1');">1, p. 45]. However, in her subsequent affidavit, Abate states that she remembers seeing Mr. Hartwig alone in his cell. [Doc. #1');">11');">13-1');">1, ¶30]. Approximately 50 minutes later, Abate let Mr. Hartwig's cellmate into the cell. The inmate then exited and reported to Abate that Mr. Hartwig had hung himself. [Doc. #1');">11');">13-1');">1, ¶35]. Abate knew that Mr. Hartwig was on precautionary status. [Doc. #1');">11');">13, ¶1');">18]. She also knew that the jail policy prohibiting precautionary status inmates from being alone in their cells did not apply during the hours that inmates were allowed to go to the day room. [Doc. #1');">11');">13-1');">1, ¶34].

         Mr. Hartwig had hung himself by anchoring his bed sheet to his bunk. [Doc. #1');">170-1');">1, p. 3]. Responding officers attempted to resuscitate him, but to no avail. [Doc. #1');">170-1');">1, p. 3]. He was then transported to a nearby hospital where he died on February 1');">11');">1, 2');">2');">2');">2');">2');">2');">2');">201');">13. [Doc. #1');">170-1');">1, p. 3].

         At all relevant times, defendant Herbert Bernsen was the director of the St. Louis County Department of Justice Services. In that capacity, Bernsen was responsible for the operations of the St. Louis County jail and was the “final policy making authority for policies that were in place in 2');">2');">2');">2');">2');">2');">2');">201');">13, ” including the suicide prevention policy. [Doc. #1');">11');">13-3, ¶¶1');">1, 1');">17, 39]. Bernsen did not have any personal involvement in the decisions regarding Mr. Hartwig's mental health treatment, his suicide risk status, or his housing. [Doc. #1');">11');">13-3, ¶1');">18].

         In a three-year period before Mr. Hartwig's death, there had been two suicides in the St. Louis County jail, both by means of hanging using a bed sheet. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">275-2');">2');">2');">2');">2');">2');">2');">276]. In each incident, the inmate was being housed in the segregation area of the jail on the 8th floor. [Doc. #1');">11');">13, ¶1');">143]. The first suicide, which occurred on October 4, 2');">2');">2');">2');">2');">2');">2');">201');">10, involved an inmate who had used the holes in the vent in his cell to create a noose. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">277; Doc. # 1');">170-7, p. 67]. In response, changes were made to the vents inside the cells on the 8th floor and in the infirmary. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">279-2');">2');">2');">2');">2');">2');">2');">280]. The vents in the cells on the 5th floor, where Mr. Hartwig committed suicide, were not changed. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">281');">1]. After the 2');">2');">2');">2');">2');">2');">2');">201');">10 suicide, Defendant Bernsen did not order any kind of inspection of the jail cells to look for other places a sheet could be anchored so an inmate could hang themselves. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">283]. On July 1');">17, 2');">2');">2');">2');">2');">2');">2');">201');">12');">2');">2');">2');">2');">2');">2');">2, a second inmate hung herself by tying a bedsheet to a bookshelf in her cell. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">276]. In response to that incident, shelves were removed from inside the cells on the 8th floor only. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">284]. Neither of the individuals who successfully committed suicide was on suicide precaution at the time, or had been identified as suicidal. [Doc. #1');">11');">13-3, ¶32');">2');">2');">2');">2');">2');">2');">2]. Mr. Hartwig was the first inmate on precautionary status to successfully commit suicide since the jail opened in 1');">1998. [Doc. #1');">11');">13, ¶1');">149].

         From May 2');">2');">2');">2');">2');">2');">2');">2008 to February 1');">1, 2');">2');">2');">2');">2');">2');">2');">201');">13, there were also 2');">2');">2');">2');">2');">2');">2');">22');">2');">2');">2');">2');">2');">2');">2 attempted suicides in the St. Louis County jail. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">285]. Sixteen of these attempts were by means of hanging using a bed sheet. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">286]. On October 2');">2');">2');">2');">2');">2');">2');">22');">2');">2');">2');">2');">2');">2');">2, 2');">2');">2');">2');">2');">2');">2');">201');">12');">2');">2');">2');">2');">2');">2');">2, an inmate attempted suicide using a bed sheet anchored the bed sheet on his bunk, similar to the means used by Mr. Hartwig. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">287]. Defendant Bernsen was aware of all the attempted and successful suicides. He did not always order an internal investigation on attempted suicides. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">288-2');">2');">2');">2');">2');">2');">2');">290]. In response to Mr. Hartwig's suicide, Policy 906 was revised so as not to permit a precautionary risk inmate in general population to be left in his cell alone at any time. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">271');">1]. The suicide policy was revised again in 2');">2');">2');">2');">2');">2');">2');">201');">15 to require inmates designated as precautionary risk to be housed at all times in a cell close to a corrections officer's work station. [Doc. #1');">170, ¶2');">2');">2');">2');">2');">2');">2');">275].

         Plaintiffs are the mother and children of decedent Hartwig. They bring this action pursuant to 42');">2');">2');">2');">2');">2');">2');">2 U.S.C. § 1');">1983 and Missouri law. In Count I of the amended complaint, plaintiffs claim that Magnoli, Abate and Bernsen were deliberately indifferent to Mr. Hartwig's mental health care needs, in violation of the Fourteenth Amendment. In Count III, plaintiffs claim that defendant St. Louis County failed to have an adequate suicide prevention policy and training program, in violation of the Fourteenth Amendment. In ...

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