4th Circuit revives detainee’s claims over missed medication

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A pretrial detainee’s constitutional and medical malpractice claims filed after he was not provided with medication to manage his mechanical heart valve (MHV) while he was incarcerated should be revived, the 4th U.S. Circuit Court of Appeals has ruled, reversing summary judgment against various government agencies, employees and contractors.

David Gunter was diagnosed with a heart condition shortly after birth and underwent open heart surgery to replace his aortic valve with a MHV at the age of 15. At the same time, he was prescribed Coumadin, a blood thinner, which reduces the formation of blood clots, as individuals with MHVs have a higher risk of blood clots.

Gunter faithfully took the medicine and regularly checked his International Normalized Range (INR) to ensure he was taking the appropriate amount of Coumadin.

In November 2012, Gunter was arrested pursuant to a bench warrant and placed at the Forsyth County local confinement facility. When he arrived, Gunter completed a medical intake form disclosing his heart condition and that he takes Warfarin, the generic brand of Coumadin.

The next day, Gunter was transferred to Davie County Detention Center and reviewed his medical history with a nurse; he was later transferred to Stokes County Detention Center. During his time incarcerated, several days went by where he did not take his medication and did not have his INR monitored.

A week after being released, Gunter was admitted to the hospital for a blood clot. His INR levels were well below range at the time. The blood clot was removed but a month later, he was diagnosed with a second blood clot requiring surgeons to resect part of his bowel.

Gunter sued various government agencies and employees, alleging that his injuries resulted from the care he received during his detainment. According to the complaint, the defendants acted with deliberate indifference toward his constitutional right to adequate medical care, and he further alleged a Monell claim against the counties, as well as a medical malpractice claim against certain defendants.

The district court granted summary judgment in favor of the defendants and Gunter appealed.

Writing for the panel in Swink v. Southern Health Partners Inc., Judge Roger L. Gregory reversed.

The district court erred in finding that Gunter’s evidence did not create a dispute of material fact that the medical professionals were deliberately indifferent to his medical needs, the court said.

As a pretrial detainee, he only needed to show that the challenged government action was “not rationally related to a legitimate nonpunitive purpose or [wa]s excessive in relation to that purpose” to establish deliberate indifference, the court explained.

“The record makes clear that Gunter has presented sufficient evidence to proceed beyond the summary judgment stage,” the court wrote.

Applying the test set forth in Short v. Hartman, the court found Gunter had an objectively serious medical condition and demonstrated that the defendants acted or failed to act in the face of an unjustifiably high risk of harm that is either known or so obvious that it should be known.

The record indicated that several employees had actual knowledge of Gunter’s condition and medication needs, and “[a] reasonable jury could therefore find that the available medical information put [the defendants] on sufficient notice that depriving Gunter of Coumadin would incite acute health issues,” the court said.

That Gunter subsequently experienced blood clots satisfied the final prong of the Short test, which required the plaintiff be harmed by the defendant’s action or inaction.

The district court further erred in dismissing Gunter’s Monell claim, the court said, which allows plaintiffs to sue local governing bodies directly under § 1983.

Evidence in the record suggested that Southern Health Partners (SHP), the counties’ contracted medical care provider, “had a custom and practice of taking days to get inmates their medication, and of not having a medical professional available to treat inmates during weekends,” the court said. “A reasonable jury could find that these decisions were ‘the ‘moving force” behind Gunter not receiving adequate medical care and suffering serious injuries.”

Dismissal of Gunter’s medical malpractice claim against SHP was also an error.

North Carolina courts agree that it is within a county’s purview to provide adequate medical care for incarcerated persons and as providing medical care to those incarcerated in county jails is a nondelegable duty, the court noted that any independent contractor hired to perform that duty is an agent of the state as a matter of law.

As for Gunter’s medical malpractice claims against individual employees, the district court abused its discretion by excluding Gunter’s evidence related to his access to medication prior to incarceration and the testimony of his treating doctors.

The district court improperly weighed the evidence of the parties and found the defendants’ expert witness (who suggested Gunter was not therapeutically medicated prior to incarceration) was more credible than the evidence put forth by Gunter. In addition, the district court improperly resolved evidence related to Gunter’s access prior to incarceration.

Considering the testimony of Gunter’s doctors, the district court improperly stated that it was speculative, the court explained.

“Dr. Yoder’s testimony that she assumed Gunter was properly anticoagulated before he was incarcerated is not based on speculation,” the court wrote. “This is because Gunter had been Dr. Yoder’s patient for years and as such, Dr. Yoder was qualified to opine on Gunter’s habits and compliance with Coumadin therapy based on her relationship with Gunter in her professional capacity.”

Similarly, the district court abused its discretion in finding both of Gunter’s doctors failed to testify with a reasonable degree of medical certainty. When testifying about the numerical percentage of fault for Gunter’s injuries, one doctor was unable to articulate a specific number, which the court said was not required; the other credibly outlined a range of times in which clot formation was likely and did not need to opine as to a specific moment when blood clotting occurred.

The court reversed and remanded.

Judge DeAndrea Gist Benjamin joined the opinion, while Judge Julius N. Richardson authored a separate opinion, concurring and dissenting in part.

David W. McDonald of McDonald Wright in Greensboro, North Carolina, who represented Swink, did not respond to a request for a comment on the case.
Neither did Columbia, South Carolina, attorney James G. Long III of Maynard Nexsen, who represented the defendants. •