# Carlos v. York County

> District Court, M.D. Pennsylvania · December 9, 2019

URL: https://www.frixlaw.com/law-library/cases/10408057

## Case

- **Court:** District Court, M.D. Pennsylvania
- **Decided:** December 9, 2019
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/10408057

## How later opinions describe it (automated extraction)

- acknowledging the Freedman holding in the context of a pretrial-detainee case
- noting that the Third Circuit has found deliberate indifference in such circumstances

## Opinion text

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 t

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10408057. Public record. Not legal advice.