Hadix v. Caruso

• Citation: 461 F.Supp.2d 574
• Decision Date: 13 November 2006
• Docket Number: No. 4:92-CV-110.,4:92-CV-110.
• Parties: Everett HADIX, et al., Plaintiffs, v. Patricia L. CARUSO, et al., Defendants.
• Court: U.S. District Court — Western District of Michigan

461 F.Supp.2d 574

Everett HADIX, et al., Plaintiffs, v. Patricia L. CARUSO, et al., Defendants.

No. 4:92-CV-110.

United States District Court, W.D. Michigan, Southern Division.

November 13, 2006.

COPYRIGHT MATERIAL OMITTED

Elizabeth Alexander, Michael Barnhart, Patricia A. Streeter, for Plaintiffs.

A. Peter Govorchin, for Defendants.

OPINION

ENSLEN, Senior District Judge.

Say a prayer for T.S. and the others who have passed. Any earthly help comes far too late for them.

I. BACKGROUND

1. Procedural History

This Court held an evidentiary hearing regarding Plaintiffs' Motion to Reopen Judgment Regarding Mental Health Care and Issue a Preliminary Injunction on October 11-13, 2006. Also considered during the hearing were two other motions by Plaintiffs, which will be determined later. The Court has now received supplemental proofs and post-hearing briefs from the parties as to the Motion to Reopen. Given the significance of the substantive issues, the Court now resolves the Motion without delay.

A short primer on the history of mental health care at the Hadix facilities maybe necessary to understand the present controversy. This suit was filed in the Eastern District of Michigan in 1980 to redress a variety of unconstitutional conditions, including inadequate mental health care, at certain designated Jackson, Michigan prison facilities operated by prison officials of the Michigan Department of Corrections pursuant to 42 U.S.C. § 1983. In 1985, a Consent Decree was entered by stipulation of the parties with the approval of United States District Judge John Feikens. Section II.B of the Consent Decree pertained to mental health care for prisoners within the Hadix facilities.

Judge Feikens initially transferred enforcement of medical care and mental health care provisions of the Consent Decree to this Court by Order of June 5, 1992 pursuant to 28 U.S.C. § 1404(a). Hadix v. Johnson, 792 F.Supp. 527, 528 (E.D.Mich. 1992). The purpose of the Order was to promote uniformity and effectiveness of remedy in light of this Court's enforcement of a Consent Decree involving the same issues in a separate suit — United States v. Michigan, Case No. 1:84-cv-63. Id. See also Hadix v. Johnson, 228 F.3d 662, 665 (6th Cir.2000) (discussing history of suit).

Mental health care at the facilities was routinely monitored by the Court until 2001. On January 8, 2001, the Court granted Defendants' request to terminate enforcement of the mental health provisions of the Consent Decree effective upon ten days after the filing of an Updated CQI Monitoring and Data Validation document. (Order of Jan. 8, 2001.) The document was filed by Defendants on January 23, 2001. (Dkt. No. 1437.) Thus, the termination became effective in early February 2001. Plaintiffs moved on September 8, 2006 to reopen the terminated provisions and for a preliminary injunction pertaining to mental health care. The cause for the Motion was the tragic death of a Michigan prisoner, T.S., and other fatal cases in which inmates' deaths were attributable to delays or malfeasance in the provision of mental health care.

2. Death of T.S.

On August 6, 2006, Michigan prisoner T.S. died. The basic circumstances of his death were discovered by medical monitor Dr. Robert Cohen, M.D. between August 7, 2006 and August 10, 2006, and conveyed to the Court by letter of August 14, 2006. (Dkt. No.2088.) T.S. was a twenty-one-year-old male with a history of mental illness. He was placed in the segregation unit at JMF (a Hadix facility) beginning on August 2, 2003; he spent five days in two segregation cells at JMF locked in four-point restraints to concrete slab beds without any effective medical or mental health care. He was unlocked shortly before he died.

T.S.'s death was investigated by both the Michigan Department of Corrections and by Plaintiffs. The following account is taken from trial exhibits, including custody logs, overhead in-cell videotape and portable videotape of the events between August 2, 2006 and August 6, 2006. The basic road map for the events is Plaintiffs' Exhibit 106A, which provides a time log. There are some slight discrepancies as to time of certain events between the log book and the video time recordings (of some ten minutes); the Court utilizes the time log in Exhibit 106A as the best record of the time sequence of the recorded events. (See also Pls.' Ex. 42, at bates nos. 320947-320971 (custody log); Pls.' Ex. 106B (video excerpts); Pls.' Ex. 106C (complete hand-held video); Pls.' Ex. 106D (complete overhead video).)

T.S. arrived at JMF in March 2006 and was housed as a level II general population prisoner. (Pls.' Ex. 106A at 1.) On July 31, 2006, he was transferred by custody staff from general population to administrative segregation due to disobedience of custodial orders. On August 2, 2006, at 1239 hours he was placed in soft standing restraints (locking leather and vinyl restraints around his hands, feet and waist). (Id.) He then flooded his sink and was placed on "top of the bed restraints" at 1327 hours. (Id. at 2.) "Top of the bed restraints" are according to policy "the securing of both arms and legs to a bed...." (Pls.' Ex. 42, MDOC Operating Procedure, bates no. 320597, emphasis in original.) Prisoners so secured are to be observed every 15 minutes and to be offered bathroom and water drinking breaks every two hours. (Id. at bates no. 320598.)

In practice, "top of the beds restraints" is a euphemism for chaining an inmate's hands and feet to a concrete slab. T.S.'s "bed" was composed of a concrete slab with four metal, arc-shaped handles emanating from the slab for the purpose of receiving the locking restraints. (See Pls.' Ex. 106-B.) Two of the handles, positioned in the longitudinal middle of the bed, were across from each other at the outside edges of the bed to receive the hand and waist restraints. (Id.) The remaining two handles were positioned across from one another at the outer edges of the foot of the bed to receive the feet restraints. (Id.) A small mattress pad was provided, but was not used for much of the restraint because T.S. removed it and/or because he urinated on the bed. (Pls.' Ex. 106A at 3-4.) For many hours of the restraint, T.S. was naked and laid in his own urine. (Id. at 4-9.) On one occasion, T.S. refused to cooperate with his restraint; this prompted five correctional officers to use a large plexiglass shield and place their weight upon T.S. while they locked him, screaming to the slab with chains. (Pls.' Ex. 106B.) On August 5, 2006, T.S. was removed from his cell for one hour for treatment of a urine burn on his back at Duane Waters Hospital. (Pls.' Ex. 106A at 6.) Apparently, such treatment never occurred because T.S. urinated on an examination table at the hospital. (Op. & Decl. of Jerry Walden, M.D. ¶ 26; trial transcript ("T.T."), vol. 1, 131 (testimony adopting declaration).)

Much of the defiant and self-destructive behavior of T.S. is explained as a product of untreated mental illness. T.S. had a documented history of bipolar disorder, depression, hyperactivity disorder and suicide attempts. (Walden Decl. ¶ 3.) T.S. was seen on August 2, 2006 by an outpatient social worker, Francis Duffy.¹ (Pls.' Ex. 103, F. Duffy Dep. 53-54.) Duffy determined that T.S. was "floridly psychotic. Exhibiting symptoms consistent with his description of manic episodes prior to incarceration." (Duffy Dep. Ex. 10.) Duffy thus referred T.S. to the "CSP" — id. — meaning the Crisis Stabilization Program that hospitalizes and treats mentally ill prisoners at the Huron Valley Men's Facility (a prison psychiatric hospital). (See Duffy Dep. 41 & 4'7.) Duffy had no expectation that T.S. would be transferred immediately, though, since he planned to examine T.S. the following day. (See Duffy Dep. Ex. 10.) The prior suicide attempts noted by Duffy referred to a series of suicide attempts in the Kalamazoo County Jail (T.S. stabbing himself in the stomach and attempting hanging); the hanging was attempted while T.S. was housed in the Kalamazoo Regional Psychiatric Hospital and nearly resulted in his death. (Walden Decl. ¶ 19.)

Duffy completed a referral form for T.S. on the morning of August 3, 2006 before examining T.S. again later in the day. (Duffy Dep. 71.) The referral form was marked "Emergent" and noted that "Prisoner decompensated ... in detention cell ... Prisoner remained agitated ... Associations loose, disintegrated. Unable to determine if prisoner is responding to internal stimuli...." (Duffy Dep. Ex. 9 at 1.) Duffy also noted that T.S.'s psychiatric medications could not be changed due to the absence of an on-site psychiatrist. (Id. at 2.)

The same day Duffy received an email that the referral had been received. (Duffy Dep. 71.) He later received an email that day that the referral had been approved. (Id. at 72.) T.S. was not transferred that day, though. Defendants blame the failure to transfer upon a "transfer coordinator" (secretary) at Huron Valley who failed to transmit the transfer order to JMF, together with the scheduled leave of the transferring psychiatrist on Friday, August 4, 2006 and Mr. Duffy's past reliance on email correspondence to affect transfer orders. (See Defs.' Resp., Dkt. No. 2177, at 5.)

The immediate consequence of the failure to transfer was that a psychotic man with apparent delusions and screaming incoherently was left in chains on a concrete bed over an extended period of time with no effective access to medical or psychiatric care and with custody staff telling him that he would be kept in four-point restraints until he was cooperative. (See Pls.' Ex. 106B.) At the time of these incidents, there was no on-site psychiatric coverage for JFM because the staff psychiatrist was on "an extended leave." (Walden Decl. ¶¶ 40-41.)

T.S. was prescribed several medications, including psychothropic medications, while at JMF. (Id. at ¶ 45.) These included Lithium (which is known to cause kidney...