Application of Qualified Immunity in Patient Death

Facts of the Case

In February 2011 after he arrived at a fire station complaining of being chased, police apprehended and transported Mr. Cornell, in accordance with Texas state law, to the Parkland psychiatric emergency room, where the doctor authorized his admission for paranoia; he believed that people had stolen his lottery ticket and were chasing him. During the admission, Mr. Cornell reported he had tachycardia. A technician, took Mr. Cornell's vital signs, which revealed hypertension and tachycardia. The technician attempted to recheck Mr. Cornell's vital signs, but he became agitated and refused cooperation, resulting in no further cardiac treatment. Mr. Cornell then attempted to elope. Two technicians placed Mr. Cornell in a seclusion room and restrained him on the floor for about five minutes (accounts varied on the exact length of the restraint) while the nurse injected Mr. Cornell with haloperidol, lorazepam, and diphenhydramine, to control his behavior.

While alone in the seclusion room, Mr. Cornell became agitated again. He ripped up a vinyl tile from the floor and banged it against the door. Because he had damaged the room, three technicians transferred him to a new room. During the transfer, Mr. Cornell again physically resisted the technicians. They held him on the floor, and he received a second injection of haloperidol, lorazepam, and diphenhydramine. Testimony regarding the length of time the technicians held him was conflicting, although Ms. Pena stated the technicians held Mr. Cornell on his stomach for 15 minutes after the injection. The technicians were trained to not hold a patient prone for more than 1 minute, because of the risk of asphyxiation. After the technicians left the room, a nurse later found Mr. Cornell cyanotic and lying prone on the floor. He was transferred to the main emergency room and pronounced dead. The medical examiner found the cause of death to be undetermined and listed three possible causes: mechanical compression; underlying heart disease; or effects of the medication he received.

In 2008, the Centers for Medicare and Medicaid Services (CMS) sent a letter to the CEO, stating that Parkland's deficiencies in providing medical screening were a serious threat to patients who come to Parkland with emergent medical conditions. A CMS report after Mr. Cornell's incident noted that, at the time of the incident, the nurse's restraint-and-seclusion training had lapsed, and his nursing supervisors should have been aware of this. After Mr. Cornell's death, Parkland was “under near constant surveillance and investigation” by CMS and the Texas Department of State Health Services because of the high number of complaints, injuries, and deaths at the hospital.

Ms. Pena, representing Mr. Cornell's estate, filed a complaint in the Texas district court alleging that technicians used excessive force and violated his Fourth Amendment and substantive due process rights. Ms. Pena further alleged that the nurse and psychiatrist violated his due process right by denying medical care for his cardiac condition. Ms. Pena asserted that the nurse supervisors and the CEO contributed to the violation of Mr. Cornell's rights because of inadequate supervision of the emergency room personnel. Parkland removed the case to federal court, and the defendants moved for summary judgment based on qualified immunity. The district court denied. The defendants then filed an interlocutory appeal.

Ruling and Reasoning

The Fifth Circuit Court of Appeals reversed the district court's denial of qualified immunity and rendered summary judgment for the appellants. The appeals court addressed each claim and stated that Ms. Pena had the burden to establish the inapplicability of qualified immunity for each defendant.

In an excessive force claim, the plaintiff must first show that Mr. Cornell was seized pursuant to the Fourth Amendment before showing that an injury resulted for an unreasonable use of force according to Flores v. City of Palacios, 381 F.3d 391 (5th Cir. 2004). The Fifth Circuit relied on Peete v. Metropolitan Government of Nashville & Davidson County, 486 F.3d 217 (6th Cir. 2007), to state that the technicians' actions were made in an attempt to provide medical treatment and not made in a law-enforcement capacity. Therefore, the technicians' restraint of Mr. Cornell did not constitute a seizure pursuant to the Fourth Amendment, and they were entitled to qualified immunity on the excessive-force claim.

Ms. Pena further argued that the technicians violated their restraint training and the use of restraints was “grossly disproportionate to the need for action under the circumstances,” Petta v. Rivera, 143 F.3d 895, p 902 (5th Cir. 1998). The Fifth Circuit stated “no reasonable jury” would find the technicians' actions were grossly disproportionate to the need for action, given Mr. Cornell's physical resistance, or find they acted out of malice. The appeals court stated Ms. Pena “gives too much weight” to the technicians violating their training. In City & Cty. of San Francisco v. Sheehan, 135 S. Ct. 1765 (2015), the Supreme Court stated that an individual acting contrary to his training “does not itself negate qualified immunity where it would otherwise be warranted” (p 1777). Thus, the technicians were entitled to qualified immunity on the substantive due process claim.

The Fifth Circuit used the standard of “deliberate indifference” for denying medical care to those with mental illness held involuntarily set by McClendon v. City of Columbia, 305 F.3d 314 (5th Cir. 2002). The lack of treatment for Mr. Cornell's cardiac condition occurred due to Mr. Cornell's refusal and physical resistance to care. The nurse's and physician's failure to provide treatment in the face of physical refusal was not evidence of knowing and disregarding the need for treatment. Therefore, the appeals court determined that the nurse's and doctor's actions did not amount to deliberate indifference, and they were also entitled to qualified immunity on the Fourteenth Amendment due process claim.

In regard to the hospital supervisors' violation of Mr. Cornell's rights, the Fifth Circuit relied on Aterberry v. Nocono Gen. Hosp., 430 F.3d 245 (5th Cir. 2005), to state that “supervisory liability requires a constitutional violation by a subordinate” (p 255). If no underlying violation of Mr. Cornell's due process rights by the technicians, nurse, and doctor existed, the supervisors were not liable and were entitled to qualified immunity on this claim, as per the above analysis.