Court: Court of Appeals for the Ninth Circuit; December 10, 2004; Federal Appellate Court
The Ninth Circuit Court of Appeals affirmed the district court's judgment favoring Dr. Soon Hwang Chung in the wrongful death case brought by Hiroshi Toguchi on behalf of the estate of Keane Toguchi. The court expressed sympathy for the Toguchis but concurred with the lower court that Dr. Chung did not exhibit deliberate indifference to Keane's serious medical needs, which included a history of mental illness and substance abuse.
Keane Toguchi was incarcerated from 1993 to 1998, receiving treatment from Dr. Chung during his time at Halawa Correctional Facility in 1997 and 1998. After being paroled in April 1998, he returned to Halawa eight months later due to a parole violation linked to drug use. Upon readmission, Dr. Chung placed Keane in therapeutic lockdown and prescribed various medications to stabilize him.
Following stabilization, Keane exhibited irrational behaviors, prompting a transfer to a mental health module and a change in medication. After further bizarre behavior, Dr. Chung ordered restraints for Keane, monitored him closely, and treated him with additional medications. Tragically, Keane stopped breathing shortly after being restrained, and despite resuscitation efforts, he died. The medical examiner attributed his death to the combined toxic effects of sertraline and diphenhydramine, indicating that the lethal levels of these medications could have been ingested either accidentally or with suicidal intent, given his altered mental state.
Keane's parents, the Toguchis, filed a 42 U.S.C. § 1983 lawsuit against prison physicians Dr. Sisar Paderes and Dr. Chung, alleging deliberate indifference to Keane's serious medical needs. Expert witnesses for Dr. Chung, Dr. Robert C. Marvit and Dr. Wayne R. Snodgrass, testified that the medications prescribed were appropriate and that Dr. Chung correctly interpreted Keane's symptoms as withdrawal from methamphetamine. In contrast, experts for the Toguchis, Dr. Bruce Victor and Dr. Randall Tackett, criticized Dr. Chung for failing to evaluate Keane's actual condition and for not conducting a differential diagnosis, which they argued contributed to Keane's death. Dr. Tackett specifically stated that Keane died from the combined effects of sertraline and diphenhydramine administered without proper assessment of his medical condition. The district court granted summary judgment for the defendants, finding no material fact issues regarding whether Dr. Chung's actions constituted deliberate indifference. The standard of review for summary judgment is de novo, requiring a check for genuine issues of material fact and correct application of substantive law. A violation of the Eighth Amendment occurs when prison officials show deliberate indifference to a prisoner's medical needs, necessitating proof of both an objective deprivation and a subjective state of mind indicating indifference.
A prison official exhibits "deliberate indifference" when they are aware of and consciously disregard an excessive risk to an inmate's health and safety. Awareness requires the official to recognize facts indicating a substantial risk and to draw that inference. If an official is unaware of the risk, even if it is severe, it does not constitute a violation of the Eighth Amendment. Mere negligence in medical treatment does not meet the standard for deliberate indifference.
In the case at hand, the Toguchis claim that Dr. Chung was deliberately indifferent to Keane's medical needs through several actions: administering Cogentin despite a prior adverse reaction, failing to consider psychotic symptoms when changing medications, not providing emergency treatment, neglecting to ensure regular physical inspections after restraints, and not accounting for risks related to Klonopin withdrawal and medication interactions. They also argue she did not conduct a differential diagnosis.
Regarding the Cogentin treatment, Dr. Chung initially denied knowledge of Keane's past reaction but later acknowledged having read the medical report, which she discounted. She stated she did not consider Cogentin a serious risk and continued its use without incident. This indicated she did not disregard a known risk, thus not meeting the threshold for deliberate indifference.
On the issue of switching Keane's medication from Seroquel to Trilafon, the Toguchis argued Seroquel was superior. However, differing medical opinions do not establish deliberate indifference; the chosen treatment must be shown as medically unacceptable and made with conscious disregard for the inmate's health, which the Toguchis failed to demonstrate.
Dr. Chung's response to Keane’s respiratory arrest was deemed adequate, as she promptly arrived to assist after being notified, finding that CPR was already in progress and emergency personnel had arrived shortly thereafter. There is no evidence suggesting Dr. Chung could have revived Keane, undermining the Toguchis' claims of her deliberate indifference. Their assertion lacks the factual support necessary to raise a material issue of fact.
Regarding the monitoring of Keane while restrained, the Toguchis criticized Dr. Chung for not properly monitoring him according to prison policy, which mandated checks every fifteen minutes. However, Dr. Chung clarified that such checks were primarily the responsibility of nursing staff, and she had consistently monitored Keane during the intervals. The absence of documentation at specific times does not substantiate their claims against Dr. Chung.
On the issue of Klonopin withdrawal, the Toguchis contended that Keane had been on Klonopin for many years, but evidence indicated he had not taken it for the last five to six months prior to his death, and he was stable on other medications. Dr. Chung was not aware of any risks of withdrawal, which negates potential liability under the Eighth Amendment.
Lastly, although Dr. Tackett speculated that Dr. Chung ignored risks associated with the combination of Zoloft, Benadryl, and Cogentin, his conclusions were not backed by insight into her knowledge or actions. The allegations of negligence do not meet the standard for deliberate indifference, which requires a conscious disregard of a serious risk. Absent evidence that Dr. Chung was aware of any withdrawal symptoms or risks when prescribing these medications, the claim of deliberate indifference is insufficient.
Dr. Chung refuted claims of administering the medication levels found in Keane's system and attributed Keane's withdrawal symptoms to flashbacks, a view that contrasted with Dr. Tackett's differing opinion. This divergence in medical opinion does not establish a claim of deliberate indifference, as per legal precedent. Although Dr. Chung acknowledged the importance of differential diagnosis, she opted not to perform one, believing her diagnosis of ice flashbacks was accurate based on her extensive knowledge of Keane's history. There was no evidence suggesting Dr. Chung was consciously aware of a substantial risk of serious harm from her failure to conduct a differential diagnosis, which could be interpreted as negligence rather than deliberate indifference. Furthermore, Dr. Chung did not believe Keane had access to contraband in prison, dismissing the possibility that his bizarre behavior stemmed from a drug overdose. The reasonableness of her assumptions was irrelevant; if she was not subjectively aware of a risk, she could not be deemed deliberately indifferent.
The Toguchis claimed a due process violation regarding their liberty interest in their son's companionship, but their claim failed for the same reasons as the deliberate indifference claim. Negligence alone does not meet the threshold for constitutional due process violations. The standard for deliberate indifference is stringent; mere medical malpractice or negligence, including gross negligence, does not constitute cruel and unusual punishment. The Toguchis did not provide evidence that Dr. Chung's actions denied or interfered with Keane's medical treatment; rather, the record indicated she was responsive to his medical needs. Consequently, the district court's summary judgment in favor of Dr. Chung on the 1983 claim was appropriate, as was the judgment on the Toguchis' due process claim due to the necessity for more than negligence. The court affirmed the judgment, noting that the details of Keane's drug ingestion were unclear and other claims against Dr. Paderes were not contested.
