Sandoval v. Cnty. of San Diego

• Decision Date: 13 January 2021
• Docket Number: No. 18-55289,18-55289
• Citation: 985 F.3d 657
• Parties: Ana SANDOVAL, individually and as successor in interest to Ronnie Sandoval, Jr.; Ronnie Sandoval, Jr.; Josiah Sandoval, Plaintiffs-Appellants, v. COUNTY OF SAN DIEGO; Romeo De Guzman; Maria Llamado; Dana Harris, Defendants-Appellees.
• Court: U.S. Court of Appeals — Ninth Circuit

985 F.3d 657

Ana SANDOVAL, individually and as successor in interest to Ronnie Sandoval, Jr.; Ronnie Sandoval, Jr.; Josiah Sandoval, Plaintiffs-Appellants,

v.COUNTY OF SAN DIEGO; Romeo De Guzman; Maria Llamado; Dana Harris, Defendants-Appellees.

No. 18-55289

United States Court of Appeals, Ninth Circuit.

Argued and Submitted October 16, 2019

Submission Vacated March 16, 2020

Resubmitted January 6, 2021 Pasadena, California

Filed January 13, 2021

OPINION

WARDLAW, Circuit Judge:

Ronnie Sandoval died of a methamphetamine overdose at the San Diego Central Jail after medical staff left him unmonitored for eight hours, despite signs that he was under the influence of drugs, and then failed to promptly summon paramedics when they discovered him unresponsive and having a seizure. Sandoval's wife and successor-in-interest, Ana Sandoval (Plaintiff), brought suit under 42 U.S.C. § 1983 against the County of San Diego and Nurses Romeo de Guzman, Dana Harris, and Maria Llamado, alleging that they violated Sandoval's Fourteenth Amendment right to adequate medical care in custody.

The district court granted summary judgment to the defendants, concluding that there were no triable issues of fact as to their liability and that the individual nurses were entitled to qualified immunity. After the district court issued its decision, we clarified that an objective standard applies to constitutional claims of inadequate medical care brought by pretrial detainees. Gordon v. County of Orange , 888 F.3d 1118, 1124–25 (9th Cir. 2018). Applying that standard here, we reverse because genuine disputes of material fact preclude the award of summary judgment, and we remand for further proceedings.

I.

Many of the facts underlying this case are in dispute. We recount them in the light most favorable to Plaintiff, as the non-moving party in the district court. Tuuamalemalo v. Greene , 946 F.3d 471, 474 (9th Cir. 2019) (per curiam).

A.

On February 22, 2014, deputies from the San Diego Sheriff's Department went to Ronnie Sandoval's residence to conduct a probation compliance check. After the deputies found a gram of methamphetamine and drug paraphernalia, they placed Sandoval under arrest and took him to the San Diego Central Jail. Unbeknownst to the arresting deputies, Sandoval had swallowed an additional amount of methamphetamine—later estimated to be several hundred times the typical recreational dose—in an effort to prevent its discovery.

At the jail, Deputy Matthew Chavez noticed that Sandoval was sweating and appeared disoriented and lethargic. When asked about these symptoms, Sandoval told Chavez that he might be diabetic. A nurse tested Sandoval's blood sugar level, which came back normal, and Sandoval was placed in a holding cell.

Approximately one hour later, Sandoval was removed from the cell to have his booking photograph taken. Deputy Chavez observed that Sandoval "was still sweating a lot and appeared to be very tired and disoriented." Chavez asked Sandoval if he was ok. Sandoval responded that he was very cold, which Chavez found odd because Sandoval was sweating. Another deputy asked Sandoval if he had swallowed anything, and Sandoval became agitated and refused to answer further questions.

Deputy Chavez took Sandoval to the second-floor medical station for an assessment. There he encountered Nurse Romeo de Guzman. Chavez told de Guzman that while Sandoval had been cleared by the medical staff downstairs, he was sweating and appeared disoriented and lethargic. According to Chavez, he specifically told de Guzman, "there [is] still something going on [with Sandoval], so you need to look at him more thoroughly."¹ De Guzman told Chavez to put Sandoval in Medical Observation Cell No. 1 (MOC1).

Shortly thereafter, around 5:00 p.m., de Guzman entered MOC1 to attend to Sandoval. Leonard Rodriguez, a deputy who accompanied de Guzman into the cell, noticed that Sandoval was "shaking mildly" and "appeared to be having withdrawals from drugs." De Guzman gave Sandoval a second, and "very quick," blood sugar test, which came back normal and then left the cell without conducting any further examination.

From there, accounts diverge. Nurse de Guzman claims that he told deputies that Sandoval was "cleared for booking process." But according to Deputy Rodriguez's written, contemporaneous police report, de Guzman instead asked whether Sandoval could be moved to a "sobering tank." The deputies conferred and determined that it would be better if Sandoval remained in MOC1, presumably so that he would be subject to closer observation by the medical staff.

All agree that Sandoval was not transferred and instead remained in MOC1. And it is undisputed that even though MOC1 was only 20 feet from the nursing station, Nurse de Guzman did not check on Sandoval at any point during the remaining six hours of his shift. When the next shift of nurses arrived at 11:00 p.m., de Guzman did not tell them anything about Sandoval either. When asked why he never checked on Sandoval, de Guzman responded simply, "I don't have to."

The failure to monitor Sandoval may have resulted in part from the "mixed use" nature of MOC1. While MOC1 was sometimes used to hold inmates requiring medical care, it was used at other times as an ordinary holding cell. Unlike other cells used for inmates with medical issues, no nurses were specifically assigned to monitor individuals being held in MOC1. Instead, nurses would attend to MOC1 only if told that an individual who was placed there needed care.

This sometimes caused confusion. For example, Nurse de Guzman claims that he did not check on Sandoval because he believed that MOC1 was used exclusively as an ordinary holding cell and that Sandoval was being held there for correctional, rather than medical, purposes. In contrast, the deputies believed that by leaving Sandoval in MOC1, they would ensure that he would be monitored by the medical staff.

Whatever the cause, Sandoval remained almost entirely unmonitored for nearly eight hours until Sergeant Robert Shawcroft walked past MOC1 at 12:55 a.m. and noticed that Sandoval's eyes "weren't tracking" and that his skin tone "wasn't a fleshy color."² As Shawcroft watched, Sandoval slumped over and his eyes rolled back in his head. Shawcroft turned away to call for help, and when he turned back, he saw Sandoval hit his head on the wall and slide down to the floor.

Sergeant Shawcroft entered Sandoval's cell and was soon joined by Deputies Nolan Edge and Matthew Andrade, and Nurses Dana Harris and Maria Llamado. Sergeant Shawcroft, Deputy Andrade, Deputy Edge, and Nurse Llamado all agree that Sandoval was unresponsive and having a seizure or "seizure-like activity." In contrast, Nurse Harris contends that Sandoval was responsive, followed verbal commands, and was not seizing.

Whether Sandoval was unresponsive and seizing bears on an important distinction in this case between emergency medical technicians (EMTs) and paramedics. While the terms are sometimes used interchangeably, paramedics receive more advanced training than EMTs. EMTs can provide only basic life support (BLS) procedures, such as performing CPR and providing a patient with an oxygen mask. In contrast, paramedics are trained to perform advanced cardiovascular life support (ACLS) procedures, including establishing IVs, administering medications, reading heart rhythms, and inserting breathing tubes

. Critically, when a patient is unresponsive, paramedics are required. In San Diego at least, EMTs will not transport unresponsive patients.

Because Nurse Harris was the first nurse to arrive on the scene, she became the "team leader" with primary responsibility for directing Sandoval's treatment. The evidence shows that even though Harris was told several times to call paramedics because Sandoval was unresponsive, she refused to do so.

Deputy Andrade, who happened to be a trained EMT, asked two or three times for paramedics to be called. Harris did not do so. Nurse Llamado says that she directly told Harris, "He has to go out 9-1-1," meaning that paramedics were needed. Harris responded, "No, EMT." Llamado then telephoned the charge nurse, Shirley Bautista, who also said that paramedics should be summoned. Llamado put the phone down and told Harris, "Shirley said he has to go now 9-1-1." Despite all of this, Harris still refused to call paramedics.³

It is undisputed that EMTs were initially summoned instead of paramedics. When the EMTs arrived around 1:20 a.m., they informed the nurses and deputies that "they would not be able to transport Sandoval in the current condition he was in." Paramedics were then called and arrived at 1:42 a.m.—47 minutes after Sandoval was first observed to be unresponsive and seizing. According to Deputy Andrade, Sandoval still had a pulse when the paramedics arrived. But he lost his pulse when he was transferred to a gurney. Resuscitation efforts failed, and Sandoval was pronounced dead at 2:11 a.m.

During discovery, it was revealed that Nurse Harris did not know on the night of the incident that only paramedics, and not EMTs, could provide the ACLS treatment that Sandoval required—even though this was common knowledge among nurses. Nurse Llamado later admitted that she should have called paramedics herself when Harris refused to do so, and that she had "learned [her] lesson."

B.

Sandoval's wife, Ana Sandoval, filed this suit in California state court against Nurses de Guzman, Harris, and Llamado, and the County of San Diego. The complaint alleged that the individual nurses had violated the Fourteenth Amendment by failing to provide Sandoval adequate medical care, and that the County was likewise liable because its policy of using MOC1 as a mixed used cell, without proper communication protocols, created the confusion among the medical staff that led to Sandoval's death. The complaint also asserted several state law claims.⁴

The defendants removed the case to federal court and later moved for summary judgment. For reasons discussed...