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Bevan v. Santa Fe County

United States District Court, D. New Mexico

October 5, 2017

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.


         This 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 Judgment.

         A. Background

         This 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.

         1. The Complaint for Wrongful Death (Complaint) (Doc. 1) at 4-19

         In 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.

         In 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.

         The County moves for summary judgment on all claims against it. Plaintiff opposes the Motion for Summary Judgment in its entirety.

         2. Facts Relevant to the Motion for Summary Judgment[1]

         a. Summary of Facts Related to Gonzales' Incarceration at the YDP

         Gonzales 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.

         Gonzales 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.

         While 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.

         About 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.

         Based 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, [2] 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.

         Valencia 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.”[3] (Doc. 145-3); (Docs. 166-6, 166-7, and 166-8).

         Valencia 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. (Doc. 166-7).

         b. The County's Policies

         In 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).

         The 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) at 2.

         c. The County's Training

         The New Mexico Administrative Code §, 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 § (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. Id.

         The 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.

         An 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.

         Two 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.

         County 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.

         Furthermore, 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.

         d. Evidence From YDP Staff Concerning Customary ...

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