Charles v. Orange County , 925 F.3d 73 ( 2019 )

17-3506-pr
Charles v. Orange County
UNITED STATES COURT OF APPEALS
FOR THE SECOND CIRCUIT
August Term, 2018
Argued: September 25, 2018
Decided: May 24, 2019
No. 17-3506-pr
MICHELET CHARLES, CAROL SMALL,
Plaintiffs-Appellants,
— v. —
ORANGE COUNTY, STATE OF NEW YORK, ORANGE COUNTY SHERIFF’S DEPARTMENT,
ORANGE COUNTY DEPARTMENT OF MENTAL HEALTH, CARMEN ELIZONDO, FORMER
CLINIC DIRECTOR, ORANGE COUNTY CORRECTIONAL FACILITY, in her individual
capacity,
Defendants-Appellees,
NICOLE KAYE, CLINIC DIRECTOR, ORANGE COUNTY CORRECTIONAL FACILITY, in her
individual capacity,
Defendant.
B e f o r e:
LYNCH and HALL, Circuit Judges, and BOLDEN, District Judge.*
Plaintiffs-Appellants Michelet Charles and Carol Small were formerly civil
immigration detainees at the Orange County Correctional Facility, where they
were treated for serious mental illnesses. They instituted this civil rights action
against Orange County and some of its agencies and officials under 42 U.S.C.
§ 1983, complaining that the failure to engage in discharge planning or to provide
them with discharge plans upon release violated their substantive due process
rights under the Fourteenth Amendment. The United States District Court for the
Southern District of New York (Nelson S. Román, J.) granted the Defendants’
motion to dismiss the complaint. We VACATE and REMAND for further
proceedings.
DANIEL J. STUJENSKE, Simpson Thacher & Bartlett LLP, New
York, NY (Thomas C. Rice, Simpson Thacher & Bartlett
LLP, on the brief), Laura F. Redman, Antony P. F. Gemmell,
New York Lawyers for the Public Interest, New York, NY
for Plaintiffs-Appellants Michelet Charles and Carol Small.
ANTHONY CARDOSO, Orange County Attorney’s Office, Goshen,
NY, for Defendants-Appellees Orange County, State of
New York, Orange County Sheriff’s Department, Orange
County Department of Mental Health and Carmen
Elizondo, Former Clinic Director, Orange County
Correctional Facility, in her individual capacity.
*
Judge Victor A. Bolden, of the United States District Court for the District of
Connecticut, sitting by designation.
2
Aaron M. Panner, Kellogg, Hansen, Todd, Figel & Frederick,
P.L.L.C., Washington, DC (Ira A. Burnim, Judge David C.
Bazelon Center for Mental Health Law, Washington, DC,
on the brief), for Amici Curiae American Psychiatric
Association, American Academy of Psychiatry and the
Law, American Psychological Association, American
Medical Association, National Association of Social
Workers, American Public Health Association, and Judge
David L. Bazelon Center for Mental Health Law, in
support of Plaintiffs-Appellants.
Jamie A. Levitt, Morrison & Foerster LLP, New York, NY, for
Amici Curiae The Bronx Defenders, Brooklyn Defender
Services, Community Initiatives for Visiting Immigrants
in Confinement, Detention Watch Network, The Florida
Justice Institute, Inc., Human Rights First, Immigrant
Defense Project, The Immigrant Rights Clinic of
Washington Square Legal Services, Inc., at NYU Law
School, the Kathryn O. Greenberg Immigration Justice
Clinic at the Benjamin N. Cardozo School of Law, The
Legal Aid Society of New York, The Prison Law Office,
Prisoners’ Legal Services of New York, and the Urban
Justice Center Mental Health Project, in support of
Plaintiffs-Appellants.
Alexander M. Wilson, New York State Sheriffs’ Association,
Albany, NY for Amicus Curiae New York State Sheriffs’
Association, in support of Defendants-Appellees.
3
GERARD E. LYNCH, Circuit Judge:
The question before us is whether the Plaintiffs-Appellants, Michelet
Charles and Carol Small, have stated a plausible claim for relief under the
Fourteenth Amendment for deliberate indifference to their serious medical
needs. Plaintiffs were confined for many months as civil immigration detainees at
the Orange County Correctional Facility, where they received treatment for their
serious mental health disorders. Defendants-Appellees are Orange County, the
municipality that oversees the Orange County Correctional Facility (“the Jail”);
the Orange County Sheriff’s Office, the specific entity that contracts with the
Federal Government to house detainees in the Jail; the Orange County
Department of Mental Health, the agency responsible for providing mental
health services to people confined at the Jail; and Carmen Elizondo, the Clinical
Director at the Jail.1 Plaintiffs filed a complaint in the United States District Court
for the Southern District of New York alleging that the Defendants, who were
responsible for providing them with medical care while they were detained at the
Jail, failed to provide them with mental health discharge planning before their
1
The parties stipulated to the dismissal of this appeal with prejudice with respect
to former defendant Nicole Kaye.
4
release from custody, in violation of the Fourteenth Amendment’s Due Process
Clause. Plaintiffs seek relief under 42 U.S.C. § 1983.
The district court (Nelson S. Román, J.) dismissed Plaintiffs’ complaint for
failure to state a claim. For the reasons that follow, we VACATE that judgment,
and REMAND for further proceedings.
BACKGROUND
Both Plaintiffs suffer from serious, ongoing mental illnesses.2 Each Plaintiff
was arrested by agents of the U.S. Immigration and Customs Enforcement
(“ICE”), the federal law enforcement agency charged with the detention and
removal of illegal immigrants. While awaiting their removal proceedings,
Plaintiffs were detained at the Jail, a county detention facility that houses civil
immigration detainees pursuant to an intergovernmental agreement between ICE
and Orange County. During their detention, Plaintiffs were treated for their
illnesses, receiving counseling and psychotropic medication. However, the
treatment Plaintiffs received while they were in custody did not include
2
On this appeal from the dismissal of a complaint for failure to state a claim, we
take the allegations in the complaint as true and construe them in the light most
favorable to Plaintiffs. See Ashcroft v. Iqbal, 556 U.S. 662, 678–80 (2009).
5
discharge planning, which Plaintiffs allege is a routine and necessary component
of institutional mental health treatment. Plaintiffs claim that as a result of
Defendants’ failure to provide them with discharge planning while they were in
custody, they suffered serious mental health consequences shortly after their
release.
I. Michelet Charles
Plaintiff Michelet Charles is a 55-year old lawful permanent resident who
has lived in the United States for 34 years. Charles has suffered from bipolar and
schizoaffective disorders since around 1984. For years, he managed his illness
through regular mental health care. When Charles is not treated for his illnesses,
he suffers from hallucinations, delusions, and periods of mania and depression.
In July 2014, Charles was arrested by ICE officials and detained at the Jail
for 363 days during the pendency of his immigration case.3 When Charles
3
ICE and Orange County confine hundreds of people in civil immigration
detention at the Orange County Detention Center every year pursuant to an
Inter-Governmental Services Agreement between ICE and Orange County. Civil
immigration detainees are held in custody to assure their presence throughout
the administrative removal proceedings. Such detainees are not charged with
crimes. Nevertheless, civil immigration detainees are housed in conditions
similar to those experienced by detainees awaiting trial on criminal charges.
6
entered the detention center, medical personnel at the facility diagnosed him
with bipolar disorder with psychotic features. During his detention, Defendants
provided Charles with psychiatric care, which included meeting with a
psychiatrist every three weeks in order to monitor his condition, and daily
psychotropic medication to keep him stable. Charles’s treatment was
documented by the Jail Clinic in an “Intervention/Care Plan” which listed his
diagnosis, the types of counseling Charles received, the medication he required,
and any suicidal or harmful tendencies he had.
On July 22, 2015, Charles was brought from the Jail to New York City for
an appearance at the Immigration Court in lower Manhattan. Prior to his
immigration hearing, Defendants had not provided Charles with any plan for his
continued mental health care after discharge, a list of his medications, a list of
outside referrals, any other information about the medication and counseling he
received while detained, or assistance or information relevant to his obtaining
future treatment for his known medical condition. Nor were any such materials
provided to Charles at or after his hearing. Charles succeeded at his immigration
hearing4 and was released directly from the court with his identification and
4
The record does not reflect the precise disposition of the matter.
7
nothing more. The ICE Deportation Officer who attended the hearing told
Charles’s attorney that ICE did not have any medication for Charles, and that he
should return to the Jail if he needed to obtain a supply of his medication.
The day after his release, Charles and his daughter drove over 65 miles
from their home to the Jail to obtain Charles’s psychiatric medication. When
Charles’s daughter asked an employee at the front desk of the Jail for her father’s
medication, the employee refused to provide it, claiming that the person who had
transported Charles to the Immigration Court was responsible for providing him
with a continuing supply of medication. The Orange County employee also
informed Charles and his daughter that as a matter of institutional policy, after a
person is released from the facility, the Jail can no longer provide him with
medication.
Charles’s immigration attorney then contacted the ICE Deportation Officer
again, requesting that Charles be provided with a supply of medication. The
Officer did not respond to the inquiry. According to Charles’s medical file from
the Jail, on July 23, 2015, the day after his release, and the same day that he
visited the facility with his daughter, a clinical social worker at the Jail signed a
document entitled “Continuing Care Plan/Discharge Summary” (“Discharge
8
Summary”) for Charles. The Discharge Summary listed Charles’ diagnosis and
expressly anticipated that Charles would have future mental health needs
including medication, psychiatric treatment, and substance abuse treatment.
However, neither Charles nor his attorney was given a copy of the Discharge
Summary.
After his release, without immediate access to his prescription anti-
psychotic and anti-depressant medications and counseling, Charles soon began
psychologically decompensating. He exhibited bizarre behavior, was
disorganized, and mumbled when he spoke. His family reported that he was
manic, anxious, and paranoid.
By August 4, 2015, Charles was experiencing symptoms of psychosis, and
his ability to control his thoughts and emotions was so impaired that he lost
contact with reality. On that date, Charles’s family called 911 for emergency
medical assistance. The police officers who responded to the call transported him
to the emergency room at a nearby hospital. The next day, Charles was
hospitalized in an inpatient psychiatric unit of North Shore LIJ South Oaks
Hospital. His admission record states that he had worsening aggressive,
disorganized, and bizarre behavior, and was preoccupied with paranoid ideas. It
9
took two months in the hospital for Charles’s condition to stabilize and for him to
return to his baseline mental state.
II. Carol Small
Plaintiff Carol Small is a 45-year old lawful permanent resident of the
United States. Before she was detained, Small lived on her own and supported
herself as a hairdresser in the Bronx.
Small was detained at the Jail in May 2015. After about a month of
detention, Small began experiencing symptoms of severe mental illness,
including visual and auditory hallucinations. She became extremely paranoid
and delusional, believing that she was being monitored by the government
through a chip implanted in her tooth, that there was a government conspiracy to
poison her, and that poison was coming through the vents in the Jail. In late June
2015, a psychiatrist at the Jail diagnosed Small with paranoid schizophrenia.
Similarly to Charles, her diagnosis, medications, and counseling needs were
documented by the Jail Clinic in a document titled “Intervention/Care Plan.” But
like Charles, Small was not provided with a copy of that document.
In September 2015, Small was transferred to the inpatient ward at Kings
County Hospital for intensive treatment for her mental illness. In October, after
10
her condition stabilized, she was transferred back to the Jail. Upon her return,
medical employees of the Orange County Department of Mental Health provided
Small with medically necessary treatment and continued to prescribe and
administer her daily prescription medication, which kept her stable.
On January 11, 2016, an Immigration Judge granted Small immigration
relief and ordered her release.5 Small was released from the Jail on January 19,
2016 at around 6:30 PM, in below-freezing temperatures, with $80 in cash. Small
was not given an interim supply of her prescribed medicines, a list of her
medications, a description of the treatment she had received while detained, or a
list of outside referrals or providers for continuing care. During the roughly six
months in which Small was treated for her mental illness at the Jail, she was not
provided with any discharge planning.
Upon her release, Small took the train from Orange County to Penn
Station. She stayed briefly with family members, and then a social worker from
the organization that had provided Small with immigration representation
arranged for her to live in a shelter. While Small was struggling to re-establish
her life after release, she was extremely distressed and worried for her own
5
Again, the record does not describe the exact nature of the disposition.
11
health and the possibility of relapsing without the medication she had been
taking to treat her mental illness. On January 21, 2016, Small checked herself into
the emergency room at North Central Bronx Hospital in an effort to obtain
medication. Because Small had written down a list of the medications she was
taking while detained, the hospital was able to prescribe her the same
medications without a full psychological evaluation. These events were
emotionally distressing for her.
III. Procedural History
Plaintiffs filed a complaint (the “Complaint”) on July 12, 2016, asserting
violations of the Fourteenth Amendment. They claim that substantive due
process requires that civil detainees be afforded adequate medical care during
their detention, and that their medical care should have included discharge
planning, because of their serious mental illnesses. They allege that discharge
planning is regarded by medical and psychological professionals as an essential
part of mental health care, especially in institutional settings, where it is
necessary to mitigate the risks of interrupted treatment while patients transition
from treatment within the institution to other sources of treatment. Plaintiffs
contend that by failing to provide them with discharge planning, Defendants
12
were deliberately indifferent to the risk that Plaintiffs would relapse upon release
and face mental decompensation and other serious health consequences.
On January 30, 2017, Defendants moved to dismiss the entire Complaint
for failure to state a claim. Defendants argued that there is no established
substantive due process right to the post-release measures inherent in discharge
plans. On their view, the government’s duty of care ends the instant the inmate
walks through the prison gates and into the civilian world, because that is when
the inmate’s ability to secure medication or care on his own behalf is restored.
On September 29, 2017, the district court granted Defendants’ motions.6 See
Charles v. County of Orange, No. 16-CV-5527 (NSR), 2017 WL 4402576 (S.D.N.Y.
Sept. 29, 2017). The district court construed the Complaint as stating three claims
under § 1983: (1) a Monell claim against Orange County, the Orange County
Sheriff’s Department, and the Orange County Department of Mental Health (the
“County Defendants”) alleging a policy, practice and custom of providing
constitutionally inadequate health care to persons held in civil immigration
detention; (2) a claim against all Defendants for deliberate indifference to
6
Defendants-Appellants filed one joint motion and former defendant Kaye filed a
separate motion.
13
Plaintiffs’ serious medical needs by discharging them from the Jail without
adequate discharge plans; and (3) supervisory liability claims against Kaye and
Elizondo (the “Individual Defendants”), successive clinic directors at the Jail,
who Plaintiffs claim were responsible for providing them with medical treatment
while they were detained.
The district court recognized that the Fourteenth Amendment Due Process
Clause requires a correctional facility to provide medical care to detainees while
they are in custody. But it understood the Complaint to claim that Defendants
did not provide Plaintiffs with necessary medical treatment after they were
released. The district court concluded that even though the Plaintiffs had
adequately pled that the Defendants were deliberately indifferent to their serious
medical needs, the standard they would have to meet if they alleged a
constitutional violation while they were in custody, Plaintiffs’ claims failed
because the failure of treatment did not “shock the conscience.” Since Plaintiffs’
substantive Fourteenth Amendment claim failed, the district court declined to
address the Monell claim against the County Defendants, or the supervisory
liability claim against the Individual Defendants.
14
Because the district court construed Plaintiffs’ allegations as regarding
deliberate indifference to post-custody medical care, rather than deliberate
indifference to needed in-custody medical care, the district court applied the
wrong standard in determining whether Plaintiffs adequately pled a Fourteenth
Amendment violation. We therefore vacate the district court’s dismissal of the
Complaint and remand for further proceedings.
DISCUSSION
We review de novo a district court’s grant of a motion to dismiss pursuant
to Rule 12(b)(6) and grant of a motion for judgment on the pleadings under Rule
12(c). See Brown Media Corp. v. K&L Gates, LLP, 854 F.3d 150, 156–57 (2d Cir. 2017);
Kirkendall v. Halliburton, Inc., 707 F.3d 173, 178 (2d Cir. 2013). In considering
Defendants’ motions, we accept as true all factual allegations in the Complaint
and draw all reasonable inferences in Plaintiffs’ favor. See id.
At this stage, we need decide only whether Plaintiffs’ claims are facially
plausible. See Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). “A claim has facial
plausibility when the plaintiff pleads factual content that allows the court to
draw the reasonable inference that the defendant is liable for the misconduct
alleged. The plausibility standard is not akin to a probability requirement, but it
15
asks for more than a sheer possibility that a defendant has acted unlawfully.” Id.
(internal citations and quotation marks omitted).
I. Discharge Planning as In-Custody Care
On appeal, Plaintiffs argue that the district court misconstrued the
allegations in their Complaint and therefore applied an incorrect legal analysis to
their Fourteenth Amendment claims. The district court construed Plaintiffs’
Complaint as contending that the Defendants owed Plaintiffs a duty to provide
them with limited medical care after they had been released from custody.
Plaintiffs argue that the deprivation of care that they allege in fact occurred
during their detention, because discharge planning occurs before release from
custody. Their argument is consistent with the Complaint, which clearly purports
to allege an in-custody deprivation of care. Whether Plaintiffs’ claim for
deprivation of discharge planning, which negatively affected them after their
release from custody, can be considered a claim for in-custody deprivation of
care is an important question in this case.
This distinction matters because the duties state actors owe to individuals
differ depending on whether the complainant was in the state’s custody. As a
general matter, the state is under no constitutional duty to provide substantive
16
services to free persons within its borders. See DeShaney v. Winnebago Cty. Dep’t of
Soc. Servs., 489 U.S. 189, 196 (1989). But when a person is involuntarily held in
state custody, and thus wholly dependent upon the state, the state takes on an
affirmative duty to provide for his or her “safety and general well-being.” Id. at
199–200. This “special relationship exception” imposes a duty on the state in
recognition of “the limitation which [the state] has imposed on [the person’s]
freedom to act on his own behalf.” Id. at 200; see also Matican v. City of New York,
524 F.3d 151, 156 (2d Cir. 2008).
In Estelle v. Gamble, 429 U.S. 97, 103 (1976), the Supreme Court held that the
state has a constitutional obligation to provide medical care to persons it is
punishing by incarceration. When the state is deliberately indifferent to the
medical needs of a person it has taken into custody, it violates the Eighth
Amendment’s prohibition on cruel and unusual punishment. Id. at 104. The
Supreme Court subsequently extended the protections for prisoners established
in Estelle to civil detainees under the Due Process Clause of the Fourteenth
Amendment, reasoning that persons in civil detention deserve at least as much
protection as those who are criminally incarcerated. See Youngberg v. Romeo, 457
U.S. 307, 321–22 (1982); City of Revere v. Mass. Gen. Hosp., 463 U.S. 239, 244 (1983).
17
The Ninth Circuit has extended the reasoning of Estelle and DeShaney beyond the
moment of release from custody, holding in Wakefield v. Thompson, 177 F.3d 1160,
1164 (9th Cir. 1999), that the state owes an affirmative duty to provide an
outgoing prisoner requiring medication with a “supply sufficient to ensure that
he has that medication available during the period of time reasonably necessary
to permit him to consult a doctor and obtain a new supply.” The Ninth Circuit
based this holding on a matter of common sense: “that a prisoner’s ability to
secure medication ‘on his own behalf’ is not necessarily restored the instant he
walks through the prison gates and into the civilian world.” Id. This Court,
however, has never held that the state’s duties to an inmate or detainee extend
beyond their release.
Plaintiffs’ theory in this case is that “[d]ischarge planning is an essential
part of mental healthcare in institutional settings” and “Defendants are
constitutionally obliged to provide Plaintiffs with adequate medical care while
they are confined to immigration detention.” App’x at 10. Plaintiffs allege that
discharge planning includes providing the detainee with (1) a summary of
medical records (including admission diagnosis, discharge diagnosis, all
diagnostic test results, a list of medications prescribed, a summary of care
18
provided, a summary of the detainee’s response to treatment, medical
complications encountered, and any outside healthcare referrals); (2) an interim
supply of medication; and (3) a continuity of care plan, including referrals to
community based providers. Plaintiffs’ Complaint alleges that the provision of
these services and documents should begin being provided to the patient at the
outset of in-custody medical treatment, and continue during the course of
treatment.
Plaintiffs’ theory raises a legal question of first impression in this Circuit:
whether a claim of constitutional entitlement to discharge planning, the alleged
inadequacy of which causes post-release harm, can be considered a claim to in-
custody care cognizable under the “special relationship” exception. Discharge
planning is fundamentally different from other measures or types of care to
which detainees may be entitled while in custody, in that its entire purpose is to
prevent post-release harm. Given the reality that the tangible harm Plaintiffs
suffered was a direct result of their lack of medication and medical records after
release from custody, the District Court understandably construed the Complaint
as asserting “a right to post-release measures inherent in discharge planning.”
Charles, 2017 WL 4402576, at *8.
19
Nevertheless, discharge planning is not so different from other measures
the state takes in providing care to those in its custody as to be categorically
beyond the reach of the “special relationship” exception. If discharge planning is
to occur at all, it must, by definition, occur prior to release from custody. Whether
the three components of discharge planning that Plaintiffs identify are an
“essential part” of mental healthcare, as Plaintiffs allege, is a factual matter that
may be proven at a later stage of litigation by expert testimony. If discharge
planning is essential to providing care for mentally ill individuals, the rationale
for the “special relationship” exception applies to this need no less than the need
for other types of care. As the Supreme Court recognized in Estelle, “an inmate
must rely on prison authorities to treat his medical needs; if the authorities fail to
do so, those needs will not be met.” 429 U.S. at 103. The Supreme Court in Estelle
was concerned with failures to provide care that may result in death or
“unnecessary” “pain and suffering.” Id. The failure to provide discharge
planning, no less than other forms of care, may inflict such suffering. In this case,
furthermore, it cannot be said that when the County released Plaintiffs, it “placed
[them] in no worse position than that in which [they] would have been had it not
acted at all . . .” DeShaney, 489 U.S. at 201; see App’x at 18, 21–22 (Charles); id. at
24 (Small).
20
That the harmful consequences of a lack of discharge planning occur after
release from custody does not remove discharge planning from the purview of
the “special relationship” exception. For example, we affirmed application of this
exception where an inmate died a few weeks after being released from custody,
allegedly due to the facility’s inadequate medical treatment. Rodriguez ex rel.
Estate of Darby v. Walrath, 94 F. App’x 864 (2d Cir. 2004).8
Common sense and experience further support Plaintiffs’ theory that
discharge planning is part of in-custody care. It comports with common sense
that someone with a serious mental illness would need to receive a summary of
his medical records, including documents indicating his diagnosis and his
prescribed medications. These aspects of a discharge plan are expected parts of
8
Similarly, in Lugo v. Senkowski, 114 F. Supp. 2d 111, 115 (N.D.N.Y. 2000), the
plaintiff had surgery to remove kidney stones while incarcerated. He was
released on parole shortly thereafter, but before Lugo’s treating physician was
able to remove a metal stent from his kidney. Id. Noting that Lugo “was
undergoing continuing treatment at the time he was released,” the district court
held that releasing Lugo with the stent in his body, and without either allowing
him to return to Albany for treatment or forwarding his medical records to
another facility to facilitate the performance of the operation there constituted
deliberate indifference. Id. Although Plaintiffs’ theory in this case does not
require us to reach the question of whether the state’s duty of care extends
beyond a detainee’s release from custody, as the district court in Lugo held, the
facts in Lugo illustrate how a failure to provide certain in-custody care may have
harmful post-release effects that are inextricably bound up with that in-custody
deprivation.
21
what non-incarcerated patients seek, and pay for, in visiting doctors and
hospitals for treatment. Those who have seen a doctor, visited a hospital
emergency room, undergone surgery, or received any kind of medical treatment
for a serious physical, emotional, dental or visual problem, understand the need
for, and have likely been provided, documentation of the medications prescribed
to them, their diagnosis, and a copy of any test results, during the course of their
treatment. Thus, to the extent Plaintiffs complain that they were not provided
with documentation regarding the treatment they received while in custody,
their complaint relates to the provision of in-custody medical care.
These common-sense understandings are consistent with expert medical
opinion. Plaintiffs point to a broad array of professional mental health and
medical associations who agree that the standard of reasonable and adequate
medical care for detained persons includes providing the detainee with interim
medications and referrals while they are still in custody. For example, the American
Psychiatric Association views discharge planning as in-custody care, stating that
it “needs to begin as part of the initial treatment plan.” Brief of Bronx Defenders
et al. as Amici Curiae Supporting Appellants at 21. The American Association of
Community Psychiatrists says that “it is imperative that any psychiatric
treatment provided during a period of incarceration include planning for post-
22
release follow-up care in the community.” App’x at 30 (emphasis added). The
National Commission on Correctional Health Care, from which the Jail has
sought and obtained accreditation, defines discharge planning as “the process of
providing sufficient medications for short-term continuity upon release and
arranging for necessary follow-up mental health services before the inmate’s release
to the community.” Id. at 31 (emphasis added). Such expert medical opinion
supports the plausibility of Plaintiffs’ claim of a deprivation of in-custody care.
We also find plausible Plaintiffs’ contention that the provision of interim
medication and referrals is part of the treatment that should have been provided
to them while they were in custody. The American Psychiatric Association, the
American Academy of Psychiatry and the Law, the American Psychological
Association, the American Medical Association, the National Association of
Social Workers, the American Public Health Association, and the Judge David L.
Bazelon Center for Mental Health (collectively the “APA Amici”) wrote in
support of Plaintiffs to explain that discharge planning, which includes a
sufficient quantity of medication to allow continuous use, conducting a pre-
discharge assessment, establishing appointments with community providers, and
ensuring that medical records are effectively transferred to community
providers, is an essential component of minimally adequate mental health care
23
for institutional patients. APA Amicus Brief at 13–14. These views are consistent
with how we think of medical services in a non-custodial setting. Doctors
routinely provide their patients with instructions on how to treat their illnesses
after they leave the doctor’s office, provide their patients with referrals to other
healthcare providers when necessary, and refill their patients’ prescriptions so as
to avoid a lapse in care. Such services are particularly essential for patients who
are hospitalized or otherwise confined, to make possible continuity of care after
their release.
That discharge planning is supposed to occur before release is also
referenced in a variety of guidelines and regulations promulgated by correctional
authorities. For example, ICE’s own Performance Based National Detention
Standards require discharge planning prior to release.9
Thus, taking Plaintiffs’ allegations as true and drawing all reasonable
9
That the contents of a discharge plan or package may be provided at or about
the time of release does not defeat the claim that the preparation and planning
for after-care is an inherent part of proper medical treatment. That a package of
after-care instructions, medication, and medical equipment such as dressings or
bandages is provided to a paying patient by a staff member on the way out of an
emergency room or doctor’s office by a nurse or receptionist, rather than in the
treatment room itself by the primary care physician, does not mean that it is not
an inherent part of the treatment required of the doctor or hospital; the same is
true for a patient who is in custody.
24
inferences in their favor, we find that Plaintiffs have plausibly alleged that
discharge planning is an essential part of in-custody care. We conclude that
despite the forward-looking nature of discharge planning, a claim for damages
caused by the lack of it can be considered a claim for deprivation of in-custody
care for purposes of the “special relationship” exception. It will be for Plaintiffs to
prove to a fact-finder, on remand, that the care they complain of is the type that
should have been provided to them during their detention.10
II. The Appropriate Standard for the Deprivation of In-Custody Care
Once we accept that Plaintiffs’ theory regards the adequacy of medical care
Plaintiffs received while in custody, the legal framework that applies to their claim
becomes clear. It is well established that when the state takes a person into
custody, severely limiting his ability to care for himself, and then is deliberately
indifferent to his medical needs, the Eighth Amendment’s proscription against
10
In recognizing that Plaintiffs’ claim for deprivation of discharge planning may
be cognizable under the “special relationship” exception, we do not hold that any
detainee who receives medical treatment while detained and subsequently
suffers a potentially preventable health problem may assert a Fourteenth
Amendment claim by alleging inadequate discharge planning. The facts alleged
in this case show a clear causal link and temporal proximity between the lack of
discharge planning and the negative effects on Plaintiffs, in addition to a serious
medical need for discharge planning and deliberate indifference to that need, as
discussed below.
25
the unnecessary and wanton infliction of pain is violated. Estelle, 429 U.S. at 104.
That is true whether the deliberate indifference is manifested by prison doctors in
their response to the prisoner’s needs, or by prison guards who intentionally
deny or delay access to medical care or intentionally deny or delay access to the
treatment once prescribed. Id. at 104–05. The Estelle Court concluded that to state
a cause of action under § 1983 for violations of the Eighth Amendment’s Cruel
and Unusual Punishment Clause, a prisoner must show that the state was
deliberately indifferent to his or her medical needs. Id. at 105. As discussed
above, pursuant to the Due Process Clause of the Fourteenth Amendment, the
Supreme Court has extended to civil detainees Estelle’s protection for prisoners
under the Eighth Amendment. See Youngberg, 457 U.S. at 321–22; City of Revere,
463 U.S. at 244. Thus, those in civil detention, as were Plaintiffs in this case, are
also afforded a right to be free from deliberate indifference to their serious
medical needs.
“In order to establish a violation of a right to substantive due process, a
plaintiff must demonstrate not only government action but also that the
government action was so ‘egregious, so outrageous, that it may fairly be said to
shock the contemporary conscience.’” Pena v. DePrisco, 432 F.3d 98, 112 (2d Cir.
2005) (quoting County of Sacramento v. Lewis, 523 U.S. 833, 847 n.8 (1998)). The
26
Supreme Court has held that the point of conscience shocking is reached when
government actors are deliberately indifferent to the medical needs of pretrial
detainees. Lewis, 523 U.S. at 849–50; see Estelle, 429 U.S. at 104–06; City of Revere,
463 U.S. at 244. In this particular context, “deliberately indifferent conduct” is
“egregious enough to state a substantive due process claim.” Lewis, 523 U.S. at
849–50. A court need not, therefore, conduct a separate analysis, over and above
the deliberate indifference analysis, of whether the state’s conduct “shocks the
conscience.”11
In accepting, at this stage, Plaintiffs’ theory that discharge planning is an
essential part of in-custody medical care and that Plaintiffs were therefore
deprived of adequate medical care while in state custody, Plaintiffs fall well
within the “special relationship” exception. Therefore, Plaintiffs’ Fourteenth
Amendment claim must meet two requirements: (1) that Plaintiffs had a serious
medical need for discharge planning, and (2) that the Defendants acted with
11
We have applied a separate “shocks the conscience” analysis in cases that do not
involve the medical needs of those the state has taken into custody. See, e.g., Matican,
524 F.3d at 155 (requiring plaintiff to show conscience-shocking behavior on the part of
the state where plaintiff confidential informant was harmed while on the streets, not in
a prison or jail); Lombardi v. Whitman, 485 F.3d 73 (2d Cir. 2007) (requiring proof of
conscience-shocking behavior when plaintiffs alleged government made false
assurances that workplace would be safe, although plaintiffs were not in custody).
27
deliberate indifference to such needs. See Estelle, 429 U.S. at 105; Darnell v. Pineiro,
849 F.3d 17, 29 (2017).
A. Serious Medical Needs
Depending on their severity, psychiatric or psychological conditions can
present serious medical needs in light of our contemporary standards. See e.g.,
Cuoco v. Moritsugu, 222 F.3d 99, 106 (2d Cir. 2000). The serious medical needs
standard contemplates a condition of urgency such as one that may produce
death, degeneration, or extreme pain. See Hathaway v. Coughlin, 99 F.3d 550, 553
(2d Cir. 1996). In determining whether a medical need is sufficiently serious to be
cognizable as a basis for a constitutional claim for deprivation of medical care, we
consider factors such as whether a reasonable doctor or patient would find the
injury important and worthy of treatment, whether the medical condition
significantly affects an individual’s daily activities, and whether the illness or
injury inflicts chronic and substantial pain. See Chance v. Armstrong, 143 F.3d 698,
702 (2d Cir. 1998). In most cases, the actual medical consequences that flow from
the denial of care are highly relevant in determining whether the denial of
treatment subjected the detainee to a significant risk of serious harm. See Smith v.
Carpenter, 316 F.3d 178, 187 (2d Cir. 2003).
28
B. Deliberate Indifference
The concept of deliberate indifference has a more complicated history in
this Circuit. See Darnell, 849 F.3d at 32–36 (explaining how the concept of
deliberate indifference has evolved in the case law since Farmer v. Brennan, 511
U.S. 825 (1994)). In Darnell, we clarified that deliberate indifference, in the context
of a Fourteenth Amendment due process claim, can be shown by something akin
to recklessness, and does not require proof of a malicious or callous state of mind.
849 F.3d at 33–34. Deliberate indifference, we held, can be established by either a
subjective or objective standard: A plaintiff can prove deliberate indifference by
showing that the defendant official “recklessly failed to act with reasonable care
to mitigate the risk that the condition posed to the pretrial detainee even though
the defendant-official knew, or should have known, that the condition posed an
excessive risk to [the plaintiff’s] health or safety.” Id. at 35 (emphasis added). This
formulation of the deliberate indifference standard was developed in cases
involving unconstitutional conditions of confinement. In Darnell, the plaintiffs
complained, inter alia, that the facility where they were detained was unsafe and
unsanitary. Id. at 23–26. Although Darnell did not specifically address medical
treatment, the same principle applies here. See id. at 33 n.9 (noting that the same
29
standard applies to claims for deliberate indifference to medical needs because
“deliberate indifference means the same thing for each type of claim under the
Fourteenth Amendment”).
A plaintiff must show “something more than mere negligence” to establish
deliberate indifference in the Fourteenth Amendment context. Weyant v. Okst, 101
F.3d 845, 856 (2d Cir. 1996). Thus, “mere medical malpractice is not tantamount
to deliberate indifference, but it may rise to the level of deliberate indifference
when it involves culpable recklessness, i.e., an act or a failure to act . . . that
evinces a conscious disregard of a substantial risk of serious harm.” Cuoco, 222
F.3d at 107 (internal quotation marks and alteration omitted).
Thus, a detainee asserting a Fourteenth Amendment claim for deliberate
indifference to his medical needs can allege either that the defendants knew that
failing to provide the complained of medical treatment would pose a substantial
risk to his health or that the defendants should have known that failing to provide
the omitted medical treatment would pose a substantial risk to the detainee’s
health.
Whether the state knew or should have known of the substantial risk of
harm to the detainee is a question of fact subject to demonstration in the usual
30
ways, including inference from circumstantial evidence. Farmer, 511 U.S. at 842;
see also Hathaway, 37 F.3d at 67–69 (whether doctor was deliberately indifferent to
inmate’s serious medical needs was for jury). “A factfinder may conclude that a
prison official knew of a substantial risk from the very fact that the risk was
obvious.” Farmer, 511 U.S. at 842.
Thus, to sustain their § 1983 cause of action, Plaintiffs must plausibly allege
that they had a sufficiently serious medical need requiring discharge planning
and that the deprivation of such planning was inflicted under circumstances
constituting deliberate indifference.
III. Whether Plaintiffs Had Sufficiently Serious Needs Requiring Discharge
Planning
Plaintiffs have plausibly alleged that they had a sufficiently serious need
for discharge planning given their serious mental illnesses. Plaintiffs’ mental
illnesses cause paranoia, delusions, hallucinations and aggressive shifts in mood
when they go untreated. Without continuous care and daily medication to keep
them mentally stable, Plaintiffs face serious risk of physical and psychological
harm.
Plaintiffs’ theory that discharge planning is integral to institutional mental
31
health care is supported by their citations to professional organizations in the
mental health field. Many professional organizations that determine appropriate
standards of mental health care regard discharge planning as an essential
component of care for the institutionalized mentally ill, including not only
sentenced prisoners and civil and criminal detainees with serious mental
illnesses, but also those, whether voluntarily hospitalized or involuntarily
committed, who are institutionalized for the very purpose of treating their
mental illnesses. For example, Plaintiffs point to guidance by the American
Psychiatric Association, the primary professional association of psychiatrists in
the United States and the largest psychiatric professional organization in the
world, which recognizes that “[t]imely and effective discharge planning is
essential to continuity of care and an integral part of adequate mental health
treatment.” App’x at 29.
Plaintiffs’ allegations regarding the importance of discharge planning are
corroborated by what befell them when such planning was not provided to them.
See Koehl v. Dalsheim, 85 F.3d 86, 88 (2d Cir. 1996). Because Plaintiffs were not
provided with discharge plans, Plaintiffs allege they both faced an abrupt
interruption in their care causing them to suffer significant mental health
32
consequences. Charles suffered complete psychiatric decompensation shortly
after being released. His family was forced to call 911 for emergency medical care
and he required two months of hospitalization to regain mental stability. Small
was somewhat more fortunate. She received treatment before she fully
decompensated, but she was still forced to check herself into a hospital
emergency room within days of her release and continues to suffer extreme
emotional and psychological distress.
We therefore find plausible Plaintiffs’ allegations that they had serious
medical needs requiring discharge planning. Of course, those are only
allegations: we leave it to the fact-finder, or to summary judgment after
discovery, to determine whether the facts, as developed, prove that Plaintiffs had
a serious medical need requiring discharge planning and if so, in what form.
IV. Whether the Defendants’ Failure to Provide Discharge Planning to
Plaintiffs Constituted Deliberate Indifference
Plaintiffs have also sufficiently alleged that Defendants knew or should
have known that failing to provide them with discharge planning would cause
Plaintiffs substantial harm. According to Plaintiffs, Defendants knew the serious
nature of Plaintiffs’ mental health conditions; they diagnosed Plaintiffs,
33
maintained their medical records, created treatment plans for them, and
prescribed anti-psychotic and anti-depressant medication for them. As noted
above, Plaintiffs point to guidance by, among others, the American Psychiatric
Association and the National Commission on Correctional Health Care, stating
that discharge planning is an essential component of adequate institutional
mental healthcare for people with Plaintiffs’ illnesses. It is reasonable to infer, at
this stage, that the defendant clinic directors, as mental health professionals
engaged in providing treatment to prisoners and detainees in an institutional
setting, were aware of these standards.
Nor is it necessary to resort solely to inference. The policies and protocols
governing Defendants and others providing treatment at the Jail themselves
demand such discharge planning. Both ICE and Orange County have written
policies recognizing that mental health discharge planning is an essential
component of mental health treatment in institutional settings. ICE’s 2011
Performance-Based National Detention Standards (revised in 2016) provide that
“[d]etainees, who have received medical care, [been] released from custody or
removed shall receive a mental health discharge plan, a summary of medical
records, any medically necessary medication and referrals to community-based
34
providers as medically appropriate.” App’x at 32 (alterations omitted). Orange
County policies similarly require that “[n]o client shall be discharged without a
discharge plan” which “shall be given to the client upon discharge.” Id. at 130.
Indeed, according to Plaintiffs, Defendants regularly provide discharge
planning to individuals who are held at the Orange County Detention Center in
criminal detention in accordance with these standards—demonstrating
Defendants’ understanding that discharge planning is important for mentally ill
inmates. In Charles’s case, the Mental Health Department expressly recognized
that Charles would have “projected mental health needs” in his Discharge
Summary. Id. at 152.
Thus, Plaintiffs have plausibly alleged that Defendants were fully aware of,
and violated, both Orange County and ICE policies by failing to provide them
with discharge planning as part of their care. Plaintiffs’ allegations, if proven
true, are sufficient to establish that Defendants knew, or should have known, of
the substantial risk that Plaintiffs would relapse and suffer serious adverse health
consequences if they were not provided with necessary discharge planning, such
that a fact-finder could infer “reckless disregard” beyond mere negligence or
medical malpractice. Weyant, 101 F.3d at 856; see Harrison v. Barkley, 219 F.3d 132,
139 (2d Cir. 2000).
35
V. Issues Remaining for Factual Development
That Plaintiffs have adequately stated a claim does not, of course, mean
that they have established their entitlement to relief. Plaintiffs will need to
provide evidence to back up their allegations. Moreover, Defendants have raised
significant factual issues that need to be fleshed out through discovery. These
include: whether the discharge planning measures Plaintiffs identify should be
provided as part of in-custody care (rather than undertaken upon or after
release), the medical effects of a temporary deprivation of psychotropic
medication, the causal relationship between the alleged interruption in Plaintiffs’
treatment and the consequences they complain of, and whether the
circumstances of Plaintiffs’ release were so unexpected that Defendants could not
have anticipated, and properly planned for, their release at the time it occurred.
Moreover, Plaintiffs’ own allegations about the existence of written Orange
County policies call into question whether Plaintiffs can establish their contention
that there is a consistent policy, custom, or practice of denying such planning to
immigrant detainees. After discovery, the district court will be in a better position
to determine the precise parameters of the treatment that should have been
provided; whether the failure to provide any mandated care was attributable to
Defendants’ deliberate indifference, mere negligence, or unforeseen and
36
unforeseeable circumstances; and what, if any, damages were caused by any
dereliction on the part of Defendants.12 But, at the pleading stage, we hold that
Plaintiffs have adequately stated a Fourteenth Amendment substantive due
process claim.
CONCLUSION
For the foregoing reasons, we VACATE the district court’s opinion and
REMAND for proceedings consistent with this opinion.
12
In addition, the district court may consider, on remand, various issues it did
not reach in its September 29, 2017 opinion, and on which we express no opinion,
such as: (1) whether the Plaintiffs adequately pled a county policy, practice, or
custom for purposes of Monell liability; (2) whether Plaintiffs have adequately
stated a claim against Elizondo; and (3) whether Elizondo is entitled to qualified
immunity.
37