United States District Court, D. New Mexico
AIMEE BEVAN, as Personal Representative of the Estate of Desiree Gonzales, deceased, Plaintiff,
SANTA FE COUNTY, GABRIEL VALENCIA, Youth Development Administrator, Individually, MATTHEW EDMUNDS, Corrections Officer, individually, JOHN ORTEGA, Corrections Officer, MOLLY ARCHULETA, Corrections Nurse, Individually, ST. VINCENT HOSPITAL, and NATHAN PAUL UNKEFER, M.D., Defendants.
MEMORANDUM OPINION AND ORDER
matter comes before the Court upon Defendant Santa Fe
County's Motion for Summary Judgment (Motion for Summary
Judgment), filed April 15, 2016. (Doc. 163). Plaintiff filed
a response on May 17, 2016, and filed exhibits on May 19,
2016. (Docs. 181 and 186). Defendant Santa Fe County (County)
filed a reply on June 22, 2016. (Doc. 205). Having considered
the Motion for Summary Judgment, accompanying briefing, and
relevant evidence, the Court grants the Motion for Summary
case involves, in part, whether Desiree Gonzales received
adequate medical care while incarcerated at the Santa Fe
Youth Development Program (YDP), a program operated by the
County. Just prior to Gonzales' incarceration at the YDP
on the night of May 7, 2014, Gonzales was treated for a
heroin overdose at St. Vincent Hospital and medically cleared
for incarceration. It is undisputed that no nurse was present
at the YDP that night and that several hours later Gonzales
stopped breathing. It is also undisputed that when Gonzales
stopped breathing and became nonresponsive non-medical YDP
staff began CPR and called 911. Several hours later, Gonzales
died at St. Vincent Hospital. The Office of the Medical
Investigator determined that the cause of death was
“Toxic effects of heroin.” (Doc. 145-4) at 1.
The Complaint for Wrongful Death (Complaint) (Doc. 1) at
Count Two of the Complaint, Plaintiff brings 42 U.S.C. §
1983 claims against the County for violations of
Gonzales' rights under the Fourteenth and Eighth
Amendments. (Doc. 1) at 14-15, ¶¶ 73-78. Plaintiff
clarifies in her response to the Motion for Summary Judgment
that the County adopted the following unconstitutional custom
or practice: “After hours, when nurses were not on
shift, residents suspected of intoxication or withdrawal were
not appropriately screened pursuant to the receiving
screening policy, were not appropriately evaluated pursuant
to the intoxication and withdrawal policy, and instead, were
allowed to ‘sleep it off' under the watch of
untrained eyes as long as they had a medical clearance from a
doctor or hospital.” (Doc. 181) at 30. Plaintiff
further alleges that the County did not implement its medical
receiving screening policy, and failed to train its YDP
officers on (1) the receiving screening policy, (2)
recognizing the signs and symptoms of heroin intoxication and
withdrawal, and (3) monitoring residents for signs and
symptoms of heroin intoxication and withdrawal. Id.
at 29, ¶ 14.
Count Three of the Complaint, Plaintiff alleges two New
Mexico Tort Claims Act (NMTCA) claims against the County.
First, Plaintiff alleges that the County, through its
employees, was negligent by failing to provide adequate
medical care to Gonzales. (Doc. 1) at 15, ¶ 82.
Plaintiff cites NMSA 1978, § 41-4-12 of the NMTCA which
provides waiver of immunity “when law enforcement
officers cause wrongful death through the deprivation of
rights, privileges and immunities secured by the U.S.
Constitution or New Mexico Constitution.” Id.
at 15, ¶ 80. Second, Plaintiff alleges that the County
was negligent in the manner it operated the YDP. Id.
at 15, ¶ 83.
County moves for summary judgment on all claims against it.
Plaintiff opposes the Motion for Summary Judgment in its
Facts Relevant to the Motion for Summary
Summary of Facts Related to Gonzales' Incarceration at
received care for a heroin overdose at St. Vincent Hospital,
which included the administration of naloxone, “a short
acting antagonist of the effects of heroin, ” and
lorazepam, a central nervous system depressant like heroin.
(Doc. 163-14) at 2. As a central nervous system depressant,
lorazepam has an additive effect to heroin. Id. In
fact, “the co-administration of lorazepam …
changes the opioid treatment scenario complicating treatment
and adding pharmacologic risk.” Id. at 4.
was discharged from St. Vincent Hospital at 9:52 p.m. with a
medical clearance noting “No further cares
[sic].” (Doc. 166-1); (Doc. 166) at 2. Gonzales arrived
at the YDP at 10:35 p.m. (Doc. 166) at 2. Defendant Gabriel
Valencia (Valencia) and YDP staff member Esmeralda Coronado
(Coronado) interacted with Gonzales in the booking process.
Coronado indicated on Gonzales' Intake Checklist that a
medical screening form was completed and placed in the
medical box so that a nurse could review it in the morning.
(Doc. 186-5) at 3. No medical screening form, however, was
completed and staff, instead, relied on the medical clearance
to accept Gonzales. Id.
Gonzales was alert, oriented, and coherent during the booking
process, she was also nauseous, “a little fogy, ”
and tired. (Doc. 67-13); (Doc. 166-2) at 3, depo. at 34-35;
(Doc. 166-3) at 2, depo. at 31-32; (Doc. 166-4); (Doc. 185-6)
at 5, depo. at 151. After Coronado dressed Gonzales out and
finger printed her, Gonzales was added “to board and
count at 10:55 pm and escorted … to the Anasazi C-pod
living unit ….” (Doc. 166-4). Once at the
Anasazi C-pod, Gonzales telephoned her mother and spoke with
her for about five minutes. Id.
that same time, Defendant Matthew Edmunds (Edmunds) arrived
at the Anasazi C-pod to accept Gonzales. Id. Edmunds
“immediately” concluded that Gonzales “was
not in a normal state of mind, ” had
“groggy” looking eyes, and had slurred speech.
(Doc. 166-6). Because no nurse was on duty at the YDP during
the night, Edmunds called Defendant Nurse Molly Archuleta
(Nurse Archuleta) to advise her of Gonzales'
“state” and ask questions about the medical
clearance. Id. Nurse Archuleta told Edmunds
“to keep an [sic] very close eye on [Gonzales] and to
notify her of any changes.” Id. Nurse
Archuleta specifically told Edmunds to monitor Gonzales'
breathing. (Doc. 145-1) at 1; (Doc. 185-7) at 4, depo. at 90.
Nurse Archuleta later acknowledged that not being in a normal
state of mind, having groggy eyes, and slurring speech would
have been “red flags” to her. (Doc. 176-5) at 3,
transcript at 37.
on the telephone conversation with Nurse Archuleta, Edmunds
and Valencia placed Gonzales in a “boat” or bed
in the dayroom of the Anasazi C-pod. (Doc. 166-4). To comply
with Nurse Archuleta's instruction to monitor
Gonzales' breathing, Edmunds and Defendant John Ortega
(Ortega), who arrived at the Anasazi C-pod at 11:40 p.m.,
conducted 15 minute checks on Gonzales, including
“extra checks.” (Doc. 166-6); (Doc. 166-8). The
checks “were conducted through the window of the
dayroom, and horseshoe, ” which placed Edmunds and
Ortega 2 to 3 feet from Gonzales. Id.; (Doc. 185-4)
at 4, depo. at 68. Edmunds kept a door unsecured because of
Gonzales' “unusual breathing.” (Doc. 166-6).
The checks included shaking Gonzales, shining a light in her
eyes once,  and asking her if she was okay, without
getting a verbal response. (Doc. 185-2) at 6, transcript at
33; (Doc. 206-6) at 3-4, depo. at 55-57.
evidently left the Anasazi C-pod around the time Gonzales
went to sleep at about 11:15 p.m., and checked on her at
least one other time at about 11:55 p.m. (Doc. 166-2) at 3,
depo. at 37; (Doc. 185-2) at 6, transcript at 33; (Doc. 171)
at 23:55:35 to 23:56:09. After Plaintiff went to sleep,
Edmunds and Ortega noted “unusual breathing, ”
“breathing difficulties, ” “awkward”
breathing, and “gasping” by taking “deep
breaths follow[ed] by extended period [sic] of no breathing
repeatedly.” (Doc. 145-3); (Docs. 166-6, 166-7, and
at some point went to clean the front lobby. (Doc.
166-4). At about 1:52 a.m., Edmunds radioed Valencia
to inform him that Gonzales stopped breathing. Id.
Edmunds and Ortega then began CPR while Valencia called the
Interim Youth Service Administrator at 1:54 a.m. and then
called 911 at 1:55 a.m. Id. Emergency personnel
arrived at 2:05 a.m. Id. Edmunds went with Gonzales
to St. Vincent Hospital, where she died several hours later.
The County's Policies
2014, the County had policies which it adopted from the 2011
“Standards for Health Services in Juvenile Detention
and Confinement Facilities, ” authored by the National
Commission on Correctional Health Care. (Docs. 163-1 and
163-2). The policies covered subjects like health training
for staff, receiving screening, health assessments, emergency
services, nursing assessment protocols, intoxication and
withdrawal, and alcohol and other drug problems. Id.
(Policy numbers Y-C-04, Y-E-02, Y-E-04, Y-E-08, Y-E-11,
Y-G-06, and Y-G-08).
County's receiving screening policy required that nursing
personnel perform the receiving screening and that they
document the screening on a form. (Doc. 186-4) at 2. That
policy, however, indicated that residents referred to St.
Vincent Hospital who return to the YDP “are accepted if
there is a written medical clearance….”
Id. If someone other than a nurse performs the
receiving screening, “[a] [n]urse will review the
completed receiving screening form and the resident within
12-hours of the resident's admission to” the YDP.
Id. at 3. Another policy, the intoxication and
withdrawal policy, required “constant observation when
severe withdrawal symptoms are observed.” (Doc. 186-3)
The County's Training
Mexico Administrative Code § 188.8.131.52, as amended in
2011, requires that New Mexico juvenile detention centers
certified by the Children, Youth, and Families Department
provide training in first aid, CPR, and “intake
criteria/and reporting.” NMAC § 184.108.40.206 (D)
(13) and (16). The County had a policy establishing minimum
staff training requirements. (Doc. 186-13). The policy
included training on first aid, CPR, and policies.
County provided evidence that, prior to Gonzales' death,
Valencia, Edmunds, Ortega, Coronado, and Nurse Archuleta
received various trainings including basic academy trainings,
basic orientation trainings, in-service trainings, training
in medical emergencies/urgencies, instruction on narcotics,
and training on CPR, first aid, and on the use of automated
external defibrillators (AED). See (Doc. 163-3) at
8-9; (Doc. 163-5) at 1-2, and 5; (Doc. 163-6) at 6-7 and10;
(Doc. 163-7) at 1and 9; (Doc. 163-8) at 1 and 7; (Doc. 163-9)
at 1, 3, and 7-8; (Doc. 163-10) at 2, 5, and 6; (Doc. 163-12)
at 6; (Doc. 205-7) at 1-3, 5-9, 13-16, and 18-19.
objective of the medical emergencies/urgencies training was
to “[r]ecognize some signs and symptoms of illnesses or
injuries that require immediate and urgent medical
attention.” (Doc. 205-4) at 1. The training reviewed
checking for breathing which includes asking whether the
resident is on drugs or withdrawing from drugs. Id.
at 2. The training noted that there was a separate course on
opiate and drug overdoses, but directed activation of the
incident management system if staff suspects an opiate or
drug overdose, and that staff watch respiratory rates and
watch for “difficulty in arousing” the resident.
Id. at 3.
other County trainings were entitled, “Alcohol, Drugs,
and Narcotics” and “NMCD Addiction
Services.” (Doc. 205-5); (Doc. 163-15). The trainings
listed as an objective identifying or recognizing “the
primary symptoms associated with the use of various
drugs/substances.” (Doc. 205-5) at 1; (Doc. 163-15) at
8. The trainings also listed the physiological effects of
narcotic use like nausea, “Mental Fogginess, ”
“Blurred vision, ” and “Reduced physical
activity.” (Doc. 205-5) at 2; (Doc. 205-3) at 3. These
trainings further listed heroin or opiate withdrawal
symptoms. (Doc. 205-5) at 3; (Doc. 205-3) at 3.
lesson plans created prior to Gonzales' death included
those on medical urgencies, narcotics recognition, substance
abuse, drugs and narcotics, and policies. (Doc. 205-6) at
1-4, and 7-8. The County also had a “Basic Book”
entitled “Drug Use and Recognition.” (Doc.
163-15) at 9.
Nurse Archuleta trained life skills staff on signs and
symptoms of opioid intoxication. (Doc. 204-1) at 4, depo. at
54. That training included monitoring the person's
breathing by watching the chest rise and fall. Id.
at 4, depo. at 54-56. It is unclear, however, whether this
training occurred prior to Gonzales' death.
Evidence From YDP Staff Concerning Customary ...