Searching over 5,500,000 cases.

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Keohane v. Lancaster County

August 12, 2010


The opinion of the court was delivered by: Goldberg, J.


This civil rights action arises out of the tragic suicide death of Joseph P. Keohane, occurring while he was held in pretrial detention at Lancaster County Prison ("LCP"). Plaintiffs, Lawrence and Patricia Keohane, Joseph's parents and the administrators of his estate, have brought suit against Defendants, Lancaster County and several prison employees for failing to prevent the suicide.*fn1

These claims primarily allege constitutional violations under 42 U.S.C. § 1983.*fn2

Before the Court are Defendants' Motions for Summary Judgment. For the reasons set out below, the Lancaster County Defendants' motion is granted in part and denied in part and Dr. Doe's motion is denied.


Unless indicated otherwise, the facts presented below are undisputed.*fn3

A. Keohane's Arrest and Initial Hospitalization - November 20, 2006

Joseph Keohane was arrested on November 20, 2006, after his parents called the Pennsylvania State Police to report the theft of their safe. (L.C. Defs.' St. of Facts, ¶¶ 1, 4.) Plaintiffs testified that they called the police because their son had been struggling with serious drug addiction and mental health problems and they were very concerned about his well being due to numerous recent statements about ending his life. (Pls.' Brief in Opp., pp. 2-3.)

Keohane was arrested and, knowing that he had threatened suicide, the arresting officer brought him to Lancaster General Hospital ("LGH") for a pre-commitment evaluation. Keohane was evaluated, found not to be suicidal, and cleared for incarceration. The evaluating physician, Dr. Bret Levy, stated in his patient report that despite superficial scratches on one of his wrists, Keohane had freely admitted that he was not suicidal and had been attempting to manipulate his parents into allowing him to come home.

Although he was still under arrest, for reasons that are not entirely clear from the written submissions, Keohane was releasedand called his father. His father in turn called the police, who re-apprehended Keohane. He again threatened to commit suicide if he was incarcerated, and was brought back to LGH for a second pre-commitment evaluation. Keohane was then discharged to a state trooper shortly after midnight on November 21, 2006, who brought him to Lancaster County Prison ("LCP") for commitment. (L.C. Defs.' St. of Facts, ¶¶ 6, 9-10, 12, 16.)

B. LCP's Suicide Status and Mental Health Operating Procedures

Prior to recounting what occurred after Keohane was brought to the LCP, we briefly summarize the facility's mental health procedures. LCP's "Suicide Status and Mental Health Operating Procedures" were implemented in March of 2001 and established a system of levels of suicide status and mental health status. Under this system, individuals are placed on various status levels based upon their behavior and review by the medical department/mental health department. The procedures require an inmate be placed on suicide status if the inmate:

(1) makes "any overt attempt to inflict bodily harm;"

(2) is severely depressed and "has given indication that he is planning to or is afraid of harming himself" . . .; and/or

(4) is "at risk for suicide as a result of intake information, and or may be in crisis during incarceration period, but not admitting to suicidal ideation."

The procedures further state that, "the utilization of suicide status is a medical staff decision. In all cases the prison physician will make the decision regarding suicide status. However precautionary measures can be taken by medical staff . . . . [The] medical staff member on duty must notify medical director to obtain verbal order for the level of suicide status: This will be completed after a medical staff assessment of the inmate's clinical condition and mental status." Additionally, individuals on Suicide Status Level I (Serious Suicide Risk) and Level II (Potential for Suicide Risk) must be housed in camera cells, and "checked at a minimum and at random once every 15 minutes by correctional officer assigned to medical housing unit." Further, "suicide status will be reviewed every 24 hours or less by medical staff." (Suicide Status Standard Operating Procedure, pp. LCP 1020, 1022, 1024-27.)

Deputy Warden for Treatment Services, Robert Siemasko, who was involved in creating the procedures, testified that the procedures were the same during Keohane's incarceration in 2006 as when they were implemented in 2001. (Pls.' Brief in Opp., p. 5.) Dr. Robert Doe, the independent contractor who acted as the medical director at LCP, testified to the contrary. He stated that in 2004, after the suicide of another inmate, changes were made to the 2001 version of the procedures, and that under the revised procedures, decisions regarding the placement of an inmate on suicide status were made solely by psychiatric staff rather than by a doctor. (Doe's Memo., pp. 3-4; Pls.' Memo in Opp. Doe's Mot., p. 5.)*fn4

C. LCP - November 21, 2006

Upon arrival at LCP, Keohane was initially interviewed by a LCP Mental Health/Mental Retardation (MH/MR) Counselor and completed the LCP Medical Department Questionnaire, indicating that he had tried to commit suicide by cutting his wrists the previous day. Consequently, Counselor Carrie McWilliams was called to perform a more comprehensive evaluation. Defendants note that McWilliams was a qualified mental health professional under the National Commission on Correctional Health Care ("NCCHC") standards, trained extensively in suicide prevention and intervention, and received her Suicide Prevention and Intervention Instructor certificate in June 2005.

According to Defendants, McWilliams placed Keohane on Suicide Status Level I as a precautionary measure because she was not sure whether he was genuinely suicidal. McWilliams noted Keohane's hospitalizations at LGH that night, and saw nothing indicating suicidal ideation on Keohane's discharge sheet from LGH. She noted that Keohane stated he was "currently suicidal and would not contract for safety."*fn5 McWilliams also noted that Keohane had positive eye contact, was angry, and that the cuts on his wrist appeared superficial. In accordance with his placement of suicide status, Keohane was transferred to a camera cell in the Medical Health Unit ("MHU"). (L.C. Defs.' St. of Facts, ¶¶ 12, 14-16, 19-20, 65.) Plaintiffs allege that McWilliams did not notify the Medical Director, Defendant Dr. Doe, that she had placed Keohane on suicide status. (Pls.' Brief in Opp., p. 4.)

D. LCP - November 22, 2006

The next day, November 22, 2006, Corrections Officer ("CO") Edward Sutton was on duty from 8 a.m. to 4 p.m. in the MHU where Keohane was held. Sutton's primary responsibility was to make pod checks. (Pls.' Brief in Opp., p. 7.)*fn6

McWilliams re-evaluated Keohane in the MHU at 1:06 p.m. while Sutton was on duty. McWilliams' progress notes of the re-evaluation state:

Patient denies suicidal ideation and contracts for safety. Patient said he wanted to die but said he has no intention of doing anything to hurt himself. Patient stated he had been overly stressed but he does not feel suicidal. Patient denies past psych treatment or meds. Patient reported no other problems. Positive eye contact. Calm and appropriate.

(L.C. Defs.' St. of Facts, ¶ 22.)

McWilliams' assessment at that time was that Keohane suffered from situational depression but was negative for suicidal ideation. Thus, McWilliams decided to have Keohane removed from all mental health status and moved to general population. McWilliams testified that Keohane had exhibited "red flags" of suicidal ideation at his first evaluation in that he had told police he was suicidal, however, there were no "red flags" during her second evaluation. McWilliams completed a "Release from Suicide Status" form enumerating the reasons for the removal, including that Keohane was negative for suicidal ideation, had no plans to harm himself, was not hopeless or helpless, and had contracted for his safety, a claim which McWilliams felt was genuine. McWilliams explained to Keohane that he would be removed from suicide status and, in response to his question about whether he would be removed from the MHU, she told him that he "may move soon," but would not be leaving immediately.

After the re-evaluation, McWilliams wrote an email to prison supervisors that Keohane should be removed from all mental health status, and could be placed in the general population.

(L.C. Defs.' St. of Facts, ¶ 23-24, 26, 28-30, 31-32, 36.) McWilliams also sent a separate email titled "Inmates to Watch For the Coming Up Four Day Weekend" to officers and staff. Keohane was not on the list. (Pls.' Brief in Opp., pp. 5-6)

Plaintiffs stress that McWilliams' re-evaluation lasted less than four minutes. They also point out that there is no record of a conversation between McWilliams and the guards regarding Keohane's behavior, nor did McWilliams ever view surveillance video from that period.*fn7

Additionally, Plaintiffs claim that McWilliams did not notify the medical director of her decision to remove Keohane from suicide status as required by LCP policy. (Id.)

According to Plaintiffs, shortly after the re-evaluation Keohane called Sutton on the cell intercom and advised that he broke his finger by "rolling on it." Plaintiffs note that the surveillance video shows Keohane trying to injure himself, and Sutton's response was to indicate that Keohane harmed himself on purpose. (Pls.' Brief in Opp., p. 7; Cell Camera Video, Nov. 22, 2006, 1:23 p.m.) Sutton then brought Keohane to the medical unit at 1:26 p.m. where he was seen by nurse Cheree Hohenwarter. Keohane told her he had hurt his finger when he was "using [his] head to move up in [his] bed while [his] hands were in [his] jumpsuit" and his "hands slipped and [he] heard a pop."

(L.C. Defs.' St. of Facts, ¶ 33.) Hohenwarter's notes indicate that Keohane hurt his finger by accident, and that after his finger was treated, Keohane asked: "So I'm not leaving here." The nurse responded: "I'm unsure where you'll be going at this point, I need to discuss it with the doctor, I don't know if he wants you to stay here (MHU) until your x-ray on Friday." (Pls.' Memo. in Opp. to Doe's Mot., pp. 6-7; Cell Camera Video, Nov. 22, 2006.)

Keohane was taken for another medical examination at some point during the evening of November 22, 2006 and presented to Dr. Doe, who authorized an x-ray for Keohane the next day, and pending evaluation of the x-ray, ordered bandaging of the finger and an ice pack. Doe had no conversation with Keohane about his suicide status, never saw his chart, nor was he asked to evaluate Keohane for mental health problems. Plaintiffs stress that Keohane was wearing the suicide status jumpsuit, that Dr. Doe had access to his charts and understood that there was no psychiatrist contracted with the prison. (Pls. Memo. in Opp. to Doe's Mot., p. 7, 19; Doe's Memo., pp. 1-2.)

E. LCP - November 23, 2006

CO Sutton came on shift in the MHU on the morning of November 23, 2006 and contacted Sgt. Ben Lefever about Keohane's status. Lefever reviewed McWilliams' email from the previous day instructing that Keohane be removed from mental health status, and instructed Sutton to carry out the removal. Keohane was not placed in general population but was moved from a camera cell to a regular cell in the MHU. (L.C. Defs.' St. of Facts, ¶¶ 37, 39.)

According to Defendants, Sutton performed 30 minute pod checks during his shift, which lasted from 8:00 a.m. to 4:00 p.m. Sutton noted three additional "normal interactions" with Keohane, including a request to call his parents which was granted. Keohane made three calls to his parents during which, according to Defendants, he gave no indication that he was depressed or suicidal, and talked of the future. Sutton's last pod check was at 3:43 p.m. (L.C. Defs.' St. of Facts, ΒΆΒΆ 40-46.) Plaintiffs claim the video recording shows no checks ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.