# CHAMBERS v. CITY OF PHILADELPHIA

> District Court, E.D. Pennsylvania · February 29, 2024

URL: https://www.frixlaw.com/law-library/cases/10406953

## Case

- **Court:** District Court, E.D. Pennsylvania
- **Decided:** February 29, 2024
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

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## How later opinions describe it (automated extraction)

- applying this standard to any type of failure to claim
- applying same standard to any type of failure to claim

## Opinion text

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF PENNSYLVANIA

EBONY CHAMBERS, in her own right
and as Administratrix of the Estate of
Rahsaan Chambers, deceased, and
ROBERT TAYLOR,
Plaintiffs,
Vv.
CITY OF PHILADELPHIA,
BLANCHE CARNEY, CIVIL ACTION
NANCY GIANETTA,
EDWIN CRUZ, NO. 23-0137
ROBERT ROSE,
STEVEN ANGELUCCI,
JESSICA BOWERS,
WALTER E. GRAY, III,
MANYEAH BURNETT,
SOJAN VARGHESE,
WANDA MURCHISON, and
C.0. JOHN/JANE DOES 3-10,
Defendants.

MEMORANDUM OPINION
Scott, J. February 29, 2024
This case is about the untimely death of 22-year-old Rahsaan Chambers. Mr. Chambers
was incarcerated at the Curran-Fromhold Correctional Facility (CFCF) in Philadelphia on April 6,
2021, when he began to have trouble breathing. Allegedly, for about 24 hours, CFCF’s staff
ignored the many calls for medical attention made by Mr. Chambers and other people incarcerated
on his cell block. When a guard finally checked on Mr. Chambers, Mr. Chambers was
unresponsive in his cell. After nine days at Jefferson Torresdale Hospital, Mr. Chambers died from
severe complications from what was determined to be a diabetic event.

The plaintiffs in this action are Mr. Chambers’s mother, Ebony Chambers, who brings
claims on her own behalf and on behalf of Mr. Chambers’s estate, and Mr. Chambers’s father,
Robert Taylor, who brings claims on his own behalf. The plaintiffs bring various claims pursuant
to 42 U.C.S. § 1983 and the state tort of intentional infliction of emotional distress against several
groups of defendants. The supervisory defendants and the City have filed or joined a motion to
dismiss the two counts of the amended complaint that are aimed only at them: Count II, a
supervisory liability claim made against most of the supervisory defendants, and Count III, a
Monell claim against the City. For the reasons set forth below, the motion to dismiss will be denied,
but these arguments may be renewed at summary judgment.
I. BACKGROUND
Taking the allegations in the amended complaint as true, the relevant facts are as follows:
A. Mr. Chambers’s Medical Emergency and Death
On April 6, 2021, Rahsaan Chambers was incarcerated at CFCF while awaiting a criminal
trial. Am. Compl. § 42, ECF No. 14. That evening, Mr. Chambers told Defendant Correctional
Officer Sojan Varghese (C.O. Varghese) that he was having difficulty breathing and asked to be
brought to the infirmary. Jd. § 43. C.O. Varghese did nothing—he refused to take Mr. Chambers
to the infirmary, and he did not contact medical staff at CFCF or any other supervisory staff. Jd.
{| 44-46. After everyone was locked down for the night, Lewis Brown, who was incarcerated on
Mr. Chambers’s housing pod, told C.O. Varghese that Mr. Chambers was in respiratory distress
and needed medical care. Jd. 48-49. C.O. Varghese also ignored Mr. Brown’s call for medical
attention. Jd. {| 50-52. C.O. Varghese also did not check on Mr. Chambers. Jd. { 53.
The following morning, Mr. Chambers did not leave his cell. Jd. § 54. Throughout that day,
inmates incarcerated on Mr. Chambers’s cell block informed C.O. Wanda Murchison and several

C.O.s whose identities are currently unknown (listed as Defendant C.O.s John/Jane Doe 3 through
10) that Mr. Chambers was bedridden and had been having serious breathing difficulties since the
previous night. Jd. | 57-59. None of the C.O.s checked on Mr. Chambers. /d. 460. That evening,
others incarcerated on Mr. Chambers’s cell block kicked their doors and yelled out for medical aid
in a collective effort to get CFCF staff members’ attention. Jd. § 61. One of the John/Jane Doe
C.O.s checked on Mr. Chambers and found him lying unresponsive on his cell cot. Jd. § 62.
Finally, more than 24 hours after Mr. Chambers’s initial complaint to C.O. Varghese, and
about 12 hours after C.O. Murchison’s shift began, medical personnel arrived at Mr. Chambers’s
cell. Jd. | 63. Registered Nurse Sarah DeRose noted that Mr. Chambers was in severe respiratory
distress, and his heart rate, blood sugar, and oxygen saturation were at emergency levels. Jd. □
64-65. R.N. DeRose gave Mr. Chambers insulin, applied a non-rebreather mask to address Mr.
Chambers’s depressed oxygen saturation, and ensured that 911 was called. Jd. | 66. Mr. Chambers
was transported to the emergency room at Jefferson Torresdale Hospital, where he was diagnosed
with diabetic ketoacidosis, which is akin to a state of diabetic shock. Jd. J] 67-68. For a few days,
he was conscious and able to provide some limited answers to questions posed by medical staff.
Id. § 69. But beginning on April 11, 2021, Mr. Chambers required intubation for breathing
assistance, suffered cardiac arrest, and fell into a vegetative state. Id. 71-73. On April 16, 2021,
Mr. Chambers died from medical complications associated with diabetic ketoacidosis. Jd. J 74.
The plaintiffs allege that if Mr. Chambers had received prompt emergency medical
treatment when he initially requested it, his diabetic condition could have been stabilized without
the more severe complications. Jd. {§ 75~76.
B. Allegations Supporting Policy and Custom
The amended complaint additionally alleges that at the time of Mr. Chambers’s medical

emergency, CFCF personnel were required to follow a written policy requiring that medical care
be immediately summoned for incarcerated people suffering from respiratory distress. Id. § 77.
Notably, a federal class action was filed in April 2020, and on June 3, 2020, the City entered into
a partial settlement agreement that was reduced to a consent order, in which it promised in relevant
part to:
[continue] to ensure access to necessary services by . . . [p]roviding
medically-necessary medical care for non-COVID-19-related
medical and mental health needs based on protocols and directives
in effect pre-COVID-19, with discretion to provide medical and
mental health care services in the housing units.
Id. § 104 (quoting Consent Order, ECF No. 35 at 3-4, Remick v. City of Philadelphia, 2:20-cv-
01959-BMS (E.D. Pa.)).
However, the amended complaint alleges that the written policy and consent order were
ignored in Mr. Chambers’s particular case, and “it was a custom or de facto policy to ignore such
medical emergencies.” Jd. 78. The amended complaint lists at least seven other incidents at CFCF
in which incarcerated people allegedly died or experienced serious injuries due to CFCF
personnel’s failures to promptly respond to medical emergencies. Jd. { 99.! The plaintiffs also cite
a joint status report filed in the Remick lawsuit approximately three weeks after Mr. Chambers’s
medical emergency, which reported that conditions had continued to deteriorate at CFCF,
including in “[d]elays in getting routine and emergency medical care.” Id. 105.
C. Parties and Claims
As previously mentioned, the plaintiffs in this suit are Mr. Chambers’s mother, Ebony

One incident allegedly involved a person who was incarcerated “in the PDP”; seven
incidents allegedly occurred at CFCF; and the plaintiffs also cite an allegation in a federal suit filed
on January 7, 2022, that there had been “consistent reports of incarcerated people describing
experiencing chest pain, seizures, diabetic shock, and panic attacks in their cells, while their urgent
calls for medical attention went ignored.” Am. Compl. § 99.

Chambers, who brings claims on her own behalf and on behalf of Mr. Chambers’s estate, and Mr.
Chambers’s father, Robert Taylor, who brings claims on his own behalf.
The defendants in this matter can be separated into three groups. First, there is a group of
correctional officers that includes named defendants C.O. Varghese and C.O. Wanda Murchison,
and up to eight additional John and Jane Doe C.O.s (collectively, “the C.O. defendants’’). The
plaintiffs raise two claims against the C.O. defendants: a § 1983 claim of pretrial punishment in
violation of the Fourteenth Amendment, and a Pennsylvania state law claim of intentional
infliction of emotional distress (Counts I and IV, respectively). These claims are not at issue in the
defendants’ motion to dismiss.
Second, there is a group of supervisory personnel at CFCF and the Philadelphia
Department of Prisons (PDP) that includes (1) Blanche Carney, the Commissioner of the PDP; (2)
Nancy Gianetta, the Warden of CFCF; (3) Edwin Cruz, the Deputy Warden for Administration at
CFCF; (4) Steven Angelucci, the Deputy Warden for Operations at CFCF; (5) Robert Rose and
(6) Jessica Bowers, who are both titled the Deputy Warden for Classification, Movement, and
Records and Administration at CFCF; and (7) Walter E. Gray, III and (8) Manyeah Burnett, who
were the highest-ranking officers on duty at CFCF during the alleged events on April 6 and 7, 2021
(collectively, “the supervisory defendants”).’ See Am. Compl. §{ 26-34. The plaintiffs raise a
supervisory liability claim under § 1983 against these supervisory defendants (Count II).
Third, the plaintiffs raise a municipal liability claim (or Monell claim) under § 1983 against
the City (Count IID.

2 The amended complaint also references a “Captain Doe,” but this may be a typographical
error, because according to the docket, a Captain John/Jane Doe was terminated as a defendant on
March 1, 2023. Compare Am. Compl. § 92 & p. 23 with Caption of Docket 2:23-cv-00137-KNS.

D. Procedural History
The plaintiffs filed an initial complaint on January 12, 2023, and an amended complaint on
March 1, 2023. See Compl., ECF No. 1; Am. Compl., ECF No. 14. On March 15, 2023, Defendants
Carney, Cruz, Gianetta, and the City moved to dismiss the amended complaint. See Mot. to
Dismiss Am. Compl., ECF No. 16 (“Mot. to Dismiss”). On March 20, 2023, Defendant Bowers
moved to adopt the motion to dismiss, and on April 25, 2023, Defendants Angelucci, Burnett,
Gray, and Rose moved to adopt the motion to dismiss. See Def. Bowers’s Mot. to Adopt, ECF No.
18; Mot. of Defs. Rose, Angelucci, Gray, & Burnett to Adopt, ECF No. 31. The Court granted the
motions to adopt on April 20, 2023, and April 26, 2023, respectively. See Order, ECF No. 30;
Order, ECF No. 33. Meanwhile, on March 31, 2023, the plaintiffs responded to the motion to
dismiss, and on April 10, 2023, the moving defendants filed a reply in support of their motion to
dismiss. See Resp. Opp’n to Defs.’ Mot. to Dismiss, ECF No. 24 (“Response”); Reply Memo. of
Law in Further Supp. of Mot. to Dismiss, ECF No. 27 (“Reply”). C.O.s Varghese and Murchison
answered the amended complaint on May 4, 2023. See Answer to Am. Compl., ECF No. 34. The
Court held an initial pretrial conference on July 25, 2023, where it informed the parties that the
motion to dismiss would be denied, with an order and opinion to follow, and directed the parties
to proceed with discovery. See Scheduling Order, ECF No. 41.
Il. STANDARD OF REVIEW
A complaint survives a motion to dismiss if it contains “sufficient factual matter, accepted
as true, to ‘state a claim to relief that is plausible on its face.’” Ashcroft v. Iqbal, 556 U.S. 662, 678
(2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)). District courts in the Third
Circuit use a three-step process to evaluate a motion to dismiss a complaint for failure to state a
claim for relief. See Lutz v. Portfolio Recovery Assocs., LLC, 49 F Ath 323, 327 Gd Cir. 2022)

(relying on framework established in Connelly v. Lane Constr. Corp., 809 F.3d 780, 787-90 (3d
Cir. 2016) and Fowler v. UPMC Shadyside, 578 F.3d 203, 210-11 (3d Cir. 2009)). First, the court
articulates the elements of the claims raised. See id. Second, the court reviews the complaint and
disregards any allegations that are merely conclusory or formulaic recitations of elements of the
claim or that are “so threadbare or speculative that they fail to cross the line between the conclusory
and the factual.” See id. at 327-28 (internal citations omitted). Third, the court considers whether
the remaining allegations plausibly entitle the plaintiffs to relief. See id. at 328. To do so, the court
must assume that all well-pleaded factual allegations are true, construe the allegations in the light
most favorable to the plaintiffs, and draw all reasonable inferences in the plaintiffs’ favor. See id.
The plausibility standard does not require the complaint to establish a probability of relief
or to demonstrate that all prima facie elements of a claim can be met. See Ashcroft, 556 U.S. at
678; Fowler, 578 F.3d at 210-11. Instead, a complaint plausibly pleads a claim if it raises “more
than a sheer possibility that a defendant has acted unlawfully,” Ashcroft, 556 U.S. at 678, or a
“reasonable expectation that discovery will reveal evidence of the necessary elements of a claim.”
Lutz, 49 F 4th at 328 (internal quotations omitted).
IW. DISCUSSION
Section 1983 provides recourse when an actor operating “under color of state law” deprives
a person of “any rights, privileges, or immunities secured by the Constitution and [federal] laws.”
See 42 U.S.C. § 1983; see also West v. Atkins, 487 U.S. 42, 48 (1988). Here, the defendants do not
argue that the plaintiffs are unable to state a plausible claim for relief under § 1983 against the
individual C.O.s who allegedly ignored or failed to learn of Mr. Chambers’s medical emergency.
Instead, the motion to dismiss challenges only the § 1983 claims pleaded against the City and the
supervisory defendants. For the reasons set forth below, the Court finds that the plaintiffs have

adequately pleaded their claims based on theories of municipal liability and supervisory liability.
A. Municipal] Liability Claim (Count ITI)
1. Applicable Law
A municipality can be held liable for the unconstitutional acts of its employees only if a
plaintiff pleads and proves a Monell claim, which requires showing that the municipality’s policy
or custom caused the violation of federal rights. See Monell v. Dep’t of Soc. Servs., 436 U.S. 658,
690-91, 694 (1978). The Third Circuit recognizes two pathways for a Monell claim: Plaintiffs may
either show that (1) “an unconstitutional policy or custom of the municipality led to [their] injuries”
or (2) the injuries “were caused by a failure or inadequacy by the municipality that reflects a
deliberate or conscious choice.” Forrest v. Parry, 930 F.3d 93, 105 (d Cir. 2019) (internal
quotations and citations omitted).
The first type of claim—a claim that the municipality’s unconstitutional or custom led to
the plaintiff's injuries—can by proven by showing either that (1) the municipality’s policy or
custom itself violates federally protected rights or (2) the policy or custom was the “moving force”
behind a municipal employee’s deprivation of federally protected rights. See Thomas v.
Cumberland Cnty, 749 F.3d 217, 222 (3d Cir. 2014) (internal citation omitted).? There must be
some “affirmative link” between the policy or custom and the alleged constitutional violation. See
Estate of Roman, 914 F.3d at 798 (internal citation omitted). For instance, an affirmative link can
be drawn between a custom and the alleged constitutional violation by showing that (1) the
municipality or its final policymaker(s) knew that similar unlawful conduct had occurred in the

3 A “policy” is made by a “decisionmaker possess[ing] final authority” to establish policy
for the municipality and comes in the form of an “official proclamation, policy, or edict.” See
Estate of Roman v. City of Newark, 914 F.3d 789, 798 (3d Cir. 2019) (internal quotations and
citation omitted). A “custom” is a “given course of conduct, although not specifically endorsed or
authorized by law, [that] is so well-settled and permanent as virtually to constitute law.” See id.
(internal quotations and citation omitted).

past, (2) but failed to take precautions against future violations, and (3) these failures contributed
to the plaintiff's injury. See id. (internal citation omitted).
The second type of claim is often framed in terms of the municipality’s failure to train,
supervise, or discipline its employees. Plaintiffs raising a “failure to” claim (such as a claim
alleging a failure to train, supervise, or discipline) need not identify a specific unconstitutional
policy or custom. See Forrest, 930 F.3d at 105. Instead, the plaintiffs must show that “the failure

. . . amounts to deliberate indifference to the rights of persons with whom the [municipal
employees] come into contact.” Reitz v. Cnty of Bucks, 125 F.3d 139, 145 (3d Cir. 1997) (quoting
City of Canton vy. Harris, 489 U.S. 378, 388 (1989)) (evaluating failure-to-train claim); see also
Forrest, 930 F.3d at 106 (applying this standard to any type of failure to claim). Deliberate
indifference is a higher bar than mere knowledge; it “require[s] proof that a municipal actor
disregarded a known or obvious consequence of [their] action.” See Thomas, 749 F.3d at 223
(citation omitted). Plaintiffs sufficiently plead that the municipality’s failure to train, supervise, or
discipline its employees amounted to deliberate indifference by demonstrating that “(1) municipal
policymakers know that employees will confront a particular situation; (2) the situation involves a
difficult choice or a history of employees mishandling; and (3) the wrong choice by an employee
will frequently cause deprivation of constitutional rights.” Doe v. Luzerne Cnty, 660 F.3d 169,
179-180 (3d Cir. 2011) (internal quotations and citations omitted) (applying standard to
failure-to-train claim); see also Forrest, 930 F.3d at 106 (applying same standard to any type of
failure to claim).
2. Analysis
A few paragraphs in the amended complaint may seem vague when read in isolation, but

the amended complaint as a whole plausibly pleads that a custom‘ exists of C.O.s failing to
adequately respond to medical emergencies at CFCF.° The City misunderstands the scope of the
plaintiffs’ alleged custom by characterizing it as “nebulous, overbroad, and extraordinarily
high-level.” Mot. to Dismiss at 6 (quoting Am. Compl. § 141).
Count III of the amended complaint alleges that the City “maintained a custom, policy, or
practice of failing to respond adequately — or at all — to the medical emergencies of those
incarcerated in the PDP in general and CFCF in particular.” Am. Compl. 141. Additionally, the
City “failed to supervise correctional staff, by appropriate training and discipline, for failing to
respond adequately — or at all — to the medical emergencies of those incarcerated in the PDP in
general and CFCF in particular.” Jd. ¢ 142. The plaintiffs more vaguely allege that the City failed
to “adopt necessary and appropriate policies.” Jd. § 143. While these three paragraphs are indeed
broad, there are pages of detailed allegations supporting these claims throughout the amended
complaint. See, e.g., id. ¥] 77-96 (outlining supervisory liability theories); §§ 97-107 (alleging
supervisors’ knowledge of similar issues and their failures to address them); {9 108-09 (alleging
that supervisory defendants created a “permissive environment” in which C.O.s believed that
supervisors would not closely monitor or discipline C.O.s’ lapses in addressing serious medical

4 Though the plaintiffs use general “custom, policy or practice” phrasing, the plaintiffs make
no allegations that Commissioner Carney issued an official policy or edict to this effect. Rather,
the plaintiffs’ allegations sound in “custom” language—the conduct challenged as unconstitutional
is described as a well-settled course of conduct that virtually constitutes law. See supra note 3
(defining policy and custom). The Court’s use of “custom” language throughout this opinion does
not foreclose the plaintiffs from later identifying an official policy or edict.
5 The Court elects to refer only to CFCF, unless specifically discussing Commissioner
Carey or the City. Notably, aside from Commissioner Carney, all other supervisory defendants
are only alleged to work at CFCF. See Am. Compl. {§ 26-35. Although the plaintiffs attribute the
custom to PDP generally, and CFCF specifically, see id. { 141, this is not a class action lawsuit,
and the allegations about Mr. Chambers’s tragic death are not generalizable to other facilities in
the PDP. This terminology is not used with an intention to limit the plaintiffs’ discovery or legal
theories narrowly to CFCF; the Court will approach any such issues on a case-by-case basis.

needs).
In context, the plaintiffs do not simply plead that the City has broadly failed to “meet its
general constitutional duty to provide adequate medical care to those with serious medical needs.”
See Mot. to Dismiss at 6. Instead, the plaintiffs more narrowly focus on the scenario in which an
incarcerated person (1) cannot directly seek medical attention, (2) reports or exhibits symptoms
that a C.O. without specialized medical training should understand to indicate a potential medical
emergency, and yet (3) is ignored or unnoticed by C.O.s until it is too late for medical professionals
to offer adequate medical care. In other words, the plaintiffs assert that C.O.s at CFCF inadequately
triage medical complaints and fail to flag potential medical emergencies for medical professionals.
The plaintiffs’ framing is not nebulous, overbroad, or high-level if we consider what the
plaintiffs are not alleging: The plaintiffs do not challenge any decisions made by people with
medical training—the amended complaint includes allegations about how R.N. DeRose and
emergency medical staff treated Mr. Chambers, but it raises no issues regarding that treatment. See
Am. Compl. 64-74. Indeed, the plaintiffs’ theory is that medical professionals could have
prevented Mr. Chambers’s death if they had had timely knowledge of his symptoms. Jd. J§ 75—
76. Additionally, the amended complaint is narrowly concerned with medical emergencies, which
the Court understands to apply to health issues that must be addressed relatively quickly to prevent
serious injury or death. The plaintiffs do not attack the very broad range of physical ailments that
are not medical emergencies but that may fall within a correctional facility’s provision of adequate
medical care. See, e.g., id. [9 35, 91, 95 (all narrowly focusing on emergency medical care).
Nor is the plaintiffs’ Monell claim nebulous or overbroad in comparison to Third Circuit
precedent that reversed district courts’ dismissals of Monell claims. In Estate of Roman v. City of
Newark, the Third Circuit partially reversed a district court’s decision to grant a motion to dismiss,

finding that the plaintiff had adequately pleaded a Monel/ claim based on allegations of “a custom
of warrantless or nonconsensual searches” by an entire police department and the city’s failure to
properly train its officers to understand the Fourth Amendment. See Estate of Roman, 914 F.3d at
798-800. And in Thomas v. Cumberland County, the Third Circuit reversed a district court’s
dismissal of a Monell claim at summary judgment, holding that reasonable jurors might find that
a county’s failure to provide de-escalation and intervention training to its corrections officers
amounted to deliberate indifference to serious injuries inflicted during a prison fight. See Thomas,
749 F.3d at 225-27. Here, the alleged custom—C.O.s’ failures to adequately respond to the
medical emergencies of those incarcerated at CFCF—appears to be narrower in scope than an
entire police force’s failure to respect citizens’ Fourth Amendment rights during searches, and it
is similar in scope to C.O.s’ failures to address potential violent conflicts between people
incarcerated in a correctional facility.
Moreover, the plaintiffs’ broad framing matches the magnitude of the failure that they have
alleged: The plaintiffs’ allegations paint a picture of a group of rank-and-file government
employees collectively failing to do anything to address Mr. Chambers’s medical emergency for
about 24 hours. It is difficult to imagine how else the plaintiffs could have framed their concerns
than to bluntly and broadly allege that the C.O.s at CFCF have adopted a custom of willful
ignorance of emergency medical situations.
The defendants repeatedly invoke Argueta v. U.S. Immigration and Customs Enforcement,
643 F.3d 60 (3d Cir. 2011),° to support an argument that the plaintiffs need to identify particular

6 In Argueta, nine New Jersey residents challenged the national federal policy known as
“Operation Return to Sender,” which spurred Immigration and Customs Enforcement (ICE) agents
to drastically scale up arrest numbers of suspected undocumented immigrants, causing what the
plaintiffs alleged to be unlawful and abusive raids of their homes. See Argueta, 643 F.3d at 62-65.
The plaintiffs sued high-level executives in the Department of Homeland Security (DHS), alleging
broadly that they failed to properly train or implement guidelines or oversight mechanisms to

“necessary and appropriate” policies that the City failed to adopt. See Mot. to Dismiss at 8; Reply
at 10. However, Argueta is inapplicable here. The Argueta Court emphasized that the plaintiffs’
challenges to national federal policy and the only allegations directed at the high-level supervisory
defendants “described conduct consistent with otherwise lawful behavior.” See Argueta, 653 F.3d.
at 75. No clear line could be drawn from the executives’ policy down to the individual federal
agents who allegedly violated the plaintiffs’ Fourth and Fifth Amendment rights during raids of
homes, absent more concrete examples of what policy or training those executives could have
enacted to safeguard the plaintiffs’ Fourth and Fifth Amendment rights. See id. at 75-76. Here,
unlike Argueta, if the plaintiffs can prove that a custom existed in which C.O.s regularly failed to
timely address the medical emergencies of people incarcerated at CFCF, then there will be a very
obvious nexus between that custom of inadequate medical treatment and the alleged violation of
Mr. Chambers’s constitutional right to adequate medical treatment. Therefore, Argueta would not
require these plaintiffs to better articulate what policies the City should have adopted instead of
whatever (currently unknown) policies the City did adopt.
Furthermore, the City repeatedly misstates the law in its efforts to minimize the plaintiffs’
discussion of many other deaths and serious injuries at CFCF and a consent order that the City

ensure that ICE agents conducted home searches without breaching Fourth and Fifth Amendment
rights, and were instead “proudly publiciz[ing] the increasing numbers of arrests.” Jd. at 65. The
Argueta Court held that the allegations were insufficient to state a supervisory liability claim
against the DHS executives, in part because the plaintiffs “did not really identify in their pleading
what exactly Appellants should have done differently, whether with respect to specific training
programs or other matters, that would have prevented the unconstitutional conduct.” See id. at 74—
75.
7 The Argueta Court noted that “a federal official specifically charged with enforcing federal
immigration law appears to be acting lawfully when he or she increases arrest goals, praises a
particular enforcement operation as a success, or characterizes a home entry and search as an
attempt to locate someone.” Argueta, 643 F.3d at 75.

voluntarily entered in a lawsuit primarily focused on unconstitutional conditions of confinement
during the early months of the coronavirus pandemic. The Court declines the City’s invitation to
dismiss a Monell claim at the pleadings stage if plaintiffs do not demonstrate ‘“‘a high degree of
similarity” between prior incidents that are alleged to be similar to the plaintiffs’ alleged harm. See
Mot. to Dismiss at 8.8 The City also erroneously asserts that this Court must restrict its analysis of
the plaintiffs’ claims only to similar incidents that occurred before Mr. Chambers’s medical
emergency.” In Forrest v. Parry, the Third Circuit held in relevant part that a district court abused
its discretion by excluding subsequent incidents from its analysis of Monell claims regarding police
misconduct. 930 F.3d at 115. Importantly, the Forrest Court reasoned that incidents that occurred
after the plaintiff's arrest could not prove causation, but they could be “highly relevant to whether
Camden was deliberately indifferent to a continued pattern of police misconduct.” See id. The
Third Circuit also reiterated its prior finding that police misconduct that occurred shortly after the
plaintiffs arrest could “support an inference that policymakers knew of the officer’s ‘propensity

8 None of the City’s cited decisions adopted such a drastic measure. Siceloff v. Twp. of West
Deer, No. 11-cv-00783, 2013 WL 3989427, at *13 (W.D. Pa. Aug. 2, 2013), which dismissed a
Monell claim at summary judgment, mentions a “high degree of similarity” only after (1) a detailed
rejection of other possible pathways to proving a failure-to-train claim, and (2) a reasonable
explanation that two prior excessive force claims would need to have a high degree of similarity
to the plaintiffs excessive force claim to have put the township on notice that it needed to address
the particular excessive force issues that the plaintiff alleged.
The other cited cases required some degree of similarity between prior and alleged
incidents—not a high degree of similarity. Cf Lesher v. Zimmerman, 822 F. App’x 116, 121 Gd
Cir. 2020) (not setting any standard for similarity between incidents in motion to dismiss, but
noting that prior incidents were not similar to alleged school sports safety issue because they either
involved different sports with different coaches or unrelated complaints against the same coach);
Abdul-Jabbar y. City of Phila., No. 21-cv-2077, 2022 WL 329576, at *2 (E.D. Pa. Feb. 3, 2022)
(observing “little” similarity between alleged police misconduct and prior instances, which
“include[d] everything from offensive social media posts to unjustified shootings”).
? See, e.g., Mot. to Dismiss at 12 (“Plaintiffs cannot rely on allegations regarding events
post-dating the decedent’s initial hospitalization to satisfy the deliberate-indifference
requirement.”’). The City cites only nonprecedential cases published before Forrest to support this
erroneous proposition.

for violence when making arrests.’” Jd. (quoting Beck v. City of Pittsburgh, 89 F.3d 966, 973 (3d
Cir. 1996)).
The Court finds that the plaintiffs’ allegations of similar incidents, see supra Section I.B,
increases the plausibility of the plaintiffs’ unconstitutional custom, failure-to-train, and failure-to-
supervise theories at this early stage of litigation, and the Court expects to see more granular
argument about the degree of similarity between incidents at summary judgment. Even if this Court
were to ignore any of the allegedly similar incidents that occurred after Mr. Chambers’s death, the
plaintiffs have alleged four examples of apparent medical emergencies at CFCF that predated Mr.
Chambers’s medical emergency and either (1) ended with the incarcerated person’s death or (2)
became the subject of a lawsuit against CFCF and PDP officials.!° This alone lends plausibility to
the allegations that Commissioner Carney was aware of prior situations in which C.O.s failed to
notice or address severe injuries and deaths that perhaps could have been prevented by prompt
medical attention. Although the cited medical emergencies may have been different types of
medical complaints, and the legal complaints filed after those incidents may have raised different
legal theories, that does not compel the Court to reject them outright as too dissimilar to have any
probative value.'! More importantly, the incidents resulting in death and federal lawsuits may be

10 It is plausible that Commissioner Carney would be aware of incidents that result in deaths
of people incarcerated in PDP facilities or lawsuits against PDP. The four incidents are the deaths
of Jonathan Gleaves, Jr., Armani Faison, and an unnamed person who committed suicide in 2020,
and the serious injuries of Ameen McCall (which did not end with Mr. McCall’s death but were
presumably made known to Commissioner Carney in a lawsuit filed on June 3, 2019). See Am.
Compl. ¥ 99.
Theoretically, if the C.O.s did ignore these incidents until it was too late to save the injured
incarcerated people from irreparable injury or death, then it might not matter if the source of the
injury was a reported respiratory issue, a vicious rape and beating, or a suicide. It would likely be
more important to show similarities in the obviousness of each emergency to a layperson, the
C.O.s’ responses to each emergency, and the modifications to training or policy that would have
enabled C.O.s to prevent the dire results of each emergency.

only the tip of the iceberg—these might just be the incidents that are publicly known. The reports
filed in the Remick case (the case that resulted in a partial settlement agreement memorialized in a
consent order) lend support to the plaintiffs’ allegations that, very close to the time of Mr.
Chambers’s medical emergency, the City and Commissioner Carney were aware of CFCF’s
delayed provisions of emergency medical care.
All arguments considered, the plaintiffs have adequately pleaded their Monell claim based
on a “custom” theory. They only need to show at this point that there is more than a sheer
possibility that (1) Commissioner Carney knew prior to April 6, 2021, that similar unlawful
conduct had occurred where C.O.s at CFCF failed to learn of or adequately address medical
emergencies that would have been obvious to people without medical training, (2) Commissioner
Carney failed to take precautions against future violations, and (3) these failures contributed to Mr.
Chambers’s death. First, the prior incidents alleged are similar enough to Mr. Chambers’s medical
emergency to satisfy the Court that they all might reflect medical emergencies that would have
been obvious to people without medical training, and yet they all went unaddressed until it was
too late to provide adequate medical care. The defendants may, of course, argue at summary
judgment that these incidents are not similar, but they are at least similar enough to warrant
discovery. Second, it is not yet clear what Commissioner Carney did or did not do after learning
of these prior unaddressed (or belatedly addressed) medical emergencies, but it is reasonable for
the plaintiffs to believe that information is discoverable. Third, it will be up to the plaintiffs to
prove that failures to take specific precautions after these incidents contributed to Mr. Chambers’s
death. Overall, this is a plausible custom theory that survives a motion to dismiss.
Additionally, the Court finds that the plaintiffs have adequately pleaded a failure-to-train
or failure-to-supervise theory, based on the limited information known to the plaintiffs. The Court

easily finds that (1) Commissioner Carney should have expected that C.O.s at CFCF would
confront situations in which incarcerated people would report possible medical emergencies, (2)
that these choices may be difficult or complex, and (3) the wrong choice—the failure to identify
and address a medical emergency—-would frequently lead to preventable serious injury or death,
in violation of the Eighth Amendment right that incarcerated people have access to adequate
medical care. Thus, if the plaintiffs are able to identify training that did not occur or that was
deficient, it is plausible that they will be able to prove that the City was deliberately indifferent.
The plaintiffs do not speculate in their amended complaint about what training and
supervision C.O.s at CFCF received regarding their responses to incarcerated peoples’ reports of
medical emergencies. However, it is reasonable for the plaintiffs to expect that discovery can
reveal this information. If vo relevant training existed, then this case is even more analogous to
Thomas v. Cumberland County, where the Third Circuit found that failure to provide C.O.s with
de-escalation training could be a basis for single-incident municipal liability (i.e., liability that
arises when the need for training is so obvious that the failure to provide it could be characterized
as deliberate indifference even without a pattern of constitutional violations). See Thomas, 749
F.3d at 223-25. And if some training occurred, it will be up to the plaintiffs to craft an argument
that the training was inadequate to a degree that reflects Commissioner Carney’s deliberate
indifference to the realities that particular medical emergencies would occur at CFCF. It is possible
that C.O.s received excellent training and ignored it, or that Commissioner Carney required that
training, but her orders were not carried out—but that can only be revealed through discovery and
further argument.

17

Finally, for similar reasons—namely, the plaintiffs’ lack of access to information about
supervisory decisions within the PDP or CFCF—the plaintiffs have stated a plausible
failure-to-supervise theory, with one caveat that is further addressed below.
B. Supervisory Liability Claim (Count I)
The Third Circuit generally recognizes two situations in which supervisors may be found
liable for their subordinates’ unconstitutional conduct: First, plaintiffs may show that a supervisor
directly participated in the violation of the plaintiff's rights, directed others to violate those rights,
or “had knowledge of and acquiesced” to the unconstitutional conduct. See Barkes v. First Corr.
Med.,, Inc., 766 F.3d 307, 316 (3d Cir. 2014), rev’d on other grounds, Taylor v. Barkes, 575 U.S.
822 (2015). Second, plaintiffs can demonstrate that a supervisor established and maintained a
policy, practice or custom that directly caused a deprivation of a federal right, and that the
supervisor acted with “deliberate indifference” to those consequences. See id.
‘Failure to” claims are a subcategory of policy or practice liability. See id. Specifically, to
prove a failure-to-supervise claim, the plaintiff must:
identify a supervisory policy or practice that the supervisor failed to
employ, and then prove that: (1) the policy or procedures in effect at
the time of the alleged injury created an unreasonable risk of a
constitutional violation; (2) the defendant-official was aware that the
policy created an unreasonable risk; (3) the defendant was
indifferent to that risk; and (4) the constitutional injury was caused
by the failure to implement the supervisory practice or procedure.
See id. at 317 (test initially developed in Sample v. Diecks, 885 F.2d 1099, 1118 (3d Cir. 1989)).
When the alleged underlying constitutional violation is a denial of adequate medical care that
violates the Eighth Amendment’s prohibition on cruel and unusual punishment, a supervisor may
be individually liable if she has acted with “deliberate indifference to known deficiencies in a
government policy or procedure,” thereby “allow[ing] to develop an environment in which there

is an unreasonable risk that a constitutional injury will occur.” See id. at 319-20.
Here, the defendants raise one argument regarding the plaintiffs’ supervisory liability claim
that is not repetitive of their municipal liability arguments above: The plaintiffs have
impermissibly lumped all of the supervisory defendants together to make boilerplate supervisory
liability claims. See Mot. to Dismiss at 14-16; Reply at 9-10. This is certainly a closer issue, but
again, this argument is premature. For each supervisory defendant, the plaintiffs have alleged (1)
what that person’s role is in the PDP or at CFCF and (2) why the plaintiffs believe that person was
responsible for implementing policy, training, or supervision “concerning the proper responses to
the emergent medical needs of persons incarcerated in CFCF.” See Am. Compl. §§ 26—35. It is
plausible for the plaintiffs to assume that any and all of the supervisory defendants may have some
degree of responsibility for developing or implementing policy or training or providing supervision
regarding C.O.s’ responses to the emergent medical needs of people incarcerated in CFCF. See
Barkes, 766 F.3d at 322 (“Under the Eighth Amendment, prison officials, from the bottom up, may
be liable if by act or omission they display a deliberate indifference to a known risk of substantial
harm to an inmate’s health or safety.”). Furthermore, for reasons addressed more thoroughly at
Section III.A.2, supra, the plaintiffs have plausibly alleged that other elements of the Sample test
could be met here—the plaintiffs raise a logical deliberate indifference argument, and discovery
will reveal whether it is merely a plausible but improvable theory, or whether a factfinder could
conclude that supervisory officials at CFCF and PDP exhibited deliberate indifference toward the
incarcerated people in their care by failing to adequately train or supervise C.O.s to respond to
medical emergencies.
However, the plaintiffs are advised that these claims will not survive summary judgment
if their allegations remain lumped together, or if the claims against any one defendant are tenuous

or vague,’” and the Court directs the plaintiffs to provide adequate notice at the close of discovery
of what specific allegations they intend to make against each supervisory defendant. This notice is
especially important in the supervisory liability context, because unlike the City, supervisory
defendants sued in their individual capacities may raise qualified immunity defenses. See Owen v.
City of Independence, Mo., 445 U.S. 622, 657 (1980). Consequently, the Court will depart from
its normal policies for summary judgment in this case, as outlined in the order accompanying this
memorandum, to ensure that the defendants are able to assert any immunity claims without filing
piecemeal arguments at summary judgment.
IV. CONCLUSION
For all of these reasons, the plaintiffs have adequately stated plausible § 1983 claims of
municipal liability and supervisory liability. Therefore, the City and supervisory defendants’
motion to dismiss these claims is denied, with the caveat that the plaintiffs are to provide more
detailed information supporting their supervisory liability claims at the close of discovery, as
further outlined in the order accompanying this memorandum.

BY THE COURT:

HON. KAI N. SCOTT
United States District Court Judge

See, e.g., McCloskey v. Welch, 803 F. App’x 578, 583 (3d Cir. 2020) (affirming award of
summary judgment on supervisory liability claim where only facts specific to supervisory
defendant was that the supervisor reviewed plaintiff's administrative grievances about alleged
medical care deficiencies).

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10406953. Public record. Not legal advice.