United States District Court, W.D. Missouri, St. Joseph Division
NANETTE K. LAUGHREY, UNITED STATES DISTRICT JUDGE
before the Court is a motion for summary judgment by
defendants Mike Strong (former Buchanan County Sheriff),
Captain Jody Hovey (Buchanan County Jail Administrator),
Buchanan County Sheriff's Deputies Brian Gross and Dustin
Nauman, and Buchanan County (collectively, the
“Buchanan County Defendants”). Doc. 350. Also
pending is a motion for summary judgment by Defendants April
Helsel, Catherine Van Voorn, M.D., Ann Slagle, and Advanced
Correctional Healthcare (“ACH”) (with Helsel, Dr.
Van Voorn, and Slagle, the “ACH Defendants”).
Doc. 370. The Buchanan County Defendants and ACH Defendants
seek summary judgment on Count IV of Plaintiffs'
complaint, which asserts civil rights claims against them in
their individual capacities and, insofar as the Buchanan
County employees are concerned, in their official capacities
reasons discussed below, the Court (1) grants the individual
Buchanan County Defendants' motions for summary judgment
on the official-capacity claims against them; (2) grants
Defendant Nauman's motion for summary judgment on Count
IV on the basis of qualified immunity, (3) grants the motion
by Defendant Van Voorn for summary judgment on Count IV, (4)
denies the motions by Gross, Strong, Hovey, and Buchanan
County for summary judgment on Count IV, and (5) denies in
part the motions by Slagle, Helsel, and ACH for summary
judgment on Count IV.
Stufflebean's Medical Conditions
Stufflebean (“Stufflebean”), the son of
plaintiffs Brenda Davis and Frederick Stufflebean, had two
endocrine disorders: Addison's disease and
hypoparathyroidism. Addison's disease is a disorder that
occurs when the adrenal glands fail to produce sufficient
amounts of cortisol, an essential hormone that helps the body
cope with stress and is critical to maintaining blood
pressure and cardiovascular function. Adrenal insufficiency
is life-threatening. Stress can trigger Addisonian crises.
However, progression into adrenal crisis is not
instantaneous, but gradual.
longtime treating physician, who canceled a trip in order to
testify at Stufflebean's sentencing hearing regarding
Stufflebean's fragile condition, explained that
“Mr. Stufflebean suffers from one of the lowest calcium
levels that any of us doctors have ever seen in the hospital
and that can make him quite - makes him quite ill and very
badly damaging to a body and can be life-threatening in and
of itself also and has to be controlled.” Doc. 447-18
(Transcript from Stufflebean's October 26, 2015
sentencing hearing, Testimony of Dr. Alan Brewer), 8:2-9:16.
Dr. Brewer explained that when Stufflebean's
Addison's disease-which is exacerbated by stress-flares
up, Stufflebean experiences “[f]atigue, malaise
that's followed by severe nausea, vomiting,
dehydration” and that, “if not intervened upon in
the hospital, in a hospital setting, it can be death within
24 to 48 hours.” Id., 9:17-24. The doctor
noted that Stufflebean's Addison's was “light
years worse” in the prior year than it had been in the
years past, perhaps because of the stress from his having
been charged with the crime at issue. Id., 11:1-18.
Stufflebean had been hospitalized 16 times in the prior year,
not counting all of the out-patient emergency room visits
that didn't involve in-patient care, and that he had been
hospitalized just the prior week. Id., 9:23-10:9.
The doctor emphasized that “to someone with
Addison's who is as brittle as he is and with his
electrolyte disturbances, not being able to have access to
the hospital would be-or delayed access could-it kills
people.” Id., 10:20-25.
October 26, 2015 (the same day that his treating physician
testified), Stufflebean was sentenced to a term in prison and
transferred to the Buchanan County Jail. Although
Stufflebean's mother brought several of his prescription
drugs to the jail on the day that he was booked in,
Stufflebean did not receive any medications the next day or
the day after (October 27 and 28, 2015). On October 29,
2015, Stufflebean was transferred from the Buchanan County
Jail to the Western Reception Diagnostic and Correctional
Center (“WRDCC”). The nurse performing intake at
the prison noted that Stufflebean complained of vomiting,
weakness, and tachycardia (elevated heart rate). ACH AF,
¶ 69. She observed that Stufflebean appeared
“lethargic” and had an “unsteady gait,
” apparently from “weakness.” Id.,
¶ 70. Stufflebean told a nurse at the prison that he had
been having “this flare-up” of his Addison's
disease since he was sentenced. Id., ¶ 71.
Stufflebean did not receive any medications at the WRDCC from
October 29-31, 2015. BC AF, ¶ 46.
October 31, 2015, Stufflebean arrived by ambulance at a
medical center, unresponsive and in cardiac and respiratory
arrest. On November 16, 2015, he was pronounced dead.
Sheriff's Deputy Gross
Gross is a Buchanan County Sheriff's Deputy. At all
relevant times, he was assigned to courtroom security at the
Buchanan County Courthouse. His duties included maintaining
order in the courtroom and transferring those sentenced from
the courthouse to the jail. BC SF,  ¶ 6; BC SF Reply,
¶ 6. Strong, the Buchanan County Sheriff at the time,
testified that the transporting officer was expected to
advise the booking officer of any medical conditions of which
the transporting officer was aware, and therefore,
“there was an expectation that the transporting officer
would be paying attention” to courtroom proceedings.
Doc. 447-1 (Deposition of Sheriff Jerry Michael Strong),
55:11-15 (Q. . . . [T]he question is here, there was an
expectation that the transporting officer would be paying
attention, fair? A. Correct.); BC AF, ¶ 6 (noting that,
as transporting officer, Gross was responsible for answering
the booking officer's standard question on the Medical
Intake Screening Questionnaire of whether “the
arresting or transporting officer believe[s] the inmate is a
medical, mental health, or suicide risk now”). The
Buchanan County Sheriff's Department policies state that,
“[w]hen a detainee requiring special needs care is
identified, the facts surrounding the case shall be relayed
to the jail commander (or designee) and the medical staff . .
. .” BC AF, ¶ 53.
was on duty in the courtroom during Stufflebean's
sentencing hearing on October 26, 2015. He was sitting
approximately 30 feet from the witness chair when
Stufflebean's longtime treating physician, Dr. Brewer,
discussed Stufflebean's uniquely fragile condition. Doc.
447-3 (Moden Affidavit), ¶ 5. Gross admits that he
normally can hear testimony in the courtroom. BC SF,
¶¶ 8, 10. Gross also acknowledged that it is
“rare” for doctors to testify at sentencing
hearings. Doc. 447-4 (Deposition of Brian M. Gross),
10:14-16. Dr. Brewer's testimony was made all the more
unusual by the fact that he claimed he had canceled a trip
“so [he] could be [t]here for Justin and to say what
[he] - to help clarify his medical condition.” Doc.
Brewer explained that Stufflebean's extraordinarily low
calcium-levels could become “life-threatening, ”
that an Addison's flare-up could manifest as
“[f]atigue, malaise that's followed by severe
nausea, vomiting, dehydration” and that, “if not
intervened upon in the hospital, in a hospital setting, it
can be death within 24 to 48 hours.” Id.,
¶¶ 3-4; Doc. 447-18, 8:2-10:9. The doctor
emphasized that “to someone with Addison's who is
as brittle as he is and with his electrolyte disturbances,
not being able to have access to the hospital would be-or
delayed access could-it kills people.” Id.,
10:20-25. Dr. Brewer testified that Stufflebean had been
hospitalized 16 times in the prior year, not counting all of
the out-patient emergency room visits that didn't involve
in-patient care, and indeed, Stufflebean had been
hospitalized just the prior week. Id., 9:23-10:9.
Stufflebean was sentenced, Gross took him into custody and
transported him to the jail. Despite Stufflebean's
doctor's detailed and unusual testimony that
Stufflebean's medical conditions would endanger his life
if they were not properly controlled, Gross provided no
information about Stufflebean's medical condition to the
booking officer. BC SF, ¶ 19.
Sheriff's Deputy Nauman
is and at all relevant times was a Buchanan County
Sheriff's Deputy assigned to the booking desk at the
Buchanan County Jail. BC SF, ¶ 17. Nauman's job per
Buchanan County's medical policies and procedures was to
review and be familiar with those policies and procedures
requiring him to conduct the “BCSD Medical Intake
Screening” carefully, with an eye towards identifying
prisoners with chronic conditions or special needs so that
their needs would be addressed properly throughout their
incarceration. BC AF, ¶ 17. This required Nauman to be
attentive to the questioning and the answers. Id.
Strong, who was Sheriff at the time, testified that he
expected that the medical history for a prisoner like
Stufflebean would be obtained “[a]t the booking
process.” Id., ¶ 92.
first question on the jail's Medical Intake Screening
form is, “Was inmate a medical, mental health or
suicide risk during any prior contact or confinement within
the department?” Id., ¶ 10. Nauman stated
that he was not certain if Stufflebean's prior Medical
Intake Screening form, from 2014, was available to him.
Id., ¶ 16. Stufflebean's prior booking
records showed that he had been classified as “Special
Condition - Medical, ” and that Stufflebean needed
medical attention due to his calcium deficiency.”
Id., ¶ 18.
second question on the form is: “Does the arresting or
transporting officer believe that the inmate is a medical,
mental health or suicide risk now?” Id.,
¶ 11. However, Gross did not report Stufflebean's
medical conditions to Nauman.
information that Nauman entered in the medical questionnaire
when he booked Stufflebean into the Buchanan County Jail on
October 26, 2015 indicates that Stufflebean reported
abdominal pain, unexplained weight loss, loss of appetite,
night sweats, and fatigue,  and that he was taking several
prescribed medications, including prednisone,
fludrocortisone, NATPARA, Calcitriol, magnesium, E, and
potassium. Id., ¶ 27. Although the Medical
Intake Screening Form asks for the “dosage, and
frequency” of medications, Nauman did not document that
information. BC AF, ¶ 12.
the facts that Stufflebean had been hospitalized just the
prior week (in addition to fifteen other in-patient
hospitalizations), and his longtime treating physician had
testified at his sentencing hearing that same day, the
medical intake screening questionnaire indicates that
Stufflebean was not under the care of a physician.
Id., ¶ 8. Nauman also recorded that Stufflebean
did not “currently” need medical attention. BC
SF, ¶ 23. In contrast, Stufflebean's medical intake
screening questionnaire from his prior booking, in December
2014, stated that Stufflebean was in need of medical
attention “BECAUSE OF A CALCIUM DEFICIENCY.” Doc.
447-9. Had Nauman recorded that Stufflebean currently needed
medical attention, Stufflebean would have been classified as
“Special Condition-Medical, ” as he was the first
time he was booked into the jail, and both the medical staff
and jail commander would have been notified of his condition.
BC SF, ¶ 24; Doc. 631 (transcript of November 18, 2019
completing the medical questionnaire for Stufflebean upon
booking him into the jail, Nauman printed a copy of the
completed questionnaire and placed it in the nurse's box,
and then contacted a nurse by telephone to advise her that he
had booked an inmate who needed to be seen for medical
issues. BC AF, ¶ 28. Stufflebean was placed in
a separate cell from other inmates being booked into the
jail, but Nauman could not recall the reason for it. Doc.
447-8 (Deposition of Dustin R. Nauman), 20:3-11.
Nauman's shift ended at 5 p.m., Stufflebean still was in
a holding cell. BC SF, ¶ 29. Nauman could not recall
following up with the nurse as to Stufflebean's care. BC
AF, ¶ 95. Nauman did not know whether, or when, a nurse
came to check on Stufflebean. BC SF, ¶ 30. Stufflebean
was in the holding cell in the booking area for 12 hours and
was never seen by a nurse while in the holding cell. BC AF,
had no further contact with Stufflebean during his stay in
the Buchanan County Jail in October 2015. BC SF, ¶ 31.
Medical Providers-ACH and Its Employees
Slagle is a Licensed Practical Nurse employed by ACH and
assigned to the Buchanan County Jail. ACH AF, ¶ 14.
Slagle was on duty on October 26, 2015 from 2 p.m. until
10:29 p.m.; October 27, 2015 from 12:07 p.m. until 10:28
p.m.; and October 28, 2015 from 1:55 p.m. until 10:24 p.m.
Helsel (also called April Powers) is a Licensed Practical
Nurse employed by ACH as the site manager for the Buchanan
County Jail. Id., ¶ 16. As site manager, Helsel
was responsible for supervising and training the nursing
staff at the jail. Id., ¶ 17. She was on duty
October 26, 2015 from 6:00 a.m. until 2:20 p.m.; October 27,
2015 from 12:14 p.m. until 10:30 p.m.; October 28, 2015 from
6:03 a.m. until 2:01 p.m.; and October 29, 2015 from 6:00
a.m. until 11:15 a.m. Id., ¶ 16.
Catherine Van Voorn was the medical director covering the
Buchanan County Jail. Doc. 447-22, 20:7-13.
Stufflebean's Medical Treatment at the Buchanan County
Nurse Slagle's Intake
claims that, on October 26, 2015, the day that Stufflebean
was booked into the jail, Nauman contacted a nurse by
telephone to let her know that he had “booked in an
inmate who needed to be seen due to medical issues.”
Id., ¶ 23. A reasonable juror could find, based
on the 14:03PM print time shown on the questionnaire (Doc.
447-5, p. 19) and Slagle's documented arrival time of 2pm
on October 26, 2015 (ACH AF, ¶ 14) that Slagle was the
nurse that Nauman contacted. During the nearly 11 hours that
Stufflebean was in the holding cell in the booking area, no
nurse came to see him. Id., ¶ 29; see
also Doc. 474-21 (Deposition of Ann Marie Slagle, Vol.
II), 30:22-31:17 (testifying that she “did not see
him” on the 26th), Doc. 474-1 (Inmate Activity Log
showing that Stufflebean was admitted to the facility at
13:54 on October 26 and was sent to housing at 00:47 on
October 27, 2015).
October 26, 2015, the day that Stufflebean was brought to the
Buchanan County Jail, his mother, Brenda Davis, delivered to
the jail what she could find of Justin's medications,
including NATPARA, melatonin, hydrocodone, ondansetron,
fludrocortisone, paroxetine, Calcitriol, prednisone, and
Vitamin D, as well as specialized injection tips for the
NATPARA, id., ¶ 24; BC AF, ¶ 19, and
Slagle retrieved the medications, id., ¶
Stufflebean was supposed to take his medications daily, and
indeed, he was supposed to take some of his medications more
than once a day. See Doc. 447-15 (records from
October 19, 2015 emergency-room visit).
medications were passed to inmates at 7 a.m. Any once-daily
medication that was not entered in the jail's system
before 7 a.m. on a given day would not be administered. Doc.
474-21, 33:9-17, 35:6-17, 48:5-6; see also id.,
49:13-21 (“Q. So the medications were to be given at
7:00 a.m.? A. That's correct. Q. Was this per Dr. Van
Voorn's orders? A. It's the per setup in the MAR
system. Q. Because it was after 7:00 a.m. when you got the
order from Dr. Van Voorn when you put it into the system, it
just bumped it to the next day? A. Correct.”). Thus,
for Stufflebean to receive his daily medications on October
27, they needed to be entered in the system before 7 a.m.
that day. Id., 33:9-17, 35:6-17, 48:5-6. Yet,
despite having picked up at least nine medications as well as
specialized injection tips prescribed for Stufflebean, and
although she worked for more than eight hours on October 26
after Nauman advised her to evaluate Stufflebean, Slagle did
not call a doctor to ask for an order to administer his
prescription medications on that day. Slagle knew that meant
that Stufflebean would not receive the nine prescription
medications in her custody for more than 24 hours.
See Doc. 474-29, 50:6-9 (“Q. . . . But in your
medication verification form, you recognize that the
medications were to be given daily? A. Yes.”)
October 27, 2015, Stufflebean filed a formal request for his
medications, stating, “I called to have my medicine
brought in. I have Addison's and hypoparathyroid disease.
Medications brought to jail.” Doc. 474-6 (Medical
Progress Notes for Stufflebean prepared at 1:16 p.m. on
October 27, 2015). Slagle made note of Stufflebean's
request, and apparently in response, called Dr. Van Voorn
that afternoon and received oral orders for some of the
prescriptions. See Id. (repeating Justin's
medication request and writing under “PLAN”
“1300 Contacted Dr. Van Voorn and received verbal
orders.”); ACH AF, ¶¶ 28, 37. As discussed
above, because Slagle entered the order after 7 a.m. on the
27th, the soonest Stufflebean could have received his
medication was October 28, 2015.
despite his formal request on October 27 for the medications
that had been brought to the jail, and although Stufflebean
told a fellow inmate that he had requested his medications
repeatedly, and that fellow inmate witnessed him requesting
his medications in person at least twice, Doc. 474-23
(Deposition of Ross Ellis), 82:16-83:10, there is no dispute
that Stufflebean was not given his medications on either
October 26 or 27, 2015. ACH AF, ¶ 48; BC AF,
claims that she saw Stufflebean on October 27, 2015 in the
infirmary before she called Dr. Van Voorn. See Doc.
474-21, 13:4-18. However, the jail's inmate activity log,
which tracks the movements of inmates within the facility,
shows that once Stufflebean was moved from the holding cell
(where he was never seen by medical staff) to the cell pod,
he did not leave the cell pod (to go to the infirmary or
elsewhere) until he was transferred to prison. AF for ACH,
¶¶ 35-36; Ex. 474-1 (inmate activity log for
only evidence that ACH points to in arguing that Slagle saw
Stufflebean on October 27, 2015 are the progress note and the
medication verification form that Slagle created.
See Doc. 631, 23:15-19. The Medical Progress Notes
contains just two sections. In the section titled
“SOA” is Stufflebean's request for his
medication, written in the first person, as though
transcribing Stufflebean's formal request (“I
called to have my medicine brought in. I have Addison's
and hypoparathyroid disease.”), and on the next line,
the statement, “Medications brought to jail.”
Doc. 474-6. The second section, titled “Plan, ”
states only “10/27/15 1300 Contacted Dr. Van Voorn and
received verbal orders.” Id. The only
indication on the medical verification form that Slagle saw a
patient are vital signs (B/P, Temp, Resp, Pulse), Doc. 474-5,
which, Plaintiffs point out, could have been fabricated.
Neither of the two documents that ACH cites contains any
notes from Slagle concerning Stufflebean's appearance,
any indication that he complained about symptoms, or even,
conversely, that he felt fine. Docs. 474-5, 474-6. Nor did
she tell Dr. Van Voorn about these factors.
testified that her list of medications on the medication
verification form was based on the bag of medications
Stufflebean's mother brought to the jail. Doc. 447-21,
16:21-25. Thus, the list of medications itself does not
indicate that Slagle spoke with Stufflebean. In fact, to the
contrary, the list of medications suggests that Slagle did
not see Stufflebean. During her deposition, Slagle testified
as follows about her usual procedure for identifying
discrepancies between the medication verification form and
Q. So you would not reconcile back to the intake screening
form or the property form that the corrections officer fills
out . . . when you were completing the medication
A. Not usually, unless there was a discrepancy.
Q. Well -
A. And that would be after I spoke to the patient, and then I
would compare it to see if maybe it got placed in his
property or was, you know, being sent back home.
Q. Okay. Well, I mean what we know in this case is
there's medications listed on the intake screening form
and the property intake form . . . that don't show up on
your medication verification report; and so the question is
did you reconcile it in this case or not?
A. No, I didn't.
Q. Is there a reason why not?
MR. HICKS: Object to the form. I feel like she just explained
A. I would talk to the patient, which I would have the
medications that were there, and I would ask him at that time
if there were other medications that he was taking, and I
would go from there. I would then look back and go,
“Okay, well, it's got Vitamin D.”
“Yeah, I took that sometimes.” You know, I
don't know if that's what he said at that point, but
that's what I would go for.
(By Mr. Bird) Are you suggesting that Mr. Stufflebean told
you not to include certain medications on his medication
A. He possibly could, yes.
Q. What is your evidence for that that's in his chart?
A. Nothing in -- in his chart.
Q. Then you're speculating, correct?
A. Yes, sir, I would be speculating.
Q. Okay. And the point being that you rec- -- recognize now
that if you had done a reconcilement with the intake
screening form and the property form, that you would have
seen medications that were identified but not listed in your
A. Yes, I would have seen that there were medications that
were not on my form.
list of medications omits at least two of the medications
that Stufflebean told Nauman he takes. Compare 474-8
(Questionnaire: BCSD Medical Intake screening listing,
inter alia, “MAGNISIUME and POTASIUME
[sic]”) with 474-5 (Slagle's
Medication Verification Form, mentioning neither magnesium
nor potassium). It is reasonable to infer that, if given the
opportunity to speak with a nurse about the medications he
had already formally requested, Stufflebean would report to
the nurse the same medications he reported to the booking
officer of the jail. The fact that Stufflebean did not tell
Slagle about at least two of his medications reasonably
suggests that Slagle never spoke with Stufflebean.
also omitted Stufflebean's Calcitriol from her
medications list, even though that was among the medications
that Davis brought to the jail. In addition, although
Stufflebean's mother had brought both NATPARA and the
special injection tips needed to administer it, Slagle wrote,
“Pt. must supply.”
Dr. Van Voorn's Orders
October 27, 2015, Dr. Van Voorn ordered continuation of some
of Stufflebean's medications: NATPARA, Vitamin D Ergo,
Paxil, Prednisone and Fludrocortisone. ACH AF, ¶ 40. Dr.
Van Voorn denied Stufflebean one of the medications from
Slagle's list: Zofran/ondansetron, a medication used to
control severe nausea and vomiting that Stufflebean had been
prescribed during an emergency room visit nine days earlier
related to an Addisonian crisis. Id., ¶¶
Voorn admitted that if a patient with hypoparathyroidism or
Addison's disease reported “fatigue or . . .
abdominal pain or tingling, those could all be symptoms of a
crisis coming on for that condition, ” and indeed
“[c]ertainly” were “red flags.” ACH
AF, ¶ 87. She acknowledged that in such a situation, she
would “know that [she] need[s] to take a closer look to
make a determination as to their state of health, ”
because otherwise “it could become a crisis” and
“could lead to serious injury or death.”
Id. She stated that she understood that
“somebody having Addison's disease and
hypoparathyroidism could be at risk if they didn't get
their medication; so [she] would take extra actions to make
sure [she] had the list correct and [she was] following the
right course.” Id. She admitted that she had
this knowledge in October 2015. Id. She further
acknowledged at her deposition that it is critical for a
brittle patient with Addison's and hypoparathyroidism to
receive medications daily. Id., ¶ 80. Yet, when
she ordered on October 27, 2015 that some of
Stufflebean's prescribed medications be administered, she
understood that Stufflebean would not receive the medications
until October 28 or 29, 2015. Doc. No. 474-24, 123:25-124:7.
Voorn visited the Buchanan County Jail once a week. ACH SF,
¶ 11. Despite knowing that Stufflebean had Addison's
Disease and hypoparathyroidism, Slagle did not put
Stufflebean on the list of patients that Dr. Van Voorn would
see on her October 28, 2015 visit. ACH AF, ¶ 49. Helsel,
too, did not put Stufflebean on the list of patients that Dr.
Van Voorn would see on October 28, 2015. Id., ¶
50. However, Helsel testified that the responsibility for
first identifying a prisoner with a chronic condition who
warranted being placed on the doctor's “list”
belonged to the doctor herself. Doc. 474-21, 8-25. (Q:
“[E]ssentially, as the nurse, you're reliant on
that first phone call with the physician to instruct you . .
. ‘I want to follow up. Let me see that patient when I
come in this week'? A. Yes.”). Consequently,
although Dr. Van Voorn was on site at the jail on October 28,
2015, she did not see Stufflebean. ACH AF, ¶ 51. Dr. Van
Voorn admitted that, as a patient with Addison's disease
and hypoparathyroidism and a long list of medications to
treat those conditions, Stufflebean should have been
“on her list” for proper evaluation.
Id., ¶ 52.
Helsel's Failure to Administer Medication
is no evidence that anyone gave Stufflebean his medications
on October 28, 2015. Helsel was on duty the morning of
October 28, 2015-during the time when once-a-day medications
were supposed to be administered. ACH AF ¶ 17. Helsel,
like Slagle, was aware at that time that Stufflebean needed
medications daily. Doc. 447-21 (Deposition of April (Powers)
Helsel), 45:6-9. Helsel testified that, on that day, she gave
Stufflebean the medication that Dr. Van Voorn had ordered.
Id., 7:8-15. However, when pressed, she admitted
that she had no recollection of having given Stufflebean his
medications, and she could point to no records supporting her
statement that she had given him medications: her statement
that she had administered his medications was mere conjecture
based on the fact that there was no notation in the record
indicating that Stufflebean had refused his medications.
Id., 7:8-23:13, 24:20-25:5. Helsel theorized that
the lack of any indication that she gave Stufflebean his
medications was just a computer error, but she could point to
no evidence supporting this theory. Id.,
evidence suggests that Stufflebean received some medication,
from a third ACH nurse, on October 29, 2015, the day that he
was transferred to the prison. Doc. 549-2 (Deposition of
Carrie Reindollar), 113:9-118:13; ACH SF, ¶ 32; see
also Doc. 474-5.
Failure to Take Vitals
is no evidence that Slagle, Helsel, or anyone else checked
Stufflebean's vital signs on October 28 or 29, 2015,
despite the fact that Dr. Van Voorn had ordered that his
vitals be taken for three consecutive days. ACH AF,
¶¶ 39, 56, 59. Indeed, Helsel admitted that nothing
in Stufflebean's record indicates that she provided any
care to him at all. Id., ¶ 60. Plaintiffs'
counsel represented that the vitals were supposed to be taken
in the afternoons, and Slagle was on duty the afternoon of
October 28, 2015. Doc. 631, 19:16-20-15.
Stufflebean's Deteriorating Condition
his incarceration at the Buchanan County Jail, Stufflebean
was not eating, and he was getting noticeably weaker. ACH AF,
¶ 61. He had difficulty getting down stairs such that he
had to lean on the rail for assistance. Id., ¶
62. He also vomited at least one time at the jail-a sign of
Addison's crisis. ACH SF, ¶ 30; see Doc.
447-18, 9:17-24 (Stufflebean's treating physician
testifying that Stufflebean's Addison's flare-up is
marked by “[f]atigue, malaise that's followed by
severe nausea, vomiting, dehydration” and that,
“if not intervened upon in the hospital, in a hospital
setting, it can be death within 24 to 48 hours”).
Transfer to Prison
October 29, 2015, at 12:35 p.m., Stufflebean was transferred
from the Buchanan County Jail to the Western Reception
Diagnostic and Correctional Center (“WRDCC”). ACH
AF, ¶ 64. During the transfer, Stufflebean
“struggl[ed]” to walk in his shackles.
Id., ¶ 63.
transfer from the Buchanan County Jail to the prison was
effectuated in just nine minutes. Id., ¶ 68.
The nurse performing intake at the prison noted that
Stufflebean complained of vomiting, weakness, and tachycardia
(elevated heart rate), and that Stufflebean appeared
“lethargic” and had an “unsteady gait,
” apparently from “weakness.” Id.,
¶¶ 69, 70. Stufflebean told a nurse at the prison
that he had been having “this flare-up” of his
Addison's disease since he was sentenced. Id.,
did not receive any medications at the WRDCC from October
29-31, 2015. BC AF, ¶ 46.
October 31, 2015, Stufflebean arrived by ambulance at a
medical center, unresponsive and in cardiac and respiratory
arrest. On November 16, 2015, Stufflebean was pronounced
dead. Id., ¶ 47; ACH AF, ¶ 72. Dr. Marius
C. Tarau, M.D., from the Jackson County Medical
Examiner's office, declared the cause of
Stufflebean's death to be “[c]omplications of
polyglandular endocrinopathy.” Id.
Plaintiffs' expert, Dr. Bilezikian, opined that, had
Justin received proper care for his Addison's disease, he
would not have died. Id., ¶ 73.
ACH and Buchanan County Policies and Procedures
discovery, ACH initially denied that it had any medical
policies or procedures for its operations at the Buchanan
County Jail. Id., ¶ 88. Buchanan County relied
on ACH's production, and therefore in effect initially
denied having any medical policies or procedures. BC AF,
¶ 67 (arguing that Buchanan County did not itself deny
having relevant policies, but instead simply referred
Plaintiffs to ACH's policies). However, ACH later
produced policies and procedures that it had provided to
Buchanan County to adopt. ACH AF, ¶ 90. Among the
policies that ACH and Buchanan County implemented is the
following: “It is the policy of the __County Jail to
provide access to appropriate care for serious medical . . .
needs . . . . Access to care- means in a timely manner, a
detainee can be seen by a clinician, to be given professional
clinical judgment, and receive care that is ordered.”
Id., ¶ 91. The policies further provide:
“Prescribed medications are reviewed and appropriately
maintained according to the medication schedule the inmate
was following before admission.” Id., ¶
policies require “regularly scheduled administrative
meetings” with the health care team and Buchanan
County. Id., ¶ 92. The jail was supposed to
arrange regular meetings with the responsible physician and
jail administrative staff to review “the effectiveness
of the healthcare system, healthcare issues that need
improvement, changes implemented since last reporting period
and any recommended changes to improve the healthcare
provided.” Id., ¶ 93.
Oversight by ACH
not presented admissible evidence that it had a real system
in place to monitor the accuracy of its Continuous Quality
Improvement (“CQI”) reporting-which covered
medication errors and prisoner grievances. Id.,
¶ 101 (stating only that “ACH clearly had a system
in place, ” without further explanation, and citing for
support only the ACH deposition transcript without page or
line references). ACH left it up to the local nurses to
provide “monthly contact logs” for the Regional
Nurse Manager to prepare the CQI reports. Id.
Regional Nurse Managers were supposed to “try” to
walk through the facility every couple of months and
“spot check” some files. Id. There was
no policy governing how many files were to be reviewed or how
they were supposed to review them. Id. Only the most
recent version of the records was kept, preventing review of
historical trends. Id., ¶¶ 101-102.
Oversight of ACH
Strong was the final decision-maker with regard to policies
and procedures at the Buchanan County Jail prior to and at
the time of Stufflebean's incarceration in October 2015.
BC AF, ¶ 69. Strong understood at that time that inmates
had a constitutional right to receive medical care for their
serious medical needs, and that he was responsible for making
sure they received it. Id., ¶ 71. Nonetheless,
Strong had no system in place to monitor the accuracy of
ACH's Continuous Quality Improvement (“CQI”)
reporting. Id., ¶ 76. Strong never compared
prisoners' medical grievances with ACH's CQI reports
to verify that ACH's “zero” grievance
reporting was accurate. Id., ¶ 77. He simply
trusted that ACH was providing proper care to the Buchanan
County prisoners. Id., ¶ 76.
Medical policies appoint the Jail Administrator, Captain
Hovey, as the Responsible Health Authority to “oversee
the medical operations of the jail, ” including
“arranging for all levels of healthcare and ensuring
the quality and accessibility of all health services provided
to the detainee population” and monitoring “to
assure all aspects of detainee care occurs for the treatment
of illnesses classified as ‘serious' by the
practitioner.” Id., ¶ 49. Strong expected
that Hovey was exercising “constant oversight”
over ACH. Id., ¶ 75. However, Hovey's
immediate supervisor, Undersheriff Bill Puett had “no
specific steps” in place to ensure that Hovey was
overseeing the provision of health care to detainees.
Id., ¶ 88.
of Buchanan County's oversight of medical care, Hovey
(and other jail officers) were supposed to review medical
grievances and attend CQI meetings and report to Strong.
Id., ¶ 79. There was no formal process for
reviewing medical grievances from a systemic viewpoint.
Id., ¶ 80. Puett testified that, while he was
undersheriff through December 2015, Buchanan County did not
review prisoner medical grievances and did not look at any
documentation outside of CQI reports to determine whether
prisoners were being provided their medications.
Id., ¶ 98.
Puett's knowledge, there was no discussion at the
Sheriff's Department in 2015 or earlier about how to
monitor ACH's performance. Id., ¶ 85. Puett
testified that routine monitoring of the basic CQI program
involved attending the CQI meetings and reviewing ACH's
CQI reports. Id., ¶ 83. In reality, however,
ACH essentially was left to self-report issues or problems
with the medical care it was providing to prisoners.
Id., ¶ 81. Outside of ACH's self-reporting,
Hovey had no system in place to analyze or review the care
being provided to prisoners. Id.
Medical Care Discrepancies and Purported
to October 2015, there were discrepancies in ACH's
self-reporting. For example, the January 2015 report showed
ten prisoner grievances in 2014, while the May 2015 report
showed zero prisoner grievances in 2014. BC AF, ¶¶
103-104; ACH AF, ¶¶ 109-10. CQI reports for 2014
and 2015 both indicated that there were zero medication
errors or prisoner grievances. BC AF, ¶ 110, ACH AF,
¶¶ 105. However, after reviewing “a summary
of the dates and prisoners . . . that . . . didn't get
their medications” in that timeframe prepared by
Plaintiffs' expert, Strong was “astonished”
by the number of errors and agreed that the medication errors
were “extensive, ” BC AF, ¶ 111, ACH AF,
¶¶ 106, and that in fact, there were “dozens
of prisoner grievances in 2014 [and] 2015.”
Id.; see also Doc. 474-34 (Roscoe
Supplemental Report), at 1 (Plaintiffs' expert opining
that she found “over 250 ...