Dominick Perniciaro, III v. Hampton Lea

Case: 17-30161 Document: 00514603781 Page: 1 Date Filed: 08/16/2018

IN THE UNITED STATES COURT OF APPEALS

FOR THE FIFTH CIRCUIT

United States Court of Appeals

Fifth Circuit

No. 17-30161 FILED

August 16, 2018

Lyle W. Cayce

DOMINICK PERNICIARO, III, Clerk

Plaintiff - Appellee

v.

HAMPTON "STEVE" LEA, M.D., In his individual and official capacity as

administrator and/or employee of Eastern Louisiana Mental Health System

("ELMHS"); JEFFREY S. NICHOLL, M.D., In his individual and official

capacity as administrator and/or employee of Eastern Louisiana Mental

Health System ("ELMHS"); JOHN W. THOMPSON, M.D., In his individual

and official capacity as administrator and/or employee of Eastern Louisiana

Mental Health System ("ELMHS"),

Defendants - Appellants

Appeal from the United States District Court

for the Middle District of Louisiana

Before HIGGINBOTHAM and HIGGINSON, Circuit Judges. *

STEPHEN A. HIGGINSON, Circuit Judge:

Dominick Perniciaro, III, who suffers from schizophrenia, has been

committed to the Eastern Louisiana Mental Health System (“ELMHS”) since

* Judge Edward C. Prado, a member of our original panel, retired from the court on

April 2, 2018, to become His Excellency the United States Ambassador to the Argentine

Republic. He therefore did not participate in this matter, which is decided by a quorum. See

28 U.S.C. § 46(d).

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he was arrested for battery and found incompetent to stand trial in 2013. He

has sustained numerous injuries throughout his commitment—some minor,

some more serious—as a result of physical altercations with other patients and

with guards. He filed suit under 42 U.S.C. § 1983, alleging that he received

inadequate medical care and that defendants—his treating psychiatrist (Dr.

Jeffrey Nicholl), ELMHS’s chief of staff (Dr. John Thompson), and its chief

executive officer (Hampton “Steve” Lea)—failed to protect him from harm.

Only Lea is a state employee. The other defendants are psychiatrists employed

by Tulane University who provide services at ELMHS pursuant to a contract

between Tulane and the state. All three defendants moved for summary

judgment on the basis of qualified immunity. The district court held that the

Tulane-employed defendants could raise the defense, but held that none were

entitled to summary judgment. We agree that the Tulane-employed

defendants may raise qualified immunity, but reverse the denial of summary

judgment. Viewing the evidence in the light most favorable to Perniciaro, he

has failed to establish that defendants violated his clearly established rights.

I.

A.

Perniciaro’s schizophrenia manifests in symptoms such as auditory

hallucinations, paranoia, delusions, and aggression. He suffers from violent

outbursts that occur without warning or apparent provocation. Due largely to

the unpredictability of his aggressive and assaultive behavior, his doctors have

described him as a “challenging” or “very difficult” patient to treat. He has

been committed to ELMHS, a mental-health facility owned and operated by

the Louisiana Department of Health, since his arrest for battery in 2013. He

was found incompetent to stand trial and committed to ELMHS for competency

2

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restoration. 1 When deemed competent to stand trial by his treating

psychiatrist in 2014, he was discharged to the Jefferson Parish Prison but was

again found incompetent by the state court and recommitted to ELMHS. One

year later, after again being deemed competent to stand trial, he was found not

guilty by reason of insanity. He was recommitted to ELMHS for treatment

until no longer dangerous to himself and others.

ELMHS is a state-run facility, but the state has contracted out the

provision of psychiatric services to Tulane University. 2 As with all

psychiatrists at ELMHS, Perniciaro’s treating psychiatrist, Dr. Jeffrey Nicholl,

is an employee of Tulane, where he serves as a professor of clinical psychiatry

and neurology. 3 In addition to his teaching duties, he maintains a caseload of

12 to 13 patients at ELMHS. As Perniciaro’s treating psychiatrist, Dr. Nicholl

was the leader of Perniciaro’s treatment team and was responsible for

developing and updating a holistic treatment plan for Perniciaro’s mental and

physical health. Dr. Nicholl was also responsible for making decisions related

to Perniciaro’s physical safety, such as separating him from other patients

following physical altercations or placing him on some form of restrictive

observation as needed.

Dr. John Thompson is the chief of staff at ELMHS. Like Dr. Nicholl, Dr.

Thompson is an employee of Tulane University. He is the chair of the

1 All patients at ELMHS, including Perniciaro, have been committed to the facility by

court order. It is the only facility in the state that treats persons who are found incompetent

to stand trial or not guilty by reason of insanity.

2 Pursuant a contract between Tulane and the state, the university provides ELMHS

with a medical director or chief of staff, two clinical directors, and some number of

psychiatrists, depending on ELMHS’s needs. The contract covers three-year terms but is

updated annually to reflect the institution’s needs and budget.

3 Perniciaro was assigned a new treating psychiatrist, Dr. John Roberts, upon his

third admission to ELMHS after being found not guilty by reason of insanity. Dr. Nicholl,

however, served as Perniciaro’s treating psychiatrist throughout Perniciaro’s first and second

admissions, which form the basis of this lawsuit.

3

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Department of Psychiatry at Tulane, but works at ELMHS several days per

week pursuant to Tulane’s contract with the state. As chief of staff, Dr.

Thompson oversees the provision of all medical and psychological care. He

supervises both the psychiatric doctors, who are not state employees, and the

medical doctors and nursing staff, who are. Dr. Thompson reports to Steve

Lea, the chief executive officer of ELMHS. Lea, who is employed directly by

the state, is responsible for overseeing operations at ELMHS, including

ensuring that all state policies are followed.

ELMHS has a policy of minimizing the use of physical restraints as a

means of preventing patients from harming themselves and others.

Accordingly, ELMHS uses alternative measures to deescalate and monitor

patients when they are agitated or likely to become violent. In acute

situations, patients are given an injection of medication to immediately calm

them down. If the medication fails to calm them down and they remain an

immediate danger to themselves or others, then physical restraints may be

used. Patients who present a continuous risk of hurting themselves or others

are monitored pursuant to either arm’s-length observation (“ALO”), meaning

that one or two guards must remain within an arm’s length of the patient, 4 or

close-visual observation (“CVO”), which requires a guard to remain within 15

feet of the patient and maintain the patient within sight at all times.

1.

Almost immediately after he was first admitted in 2013, Perniciaro was

involved in numerous physical altercations with treatment providers, guards,

and other patients. In light of his violent outbursts, Dr. Nicholl placed

Perniciaro on ALO within one day of his admission. A few weeks later, while

4 Even while on ALO, however, patients are typically given a little more space while

in the bathroom or while sleeping.

4

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the guards assigned to monitor him assisted with another violent patient,

Perniciaro ran out of his room and repeatedly struck another patient, referred

to as Patient 3800, in the face. Following that incident, Dr. Nicholl spoke to

Patient 3800, who denied any feelings of revenge. Perniciaro remained on ALO

for approximately three months, at which point he had not had a violent

incident in seven weeks. Dr. Nicholl then downgraded Perniciaro from ALO to

CVO. He also prescribed various medications for Perniciaro, adjusting them

frequently based on Perniciaro’s level of violence.

By March 2014, Perniciaro had not been involved in any violent behavior

in nearly three months. He was taken off CVO, deemed competent to stand

trial by Dr. Nicholl, and discharged to the Jefferson Parish Prison. While at

the jail, Perniciaro apparently stopped taking his medication and was involved

in one physical altercation, which he said was in self defense. He was again

found incompetent to stand trial by the state court and ordered to return to

ELMHS.

2.

Upon Perniciaro’s readmission to ELMHS, he was evaluated by Dr.

Nicholl, who found him to be “quite coherent” with “fairly good” judgment. He

was also evaluated by two psychologists who found him to be “fairly stable.” It

appears Perniciaro went for about two weeks without incident after his

readmission. However, that ended early one morning in April 2014, when

Patient 3800 ran into Perniciaro’s room after asking to go to the water fountain

and hit him in the face. Perniciaro suffered a black eye, bloody lip, and

fractured jaw. He was sent to the hospital for treatment, including surgery to

repair his jaw. He returned to ELMHS a few days later, and was placed on a

liquid diet and ALO for medical purposes in order to prevent choking.

According to Dr. Nicholl, Perniciaro was “very different when he came back

5

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from the hospital,” possibly because he “may not have gotten his medications”

while hospitalized.

Following his return from the hospital, Perniciaro was involved in a

number of physical altercations. For example, on one occasion about two

months after his return, he struck one guard in the face, punched another in

the groin, and attempted to attack a third. That day, the justification for his

ALO was changed from “medical” to “assaultive behavior towards others.” On

another occasion, Perniciaro hit one guard in the jaw and attempted to bite

and scratch the eyes of another. He was also involved in physical altercations

with other patients. In the vast majority of such altercations, Perniciaro was

indicated as the aggressor.

On one occasion, Perniciaro reported that “they” (apparently referring to

guards) had attacked him the night before. He had bruising on his arms,

knuckles, hips, chest, and legs, which a doctor determined likely resulted from

the use of manual holds to break apart physical altercations. Nonetheless, in

light of Perniciaro’s allegations, a report was made to Adult Protection

Services, a division of the Office of Aging and Adult Services (“OAAS”), which

is itself part of the Department of Health and Hospitals. During OAAS’s

investigation, two guards disclosed that Perniciaro’s injuries may have been

caused by an unreported incident that occurred the day before Perniciaro

claimed to have been attacked. The guards disclosed that they had been trying

to keep Perniciaro in his room while he tried to push his way out and, in the

course of the struggle, Perniciaro’s hip and leg were caught between the door

and door frame as the guards tried to push the door closed. Following its

investigation, OAAS generated a report that was reviewed by an investigative

review committee and CEO Lea. After reviewing the report, the committee

and Lea found the allegations of abuse to be unsubstantiated.

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At some point, Perniciaro developed a shoulder injury. The first report

of a shoulder injury occurred in July 2014, when Perniciaro lost his balance

running out of his room, slipped, and fell, hitting his left shoulder on the

ground. He complained of severe shoulder pain and was examined by a medical

doctor who did not detect any serious injury or disfigurement but ordered x-

rays to confirm. The x-rays did not indicate any injury. During a medical exam

about a month later, Perniciaro’s left shoulder was found to have a possible old

dislocation injury. Subsequent x-rays indicated a displacement and injury to

ligaments in the shoulder. A medical exam a few weeks later noted a possible

separation of the acromioclavicular (“AC”) joint, but found no intervention

necessary at that time. At another exam a few weeks after that, Perniciaro did

not complain of any pain with shoulder movement. The medical report from

that exam notes that “AC Separation Type III can be managed conservatively”

and indicates that the treating physician would prescribe pain killers if

Perniciaro ever complained of shoulder pain. A few days later, Perniciaro was

sent to physical therapy, but the therapist concluded that physical therapy

would likely not be helpful at that time. Perniciaro was then referred to an

orthopedic specialist for a consultation. 5

Concerned about his son’s injuries, Perniciaro’s father, Dominick

Perniciaro, Jr., called Lea in the fall of 2014 to discuss Perniciaro’s shoulder.

Lea then observed Perniciaro’s shoulder himself, spoke with one of the ELMHS

medical doctors about the treatment Perniciaro was receiving for the injury,

and then reported back to Perniciaro, Jr. Perniciaro, Jr. filed an official

complaint regarding his son’s treatment. The Total Quality Management

department at ELMHS responded to the complaint by noting that Lea had

5 Because Perniciaro was discharged in December 2014 when he was deemed

competent to stand trial, he did not see the orthopedic specialist until his return to ELMHS

in June 2015 after being found not guilty by reason of insanity.

7

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already addressed Perniciaro, Jr.’s concerns and that the administration was

still investigating. 6

In early November 2014, Dr. Nicholl started Perniciaro on a new

medication. Dr. Nicholl had been wary of prescribing the drug due to its risk

of serious side effects. After trying various other drugs, however, he concluded

that it was worth the risk because nothing else was able to manage Perniciaro’s

psychosis and violent tendencies without rendering him overly sedated.

Within one week of starting the new drug, Dr. Nicholl described Perniciaro’s

progress as “nearly unbelievable.” Perniciaro was deemed competent to stand

trial in December 2014.

3.

Perniciaro stood trial and was found not guilty by reason of insanity. He

was readmitted to ELMHS in June 2015, and was assigned a new treating

psychiatrist. 7 In July, he was seen by an orthopedic specialist, who confirmed

an AC separation. The specialist stated in his notes from the exam that

“[l]iterature supports treating Grade III AC separation non-operatively,” and

that “AC repair is controversial” and “not recommend[ed].”

B.

Perniciaro initiated this § 1983 action in April 2015, alleging that

defendants failed to maintain reasonably safe conditions of confinement and

that the medical care he had received at ELMHS fell below the level required

under the Fourteenth Amendment. The parties filed cross motions for

summary judgment, which the district court denied. As is relevant here, the

district court held that although defendants—including the privately employed

6 It appears, however, that the investigation into the incident had already been

concluded.

7 It is unclear whether the change in Perniciaro’s treating psychiatrist was due to

random assignment or to this litigation.

8

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Drs. Nicholl and Thompson—were entitled to assert the defense of qualified

immunity, issues of material fact precluded summary judgment on that

defense. Defendants timely appealed.

II.

We must first decide whether we have jurisdiction over this interlocutory

appeal. “Ordinarily, we do not have jurisdiction to review a denial of a

summary judgment motion because such a decision is not final within the

meaning of 28 U.S.C. § 1291.” Palmer v. Johnson, 193 F.3d 346, 350 (5th Cir.

1999). However, the “denial of qualified immunity on a motion for summary

judgment is immediately appealable if it is based on a conclusion of law.” Id.

(citing Johnson v. Jones, 515 U.S. 304 (1995)). Perniciaro argues that

immediate appeal is foreclosed here because the district court’s decision was

based not on a conclusion of law but on its finding genuine disputes of material

fact. See Johnson, 515 U.S. at 313 (“[T]he District Court’s determination that

the summary judgment record in this case raised a genuine issue of fact . . .

was not a ‘final decision’ within the meaning of [28 U.S.C. § 1291].”).

But as the Supreme Court clarified in Behrens v. Pelletier, 516 U.S. 299

(1996), the “[d]enial of summary judgment often includes a determination that

there are controverted issues of material fact, and Johnson surely does not

mean that every such denial of summary judgment is nonappealable.” Id. at

312–13 (citation omitted). Although we lack jurisdiction to consider “whether

there is enough evidence in the record for a jury to conclude that certain facts

are true,” we do have jurisdiction “to decide whether the district court erred in

concluding as a matter of law that officials are not entitled to qualified

immunity on a given set of facts.” Kinney v. Weaver, 367 F.3d 337, 347 (5th

Cir. 2004) (en banc).

Accordingly, we have jurisdiction to review whether—taking Perniciaro’s

summary judgment evidence as true—defendants’ “course of conduct [is]

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objectively unreasonable in light of clearly established law.” Id. at 347. Within

that narrow universe, our review is de novo. Id. at 349.

III.

A.

One more precursory issue requires our attention. Before addressing

whether defendants are entitled to qualified immunity, we must decide

whether Drs. Thompson and Nicholl are eligible to assert the defense at all.

Perniciaro argues that they are not because they are not state employees.

Under the facts of this case, however, we hold that Drs. Thompson and Nicholl

may raise the defense of qualified immunity even though they are not directly

employed by the state.

Private actors may, under some circumstances, be liable under § 1983,

see West v. Atkins, 487 U.S. 42, 54–57 (1988), but it does not necessarily follow

that they may assert qualified immunity, see Wyatt v. Cole, 504 U.S. 158, 168–

69 (1992). Whether they may depends on two things: (1) principles of tort

immunities and defenses applicable at common law around the time of § 1983’s

enactment in 1871 and (2) the purposes served by granting immunity. Filarsky

v. Delia, 566 U.S. 377, 383–84 (2012) (holding that a private attorney retained

by a county to perform government work may assert qualified immunity);

Richardson v. McKnight, 521 U.S. 399, 403–04 (1997) (holding that prison

guards employed by a private prison-management firm are not entitled to

assert qualified immunity).

Circuits are divided on whether privately employed doctors who provide

services at prisons or public hospitals pursuant to state contracts are entitled

to assert qualified immunity. Compare McCullum v. Tepe, 693 F.3d 696 (6th

Cir. 2012) (no immunity for privately paid physician working at county prison),

Jensen v. Lane Cty., 222 F.3d 570 (9th Cir. 2000) (no immunity for privately

employed psychiatrist providing services at public psychiatric hospital), and

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Hinson v. Edmond, 192 F.3d 1342 (11th Cir. 1999) (no immunity for privately

employed physician providing services at county jail), with Estate of Lockett ex

rel. Lockett v. Fallin, 841 F.3d 1098 (10th Cir. 2016) (immunity for privately

employed physician providing services at state penitentiary). 8 After

considering the facts of this case in light of the history and purposes of

immunity, we find the cases disallowing immunity distinguishable and hold

that Drs. Thompson and Nicholl may assert the defense of qualified immunity.

1.

At common law, courts “did not draw a distinction between public

servants and private individuals engaged in public service in according

protection to those carrying out government responsibilities.” Filarsky, 566

U.S. at 387. Because § 1983 was not intended to abrogate well-established

common-law protections, id. at 383–84, it follows that “immunity under § 1983

should not vary depending on whether an individual working for the

government does so as a full-time employee, or on some other basis,” id. at 389.

Accordingly, the Supreme Court held in Filarsky that general principles of

immunity at common law supported the right of a private attorney to assert

qualified immunity where he had been retained by a municipality on a

temporary basis to assist in an internal investigation. See id. at 381, 384–89.

Here, as in Filarsky, see id. at 381, Drs. Thompson and Nicholl are

private individuals who work in a public institution and alongside government

employees, but who do so as something other than full-time public employees.

And here, as in Filarsky, see id. at 383, it is clear that their public counterparts

would be entitled to assert qualified immunity, see Domino v. Tex. Dep’t of

Criminal Justice, 239 F.3d 752, 753 (5th Cir. 2001); Dolihite v. Maughon ex rel.

8 Although we have not previously decided the issue in a published opinion, we did

decide in Bishop v. Karney, 408 F. App’x 846 (5th Cir. 2011), that a privately employed

psychiatrist providing services at a state prison could assert qualified immunity.

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Videon, 74 F.3d 1027, 1032–33 (11th Cir. 1996). Accordingly, as in Filarsky,

general principles of immunity at common law support the right of Drs.

Thompson and Nicholl to raise the defense of qualified immunity. 9

2.

The purposes of qualified immunity also weigh in favor of permitting

Drs. Thompson and Nicholl to seek its protection. The Supreme Court has

identified three purposes served by qualified immunity: (1) preventing

unwarranted timidity in the exercise of official duties; (2) ensuring that highly

skilled and qualified candidates are not deterred from public service by the

threat of liability; and (3) protecting public employees—and their work—from

9 We note that while the Ninth and Eleventh Circuits reached contrary conclusions in

Jensen and Hinson, respectively, they did so before the Supreme Court decided Filarsky.

Accordingly, they followed Richardson’s lead and framed the relevant question as whether

there was a firmly-rooted tradition of immunity for private doctors performing some

government-related function. See Jensen, 222 F.3d at 576–77; Hinson, 192 F.3d at 1345; see

also Richardson, 521 U.S. at 404 (framing relevant historical inquiry as whether there was

“a ‘firmly rooted’ tradition of immunity applicable to privately employed prison guards”).

Finding no tradition of immunity even for doctors working directly for the state, the Ninth

and Eleventh Circuits concluded that history did not support immunity for the privately

employed doctors there at issue. See Jensen, 222 F.3d at 577; Hinson, 192 F.3d at 1345–46.

But Richardson considered only the issue of qualified immunity for prison guards

employed by and working at a private prison; it explicitly did not consider the more nuanced

question of whether a person “briefly associated with a government body, serving as an

adjunct to government in an essential governmental activity, or acting under close official

supervision” would be entitled to assert immunity. 521 U.S. at 413. That reserved question

was then expressly taken up in Filarsky, resulting in a different focus to the necessary

historical excavation. As described above, the Court in Filarsky suggests that where the

defendant at issue worked in a governmental entity and alongside government employees,

the relevant historical question asks whether someone bearing that relationship to the state

would have had immunity at common law, not whether immunity was accorded to purely

private persons performing some governmental function. See 566 U.S. at 384 (asking

whether the common law drew a “distinction” between “public employees” and “private

individual[s] ‘retained by the City’” (quoting Delia v. City of Rialto, 621 F.3d 1069, 1079–80

(9th Cir. 2010))). The Court’s deep dive into the common law yielded an answer in the

negative. Id. at 387 (“[T]he common law did not distinguish between public servants and

private individuals engaged in public service in according protection to those carrying out

government responsibilities.”). The Sixth Circuit decided McCullum just months after the

Supreme Court decided Filarsky. With respect for our sister circuit’s deep historical analysis

of whether doctors had any special immunity at common law, see 693 F.3d at 702–04, we read

Filarsky to require a different focus.

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all of the distraction that litigation entails. Richardson, 521 U.S. at 407–12;

Filarsky, 566 U.S. at 389–90. Those concerns are equally salient, and equally

served by the availability of qualified immunity, in the circumstances of this

case as in those involving physicians employed directly by the state.

a.

First up is preventing unwarranted timidity, “the most important special

government immunity-producing concern.” Richardson, 521 U.S. at 409. In

the government context, where institutional rules and regulations “limit the

incentive or the ability of individual departments or supervisors flexibly to

reward, or to punish, individual employees,” immunity is necessary to prevent

“overly timid” job performance. Id. at 410–11. In contrast, when private

entities—like the large prison-management firm at issue in Richardson—are

“systematically organized to perform a major administrative task for profit,”

and do so “independently, with relatively less ongoing direct state supervision,”

then “ordinary marketplace pressures” typically suffice to incentivize vigorous

performance and prevent unwarranted timidity. Id. at 409–10. Richardson

explained that private firms generally have more latitude than do public

entities to flexibly and creatively use rewards and punishments to encourage

employees to strike the right balance between vigor and caution. See id. at

410. And, unlike a state entity, any firm that fails to strike that balance risks

being replaced by a ready competitor. See id. 409.

But the market forces assumed in Richardson’s reasoning are much

weaker here. First, the state, not Tulane, oversees the operation of ELMHS

and the services that Drs. Thompson and Nicholl provide there. ELMHS is a

state-run facility, operated pursuant to state policies and overseen by a state

employee. Dr. Thompson reports directly to Lea, not to anyone at Tulane.

Similarly, issues pertaining to patient safety and the quality of care provided

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by the Tulane psychiatrists are reviewed by state employees, including Lea. 10

Whereas the Supreme Court in Richardson concluded that the private prison

guards there at issue “resemble those of other private firms and differ from

government employees,” 521 U.S. at 410, here we conclude just the opposite.

When Drs. Thompson and Nicholl go to work at ELMHS, they act within a

government system, not a private one. The market pressures at play within a

purely private firm simply do not reach them there. 11

Furthermore, their direct employer, Tulane University, is not

“systematically organized” to perform the “major administrative task” of

providing mental-health care at state facilities. Id. at 409. Unlike the private

entities at issue in cases denying qualified immunity, see McCullum, 693 F.3d

at 697 (“Community Behavioral Health”); Jensen, 222 F.3d at 573 (“Psychiatric

Associates”); Hinson, 192 F.3d at 1344 (“Wexford Health Sources”), the

university’s primary function is not providing health-care services, whether by

contract or directly. The professors it employs have many duties, including

research and teaching, and their pay, as well as other means of incentivization,

are likely determined by factors besides the quality of care they provide to any

patients they may see at ELMHS. Any marketplace pressures influencing the

performance of the university’s employees, therefore, are likely not fine-tuned

to preventing overly timid care at ELMHS.

10 For example, complaints concerning the provision of psychiatric care are reviewed

and addressed by state employees, including Lea, and the Office of Behavior Health, a

division of the Louisiana Department of Health. Furthermore, topics pertaining to the

quality of psychiatric care and patient safety are discussed by Lea and others, including other

state employees, at ELMHS executive board meetings.

11 This level of state involvement and supervision sets this case apart from the Ninth

and Eleventh Circuit cases denying qualified immunity to privately employed doctors. See

Jensen, 222 F.3d at 573 (denying immunity to psychiatrist employed by one private entity

and providing services at county hospital operated by another private entity); Hinson, 192

F.3d at 1346–47 (denying immunity to doctor employed by private entity responsible for all

policies and procedures regarding provision of medical care at county jail).

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Finally, it does not appear that the pressures created by the threat of

replacement are at play here. Unlike in Hinson, where the firm responsible

for providing health services in a county jail had recently been replaced in light

of performance concerns, 192 F.3d at 1346, Tulane has held the contract to

provide psychiatric services for the state since 1992. There is no indication in

this record of any other private entities vying for the contract. Under these

circumstances, it is unlikely that, absent immunity, market forces would

swiftly intervene to discipline overly timid performance.

b.

The second purpose identified in Richardson is ensuring that the threat

of litigation and liability does not deter talented candidates from public service.

Richardson explained that employees of private firms generally do not need

immunity because private firms can offset the risk of litigation and liability

with higher pay or better benefits. 521 U.S. at 411. As discussed above,

psychiatrists employed by Tulane have many responsibilities, and it is unclear

how responsive their pay is to the risks involved in this one subset of their

duties. Furthermore, as discussed in Filarksy, it is precisely those highly

skilled individuals—those who do not depend on any one stream of work for

their livelihoods and who have the freedom to select other opportunities that

carry less risk of liability—who are particularly likely to decline public service

if not given the same immunity as their public counterparts. 566 U.S. at 390.

This is particularly so where, as here, the private individuals work in close

coordination with government employees who may leave them “holding the

bag—facing full liability for actions taken in conjunction with government

employees who enjoy immunity for the same activity.” Id. at 391.

c.

The third and final purpose of qualified immunity identified in

Richardson is protecting public employees from frequent lawsuits that might

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distract them from their official duties. 521 U.S. at 411. As explained in

Filarksy, the interest in protecting those who perform public duties from

distraction applies regardless of whether they are full-time public employees

or contractors. 566 U.S. at 391. And the distraction of a lawsuit against a

private individual will “often also affect public employees with whom they work

by embroiling those employees in litigation.” Id. So once again, where private

individuals work alongside public employees, the interest in extending

qualified immunity to those individuals is far greater.

In sum, considering the history and purposes of immunity in conjunction

with the facts of this case, we hold that Drs. Thompson and Nicholl may raise

the defense of qualified immunity.

B.

We now turn to the crux of this appeal. Having decided that all three

defendants are entitled to assert the defense of qualified immunity, we must

decide whether they are actually entitled to its protection. “The doctrine of

qualified immunity shields officials from civil liability so long as their conduct

‘does not violate clearly established statutory or constitutional rights of which

a reasonable person would have known.’” Mullenix v. Luna, 136 S. Ct. 305,

308 (2015) (quoting Pearson v. Callahan, 555 U.S. 223, 231 (2009)). Once

invoked, a plaintiff bears the burden of rebutting qualified immunity by

showing two things: (1) that the officials violated a statutory or constitutional

right and (2) that the right was “‘clearly established’ at the time of the

challenged conduct.” Ashcroft v. al-Kidd, 563 U.S. 731, 735 (2011) (quoting

Harlow v. Fitzgerald, 457 U.S. 800, 818 (1982)); see also McClendon v. City of

Columbia, 305 F.3d 314, 323 (5th Cir. 2002) (en banc) (per curiam) (“When a

defendant invokes qualified immunity, the burden is on the plaintiff to

demonstrate the inapplicability of the defense.”). Law is “clearly established”

for these purposes only if “the contours of the right [were] sufficiently clear

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that a reasonable official would understand that what he [was] doing violate[d]

that right.” Anderson v. Creighton, 483 U.S. 635, 640 (1987). An official that

violates a constitutional right is still entitled to qualified immunity if his or

her actions were objectively reasonable. Spann v. Rainey, 987 F.2d 1110, 1114

(5th Cir. 1993). At bottom, a plaintiff must show that “no reasonable officer

could have believed his actions were proper.” Brown v. Callahan, 623 F.3d

249, 253 (5th Cir. 2010).

The parties agree that state officials have a duty under the Fourteenth

Amendment to provide involuntarily detained persons with “basic human

needs, including medical care and protection from harm.” Hare v. City of

Corinth, 74 F.3d 633, 650 (5th Cir. 1996) (en banc). They dispute, however,

what body of law clearly establishes the contours of Perniciaro’s rights and the

corresponding scope of defendants’ duties. Perniciaro contends that because

he has been involuntarily committed, rather than incarcerated, the deliberate-

indifference standard is inappropriate and defendants’ conduct should instead

be evaluated in light of the professional-judgment standard established in

Youngberg v. Romeo, 457 U.S. 307 (1982). Accordingly, he contends that he

has a due-process right to personal safety that is violated if a decision made

about his care and safety “is such a substantial departure from accepted

professional judgment, practice, or standards as to demonstrate that the

person responsible actually did not base the decision on such a judgment.” Id.

at 323. Defendants respond that, unlike the plaintiff in Youngberg, Perniciaro

was not involuntarily civilly committed but was, at all times relevant to this

appeal, a pre-trial detainee. They argue that the deliberate-indifference

standard, which we have held applies to pre-trial detainees, see Hare, 74 F.3d

at 647–48, is therefore appropriate. Because we conclude that defendants are

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entitled to qualified immunity under either standard, we need not decide which

applies. 12

1.

Even if we agreed that the professional-judgment standard applies to

persons detained pre-trial for competency restoration, Perniciaro still would

have failed to establish that defendants’ conduct violated clearly established

law. 13 See Bennett v. City of Grand Prairie, 883 F.2d 400, 408 (5th Cir. 1989)

(“The party seeking damages from an official asserting qualified immunity

bears the burden of overcoming the defense.”). Perniciaro has not cited a single

case—either in his briefing before the district court or before us—clearly

establishing that the particular conduct at issue here violates the professional-

judgment standard. Thus, he has failed to address the dispositive question:

“[W]hether the violative nature of particular conduct is clearly established.”

Mullenix, 136 S. Ct. at 308 (quoting al-Kidd, 563 U.S. at 742).

Perniciaro relies on the general statement that, under Youngberg, his

due-process rights to care and safety were violated because defendants’ actions

“[were] such a substantial departure from accepted professional judgment,

practice, or standards as to demonstrate that the person responsible actually

did not base the decision on such a judgment.” But general propositions of law

12 The district court similarly declined to decide which standard applies. The district

court concluded that summary judgment was inappropriate under either standard, but

analyzed the facts of the case only under the “more stringent ‘deliberate [in]difference’

standard.’”

13 We harbor doubt, however, that it has been clearly established that Youngberg

applies to persons detained pre-trial for competency restoration. Youngberg considered

persons who were involuntarily civilly committed, and reasoned that deliberate indifference

was an inappropriate metric by which to assess alleged violations of their constitutional

rights to safety and care because “[p]ersons who have been involuntarily committed are

entitled to more considerate treatment and conditions of confinement than criminals whose

conditions of confinement are designed to punish.” 457 U.S. at 321–22. However, we have

held that deliberate indifference is the appropriate standard to apply to inadequate-medical-

care or failure-to-protect claims brought by pre-trial detainees who, like persons

involuntarily committed, may not constitutionally be punished. Hare, 7 F.3d at 639, 643.

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defined at “high level[s] of generality” are insufficient to define clearly

established law for purposes of defeating qualified immunity. al-Kidd, 563

U.S. at 742 (“We have repeatedly told courts . . . not to define clearly

established law at a high level of generality.”); see also Mullenix, 136 S. Ct. at

308–09 (holding general rule that police “may not ‘use deadly force against a

fleeing felon who does not pose a sufficient threat of harm to the officer or

others’” was insufficient to define clearly established law in qualified-

immunity inquiry (quoting Luna v. Mullenix, 773 F.3d 712, 725 (5th Cir.

2014))).

Even assuming that the Youngberg standard applies, Perniciaro has

failed to establish that defendants’ conduct was objectively unreasonable in

light of clearly established law. 14

2.

Perniciaro also argues, in the alternative, that defendants are not

entitled to qualified immunity under the clearly established deliberate-

indifference standard. But assuming—as did the district court—that the

deliberate-indifference standard applies, defendants would still be entitled to

qualified immunity. The evidence, taken in the light most favorable to

14 Of course, Youngberg is, if anything, a less deferential, higher standard for state

officials than is deliberate indifference. See Youngberg, 457 U.S. at 321–22 (adopting

professional-judgment standard, instead of applying deliberate indifference, because

“[p]ersons who have been involuntarily committed are entitled to more considerate treatment

and conditions of confinement than criminals”); Shaw ex rel. Strain v. Strackhouse, 920 F.2d

1135, 1145 (9th Cir. 1990) (contrasting deliberate-indifference and professional-judgment

standards and indicating that the latter is easier for plaintiffs to meet). But see Yvonne L. ex

rel. Lewis v. New Mex. Dep’t of Human Servs., 959 F.2d 883, 894 (10th Cir. 1992) (doubting

whether there is a difference between the two standards). Accordingly, assuming that the

professional-judgment standard applied, Perniciaro would be able to defeat qualified

immunity despite the failure to cite cases establishing that the particular conduct here at

issue violated that standard if he were able to establish that defendants’ conduct violated

clearly established law applying the deliberate indifference standard. However, as discussed

below, he has failed to do that.

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Perniciaro, fails to establish a dispute of material fact as to whether

defendants’ conduct was objectively unreasonable in light of clearly established

law.

a.

We first address Dr. Nicholl, Perniciaro’s treating psychiatrist and the

leader of his treatment team. In denying Dr. Nicholl’s motion for summary

judgment, the district court cited evidence of Dr. Nicholl’s failure to: protect

Perniciaro from numerous injuries; place Perniciaro on ALO immediately upon

his second admission; protect him from Patient 3800; treat his shoulder injury;

and implement reasonable alternative psychiatric treatments. We conclude

that Dr. Nicholl’s conduct was objectively reasonable in light of clearly

established law. He is therefore entitled to qualified immunity.

The first three grounds for denying summary judgment cited by the

district court pertain to Perniciaro’s claim that defendants failed to protect him

from harm. Under the deliberate-indifference standard, an official may be held

liable for his or her failure to protect only when he or she is deliberately

indifferent to a substantial risk of serious harm. Adames v. Perez, 331 F.3d

508, 512 (5th Cir. 2003). An official is deliberately indifferent if he or she both

knows of an excessive risk of harm and disregards that risk. Id. (citing Farmer

v. Brennan, 511 U.S. 825, 837 (1994)). Knowledge, in this context, requires

that an official is both aware of facts from which an inference of harm could be

drawn and actually draws that inference. Id. (citing Farmer, 511 U.S. at 839–

40). An official with subjective knowledge of a risk may still be free from

liability if he or she “responded reasonably to the risk, even if the harm

ultimately was not averted.” Farmer, 511 U.S. at 844.

Here, Perniciaro failed to present evidence that Dr. Nicholl was

deliberately indifferent to a substantial risk of serious harm. With respect to

the number of injuries, the record establishes that Perniciaro was the

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aggressor in the vast majority of violent incidences in which he was involved,

and that Dr. Nicholl responded reasonably by placing Perniciaro on ALO

following incidences of violence, keeping him on ALO until such time as he had

been free of violent outbursts for several weeks, 15 adjusting his medications to

help control his violent tendencies, and, in acute situations, placing Perniciaro

in clinical seclusion or authorizing additional doses of medication to

immediately calm him.

Although Dr. Nicholl did not place Perniciaro on ALO immediately upon

his second admission, that, too, was objectively reasonable in light of clearly

established law. Liability attaches only when an official has actual knowledge

of a substantial risk of serious harm. Farmer, 511 U.S. at 837. Upon

Perniciaro’s second admission, Dr. Nicholl reasonably believed that Perniciaro

did not face a substantial risk of harm from his violent outbursts; evaluations

at the time of his readmission found Perniciaro to be “fairly stable,” “quite

coherent,” and with “fairly good” judgment. Notably, Dr. Nicholl’s report

indicated that Perniciaro “did not seem to have demonstrated any violent

behavior” while incarcerated before his readmission, with the exception of one

incident that Perniciaro claimed was in self defense. It was also reasonable for

Dr. Nicholl to believe that Patient 3800 did not pose any threat to Perniciaro.

After Perniciaro attacked Patient 3800, Patient 3800 denied any feelings of

revenge when Dr. Nicholl spoke with him. Significantly, there is no evidence

of any other physical altercation between Perniciaro and Patient 3800 between

the initial incident in September 2013 and Perniciaro’s discharge to the

Jefferson Parish Prison in March 2014. Even if Dr. Nicholl should have

15 We note that there are not claims in this case against the guards responsible for

carrying out the ALO.

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inferred some risk of harm, that alone would not establish deliberate

indifference. See Adames, 331 F.3d at 514.

The remaining grounds on which the district court denied Dr. Nicholl’s

motion for summary judgment pertain to Perniciaro’s inadequate-medical-care

claim. Here again, deliberate indifference requires that an official know of and

disregard an excessive risk to health or safety. See Domino, 239 F.3d at 755

(citing Farmer, 511 U.S. at 837). Disagreements regarding the proper course

of treatment or the failure to provide optimal care are insufficient. See Gobert

v. Caldwell, 463 F.3d 339, 349 (5th Cir. 2006); Domino, 239 F.3d at 756; Gibbs

v. Grimmette, 254 F.3d 545, 549 (5th Cir. 2001). Rather, a plaintiff must show

that officials “refused to treat him, ignored his complaints, intentionally

treated him incorrectly, or engaged in any similar conduct that would clearly

evince a wanton disregard for any serious medical needs.” Johnson v. Treen,

759 F.2d 1236, 1238 (5th Cir. 1985).

With respect to his shoulder injury, Perniciaro has failed to muster

evidence that Dr. Nicholl was deliberately indifferent to a substantial risk of

serious harm. Perniciaro does not dispute that he was treated for this injury. 16

Rather, he contends that Dr. Nicholl was deliberately indifferent to his serious

medical needs by failing to create a holistic treatment plan that adequately

considered both his mental and medical health. Perniciaro points to Dr.

Nicholl’s deposition testimony that his involvement in the “treatment of

nonpsychiatric medical conditions” was “basically, none.” But that does not

16 Indeed, his shoulder was examined by medical doctors at least five times between

July 2014 (when it appears Perniciaro first reported shoulder pain) and October 2014. X-

rays were taken at least twice, and Perniciaro was prescribed pain killers and was sent for

physical therapy. Notes in his medical records indicate that the type of shoulder injury he

suffered—an “AC Separation Type III”—“can be managed conservatively” and that surgery

is generally not recommended. To the extent Perniciaro contends he should have received

more aggressive treatment, such disputes about the proper course of treatment are

insufficient to establish deliberate indifference. See Gobert, 463 F.3d at 349.

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establish deliberate indifference. Dr. Nicholl further testified that if he

thought one of his patients had a medical problem, he would “refer them to the

medical doctor.” Delegation to a doctor trained to address a patient’s medical

needs does not evince the kind of wanton disregard necessary to establish

deliberate indifference. See Gobert, 463 F.3d at 350 n.35 (“Continuous personal

treatment by the defendant physician is not constitutionally mandated.”). The

undisputed evidence shows that Dr. Nicholl regularly reviewed Perniciaro’s

medical records and incident reports and that he referred his patients to

medical doctors in the event of a medical concern. Doing so was objectively

reasonable.

The district court also concluded that summary judgment could not be

granted in light of a factual dispute regarding whether “there are reasonable

treatments available that would assist this Plaintiff but are not being offered

or considered by Defendants.” It appears that the district court was referring

to the testimony of Perniciaro’s expert, who identified a different antipsychotic

drug and electro-shock therapy as other, untried treatment options. But the

existence of alternative treatment options does not itself render the treatment

received unconstitutional. See Estelle, 429 U.S. at 107 (“[T]he question

whether . . . additional diagnostic techniques or forms of treatment is indicated

is a classic example of a matter for medical judgment.”); Norton v. Dimazana,

122 F.3d 286, 292 (5th Cir. 1997) (observing that “[d]isagreement with medical

treatment does not state a claim” for deliberate indifference). And even

Perniciaro’s expert testified that the medications Dr. Nicholl did prescribe

were “very good medicines at very good doses.”

In sum, Perniciaro has failed to show that Dr. Nicholl’s conduct was

objectively unreasonable in light of clearly established law, and Dr. Nicholl is

therefore entitled to qualified immunity.

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b.

The district court also denied summary judgment for Dr. Thompson and

Lea. Perniciaro argues that both were deliberately indifferent by failing to

train and supervise their subordinates, including Dr. Nicholl. Of course, there

is no vicarious or respondeat superior liability under § 1983. See Estate of

Davis ex rel. McCully v. City of N. Richland Hills, 406 F.3d 375, 381 (5th Cir.

2005). Supervisory liability attaches only when: “(1) the supervisor either

failed to supervise or train the subordinate official; (2) a causal link exists

between the failure to train or supervise and the violation of the plaintiff’s

rights; and (3) the failure to train or supervise amounts to deliberate

indifference.” Id.

Perniciaro contends that Dr. Thompson—the chief of staff at ELMHS

responsible for overseeing the provision of care—was deliberately indifferent

by failing to adequately supervise Dr. Nicholl in light of Perniciaro’s myriad

injuries and Dr. Nicholl’s failure to create a holistic treatment plan. But

without an underlying constitutional violation—of which we have found

none—there can be no supervisory liability. See Rios v. City of Del Rio, 444

F.3d 417, 425 (5th Cir. 2006) (“It is facially evident that this test [for

supervisory liability] cannot be met if there is no underlying constitutional

violation.”). Perniciaro has failed to establish that Dr. Thompson violated his

clearly established rights, and Dr. Thompson is therefore entitled to qualified

immunity.

As to Lea, the CEO of ELMHS, Perniciaro contends that he was

deliberately indifferent by failing to adequately supervise Dr. Nicholl, failing

to adequately supervise and train the guards on the proper implementation of

ALO, and failing to ensure that all incidences of injuries or violence were

reported. Regarding Lea’s supervision of Dr. Nicholl, once again the absence

of an underlying constitutional violation precludes supervisory liability.

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Regarding the supervision and training of guards and reporting of injuries,

Perniciaro’s claims fare no better. Perniciaro has failed to identify any

deficiency in the guards’ training, see Roberts v. City of Shreveport, 397 F.3d

287, 293 (5th Cir. 2005) (“[F]or liability to attach based on an ‘inadequate

training’ claim, a plaintiff must allege with specificity how a particular

training program is defective.”), and there is neither evidence that Lea knew

that guards were not properly implementing ALO nor evidence that the need

for additional supervision or training should have been obvious. In an

environment like ELHMS, where guards are tasked with the difficult job of

keeping mentally ill and potentially violent individuals safe from themselves

and from one another, the fact that Perniciaro was injured while on ALO is not

itself sufficient to make the need for further supervision or training obvious.

See Roberts, 397 F.3d at 294 (concluding that past instances of police officer’s

displaying weapon during traffic stop did not place police chief on notice

regarding risk that the officer would use excessive force in part because “traffic

stops . . . are inherently dangerous”).

Finally, although Perniciaro points to evidence that he twice sustained

injuries that were either unreported or untimely reported, he presented no

evidence, nor even argument, that those failures were causally connected to

any constitutional violation. Nor is there evidence that those two failures

made the inadequacy of existing training and supervision “obvious and

obviously likely to result in a constitutional violation.” Brown, 623 F.3d at 255

(quoting Estate of Davis, 406 F.3d at 381). Accordingly, Lea, too, is entitled to

qualified immunity.

IV.

For the foregoing reasons, we REVERSE the denial of summary

judgment and RENDER judgment in favor of Lea, Dr. Thompson, and Dr.

Nicholl.

25