Sherie Lemire, Individually and as personal representative for the Estate of Robert St. Jovite; Gerard Charles St. Jovite and Nicole St. Jovite; Nicole St. Jovite; Gerard Charles St. Jovite;Estate of Robert St. Jovite, Plaintiffs-Appellants,
California Department of Corrections and Rehabilitation; Arnold Schwarzenegger, Individually and in his official capacity as Governor of the State of California; James E. Tilton, Individually and in his official capacity as Secretary of CA Department of Corrections and Rehabilitation; Tom L. Cary, Individually and in his official capacity as Warden of CSP-Solano; D. K. Sisto, Individually and in his official capacity as Warden of CSP-Solano; Cahoon, Individually and in her official capacity as Correctional Officer; Alcaraz, Individually and in his official capacity as Correctional Officer; Wade, Individually and in his official capacity as Correctional Officer; Orrick, Individually and in her official capacity as Correctional Officer; Martinez, Individually and in her official capacity as Correctional Officer; Gordon Wong, Individually and in his official capacity; Hak, MTA, Individually and in her official capacity; Alvara C. Traquina, M.D., Individually and in his official capacity as Chief Medical Officer/Health Care Manager; Noriega, Individually and in his official capacity; Dusay, Dr., Individually and in his official capacity; Neuring, Individually and in his official capacity; Dodie Hicks, Senior RN; C. Holliday, Correctional Officer, Badge No. 70808; Jaime Chua, Correctional Officer, Badge No. 55696, Defendants-Appellees
Argued and Submitted May 15, 2012 San Francisco, California
Appeal from the United States District Court for the Eastern District of California, D.C. No. 2:08-cv-00455-GEB-EFB Garland E. Burrell, District Judge, Presiding
Geri Lynn Green, Attorney, San Francisco, California, for Plaintiffs-Appellants.
Kamala D. Harris, Attorney General of California, Jonathan L. Wolff, Senior Assistant Attorney General, Thomas S. Patterson, Supervising Deputy Attorney General, Diana Esquivel (argued), Deputy Attorney General, Sacramento, California, for Defendants-Appellees.
Before: Stephen Reinhardt, Richard R. Clifton, and N. Randy Smith, Circuit Judges.
Prisoner Civil Rights
The panel affirmed in part and vacated in part the district court's summary judgment and remanded in an action arising from the apparent suicide of an inmate in the California prison system.
The panel held that the district court erred in granting summary judgment with respect to plaintiffs' claims that defendants Warden Dennis Sisto and Captain James Neuhring impermissibly convened a staff meeting that resulted in the absence of all floor officers from the building where the inmate was incarcerated for a period of as long as three and a half hours because those claims presented triable issues of fact. The panel held that a jury could conclude, on the basis of the factual record before the district court, that the complete withdrawal of all supervision created an unconstitutional risk of harm to the mentally ill inmates, that Sisto and Neuhring were responsible for, and deliberately indifferent to, this lack of supervision and that the lack of floor staff was an actual and proximate cause of the inmate's death. The panel affirmed, however, the grant of summary judgment on the inadequate staffing claim with respect to defendants Lieutenant Gordon Wong, Sergeant Gale Martinez, and Sergeant Cheryl Orrick.
The panel also held that the district court erred in granting summary judgment with respect to plaintiffs' claims based on the failure to administer CPR by defendants Officer Rebecca Cahoon and Officer Chris Holliday. The panel concluded that there was a triable issue of fact as to whether defendants Cahoon and Holliday were deliberately indifferent to the inmate's potentially serious medical need when they first arrived at his cell. The panel affirmed with respect to plaintiffs' claims for failure to provide proper medical treatment with respect to the remaining defendants. The panel also affirmed with respect to the failure to train claims.
CLIFTON, Circuit Judge:
This action under 42 U.S.C. § 1983 arises from the apparent suicide of an inmate in the California prison system, Robert St. Jovite. The estate, parents, and daughter of the deceased prisoner seek to recover damages for alleged violations of the Eighth Amendment, based on St. Jovite's right to be free from cruel and unusual punishment, and the Fourteenth Amendment, based on the family's substantive due process right of familial association. These claims are predicated on allegations that members of the custodial, medical, and supervisory staff at California State Prison at Solano ("CSP-Solano") failed to protect and provide adequate medical care by failing to (1) ensure the presence of floor officers to provide sufficient supervision of the inmates, (2) administer CPR immediately after St. Jovite was found unconscious in his cell, and (3) sufficiently train the prison staff in proper CPR procedure. The district court granted summary judgment to Defendants on all claims.
We hold that the district court erred in granting summary judgment with respect to Plaintiffs' claims that Defendants Warden Dennis Sisto and Captain James Neuhring impermissibly convened a staff meeting that resulted in the absence of all floor officers from the building where St. Jovite was incarcerated for a period of as long as three and a half hours because those claims present triable issues of fact. A jury could conclude, on the basis of the factual record before the district court, that the complete withdrawal of all supervision created an unconstitutional risk of harm to the mentally ill inmates in St. Jovite's building and that Sisto and Neuhring were responsible for, and deliberately indifferent to, this lack of supervision. The jury could also conclude that the lack of floor staff was an actual and proximate cause of St. Jovite's death. We affirm, however, the grant of summary judgment on the inadequate staffing claim with respect to Defendants Lieutenant Gordon Wong, Sergeant Gale Martinez, and Sergeant Cheryl Orrick.
We also hold that the district court erred in granting summary judgment with respect to Plaintiffs' claims based on the failure to administer CPR by Defendants Officer Rebecca Cahoon and Officer Chris Holliday. We conclude that there is a triable issue of fact as to whether Defendants Cahoon and Holliday were deliberately indifferent to St. Jovite's potentially serious medical need when they first arrived at his cell. We affirm with respect to Plaintiffs' claims for failure to provide proper medical treatment with respect to the remaining defendants. We also affirm with respect to the failure to train claims.
Accordingly, we vacate the summary judgment as to the claims against Defendants Sisto and Neuhring for withdrawing all floor officers from St. Jovite's building, and as to the claims against Defendants Cahoon and Holliday for failure to provide CPR and remand for further proceedings with respect to these claims.
Robert St. Jovite was found unconscious and unresponsive in his cell at CSP-Solano on May 10, 2006. During his incarceration, St. Jovite was treated for depression, anxiety, panic attacks, and early stages of agoraphobia. After his last treatment session, St. Jovite filled out an inmate appeal form in which he stated that his "daily life [was] almost unmanageable" as a result of his mental condition. St. Jovite never expressed any suicidal thoughts, intentions, or feelings to his treating psychiatrist, however, and his psychiatrist saw no evidence of suicidal ideation during his treatment or through his review of St. Jovite's medical records.
In order to explain St. Jovite's death, we first recount the circumstances that led to his being left without supervision, along with his fellow inmates, for as much as three and a half hours. We then recount the chaotic and disputed circumstances surrounding the response of CSP-Solano's staff to St. Jovite's apparent suicide as stated by the parties, in that same light. As we must at the summary judgment stage, we view the relevant facts in the light most favorable to Plaintiffs.
A. The Staffing of Building 8
The high rate of suicides in California prisons was a "focus" of California prison administrators, including those at CSP-Solano, from 2004 onwards as a result of the Coleman v. Schwarzenegger litigation. In addition to suicide concerns, inmate-on-inmate violence was also a problem at CSP-Solano. Warden Sisto explained that when he was hired to run CSP-Solano he was told that the prison "needed some work" and that "due to all the violence they were having, they continued to have lockdowns, a lot of violence."
St. Jovite was housed on the second tier in Building 8 of CSP-Solano. Each of the two tiers in Building 8 had fifty cells, and there were roughly 190 inmates between them at the time of St. Jovite's death. Building 8 was the designated facility at CSP-Solano for housing inmates who utilized certain psychotropic medications including patients classified as Correctional Clinical Case Management System inmates ("CCCMS"), a status given to inmates with psychiatric illnesses. The majority of the inmates in Building 8, including St. Jovite and his cell mate John Lee Harden, were classified as CCCMS inmates, meaning they suffered from any of a variety of psychiatric illnesses. CCCMS is the lowest level of care in the State's prison mental health delivery system, and is designed to provide a level of care equivalent to that received by non-incarcerated patients through outpatient psychiatric treatment. Although CSP-Solano provided air conditioned facilities and otherwise protected the inmates from exposure to heat, it did not provide any additional security to the inmates in Building 8.
The security staffing at CSP-Solano was broken into three watches: first watch (10:00 p.m. to 6:00 a.m.), second watch (6:00 a.m. to 2:00 p.m.), and third watch (2:00 p.m. to 10:00 p.m.). During the daytime watches (second and third watch), Building 8 was staffed with two floor officers and one control booth officer. During the graveyard shift (first watch), Building 8 had a leaner staff, with a control booth operator and one floor officer who split his time between Building 8 and another housing unit.
According to the Post Orders for correction officers at Building 8, one of a floor officer's "primary function[s] is to act as a safeguard against suicide attempts as well as fires set by inmates within the unit." Naturally, floor officers are also responsible for preventing crime, including inmate-on-inmate violence, and maintaining order and safety. In order to accomplish these goals, "[s]ecurity inspections of the unit shall be made upon assuming and prior to leaving the post and on an irregular basis throughout the shift" (emphasis added). Security checks are supposed to be performed at least after every unlock, and at least once an hour during daytime watches regardless of whether there has been an unlock. According to Neuhring, the Facility Captain in charge of Building 8 and the officer who called the May 10 staff meetings during which St. Jovite's apparent suicide attempt occurred, "[i]f the [floor] officers are doing their job" they should regularly be "checking their tiers" and "walking around." The purpose of doing so is to "check the welfare of the inmates, both looking for crime occurring and their welfare."
The extended absence of floor officers at Building 8 was generally considered unacceptable. Neuhring stated that floor officers should not all be pulled from the floor at the same time except in "very rare" circumstances and that such absences "shouldn't be getting longer than [15–30 minutes]. It may be go [sic] into 45 minutes, but not normally." Sisto stated that if any inmates were out of their cells "you don't pull a floor officer out of the building." By contrast, during the graveyard shift, when prisoners are asleep, Sisto considered it acceptable for there to be no floor officer actively patrolling for up to an hour and a half, but two hours "would be pushing it."
CSP-Solano's supervisors' views of what was safe was more lax than the standards promulgated by the American Correctional Association and the CDCR. Those standards, as explained by Plaintiffs' expert witness, mandate that "all special management inmates [be] personally observed by a correctional officer at least every 30 minutes on an irregular schedule."
When Defendants Cahoon and Holliday, the third shift floor officers assigned to Building 8 on May 10, 2006, reported for duty at Building 8 shortly before 2:00 p.m., they were both told to report directly to a staff meeting convened by Neuhring rather than conducting the beginning-of-shift security check that was required by their Post Orders.According to Holliday, the floor officers from the second watch were also not on the floor at Building 8 at the time that he and Cahoon were told to report to the staff meeting, as second watch's floor officers also had been called into a staff meeting on the same subject, sometime between 12:00 and 12:30 p.m. This left only Control Booth Officer Jaime Chua on watch in Building 8, but he was not permitted to leave the control booth for any reason, and could not see into most cells from his control booth. Harden testified that at some point around 12:30 p.m., a prison official announced to the inmates of Building 8 that a staff meeting was occurring. As a result, the inmates were on notice that they were unsupervised.
Cahoon and Holliday returned to Building 8 around 3:30 p.m. At that point, viewing the evidence in the light most favorable to Plaintiffs, the inmates in Building 8 had been left without any floor supervision, without security checks, and without any prison official (other than the control booth officer) able to respond to an emergency call, for as much as three and a half hours. Although Cahoon and Holliday believed that Building 8 was on lockdown during their absence, when they returned there were 10 or 15 inmates who "weren't supposed to be out" milling around in the day room.
B. St. Jovite's Death
Almost immediately upon their return, Cahoon and Holliday heard St. Jovite's cell mate Harden yelling "man down." After identifying which cell the shouts were coming from, Cahoon and Holliday went up to the second tier, where the cell was located. Cahoon testified that through the cell door she saw St. Jovite sitting on the ground with his back against the corner of the door. Harden was standing above St. Jovite and looked like he was slapping him. Believing that Harden and St. Jovite had been fighting, Cahoon told Harden to back away and asked what happened. Harden stated that he had been asleep and woke up to find St. Jovite hanging from the grill over the sink.
The events that followed are disputed, and the evidence in the record is contradictory. Defendants, relying primarily on the incident reports and deposition testimony of Cahoon and Holliday, argue that Cahoon called a medical code 2 at that time, 3:44 p.m., and sent Holliday to get a cut-down kit and CPR mask from the control booth. While waiting for Holliday to return, Cahoon saw Defendant Medical Technical Assistant Shabreen Hak (MTA Hak) approaching the building and Defendant Search and Escort Officer Raymond Wade coming up the stairs to the second tier. CSP-Solano policy was that staff members could not open a cell door without at least one other staff member present, so Cahoon waited until Hak and Wade were close and then signaled to Chua, the control booth officer, to open the cell door. According to Defendants, MTA Hak arrived at 3:45 p.m. just as the cell door was opening. Holliday testified that he arrived back at the cell door with the cut-down kit along with MTA Hak and Wade. After cracking the door open, Cahoon saw that St. Jovite had a noose around his neck and instructed Wade to call a medical code 3.
When the door opened fully, St. Jovite, who had been sitting against the corner of the cell, rolled onto his back until his body was partially protruding from the cell. Wade then escorted Harden downstairs. Cahoon described St. Jovite as cold to the touch with a sheet around his neck, a purplish color on his face, and dried mucous and spit around his mouth. Cahoon attempted to get a response from him by saying "Hey, St. Jovite." Holliday similarly asked St. Jovite if he was okay, but St. Jovite did not respond. Because MTA Hak was at the ...