Estate of Nunez by and through Nunez v. County of San Diego
Docket: Case No.: 3:16-cv-01412-BEN-MDD
Court: District Court, S.D. California; May 17, 2019; Federal District Court
The Court recognizes that the evidence presented by Plaintiffs is newly discovered and could not have been discovered earlier, a point not contested by CPMG. Plaintiffs properly requested this late-produced evidence, which was inadvertently withheld until after the summary judgment order. The Court finds that Plaintiffs had no reasonable way of knowing about the evidence sooner, as they relied on CPMG's responses indicating that all evidence had been produced.
The Court then examines whether this newly discovered evidence justifies vacating the summary judgment in favor of CPMG. CPMG raises evidentiary objections, claiming that Dr. Gage's supplemental expert report lacks proper authentication and relies on inadmissible evidence related to subsequent remedial measures. In response, Plaintiffs provided an affidavit from Dr. Gage to authenticate his report, which the Court finds sufficient to address any procedural issues.
The Court notes that Dr. Gage timely supplemented his report, meeting the requirement of submission more than 30 days before trial. While CPMG argues that Dr. Gage's opinions and much of Plaintiffs' newly discovered evidence are inadmissible under Federal Rule of Evidence 407, which excludes evidence of subsequent remedial measures to prove negligence, the Court clarifies that internal quality assurance discussions and peer reviews do not fall under this exclusion. These internal investigations are considered preliminary steps toward identifying the need for remedial action, rather than measures that would have made prior harm less likely.
Thus, CPMG's objections regarding the admissibility of this evidence are overruled. The factual background indicates that on September 4, 2014, CPMG contracted with the County to provide various psychiatric clinical services, led by Dr. Steven Mannis as the sole owner, Dr. Nicholas Badre as the Lead Physician at the Central Jail, and Dr. Sanjay Rao as the Medical Director of Psychiatry for all CPMG providers.
CPMG and the County's contract stipulated that neither party would supervise the other's employees, placing the responsibility of supervision and training solely on CPMG. CPMG was required to appoint a 'Lead Psychiatrist' to conduct Quality Assurance/Quality Inspections (QA/QI) on patient charts and to keep the Sheriff's Chief Medical Officer (CMO) informed of the results. Monthly, 12 to 20 patients were transferred from Patton State Hospital to the Central Jail, including Mr. Ruben Nunez, who died from serious medical conditions shortly after his transfer in August 2015.
In the lead-up to Mr. Nunez's death, CPMG's training for new physicians involved a one-day job shadowing and an informational packet covering various topics relevant to correctional psychiatry. CPMG lacked a Director of Training, and although Dr. Mannis claimed Dr. Rao was responsible for training, Dr. Rao was unaware of this duty and had no knowledge of the number of employees at CPMG. In 2015, CPMG employed approximately 30 physicians and 4 nurse practitioners, with training efforts being informal and conducted on an 'as needed' basis, supplemented by biannual journal club meetings that were not mandatory for attendance.
CPMG did not perform any performance reviews of its providers, and Dr. Rao, who oversaw chart reviews, did not provide counseling on deficiencies nor did he distribute any reviews to the physicians. Dr. Naranjo and other providers reported never having been audited or reviewed. Although there was a recommendation to terminate one provider due to documentation issues, no contracts were terminated for poor performance before Mr. Nunez's death. The Psychiatric Security Unit (PSU) at the Central Jail is designated for treating mentally ill patients, where staff can administer medication involuntarily and regulate patients' water intake, which is critical given Mr. Nunez's medical condition. At the start of the contract in November 2014, Dr. Alfred Joshua, the Sheriff's CMO, communicated action items to CPMG, including the drafting of an admissions policy for the PSU by December 15, 2014.
Nurse Practitioners are not authorized to admit patients to the Psychiatric Security Unit (PSU); only psychiatrists can conduct evaluations and admissions. Upon Mr. Nunez’s transfer to Central Jail, a court order was provided to administer antipsychotic medication, but he was not placed in the PSU and had unrestricted access to water, despite Dr. Sara Hansen knowing that water restriction was necessary. CPMG failed to train Dr. Hansen on the requirement to place a patient in the PSU for water restriction. Dr. Badre also lacked training on housing decisions and believed CPMG staff had no influence over them. Dr. Rao, responsible for training, did not understand the admission process for inmates from state hospitals. Dr. Jorge Naranjo, the psychiatrist for incoming inmates, denied having authority over housing decisions. Both Dr. Hansen and Dr. Naranjo exhibited insufficient review of patient records, with Dr. Hansen neglecting to check Mr. Nunez’s discharge summary from Central Jail. Following Mr. Nunez's death, it was revealed that Dr. Hansen failed to document his medical history or water restriction alerts in the JIMS system, which Dr. Rao believed physicians were not responsible for updating. CPMG, as a private entity, is subject to liability for failure to train and supervise under § 1983, akin to municipalities under Monell v. Dept. of Soc. Servs. CPMG cannot be held vicariously liable for constitutional rights violations by its employees, as established by relevant case law.
To establish Monell claims against CPMG for inadequate training and supervision, Plaintiffs must demonstrate four elements: (1) CPMG acted under color of state law; (2) CPMG's training and supervision policies were insufficient to prevent employee violations of law; (3) CPMG was deliberately indifferent to the known inadequacies of its policies; and (4) the inadequate training or supervision directly caused the deprivation of Mr. Nunez's rights resulting in his death. Plaintiffs allege specific failures in CPMG's training, including: failing to educate physicians on their authority regarding patient housing in the PSU, terminology from the Department of State Hospitals, communication of critical medical information via the Central Jail's computerized system, reading patients' medical records, monitoring water restrictions, conducting quality assurance on physician performance, and taking corrective actions for identified deficiencies.
In response, CPMG contends that the summary judgment should remain in their favor, arguing that the new evidence does not establish that their alleged failures constituted "deliberate indifference" or that these failures caused Mr. Nunez's death. However, the Court concludes that Plaintiffs have sufficiently raised a triable issue regarding CPMG's deliberate indifference. CPMG's defense cites the necessity of demonstrating a pattern of constitutional violations to support a failure to train claim, asserting that without evidence of such a pattern, it cannot be shown that CPMG disregarded the risk of constitutional violations resulting from its training deficiencies. The Supreme Court indicates that a failure to address known deficiencies in training may signify deliberate indifference, essential for municipal liability under Section 1983.
Plaintiffs have not demonstrated a pattern of violations; however, the Supreme Court allows for claims of deliberate indifference in certain circumstances without such a pattern. Specifically, a failure to train claim can succeed if a violation of federal rights is a predictable result of inadequate training. The Court illustrated this with a hypothetical scenario where police officers are provided firearms but lack training on constitutional limits regarding the use of deadly force.
In this case, the evidence indicates that CPMG’s training and supervision were so insufficient that their inadequacy should have been obvious. The situation involving Mr. Nunez's transfer to Central Jail was not unique, as inmate-patients typically require specific medical alerts and housing arrangements. With a regular influx of state hospital patients, the failure to train CPMG providers on their responsibilities for these patients raises a triable issue as to whether Mr. Nunez's death was a foreseeable outcome of inadequate training.
The lack of accountability within CPMG for training and the absence of understanding among its staff about the responsibilities tied to patient placement in the PSU suggest a systemic problem. The foreseeable consequence of not equipping CPMG doctors with necessary knowledge about patient care and placement procedures could lead to critically ill patients not receiving required care, thereby violating constitutional standards. The Court emphasizes that it cannot be assumed that physicians would automatically understand their responsibilities without proper training.
A lack of a pattern of constitutional violations undermines claims that CPMG was deliberately indifferent to the need for training police officers against sexual assault, as applicants are expected to know the law. Evidence presented by plaintiffs suggests CPMG's training is severely lacking, with only minimal job shadowing and inadequate orientation materials. CPMG physicians managed complex patient needs without clear oversight on training responsibilities or patient placement protocols. For instance, Dr. Naranjo, responsible for psychiatric evaluations, was unaware of his authority to order patient placements in the PSU, focusing instead on medication reviews. CPMG's training efforts, primarily through infrequent and voluntary journal club meetings, failed to ensure adequate preparation for its providers. The absence of a systematic auditing system prevented CPMG from identifying training deficiencies in Dr. Hansen and Dr. Naranjo, which may have contributed to the inadequate care resulting in Mr. Nunez's death. New evidence indicates a genuine issue of fact regarding CPMG's deliberate indifference, as regular audits could have revealed significant deficiencies in patient care and treatment coordination, raising concerns about the adequacy of CPMG's training and oversight practices.
In Kirkpatrick v. Cty. of Washoe, the Ninth Circuit denied summary judgment on the plaintiff's failure to train claim due to evidence indicating a complete lack of training for social workers regarding the warrant procedures necessary for child removal. Despite challenges faced by CPMG physicians in managing inmate-patients' psychological needs, new evidence suggested CPMG's supervision was constitutionally inadequate. This evidence raised questions about whether CPMG conducted any formal reviews or audits of its physicians, leading to a potential finding that basic oversight could have prompted additional training. Specifically, gaps in understanding the housing placement process for vulnerable patients and the medical alert system were highlighted.
Plaintiffs successfully established a triable issue regarding CPMG's alleged failures and the potential deliberate indifference to Mr. Nunez's medical needs. Although CPMG argued that causation could not be demonstrated, as Mr. Nunez would have access to water unless restricted, this argument was undermined by the apparent lack of training and awareness among the physicians involved in his care. The evidence indicated that patients in the PSU received closer monitoring, suggesting a likelihood that staff would have recognized Mr. Nunez's critical condition sooner.
The court found that the new evidence also raised significant questions regarding the appropriateness of punitive damages. A reasonable jury might conclude that CPMG's actions constituted a deliberate disregard for patient safety, justifying such damages. Consequently, Plaintiffs' motion was granted, and the parties were instructed to resubmit their proposed joint pretrial order and jury instructions, including counts for punitive damages against CPMG within seven days.
The parties are required to ensure their proposed jury instructions conform to the Court's prior formatting order and must confer regarding additional instructions before submission. The Court has granted CPMG's request for judicial notice of its pleadings and prior Orders, confirming that it can take judicial notice of its own records. The Court declined to address arguments related to evidence regarding the removal of psychiatrist Dr. B, as it is not relied upon in this order. CPMG's assertion of California's peer review privilege is rejected; federal privilege law governs in this case, as established by Magistrate Judge Dembin, noting that the self-critical analysis privilege is not recognized in this context by the Ninth Circuit. The Court emphasizes that while it references certain evidence, it has considered all relevant admissible evidence, with disputes of material fact viewed favorably towards Plaintiffs. CPMG cannot be held liable under supervisory liability theory as no supervisors are named as defendants. The unique circumstances of Mr. Nunez's need for water restrictions do not establish a pattern of violations necessary to demonstrate deliberate indifference under Monell, although the context of his treatment at the Central Jail is not deemed unusual.
