Beauford v. Mesa Cnty.

• Decision Date: 25 May 2022
• Docket Number: 21-1010
• Citation: 35 F.4th 1248
• Parties: ESTATE OF Tomas BEAUFORD; Tiffany Marsh, personally and as representative of the estate of Tomas Beauford, Plaintiffs - Appellants, v. MESA COUNTY, COLORADO; Correct Care Solutions, LLC; Correctional Healthcare Companies, Inc.; Correctional Healthcare Physicians, P.C.; Correctional Healthcare Management, Inc.; Sheriff Matt Lewis, in his official capacity; Deputy Peter M. Dalrymple; Deputy Richard D. Perkinson; Nurse Renee Workman; Nurse Velda Havens; Nurse Audra Keenan; Nurse Jeanne Annmarie Schans; Michael LeFebre, in his official and individual capacities; Dr. Kurt Holmes, in his official and individual capacities, Defendants - Appellees.
• Court: U.S. Court of Appeals — Tenth Circuit

35 F.4th 1248

ESTATE OF Tomas BEAUFORD; Tiffany Marsh, personally and as representative of the estate of Tomas Beauford, Plaintiffs - Appellants,

v.MESA COUNTY, COLORADO; Correct Care Solutions, LLC; Correctional Healthcare Companies, Inc.; Correctional Healthcare Physicians, P.C.; Correctional Healthcare Management, Inc.; Sheriff Matt Lewis, in his official capacity; Deputy Peter M. Dalrymple; Deputy Richard D. Perkinson; Nurse Renee Workman; Nurse Velda Havens; Nurse Audra Keenan; Nurse Jeanne Annmarie Schans; Michael LeFebre, in his official and individual capacities; Dr. Kurt Holmes, in his official and individual capacities, Defendants - Appellees.

No. 21-1010

United States Court of Appeals, Tenth Circuit.

FILED May 25, 2022

David A. Lane (Darold W. Killmer, Michael Fairhurst, and Andy McNulty with him on the briefs), Killmer, Lane & Newman, LLP, Denver Colorado, for Plaintiffs – Appellants

Jacob Z. Goldstein (Eric P. Schoonveld, Theodore C. Hosna, and Casey Kannenberg with him on the brief), Hall Prangle & Schoonveld, LLC, Chicago, Illinois, for CHC Defendants – Appellees

Andrew B. Clauss (Chris W. Brophy with him on the brief), Dinsmore & Shohl LLP, Denver, Colorado, for Mesa County Defendants – Appellees

Before McHUGH, MURPHY, and ROSSMAN, Circuit Judges.

ROSSMAN, Circuit Judge.

After midnight on April 16, 2014, Tomas Beauford suffered a fatal epileptic seizure in his cell while in pretrial custody at the Mesa County Detention Facility ("MCDF"). The administrator of Mr. Beauford's estate sued various Mesa County and medical defendants¹ in federal district court in Colorado under 42 U.S.C. § 1983 alleging they were deliberately indifferent to Mr. Beauford's serious medical needs in violation of the Fourteenth Amendment. The district court granted summary judgment to all defendants. Exercising jurisdiction under 28 U.S.C. § 1291, we reverse the district court's grant of summary judgment to Deputy Dalrymple, and accordingly, we also reverse the grant of summary judgment to the Mesa County Defendants on the Estate's entity liability claim under Monell v. Department of Social Services of New York , 436 U.S. 658, 98 S.Ct. 2018, 56 L.Ed.2d 611 (1978). The district court's order is otherwise affirmed.

I. Background

A. Factual Background²

Mr. Beauford was a 24-year-old Black male who suffered from epilepsy

. He also had a severe intellectual disability and several mental health disorders, including bipolar disorder, paranoid schizophrenia, attention hyperactivity disorder, and oppositional defiant disorder. Mr. Beauford's IQ was 52, and he functioned at the level of a five- or six-year-old child.

Mr. Beauford was prescribed many medications, including anti-seizure medicine, which he had a history of refusing. Mr. Beauford also had an implanted Vagus Nerve Stimulator ("VNS") to control his epilepsy

. A VNS is a "bodily implant that interferes with a seizure by sending a shock through the nervous system." Aplt. App. vol. 12 at 3292. The device "has a microprocessor that automatically stimulates the vagus nerve every few minutes," and it also can be activated by a magnetic bracelet. Id. It is undisputed that, at the time he was arrested, Mr. Beauford had a VNS bracelet, but it was not with him when he died.

1. Mr. Beauford's 2014 Detention at MCDF

On March 1, 2014, Mr. Beauford was arrested on charges of assault and unlawful sexual contact and booked into MCDF. He was housed alone in a single cell, located either in the booking area or in an administrative segregation area called Cedar Pod.

Mesa County contracted with a private company—defendant CHC—to provide medical services to inmates at MCDF. Defendant Dr. Kurt Holmes oversaw CHC's medical care services and defendant Michael LeFebre was the mental health supervisor at MCDF. CHC also employed defendant nurses Velda Havens, Audra Keenan, Jeanne Schans, and Renee Workman. Each of these defendants cared for Mr. Beauford in some capacity while he was detained at MCDF.³

During his detention, Mr. Beauford refused medications about fifty percent of the time. The defendant nurses encouraged him to take his medicine by offering his favorite snacks, such as Taco Bell burritos and Sprite. Dr. Holmes and Mr. LeFebre knew Mr. Beauford at times refused medication, including his anti-seizure medicine. But they took no action other than to advise the nurses they should continue to offer medication and to entice Mr. Beauford to take it.

Mr. Beauford's physical and mental condition deteriorated at MCDF. On March 20, Mr. LeFebre visited Mr. Beauford and marked his clinical status as "poor." Aplt. App. vol. 6 at 1718-19. The nursing staff logs reported Mr. Beauford had developed a sore from spending so much time lying in bed in the same position. He sometimes refused to eat. Mr. Beauford struggled to get dressed, sit up, stand, or use the restroom on his own. He was sometimes found to be wet with urine. The jail guards frequently called for the nurses to change Mr. Beauford's clothes and bring him a new adult diaper. The nurses often observed Mr. Beauford struggle—or outright refuse—to verbalize his wants and needs. During his approximately six-week detention, Mr. Beauford suffered documented seizures on March 1, 3, and 18 and April 15. See Aplt. App. vol. 10 at 2778.

2. The Night of April 15-16⁴

By the evening of April 15, Mr. Beauford had been refusing all medications, including his anti-seizure medicine, for the past three days. That evening and through the early morning of April 16, defendant Deputies Dalrymple and Perkinson were on duty in Cedar Pod, along with Nurse Workman. Officers on the night shift conducted inmate security checks every half hour as required by MCDF policy. The exact time of each security check was recorded in the jail's computer system. While one officer performed the security check, the other officer staffed the pod station. Officers also assisted the on-duty nurse with medication rounds and took inmate head counts.

Deputies Dalrymple and Perkinson each conducted security checks from 6:00 p.m. to 7:20 p.m. on April 15 and observed no issue with any inmate. Aplt. App. vol. 8 at 2282-83. During a security check at 7:50 p.m., Deputy Perkinson stepped into Mr. Beauford's cell to pick up a dinner tray. He observed Mr. Beauford grunting underneath his blanket. Deputy Perkinson thought Mr. Beauford was probably masturbating and otherwise "seemed normal," so he did not talk to him. Id. at 2283. "[A]ll seemed okay" with Mr. Beauford during the next security check at 8:20 p.m. Id.

Around 8:40 p.m., Deputy Perkinson and Nurse Workman were on medication rounds when they came to Mr. Beauford's cell and observed him "on the bed, and completely covered by a blanket." Id. Deputy Perkinson first thought Mr. Beauford might be masturbating again. But "due to how he was shaking" and knowing that Mr. Beauford was an epileptic, Deputy Perkinson "had a second thought that Mr. Beauford may be seizing." Id. Deputy Perkinson and Nurse Workman entered Mr. Beauford's cell and discovered he was having a seizure. Nurse Workman turned Mr. Beauford on his side and sat with him through the duration of the seizure, which lasted five more minutes. Deputy Perkinson and Nurse Workman then left Mr. Beauford's cell at 8:49 p.m. to finish medication rounds. Id. at 2383.

At 9:01 p.m., Deputy Dalrymple performed another security check. Id. He looked into Mr. Beauford's cell and saw him lying on his bed shaking with his eyes open. Deputy Dalrymple said nothing to Mr. Beauford and continued on to complete his check of other inmates. When interviewed by an MCDF officer a few hours after Mr. Beauford died, Deputy Dalrymple said he reported the shaking to Deputy Perkinson, who had assured him that, according to Nurse Workman, Mr. Beauford would be "fine." Id. at 2282. At his deposition, Deputy Dalrymple likewise testified he had reported the shaking to someone but was uncertain whether he told Deputy Perkinson or Nurse Workman. Id. at 2311.

Deputy Perkinson and Nurse Workman returned to Mr. Beauford's cell at 9:21 p.m. Id. at 2284, 2383. Mr. Beauford refused to let Nurse Workman take his vitals and asked them to leave. Nurse Workman assured Deputy Perkinson that Mr. Beauford would be fine and she did not instruct the deputies to conduct extra monitoring of Mr. Beauford.

The deputies completed more security checks about every half-hour over the next several hours, and each time, observed Mr. Beauford laying on his bed, reading or sleeping. After doing a security round at 10:15 p.m., Deputy Perkinson moved off Cedar Pod to other duties, leaving Deputy Dalrymple as the only officer on the pod.⁵

During his security check at 11:55 p.m., Deputy Dalrymple saw Mr. Beauford laying on the floor of his cell, facedown, with his head under his desk. Id. at 2281, 2310. Deputy Dalrymple used his flashlight to illuminate Mr. Beauford and watched him for a few moments. He knew Mr. Beauford often slept in unusual positions in his cell and believed Mr. Beauford was breathing because he saw Mr. Beauford's covers rising and falling. Id. at 2282. Deputy Dalrymple then finished his security check and returned to the pod officer station.

On his next security round at around 12:15 a.m.,⁶ Deputy Dalrymple observed Mr. Beauford lying motionless in the same position on the floor of his cell. This time, however, Deputy Dalrymple "could not tell for sure" if Mr. Beauford was breathing. Id. at 2282-83. After completing his security check, Deputy Dalrymple alerted medical personnel he had observed Mr. Beauford lying on the floor of his cell. "About ten minutes passed between Deputy Dalrymple's observation and his call to the [MCDF] medical staff." Aplt. App. vol. 12 at 3293. Around 12:25 a.m.,⁷ Deputy Dalrymple and Nurse Workman entered Mr. Beauford's cell and found him unresponsive.

Nurse Workman retrieved a medical kit while Deputy Dalrymple started CPR and other staff called 911. Deputies moved Mr. Beauford into the "dayroom area outside the...