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Davis v. Buchanan County

United States District Court, W.D. Missouri, St. Joseph Division

December 23, 2019

BRENDA DAVIS, et al., Plaintiffs,
v.
BUCHANAN COUNTY MISSOURI, et al., Defendants.

          ORDER

          NANETTE K. LAUGHREY, UNITED STATES DISTRICT JUDGE

         Pending 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 as well.[1]

         For the 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.

         I. Background

         a. Stufflebean's Medical Conditions

         Justin 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.

         Stufflebean's 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.

         On 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).[2] 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, [3] ¶ 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, [4]¶ 46.

         On 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.

         b. Sheriff's Deputy Gross

         Brian 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, [5] ¶ 6; BC SF Reply, [6] ¶ 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.

         Gross 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. 477-18, 12:4-7.

         Dr. 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.

         After 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.

         c. Sheriff's Deputy Nauman

         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.

         The 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.

         The 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.

         The 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, [7] 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.

         Despite 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 teleconference), 7:2-8:19.

         After 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.

         When 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, ¶ 96.

         Nauman had no further contact with Stufflebean during his stay in the Buchanan County Jail in October 2015. BC SF, ¶ 31.

         d. Medical Providers-ACH and Its Employees

         Ann 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. Id.

         April 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.

         Dr. Catherine Van Voorn was the medical director covering the Buchanan County Jail. Doc. 447-22, 20:7-13.

         e. Stufflebean's Medical Treatment at the Buchanan County Jail

         i. Nurse Slagle's Intake

         Nauman 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).

         On 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., ¶ 26.[8] 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).

         Once-a-day 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.”)

         On 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.

         Thus, 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, ¶¶ 35-36.

         Slagle 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 Stufflebean).

         The 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.

         Slagle 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 other documentation:

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 verification form?
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 everything.
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 verification form?
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 verification form?
A. Yes, I would have seen that there were medications that were not on my form.

         Slagle's 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.

         Slagle 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.”

         ii. Dr. Van Voorn's Orders

         On 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., ¶¶ 41, 44.

         Dr. Van 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.

         Dr. Van Voorn visited the Buchanan County Jail once a week. ACH SF, [9] ¶ 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.

         iii. Helsel's Failure to Administer Medication

         There 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., 29:12-17.[10]

         Some 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.

         iv. Failure to Take Vitals

         There 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.

         v. Stufflebean's Deteriorating Condition

         During 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”).

         f. Transfer to Prison

         On 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.

         The 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., ¶ 71.

         Stufflebean did not receive any medications at the WRDCC from October 29-31, 2015. BC AF, ¶ 46.

         On 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.

         g. ACH and Buchanan County Policies and Procedures

         During 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., ¶ 96.

         The 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.

         h. Oversight by ACH

         ACH has 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.

         i. Oversight of ACH

         Sheriff 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.

         BCSD 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.

         As part 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.

         To 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.

         j. Medical Care Discrepancies and Purported Deficiencies

         Prior 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 ...


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