Deliberate Indifference to Inmate Suicide Risk and Qualified Immunity in Correctional Settings

Vera Klinoff; Ira K. Packer

doi:10.29158/JAAPL.3773L1-18

A Private Medical Contractor Working in a Correctional Setting Is Not Entitled to Qualified Immunity; a Prisoner Has the Right to be Free From Deliberate Indifference to his Suicide Risk

In the current case, Estate of Clark v. Walker, 865 F.3d 544 (7th Cir. 2017), Ryan Clark died by suicide after his admission to a county jail in Green Lake, Wisconsin. Despite being assessed as having a “maximum risk” of suicide upon admission, intake staff (a correctional officer employed by the jail and a privately contracted nurse) did not initiate the institution's suicide prevention protocol. Mr. Clark's estate brought a suit under 42 U.S.C. §1983 (1996), alleging that the staff violated Mr. Clark's Eighth Amendment rights, by acting with deliberate indifference toward his suicide risk. The defendants moved for summary judgment and invoked qualified immunity, which was denied by the district court. The Seventh Circuit affirmed the denial of summary judgment. It was determined that the nurse was not entitled to qualified immunity as privately contracted personnel and that the facts of this case were sufficient for a jury to determine whether there was deliberate indifference to the inmate's suicide risk.

Facts of the Case

Mr. Clark died by suicide five days after his admission to the Lake County Jail in Wisconsin. He had a history of alcohol abuse and depression; records from previous incarcerations at the current jail revealed that he received psychotropic medications regularly for depression and that he experienced “panic attacks.” He also had five past offenses related to operating a vehicle under the influence of alcohol, and was intoxicated each time he was reincarcerated for violations of the conditions of supervision. In addition, records detailed a history of self-harm, including a suicide attempt in 2011. Mr. Clark had past documented instances of being placed on “special watch observation,” where he was observed every 15 minutes for suicide prevention. Although Mr. Clark was assessed as having a “maximum risk” of suicide upon admission to the Lake County Jail, the intake staff members (Bruce Walker, a correctional officer employed by the jail, and Tina Kuehn, a nurse employed by a private health care company under contract with the jail) did not initiate the jail's suicide prevention protocol. Mr. Walker indicated that officers often made discretionary decisions regarding suicide risk; in fact, he testified believing at the time that the assessment measure rendered a maximum suicide rating for all intoxicated inmates. Therefore, Mr. Walker subsequently placed Mr. Clark in a holding cell pending Ms. Kuehn's medical assessment, without implementing the suicide prevention protocol (i.e., checking records for prior mental health/risk history, placing the inmate in a suicide prevention cell, initiating monitoring, or referring to a mental health provider). Ms. Kuehn subsequently completed a medical intake, put Mr. Clark's completed suicide risk assessment in the chart, and placed Mr. Clark in a detoxification cell (where inmates are alone 24 hours per day). She subsequently followed up with Mr. Clark several times. She later testified to having had the knowledge that alcohol detoxification increases the risk of suicide. Four days later, Mr. Clark killed himself by fashioning a noose with pieces of fabric, tying it to his bedroll, and hanging himself. The officer on duty at the time, who was not aware of Mr. Clark's suicide risk, discovered him approximately one hour later. Mr. Clark's estate brought a suit under 42 U.S.C. §1983 (1996), alleging that the intake staff violated Mr. Clark's Eighth Amendment rights, by acting with deliberate indifference toward his suicide risk.

The defendants (correctional officer and nurse) moved for summary judgment; they asserted that there was insufficient evidence for a jury to find deliberate indifference, and they invoked qualified immunity (i.e., protection for government officials “from liability for civil damages in regard to their conduct does not violate clearly established statutory or constitutional rights of which a reasonable person would have known” (Clark, p 549–50 citing Pearson v. Callahan, 555 U.S. 223 (2009)). The district court denied their motions. It found that there were genuine questions of material fact in the case that precluded summary judgment for the defendants; specifically, the officer and the nurse disputed who was responsible for initiating the suicide protocol. In addition, the court ruled that, as a private contractor, Ms. Kuehn was not eligible for a qualified immunity defense, and also concluded that there was sufficient evidence to allow a jury to find that the defendants acted with deliberate indifference to Clark's suicide risk. The defendants appealed to the United States Court of Appeals for the Seventh Circuit. The questions at hand in this case were 1) whether the nurse was entitled to qualified immunity as a private medical contractor and 2) whether it was clearly established that Mr. Clark had a right to be free from deliberate indifference to his serious risk of suicide.

Ruling and Reasoning

The United States Court of Appeals for the Seventh Circuit affirmed the district court's denial of summary judgment for both defendants. The court did not rule on whether the district court erred by denying the defendants' motions for summary judgment on the merits of the deliberate indifference claim because of a lack of jurisdiction over that area. However, the court reviewed de novo the district court's denial of summary judgment based on qualified immunity.

In reviewing the motion for summary judgment based on qualified immunity, the court considered 1) whether facts show that the defendant violated a constitutional right and 2) “whether the constitutional right was clearly established at that time” (Pearson, p 232). In addition, the court addressed whether the nurse, as a private contractor, was entitled to invoke qualified immunity. The court determined thatthe nurse was unable to invoke qualified immunity, because she was a private contractor, not a government employee. The court cited recent Supreme Court cases (e.g., Richardson v. McKnight, 521 U.S. 399 (1997)) that established that private contract personnel in prisons are not eligible for qualified immunity.

Turning to the general question of qualified immunity, the court found that, when the facts are taken in the light most favorable to the plaintiff, Mr. Clark had a serious medical condition that posed a substantial risk (Walker v. Benjamin, 293 F.3d 1030 (7th Cir. 2002)), and Mr. Walker was aware of the risk and failed to act on this knowledge. In regard to the second step in establishing qualified immunity, the court stated that Mr. Clark's right to be free from deliberate indifference to his suicide risk was clearly established before the time of his death. The opinion also stated that the Supreme Court has long held that prisoners have an Eight Amendment right to treatment “for their ‘serious medical needs,” for which suicide risk qualifies (Clark, p 553, citing Estelle v. Gamble, 429 U.S. 97, 104 (1976)). Accepting the facts of the case provided by the district court, Mr. Clark's estate offered sufficient evidence of material facts for a jury to find that Mr. Walker was aware of Mr. Clark's risk of suicide (citing that Mr. Clark scored at maximum risk of suicide on the screening tool), and his failure to take action violated clearly established law. As such, the Seventh Circuit ruled that Mr. Clark's estate had offered sufficient evidence to defeat summary judgment.

Discussion

Several points in this case are pertinent to administrative and clinical practice in correctional settings, such as the importance of following appropriate suicide prevention protocols, and the limited protections for privately contracted medical personnel.

Clark reinforces the importance of current clinical standards, which do not conclude with suicide risk assessment. Indeed, suicide prevention hinges on the appropriate use of the information gleaned from risk assessments by fully implementing the relevant institutional suicide prevention protocol. Imperative steps in the protocol include placing the inmate in an environment that maximizes safety, monitoring the individual, conveying clinical data to other institutional staff (particularly between shifts, where the continuity of information is sometimes ruptured), continuing efforts to gain further clinical information on the individual (e.g., review of previous incarceration/treatment records), continuing assessment of the individual's risk of harm, and implementing appropriate interventions to reduce suicide risk. Of importance, discretionary decisions on clinical concerns such as suicide risk should not be made without appropriate training and credentials. Even with suitable training, it remains imperative to follow institutional protocol for suicide risk assessment, rather than use subjective judgment to override suicide risk data.

Cases often become more clinically complex when the use of substances is involved, particularly if the person under evaluation is in some form of substance withdrawal. Although it is important to stabilize the individual medically before using full mental health assessments or interventions, this necessity cannot diminish efforts at risk management. As testified to in this case, Mr. Clark was placed in a detoxification cell, presumably for medical stabilization, but at the expense of protocols to manage risk. Mr. Clark's suicide assessment results reflecting high risk, together with knowledge of heightened suicide risk during alcohol detoxification, was disregarded and therefore the suitable safeguards were not applied.

In addition, lack of immunity for contracted medical and mental health personnel is particularly relevant, as the use of privately contracted personnel providing care and services to detainees and prisoners is steadily increasing. It is important for administrators and practitioners to consider the limits of legal protections available to privately contracted staff, which further underscores the importance of appropriate training, clearly defined protocols, and adherence to standards of care.