Carlos v. York County

UNITED STATES DISTRICT COURT

MIDDLE DISTRICT OF PENNSYLVANIA

ANGELA CARLOS, as :

ADMINISTRATRIX of the ESTATE OF :

TIOMBE KIMANA CARLOS, :

Plaintiff :

: CIVIL NO. 1:15-CV-1994

v. :

:

YORK COUNTY, et al., :

Defendants :

M E M O R A N D U M

I. Introduction

The plaintiff, Angela Carlos (“the plaintiff”), has brought a federal civil rights survival

and wrongful death action under 42 U.S.C. §1983, and also raises supplemental state-law

claims. The action, proceeding via an amended complaint (Doc. 36), arises out of the

death of the plaintiff’s daughter, Tiombe Kimana Carlos (“Carlos”), who committed suicide

in October 2013 at York County Prison (“YCP”) where she was being held as an

immigration detainee. Presently before the court is Magistrate Judge Joseph F. Saporito

Jr.’s report and recommendation (Doc. 94) addressing three motions (Docs. 65, 68, and

74) for summary judgment filed by various defendants. The plaintiff has filed multiple

objections (Doc. 101) to the report and recommendation, and York County, one of the

defendants moving for summary judgment, has also filed an objection (Doc. 97) to the

report and recommendation. For the reasons that follow, the court will sustain in part, and

overrule in part, the objections.

II. Factual Background and Procedural History

A. Defendants Named in the Instant Action

The plaintiff’s amended complaint names a multitude of institutional and individual

defendants, each of whom is alleged to have played a role in failing to prevent Carlos’s

suicide at YCP. Considering the numerosity of named defendants, it may be helpful to list

all of the defendants at the outset because many of them will be referenced in the factual

recitation below. The defendants are as follows: (1) York County; (2) PrimeCare Medical,

Inc. (“PrimeCare”); (3) Pamela Rollings-Mazza, M.D. (“Dr. Rollings-Mazza,” “Rollings-

Mazza,” or “the Doctor”); (4) Patrick Gallagher, Licensed Professional Counselor (“LPC

Gallagher” or “Gallagher”); (5) Aimee Leiphart, LPN (“Nurse Leiphart” or “Leiphart”); (6)

Medical John Does 1-10; (7) Corrections Officer John Does 1-10; (8) Deputy Warden Clair

Doll (“Deputy Warden Doll” or “Doll”); (9) Corrections Officer Erika Collins (“CO Collins” or

“Collins”); (10) Corrections Counselor Janet Jackson (“Counselor Jackson” or “Jackson”;

(11) Corrections Officer Grissell Santos-Heredia (“Santos-Heredia”); (12) Corrections

Counselor McNicholas (“McNicholas”); (13) Corrections Counselor Crist (“Crist”); (14)

Corrections Counselor Nadeau (“Nadeau”); (15) Corrections Counselor Trig (“Trig”)1; (16)

Captain Carl Neeper (“Captain Neeper” or “Neeper”); (17) Holly A. Snyder, RN (“Nurse

Snyder” or “Snyder”); and (18) Robert Davis, M.D. (“Dr. Davis” or “Davis”).2

1 Although the plaintiff’s amended complaint refers to this defendant as “Corrections Counselor Trig,”

it appears that his last name is in fact “Trigilio,” based on an affidavit (Doc. 67-9) from Trigilio

himself. Nonetheless, since he is referred to as “Trig” on the docket and in the plaintiff’s amended

complaint, we will refer to him as “Trig” throughout this memorandum.

2 On July 8, 2016, the plaintiff voluntarily dismissed all of her claims against Dr. Davis, (Doc. 59), and

on July 12, 2016, Davis was terminated as a defendant.

B. Events Leading to Carlos’s Incarceration at York County Prison

Carlos, who was born in Antigua and Barbuda in 1978, immigrated to the United

States with her parents in 1983. Carlos maintained lawful permanent resident status, but

unlike her parents, she never became a naturalized citizen. Since her teenage years,

Carlos suffered from mental health problems, including paranoia and hallucinations, for

which she was prescribed medication and hospitalized on numerous occasions since

1994.

Around 2003, Carlos was involved in an altercation with police officers in a

Connecticut bar for which she was arrested, convicted of an aggravated felony, and

sentenced to a term of incarceration in a Connecticut state prison. Because Carlos was a

non-citizen, her conviction of an aggravated felony rendered her removable from the

United States. In 2008, Immigrations and Customs Enforcement (“ICE”) took custody of

Carlos, however she remained incarcerated in the Connecticut prison while removal

proceedings were initiated. Subsequently, Carlos assaulted a corrections officer in the

Connecticut prison, and her custody was turned back over to the Connecticut State

authorities. In 2011, after an additional period of incarceration, Carlos was again released

into ICE custody, and in April of 2011, she was transported to York County Prison (“YCP”

or “the Prison”) in York, Pennsylvania, for detention pending completion of removal

proceedings.

C. YCP – An Overview of the Facility’s Mental Health Protocol and Policy at

the Time of Carlos’s Incarceration

1. YCP’s Official Suicide-Prevention Policy Circa 2011-2013

According to the YCP suicide prevention policy, (see Doc. 85-2), effective at the time

of Carlos’s incarceration,3 each county prison employee and contracted employee was to

receive two hours of initial suicide prevention training followed by one hour of annual

training to be provided by the Prison’s training department in cooperation with the Prison’s

mental health department. (Id. at 2). All inmates, immediately upon admission to YCP,

were to be screened for suicidal tendencies. (Id.) If an inmate was deemed suicidal upon

admission or at any time thereafter during incarceration, any staff member could order that

the inmate be placed on a designated level of observation4 in suicide resistant housing

quarters.5 (Id.) Furthermore, pursuant to established YCP practice, inmates on

psychotropic medications who became involved in an altercation were automatically to be

placed on a suicide watch regardless of whether they otherwise exhibited suicidal

tendencies. (Docs. 85-14 at 14; and 85-15 at 8, 12). Any inmate placed on a suicide

observation level was to remain on that level of observation until seen by a mental health

counselor. (Doc. 85-2 at 2). The mental health counselor would then assess the inmate

and determine whether the inmate should remain on that level of observation, be stepped

down to a lower level of observation, or be removed from observation altogether. (Doc.

85-15 at 7).

3 YCP’s official suicide prevention has been updated at least once since Carlos’s death in October of

2013. (See Doc. 85-14 at 17). As for the policy that was in effect throughout the duration of

Carlos’s incarceration, it is unclear exactly when that policy took effect, although the Prison’s Deputy

Warden Clair Doll recalled that it had been in effect since at least 2008 when he began his

employment with the Prison. (Id. at 14).

The policy also provided that in the event of a suicide or suicide attempt, all staff

involved in the discovery and intervention must submit reports relaying their full knowledge

of the inmate and incident. (Id. at 3). Furthermore, the policy dictated that every

completed suicide, as well as every “serious suicide attempt,” must be examined by a

“mortality review”6 committee. (Id.)

4 Although defendants in their depositions often referred to the observation levels using the general

term “suicide watch,” the suicide prevention policy actually set forth two specific levels of observation

for suicidal or mentally unstable inmates. The first level of observation, referred to as constant

observation, was reserved for inmates who were “actively suicidal and/or . . . engaged in self-

destructive behavior and [for whom] chemical and physical restraints with visual checks alone are

not sufficient.” (Doc. 85-2 at 2). Inmates on the constant observation level were continuously

observed by an officer. (Id.) The second level of observation, referred to as close observation, was

“reserved for inmates who have expressed suicidal ideation or display symptoms of mental illness.

Within the “close observation” level, there were two types of precautions: 1) suicide precaution,

reserved for inmates who expressed suicidal ideation; and (2) psychiatric observation, reserved for

inmates “who appear[ed] mentally ill and need[ed] observation to determine appropriate level of

treatment and/or appropriate housing.” (Id. at 2-3). Inmates on either suicide precaution or

psychiatric observation were observed at intervals of no more than fifteen minutes. (Id. at 2; Doc.

85-14 at 18). Only the mental health department could place an inmate on psychiatric observation

status. (Doc. 85-2 at 3). On the other hand, corrections counselors, supervisors, and medical

employees were all permitted to place an inmate on suicide precaution. (Id.) Inmates on suicide

precaution typically only had a suicide resistant paper gown and a mattress in their cell, unless the

precaution was modified. (Id.) Only the mental health counselor was permitted to discontinue,

change, or modify the level of suicide precaution. (Id.)

5 The policy provided that “[i]nmates believed to be suicidal and/or mentally unstable can be isolated

from general population for their own protection.” (Id. at 2). Such inmates were to be housed in

“suicide resistant” cells that were offered in the following areas of the Prison: Segregation Units B, C,

and E, and Cell 5 of the Female Behavioral Adjustment Unit. (Id.)

6 According to the policy, a mortality review should include the following:

a. Review of the circumstances surrounding the incident.

b. Review of Prison procedures relevant to the incident.

c. Review of all relevant training received by involved staff.

d. Pertinent medical and mental health services/reports involving victim.

e. Recommendations, if any, for change in policy, training, physical plant, medical or mental

health services, and operational procedures.

(Id. at 3).

2. YCP’s Mental Health Department and Protocol

Individuals from YCP’s mental health department remain as defendants in the instant

action. Also named as a defendant is PrimeCare, the company with which YCP has

contracted to provide mental-health services.

YCP’s mental health department consists of six individuals who are responsible for

providing mental health services at the Prison: one psychiatrist, three mental health

counselors, and two mental health nurses. (Doc. 85-19 at 8). YCP’s psychiatrist is

defendant Dr. Rollings-Mazza,7 an employee of PrimeCare. As YCP’s psychiatrist, Dr.

Rollings-Mazza’s primary responsibility is “medication management.” (Id. at 7, 9). She

performs initial evaluations on individuals who are already on mental health medications

when they arrive at the Prison, and after the initial evaluation, she then follows up with

patients with respect to medication management by conducting periodic medication

checks to ensure that an inmate is stable on his or her current medication. (Id. at 8-9).

For inmates that appear to be mentally stable on their medication, the Doctor will conduct

medication checks every four to eight weeks, and for inmates that appear to be unstable,

the Doctor will conduct checks on a weekly basis. (Id. at 9). The Doctor may conduct a

medication check sooner than planned if an inmate complains that his or her medication is

not working. (Id.) At each medication check, the Doctor conducts a suicide-risk

assessment by asking inmates a series of questions to determine whether they would

likely hurt themselves. (Id. at 34). While Dr. Rollings-Mazza’s primary responsibility is

medication management, she may also refer an inmate to a mental health counselor if she

believes that psychotherapy may be beneficial. (Id. at 10).

7 Dr. Rollings-Mazza is normally the only psychiatrist at YCP, unless she is on vacation, in which

case another psychiatrist will fill in for her. (Doc. 85-19 at 8, 25).

The prison’s mental health department also includes three mental health counselors.

One of those three counselors is defendant LPC Gallagher, who also serves as the

Prison’s Mental Health Coordinator. (Doc. 85-15 at 5). Gallagher’s first task each

workday is to visit inmates who recently have been placed on a suicide observation level

and assess whether they should remain on a suicide observation level, be stepped down

to psychiatric observation, or be removed from observation altogether. (Id. at 6-7). During

the timeframe of Carlos’s detention, any segregated inmate on constant observation

status or suicide precaution status was seen by Gallagher on a daily basis. (Id. at 28).

Once Gallagher stepped a segregated inmate down to psychiatric observation status, he

would check that individual on a weekly basis.8 (Id. at 9). In addition to regularly seeing

segregated inmates on observation statuses, Gallagher also may see inmates for

counseling on a request or referral basis. (Id. at 19). Gallagher also was part of the

Program Review Committee (“PRC”) Team, a group of individuals9 who regularly met with

inmates in segregation to evaluate their status and determine whether their placement is

still appropriate based on multiple factors. (See Doc. 85-14 at 22).

Finally, the Prison’s mental health department employs two mental health nurses. At

the time of Carlos detention, they were defendants Nurse Leiphart and Nurse Snyder.

8 PrimeCare’s policy in effect at the time of Carlos’s detention called for daily checks of all

segregated inmates. The PrimeCare policy, however, explicitly provided that it was to be

superseded by policies or practices already in place at any given prison. (Id. at 9). Gallagher

explained that since he started working at YCP in the 1980s, the Prison had an established and

accepted practice that checks on segregated inmates on psychiatric observation status were

conducted on a weekly basis. (Id. at 10). Thus, he followed the Prison’s established practice and

conducted weekly evaluations of segregated inmates on psychiatric observation status, rather than

doing so on a daily basis. (Id. at 9-10).

9 The PRC Team typically consisted of defendants Gallagher and Doll, as well as a classification

supervisor, a shift captain, an assistant director of nursing, and a deportation officer from ICE. (Doc.

85-14 at 22).

During this time, some of the primary responsibilities of the mental health nurses were to

conduct weekly checks of inmates in segregated housing, check on mental health inmates

who put in sick-call slips, assist Dr. Rollings-Mazza on the days that she was at the Prison,

and attend ICE meetings to discuss immigration detainees experiencing specific mental

health problems. (Doc. 85-17 at 5-6, 8). Mental health nurses also have a general

familiarity with suicide risk factors, and they have the authority to place an inmate on

constant watch or suicide precaution. (See id. at 7).

3. YCP Administrators and Corrections Employees

At all times relevant to the instant action, the Prison’s Deputy Warden of Treatment

was defendant Doll. Doll’s responsibilities include overseeing the Prison’s corrections

staff, education department, religious services, work release program, and inmate

grievance system. (Doc. 85-14 at 11). Doll’s daily interaction with inmates is fairly limited,

but he may have contact with inmates when taking part in PRC reviews or when dealing

with an inmate’s appeal through the grievance system. (Id. at 12). Of the contact Doll has

with inmates, little pertains to mental health treatment issues unless individuals from the

mental health department call him for assistance in formulating some sort of plan or to

ensure that they are comporting with a policy. (Id.) Doll has the authority to place inmates

in certain segregation units, and if a particular inmate has a mental health concern, he will

consult with a mental health counselor before placing that inmate in segregation. (Id. at

13, 25). Doll has frequent interactions with mental health staff, including psychiatrists and

mental health counselors. (Id. at 12-13). Doll and LPC Gallagher have occasionally

discussed what type of things could be provided to assist segregated inmates in

occupying their time. (Id. at 12).

Corrections officers such as defendants Collins and Santos-Heredia are responsible

for conducting rounds by performing alternating tours of their assigned housing block and

periodically checking on inmates. (Doc. 85-13 at 8). As for segregated inmates on

psychiatric observation, suicide precaution, or medical observation, corrections officers

are required to check on those inmates every fifteen minutes and sign a sheet explaining

what the inmate was doing at the time of the check. (Id. at 10-11). Inmates who were not

on any observation status (i.e., they did not have a “sign” on their cell) would only be

checked every thirty minutes. (Id. at 10). Additionally, specific corrections officers were

assigned to continuously observe each individual on constant watch. (Id. at 9-10). When

corrections officers are first hired by the Prison, they are taught risk factors for inmate

suicide, and are trained as to what signs they should look for. (Id. at 11).

YCP’s corrections counselors are responsible for conducting intake interviews of

inmates upon their arrival to the Prison and for performing monthly “contact reviews” with

inmates to whom they are assigned. (Doc. 85-16 at 4). Carlos’s assigned corrections

counselor was defendant Counselor Jackson. According to Counselor Jackson, her

responsibilities at monthly contact reviews with regard to Carlos were to check in on her

and make sure she was provided with clothing, writing utensils, communication with

family, and contact with immigration services. (Id. at 9). If an inmate needs assistance

between monthly contact reviews, the inmate can send a request slip to the corrections

counselor, which the counselor would answer by writing on the request slip and returning

it to the inmate. (Id.) A corrections counselor may authorize that an inmate be moved

from one cell to another, unless the inmate is on an observation status, in which case the

corrections counselor would have to consult with mental health staff prior to authorizing a

move. (Id. at 19).

D. Carlos’s Detention at YCP

Given the duration of Carlos’s detention at YCP and the chain of events underlying

the instant action, it is helpful to separate the operative facts into three specific time

periods: (1) April 14, 2011, to August 13, 2013; (2) August 13, 2013, to October 23, 2013;

and (3) October 23, 2013, and thereafter.

1. April 14, 2011 to August 13, 2013

a. Carlos’s Arrival at YCP

Carlos arrived at YCP on April 14, 2011, and she was seen by LPC Gallagher upon

arrival. (Doc. 85-15 at 12). Because of Carlos’s agitation, Gallagher placed her on

psychiatric observation status. (Id. at 12-13). Due to her aggressive behavior and

behavior during transport to the Prison, she was placed in segregated housing conditions

in the Behavioral Adjustment Unit (BAU) pod of the Prison’s female maximum security

block.10 (Doc. 85-6 at 2-3). On April 15, 2011, nonparty Corrections Counselor Schneider

conducted an intake of Carlos. According to Counselor Schneider, Carlos did not

understand why she was at the Prison, and she did not remember getting into trouble.

(Doc. 85-6 at 3). Carlos was classified under Security Level III11 due to her confusion and

her mental health status. (Id.)

10 Carlos was housed in YCP’s female maximum security block for most of her detention at the

Prison. At the time of Carlos’s incarceration at the Prison, the female maximum security block was

divided into the following five pods of cells: A pod, B pod, C pod, D pod, and BAU pod. (Doc. 85-13

at 8).

11 YCP’s custody security levels are determined by an “objective classification system” developed by

the National Institute of Corrections and utilized by the Immigration Service. (Doc. 85-14 at 12).

YCP has five security levels ranging from “zero” to “four,” with “four” being the highest level of

security and “zero” being the lowest. (Id.)

On, April 20, 2011, Carlos was removed from psychiatric observation status per LPC

Gallagher’s recommendation, and she was transferred to a cell in general population. (Id.)

On April 25, 2011, Carlos was seen by psychiatrist Dr. Rollings-Mazza for the first time.

(See Doc. 85-11 at 5). It was conveyed to the Doctor that Carlos had previously been

diagnosed with schizophrenia and that she had been prescribed Haldol Decanoate

(“Haldol”) injections which she received every two weeks. (Doc. 85-19 at 14, 17). The

Doctor diagnosed Carlos with “likely [ ] schizoaffective disorder” and reported that Carlos

was stable on her meds, exhibited no overt psychosis, and denied suicidal ideation. (Doc.

85-11 at 5).

b. Carlos’s Disruptive Behavior

Throughout the first twenty-eight months of her detention at YCP, Carlos repeatedly

engaged in disruptive behavior.12 As a result of this behavior, Carlos spent much of her

time on either BAU status or Intensive Custody Unit (ICU) status.13 During the period of

April 14, 2011, to early August 2013, she was housed in disciplinary segregation on eight

separate occasions, and she was on ICU status for one extended period of time—from

12 More specific information pertaining to Carlos’s disruptive behavior can be found in Corrections

Counselor Notes, (Doc. 85-6), and in Judge Saporito’s report, (Doc. 94 at 6-20).

13 BAU placement and ICU placement differed in various ways. As explained in Judge Saporito’s

report:

A BAU placement was typically based on a specific disciplinary

violation, and inmates in the BAU were permitted only one hour

outside of their cells each day, five days per week, and they were

limited in the type and amount of personal property they could

possess. ICU status was based on an administrative determination

that an inmate had a “history of violence” and was a “threat to the

general population”—ICU inmates were usually placed in A or D pods,

they were not limited in the personal property they could possess, but

they were only permitted two hours outside of their cells each day.

(Doc. 94 at 4 n.4).

January 23, 2013 to June 7, 2013. (Docs. 85-6 at 6; 85-9 at 13). Moreover, in

accordance with YCP’s policy of automatically placing mental health inmates on suicide

precaution after involvement in an altercation, Carlos was placed on suicide precaution on

four specific dates during that time period: June 8, 2011; November 11, 2012; December

13, 2012; and July 11, 2013. (Doc. 85-9 at 11). Each of the four times that she was

placed on suicide precaution following an altercation, she was stepped down to psychiatric

observation status the very next day by LPC Gallagher. (See Doc. 85-6 at 3, 6-7).

c. Defendants’ Interactions with Carlos

Many of the individual defendants named in the instant action observed Carlos on a

regular basis throughout the first twenty-eight months of her detention. Those observers

reported varying accounts as to Carlos’s mood and behavioral tendencies.

Dr. Rollings-Mazza typically conducted a medication check on Carlos every four to

eight weeks. (Doc. 85-19 at 9). Dr. Rollings-Mazza recalled that Carlos was “remarkably

stable” on her Haldol shots, and Carlos never exhibited any psychotic symptoms when the

Doctor observed her. (Id. at 14). Additionally, the Doctor recalled that on the majority of

occasions where she observed Carlos, Carlos was engaged in terms of conversation.

(Id.) Dr. Rollings-Mazza also spoke with Carlos frequently on a social, non-evaluative

basis because Carlos was often housed in a segregation area that was directly across

from Dr. Rollings-Mazza’s office. (Id. at 4). The Doctor recalled that Carlos expressed

frustration about three things: (1) lack of contact with her family; (2) confusion about her

deportation status; and (3) being housed in a segregated environment. (Id. at 4, 11).

Although Dr. Rollings-Mazza was aware that Carlos engaged in disruptive behavior

from time to time, she did not believe that the disruptions were caused by her

schizophrenia, and she elected not to make any changes to her medication regimen. (Id.

at 32). The Doctor acknowledged that there were some occasions where Carlos refused

her Haldol shot, but according to the Doctor’s recollection, Carlos usually received the

shot within a day thereafter. (Id. at 4, 14). The Doctor did not recall any exacerbation of

Carlos’s psychiatric symptoms on the occasions that her shot was delayed, and the Doctor

testified that a delay of a day or two should not cause any problems. (Id.)14

Each time Carlos was housed in segregation due to her behavior, defendant LPC

Gallagher saw her at her cell on a weekly basis to review her mental health status until he

believed she could be removed from psychiatric observation status. (Doc. 85-15 at 13).

Gallagher would also see Carlos intermittently on other occasions when she requested

him or simply needed support; on those occasions, when he could, Gallagher would pull

Carlos out for counseling sessions (which lasted between twenty and thirty minutes) in the

female mental health office. (Id.) When talking with Gallagher, Carlos frequently

expressed concerns about deportation, and she often complained about her placement in

segregated housing. (Id. at 11-12). On one occasion, Carlos expressed distress over the

14 In addition to her multiple visits with Dr. Rollings-Mazza, Carlos was also evaluated by nonparty

clinical psychologist, Ronald Noble, Ph.D., on May 25, 2011. Dr. Noble’s prognosis for Carlos

appeared to be grimmer than that of Rollings-Mazza. Judge Saporito summarized Dr. Noble’s

evaluation, in relevant part, as follows:

[Dr. Noble] noted that Carlos was “likely to suffer from her psychotic

disorder permanently, and to need psychotropic medications and

supportive care for the rest of her life.” His prognosis for Carlos was

for a “[r]isk of future hospitalization and danger to self and others.” Dr.

Noble recommended that Carlos be placed “under the care of a

psychiatrist who can prescribe appropriate psychotropic medications

and monitor her symptoms,” and he suggested that, due to her need

for a “supportive and structured living environment,” she would be best

placed in “[a] group home setting for individuals suffering from chronic

mental illness.”

(Doc. 94 at 5-6) (internal citations omitted); (see also Doc. 85-5 at 3, 12-13).

fact that her parents were having relationship problems. (Id. at 12). Gallagher reported

that Carlos’s mood fluctuated; Gallagher recalled that sometimes, Carlos could be “very

reasonable” and at other times, she would be “difficult to handle.” (Id. at 14). Gallagher

expressed that Carlos was not the “easiest compliant inmate in the [Prison],” but she was

generally “workable.” (Id.) According to Gallagher, there was an attempt at one point to

have Carlos participate in an anger-management class, but she was unable to participate

because of her illiteracy. (Id. at 13).

Gallagher testified that in his many personal assessments of Carlos between April

2011 and August 2013, he observed nothing that led him to believe Carlos may be at risk

for harming herself, and none of his interactions with her led him to believe that he should

talk to Dr. Rollings-Mazza about a possible medication change. (Id. at 11, 13). Gallagher

recalled that there were occasions where Carlos refused her Haldol injection and her

treatment was briefly delayed, but like Dr. Rollings-Mazza, Gallagher did not observe any

changes in Carlos’s behavior when the treatment was delayed. (Id. at 13-14).

Any time that Carlos was in segregation, she would also be seen by a mental health

nurse on a weekly basis for a mental health check. The nurse that saw Carlos most

frequently was defendant Nurse Leiphart, but Carlos was also seen occasionally by

defendant Nurse Snyder.15 (See Doc. 85-21 at 8). According to Nurse Leiphart, Carlos

frequently was involved in altercations with other inmates and staff and would easily

become agitated at times. (Doc. 85-17 at 8). When speaking with Nurse Leiphart, Carlos

would often complain about being locked up in segregation, but Leiphart had no authority

15 Nurse Snyder only saw Carlos sporadically for weekly segregation checks, and she did not have

much contact with her other than that. (Doc. 85-21 at 8). Snyder did not remember much about

Carlos’s demeanor and behavior. (Id.) Snyder recalled hearing from others that Carlos was upset

about her housing status and that she was “ready to be out of prison,” but she never heard these

complaints from Carlos directly. (Id. at 8-9).

to move Carlos to different housing quarters. (Id. at 12). Although Carlos was difficult for

many Prison staff members to deal with, Nurse Leiphart believed that she and Carlos had

established a rapport, and Carlos was more cooperative with her than with other staff. (Id.

at 6, 9). On occasions where Carlos refused her Haldol shot from other staff, Nurse

Leiphart could usually convince Carlos to receive the shot shortly thereafter. (Id. at 9-10).

Defendant Deputy Warden Doll did not personally speak with Carlos until he became

part of the PRC around June or July of 2013 and began observing Carlos as a part of that

Committee. (Doc. 85-14 at 23). Although Doll did not actually speak with Carlos until

2013, he had been previously aware that she was involved in altercations and was

“difficult to manage.” (Id.) Doll also recalled that he had placed Carlos on ICU status on

at least one occasion and that he had consulted with Gallagher before doing so. (Id. at

13). Doll was also aware that Carlos refused her Haldol shot on various occasions, but it

was his understanding that she was stable on her medication. (Id. at 25). At various

times prior to August 2013, Doll spoke with Joe Dunn, Assistant Field Director for ICE, to

recommend that Carlos be moved out of YCP and into a different facility because Doll

knew that Carlos was concerned about her immigration status, and he believed that she

may have benefited from a “change in scenery.” (Id.) Doll also discussed this matter with

Gallagher who similarly “believe[d] [Carlos] would have been better off in some other type

of environment” because she was “getting tired of being where she was.” (Doc. 85-15 at

15). ICE did not accept Doll’s recommendations, however, and Carlos remained detained

at YCP. (Doc. 85-14 at 25).

Defendant Jackson was Carlos’s assigned corrections counselor at YCP. (Doc. 85-

16 at 4). As Carlos’s assigned corrections counselor, one of Counselor Jackson’s primary

responsibilities was to conduct a monthly contact review at which she would check to

make sure Carlos had clothing, writing utensils, communication with family, and contact

with immigration services. (Id. at 9). Like many other defendants, Jackson recalled that

Carlos expressed concern about her immigration case, and that she wanted to stay in the

United States because she did not want to be separated from her family. (Id. at 14).

Jackson recalled that she usually did not observe Carlos more than once a month, and,

therefore, she did not observe Carlos’s behavior on a daily basis. (Id.)

The record reflects that many interactions between Jackson and Carlos were

unamiable, and contact reviews were often unproductive due to Carlos’s behavior. After

one contact review, Jackson reported that Carlos refused to listen, was “very frustrating to

speak with,” and would not let Jackson “get a word in.” (Id. at 12). At other contact

reviews, Jackson reported that Carlos would “wast[e] time,” repeatedly ask questions that

had already been answered, argue, and refuse to talk to Jackson in a respectful manner.

(Id. at 14-15). Jackson also recalled that Carlos said some “very colorful things” at the

contact reviews and that she once accused Jackson of “not lik[ing] black people.” (Id. at

7). On another occasion, Jackson reported that Carlos “[was] always needing something

or complaining about something.” (Id. at 17). Jackson also recalled that Carlos would

sometimes engage in interruptive and “attention-grabbing” behavior, but she stated that

such behavior is common among inmates. (Id. at 7).

Defendant CO Collins, who began working at YCP in October 2011, often worked in

the prison block on which Carlos was housed, and she had frequent contact with Carlos.

(Doc. 85-13 at 3-4). Collins was not aware of Carlos’s specific mental health diagnosis,

but she could tell that something was “a little off” with her. (Id. at 5). According to Collins,

Carlos acted mentally immature in some ways and would sometimes talk in a child-like

manner in an attempt to “get what she wanted.” (Id. at 4). Collins did not personally have

any significant problems with Carlos, as Carlos was very comfortable with her and

respectful to her. (Id. at 4, 12). Collins recalled, however, that Carlos was verbally

assaultive with and problematic for other corrections officers and inmates. (Id. at 12-13).

Collins testified that Carlos would get agitated very easily and that she could “fly off the

handle” when she became agitated. (Id. at 12). Collins remembered that the factors

which agitated Carlos most were other inmates and frustration surrounding her lengthy

stay at the Prison. (Id. at 14). Collins did not recall talking to Carlos about the status of

her immigration case, but Carlos had informed her that she was from Antigua. (Id. at 13).

When Carlos became agitated, corrections officers, including Collins, would try to talk to

her, calm her down, and divert her mind away from whatever was agitating her. (Id. at

14). This would be effective for “certain officers,” including Collins. (Id.)

2. August 13, 2013 to October 23, 2013

On August 10, 2013, Carlos was removed from BAU status, after having been placed

on that status on July 11, 2013. (Doc. 85-6 at 7). On August 13, 2013, however, three

days after she was removed from BAU status, Doll placed her on ICU status due to her

“continued assaultive behavior.” (Id.) Later that same day, Carlos was found in her cell

attempting to hang herself from a window by tying a sheet around her neck. (Doc. 76-12

at 2). Security staff members cut her down to the floor to assess her, and according to a

medical chart note from nonparty medical nurse Angela Schmuck, Carlos began crying

and saying, “It’s not fair, I don’t wanna live.”16 (Id.) Carlos was taken to the Prison’s

medical department, and then ultimately to an outside hospital for further treatment. (Id.)

Dr. Rollings-Mazza and Nurse Leiphart were both near Carlos’s cell when the August

13, 2013 suicide attempt occurred. Carlos was being housed in the female maximum

security area’s “A” pod, which is located directly across from Nurse Leiphart’s office. (Doc.

85-17 at 10). Nurse Leiphart ran over to Carlos’s cell after she heard officers yelling that

there was a medical emergency. (Id.) By the time Nurse Leiphart arrived, Carlos had

been cut down and was on the ground and “pretty alert.” (Id.) Although Dr. Rollings-

Mazza was not present on the A pod at the time of the incident, she was working close

enough that she could hear a “commotion” in the area of that pod.17 (Doc. 85-19 at 20).

The Doctor recalled Leiphart emerging from the A pod and informing her that Carlos had

16 A review of the record evidence suggests that prior to Carlos’s October 2013 suicide, most of the

defendants were not aware that Carlos made the statement that was heard by Nurse Schmuck.

Gallagher acknowledged reading this statement in Nurse Schmuck’s report, but he could not recall

whether he had learned of the statement at the time Carlos was still alive. (See Doc. 85-15 at 16).

17 Additionally, shortly before the suicide attempt, the Doctor had been in A pod visiting with another

patient when Carlos called out to the Doctor to see if she had any more information about her

deportation status. (Doc. 85-19 at 19). The Doctor told Carlos that she was unsure and told her that

she should ask the PRC individuals when they came around for their next weekly meeting. (Id. at

19-20).

attempted suicide. (Id.) Leiphart also told the Doctor that Carlos had been very upset,

and was yelling and screaming that she wanted to talk to somebody about her deportation

status. (Id.) According to Nurse Leiphart, Dr. Rollings-Mazza decided to place Carlos on

constant observation status and put her in “four-point” restraints upon her return from the

hospital. (Doc. 85-17 at 12).

Gallagher was at the Prison when Carlos attempted suicide, but he was not located

in the area in which the attempt occurred. (Doc. 85-15 at 15). Doll, Collins, and Santos-

Heredia did not recall being at the Prison at the time of the suicide attempt, but they

learned of it shortly afterwards. (Docs. 85-14 at 26; 85-13 at 13; and 85-20 at 10).

Jackson testified that she “vaguely” remembered the suicide attempt, but she did not

discuss the attempt with Carlos at subsequent contact reviews because she felt such

discussions would be more appropriate for mental health staff. (Doc. 85-16 at 8-9, 11).

Snyder, McNicholas, Crist, Nadeau, and Trig all assert that they were unaware of Carlos’s

suicide attempt. (Docs. 85-21 at 7-8; 76-23 at 3; 67-7 at 3; 67-8 at 3; and 67-9 at 2).

On August 14, 2013, one day after her suicide attempt, Carlos returned from the

hospital to YCP, where she was placed on ICU status and on constant observation. On

that day, Carlos was seen by both Dr. Rollings-Mazza and Gallagher. Dr. Rollings-Mazza

observed that Carlos was uncooperative, refused an evaluation, and refused to take her

medication. (Doc. 85-19 at 25; Doc. 76-13 at 48). The Doctor directed that Carlos’s

current medication regimen continue and that she be seen again by a psychiatrist in one

week. (Doc. 76-13 at 48). Carlos also refused an interview with Gallagher, who assessed

her to be a suicide risk and kept her on constant observation. (Id.) On August 15, 2013,

Carlos was again uncooperative with Gallagher, and he kept her on constant observation.

(Id. at 47-48).

When Gallagher saw Carlos on August 16, 2013, Carlos exhibited a “normal” mood,

but her insight and judgment were limited, and she was “unable to commit to safety.” (Id.

at 47). As a result, Gallagher ordered that she remain on constant observation. (Id.)

On August 17, 2013, Carlos was seen by nonparty Shannon M. Taylor, LPC. Taylor

noted that Carlos exhibited little cooperation and was unable to commit to safety, and,

therefore, she was kept on constant observation. (Id.)

On August 18, 2013, Carlos was again kept on constant observation after being seen

by another nonparty, Jeff Leer. (Doc. 76-14 at 4). According to Leer, Carlos stated that

she was “OK,” but she would not come to her cell door. (Id.)

On August 19, 2013, Carlos was seen by Gallagher, and for the first time since her

suicide attempt, Gallagher stepped her down from constant observation to suicide

precaution status. (Id. at 3). Gallagher noted that she was “appropriate and cooperative,”

and that she “contracted for safety”18 and agreed to cooperate with treatment. (Id.)

On August 20, 2013, Carlos was seen by both Gallagher and former defendant Dr.

Davis. When she saw Dr. Davis, Carlos was “animated” and “angry” about her deportation

case, but she was goal-oriented and maintained good eye contact. (Id.) Dr. Davis

ordered that Carlos maintain her current treatment plan, and that she be seen again by a

psychiatrist in eight weeks. (Id.) When Carlos saw Gallagher on the same day, she was

“appropriate and cooperative,” she denied suicidal ideations, and her mood was normal.

18 Gallagher testified that when he refers to “contracting for safety,” this means that he and Carlos

discussed how they were going to manage her behavior following the suicide attempt, that she

agreed to cooperate and be communicative if she had any problems, and that she would let him

know if she was having any difficulties. (Doc. 85-15 at 21).

(Id.) Gallagher stepped Carlos down from suicide precaution to psychiatric observation,

and she remained on ICU status. (Id.)

After she was stepped down to psychiatric observation on August 20, 2013, Carlos

remained on that observation level for more than a month, during which time Gallagher

saw her at her cell on an approximately once-per-week basis. (See id. at 1-3). On most

visits during this time period, Gallagher observed that Carlos’s mood was normal, her

thought process was intact, and she denied suicidal ideation. (See id.) When Gallagher

saw Carlos on September 19, 2013, she was cooperative and denied suicidal thoughts,

but she exhibited an anxious and depressed mood, expressing that she could no longer

handle being on ICU status. (Id. at 2). Gallagher explained to her that he did not have the

authority to take her off of ICU status, and he suggested some ways that she could

mitigate the anger she felt. (Doc. 85-15 at 21).

On September 30, 2013, Carlos saw Dr. Rollings-Mazza for a follow-up psychiatric

evaluation. Finding that Carlos was stable with no overt psychosis, the Doctor ordered

that her medication regimen be continued and that she be seen by a psychiatrist again in

six weeks. (Doc. 76-14 at 1). This was the last time that Dr. Rollings-Mazza saw Carlos

for a clinical evaluation. (Doc. 85-19 at 26).

On October 2, 2013, Gallagher saw Carlos at her cell. Carlos’s mood was normal,

but she told Gallagher that she was tired of being on psychiatric observation because it

made other people think that she was “crazy.” (Doc. 85-15 at 21). Gallagher told Carlos

that he would be willing to recommend her removal from psychiatric observation if she

would continue to work with him to move forward on her mental health progress; Carlos

agreed to do so. (Id.) After consulting with various PRC members, including Doll,

Gallagher decided to take Carlos off psychiatric observation;19 Carlos, however, remained

on ICU status. (Id.) Gallagher believed that taking Carlos off psychiatric observation

would give him more room to work with her because she would perceive that he was being

supportive of her. (Id.) Once Carlos was taken off psychiatric observation, Gallagher

made no arrangements for further clinical evaluations, but he did make arrangements to

see her for weekly meetings with the PRC Team. (Id.) Gallagher did not recall anything

worrisome about Carlos in those PRC meetings. (Id. at 21-22). Doll, who also took part in

the PRC meetings with Carlos, perceived that the meetings had been positive, and he

believed that Carlos “was actively engaged in moving back to general population.” (Doc.

85-14 at 30).

Nurse Leiphart also testified about her interactions with Carlos in the weeks following

the August 2013 suicide attempt. Leiphart recalled that during that time, Carlos was more

agitated than usual, and on various occasions, Carlos refused her Haldol shot when

medical nurses attempted to give it to her. (Doc. 85-17 at 9, 14). Generally, when Carlos

refused her Haldol shot initially, Nurse Leiphart could convince her to take it later on the

same day. (Id. at 9-10). Leiphart testified that she was not concerned that Carlos’s

increased agitation would cause her to harm herself, and she did not specifically recall

talking to anyone about Carlos’s increased agitation. (Id.)

3. Carlos’s Suicide – October 23, 2013

At around 8:30 p.m. on the night of October 23, 2013, Officer Collins was on a routine

shift at the Prison when she heard screaming coming from one of the pods on the female

maximum security block. (Doc. 85-13 at 17, 19). Collins entered “A” pod and observed

19 According to Doll, removing Carlos from psychiatric observation meant that she would be checked

by corrections staff at staggered 30-minute intervals rather than 15-minute intervals. (Doc. 85-14 at

29).

that Carlos and another inmate two cells over, Janette Cruz-Rivera, were yelling at each

other and arguing about the television. (Id. at 16-17). The argument culminated with

Cruz-Rivera saying to Carlos, “why don’t you kill yourself?” (Id. at 17). In response,

Collins said to Cruz-Rivera, “Why would you say that to her?” (Id.) Collins then turned to

Carlos and began speaking with her. (Id.) Collins told Carlos to ignore Cruz-Rivera and to

sit down and listen to her radio. (Id.) Immediately following the argument, Carlos was

very upset, but after Collins talked with her for about five minutes, it appeared that Carlos

had calmed down, and Collins departed from “A” pod for the time being. (Id. at 17-18).

According to Collins, because Carlos appeared to have calmed down, Collins did not think

of having Carlos speak to someone from the mental health department, and she did not

suggest that anyone go back to check on Carlos to see if she was okay. (Id. at 18).

At around 9:00 p.m. on the same evening, Officer Santos-Heredia, while conducting

her rounds, checked on Carlos. (Doc. 85-20 at 15). Santos-Heredia observed that Carlos

was sitting at the end of her bunk, and it appeared as if she was preparing to go to bed.

(Id. at 14-15). Then, at 9:17 p.m., while conducting rounds, Officer Collins found Carlos

with a bed sheet tied to the window and around her neck, and she was hanging from a bar

on her cell window. (Docs. 85-13 at 16, 19; and 85-9 at 22). Carlos was taken to York

Hospital where she was pronounced dead. (Doc. 76-12 at 1). None of the defendants

other than Collins and Santos-Heredia were in the prison at the time that Carlos’s suicide

occurred. (See Docs. 85-19 at 28; 85-17 at 14; 85-16 at 10; 85-15 at 22; 85-14 at 30).

Rollings-Mazza, Gallagher, Leiphart, Doll, and Jackson all stated that they were surprised

when they learned of Carlos’s suicide. (Docs. 85-19 at 28; 85-17 at 15; 85-16 at 10; 85-15

at 22; and 85-14 at 30). Similarly, Collins recalled that nothing stood out to her about her

encounters with Carlos in the days leading up to the suicide. (Doc. 85-13 at 16).

On October 21, 2013, two days prior to the suicide, Counselor Jackson had

authorized Carlos’s movement from a cell in “D” pod to a cell in “A” pod because the “D”

pod cell, which was close to the medical department, was needed for an inmate with a

medical appliance. (Docs. 85-16 at 11; and 85-15 at 23). Counselor Jackson did not

consult with mental health staff before authorizing Carlos’s move because Carlos was not

on psychiatric observation at the time. (Doc. 85-16 at 18-19). Deputy Warden Doll

testified that the cell to which Carlos was moved was “an exact copy” of the cell that she

had been in previously. (Doc. 85-14 at 32). Similarly, Gallagher averred that the two cells

were “mirror images,” and that Carlos could have committed suicide in the “D” pod cell just

as easily as in the “A” pod cell. (Doc. 85-15 at 23). Doll acknowledged that Carlos was

not in a suicide-resistant cell when she committed suicide, but stated that her placement

into such a cell was allowable because she had been removed from psychiatric

observation. (Doc. 85-14 at 41).

E. Post-Suicide Investigations and Reports

Two federal investigations were conducted subsequent to Carlos’s death. The first

investigation, which was conducted by Lindsay M. Hayes (“Hayes”) for the Office of Civil

Rights and Civil Liberties of the U.S. Department of Homeland Security, engaged in a

review of YCP’s suicide prevention practices. After that investigation, on April 1, 2014,

Hayes issued a report (Doc. 85-11) which consisted of a summary of his observations,

conclusions, and suggested remedies in regard to suicide prevention practices within

YCP. Judge Saporito summarized Hayes’ findings as follows:

[Hayes'] report found a number of deficiencies in the

implementation of suicide prevention programs by York County

Prison and PrimeCare, including inadequate guidance with

respect to training, problematic housing of inmates in cells that

were not suicide-resistant, and failure of mental health personnel

to comply with suicide prevention requirements set out in the

written policies. The report also noted an ICE policy requirement

that a mortality review be conducted following any detainee

suicide attempt, but it deferred making any findings due to lack of

documentation.

(Doc. 94 at 31) (internal citations omitted). The Hayes report also found that YCP mental

health staff “are not developing any treatment plans,” as required for all inmates on suicide

precautions greater than 24 hours. (Doc. 85-11 at 28). Moreover, Hayes found that

“mental health staff continue to utilize ‘contracting for safety’ when discharging detainees

from suicide precautions and/or psychiatric observation.” (Id.) Hayes averred that this

practice is problematic and should be discontinued because “[w]hile there may be some

positive therapeutic aspects to safety contracts, most experts agree that once a patient

becomes suicidal, their written or verbal assurances are no longer sufficient to counter

suicidal impulses.” (Id.)

The second federal investigation pertaining to Carlos’s death was conducted by the

ICE Office of Professional Responsibility, Office of Detention Oversight (“ODO”). On July

17, 2014, the ODO issued a report (Doc. 85-9) pertaining to its investigation. Judge

Saporito summarized the findings of that report as follows:

This [ODO] report found York County Prison to be deficient in

following various ICE standards, including inadequate

documentation of administrative segregation orders, untimely

segregation reviews, a failure to collect incident reports from all

staff who responded to Carlos’s October 2013 suicide and her

August 2013 suicide attempt, a failure by medical staff [including

LPC Gallagher and Dr. Rollings-Mazza] to document any

treatment plan for Carlos during her thirty months of detention,

and a failure to prepare a psychiatric alert report following

Carlos’s August 2013 suicide attempt.

(Id. at 31-32) (internal citations omitted).

In addition to the two federal investigations, Dr. Raymond F. Patterson, a Board

certified forensic psychiatrist and retained expert of the plaintiff, issued a forensic

psychiatric report (Doc. 85-22) on June 23, 2015, and, thereafter an addendum (Doc. 85-

23) dated September 30, 2016. Of particular relevance, Dr. Patterson concluded in his

original report (which was issued prior to the initiation of the instant action) that “to a

reasonable degree of medical certainty . . . the mental health care, treatment, and

management provided by PrimeCare Inc., and the York County Prison did not meet the

standard of care for mental health care in similar situations and institutions, and indeed

reflected negligence and deliberate indifference.” (Doc. 85-22 at 11). Moreover, in the

report, Dr. Patterson found “to a reasonable degree of medical certainty that [Carlos’s]

suicide was foreseeable and preventable” if she had been housed in a better environment,

had her mental health treatment increased, and been provided with comprehensive

treatment planning and formal suicide risk assessment and management. (Id. at 14-15).

In the September 30, 2016 addendum to his original report, Dr. Patterson concluded

that he reviewed the discovery materials and deposition testimony from this case—

including the deposition transcripts of LPC Gallagher, Dr. Rollings-Mazza, and Nurse

Leiphart—and that those materials supported the opinions he expressed in his initial

report. (Doc. 85-23 at 4-5). Moreover, in the addendum, Dr. Patterson expressly

endorsed the opinions that Hayes had previously presented in his own report from April 1,

2014. (See id. at 4).

F. Procedural History of the Instant Action

The original complaint in this wrongful death and survival action was filed on October

14, 2015. Defendant York County responded by filing an answer with affirmative defenses

on October 23, 2015. Defendants PrimeCare and Dr. Rollings-Mazza responded by filing

a joint answer with affirmative defenses on November 5, 2015. Defendant Gallagher

responded by filing a motion dismiss for failure to state a claim on November 6, 2015.20

On February 11, 2016, the plaintiff filed a motion for leave to amend her complaint,

and included a proposed three-count amended complaint with the motion. On April 27,

2016, the court granted the plaintiff’s motion to amend, (see Doc. 35), and the plaintiff’s

amended complaint (Doc. 36) was filed on the same date. Count I of the amended

complaint raises claims under the Eighth and Fourteenth Amendments to the United

States Constitution, as well as Fourteenth Amendment due-process claims against

defendants Rollings-Mazza, Gallagher, Davis, Snyder, Leiphart, Doll, Neeper, Collins,

Santos-Heredia, McNicholas, Crist, Nadeau, Jackson, Trig, Correctional Officer John

Does 1-10, and Medical John Does 1-10. Count II of the amended complaint raises

Eighth Amendment and Fourteenth Amendment claims against defendants York County

and PrimeCare. Finally, Count III of the amended complaint raises state-law medical

negligence claims against defendants Rollings-Mazza, Gallagher, Davis, Snyder, Leiphart,

Medical John Does 1-10, and PrimeCare. The plaintiff seeks compensatory damages

from all defendants, punitive damages from the individual defendants, and reasonable

attorney fees and costs.

20 Gallagher’s motion to dismiss the plaintiff’s original complaint for failure to state a claim was

ultimately denied on September 16, 2016. (See Doc. 64).

Eventually, three motions for summary judgment were filed. The first motion for

summary judgment (Doc. 65) was collaboratively filed by defendants Collins, Crist, Doll,

Jackson, McNicholas, Nadeau, Neeper, Santos-Heredia, Trig, Corrections Officer John

Does 1–10, and York County (hereinafter referred to collectively as the “York County

defendants”). The York County defendants move for summary judgment on the merits of

the plaintiff’s federal constitutional claims and, in the alternative, on qualified-immunity

grounds.

The second motion for summary judgment (Doc. 68) was collaboratively filed by

defendants Leiphart, Dr. Rollings-Mazza, Snyder, and PrimeCare (hereinafter referred to

collectively as the “PrimeCare defendants”). The PrimeCare defendants move for

summary judgment on the merits of the federal constitutional claims, the state-law medical

malpractice claims against Nurses Snyder and Leiphart, and the state-law claims for

punitive damages. Additionally, the PrimeCare defendants request that this court decline

to exercise jurisdiction over the remainder of the plaintiff’s state-law claims and that they

be dismissed without prejudice for litigation in state court.

The third motion for summary judgment (Doc. 74) was filed by defendant Gallagher,

who moves for judgment on the merits of all claims against him. The plaintiff filed

responses in opposition to all of the motions for summary judgment. While she opposes

summary judgment as to many of the defendants, the plaintiff has expressly stated that

she “agrees to dismissal” of defendants Snyder, (see Doc 87 at 6 n.1), Neeper, Santos-

Heredia, McNicholas, Crist, Nadeau, and Trig. (See Doc. 88 at 5 n.1).

G. Judge Saporito’s Report and Recommendation

On September 1, 2017, Magistrate Judge Joseph F. Saporito, Jr. issued a report and

recommendation (Doc. 94) addressing the three pending summary judgment motions. In

analyzing the plaintiff’s claims, Judge Saporito found from the outset that the plaintiff

abandoned all of her claims against Snyder, Neeper, Santos-Heredia, McNicholas, Crist,

Nadeau, and Trig because she explicitly stated that she agreed to the dismissal of those

defendants. Judge Saporito then went on to analyze the claims against the remaining

defendants. He found that the plaintiff’s federal constitutional claims against all of the

defendants failed on the merits, and that the court should decline to exercise

supplemental jurisdiction over the plaintiff’s state-law negligence claims because there is

nothing exceptional about this case that would justify keeping the state-law claims.

In light of his findings, Judge Saporito recommended that: (1) all of the motions for

summary judgment be granted; (2) judgment be entered in favor of all defendants and

against the plaintiff on the federal constitutional claims set forth in Counts I and II of the

amended complaint; (3) judgment be entered in favor of defendant Snyder and against the

plaintiff on the supplemental state-law claims set forth in Count III of the amended

complaint; and (4) the supplemental state-law claims against defendants Gallagher, Dr.

Rollings-Mazza, Leiphart, and PrimeCare set forth in Count III of the amended complaint

be dismissed without prejudice to those claims being raised in state court pursuant to 28

U.S.C. §1367(c)(3).

Two parties have filed objections to Judge Saporito’s report and recommendation.

On September 11, 2017, defendant York County filed an objection (Doc. 97), objecting

only to Judge Saporito’s finding that the County could properly be subject to 42 U.S.C.

§1983 liability as a “person” that operated and established policy for the YCP. The County

does not object to any other parts of the report and recommendation.

On October 6, 2017, the plaintiff filed objections (Doc. 101) to most of the

recommendations contained within the report and recommendation. Specifically, the

plaintiff objects to the following: (1) Judge Saporito’s recommendation to grant summary

judgment in favor of Gallagher as to the plaintiff’s federal constitutional claims; (2) Judge

Saporito’s recommendation to summary judgment in favor of Dr. Rollings-Mazza as to the

plaintiff’s federal constitutional claims; (3) Judge Saporito’s recommendation to grant

summary judgment in favor of Nurse Leiphart as to the plaintiff’s federal constitutional

claims; (4) Judge Saporito’s recommendation to grant summary judgment in favor of

Deputy Warden Doll as to the plaintiff’s federal constitutional claims; (5) Judge Saporito’s

recommendation that the court grant summary judgment in favor of Counselor Jackson as

to the plaintiff’s federal constitutional claims; (6) Judge Saporito’s recommendation to

grant summary judgment in favor of Collins as to the plaintiff’s federal constitutional

claims; (7) Judge Saporito’s recommendation to grant summary judgment in favor of York

County as to the plaintiff’s federal constitutional claims; (8) Judge Saporito’s

recommendation to grant summary judgment in favor of PrimeCare as to the plaintiff’s

federal constitutional claims; and (9) Judge Saporito’s recommendation to decline to

exercise supplemental jurisdiction over the plaintiff’s state-law negligence claims against

Gallagher, Rollings-Mazza, Leiphart, and PrimeCare. The plaintiff, however, does not

object to Judge Saporito’s recommendation that the claims against Snyder, Neeper,

Santos-Heredia, McNicholas, Crist, Nadeau, and Trig all be dismissed. (See Doc. 101-1

at 11 n.1).

III. Legal Standards

A. Standard of Review – Report and Recommendation

“Where objections to a magistrate judge's report and recommendation are filed, the

court must perform a de novo review of the contested portions of the report.” Behar v. Pa.

Dept. of Transp., 791 F. Supp. 2d 383, 389 (M.D. Pa. 2011); see also 28 U.S.C.

§636(b)(1)(C); M.D. Pa. Local Rule 72.3. In performing that de novo review, the court

“may accept, [not accept], or modify, in whole or in part, the magistrate judge’s findings or

recommendations.” Owens v. Beard, 829 F. Supp. 736, 738 (M.D. Pa. 1993) (citing 28

U.S.C. §636(b)(1); M.D. Pa. Local Rule 904.2).

On the other hand, with regard to uncontested portions of a report and

recommendation, “de novo review of the record and plenary consideration of the parties’

contentions are not required.” Cruz v. Chater, 990 F. Supp. 375, 376 (M.D. Pa. 1998)

(emphasis in original). Rather, “[t]he court will review the uncontested portions of the

magistrate judge’s report for ‘clear error on the face of the record.’” Clouser v. Johnson,

40 F. Supp. 3d 425, 430 (M.D. Pa. 2014) (citing Cruz, 990 F. Supp. at 375-78).

B. Standard of Review – Summary Judgment

Pursuant to Federal Rule of Civil Procedure 56(a), “[t]he court shall grant summary

judgment if the movant shows that there is no genuine dispute as to any material fact and

the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a); see also

Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986). “[T]his standard provides that the

mere existence of some alleged factual dispute between the parties will not defeat an

otherwise properly supported motion for summary judgment; the requirement is that there

be no genuine issue of material fact.” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247-

48 (1986).

A disputed fact is material if proof of its existence or nonexistence would affect the

outcome of the case under applicable substantive law. Anderson, 477 U.S. at 248; Gray

v. York Newspapers, Inc., 957 F.2d 1070, 1078 (3d Cir. 1992). An issue of material fact is

“genuine” if the evidence is such that a reasonable jury could return a verdict for the

nonmoving party. Anderson, 477 U.S. at 257; Brenner v. Local 514, United Bhd. of

Carpenters & Joiners of Am., 927 F.2d 1283, 1287-88 (3d Cir. 1991).

When determining whether there is a genuine issue of material fact, “all facts and

inferences are construed in the light most favorable to the non-moving party.” Boyle v.

County of Allegheny Pa., 139 F.3d 386, 393 (3d Cir. 1998). In order to avoid summary

judgment, however, parties may not rely on unsubstantiated allegations. Parties seeking

to establish that a fact is or is not genuinely disputed must support such an assertion by

“citing to particular parts of materials in the record,” by showing that an adverse party's

factual assertion lacks support from cited materials, or demonstrating that a factual

assertion is unsupportable by admissible evidence. FED. R. CIV. P. 56(c)(1); see also

Celotex, 477 U.S. at 324 (requiring evidentiary support for factual assertions made in

response to summary judgment). The party opposing summary judgment “must do more

than simply show that there is some metaphysical doubt as to the material facts.”

Matsushita Elect. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586 (1986). Parties

must produce evidence to show the existence of every element essential to its case that

they bear the burden of proving at trial, for “a complete failure of proof concerning an

essential element of the nonmoving party’s case necessarily renders all other facts

immaterial.” Celotex, 477 U.S. at 323; see also Harter v. GAF Corp., 967 F.2d 846, 852

(3d Cir. 1992).

IV. Discussion

A. The Uncontested Portions of the Report and Recommendation

Judge Saporito found that the plaintiff has abandoned all of her claims against

Snyder, Neeper, Santos-Heredia, McNicholas, Crist, Nadeau, and Trig because she

explicitly stated that she agreed to the dismissal of those defendants. No party objects to

this finding. Upon review, we find no error, and, accordingly, we adopt Judge Saporito’s

discussion of this issue. (Doc. 94 at 36-37). Therefore, judgment shall be entered in favor

of defendants Snyder, Neeper, Santos-Heredia, McNicholas, Crist, Nadeau, and Trig on

all claims in the amended complaint.

B. The Contested Portions of the Report and Recommendation

Judge Saporito concluded that the plaintiff’s federal constitutional claims against

defendants Gallagher, Rollings-Mazza, Leiphart, Doll, Jackson, Collins, York County, and

PrimeCare fail on the merits, and thus recommended that we grant summary judgment in

favor of all those defendants. Moreover, Judge Saporito recommended that we decline to

exercise supplemental jurisdiction over the state-law negligence claims against

defendants Gallagher, Rollings-Mazza, Leiphart, and PrimeCare because there is nothing

exceptional about this case that would justify retaining jurisdiction. The plaintiff objects to

all of these findings, and, therefore, they must be reviewed de novo.

Additionally, defendant York County objects to Judge Saporito’s finding that the

County could properly be subject to 42 U.S.C. §1983 liability as a “person” that operated

and established policy for the YCP. Consequently, we conduct a de novo review of that

finding as well.

1. Section 1983 Claims

a. Section 1983 Claims in General

With respect to Counts I and II of the amended complaint, the plaintiff seeks relief

pursuant to 42 U.S.C. §1983. Section 1983 states, in relevant part:

Every person who, under color of any statute, ordinance,

regulation, custom, or usage, of any State or Territory or the

District of Columbia, subjects, or causes to be subjected, any

citizen of the United States or other person within the jurisdiction

thereof to the deprivation of any rights, privileges or immunities

secured by the Constitution and laws, shall be liable to the party

injured in an action at law, suit in equity, or other proper

proceedings for redress. . . .

42 U.S.C. §1983. Thus, “§1983 is not itself a source of substantive rights, but merely

provides a method for vindicating federal rights elsewhere conferred.” Graham v. Connor,

490 U.S. 386, 393-94 (1989) (citation and internal quotation marks omitted). “A prima

facie case under §1983 requires a plaintiff to demonstrate: (1) a person deprived him of a

federal right; and (2) the person who deprived him of that right acted under color of state

or territorial law.” Groman v. Township of Manalapan, 47 F.3d 628, 633 (3d Cir. 1995)

(citing Gomez v. Toledo, 446 U.S. 635, 640 (1980)).

In raising her §1983 claims, the plaintiff references both the Eighth and Fourteenth

Amendments to the United States Constitution. As Judge Saporito noted, however, (see

Doc. 94 at 38-39), Carlos was an immigration detainee rather than a convicted prisoner.

The Third Circuit has recognized that immigration detainees are “entitled to the same

protections as a pretrial detainee.” Adekoya v. Chertoff, 431 F. App’x 85, 88 (3d Cir.

2011) (per curiam) (citing Edwards v. Johnson, 209 F.3d 772, 778 (5th Cir. 2000)). As

opposed to convicted prisoners, “[p]retrial detainees are not within the ambit of the Eighth

Amendment but are entitled to the protections of the Due Process Clause.” Boring v.

Kozakiewicz, 833 F.2d 468, 471 (3d Cir. 1987) (citing Bell v. Wolfish, 441 U.S. 520 (1979);

Hampton v. Holmesburg Prison Officials, 546 F.2d 1077 (3d Cir. 1976)), cert. denied, 485

U.S. 991 (1988). Consequently, any federal civil rights claims in the instant matter are

governed solely by the Due Process Clause of the Fourteenth Amendment, rather than

the Eighth Amendment’s proscription against cruel and unusual punishment.

b. The Framework of Estelle v. Gamble

In Estelle v. Gamble, 429 U.S. 97 (1976), the Supreme Court of the United States

found that a failure to provide adequate medical care to a convicted prisoner amounts to a

violation of the Eighth Amendment’s Cruel and Unusual Punishment Clause. To succeed

on a constitutional claim under the principles of Estelle, evidence must show: (1) a serious

medical need, and (2) acts or omissions by prison officials that indicate deliberate

indifference to that need. Natale v. Camden Cty. Corr. Facility, 318 F.3d 575, 582 (3d Cir.

2003) (citing Rouse v. Plantier, 182 F.3d 192, 197 (3d Cir. 1999)). Although the holding in

Estelle specifically pertained to convicted prisoners within the ambit of the Eighth

Amendment, the Third Circuit has “found no reason to apply a different standard than that

set forth in Estelle . . . when evaluating whether a claim for inadequate medical care by a

pre-trial detainee is sufficient under the Fourteenth Amendment.” Id. at 581 (citing Boring,

833 F.2d at 472). This is because “the Supreme Court has concluded that the Fourteenth

Amendment affords pretrial detainees protections ‘at least as great as the Eighth

Amendment protections available to a convicted prisoner.’” Id. (quoting City of Revere v.

Mass. Gen. Hosp., 463 U.S. 239, 244 (1983)).

c. Detainee Suicide Cases in Light of Estelle

The Third Circuit has recognized that since “a ‘particular vulnerability to suicide’

represents a ‘serious medical need,’” the Estelle framework can apply to detainee suicide

cases. Colburn v. Upper Darby Township, 946 F.2d 1017, 1023-24 (3d Cir. 1991)

(“Colburn II”) (citing Colburn v. Upper Darby Township, 838 F.2d 663, 669 (3d Cir. 1988),

cert. denied, 489 U.S. 1065 (1989) (“Colburn I”); Partridge v. Two Unknown Police Officers

of Houston, 791 F.2d 1182, 1187 (5th Cir. 1986)). Pursuant to that framework, a plaintiff

raising a §1983 constitutional claim on the basis of a detainee’s suicide must establish the

following elements: “(1) the detainee had a ‘particular vulnerability to suicide,’ (2) the

custodial officer or officers knew or should have known of that vulnerability, and (3) those

officers ‘acted with reckless indifference’21 to the detainee’s particular vulnerability.”

Woloszyn v. County of Lawrence, 396 F.3d 314, 319 (3d Cir. 2005) (quoting Colburn II,

946 F.2d at 1023).

i. Element 1 - “Vulnerability to Suicide”

Whether a detainee bears a “particular vulnerability to suicide” depends on the

“degree of risk inherent in the detainee’s condition.” Id. at 320 (quoting Colburn II, 946

F.2d at 1024). “[T]here must be a strong likelihood, rather than a mere possibility, that

self-inflicted harm will occur.” Id.

21 In analyzing this element of the vulnerability-to-suicide framework, it seems that some courts use

the phrase “deliberate indifference,” whereas others utilize the term “reckless indifference.” The

Third Circuit has noted that “whichever [of those phrases] is employed, it indicates a level of

culpability beyond mere negligence,” and, therefore, has “not [found] it necessary to parse these

phrases to determine whether there is some distinction between them.” Palakovic v. Wetzel, 854

F.3d 209, 224 n.15 (3d Cir. 2017).

ii. Element 2 – “Knowledge” of a Particular Vulnerability

to Suicide

“Even where a strong likelihood of suicide exists, it must be shown that the custodial

officials ‘knew or should have known’ of that strong likelihood.’” Colburn II, 946 F.2d at

1024. In Colburn II, the Third Circuit emphasized that in the context of a pretrial-detainee

suicide, a plaintiff need not establish that a defendant had a subjective appreciation of a

pretrial detainee’s particular vulnerability to suicide; rather, it was sufficient for a plaintiff to

show that a defendant should have known that the pretrial detainee had a particular

vulnerability to suicide. 946 F.2d at 1024-25. The Colburn II court described the phrase

“should have known” as follows:

[The phrase “should have known”] does not refer to a failure to

note a risk that would be perceived with the use of ordinary

prudence. It connotes something more than a negligent failure

to appreciate the risk of suicide presented by the particular

detainee, though something less than subjective appreciation of

that risk. The strong likelihood of suicide must be so obvious

that a lay person would easily recognize the necessity for

preventative action; the risk of self-inflicted injury must be not

only great, but also sufficiently apparent that a lay custodian’s

failure to appreciate it evidences an absence of any concern for

the welfare of his or her charges.

Id. (citations and internal quotation marks omitted).

Three years after the Third Circuit’s decision in Colburn II, the Supreme Court in

Farmer v. Brennan, 511 U.S. 825 (1994), raised the standard when addressing a

convicted inmate’s deliberate indifference claim under the Eighth Amendment.

Specifically, the Court stated, in relevant part:

[A] prison official cannot be found liable under the Eighth

Amendment for denying an inmate humane conditions of

confinement unless the official knows of and disregards an

excessive risk to inmate health and safety; the official must both

be aware of facts from which the inference could be drawn that a

substantial risk of serious harm exists, and he must also draw

the inference.

511 U.S. at 837 (emphasis added). Seven years after Farmer, the Third Circuit in Beers-

Capitol v. Whetzel, 256 F.3d 120 (3d Cir. 2001), also addressing an inmate’s Eighth

Amendment deliberate indifference claim, seemingly refined Farmer as follows:

To be liable on a deliberate indifference claim, a . . . prison

official must both know of and disregard an excessive risk to

inmate health and safety. The . . . element of deliberate

indifference is subjective, not objective . . . meaning that the

official must actually be aware of the existence of the excessive

risk; it is not sufficient that the official should have been aware.

However, subjective knowledge on the part of the official can be

proved by circumstantial evidence to the effect that the

excessive risk was so obvious that the official must have known

of the risk.

256 F.3d at 133 (citations, internal quotation marks, and brackets omitted).

Thus, Farmer and Beers-Capitol established that subjective knowledge of a

vulnerability to suicide is required for liability in cases involving convicted inmates. Relying

on Farmer and Beers-Capitol, Judge Saporito concluded in his report that subjective

knowledge of Carlos’s particular vulnerability to suicide must be established for the

defendants to be held liable in this case. (See Doc. 94 at 42-43).

It is noteworthy that the instant matter may be distinguishable from Farmer and

Beers-Capitol because those cases involved convicted inmates raising deliberate

indifference claims under the Eighth Amendment, whereas this case involves Fourteenth

Amendment claims pertaining to an immigration detainee. The Third Circuit has not held

that the subjective knowledge requirement of Farmer and Beers-Capitol applies to cases

in which the plaintiff or decedent is a pretrial detainee. In fact, in Woloszyn, a case

involving a pretrial-detainee suicide, the Third Circuit, after discussing the Supreme

Court’s holding in Farmer, explained as follows:

Farmer defined “deliberate indifference” in the context of the

claim of a convicted prisoner under the Eighth Amendment. It

does not, therefore, directly control our analysis here because,

as we have explained, Woloszyn’s claim arises under the Due

Process Clause of the Fourteenth Amendment.

396 F.3d at 321. Despite this, even applying Farmer and Beers-Capitol it appears that

there are material facts in question as to whether some defendants knew of and

disregarded an excessive risk to Carlos’s health and safety as more particularly outlined

below.

iii. Element 3 – Acting With Reckless or Deliberate

Indifference

The third element of the vulnerability-to-suicide analysis requires a plaintiff to show

that a defendant who knew of a detainee’s particular vulnerability to suicide acted with

reckless or deliberate indifference to that vulnerability. In the context of pretrial-detainee

suicides, a defendant with the requisite knowledge of a particular vulnerability to suicide

can be said to act with deliberate indifference to that vulnerability if he or she “disregarded

that [vulnerability] by failing to take reasonable measures to address it.” Estate of Puza v.

Carbon County, 586 F. Supp. 2d 271, 277 (M.D. Pa. 2007). Similarly, the Third Circuit has

held, albeit in the context of a convicted inmate’s suicide, that a defendant can be said to

exhibit deliberate indifference to a particular vulnerability to suicide if he or she “fail[s] to

take necessary and available precautions to protect the prisoner from self-inflicted

wounds.” Freedman v. City of Allentown, 853 F.2d 1111, 1115 (3d Cir. 1988); see also

Francis ex rel. Estate of Francis v. Northumberland County, 636 F. Supp. 2d 368, 385

(M.D. Pa. 2009) (acknowledging the Freedman holding in the context of a pretrial-detainee

case); Plasko v. City of Pottsville, 852 F. Supp. 1258, 1263 (E.D. Pa. 1994) (same).

However, “[a] court ‘cannot infer from the prisoner’s act of suicide itself that the prison

officials have recklessly disregarded their obligation to take reasonable precautions to

protect the safety of prisoners entrusted to their care.’” Estate of Puza, 586 F. Supp. 2d at

276 (quoting Freedman, 853 F.2d at 1115). “Because of the nature of the [vulnerability-to-

suicide] analysis,” determinations as to whether a plaintiff can establish deliberate

indifference or merely negligence in prison suicide cases “are very fact sensitive.” Id. at

278.

d. Applying the Vulnerability-to-Suicide Framework to the

Instant Matter

Having set forth the vulnerability-to-suicide framework, we now must apply that

framework to the facts presented in the instant matter. From the outset, we note that our

discussion for the individual defendants will focus on the third element of the framework,

i.e., whether each defendant exhibited deliberate indifference to a particular vulnerability

to suicide. This is because, upon review of the record, it appears that there are sufficient

facts from which a reasonable juror could find that Carlos indeed had a particular

vulnerability to suicide and that some of the remaining defendants knew of that

vulnerability at the time Carlos took her own life.

Record evidence establishes that throughout her incarceration Carlos was difficult for

staff to manage; she suffered mood swings; she was easily agitated and frequently

engaged in disruptive and, sometimes, violent, behavior; she was placed on suicide watch

on multiple occasions; she repeatedly expressed frustration and despondency about her

placement in segregated housing and about the status of her immigration case; and she,

at times, refused her mental-health medication. While some of the defendants were

arguably on better terms with Carlos than others, the record evidence suggests that

virtually all were aware of her behavioral tendencies and frustrations. Additionally of

importance, while each of the defendants had varying levels of interaction with Carlos, all

of the defendants had actual knowledge that Carlos attempted suicide approximately ten

weeks before her completed attempt. See Cruise v. Marino, 404 F. Supp. 2d 656, 669

(M.D. Pa. 2005) (“Whether the custodial officials ‘knew or should have known’ can be

demonstrated when the officials have ‘actual knowledge of an obviously serious suicide

threat, a history of suicide attempts, or a psychiatric diagnosis identifying suicidal

propensities.’” (quoting Colburn II, 946 F.2d at 1025 n.4)). Moreover, at the time Carlos

committed suicide, she was housed in the very environment in which she had been

housed when she recently attempted to take her life.

Combining all of these facts, it appears that the plaintiff has presented sufficient facts

that would permit a reasonable juror to conclude that (1) Carlos had a particular

vulnerability to suicide; and (2) some of the remaining defendants knew of that particular

vulnerability to suicide at the time Carlos took her own life. See, e.g., Nealman v.

Laughlin, No. 1:15-CV-1579, 2016 WL 4539203, at *8 (M.D. Pa. Aug. 31, 2016) (noting

that while psychotic behavior by itself does not signal a particular vulnerability to suicide,

such behavior in coalescence with a history of depression, mental health hospitalizations,

and a prior suicide may constitute sufficient evidence of a particularized vulnerability to

suicide). Thus, the remainder of our discussion will focus on the third element (i.e.,

deliberate indifference) of the vulnerability-to-suicide analysis as it pertains to each

defendant.

e. Section 1983 Claims Against the Individual Defendants

i. Medical John Does 1-10 and Corrections Officer John

Does 1-10

To start, we note that the plaintiff has listed various unidentified medical and

corrections defendants in her amended complaint. The plaintiff refers to the unidentified

medical defendants as “Medical John Does 1-10,” and she refers to the unidentified

corrections defendants as “Corrections Officer John Does 1-10.” The plaintiff’s amended

complaint raises federal constitutional claims against Medical John Does 1-10 and

Corrections Officer John Does 1-10. Moreover, the amended complaint raises state-law

claims against Medical John Does 1-10. When the plaintiff filed the amended complaint

on April 27, 2016, she averred that she “[did] not . . . know the names of these defendants

but [would] seek leave to amend the Complaint so as to name each appropriate defendant

after the completion of additional discovery.” (Doc. 36 ¶¶ 16, 26). To date, the plaintiff

has not sought our leave to amend the complaint to identify the names of either Medical

John Does 1-10 or Corrections Officer John Does 1-10.

This court has previously noted that “[t]he use of John Doe defendants is permissible

in certain situations until ‘reasonable discovery permits the true defendants to be

identified.’” King v. Mansfield Univ. of Pa., 1:11-CV-1112, 2014 WL 3734551, at *1 n.1

(M.D. Pa. July 28, 2014) (quoting Blakeslee v. Clinton County, 336 F. App’x 248, 250 (3d

Cir. 2009)). However, district courts within the Third Circuit have held that “if reasonable

discovery fails to unveil the true identities” of the John Doe defendants, the John Doe

defendants should be dismissed. Id. (dismissing a plaintiff’s claims against John Doe

defendants at summary judgment stage because the true identities of those individuals

were not made known after a “lengthy period of discovery,” and they had not been served

by the plaintiff); see also Aponte v. Karnes, No. 08-cv-0183, 2008 WL 360879, at *1 n.1

(M.D. Pa. Feb. 8, 2008) (“Absent compelling reasons, a district court may dismiss [John or

Jane Doe] defendants if the plaintiff, after being granted a reasonable period of discovery,

fails to identify them.”); Scheetz v. Morning Call, Inc., 130 F.R.D. 34, 37 (E.D. Pa. 1990)

(“[Doe defendants] must eventually be dismissed, if discovery yields no identities.”).

In the instant matter, more than three years have passed since the filing of the

plaintiff’s amended complaint, and the parties have been provided ample time for

reasonable discovery. Nonetheless, the plaintiff has identified neither the Medical John

Does nor the Corrections Officer John Does, nor is there anything in the record to suggest

that any of these John Doe parties have been served by the plaintiff. Moreover, the John

Doe defendants are discussed nowhere in the parties’ summary judgment filings, and the

plaintiff has put forth no compelling reason as to why dismissal of those defendants would

be inappropriate. Therefore, all of the plaintiff’s claims against Medical John Does 1-10

and Corrections Officer John Does 1-10, are dismissed with prejudice.

ii. Section 1983 Claim Against LPC Gallagher

Turning to the identified individual defendants, we begin with the plaintiff’s §1983

claim against LPC Gallagher. With regard to that claim, Judge Saporito recommended

that summary judgment be granted in favor of Gallagher, and the plaintiff objects to Judge

Saporito’s recommendation. Upon de novo review, it appears that viewing the evidence in

the light most favorable to the plaintiff, these are issues of material fact and a reasonable

juror could find that Gallagher exhibited deliberate indifference to Carlos’s particular

vulnerability to suicide.

In arguing that Gallagher acted with deliberate indifference, the plaintiff cites to the

following facts and evidence: (1) throughout the course of Carlos’s incarceration,

Gallagher persistently failed to prepare a comprehensive treatment plan for her, even

though ICE and PrimeCare policy required him to do so; (2) Gallagher failed to conduct a

suicide risk assessment for Carlos, even though relevant policy required him to do so; (3)

Gallagher failed to consider alternative placement for Carlos, even though ICE required

such consideration for mentally ill detainees; (4) Gallagher relied on “contracting for

safety,” an allegedly discredited practice argued to be insufficient to address an inmate’s

suicidal tendencies; (5) Gallagher removed Carlos from any form of psychiatric

observation on October 2, 2013, even though she remained on the same ICU status that

caused her to attempt suicide in August of 2013; and (6) Gallagher cut off Carlos from

further clinical evaluations after she was removed from psychiatric observation on October

2, 2013. (Doc. 86 at 35-37; Doc. 101-1 at 41-43).

The plaintiff further cites to the respective post-suicide reports prepared by ICE and

Hayes, as well as the report and addendum prepared by the plaintiff’s proffered expert Dr.

Raymond F. Patterson. First, the plaintiff points out that the ICE report notes Gallagher’s

failure to implement a treatment plan for Carlos as required under ICE standards and

PrimeCare policies. (Doc. 101-1 at 29-30). Second, the plaintiff notes that in the Hayes

report, Hayes concluded that Gallagher “appeared indifferent to the suicide prevention

requirements” in both PrimeCare’s policies and ICE’s detention standards. (Id. at 30).

Third, the plaintiff cites to Dr. Patterson’s report and addendum, in which Dr. Patterson

concluded that the mental health care provided to Carlos was deficient, that her suicide

was preventable, and that Gallagher, in particular, “was responsible for failing to follow

suicide prevention policies, which led to his improperly releasing Carlos from observation

status on October 2, 2013.” (Id.)

In response to the plaintiff’s contentions, Gallagher argues that Carlos appeared to

be stable at the time she was removed from psychiatric observation, and, therefore, the

decision to remove her from that status cannot amount to deliberate indifference.

Moreover, Gallagher suggests that it would be unreasonable to expect that a person who

has previously attempted suicide be maintained on suicide watch or psychiatric

observation perpetually. The court agrees with Gallagher that there is no case law to

suggest that a formerly suicidal inmate must be kept on an observation status perpetually,

and removal of an individual from an observation status may not constitute deliberate

indifference in all circumstances.

However, at the time Gallagher removed Carlos from psychiatric observation on

October 2, 2013, Gallagher was aware that Carlos had attempted suicide less than two

months earlier, and he was aware that it had been her recent placement onto ICU status

that upset her and led her to engage in the attempt. When Carlos returned from the

outside hospital after her suicide attempt, she remained despondent and exhibited

behavioral tendencies such that Gallagher deemed it necessary to keep her on suicide

watch for a week before stepping her down to psychiatric observation. Moreover, as

recent as September 19, 2013, Carlos had exhibited a depressed and anxious mood, and

expressed that she “could no longer handle” being on ICU status. Less than two weeks

later, Gallagher made the decision to remove Carlos from psychiatric observation,

effectively permitting Carlos’s placement into non-suicide-resistant cells, and ceasing

regular clinical evaluations of Carlos other than brief PRC reviews at her cell. Gallagher

made this decision in spite of the fact that Carlos remained on ICU status—the status that

arguably contributed to her attempted suicide less than two months earlier, and the status

which, less than two weeks earlier, Carlos told Gallagher that she “could no longer

handle.”

Furthermore, record evidence—including the respective post-suicide reports

prepared by ICE and Hayes—suggests that Gallagher violated various PrimeCare and

ICE suicide-prevention policies, and the Hayes report specifically found that Gallagher

“appeared indifferent” to said policies. Additionally, as pointed out above, the initial report

of the plaintiff’s expert, Dr. Patterson, explicitly found that “to a reasonable degree of

medical certainty,” the mental health care provided to Carlos by PrimeCare during her

incarceration at YCP reflected “negligence and deliberate indifference.” Dr. Patterson

issued a later addendum confirming the findings of his initial report, and in so confirming,

Dr. Patterson explicitly stated that he relied upon the deposition testimony of Gallagher.

Dr. Patterson found that Gallagher was responsible for failing to follow suicide prevention

policies, and that this led to Carlos’s improper release from observation status on October

2, 2013.

Viewing all of these facts in the light most favorable to the plaintiff, it appears that a

reasonable juror could find that Gallagher’s actions amounted to deliberate indifference.

See, e.g., Palakovic v. Wetzel, 854 F.3d 209, 231-32 (3d Cir. 2017) (holding that the

subjection of a particularly vulnerable prisoner to prolonged periods of isolation and his

placement in an environment “characterized by extreme deprivation of social interaction

and environmental stimulation” could constitute deliberate indifference to a particular

vulnerability to suicide); Brandt v. PrimeCare Med., Inc., 1:11-CV-1692, 2013 WL

3863936, at *4 (M.D. Pa. July 24, 2013) (concluding that expert report which opined that

prisoner was prematurely removed from a “stripped cell” constituted “sufficient evidence

from which a reasonable trier of facts could determine that Defendants . . . acted with

deliberate indifference.”).

iii. Section 1983 Claim Against Dr. Rollings-Mazza

We next address the plaintiff’s §1983 claim against Dr. Rollings-Mazza. Judge

Saporito recommended that summary judgment be granted in favor of Dr. Rollings-Mazza,

and the plaintiff objects to Judge Saporito’s recommendation. For the reasons set forth

below, upon de novo review, it appears that there is sufficient evidence for the plaintiff’s

deliberate indifference claim against Dr. Rollings-Mazza to survive summary judgment.

In arguing that Dr. Rollings-Mazza acted with deliberate indifference to Carlos’s

particular vulnerability to suicide, the plaintiff points us to the following facts and evidence:

(1) Dr. Rollings-Mazza never considered any treatment plan, as required by ICE and

generally accepted standards of practice; (2) Dr. Rollings-Mazza never conducted a

suicide-risk assessment as required by PrimeCare and generally accepted standards of

practice; (3) following Carlos’s August 2013 suicide attempt, Dr. Rollings-Mazza initiated

no clinical review as required by PrimeCare, which was a step critical to determining the

reasons for Carlos’s actions; (4) Dr. Rollings-Mazza maintained the “status quo” and failed

to change Carlos’s medication regimen after the August 2013 suicide attempt. (Doc. 101-

1 at 47-48).

Additionally, the plaintiff cites to the respective post-suicide report prepared by ICE,

as well as the report and addendum prepared by Dr. Patterson. First, the plaintiff notes

that the ICE report identifies Dr. Rollings-Mazza’s failure to implement a treatment plan for

Carlos as required under ICE standards and PrimeCare policies. (Id. at 29-30). Second,

the plaintiff refers to Dr. Patterson’s report and addendum, in which Dr. Patterson

concluded that the mental health care provided to Carlos was deficient, that her suicide

was preventable, and that Dr. Rollings-Mazza acted improperly by viewing her role only as

monitoring medications and by failing to conduct treatment planning and suicide-risk

assessments for Carlos. 22 (Id. at 30).

We first address the plaintiff’s argument that Dr. Rollings-Mazza acted deliberately

indifferent by maintaining the “status quo” and failing to change Carlos’s medication

regimen after the August 2013 suicide attempt. Upon a review of pertinent authority, it

22 We note that there appears to be a factual dispute as to precisely what responsibilities Dr.

Rollings-Mazza’s bore as a psychiatrist in the Prison setting. As alluded to above, Dr.

Rollings-Mazza testified at her deposition that her primary responsibility at the Prison was

“medication management.” (Doc. 85-19 at 7, 9). On the other hand, Dr. Patterson

suggested in the addendum to his initial report that Dr. Rollings-Mazza acted improperly by

viewing her role only as monitoring medications, and that her role should also have

encompassed the preparation of treatment plans and suicide-risk assessments. (Doc. 85-

23 at 4). To the extent the factual dispute surrounding Dr. Rollings-Mazza’s precise job

responsibilities would impact a deliberate indifference determination, such factual dispute is

most appropriately resolved by a jury.

appears this alleged omission alone is insufficient to support a finding of deliberate

indifference. The instant case does not present a situation where Rollings-Mazza refused

to provide Carlos with mental health care, delayed treatment for a non-medical reason, or

prevented her from receiving recommended treatment. See Rouse, 182 F.3d at 197

(noting that the Third Circuit has found deliberate indifference in such circumstances).

Rollings-Mazza saw Carlos for multiple evaluations before and after her August 2013

suicide attempt, and based on her observations of Carlos, she reached the conclusion that

she was stable on her Haldol and that any disruptive or uncooperative behavior she

exhibited was prompted by factors other than her mental health issues. Even assuming

that Dr. Rollings-Mazza’s conclusions about Carlos’s medication amounted to bad

judgment or were erroneous, the Doctor’s failure to change Carlos’s medication regimen,

at worst, amounts to poor medical judgment or medical malpractice; this is not sufficient to

establish deliberate indifference or a constitutional violation. See id. at 197 (“It is well-

settled that claims of negligence or medical malpractice, without some more culpable state

of mind, do not constitute deliberate indifference.”); White v. Napoleon, 897 F.2d 103, 110

(3d Cir. 1990) (“If the doctor’s judgment is ultimately shown to be mistaken, at most what

would be prove[n] is medical malpractice.”); Estate of Thomas v. Fayette County, 194 F.

Supp. 3d 358, 373 (W.D. Pa. 2016) (“[A]n incorrect or negligent medical judgment . . .

does not give rise to deliberate indifference.”) (emphasis in original).

While a failure to change Carlos’s medication alone could not amount to deliberate

indifference, we conclude that the Doctor’s other alleged omissions, considered together,

are sufficient to present a question for a jury as to whether the Doctor acted with

deliberate indifference to Carlos’s particular vulnerability to suicide. There is evidence,

including post-suicide investigative reports, suggesting that Dr. Rollings-Mazza, like

Gallagher, violated various suicide-prevention policies. Most notably, despite the fact that

Carlos attempted suicide in August 2013, Dr. Rollings-Mazza appears to have violated

PrimeCare policy by failing to subsequently conduct a clinical review or take any other

steps to evaluate what led Carlos to take such a drastic action in the first instance. When

all of these facts are viewed in the light most favorable to the plaintiff, a reasonable juror

could conclude that Dr. Rollings-Mazza exhibited deliberate indifference to Carlos’s

particular vulnerability to suicide.

iv. Section 1983 Claim Against Nurse Leiphart

With regard to the plaintiff’s §1983 claim against Nurse Leiphart, Judge Saporito

recommended that summary judgment be granted in favor of Nurse Leiphart. The plaintiff

objects to that recommendation, and upon de novo review of the plaintiff’s claim a

reasonable juror could conclude that Nurse Leiphart acted with deliberate indifference.

The plaintiff asserts that Leiphart exhibited deliberate indifference to a particular

vulnerability to suicide because she observed an increase in Carlos’s agitation in the

weeks leading up to the suicide and failed to report this observation until after Carlos had

committed suicide. As noted above, a defendant can be considered to have acted with

deliberate indifference to a particular vulnerability to suicide if he or she disregarded that

vulnerability by failing to take reasonable measures to address it.

Nurse Leiphart was aware of Carlos’s August 2013 suicide attempt, and in

fact, she was present near Carlos’s cell right after Carlos had been cut down from her

hanging attempt. Leiphart recalled that at the time of the suicide attempt, Carlos was very

upset and was yelling and screaming that she wanted to talk to somebody about her

deportation status. When Carlos returned to the prison from the outside hospital, Nurse

Leiphart continued to see Carlos on a regular basis, and Leiphart observed an increase in

Carlos’s agitation in the weeks leading up to Carlos’s completed suicide. In spite of this,

Leiphart appears to have taken no action. As a result, it appears from the record that no

one other than Leiphart was aware of Carlos’s increasing agitation, and, therefore, no one

was alerted that action may be necessary to address that condition in a suicidal detainee.

A reasonable juror could find that given Carlos’s recent suicide attempt and her increasing

agitation in the immediate aftermath of that attempt, Nurse Leiphart should have taken

some action—i.e. reasonable steps—to address Carlos’s vulnerability to suicide. Given

that Nurse Leiphart took no action whatsoever, a reasonable juror could find that Nurse

Leiphart exhibited deliberate indifference to Carlos’s particular vulnerability to suicide.

Therefore, we will deny Nurse Leiphart’s motion for summary judgment.

v. Section 1983 Claim Against Deputy Warden Doll

We now turn to the plaintiff’s §1983 claim against Deputy Warden Doll, for which

Judge Saporito recommended granting summary judgment in favor of Doll. The court

agrees with Judge Saporito’s recommendation.

In asserting that Doll acted with deliberate indifference, the plaintiff cites to the

following facts and evidence: (1) Doll waited for more than two years to seek alternative

placement for Carlos; and (2) even though Doll knew that his decision to place Carlos in

ICU status in August 2013 led to her suicide attempt, Doll maintained Carlos in that exact

same status in October 2013 after Gallagher had removed Carlos from psychiatric

observation. (Doc. 101-1 at 52-53).

First, with regard to Doll’s alleged failure to seek alternative placement for Carlos for

two years, this alleged omission is insufficient to permit a reasonable juror to find

deliberate indifference. Doll testified that when he spoke with ICE Assistant Field Director

Joe Dunn to recommend alternative placement for Carlos, ICE ultimately declined Doll’s

recommendation. Thus, Doll had sought alternative placement for Carlos, but this request

was denied by ICE.

Second, no reasonable juror viewing the facts in the light most favorable to the

plaintiff and drawing all inferences in her favor could find that Doll acted with deliberate

indifference by maintaining Carlos on ICU status in October of 2013 after she was

removed from psychiatric observation by Gallagher.

Doll’s decision to maintain Carlos on ICU status was justified given her behavioral

history and difficulty living among the Prison’s general population. Taking all of these facts

into consideration, the court finds there is insufficient evidence from which a reasonable

juror may find that Doll acted with deliberate indifference to Carlos’s particular vulnerability

to suicide. Therefore, Doll’s motion for summary judgment will be granted.

vi. Section 1983 Claim Against Collins

We proceed to the plaintiff’s §1983 claim against Officer Collins. In objecting to

Judge Saporito’s recommendation that summary judgment be granted in favor of Collins,

the plaintiff contends that Collins exhibited deliberate indifference by failing to inform

mental health professionals or take other action to ensure Carlos’s safety after she

observed the argument between Carlos and the other inmate on the night of the suicide.

The plaintiff contends that Collins should have taken further protective action given that

she knew of Carlos’s emotional and reactive nature and that she was aware that the

argument with Cruz-Rivera upset Carlos. The court finds that the plaintiff has presented

insufficient facts from which a reasonable juror could find that Officer Collins acted with

deliberate indifference.

Collins was aware of Carlos’s volatile behavior throughout her period of incarceration

at the Prison. In her deposition, Collins herself recalled that Carlos became easily

agitated and could “fly off the handle” when she became agitated. Having this knowledge,

Collins personally witnessed the altercation between Carlos and Cruz-Rivera that occurred

on the night of Carlos’s completed suicide. During that altercation, Cruz-Rivera allegedly

suggested that Carlos kill herself. Collins recalled that Carlos was very upset and

therefore Collins appropriately spent time discussing the matter with her, calming her

down. She redirected Carlos’s attention from the incident toward other activities like

relaxing and listening to her radio. Based upon this isolated interaction, a reasonable juror

could not conclude that Collins disregarded a particular vulnerability to suicide by failing to

take any reasonable measures to address it, and, therefore, exhibited deliberate

indifference. Consequently, summary judgment will be granted as to Collins.

vii. Section 1983 Claim Against Jackson

Finally, we address the plaintiff’s §1983 claim against Counselor Jackson. As with

the other individual defendants, Judge Saporito recommended summary judgment be

granted in Jackson’s favor. Although the plaintiff similarly objects to this recommendation,

we have conducted a de novo review, and we agree with Judge Saporito’s

recommendation that summary judgment be granted in favor of Counselor Jackson.

The plaintiff asserts that Counselor Jackson exhibited deliberate indifference to

Carlos’s vulnerability to suicide because (1) she showed no willingness to constructively

address Carlos’s behavior; (2) she failed to discuss the August 2013 suicide attempt with

Carlos in her first encounter after that attempt; and (3) in October of 2013, two days prior

to the suicide, Jackson moved Carlos into a non-suicide-resistant cell on A pod—where

Carlos was housed at the time of her August 2013 suicide attempt—without first

consulting with mental health staff. For the reasons set forth below, we find that, as a

matter of law, there is insufficient evidence from which a reasonable juror could conclude

that Counselor Jackson acted with deliberate indifference.

To the extent that Counselor Jackson failed to show willingness to constructively

address Carlos’s behavior or failed to discuss Carlos’s August 2013 suicide attempt with

her, these alleged failures do not constitute deliberate indifference. Jackson testified that

she did not discuss the attempt with Carlos at subsequent contact reviews because she

believed that such discussions would be more appropriate for mental health staff. Given

that Jackson was a corrections counselor and was not trained as a mental health

professional, Jackson’s decision to refrain from discussing the suicide attempt has little, if

any, probative value for the issue at hand. Moreover, the record evidence suggests that

Jackson’s relationship with Carlos was not particularly cordial. Prior to the suicide

attempt, Jackson had previously attempted to conduct multiple contact reviews with

Carlos, but most were unproductive to Carlos’s failure to cooperate and communicate

amicably with Jackson. Given the strained relationship Jackson had with Carlos, it is far

from certain that any attempts by Jackson to discuss the sensitive issue of a suicide

attempt would have been constructive.

As for Jackson moving Carlos into a non-suicide resistant cell in A pod in October of

2013 without consulting mental health staff, we also find that such evidence is insufficient

to show deliberate indifference. Jackson testified that nothing required her to inform

mental health staff of the move because Carlos had been taken off psychiatric observation

status. Moreover, there is no evidence to suggest that Carlos was actively threatening to

harm herself at the time she was moved. Most importantly, the cell to which Carlos was

moved was essentially a carbon copy of her prior cell. Thus, even if Jackson had

informed mental health staff of the move, there is no evidence to suggest that mental

health staff would have prevented such a move or that the new cell was riskier than the

previous cell. Accordingly, when viewing the proffered evidence as a whole, the plaintiff

has failed to provide sufficient evidence from which a trier of fact could conclude that

Jackson acted with deliberate indifference to Carlos’s particular vulnerability to suicide.

Therefore, summary judgment will be granted in favor of Jackson.

viii. Qualified Immunity

In addition to arguing that the plaintiff’s claims failed on the merits, defendants Doll,

Collins, and Jackson also argued that they are entitled to summary judgment on the

ground of qualified immunity. Because Judge Saporito determined that none of those

defendants’ actions or omissions amounted to constitutional violations, he did not address

their qualified immunity argument. Since we agree with Judge Saporito’s analysis with

respect to Doll, Collins and Jackson, we need not address the qualified immunity

argument either.

f. Section 1983 Claims Against York County and PrimeCare

Having addressed the constitutional claims against the individual defendants, we now

turn to the plaintiff’s constitutional claims against York County and PrimeCare.

i. Section 1983 Claim Against York County

As discussed above, Section 1983 generally imposes liability upon any “person,”

acting under color of state-law, who violates a plaintiff’s constitutional rights. The courts

though have made it clear that the word “person,” as used in Section 1983, does not

merely encompass natural persons. For example, in Monell v. New York City Dept. of

Social Servs., 436 U.S. 658 (1978), the Supreme Court held that a municipality constitutes

a “person” under Section 1983. Id. at 690. However, pursuant to the holding in Monell, “a

municipality cannot be held liable under §1983 on a respondeat superior theory.” Id. at

691. Rather, a municipality will only be held liable “when execution of a government’s

policy or custom, whether made by its lawmakers or by those whose edicts or acts may

fairly be said to represent official policy, inflicts the injury” of which a plaintiff complains.

Id. at 694; see also Estate of Bailey by Oare v. County of York, 768 F.2d 503, 507 (3d Cir.

1985) (“Only if there is a plausible nexus between the policy or established state

procedure and the infringement of constitutional rights can a §1983 action be

maintained.”).

“A government policy or custom can be established in two ways.” Andrews v. City of

Philadelphia, 895 F.2d 1469, 1480 (3d Cir. 1990). First, “policy is made when ‘a

decisionmaker possess[ing] final authority to establish municipal policy with respect to the

action’ issues an official proclamation, policy, or edict.’” Id. (alteration in original) (quoting

Pembaur v. City of Cincinnati, 475 U.S. 469, 481 (1986)). Second, “[a] course of conduct

is considered to be a ‘custom’ when, though not authorized by law, ‘such practices of state

officials [are] so permanent and well settled’ as to virtually constitute law.” Id. (second

alteration in original) (citing Monell, 436 U.S. at 691).

As a threshold matter, we must address whether York County is an appropriate

defendant in the instant matter. The County asserts that pursuant to Pennsylvania

statute, the sole responsibility for the government and management of YCP is exclusively

vested in an independent body referred to as the York County Prison Board, which is not

operated or controlled by the County. The County thus argues that it cannot be held liable

for the Prison Board’s policies or decision making.

In his report and recommendation, Judge Saporito concluded that the County was an

appropriate defendant. In reaching that conclusion, Judge Saporito reasoned that “the

weight of authority . . . holds that the county may be held liable under Monell for policies

implemented by the county prison board.” (Doc. 94 at 60 n.17). Judge Saporito cited to

Barry v. Luzerne County, 447 F. Supp. 2d 438, 451 (M.D. Pa. 2006), in which this court

held that a county “cannot immunize itself from constitutional harm that its policies cause

merely by delegating the authority to create the policy to an independent board.”

The County argues that the instant matter is distinguishable from Barry and that,

therefore, Judge Saporito’s reliance upon that case was misplaced. Specifically, the

County avers as follows:

This is not a question of the County immunizing itself from

constitutional harm that its policies caused merely by delegating

the authority to create the policy to an independent Board. In

this case, the Board was established by the Commonwealth of

Pennsylvania. It is the State Legislature that enacted the statue

which creates the Prison Board and delegates specific authority

to be responsible for the government and management of the

prison.

(Doc. 98 at 7).

Having reviewed the County’s argument, Judge Saporito’s report, and the pertinent

law, we agree with Judge Saporito’s conclusion that the County is an appropriate

defendant in the instant matter. A review of case law reveals that this court previously

rejected an argument practically identical to that raised by York County. In Bills v. Monroe

County, No. 3:05cv1403, 2007 WL 2907932 (M.D. Pa. Sept. 28, 2007), defendant Monroe

County asserted the following argument: “[I]t is the Prison Board that possesses the

statutory authority to establish the policies, customs and training in effect at the [Monroe

County Correctional Facility]. Therefore, the County cannot be held liable for those

policies, customs and training.” Id. at *2. The court, however, rejected that argument, and

denied Monroe County’s motion for summary judgment on the County’s liability as a

municipality. Id. The court reasoned that “the Prison Board was the authorized

decisionmaker possessing authority to establish municipal policy with regard to the prison,

and the County can be bound based on the Board’s official proclamations, policies, or

edicts.” Id. Thus, we are unable to conclude that York County is an inappropriate

defendant merely because the Prison Board is the entity responsible for government and

management of YCP.

Having determined that York County is an appropriate party, we must now determine

whether the plaintiff’s constitutional claims against the County survive the motion for

summary judgment on the merits. Judge Saporito recommended that summary judgment

be granted in favor of the County. The plaintiff objects to Judge Saporito’s

recommendation, claiming that York County should be held liable for its failure to follow its

own written policy requiring a mortality review committee evaluation of all suicide attempts.

We disagree with the plaintiff and will overrule her objection.

The plaintiff does not allege that a County policy itself caused a constitutional

violation. Rather, the plaintiff contends that the County’s failure to follow a particular

requirement of its own suicide-prevention policy—namely that which requires mortality

reviews after suicide attempts—amounted to a constitutional violation. First, plaintiff’s

claim against the County could be based upon a “custom” theory, i.e., that the County had

a “custom” of failing to conduct mortality reviews following suicide attempts at YCP and

that this custom led to Carlos’s death by suicide.

As noted by Judge Saporito in his report and recommendation, the Third Circuit in

Colburn I held that “a custom of laxity regarding the supervision and monitoring of their jail

cells and in searching individuals taken into police custody,” which led to a detainee’s

suicide utilizing a concealed firearm, amounted to an “official policy.” 838 F.2d at 671.

The court reasoned that the detainee had been the third inmate in three years to commit

suicide at the subject prison, and, therefore, this was sufficient to provide the municipality

and its governing officials with actual or constructive knowledge of the alleged custom of

inadequate monitoring of jail cells. Id. at 672.

The instant matter is distinguishable from Colburn I, however. The plaintiff has put

forth no facts to suggest that York County or its governing officials should have been

aware of a custom of failing to conduct mortality reviews subsequent to suicide attempts.

There are also no facts to suggest that failure to conduct such reviews had been a

widespread practice prior to Carlos’s suicide attempt or that such practice had led to other

prison suicides. Consequently, we find that York County cannot be subject to municipal

liability based on custom or policy.

The plaintiff asserts that even if there were no prior incidents giving the County

notice of a policy deficiency or problematic custom, this provides no basis for summary

judgment. The plaintiff argues that the instant case is one where “a municipality may be

liable [for a single incident] for failure to implement appropriate policies when it is obvious

that its failure could lead to constitutional violations.” (Doc. 101-1 at 59).

In raising this assertion, the plaintiff cites Thomas v. Cumberland County, 749 F.3d

217 (3d Cir. 2014), which allowed a Monell claim to proceed based on a single incident of

a constitutional violation caused by a County’s failure to train correctional officers in de-

escalating inmate conflicts. The Thomas court noted that in order for a municipality to be

held liable based on a single incident of a constitutional violation, a plaintiff must show

either: (1) the existence of a “pattern of violations [that] puts municipal decisionmakers on

notice that a new program is necessary”; or (2) that “the need for training [is] so obvious

that failure to do so could properly be characterized as deliberate indifference to

constitutional rights even without a pattern of constitutional violations.” Id. at 223 (internal

quotations marks omitted) (citing City of Canton v. Harris, 489 U.S. 378, 390 n.10 (1989)).

Thomas, however, is distinguishable from the instant matter. Here, there is no

evidence to suggest that the County knew that its policies were being ignored, as there

was no “pattern of violations” to put the municipal decisionmakers on notice. Moreover,

this is not a case where the County failed to institute a policy or provide training—the

mortality review policy had been instituted. But just because county employees failed to

follow that policy in this case does not automatically result in Monell liability for York

County. Rather, the Third Circuit has found that isolated incidents in which county

employees fail to follow a facially appropriate municipal policy generally do not impose

liability upon the municipality itself. See, e.g., Rago v. City of Pittsburgh, 429 F. App’x 86,

89 (3d Cir. 2011) (nonprecedential) (affirming summary judgment in favor of defendant

municipality in §1983 action where plaintiff “produced no evidence that anything other than

a one-time failure to follow municipal policy occurred”); Talbert v. Kelly, 799 F.2d 62, 67

(3d Cir. 1986) (noting that in §1983 actions against governmental agencies, “the

carelessness of an employee in failing to follow a policy . . . may establish the negligence

of the employee but does not fasten liability on the governmental agency.” (quoting

Kranson v. Valley Crest Nursing Home, 755 F.2d 46, 51 (3d Cir. 1985))). Therefore, the

plaintiff has provided insufficient evidence to create a genuine dispute of material fact

regarding municipal liability for York County. As such, summary judgment will be entered

against plaintiff on the constitutional claims against York County.

ii. Section 1983 Claim Against PrimeCare

As is the case with municipalities, under §1983, “a private corporation contracted by

a prison to provide healthcare for inmates cannot be held liable on a respondeat superior

theory; rather, pursuant to [Monell], a private corporation can be held liable for

constitutional violations only if it has a custom or policy exhibiting deliberate indifference to

a prisoner’s serious medical needs.” Gannaway v. Prime Care Medical, Inc., 150 F. Supp.

3d 511, 530 (E.D. Pa. 2015) (citing Natale, 318 F.3d at 583-84). Thus, since the courts

have recognized a particular vulnerability to suicide as a serious medical need, PrimeCare

may be held liable in the instant matter if the plaintiff shows that it has a custom or policy

exhibiting deliberate indifference to prisoners’ particular vulnerabilities to suicide.

Like her claim against York County, the plaintiff’s §1983 claim against PrimeCare

arises primarily out of PrimeCare’s alleged failure to follow its own suicide-prevention

policies. Specifically, the plaintiff avers that PrimeCare failed to ensure that its mental

health clinicians at YCP were complying with the policy’s requirement that a

comprehensive clinical review be conducted in all situations involving suicide attempts and

completed suicides, and that remedial action be taken. The plaintiff claims that

PrimeCare’s failure to comply with these requirements after Carlos’s August 2013 suicide

attempt led to her completed suicide in October 2013.

However, we find that the record is devoid of facts to suggest that PrimeCare could

be found liable under §1983 based on the failures of its employees to follow its suicide

prevention policies. The plaintiff does not specifically allege a failure to train or implement

critical policies, nor does she point to any facts specifically showing that there was a

pattern of policy violations that would have made PrimeCare aware of policy-

implementation deficiencies. Therefore, we agree with Judge Saporito’s recommendation

that summary judgment be granted in favor of PrimeCare with respect to the plaintiff’s

federal constitutional claims.

g. State-Law Claims Against Rollings-Mazza, Gallagher,

Leiphart, and PrimeCare

Having determined that the plaintiff’s federal constitutional claims were all meritless,

Judge Saporito recommended that this Court decline to exercise supplemental

jurisdiction23 over the remaining state-law claims because there is “nothing in the record to

distinguish this case from the ordinary one.” (Doc. 94 at 68). However, since we have

23 A district court may decline to exercise supplemental jurisdiction over a state-law claim if

the court “has dismissed all claims over which it has original jurisdiction.” 28 U.S.C.

§1367(c)(3).

found that there is sufficient evidence to permit at least some of the plaintiff’s federal

constitutional claims to go to a jury, we will not adopt Judge Saporito’s recommendation,

and instead continue to exercise supplemental jurisdiction over the plaintiff’s state-law

claims.

As stated above, Count III of the plaintiff’s amended complaint consists of medical

negligence claims against defendants Gallagher, Rollings-Mazza, Leiphart, and

PrimeCare.24 Moreover, the plaintiff raises state-law claims for punitive damages against

all of the individual defendants. Leiphart and Gallagher have moved for summary

judgment on the plaintiff’s medical negligence claim. Additionally, Leiphart, Rollings-

Mazza, and Gallagher have moved for summary judgment on the plaintiff’s claims for

punitive damages.

i. Medical Negligence Claims

Under Pennsylvania law, a plaintiff claiming medical negligence “must establish a

duty owed by the physician or medical personnel to the patient, a breach of that duty, that

the breach was the proximate cause of the plaintiff’s injury, and that the damages suffered

were a direct result of the harm.” Rodriguez v. United States, Civil Action No. 3:14-1149,

2016 WL 4480761, at *4 (M.D. Pa. Aug. 23, 2016) (citing Toogood v. Owen J. Rogal,

D.D.S., P.C., 824 A.2d 1140, 1145 (Pa. 2003)). “In addition, ‘[w]ith all but the most self-

evident medical malpractice actions there is also the added requirement that the plaintiff

24 Count III of the amended complaint also raised state-law medical negligence claims

against Davis, Snyder, and Medical John Does 1-10. As explained above, however, Davis

was already terminated as a defendant from this action, and all of the plaintiff’s claims

against Snyder will be dismissed as we deem them to be abandoned. Moreover, the claims

against Medical John Does 1-10 will be dismissed because the plaintiff has failed to amend

her complaint to identify the Medical John Does despite an ample period of discovery.

must provide a medical expert who will testify as to the elements of duty, breach, and

causation.’” Id. (quoting Quinby v. Plumsteadville Family Practice, Inc., 907 A.2d 1061,

1070-71 (Pa. 2006)).

The plaintiff has presented a report and addendum prepared by Dr. Raymond F.

Patterson, a Board certified forensic psychiatrist. As discussed above, Dr. Patterson

concluded in his original report that “to a reasonable degree of medical certainty . . . . the

mental health care, treatment, and management provided by PrimeCare Inc., and the York

County Prison did not meet the standard of care for mental health care in similar situations

and institutions, and indeed reflected negligence and deliberate indifference.” (Doc. 85-22

at 11). Moreover, in the report, Dr. Patterson found “to a reasonable degree of medical

certainty that [Carlos’s] suicide was foreseeable and preventable.” (Id. at 14-15). In Dr.

Patterson’s subsequent addendum, which was prepared after discovery, he affirmed his

previous findings of negligence and deliberate indifference; in doing so, Dr. Patterson

specifically referenced the omissions of Rollings-Mazza, Leiphart, and Gallagher, as

gleaned from a review of those defendants’ depositions. (See Doc. 85-23 at 4-5). Based

on Dr. Patterson’s opinion, a reasonable juror could conclude that Leiphart and Gallagher

breached the pertinent standard of care for mental health patients in prisons, and that this

breach was the proximate cause of Carlos’s injury.

Considering the foregoing, it appears that the plaintiff has presented sufficient

evidence to survive summary judgment on the medical negligence claims against Leiphart

and Gallagher. Therefore, to the extent Leiphart and Gallagher move for summary

judgment on the plaintiff’s state-law medical negligence claims, we will deny summary

judgment on those claims.

ii. Claims for Punitive Damages

To the extent Leiphart, Rollings-Mazza, and Gallagher move for summary on

the plaintiff’s claims for punitive damages, those motions will also be denied at this time.

Punitive damages may be awarded when “the defendant’s conduct is shown to be

motivated by evil motive or intent, or when it involves reckless or callous indifference to

the federally protected rights of others.” Tenon v. Dreibelbis, 190 F. Supp. 3d 412, 418

(M.D. Pa. 2016) (quoting Smith v. Wade, 461 U.S. 30, 56 (1983)). Because “the standard

to show ‘deliberate indifference’ is substantially the same as the standard to show

‘reckless or callous indifference,’” courts have typically held that a claim for punitive

damages should survive provided that a plaintiff sets forth a cognizable deliberate

indifference claim. See id. (collecting cases). Thus, since there are sufficient facts from

which a reasonable juror could find deliberate indifference on the part of Leiphart,

Rollings-Mazza, and Gallagher, it follows that the plaintiff’s claims for punitive damages

against those defendants likewise survive summary judgment.

V. Conclusion

As set forth in further detail above, the plaintiff’s objections to Judge Saporito’s report

and recommendation will be sustained in part and overruled in part, and York County’s

objection to the report and recommendation will be overruled. An appropriate order with

further details will follow.

s/Malachy E. Mannion

MALACHY E. MANNION

United States District Judge

Date: December 9, 2019