Rouster Ex Rel. Estate of Rouster v. County of Saginaw , 749 F.3d 437 ( 2014 )

RECOMMENDED FOR FULL-TEXT PUBLICATION
Pursuant to Sixth Circuit I.O.P. 32.1(b)
File Name: 14a0069p.06
UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT
_________________
DANIEL ROUSTER, as Personal Representative of the ┐
Estate of Jerry Rouster, Deceased, │
Plaintiff-Appellant, │
│ No. 13-1673
│
v. >
│
│
COUNTY OF SAGINAW, et al., │
Defendants, │
│
│
SECURE CARE, INC., CATHLEEN CONLEY, RMA; │
STELLA MENCHACA, LPN, and DEBRA MARRS, LPN, │
Defendants-Appellees. │
┘
Appeal from the United States District Court
for the Eastern District of Michigan at Bay City
No. 1:11-cv-10986—Thomas L. Ludington, District Judge.
Argued: January 28, 2014
Decided and Filed: April 9, 2014
Before: MOORE and COOK, Circuit Judges; GWIN, District Judge.*
_________________
COUNSEL
ARGUED: Christopher P. Desmond, JOHNSON LAW, PLC, Detroit, Michigan, for Appellant.
Susan J. Zbikowski, SIEMION HUCKABAY, P.C., Southfield, Michigan, for Appellees Secure
Care, Menchaca, and Marrs. R. Paul Vance, CLINE, CLINE & GRIFFIN, P.C., Flint, Michigan,
for Appellee Conley. ON BRIEF: Ven R. Johnson, JOHNSON LAW, PLC, Detroit, Michigan,
for Appellant. Susan J. Zbikowski, SIEMION HUCKABAY, P.C., Southfield, Michigan, for
Appellees Secure Care, Menchaca, and Marrs. J. Brian MacDonald, CLINE, CLINE &
GRIFFIN, P.C., Flint, Michigan, for Appellee Conley.
*
The Honorable James S. Gwin, United States District Judge for the Northern District of Ohio, sitting by
designation.
1
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OPINION
_________________
KAREN NELSON MOORE, Circuit Judge. While being held in Saginaw County Jail
(“Saginaw”), Jerry Rouster (“Jerry”) succumbed to sepsis and died as a result of a perforated
duodenal ulcer. Before his death, he complained of stomach pain, engaged in bizarre behaviors
indicative of mental-health problems, and displayed signs of agitation. His brother, Daniel
Rouster (“Rouster”), as representative of Jerry’s estate, brought suit under 42 U.S.C. § 1983against the medical staff who interacted with Jerry during the final thirty-six hours of his life,
alleging that they were deliberately indifferent to his medical needs. It is unfortunate that Jerry
died when prompt medical attention could have saved his life. However, we cannot conclude
that the medical staff became aware of Jerry’s serious medical need and deliberately refused to
provide appropriate treatment. Accordingly, we AFFIRM the judgment of the district court.
I. BACKGROUND
On May 7, 2007, Jerry Rouster was arrested on a misdemeanor charge of contempt of
court for failing to pay court fines related to an incident of driving on a suspended license. He
was brought to Saginaw to be held pending an appearance in court. The arresting officer did not
notice any obvious signs that Jerry was intoxicated, such as bloodshot eyes, slurring of speech, or
the odor of alcohol on Jerry’s breath. R. 99-3 (Lutz Dep. at 24) (Page ID #1858). However, the
individual who conducted Jerry’s intake screening at Saginaw noted that he was “[u]nder the
influence of drugs/alcohol.” R. 95-2 (Intake Screening Form) (Page ID #900). Jerry was placed
in a “general population” cell with several other inmates until he appeared before a judge on the
morning of May 9. The judge sentenced Jerry to an additional three days in jail, and Jerry
returned to a general population cell.
A. The First Shift – Cathleen Conley
At approximately 8:00 on the evening of May 9, Jerry began complaining of stomach
pains and abdominal cramping. A corrections officer (“CO”) called Cathleen Conley, the
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Registered Medical Assistant (“RMA”)1 on duty, to see Jerry in the general population cell.
When Conley arrived, Jerry was lying on the floor. R. 95-3 (Conley Dep. at 29) (Page ID #942).
He did not respond to her questions about how he was feeling, and he would not get up off the
floor to speak to her or show her any identification. Id. at 31–33 (Page ID #944–46). Pursuant
to Saginaw procedure, Conley was not permitted to enter the general population cell to examine
Jerry where other inmates were present. Id. at 31 (Page ID #944). Therefore, Conley asked the
COs to bring Jerry to the medical department when he got up. A few minutes later, Jerry walked
into the medical clinic. Id. at 34 (Page ID #947).
Upon entering the clinic, Jerry protested that he did not want to be there, but he
eventually submitted to Conley’s examination and assessment. Id. Conley noted on Jerry’s
medical chart that his pain from “cramping” was “between moderate and severe.” Id. at 37 (Page
ID #950). She also noted that Jerry reported that his last bowel movement had been on the
morning of May 9, and that it had been “like H2O,” but that he was not experiencing nausea or
vomiting. R. 100-7 (Conley Notes) (Page ID #2055). Upon palpating Jerry’s abdomen, Conley
noted no distension or rebound tenderness, and she observed that his bowel sounds were normal.
Id. She did notice, however, that Jerry was “guarding” (i.e., that his abdominal muscles were
“flexed [and] wouldn’t unflex”). Id. She attributed the flexing of his muscles to his attempts to
sit up: “He was fighting me. He was trying to get up off the table.” R. 95-3 (Conley Dep. at 39–
40) (Page ID #952–53). Conley concluded that Jerry suffered from “abdominal pain, gas and
diarrhea.” R. 100-7 (Conley Notes) (Page ID #2055). She gave him Tums and advised him to
increase his fluid intake and lie on his side. Id. At no time during this examination did Jerry
describe any medical history. After receiving the over-the-counter medication, Jerry returned to
the general population cell.
Just before midnight, when Conley was walking past Jerry’s cell, she observed him using
the toilet. She asked him if he was still experiencing any cramping, but he did not respond. R.
95-3 (Conley Dep. at 48) (Page ID #961). She concluded that the cramps had “resolved
1
A medical assistant has less formal education and training than a licensed practical nurse, and neither is
permitted to make an independent medical decision. R. 97-14 (Goldenson Dep. at 39) (Page ID #1800). Secure
Care, Inc., defendant-appellee in this case, is a private company that provides medical services to Saginaw,
including scheduling the medical personnel sued as individual defendants in this case. R. 1 (Compl. ¶ 7) (Page ID
#3).
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themselves.” R.100-7 (Conley Notes) (Page ID #2057). At approximately 12:30 on the morning
of May 10, the COs informed Conley that Jerry had vomited. R. 95-3 (Conley Dep. at 50) (Page
ID #963). She returned to his cell, but she did not observe him vomiting. Id. When Conley
asked Jerry whether he had an alcohol or drug abuse problem, Jerry denied abusing alcohol and
drugs. Id. Jerry did not complain about cramping or abdominal pain at this time.
Approximately thirty minutes later, the guards informed Conley that Jerry was eating the
leftover food from the bag lunches given to the inmates from off the floor of the cell. Id. at 51(Page ID #964). When Conley returned to the cell to check on Jerry, he was no longer eating
food from the ground. However, Jerry complained of cramping again. Id.At approximately 2:00 in the morning, the other inmates housed in Jerry’s general
population cell reported to the COs that Jerry was drinking out of the toilet. Id. at 53 (Page ID
#966). At this point, Conley became concerned about Jerry’s mental-health status. Id. at 54(Page ID #967). She moved him to an observation cell, where the COs could easily observe him
on a closed-circuit monitor. Id. at 55 (Page ID #968). Conley did not interact with Jerry again
before her shift ended at 6:00 on the morning of May 10, but she testified that it would have been
her “usual practice” to check the monitor periodically. Id. at 56–57 (Page ID #969–70). At no
point during her shift did she call Dr. Natole, the on-call physician. Conley explained that she
had not observed any of Jerry’s bizarre behaviors herself, and that she could not “call a doctor
with assumptions.” Id. at 54 (Page ID #967).
B. The Second Shift – Debra Marrs
At 6:00 on the morning of May 10, Debra Marrs, a Licensed Practical Nurse (“LPN”)
came on duty to relieve Conley. Conley reported to Marrs that she had placed Jerry under
observation because the guards and inmates had witnessed his bizarre behaviors. R. 95-4 (Marrs
Dep. at 74) (Page ID #1007). Conley also testified that she relayed information regarding Jerry’s
abdominal cramping, but Marrs could not remember if Conley discussed Jerry’s stomach pain
with her. Id. at 76 (Page ID #1007); R. 95-3 (Conley Dep. at 58) (Page ID #971). Throughout
the morning, Marrs observed Jerry in the observation cell and noted nothing unusual. During the
afternoon, a CO told Marrs that he personally knew that Jerry “drinks a lot.” R. 95-4 (Marrs
Dep. at 92) (Page ID #1011). Based on this information, Marrs thought that alcohol abuse might
13-1673 Rouster v. Saginaw Cnty. et al. Page 5
explain the bizarre behaviors Conley had described. Id. at 93 (Page ID #1011). At
approximately 2:45 on the afternoon of May 10, Marrs performed an alcohol withdrawal
assessment (“CIWA”). R. 100-14 (Marrs Notes) (Page ID #2111). She noted several aberrant
symptoms: Jerry was experiencing moderate hand tremors, he was disoriented (e.g., he believed
that the year was 1999 instead of 2007), and he was displaying “moderately anxious or guarded”
behaviors. R. 95-4 (Marrs Dep. at 104, 123–24) (Page ID #1014, 1019). After scoring Jerry’s
symptoms, Marrs calculated a total CIWA score of fifteen.2
Upon concluding that Jerry was likely experiencing alcohol withdrawal, Marrs called Dr.
Natole. She is unsure if she told Dr. Natole about Jerry’s abdominal complaints, and Dr. Natole
is unable to recall if Marrs described those symptoms. Id. at 114–16 (Page ID #1017); R. 97-12
(Natole Dep. at 59–61) (Page ID #1740–41). However, both Marrs and Dr. Natole agree that
Marrs reported Jerry’s CIWA score and that Dr. Natole prescribed Librium to treat his
withdrawal symptoms. R. 95-4 (Marrs Dep. at 105–18) (Page ID #1014–18); R. 97-12 (Natole
Dep. at 33–34) (Page ID #1734). Ordinarily, an inmate who received a CIWA score greater than
fifteen would be sent to the hospital for closer monitoring. R. 97-12 (Natole Dep. at 65–66)
(Page ID #1742). However, because Jerry’s score was just below that point, he was kept at
Saginaw for treatment. Marrs administered the prescribed medication and kept Jerry under
observation in a separate cell. At some point later in Marrs’s shift, she noticed that he was lying
behind the privacy partition in the observation cell. Marrs and a CO helped to move Jerry away
from the privacy partition so that they could observe him more easily. R. 95-4 (Marrs Dep. at
156–57) (Page ID #1027). Jerry did not complain to Marrs that he was experiencing abdominal
discomfort at any time during her twelve-hour shift. Id. at 158–59 (Page ID #1028). Nor did
Marrs observe any behaviors that would indicate to her that he was in pain (e.g., rubbing his
stomach or lying in a fetal position). Id. at 161–62 (Page ID #1028–29).
C. The Third Shift – Cathleen Conley and Stella Menchaca
When Marrs’s shift ended at 6:00 on the evening of May 10, Stella Menchaca, an LPN,
and Conley took over for the night shift. Marrs reported that she had started treating Jerry for
2
It appears that Marrs miscalculated: according to the notations on the CIWA assessment, Jerry actually
scored a 13. R. 100-14 (Marrs Notes) (Page ID #2111).
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alcohol withdrawal. R. 95-3 (Conley Dep. at 60) (Page ID #973). Conley also told Menchaca
about Jerry’s abdominal complaints and the bizarre behaviors that had led her to place him in the
observation cell. R. 97-13 (Menchaca Dep. at 69) (Page ID #1766). At 7:30, Menchaca
delivered Jerry’s medication and conducted a second CIWA. She noted that his skin was “cool
to touch,” that he had a “slight tremor,” and that his “gait [was] unsteady.” R. 100-16
(Menchaca Notes) (Page ID #2127). She also observed that he was mumbling and talking to
himself. R. 97-13 (Menchaca Dep. at 106) (Page ID #1776). When she asked Jerry how his
stomach was feeling, he denied that he was in pain. Id. at 111–12 (Page ID #1777). She also
observed Jerry reaching up high and bending over, and concluded that he did not have “an acute
abdomen.” Id. at 114 (Page ID #1178). Based on her observations, she believed that “he was
probably in a state of withdrawal.” Id. at 109 (Page ID #1776).
At approximately 1:30 on the morning of May 11, Conley gave Jerry the medication
prescribed by Dr. Natole and conducted a third CIWA.3 On the form, Conley noted that Jerry
“still [complained of] stomach pains [and] state[d that he] wants to go home.” R. 100-7 (Conley
Notes) (Page ID #2061). Victor Gomez, a CO near Jerry’s cell at the time, reported that Jerry
looked pale and sick, that it was clear he was in pain, and that he was obviously getting worse.
R. 99-18 (Gomez Dep. at 99–100, 118) (Page ID #1970–72). However, Conley observed that
“he was very strong at that time” and that “[h]e was pushing on the door . . . trying to get out.”
R. 95-3 (Conley Dep. at 65–66) (Page ID #978–79). Shortly thereafter, both Menchaca and
Conley observed Jerry kicking at the glass walls of his cell and picking at screws in the door. He
did not complain of abdominal pain or exhibit any behaviors that indicated he was in pain.
At 5:45 on the morning of May 11, 2007, less than thirty-six hours after he first began to
make medical complaints, Jerry was found dead in the observation cell. Medical examiners
determined that Jerry had a perforated duodenal ulcer, which had begun bleeding and leaking
toxic materials into his stomach; he eventually became septic and died. Jerry had been surgically
treated for an upper gastrointestinal bleed from the same ulcer the previous August. R. 96-6
3
Conley did not record her observations on a CIWA form until her shifted ended, which was after Jerry had
died in the observation cell. R. 95-3 (Conley Dep. at 62–63) (Page ID #975–76).
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(Hosp. Records) (Page ID #1284–87). However, at no point did Jerry inform any medical staff
member or other prison official about his history of treatment for an ulcer.
After Jerry’s death, Daniel Rouster, as the personal representative of Jerry’s estate, filed a
complaint against Conley, Marrs, Menchaca, and Secure Care, as well as several other
defendants, alleging that their denial of medical treatment for Jerry’s serious medical needs
constituted cruel and unusual punishment, that Secure Care had failed to train employees
adequately to detect serious medical problems, and that they were liable under state law for
medical malpractice. R. 1 (Compl.) (Page ID #1–20). In his amended complaint, Rouster added
a claim for ordinary negligence. R. 3 (Am. Compl.) (Page ID #58–80). Rouster settled with five
of the defendants, including the county, and the district court dismissed two others. R. 72 (Order
Approving Partial Settlement) (Page ID #759–63); R. 73 (Order Dismissing Natole) (Page ID
#764). Conley, Marrs, Menchaca, and Secure Care remained as defendants, and the parties
proceeded to discovery.
D. Medical Expert Testimony
During discovery, the parties retained medical experts to give opinions regarding the
significance of Jerry’s medical symptoms and the treatment provided by the medical staff at
Saginaw. The experts gave varying opinions on whether Jerry’s symptoms were consistent with
those of patients experiencing alcohol withdrawal. One expert opined that “[a]bdominal pain is
not a usual part [of withdrawal]. Muscular cramps are, but abdominal pain, in my experience, is
not a usual part.” R. 99-6 (Gouge Dep. at 34) (Page ID #1879). However, another expert
believed that abdominal pain and vomiting are consistent with alcohol withdrawal. R. 95-5
(Tennessen Dep. at 107) (Page ID #1081); see also R. 97-12 (Natole Dep. at 40) (Page ID
#1735). Other symptoms of alcohol withdrawal identified by the experts include hallucinations,
R. 95-5 (Tennessen Dep. at 107) (Page ID #1081) and other changes in mental status. R. 97-12
(Natole Dep. at 42–43) (Page ID #1736). However, no expert stated that the bizarre behaviors
Jerry engaged in were indicative of alcohol withdrawal. R. 95-5 (Tennessen Dep. at 139) (Page
ID #1089). Nonetheless, they concluded that, if Jerry had been suffering from withdrawal, he
was treated appropriately. R. 97-14 (Goldenson Dep. at 92) (Page ID #1813).
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Although they disagreed about whether certain of Jerry’s symptoms were consistent with
alcohol withdrawal, the medical experts were unanimous in their opinion that the medical
personnel who interacted with Jerry provided substandard care. At a basic level, Conley, Marrs,
and Menchaca were not trained to assess and diagnose patients. Valerie Tennessen, the R.N.
who testified to the appropriate standard of care for nurses, explained: “RMAs do not assess.
LPNs do not assess. All they do is gather information and pass it along. They don’t get to make
a nursing diagnosis.” R. 95-5 (Tennessen Dep. at 40–41) (Page ID #1064–65). Indeed, because
Conley was only an RMA, she lacked the medical knowledge to understand the symptoms she
observed and the medical terms on the assessment forms. Id. at 135 (Page ID #1088). However,
even the medical experts who opined that RMAs and LPNs lacked the credentials to assess or
diagnose patients conceded that they would need to screen patients to determine whether they
had a significant medical problem that should be evaluated by a doctor. R. 97-14 (Goldenson
Dep. at 108) (Page ID #1817).
Regardless of whether the RMAs and LPNs who saw Jerry were qualified to assess Jerry
as having mild digestive complaints or alcohol withdrawal, the experts believed that Jerry
exhibited several symptoms that should have alerted the nursing staff that a physician should be
called immediately. One expert testified that a physician should be called to evaluate any patient
who experiences “significant abdominal pain.” R. 99-6 (Gouge Dep. at 40) (Page ID #1881); see
also R. 97-14 (Goldenson Dep. at 69–70) (Page ID #1808). Another explained that a nurse who
observed an inmate eating off of the floor or drinking from the toilet should have seen it as a
“[b]ig red flag” and immediately called a doctor. R. 95-5 (Tennessen Dep. at 139) (Page ID
#1089).
In addition to the failure to contact a physician immediately, the experts were also critical
of the other steps the nursing staff took in caring for Jerry. They explained that, although it was
appropriate to remove Jerry from the general population cell once he began exhibiting bizarre
behaviors, the medical staff should have done more. R. 95-5 (Tennessen Dep. at 85–87) (Page
ID #1076); R. 97-14 (Goldenson Dep. at 55–56) (Page ID #1804). One expert opined that the
failure to contact a physician when Jerry was placed in the observation cell was “absolutely” a
breach of the standard of care. R. 95-5 (Tennessen Dep. at 85–88) (Page ID #1076). In addition,
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when the medical staff did personally observe Jerry in his cell, their assessments were
inadequate. Merely watching Jerry sit in his cell was not sufficient to assess his condition;
instead, the medical attendants were obligated to go into the cell themselves or have Jerry walk
over to the door and communicate with them. Id. at 123–24 (Page ID #1085). Ultimately, the
medical experts generally concluded that the treatment provided by the medical staff fell far
short of the optimal standard of care.
E. Procedural History
After the completion of discovery, Conley, Marrs, Menchaca, and Secure Care, as the
only remaining defendants, moved for summary judgment. R. 95 (Conley Mot. for Summ. J.)
(Page ID #870–97); R. 97 (Marrs, Menchaca, and Secure Care Mot. for Summ. J.) (Page ID
#1493–1519). The district court granted summary judgment in favor of all four defendants,
concluding that “no facts establish that [the defendants] subjectively knew that Mr. Rouster faced
a substantial risk of serious harm and consciously disregarded that risk.” R. 108 (D. Ct. Op. at
29) (Page ID #2247). The district court reasoned that there was no direct evidence that any of
the defendants knew that Jerry’s stomach pain indicated a serious medical risk. Nor was there
circumstantial evidence that “the risk was so obvious that Defendants must have known of the
risk.” Id. at 31–32 (Page ID #2249–50). Because the defendants misdiagnosed Jerry and treated
him for the wrong ailment, their actions might support a negligence claim; however, the district
court determined that the allegations did not support a constitutional claim. Id. The district court
also granted summary judgment in favor of Secure Care on the claim for failure to train,
concluding that Rouster was unable to pursue a municipal-liability theory because he had not
shown that Jerry’s constitutional rights were violated. Id. at 33 (Page ID #2251). After granting
summary judgment on both federal claims, the district court declined to exercise supplemental
jurisdiction over the remaining state claims. Id. at 34 (Page ID #2252). This timely appeal
followed.
II. STANDARD OF REVIEW
We review de novo the district court’s grant of summary judgment. Blackmore v.
Kalamazoo Cnty., 390 F.3d 890, 894 (6th Cir. 2004). Summary judgment is appropriate when
“the movant shows that there is no genuine dispute as to any material fact and the movant is
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entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). We must consider “whether the
evidence presents a sufficient disagreement to require submission to a jury or whether it is so
one-sided that one party must prevail as a matter of law.” Anderson v. Liberty Lobby, Inc.,
477 U.S. 242, 251–52 (1986). In determining whether there is a “genuine issue for trial,” we
interpret the facts and draw all reasonable inferences therefrom in favor of the nonmoving party.
Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986).
III. DELIBERATE INDIFFERENCE
Rouster asserts a claim under 42 U.S.C. § 1983, arguing that the three members of the
nursing staff who attended to Jerry while he was held at Saginaw were each deliberately
indifferent to his medical needs. To assert a cause of action arising under § 1983, a plaintiff
must demonstrate a deprivation of a constitutional right caused by a state government official.
The Supreme Court has held that “deliberate indifference to serious medical needs of prisoners
constitutes the unnecessary and wanton infliction of pain proscribed by the Eighth Amendment.”
Estelle v. Gamble, 429 U.S. 97, 104 (1976) (internal citation and quotation marks omitted). The
Eighth Amendment protection against deliberate indifference extends to pretrial detainees in
state prisons by operation of the Due Process Clause of the Fourteenth Amendment. Blackmore,
390 F.3d at 895. However, because the Eighth Amendment prohibits cruel or unusual
punishment, an official must have actually perceived a significant risk to an inmate’s health to
have violated his constitutional right: “[A]n official’s failure to alleviate a significant risk that he
should have perceived but did not, while no cause for commendation, cannot under our cases be
condemned as the infliction of punishment.” Farmer v. Brennan, 511 U.S. 825, 838 (1994); see
also Wilson v. Seiter, 501 U.S. 294, 300 (1990).
Accordingly, an Eighth Amendment inquiry has two components, one objective and one
subjective. A plaintiff satisfies the objective component by alleging that the prisoner had a
medical need that was “sufficiently serious.” Farmer, 511 U.S. at 834 (internal quotation marks
omitted). It is clear that Jerry suffered from a serious, indeed dire, medical need while he was
held at Saginaw. He had a perforated duodenum, which leaked toxic materials into his
abdominal cavity and caused internal bleeding. Jerry was held at Saginaw for only a few days,
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but within that time he succumbed to sepsis and died. Clearly then, Jerry had an objectively
serious need for medical treatment. See Blackmore, 390 F.3d at 897.
The central question in this appeal is whether Rouster has provided sufficient evidence to
prove the subjective component of the deliberate-indifference inquiry. A plaintiff satisfies the
subjective component by “alleg[ing] facts which, if true, would show that the official being sued
subjectively perceived facts from which to infer substantial risk to the prisoner, that he did in fact
draw the inference, and that he then disregarded that risk.” Comstock v. McCrary, 273 F.3d 693,
703 (6th Cir. 2001). The subjective requirement is designed “to prevent the constitutionalization
of medical malpractice claims; thus, a plaintiff alleging deliberate indifference must show more
than negligence or the misdiagnosis of an ailment.” Id. (citing Estelle, 429 U.S. at 106). We
have described the mental state of a prison official who has been deliberately indifferent to a
prisoner’s medical needs as akin to recklessness:
When a prison doctor provides treatment, albeit carelessly or inefficaciously, to a
prisoner, he has not displayed a deliberate indifference to the prisoner’s needs, but
merely a degree of incompetence which does not rise to the level of a
constitutional violation. On the other hand, a plaintiff need not show that the
official acted “for the very purpose of causing harm or with knowledge that harm
will result.” Instead, “deliberate indifference to a substantial risk of serious harm
to a prisoner is the equivalent of recklessly disregarding that risk.”
Id. (internal citations omitted) (quoting Farmer, 511 U.S. at 835–36). The plaintiff bears the
burden of proving subjective knowledge, but he may do so with ordinary methods of proof,
including by using circumstantial evidence. Farmer, 511 U.S. at 842. Indeed, “a factfinder may
conclude that a prison official knew of a substantial risk from the very fact that the risk was
obvious.” Id. Bearing these principles in mind, we turn to addressing whether Rouster can
prove the subjective component of his claim as to each of the medical attendants who interacted
with Jerry. See Gray v. City of Detroit, 399 F.3d 612, 616 (6th Cir. 2005) (explaining that each
defendant’s subjective knowledge should be assessed separately, and that information available
to one defendant may not be automatically imputed to the others).
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A. Cathleen Conley
Rouster argues that Conley had subjective knowledge of Jerry’s need for medical
treatment because she had examined him for his abdominal complaints and was aware of his
bizarre behaviors. Specifically, Conley knew by the end of her first shift (1) that Jerry had
complained of stomach cramping, (2) that he displayed abdominal “guarding,” (3) that he had
diarrhea, (4) that the COs had observed him vomiting, (5) that he had been observed eating
leftover food from the floor, and (6) that other inmates had observed him drinking from the
toilet. During her shift the next evening, she also learned (7) that twenty-four hours after Jerry
first experienced abdominal pain he again complained of stomach cramping. Based upon this
knowledge, Rouster asserts that Jerry’s serious medical need was so obvious that Conley must
have been subjectively aware of it, see Farmer, 511 U.S. at 842, and that she consciously
disregarded Jerry’s needs by failing to contact a physician or provide appropriate treatment.
There are three critical points during Conley’s interactions with Jerry when she might
have become aware that he suffered from a serious medical condition and needed treatment:
(1) during her initial examination of Jerry in the medical clinic, (2) after she was notified that
Jerry had been seen drinking from the toilet, and (3) during her second shift, when Jerry again
complained to her of stomach cramping. First, we cannot conclude that Conley was subjectively
aware of Jerry’s serious medical need at the time she initially examined him in response to his
abdominal complaints. After her examination, Conley knew that Jerry suffered from stomach
pain and diarrhea, and that his abdominal muscles were flexed and would not unflex. Although
the symptoms Jerry was exhibiting could well have indicated a serious medical condition,
Conley interpreted the symptoms as indicative of a relatively minor condition. She concluded
that Jerry suffered from gas and diarrhea, and she treated him accordingly.
“[C]ourts are generally reluctant to second guess the medical judgment of prison medical
officials.” Jones v. Muskegon Cnty., 625 F.3d 935, 944 (6th Cir. 2010); see also Comstock,
273 F.3d at 703 (noting that a prison medical official who merely provides careless or
inefficacious treatment has not been deliberately indifferent to a prisoner’s needs). In Jones, a
doctor examined a prisoner who complained of sharp stomach pains, rapid weight loss, and other
bowel complaints, and concluded that he suffered from severe constipation. The doctor
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prescribed an over-the-counter medication to relieve the prisoner’s symptoms. However, when
the prisoner was later treated at a hospital, the doctors determined that his symptoms were caused
by cancer. In finding summary judgment in favor of the prison doctor appropriate, we reasoned:
Dr. Deitrick’s initial diagnosis and treatment of Jones with a laxative seems
inappropriate in light of Jones’s substantial weight loss and sharp stomach pain;
however, Jones had indicated an inability to have a bowel movement for several
days and other stomach pains, which could have been consistent with Dr.
Deitrick’s diagnosis of obstipation. Even though Dr. Deitrick’s initial diagnosis
was incorrect, negligence in diagnosing a medical condition does not constitute
unconstitutional deliberate indifference.
Id. at 945 (internal quotation marks omitted). Conley’s interaction with Jerry closely parallels
the circumstances described in Jones: she assessed his symptoms (e.g., cramping and diarrhea)
and misdiagnosed him as suffering from gas and diarrhea.
Furthermore, Rouster acknowledges that Conley did provide some level of treatment in
response to Jerry’s complaints. Conley immediately evaluated him after receiving a report that
his stomach was cramping, and then provided him with over-the-counter medication to treat
appropriately the relatively minor stomach ailment that she diagnosed. Rouster argues that such
a minimal response to serious medical needs is constitutionally deficient: “‘[A] prisoner is not
required to show that he was literally ignored by the staff’ to prove an Eighth Amendment
violation, only that his serious medical needs were consciously disregarded.” LeMarbe v.
Wisneski, 266 F.3d 429, 439 (6th Cir. 2001) (quoting Sherrod v. Lingle, 223 F.3d 605, 611 (7th
Cir. 2000)); see also Terrance v. Northville Reg’l Psychiatric Hosp., 286 F.3d 834, 843 (6th Cir.
2002) (“[W]hen the need for treatment is obvious, medical care which is so cursory as to amount
to no treatment at all may amount to deliberate indifference.”) (internal quotation marks
omitted); Westlake v. Lucas, 537 F.2d 857, 860 n.5 (6th Cir. 1976) (noting that “[o]f course, in
some cases the medical attention rendered may be so woefully inadequate as to amount to no
treatment at all”).
Had Conley been subjectively aware of the seriousness of Jerry’s medical condition, her
decision to treat him only with over-the-counter medication might have been so cursory as to
amount to a conscious disregard of his needs. However, Rouster has not shown that Conley was
in fact aware that Jerry had a serious medical need. Indeed, Conley did not have one very critical
13-1673 Rouster v. Saginaw Cnty. et al. Page 14
piece of information, which might have allowed us to draw such a conclusion: she did not know
that Jerry had been treated the previous year for a perforated duodenal ulcer. Cf. Westlake,
537 F.2d at 859 (concluding that a prisoner stated a claim of deliberate indifference because
prison officials provided no treatment even after the prisoner informed them that he suffered
from an ulcer and needed medication and a special diet). It is true that the medical experts
retained in this case testified that Conley should have called a physician whenever any inmate
complained of “significant abdominal pain.” R. 99-6 (Gouge Dep. at 40) (Page ID #1881).
However, Conley’s failure to follow best medical practices is not necessarily evidence of
deliberate indifference if she did not know that Jerry’s stomach pain was caused by a serious
ailment. Furthermore, even if Conley should have known that Jerry’s abdominal “guarding” was
indicative of a serious medical condition, she was not deliberately indifferent because she
inferred that he was clenching his muscles on purpose as he attempted to sit up and get off the
table. Indeed, Conley did not have the training to understand the significance of the symptoms
she observed during her abdominal assessment. R. 95-5 (Tennessen Dep. at 167–68) (Page ID
#1096). Therefore, Conley did not display deliberate indifference to a known serious medical
need during her first interaction with Jerry, at the time he complained of stomach pain.
Nor was Conley deliberately indifferent to Jerry’s medical needs later that evening at the
second critical point, after he had begun exhibiting bizarre behaviors indicative of mental-health
problems. Conley promptly responded to every call made by correctional staff regarding Jerry’s
medical complaints (i.e. that he vomited, that he ate leftover food from the floor, and that he
drank from the toilet). Cf. Dominguez v. Correctional Med. Servs., 555 F.3d 543, 550–51 (6th
Cir. 2009) (finding deliberate indifference when a nurse refused to see a patient experiencing
severe symptoms until her regularly scheduled medication run several hours later). This last
event is perhaps the most concerning: it seems obvious to us that anybody who has started
drinking from a toilet is suffering from some kind of serious medical ailment. Indeed, Conley
acknowledged that, after the inmates told her that he had been drinking from the toilet, she
became concerned that there was a “significant change in [Jerry’s] mental status.” R. 95-3
(Conley Dep. at 54) (Page ID #967). However, we cannot conclude that Conley exhibited
deliberate indifference to Jerry’s medical needs because she responded to her concerns by
moving Jerry to an observation cell where he could be closely monitored by correctional staff.
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Perhaps Conley could have and should have done more, including notifying the on-call
physician. But she clearly took appropriate steps to protect Jerry. She isolated him from the
other inmates in a room where he could not be a danger to himself or others and positioned him
in a cell where he would be under near-constant supervision. Although she cannot say for
certain that she personally checked on him in the remaining four hours of her shift, she did not
deliberately ignore Jerry’s needs by relying on the COs to monitor his health and behavior at
regular intervals.
Furthermore, Conley was not aware that Jerry’s stomach continued to trouble him.
Conley did not provide constitutionally deficient treatment by failing to address pain of which
she was not aware. “Generally, courts find deliberate indifference where there is evidence
tending to establish that the physician is present while the inmate is in distress, that distress is
communicated to the physician, and the physician purposefully ignores the distress knowing that
an adverse outcome is likely to occur.” Jones, 625 F.3d at 945 (emphasis added). After Jerry’s
first encounter with Conley, when she provided medication to treat gas and diarrhea, Jerry did
not consistently communicate to Conley that he continued to experience cramping and pain.
When she asked him how he was feeling at several points during the evening, he either denied
that he was in pain or refused to answer. R. 95-3 (Conley Dep. at 48, 68) (Page ID #961, 981).
Jerry mentioned that his stomach was cramping only at one other point that night—when Conley
checked on him after he was observed eating off of the floor. Id. at 51–52 (Page ID #964–65).
This complaint was only a few hours after Jerry had taken medication to alleviate his symptoms,
and Conley could easily have concluded that the medication simply needed more time to take
effect. In any event, Jerry’s denial of pain when Conley checked on him at several points
throughout the evening did not alert her that the treatment she had already provided was
inefficacious to treat the minor ailment from which she had concluded that he suffered.
Finally, Conley did not display deliberate indifference when she encountered Jerry to
perform a CIWA during her third shift. Rouster argues that a reasonable jury could conclude
that Conley knew that Jerry suffered from a serious medical need at this point because his
condition was obvious. Victor Gomez, a CO who observed Jerry at the same time as Conley on
the evening of May 10, testified that Jerry looked “pale” and “sick,” and that he could tell by the
13-1673 Rouster v. Saginaw Cnty. et al. Page 16
way that Jerry was looking and acting that “it was pretty obvious that [he] wasn’t getting better
but getting worse.” R. 99-18 (Gomez Dep. at 99–100, 118) (Page ID #1970–72).4 Gomez also
testified that it was “[s]ometimes” clear that Jerry was in pain, and that he complained that “his
stomach was hurting, [and that] he wanted water.” Id. at 122–23 (Page ID #1973–74). Gomez
did not share his concerns with Conley or any other medical professional. Id. at 118 (Page ID
#1972). Because a lay person without medical training was able to perceive Jerry’s serious need,
however, Rouster argues that the risk must have been obvious to trained medical staff. See
Phillips v. Roane Cnty., Tenn., 534 F.3d 531, 541 (6th Cir. 2008) (concluding that correctional
officers were deliberately indifferent to a prisoner’s medical needs because the seriousness of the
medical condition was obvious to a fellow inmate who shared her concerns and because the
officers made comments demonstrating that they were aware of an ongoing medical problem).
Gomez’s testimony does support Rouster’s argument that it was obvious as of the late evening of
May 10 that Jerry was ill. In addition, Conley acknowledged that Jerry again complained of
stomach cramping when she conducted the CIWA. R. 95-3 (Conley Dep. at 64) (Page ID #977).
However, Jerry’s weakness at that time would not necessarily have indicated a serious medical
condition.
At the point when Gomez claims that Jerry was visibly ill, Conley was aware that Jerry
had been assessed for alcohol withdrawal. Jerry was already being treated in accordance with
withdrawal protocols, and indeed Dr. Natole was scheduled to see him within the next twelve
hours during his regular visit to Saginaw. R. 97-12 (Natole Dep. at 67–68) (Page ID #1742)
(explaining that Dr. Natole would ordinarily see a patient he had received a call about on his next
scheduled visit, which coincided with the day that Jerry died). Jerry’s visible illness and his
complaints of stomach cramping were consistent with the symptoms experienced by an
individual going through alcohol withdrawal. See R. 95-5 (Tennessen Dep. at 107) (Page ID
#1081); R. 97-12 (Natole Dep. at 40) (Page ID #1735). Even Gomez’s conclusion that Jerry was
clearly getting worse was consistent with the course of withdrawal: Marrs’s experience was that
4
Conley described Jerry as being “very strong at that time,” and recalled that “[h]e was pushing on the door
. . . [and] trying to get out.” Id. at 65 (Page ID #978). Rouster disputes Conley’s testimony by pointing to Gomez’s
claim that Jerry was weak and could not “put up much physical resistance.” R. 99-18 (Gomez Dep. at 118) (Page ID
#1972). We must interpret all disputed facts in Rouster’s favor, and therefore we assume that Jerry was visibly
weak and ill at this point in the evening.
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the “[t]hird day is usually the worst” for patients experiencing alcohol withdrawal. R. 95-4
(Marrs Dep. at 101) (Page ID #1013). If Jerry had consumed alcohol for the last time on May 7
before he was arrested, it would not be surprising that his symptoms of withdrawal would be
particularly severe on the morning of May 10, three days later.
Although it was obvious to a layperson that Jerry suffered from some kind of serious
illness, Conley was not subjectively aware that Jerry was suffering from a more serious condition
than the alcohol withdrawal with which he had been diagnosed. See Farmer, 511 U.S. at 844(concluding that prison officials may show that they were unaware of a risk, even an obvious
one, by proving that they were unaware of the facts indicating significant danger or that they
believed the risk posed by known facts was insignificant). Therefore, Rouster has not presented
sufficient evidence from which a reasonable jury could conclude that Conley was deliberately
indifferent to Jerry’s medical needs.
B. Debra Marrs
Rouster cannot prove that Marrs was subjectively aware of Jerry’s serious medical needs
and was deliberately indifferent to his welfare. Like Conley, Marrs had limited information
about Jerry’s symptoms and medical history. When Marrs came on duty for her shift, Conley
informed her that Jerry had been placed in an observation cell because he had exhibited bizarre
behaviors, such as eating from the floor and drinking from the toilet. R. 95-4 (Marrs Dep. at 74)
(Page ID #1007). Marrs received one more critical piece of information during her shift that
changed the course of Jerry’s treatment for the remaining hours of his life: a CO told her that
Jerry was known as a heavy drinker. Id. at 92–93 (Page ID #1011). Based on this information,
Marrs conducted a CIWA to assess Jerry for alcohol-withdrawal symptoms. Marrs concluded
that Jerry’s various complaints and ailments could be explained by alcohol withdrawal and she
began to treat him accordingly. As explained above, we do not ordinarily second-guess a
diagnosis made by a medical provider in a prison setting. Jones, 625 F.3d at 944.
To be sure, medical providers may “not escape liability if the evidence showed that [they]
merely refused to verify underlying facts that [they] strongly suspected to be true, or declined to
confirm inferences of risk that [they] strongly suspected to exist.” Farmer, 511 U.S. at 843 n.8.
Thus, if Jerry’s symptoms had been clearly inconsistent with alcohol withdrawal, Marrs might
13-1673 Rouster v. Saginaw Cnty. et al. Page 18
have been deliberately indifferent by failing to confirm that his symptoms were not indicative of
a different and more serious condition. Indeed, there is some evidence that not all of Jerry’s
symptoms could be explained by withdrawal: the behavioral anomalies he exhibited were not
the kinds of mental disturbances that were typical of withdrawal patients. R. 95-5 (Tennessen
Dep. at 139) (Page ID #1089). However, the majority of Jerry’s symptoms were entirely
consistent with those experienced by patients suffering from alcohol withdrawal. See Jones,
625 F.3d at 945 (concluding that a doctor had not shown deliberate indifference by
misdiagnosing a prisoner’s medical condition when the diagnosis accounted for some, but not
all, of the prisoner’s symptoms). His abdominal pain,5 vomiting, agitated behavior, and physical
tremors were all symptoms associated with withdrawal. Therefore, given that Jerry’s intake
form indicated that he was intoxicated when he was admitted to Saginaw, R. 100-4 (Intake
Screening Form) (Page ID #2029), Marrs’s conclusion that Jerry suffered from alcohol
withdrawal was entirely reasonable. Rouster has presented no evidence that Marrs considered an
alternative, more serious diagnosis but refused to verify that Jerry’s symptoms were consistent
with such a condition. Rather, she diagnosed Jerry as suffering from alcohol withdrawal and
took the appropriate steps to provide treatment, including calling a physician and placing Jerry
on withdrawal protocols. We cannot conclude under these facts that Marrs was subjectively
aware that Jerry suffered from a serious medical condition and chose to ignore his need for
treatment.
C. Stella Menchaca
Finally, Rouster has not provided evidence to show that Menchaca knew that Jerry had a
serious medical need which she deliberately ignored. When Menchaca began her shift on the
evening of May 10, Marrs informed her that Dr. Natole had placed Jerry on withdrawal
5
It is not clear whether Marrs was even aware that Jerry had complained of stomach cramping at any point.
Marrs does not recall whether Conley informed her during shift change that Jerry had been assessed for stomach
cramping. R. 95-4 (Marrs Dep. at 76) (Page ID #1007). However, Conley testified that she did relay information
regarding Jerry’s abdominal complaints. R. 95-3 (Conley Dep. at 58) (Page ID #971). Interpreting all facts in
Rouster’s favor, we may infer that Marrs knew that Jerry had been experiencing abdominal discomfort at 8:00 the
previous evening. But Jerry did not complain of stomach pain or cramping to Marrs during any of her interactions
with him. R. 95-4 (Marrs Dep. at 114, 158–61) (Page ID #1017, 1028). As we noted above, a medical professional
is deliberately indifferent when she ignores complaints of pain that are communicated to her. Jones, 625 F.3d at
945. However, Jerry never communicated to Marrs that he continued to suffer abdominal pain, and therefore we
cannot conclude that she was subjectively aware that he continued to experience pain and needed treatment.
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protocols. Conley also told her about Jerry’s medical issues during her first shift, including his
abdominal complaints and his bizarre behavioral episodes. In accordance with withdrawal
protocols, when she delivered Jerry’s medication shortly after her shift began, Menchaca
conducted a CIWA to evaluate Jerry for withdrawal symptoms. She noted that his behavior was
agitated, that he appeared to be confused, and that he was experiencing physical tremors. R. 97-
13 (Menchaca Dep. at 109) (Page ID #1776). These symptoms were consistent with those
experienced by individuals going through alcohol withdrawal. R. 95-5 (Tennessen Dep. at 107)
(Page ID #1081) (hallucinations, abdominal pain, and vomiting); R. 99-6 (Gouge Dep. at 34)
(Page ID #1879) (anxiety and tremors). Furthermore, Menchaca was unaware that Jerry
continued to suffer stomach pain: He did not complain of cramping to her at any time, and she
observed him engaging in behaviors, such as reaching up high or bending over, that indicated he
was not suffering from an “acute abdomen.” R. 97-13 (Menchaca Dep. at 110–12, 114, 119)
(Page ID #1777–79). Like Marrs, Menchaca believed that Jerry was suffering from alcohol
withdrawal, and she treated him appropriately for the medical needs that she believed he had.
The medical care provided to Jerry while he was held in Saginaw was questionable.
Medical staff providing proper care would have, in an abundance of caution, caused Jerry to see
a physician when he began experiencing severe abdominal pain; at the least, they would have
continued to assess his abdomen for rigidity or other signs of “acute abdomen” while he was held
in observation. However, none of the medical personnel who interacted with Jerry displayed
deliberate indifference. They were each ignorant of the single critical fact that might have
caused them to interpret his symptoms in a different light: At no point in time did Jerry tell any
member of the medical staff about his previous treatment for a perforated duodenal ulcer. R. 95-
5 (Tennessen Dep. at 14, 136) (Page ID #1058, 1088); R. 97-14 (Goldenson Dep. at 85–91)
(Page ID #1812–13). Had they received full information regarding Jerry’s medical history, we
could easily conclude that Conley, Marrs, and Menchaca were deliberately indifferent to Jerry’s
needs. See Johnson v. Karnes, 398 F.3d 868, 875–76 (6th Cir. 2005). However, “the standard is
not whether there is something easy that the doctors, with the benefit of hindsight, could have
done.” Williams v. Mehra, 186 F.3d 685, 692 (6th Cir. 1999) (en banc). We must judge their
actions based on the information that was available to them at the time.
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Because the nursing staff did not know that Jerry suffered from a serious medical
ailment, and they instead interpreted his symptoms as indicating a different condition, for which
they provided appropriate treatment, they were not deliberately indifferent to his medical needs.
No record evidence indicates that any member of the nursing staff ever suspected that Jerry was
suffering from a more serious condition than alcohol withdrawal. Cf. Perez v. Oakland Cnty.,
466 F.3d 416, 425 (6th Cir. 2006) (concluding that a genuine question of material fact existed
regarding a prison doctor’s subjective awareness of serious medical risk to a prisoner who
committed suicide when the doctor had several times previously placed a prisoner on elevated
suicide watch). Because Jerry was not deprived of any constitutional rights, Rouster cannot
successfully assert a § 1983 claim. Accordingly, it was appropriate for the district court to grant
summary judgment in favor of Conley, Menchaca, and Marrs on the claim that they violated
Jerry’s constitutional rights by depriving him of treatment for his serious medical needs.
IV. FAILURE TO TRAIN
Rouster also asserts a § 1983 claim against Secure Care for failing to staff Saginaw with
“competent medical personnel” and failing adequately to train and supervise medical staff in
monitoring prisoners for serious medical conditions. R. 1 (Compl. ¶¶ 53–54) (Page ID #11–12).
Private corporations that “perform a traditional state function such as providing medical services
to prison inmates may be sued under § 1983 as one acting under color of state law.” Street v.
Corrections Corp. of Am., 102 F.3d 810, 814 (6th Cir. 1996) (internal quotation marks omitted).
However, private corporations cannot be held liable on the basis of respondeat superior or
vicarious liability. Id. at 818. Accordingly, a plaintiff must prove both “that his or her
constitutional rights were violated and that a policy or custom of the municipality was the
‘moving force’ behind the deprivation of the plaintiff’s rights.” Miller v. Sanilac Cnty., 606 F.3d
240, 254–55 (6th Cir. 2010) (citation omitted); see also Savoie v. Martin, 673 F.3d 488, 494 (6th
Cir. 2012); Broyles v. Correctional Med. Servs., Inc., No. 08-1638, 2009 WL 3154241, at *2 (6th
Cir. Jan. 23, 2009). As discussed above, Rouster is unable to prove that Jerry’s constitutional
rights were violated. Therefore, we need not consider whether Secure Care’s staffing or training
policies might have caused such a violation. The district court appropriately granted summary
judgment in favor of Secure Care on Rouster’s claim that the private corporation failed
adequately to train and supervise medical staff in the prison.
13-1673 Rouster v. Saginaw Cnty. et al. Page 21
V. STATE MALPRACTICE AND NEGLIGENCE CLAIMS
Rouster’s remaining claims arise under state law and implicate complex questions
regarding the standard of care for nursing professionals in Michigan. We have held that “a
federal court that has dismissed a plaintiff’s federal-law claims should not ordinarily reach the
plaintiff’s state-law claims.” Moon v. Harrison Piping Supply, 465 F.3d 719, 728 (6th Cir. 2006)
(citation omitted); see also United Mine Workers of Am. v. Gibbs, 383 U.S. 715, 726 (1966)
(“Certainly, if the federal claims are dismissed before trial . . . the state claims should be
dismissed as well.”). This rule accords with principles of federalism: “Needless decisions of
state law should be avoided both as a matter of comity and to promote justice between the
parties, by procuring for them a surer-footed reading of applicable law.” Gibbs, 383 U.S. at 726.
Because we have affirmed the grant of summary judgment in favor of the defendants on the
federal-law claims, we conclude that the district court appropriately declined to exercise
supplemental jurisdiction over the remaining state-law claims. Rouster may pursue his
malpractice and negligence claims in the appropriate state court.
VI. CONCLUSION
For the foregoing reasons, we AFFIRM the district court’s judgment.