Shepherd v. Dallas County

• Decision Date: 18 December 2009
• Docket Number: No. 08-10918.,08-10918.
• Citation: 591 F.3d 445
• Parties: Stanley SHEPHERD, Plaintiff-Appellee Cross-Appellant, v. DALLAS COUNTY, Defendant-Appellant Cross-Appellee.
• Court: U.S. Court of Appeals — Fifth Circuit

591 F.3d 445

Stanley SHEPHERD, Plaintiff-Appellee Cross-Appellant, v. DALLAS COUNTY, Defendant-Appellant Cross-Appellee.

No. 08-10918.

United States Court of Appeals, Fifth Circuit.

December 18, 2009.

Don A. Tittle, Dallas, TX, Debbie Branscum (argued), Bedford, TX, Robert Lawrence Chaiken, Chaiken & Chaiken, P.C., Dallas, TX, for Shepherd.

Dolena Tutt Westergard (argued), Dallas, TX, for Dallas County.

Appeal from the United States District Court for the Northern District of Texas.

Before JONES, Chief Judge, and GARZA and STEWART, Circuit Judges.

EDITH H. JONES, Chief Judge:

Stanley Shepherd, a pretrial detainee, suffered a stroke and permanent disability due to the failure of the Dallas County Jail to administer the pills he had to take to ameliorate his chronic hypertension. That failure, Shepherd showed below, was not an unintended error but the predictable result of a de facto policy that denied inmates adequate care for chronic conditions. At summary judgment, the district court ruled that Shepherd's § 1983 claim was best characterized as a challenge to his conditions of confinement, and the jury subsequently awarded him $890,336 in damages. Dallas County appeals, contending, inter alia, that the district court erred in so characterizing Shepherd's claim and in instructing the jury. Because this is the rare case in which a plaintiff demonstrated deficiencies in the conditions of confinement that amounted to punishment before he was judged guilty and thus violated due process of law, Bell v. Wolfish, 441 U.S. 520, 535, 99 S.Ct. 1861, 1872, 60 L.Ed.2d 447 (1979), the district court's judgment is AFFIRMED.

I. BACKGROUND

On October 4, 2003, Stanley Shepherd was booked into the Dallas County Jail as a pretrial detainee. At intake, he informed a nurse at the jail that he had hypertension and had been taking Clonidine twice daily to treat that condition.

In his first two weeks at the jail, Shepherd requested Clonidine several times — one nurse practitioner recorded that he "wants and insists on Clonidine" — and, after a high blood-pressure reading on October 14, 2003, he was prescribed a different medication. Despite frequent complaints, he waited weeks between doses, was not monitored, and received no other medical treatment.

On November 27, Shepherd was brought to the jail clinic complaining of a severe headache. His blood pressure was high — 165/117. Dr. Kathryn Flangin ordered that Shepherd be given one dose of Clonidine and that his blood pressure be checked for three days.

Four days later, on December 1, Shepherd's blood pressure read 181/133, a level considered a "hypertensive emergency." He was given nitroglycerine and a prescription for twice-daily doses of Clonidine.

On December 3, Shepherd experienced a second hypertensive emergency, with his blood pressure reading 242/132. At that time, a nurse noted on Shepherd's chart that he "had not received his Clonidine as ordered." He was administered an initial dose, which proved effective.

For the next seven weeks, Shepherd received no medical treatment. His medication was not dispensed as prescribed, and no medical provider checked his blood pressure. The record shows that he and his wife, who was aware of the situation, complained to jail staff and medical personnel about the lack of treatment. His wife, in particular, repeatedly expressed the concern that Shepherd would have a stroke if he did not receive his medication regularly.

Shepherd did not see a medical provider until January 22, 2004. Early that afternoon, he went to the nurse's station complaining of weakness on the left side of his body and hypertension. A nurse took his blood pressure, which was high, and reported it to Dr. Flangin, who ordered the nurses to monitor Shepherd's blood pressure and administer doses of two drugs, Lasix and Lopressor. Shepherd was sent back to his cell, over his protests that he was not well.

An hour later, Shepherd was found lying on the floor of his cell, with slurred speech, sweating, and left-side weakness. He was immediately taken by ambulance to the hospital, where doctors concluded that he had suffered a stroke because of a hypertensive emergency. After 26 days in the hospital, he was discharged to a rehabilitation center, where he recuperated for several months.

Since his stroke, Shepherd has been permanently confined to a wheelchair, has lost most of his left-side functions, suffered impairment of his left-side sight and hearing, and has slurred speech.

In 2005, Shepherd filed suit against Dallas County seeking damages under 42 U.S.C. § 1983 for violations of his Fourteenth Amendment right to medical care while in custody, challenging both specific "episodic acts and omissions" and the "conditions of confinement." The district court granted summary judgment to the County on Shepherd's episodic acts claim, on the ground that he failed to identify any jail employee who had shown deliberate indifference to his plight, but it allowed his "conditions of confinement" claim to proceed to trial.

At trial, Shepherd presented extensive evidence on the jail's treatment of inmates with chronic illness. Witnesses, including the jail's Medical Director at the time of Shepherd's confinement, the jail's pharmacist, and an employee of the medical services contractor responsible for monitoring the jail's contract, testified that the jail's medical program was understaffed to the point that routine treatment could not be provided; that at times, no medical personnel were present at the jail; that fifty percent or more of prescriptions regularly went undelivered to inmates; that records concerning medication administration were regularly falsified; and that Dallas County officials had been repeatedly notified of these problems.

Two extensive reports entered into evidence buttressed Shepherd's claims. In December 2004, Dallas County retained Health Management Associates ("HMA") to perform a comprehensive review of the health services at the Dallas County Jail. The review was performed, and a report written, by a team led by Dr. Michael Puisis ("Dr. Puisis"), an expert in correctional health. Dr. Puisis made the following findings in his report to the County:

• The jail has "no capacity to diagnose illness at intake" (emphasis in the original). Further, "There is no policy or procedure for how inmates who come into the jail at intake are to receive their medication or be referred to a physician." Overall, "only about 25% of incoming inmates with a chronic illness are actually physically seen by a physician following intake," with the result that "[p]atients with chronic illness ... may never be adequately evaluated."

• "The sick call process in Dallas County Jail is not adequate and its steady state is that inmates, by attrition, leave the jail before being seen more frequently than being appropriately evaluated." Dr. Puisis found "multiple barriers to access" to care, including a dysfunctional "kite" system for inmate requests; the lack of timely review of health care requests by nurses; the unavailability of officers to bring inmates for health services; the lack of adequate capacity to examine inmates who manage to appear at sick call; and understaffing of physicians.

• Monitoring of inmates with chronic conditions is "poor to non-existent." Specifically: "There are no policies, procedures or chronic care guidelines that are used in the management of chronic diseases. There is no mechanism to track individuals who have a chronic illness ..., and there is no mechanism in place to assign acuity to patients with chronic illness." Generally, inmates with chronic illness are seen only "when their conditions deteriorate to an urgent status"; inmates whose conditions have not yet reached that point "usually are discharged before being seen" by a doctor. The result of this system, according to Dr. Puisis's review of inmate medical charts, is "disease deterioration to the point of requiring hospitalization."

Dr. Puisis's findings were echoed in a 2006 report by the Department of Justice ("DOJ"). In on-site inspections in February and March 2006, the DOJ found that the jail "fails to adequately identify inmates' health needs through appropriate intake screening, thereby preventing inmates from receiving adequate care for acute or chronic needs." The jail "has no clinical practice guidelines for chronic and communicable diseases," including hypertension. It "fails to ensure that inmates receive thorough assessments and monitoring of their chronic illnesses." Care for inmates with chronic conditions is "plagued by delays in the treatment and administration of medication." Like Dr. Puisis, the DOJ found that the system for obtaining medical treatment was "inadequate" due, in large part, to "significant" barriers to access, including a complete lack of any protocols for collecting, processing, distributing, logging, and triaging medical requests. The jail regularly lost track of inmates with chronic illness and, overall, "fails to provide adequate treatment for their needs." The DOJ was particularly critical of the jail's system of administering medication, as a result of which "inmates routinely miss doses of life-sustaining medications." The DOJ identified numerous cases where inmates suffered or died because of the jail's inadequate treatment of chronic conditions. It concluded that the jail was operating in violation of inmates' constitutional right to adequate medical care.

The jury rendered a verdict for Shepherd, and a judgment was entered in his favor. Both parties appealed.

II. DISCUSSION

Dallas County raises four issues in this appeal: (1) whether the district court erred in classifying the plaintiff's § 1983 claim as an attack on conditions of confinement; (2) whether the district court erred in failing to require the jury to find that the County adopted or maintained any unconstitutional conditions of confinement with the intent to punish...