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Ponzini v. Primecare Medical, Inc.

United States District Court, M.D. Pennsylvania

August 30, 2017

PETER PONZINI, ESQUIRE and MIRYEM BARBAROS, as Co-Administrators of the Estate of Mumun Barbaros, Deceased, Plaintiffs,
v.
PRIMECARE MEDICAL, INC, et al., Defendants.

          MEMORANDUM OPINION

          Robert D. Mariani United States District Judge.

         TABLE OF CONTENTS

         I. INTRODUCTION AND PROCEDURAL HISTORY ...................................................................... 2

         II. STATEMENT OF FACTS ................................................................................................................. 5

         A. PrimeCare Medical, Inc. . .............................................................................................................................. 5

         B. March 18, 2009 - March 22, 2009 ................................................................................................................ 13

         1. Paul James ..................................................................................................................................... 13

         2. Patricia Bauer ................................................................................................................................ 16

         3. Christina Rowe ............................................................................................................................. 19

         4. Wendy Johnson ............................................................................................................................. 22

         5. Grace Ramos ................................................................................................................................. 25

         6. Dr. Alex Thomas ........................................................................................................................... 28

         7. William Buffton .............................................................................................................................. 31

         8. Correctional Officers Cleary and Ryan ........................................................................................ 34

         C. Expert Witnesses ........................................................................................................................................ 36

         1. Kathryn Wild .................................................................................................................................. 36

         2. Dr. Peter Breggin ........................................................................................................................... 40

         3. Dr. Lorne Sheren .......................................................................................................................... 43

         4. David Hopkins ................................................................................................................................ 44

         5. Terry Fillman .................................................................................................................................. 45

         6. Dr. Lawrence Mendel .................................................................................................................... 49

         7. Dr. Lawrence Guzzardi .................................................................................................................. 51

         8. Dr. Cheryl Wills .............................................................................................................................. 52

         9. Dr. Susan Rushing ........................................................................................................................ 56

         III. STANDARD OF REVIEW .................................................................................................... 59

         A. Motion for Judgment as a Matter of Law ................................................................................................... 59

         B. Motion for a New Trial; Remittitur .............................................................................................. 62

         IV. MOTION FOR JUDGMENT AS A MATTER OF LAW ..................................................... 64

         A. 42 U.S.C. § 1983 - Adequate Medical Care ............................................................................................... 64

         1. The Individual PrimeCare Defendants ......................................................................................... 65

         a. Paul James ...................................................................................................................... 75

         b. Patricia Bauer .................................................................................................................. 80

         c. Christina Rowe ................................................................................................................ 84

         d. Grace Ramos ................................................................................................................... 90

         e. The Individual PrimeCare Defendants Did Not Violate Mr. Barbaros' Constitutional Right To Adequate Medical Care ................................................................................... 94

         2. Dr. Alex Thomas ............................................................................................................................ 99

         3. PrimeCare Medical, Inc. . ............................................................................................................ 108

         a. PrimeCare's Policy, Practice, or Custom .................................................................... 111

         i. Failure to Adopt Needed Policy .................................................................... 113

         ii. Failure to Train/Supervise .............................................................................. 115

         b. Section 1983 Causation ................................................................................................ 122

         4. Conditional Ruling on Motion for New Trial .............................................................................. 124

         B. Negligence ................................................................................................................................................. 126

         1. The PrimeCare Defendants ......................................................................................................... 127

         2. Dr. Alex Thomas .......................................................................................................................... 138

         C. Punitive Damages ..................................................................................................................................... 142

         V. MOTION FOR NEW TRIAL ........................................................................................................................ 154

         A. The PrimeCare Defendants ...................................................................................................................... 154

         1. Jury Instructions ......................................................................................................................... 158

         a. Negligence Per Se Jury Instruction and Argument .................................................... 158

         b. Direct Causation and Increased Risk of Harm ........................................................... 167

         c. Unpreserved Claims of Error ....................................................................................... 172

         i. Inconsistent Verdicts ...................................................................................... 173

         ii. Double Recovery ............................................................................................. 175

         iii. Vicarious Liability - Punitive Damages ........................................................ 177

         2. Evidentiary Rulings ..................................................................................................................... 183

         a. The Criminal Charges Filed Against Barbaros ........................................................... 183

         b. Preclusion of Alleged Statement Made to Correctional Officer Ryan ...................... 190

         c. Permitting Evidence of the Misspelling of Mr. Barbaros' First Name ....................... 195

         d. Permitting Mumtaz Barbaros to Testify ...................................................................... 199

         e. Preclusion of Testimony Regarding Alleged Misconduct of Correctional Officer Jesse Cleare ................................................................................................................. 205

         f. Unpreserved Claims of Error ....................................................................................... 206

         3. Weight of The Evidence ............................................................................................................. 208

         a. The Individual PrimeCare Defendants ......................................................................... 210

         b. William Buffton ............................................................................................................. 222

         c. PrimeCare Medical, Inc. . ............................................................................................... 224

         i. Respondeat Superior ..................................................................................... 225

         ii. Liability for Negligence of Independent Contractors .................................. 225

         iii. Corporate Negligence ..................................................................................... 231

         B. Dr. Alex Thomas ....................................................................................................................................... 237

         1. Permitting Dr. Breggin to Testify ............................................................................................... 238

         2. Failure to Include Agency Question on Verdict Sheet ............................................................. 244

         3. Weight of the Evidence ............................................................................................................... 246

         VI. MOTION FOR NEW TRIAL - DAMAGES/REMITTITUR ..................................................... 249

         A. Wrongful Death Damages ........................................................................................................................ 251

         B. Survival Action Damages .......................................................................................................................... 256

         C. New Trial - Compensatory Damages ...................................................................................................... 259

         VII. MOTION FOR DELAY DAMAGES .......................................................................................... 259

         VIII. CONCLUSION ................................................................................................................................... 267

         Presently before the Court are several post-trial motions filed by Defendants PrimeCare Medical, Inc., Paul James, Patricia Bauer, Christina Rowe, Wendy Johnson, and Grace Ramos (collectively, the “PrimeCare Defendants”) and Dr. Alex Thomas (“Dr. Thomas”). (Docs. 354, 366). The Court notes at the outset that its decisions stated in this opinion were arrived at with little assistance from the submissions of the parties. In particular, the submissions of the PrimeCare Defendants and Dr. Thomas were consistently made without citations to the record and in many instances without supporting arguments or references to the applicable law. Nevertheless, and for the reasons set forth below, the PrimeCare Defendants and Dr. Thomas' motions will be granted in part and denied in part.

         I. INTRODUCTION AND PROCEDURAL HISTORY

         This case arises from the circumstances surrounding the death of Mumun Barbaros, a pretrial detainee at the Monroe County Correctional Facility (the “MCCF”). Plaintiffs Peter Ponzini and Miryem Barbaros, as Co-Administrators of the Estate of Mumun Barbaros (“Plaintiffs”), commenced this action on March 3, 2011 pursuant to 42 U.S.C. § 1983 and Pennsylvania's Wrongful Death and Survival statutes, 42 PA. CONS.STAT.ANN. §§ 8301, 8302. (Doc. 1). The amended complaint alleged that the PrimeCare Defendants, Dr. Thomas, and Monroe County and various County officials violated Mr. Barbaros' Fourteenth Amendment right to adequate medical care. The amended complaint also alleged, inter alia, that the PrimeCare Defendants and Dr. Thomas were negligent in their treatment of Mr. Barbaros, and that their negligence caused Mr. Barbaros' death. (Doc. 43).

         Following the conclusion of discovery, the PrimeCare Defendants, Dr. Thomas, and Monroe County moved for summary judgment. The Court granted in part and denied in part the motions. (Docs. 174, 176, 178).

         An eight day jury trial was held September 6, 2016 through September 15, 2016.[1] At the close of Plaintiffs' case-in-chief, the PrimeCare Defendants orally moved for judgment as a matter of law pursuant to Federal Rule of Civil Procedure 50(a) on Plaintiffs' § 1983 claim, arguing that there was insufficient evidence as a matter of law to find any of the PrimeCare Defendants liable. Defendant Paul James moved pursuant to Rule 50(a) and sought a directed verdict on Plaintiffs' negligence claim. Dr. Thomas also moved for judgment as a matter of law on Plaintiffs' § 1983 claim. The Court deferred ruling on the motions.

         At the close of the evidence, the PrimeCare Defendants, Paul James, and Dr. Thomas renewed their motions and the Court again deferred ruling on the motions. The day after the closing of the evidence and the charge conference, but before the case was submitted to the jury, PrimeCare Medical Inc. (“PrimeCare”) moved for judgment as a matter of law, seeking dismissal of Plaintiffs' claim for punitive damages. The Court deferred ruling on the motion and the case was submitted to the jury.

         The jury returned a verdict in favor of Plaintiffs, finding that Dr. Thomas and the PrimeCare Defendants, with the exception of Wendy Johnson, violated Mr. Barbaros' Fourteenth Amendment right to adequate medical care and that these deprivations caused him harm. The jury awarded compensatory damages in the amount of $1, 057, 344 and apportioned liability as follows: 7% to Paul James, 7% to Patricia Bauer, 7% to Christina Rowe, 7% to Grace Ramos, 20% to Dr. Alex Thomas, and 52% to PrimeCare.

         The jury also found that the PrimeCare Defendants and Dr. Thomas were negligent, and that each of the Defendants' negligence was a factual cause of Mr. Barbaros' death. The jury awarded compensatory damages in the amount of $2, 000, 000 under the Wrongful Death Act and $800, 000 under the Survival Act. The jury found that 4% of the causal negligence was attributable to Paul James, Patricia Bauer, Christina Rowe, Grace Ramos, and Wendy Johnson each (for a total of 20%), 5% attributable to William Buffton, 20% to Dr. Alex Thomas, and 55% to PrimeCare.[2] The jury also imposed $8, 000, 000 in punitive damages against PrimeCare on Plaintiffs' negligence claim only. On September 16, 2016 the Court entered judgment in the total amount of $11, 857, 344. (Doc. 338).

         The PrimeCare Defendants subsequently filed various post-trial motions. (Doc. 366). Specifically, the PrimeCare Defendants renewed their motions pursuant to Rule 50(b), asserting that the evidence presented at trial was insufficient, as a matter of law, for a reasonable jury to find any of them liable under § 1983. PrimeCare also claimed there was insufficient evidence, as a matter of law, for the jury to award punitive damages. Additionally, the PrimeCare Defendants alleged that the evidence presented at trial was insufficient, as a matter of law, for a reasonable jury to find each of them liable for negligence. In the alternative, the PrimeCare Defendants requested a new trial pursuant to Federal Rule of Civil Procedure 59 and/or remittitur.[3]

         Dr. Thomas also sought post-trial relief. (Doc. 354). He renewed his motion for judgment as a matter of law on Plaintiffs' § 1983 claim and also filed a Rule 50(b) motion with respect to the negligence claim. Alternatively, Dr. Thomas requested a new trial and/or remittitur.

         II. STATEMENT OF FACTS

         In the early morning hours of Wednesday March 18, 2009, Mr. Barbaros was arrested and transported to the MCCF, a correctional facility in Monroe County, Pennsylvania, housing approximately 350 inmates. He was held in the segregated housing unit without a cellmate and confined to his cell 22 hours per day. On the morning of March 22, 2009, Mr. Barbaros was found dead in his cell. An autopsy was performed and a fifteen centimeter long object consisting of tightly rolled remnants of a t-shirt that had been fabricated into the shape of a tubular plug was found wedged in Mr. Barbaros' posterior oropharynx. The cause of death was listed as “choking on a foreign object” and “suicide”.

         A. PrimeCare Medical, Inc.

         PrimeCare is a for-profit corporation that contracts with state and local governments to provide correctional healthcare services, including nursing, physician, and mental health services. Sept. 8, 2016 Trial Tr. at 91:16-94:24. It was incorporated in Pennsylvania and provides services throughout Pennsylvania, Maryland, New Hampshire, New York and West Virginia. Id. at 99:5-22. It was founded by Dr. Carl Hoffman, PrimeCare's Corporate Medical Director and former President. Dr. Hoffman and his wife, who also serves as Executive Vice President, are the sole shareholders. In 2009, approximately 1200 employees and/or independent contractors worked for or on behalf of PrimeCare throughout 74 prison facilities. Id. at 99:24-12. More than half of all county inmates in Pennsylvania receive their healthcare through PrimeCare. Sept. 15, 2016 Trial Tr. at 85:11-16.

         At the MCCF, the only individuals who can determine whether an inmate will receive medical care are PrimeCare employees or agents. Id. at 111:23-112:1. It is PrimeCare's responsibility to supervise its employees and agents to ensure that they are complying with its policies and procedures. Id. at 128:25-129:3.

         Todd Haskins is the Vice President of Operations for PrimeCare. Id. at 101:1-9. In that capacity, he has “clinical oversight and operational oversight” over Central and Eastern Pennsylvania and Maryland. Id. Among his responsibilities, he writes and reviews PrimeCare's policies and procedures annually.[4] Id. at 102:3-103:6. Mr. Haskins “did not have absolute operational oversight” at the MCCF but “did oversee the facility.” Id. at 101:8-12; 103:7-10. He was not, however, involved in the day-to-day care provided to inmates at the MCCF. Id. Rather, Dr. Deborah Wilson, PrimeCare's Medical Director at the MCCF, and PrimeCare's Health Services Administrator Wendy Johnson were responsible for day-to-day operations. Id. at 102:16-19.

         Dr. Wilson has been employed by PrimeCare since 2005.[5] Id. at 71:21-22. She is the Medical Director at the MCCF and at Schuylkill and Pike County Correctional Facilities. Id. at 72:23-73:1. In 2009, Dr. Wilson was the only medical doctor at the MCCF. Id. at 78:17-79:1. As the Medical Director and the only medical doctor at the MCCF, she treated patients once a week from 9:00 a.m. to 1:15 p.m. Id. at 78:17-80:10. If she did not get through the list of patients to see she would not stay to finish. Id. The nursing staff at the MCCF complained to PrimeCare about the lack of physicians in the facility and the need for a doctor to be present more than four hours per week. Id. at 12:23-16:4.

         Dr. Wilson testified that her role as Medical Director “pretty much” involves nothing other than being a physician. Id. at 73:2-8. She does not attend any meetings, does not participate in quarterly meetings with the warden, and does not participate in death summaries or mortality reviews. Id. at 73:9-16. None of the medical staff at the MCCF report to her and she does not consider herself to be anyone's supervisor or boss.[6] Id. at 74:21-75:6. Rather, it is the responsibility of Wendy Johnson, a licensed practical nurse (“LPN”) and PrimeCare's Health Services Administrator, to supervise the nursing staff at the MCCF. Id. at 90:4-10.

         Dr. Wilson is not involved in the creation or implementation of PrimeCare's policies and procedures. Id. at 75:11-76:8. Rather, PrimeCare sends her the policies and procedures it wants implemented at each facility and then she signs off on the policies and procedures, on behalf of PrimeCare, without reading them in any detail. Id. She testified that she signs whatever PrimeCare wants her to sign and implements whatever PrimeCare wants her to implement. Id. at 77:13-16. Dr. Wilson could not recall ever speaking with any individual at PrimeCare's corporate offices regarding policies and procedures. Id. at 76:12-18. She acknowledged that, in 2009, for individuals like Mr. Barbaros who arrived at the MCCF on a Wednesday, the first time they would have been able to see a doctor or a physician's assistant would be the following Monday - five days later. Id. at 79:11-17.

         Wendy Johnson is a LPN and PrimeCare's Health Services Administrator at the MCCF. She has been employed by PrimeCare since 2002. Mrs. Johnson was hired by Todd Haskins, who is both a Registered Nurse (“RN”) and PrimeCare's Vice President of Operations. Mr. Haskins was Wendy Johnson's supervisor but he was not involved in day-to-day operations or medical care. Wendy Johnson's responsibilities included, among other things, acting as the liaison between PrimeCare's medical department at the MCCF and Monroe County. Id. at 162:19-22; Sept 7, 2016 Trial Tr. at 165:20-166:24. She was also responsible for training and supervising the nursing staff, quality assurance, and the overall workings of the medical department at the MCCF. Sept. 8, 2016 Trial Tr. at 165:15-166:24. PrimeCare trains its nursing staff in various areas, including suicide prevention, recognition of withdrawal, and National Commission on Correctional Healthcare (“NCCHC”) standards, among other things. All of the nurses employed by PrimeCare at the MCCF were LPNs. Id. at 162:19-22.

         There are important distinctions between a LPN and a RN. A LPN is qualified to undertake “the performance of selected nursing acts under the direction of a Licensed Professional Nurse, a Licensed Physician, or Licensed Dentist which do not require specialized skill, judgment and knowledge required in Professional Nursing.” Id. at 155:9-158:2. In contrast, a RN, also known as a Licensed Professional Nurse, “assesses human responses and plans, implements, and evaluates nursing care for individuals.” Id. at 149:10-150:11. In order to become a RN, an individual is required to engage in more training and schooling than a LPN. Id. at 153:23-154:6. Thus, if an individual is going to provide nursing care as a LPN, that individual is required to be supervised by either a RN, licensed physician, dentist, or psychiatrist. Id. at 160:14-18. At the MCCF, however, a LPN was supervising other LPNs.

         PrimeCare, through independent contractors, also provided psychiatric and mental health services for inmates at the MCCF. PrimeCare contracted with Dr. Thomas, a psychiatrist, to provide psychiatric services to inmates at the MCCF on its behalf. Sept. 9, 2016 Trial Tr. at 4:1-12. Dr. Thomas provided on-call psychiatric services and also came into the facility for a few hours per week every other week. PrimeCare also contracted with Forensic Counseling Services to provide psychological services to inmates at the MCCF on its behalf. Sept. 8 2016 Trial Tr. at 166:7-11. William Buffton, a master's level psychologist and employee of Forensic Counseling Services, was given the title “Mental Health Worker” by PrimeCare and was at the facility each week for approximately twelve hours. Id. at 166:22-167:2. Mr. Buffton testified that while working at MCCF he was acting as a psychologist and providing psychological services to inmates. As such, he was required to work under the supervision of a licensed and doctoral level psychologist or psychiatrist. Sept. 9, 2016 Trial Tr. at 56:10-62:8. However, he was not supervised by either a licensed doctoral level psychologist or psychiatrist. Id. Instead, he was supervised by a Licensed Social Worker at Forensic Counseling Services. Mr. Buffton was required to conduct suicide assessments of patients he met with at the MCCF and had the ability to place inmates on suicide watch or monitoring, but the decision was not his final call. Id. at 64:24-65:5. He did not receive any suicide prevention training from PrimeCare. Id. at 77:12-14.

         PrimeCare's policies and procedures mimic the minimum standard of care for a correctional environmental as set forth by the NCCHC. Sept. 8, 2016 Trial Tr. at 110:8-14. These policies and procedures include, among other things, monitoring and suicide watch. It is a “very easy process” to place an inmate under observation. Sept 8, 2016 at 30:14-31:4.

         PrimeCare also has policies and procedures for verification of medications, which provide for four ways a patient's medication can be verified: calling the patient's pharmacy, contacting the prescribing doctor, calling a family member and asking them to bring in the medication, or if the inmate simply brings the prescriptions with him into the facility. Sept. 8, 2016 Trial Tr. at 116:20-119:13. If a nurse makes only one of these efforts (such as only calling the pharmacy), cannot verify the medication, and makes no attempt to obtain the medication using the alternative methods, he or she has failed to comply with the policies and procedures of PrimeCare. Id. at 124:16-23. If a nurse is unable to verify a medication, he or she is required to contact the on-call medical provider to let them make the final determination. Id. at 118:25-119:4.

         PrimeCare's policies and procedures require that the medical staff must document all efforts to verify medications and provide that medications should be verified by the end of the next business day following admission. Id. at 119:8-16. If an individual comes into the MCCF and indicates that he or she takes psychiatric medications, such as Paxil or Prozac, and the nursing staff cannot verify the medication, PrimeCare's policies require the on-call psychiatrist to be called and have the patient placed on the provider line.[7] Id. at 119:21-120:21; 124:3-23.

         PrimeCare expects that if the nursing staff is unfamiliar with a particular medication or its side effects, the nurse should research the medication. It does not, however, provide any training regarding different types of medications or the impact they have on the body. Id. at 126:9-127:23. PrimeCare's policies and procedures also require that all employees and agents review a patient's medical file before rendering treatment and completely and accurately fill out medical forms, including documenting when the last time a patient has taken his or her medication. Id. at 130:14-17. If information is missing from a patient's intake form and medical chart, the nurses have a duty to investigate and obtain the missing information. Id. at 21:8-14.

         To ensure adequate supervision of its employees and agents, PrimeCare utilizes a Continuous Quality Improvement (“CQI”) program. Sept. 8, 2016 Trial Tr. at 130:14-131:10. In general, CQI consists of pulling approximately 5% of medical charts at random and reviewing those charts to see if there any mistakes the nursing staff is making and, if so, to implement a corrective plan of action. At the MCCF, CQI was Wendy Johnson's responsibility. At the corporate level, PrimeCare also utilizes a “peer review process” where individuals not associated with the facility conduct a mock NCCHC audit. Id. at 131:11-17. In addition, approximately every three years the NCCHC sends a team of doctors and nurses to conduct a complete review of the medical department. Id. Both the CQI program and the peer review process are the tools PrimeCare utilizes to “know… what's going on in [its] facilities.” Id. at 131:18-20. When asked about PrimeCare's CQI program, Dr. Wilson testified that nobody from PrimeCare or anywhere else comes into the facility to supervise her work or the work of the physician's assistant. Id. at 77:23-78:16. She testified that she believes “there is a quality control that goes on, but I don't really know who does it or when it's done.” Id. It is the responsibility of Wendy Johnson, as Health Services Administrator, to oversee the CQI process.

         B. March 18, 2009 - March 22, 2009

         1. Paul James

         Shortly after Mr. Barbaros was arrested, Paul James, a LPN employed by PrimeCare at the MCCF, conducted an intake medical screening. In 2009, Nurse James was the only medical personnel at the MCCF during the overnight shift and testified it was “very busy at night.” Sept. 7, 2016 Trial Tr. at 61:23-62:5. While conducting the intake, Nurse James made numerous mistakes and violated several policies and procedures. For example, he listed Mr. Barbaros' first name as “Nunuun” and took no steps to verify the correct spelling of his name. Id. at 32:12-19. On another form, he spelled Mr. Barbaros' first name as “Munmum.”[8] Id. at 45:5-13. Nurse James indicated on the intake form that Mr. Barbaros was taking the prescription medications Trazodone and Prozac. He also documented that he had a history of ulcers. Id. at 38:16-41:2. Mr. Barbaros, however, had been prescribed Paxil, not Prozac. Because Mr. Barbaros had a history of ulcers, Nurse James placed him on the provider line to see a medical doctor.

         Nurse James also obtained the name of Mr. Barbaros' prescribing physician, Dr. Richard Katz, as well as the name of the pharmacy where Mr. Barbaros filled his prescriptions - the CVS in Mountainhome. Id. at 39:16-22. He correctly documented Mr. Barbaros' address, date of birth, and social security number. Id. Due to the late hour, however, Nurse James could not verify Mr. Barbaros' medications. Id. at 51:3-10. Instead, he passed the information he collected to the nurse on the morning shift.

         Nurse James did not obtain and document all of the information required on the intake form, including whether Mr. Barbaros was a pretrial detainee or sentenced prisoner. Id. at 35:21-36:2. Although Nurse James noted that Mr. Barbaros was taking psychiatric medications, he did not document why Mr. Barbaros took these medications, the dosages, or the last time he took these medications. Id. at 38:20-39:15; 49:9-50:5. PrimeCare's policies require that when an incoming patient is taking psychiatric medications, like those taken by Mr. Barbaros, the patient should be placed on the psychologist's list to be seen the next day. Id. at 43:19-25. Nurse James did not place Mr. Barbaros on the “psych list.” Id. at 44:7-13. He acknowledged that, in accordance with PrimeCare's policies and procedures, he should have placed Mr. Barbaros on a list to see a mental health professional the next day. He testified that he did not know at the time that “our mental health or psychologist was part time.” Id. at 43:6-44:10.

         During the intake, Nurse James checked Mr. Barbaros' vital signs, which were found to be normal. Id. at 46:15-47:5. He also completed an intake suicide screening. Id. at 53:13- 21. Based on Mr. Barbaros' answers to his questions, Nurse James determined that Mr. Barbaros did not warrant observation.[9] Id. at 53:13-21. The parties agree that Mr. Barbaros was not suicidal at the time of the intake. Sept. 8, 2016 Trial Tr. at 33:24-5. Nurse James had no other interactions or involvement in the care of Mr. Barbaros.

         At trial, Nurse James testified that he knew it was important to accurately and completely fill out the intake forms in order to ensure proper medical treatment is rendered to patients. Id. at 29:20-30:10. He acknowledged that if information necessary for diagnosis or treatment of a patient is missing from an intake form that the nursing staff should investigate. Id. at 31:4-8. He testified that he was aware that if an individual like Mr. Barbaros did not promptly receive his medications, he could potentially suffer from withdrawal. Id. at 57:11-14. He further acknowledged that he knew errors on an intake form can put a patient at risk of physical harm. Id. at 81:5-17. Nurse James testified that when an individual comes into the MCCF with psychiatric issues and on psychiatric medications he considers this a serious medical need. Id. at 81:5-17.

         2. Patricia Bauer

         The next person involved in Mr. Barbaros' care was Patricia Bauer.[10] Nurse Bauer is a LPN and had been working for PrimeCare only for a few months. She received her nursing degree in 2008 and this was her first permanent nursing job. She described the training she received from PrimeCare as consisting of shadowing other nurses and learning the job “as you go.” Id. at 127:4-10. She could not recall very much, if any, formal training she received from PrimeCare. Id. at 128:6-13.

         Using the information communicated to her by Nurse James earlier that day, she made a telephone call to CVS at approximately 2:00 p.m. and attempted to verify Mr. Barbaros' medications.[11] Id. at 134:8-18. For unknown reasons, Nurse Bauer could not verify Mr. Barbaros' prescriptions. She testified that she called multiple CVS pharmacies in the area but they were all unable to verify his medications.[12] She indicated on Mr. Barbaros' medical chart that “CVS denies customer” and “may put on the psych list.” Id. at 134:15-18. Although Nurse Bauer made a notation that “CVS denies customer” she neglected to fill out the section requiring her to state “If not verified, please explain.” Id. at 51:25:52:14.

         Nurse Bauer placed Mr. Barbaros on the “psych list” to meet with a mental health professional. Id. at 134:24-135:6. She did not, however, contact Mr. Barbaros' prescribing physician or call his wife and ask her to bring the medications (despite having this information). Id. at 145:25-148:8. Nor did she speak with Mr. Barbaros in an attempt to obtain more information that could assist with the verification of his medications. She also did not contact the on-call psychiatrist. Her acts and omissions violated PrimeCare's policies and procedures.

         Nurse Bauer testified that she would never call an inmate's physician for medication verification. Id. at 145:146:20. When asked if it was that much extra effort to call the inmate's prescribing physician she testified: “Do we have a phone number for the doctor? Do we have an address for the doctor? Is he even telling the truth? Do I have 15 other intakes that I have to get through and it's 2 p.m. in the afternoon already?” Id. at 147:10-21. She said “you do the best you can with the time you have with the amount of inmates you're dealing with.” Id. at 147:22-148:2.

         Nurse Bauer then described her experiences with inmates lying about being on medications and other types of drug seeking behavior. She testified that an inmate seeking an SSRI (“Selective Serotonin Reuptake Inhibitor”) medication like Paxil could be among those inmates lying about their medication to obtain mind altering drugs, but did not recall that ever having occurred. Id. at 137:12-145:13. When asked whether an individual coming into the MCCF reporting depression and that he or she is taking psychiatric medications “raises any kind of red flag” she said, “At the jail? No. So many of them will say that because they want that drug. They walk in the doors, they say, Hi, you're the nurse, put me on the psych list.” Id. at 148:3-8.

         Nurse Bauer testified that she knew it was important that complete and accurate information is documented on the intake forms because it affects her ability to verify medications. Id. at 129:17-130:4; 138:4-139:2. She was also aware that if a patient is without medications, including psychiatric medications like Paxil, there is a possibility that patient can suffer from withdrawal. When confronted with Nurse James' intake forms she testified: “I don't know what happened with the man that did this intake, why he would do this. I'm sure it was just trying to be fast.” Id. at 137:13-141:12. Nurse Bauer's only other involvement in the care of Mr. Barbaros lasted “seconds” when she gave him his Paxil and Lopressor on the morning of March 21. Id. at 130:5-132:12.

         On March 19, 2009 (the day after Nurse Bauer attempted to verify Mr. Barbaros' medications), Mr. Barbaros was not seen by any medical staff and there is no record that anyone made an attempt to verify and obtain his medications. Later that day, he developed a headache and submitted a sick call slip that stated: “I'm experiencing headaches. Could I get something to relieve the pain? Also, I have a stomach ulcer. Would it be possible for me to get something for this as well?” Rowe Dep. Tr. at 14:14-19.

         3. Christina Rowe

         At 10:30 a.m. on March 20, 2009, Mr. Barbaros was seen by Christina Rowe, a LPN employed by PrimeCare at the MCCF.[13] Working for PrimeCare at the MCCF was Nurse Rowe's first nursing job. Id. at 7:6-22. She, like Nurse Bauer, testified that the extent of the training she received from PrimeCare was being paired with another nurse and following them around. Id. Nurse Rowe nevertheless testified that she still received “a lot of training” from PrimeCare but did not recall the specifics. Id. She also did not recall if she received suicide prevention training, but said there “probably was” suicide prevention training. Id. 61:3-24.

         Nurse Rowe assessed Mr. Barbaros in response to his sick call request. She did not, however, review his medical chart prior to performing the assessment and providing treatment. Id. at 16:20-18:3. Performing an assessment and providing treatment without accessing or reviewing a patient's medical chart is a violation of PrimeCare's policies and procedures. Id. However, Nurse Rowe testified it was “very normal” not to have an inmate's medical file at her disposal while performing sick call assessments. Id. at 19:8-24. On the assessment forms, Nurse Rowe identified Mr. Barbaros as a “female” and also spelled his name incorrectly. Id. at 79:14-89:4. She also made several other mistakes on the forms, and conceded she did not obtain complete and accurate information. Id. at 79:14-80:4.

         During the assessment, Mr. Barbaros described his headache to Nurse Rowe as moderate, frontal, and constant and stated that nothing made the pain better. Id. at 22:21-23:4. Nurse Rowe took Mr. Barbaros' vital signs and noted he had high blood pressure that was clinically significant. Id. at 23:5-16. Specifically, Mr. Barbaros' blood pressure was 170/105 (a significant increase from his blood pressure at intake). Nurse Rowe ordered and provided Mr. Barbaros with Acetaminophen 325 mg for his headaches, to be taken twice daily for five days. Id. at 31:18-21. She, like Nurse James, placed Mr. Barbaros on a list to see a medical provider because of his ulcer. Id. at 32:2-6. Nurse Rowe acknowledged that when performing an assessment on a patient complaining of a headache and with irregular vital signs, it would be important to know what medications the patient had been taking. She conceded that it would have been helpful if she had Mr. Barbaros' medical files with her at the time of her assessment. Id. at 26:25-28:6.

         At 2:00 p.m., Nurse Rowe spoke with Jennifer Mroz, the on-call physician's assistant at the MCCF. She did not inform Ms. Mroz that Mr. Barbaros claimed he was on medications and they had not been verified. Ms. Mroz verbally ordered 50 milligrams of Lopressor, a blood pressure medication, to be given to Mr. Barbaros twice a day for thirty days. Id. at 36:6-14. She also ordered daily blood pressure checks for the next five days. Id. Nurse Rowe documented this information on Mr. Barbaros' medical chart and would or should have known at this time that his medications had not been verified in over 48 hours. Despite receiving medical orders to check Mr. Barbaros' blood pressure daily, there is no record that his blood pressure was ever checked again by any member of the nursing staff.[14] Id. at 37:5-15. This, too, was a violation of PrimeCare's policies and procedures. Nurse Rowe acknowledged that if a physician or physician's assistant orders blood pressure checks they must be performed, and that failing to do so puts the patient at risk of harm.[15] Id. at 38:24-39:3. She conceded that she took no steps to verify Mr. Barbaros' medications and acknowledged that her failure to do so could put a patient at risk of harm. Id. at 41:22-43:5; 47:5-10; 52:20-53:16.

         On the afternoon of March 20, 2009, Mr. Barbaros was transported from the MCCF to Court for his arraignment. During the arraignment, he learned he would face additional charges and his bail would be increased. While in court, Mr. Barbaros complained to the Judge that he was not receiving his medications. The Judge asked the police officers escorting Mr. Barbaros back to the MCCF to relay Mr. Barbaros' concerns to the appropriate personnel.

         At the arraignment, Howard Frank, a staff reporter for the Pocono Record, observed Mr. Barbaros from the time he arrived in Court until the time he left. Id. at 163:8-10. Mr. Frank observed Mr. Barbaros with his shoulders slumped and head down. Id. at 163:11-12. He also confirmed that Mr. Barbaros complained to the Judge about not receiving his medications.[16] Id. at 163:18-19.

         4. Wendy Johnson

         Mr. Barbaros returned to the MCCF at approximately 5:00 p.m. Shortly after his arrival, Wendy Johnson, a LPN and PrimeCare's Health Services Administrator at the MCCF, was notified that Mr. Barbaros complained about not receiving his medications. Id. at 168:1-10. It is Wendy Johnson's responsibility to, among other things, supervise and train the nursing staff on behalf of PrimeCare and act as a liaison between Monroe County and the PrimeCare staff at the MCCF. Id. at 165:20-166:24.

         Wendy Johnson reviewed Mr. Barbaros' medical chart and saw that his prescriptions had not been verified and was aware that important information was missing from his forms. She then called Grace Ramos, another LPN employed by PrimeCare at the MCCF, and instructed her to try to verify his medications. Id. at 170:10-16. She did not, however, tell Nurse Ramos to report back to her. Nor did she inform Nurse Ramos about the deficiencies in Mr. Barbaros' forms or ask her to obtain the missing information. Id. at 179:9-23. Mrs. Johnson acknowledged that after reviewing the medical chart and seeing that Mr. Barbaros' medications had been denied and that no further efforts to verify the medications had been documented, she should have investigated to make sure further efforts were taken to verify the medications.[17] Id. at 183:3-9.

         Todd Haskins echoed much of Wendy Johnson's testimony. Mr. Haskins is a RN, PrimeCare's VP of Operations, and Wendy Johnson's supervisor. He testified that if Wendy Johnson reviewed Mr. Barbaros' chart and saw that the last time he had taken his medication was unknown, PrimeCare's policies required her to communicate this information to the nursing staff. Sept. 8, 2016 Trial Tr. at 132:22-133:6. Mr. Haskins also testified that, as the nursing supervisor, Wendy Johnson should have investigated the failures of the nursing staff in connection with Mr. Barbaros' treatment. Id. at 135:11-23. Despite these obligations, at no time did Wendy Johnson communicate to Nurse Ramos or any other medical provider or member of the nursing staff that there had been a delay in Mr. Barbaros receiving his psychiatric medications. Nor did Mrs. Johnson speak with Mr. Barbaros to inquire into his well-being.

         At trial, Mrs. Johnson testified that it is important to know the last time a patient took his or her medications and the proper dosage because, among other things, it is possible that a patient without their medications could go through withdrawal. She acknowledged that when an intake nurse fails to accurately and completely fill out the intake form they could potentially be putting the patient's safety at risk. Id. at 173:2-12; 173:20-23. She testified that she was aware that failure to record this information was a violation of PrimeCare's policies and procedures. Id. at 173:13-19. She acknowledged that a nurse performing an assessment of a patient should obtain and review the patient's medical records prior to assessing the patient. Id. at 182:6-15. She also conceded that she knew that if medications are denied to a patient, and nothing is done to investigate, then there is a risk that the patient could suffer side effects from being without those medications. Id. at 184:7-18.

         Wendy Johnson testified that PrimeCare trains its employees and agents on recognition of withdrawal symptoms. Id. at 175:19-21. She acknowledged that symptoms such as a headache and high blood pressure could be symptoms of withdrawal. Id. at 175:22-25. She also conceded that, when reviewing Mr. Barbaros' records, she would have seen that he had been prescribed Lopressor earlier that day, was suffering from high blood pressure that he did not experience upon intake, and had not received his medications in at least three days. Id. at 177:6-10. Despite this knowledge, she did not make any efforts to investigate, or ask any staff member to research possible side effects of Paxil withdrawal.[18]Id. at 178:19-179:5.

         5. Grace Ramos

         Nurse Ramos was the only member of the medical staff at the MCCF on the evening of March 20, 2009. She testified that she and the other nurses complained to PrimeCare about lack of staffing and that the nurses needed extra help to complete tasks during their shifts. PrimeCare, however, felt that one LPN per shift was appropriate. Id. at 12:23-16:4. Nurse Ramos also testified that she and the nursing staff complained to PrimeCare about the lack of physicians in the facility, and that they needed access to a doctor more than four hours per week. Id. Specifically, she testified the reasons for the complaints were “because the doctors would come in at the beginning of the week, and by the time they did all the sick calls from Wednesday through the weekend, the nursing staff would have a backlog of patients to see.” Id. at 16:9-14. She then noted that Dr. Wilson's sick call list “would be around 20 patients or more.” Id. at 16:15-19. Although they had access to on-call providers, she testified that none of the providers would actually review medical records.[19]

         After receiving a call from Wendy Johnson apprising her of Mr. Barbaros' complaints, Nurse Ramos called CVS pharmacy at approximately 9:35 p.m. on the evening of March 20. Nurse Ramos, using the same information obtained and documented by Nurse James, successfully verified his medications with CVS. She did not review Mr. Barbaros' medical chart and was unaware when he had last taken his medications. Id. at 20:23-21:1. Nurse Ramos acknowledged that if she had reviewed the file she would have learned that important information was missing and she would have had a duty to investigate or communicate this information to the medical provider. Id. at 21:8-14. She also acknowledged she knew one of the reasons to conduct such an investigation would be to determine whether a patient was suffering from any withdrawal or side effects, and that she should have looked into potential side effects related to abrupt discontinuation of Paxil. Id. at 21:23-26:9. She testified, however, that her “main goal was to verify his meds and get it to him as soon as possible.” Id. at 25:5-7.

         After verifying Mr. Barbaros' medications with CVS, Nurse Ramos called Dr. Thomas, an independent contractor and PrimeCare's on-call psychiatrist. She spoke to him over the telephone for approximately one minute. Id. at 27:14-19. Nurse Ramos could not recall whether Dr. Thomas asked her to review Mr. Barbaros' medical records, asked her to check the last time he took his medications, or asked about his physical condition and vital signs. Id. at 28:2-19.

         Nurse Ramos acknowledged that PrimeCare's policies require the medical staff completing intake paperwork to verify the spelling of the patient's name and to take steps to ensure the intake paperwork is fully and completely filled out. She conceded that if a patient says he is taking medications, a nurse must find out when they were last taken and why they were taken. Id. at 5:9-23. She also acknowledged that when a nurse does not complete the paperwork properly, they are potentially putting their patient at risk. Id. at 6:15-18. Nurse Ramos testified that if a nurse is having trouble verifying a patient's medication with a pharmacy, they could call the patient's physician to verify the medication, but that she never did this. Id. at 6:19-7:20.

         Nurse Ramos was trained to recognize withdrawal symptoms. She testified that among the symptoms to look for are fluctuations in vital signs. Id. at 9:5-10. She acknowledged that signs of withdrawal may include a headache, high blood pressure, and pacing. She said it is the responsibility of the medical staff to recognize someone suffering from withdrawal. Id. at 9:16-10:1. Finally, she acknowledged that it is a very easy process to put someone on a watch or under observation and that it is better to err on the side of caution and put someone on watch when in doubt.[20] Id. at 30:14-31:4.

         6. Dr. Alex Thomas

         Upon receiving the call from Nurse Ramos that Mr. Barbaros' prescriptions had been verified by CVS, Dr. Thomas (who had no information about Mr. Barbaros other than the fact his prescriptions had been verified) verbally prescribed Paxil and Trazodone in the same doses he had been prescribed by Dr. Katz, Mr. Barbaros' physician. Before prescribing the medications, Dr. Thomas did not: (1) ask Nurse Ramos any questions about Mr. Barbaros' condition or history; (2) review his medical charts or ask Nurse Ramos to review his medical charts; (3) ask if Mr. Barbaros had a history of mental illness; (4) ask when Mr. Barbaros had last taken his medications; or (5) ask if Mr. Barbaros was exhibiting any signs or symptoms associated with withdrawal. Sept . 9, 2016 Trial Tr. at 16:25-18:1; 18:22-19:7; 29:16-32:12. Dr. Thomas testified that it was his usual practice to speak with the nurse about the medications the inmates were taking and that most of the time he would have asked these questions. However, his primary and immediate concern was that Mr. Barbaros receive the medications he had been taking prior to his incarceration and then note that he needed to be re-evaluated. Id. at 18:8-18.

         Dr. Thomas acknowledged that he was at fault for neither asking for nor obtaining any information about Mr. Barbaros prior to prescribing him psychiatric medications. Id. at 31:6-7. He agreed that, as a physician, he had an obligation to investigate to find out why a patient is taking a medication like Paxil and the last time they took the medication prior to prescribing them medication. Id. at 32:24-33:5. He acknowledged that, in some instances, when a patient has been off their medications for a number of days and the medication has a short half-life (like Paxil), a patient may be exhibiting signs and symptoms of withdrawal. Id. at 33:6-10.

         Dr. Thomas acknowledged that he could have come into the MCCF that evening. However, he did not believe it was necessary because it was not an emergency situation and he was scheduled to come into the MCCF on Sunday.[21] Id. at 39:13-16. He testified that he could have put Mr. Barbaros on suicide watch or monitoring but that, in his clinical judgment, he did not believe it was necessary. Id. at 49:8-21. Dr. Thomas acknowledged that he knew nothing about Mr. Barbaros other than that a previous physician had prescribed him Paxil and Trazodone.

         At trial, Dr. Thomas acknowledged that certain prescription medications can cause withdrawal and pose a risk of suicide when started or restarted, including Paxil. Id. at 9:16-22. Specifically, he testified that he was aware that one of the risks of prescribing Paxil is that the drug itself may cause suicidal ideations. Id. at 14:12-18. He agreed that an individual starting on SSRI medications like Paxil should be monitored and observed closely, id. at 14:21-15:3, and that the only way to communicate information about these risks is to speak with the patient or with the patient's family. Id. at 15:4-7. However, he stated that because these medications had already been prescribed by someone else he has “to assume that the patient has been educated about the potential side effects and things to watch for.” Id. at 15:18-19.

         When asked by Plaintiffs' counsel whether he was subjectively aware, at the time he prescribed Paxil to Mr. Barbaros, that when starting a patient on medications like Paxil there was a tendency that the patient could become suicidal, Dr. Thomas testified: “[o]nly if somebody is started for the first time, not once it is resumed within a few days, no.” Id. at 41:14-22; 44:3-8. However, Dr. Thomas acknowledged that because he did not ask for any information about Mr. Barbaros' history, he had no way of knowing how long Mr. Barbaros had been off his medications.

         Dr. Thomas acknowledged the importance of early recognition and diagnosis of a deteriorating mental condition, and also acknowledged that early recognition increases the likelihood of avoiding injury to a patient. Id. at 21:25-22:8. He testified that without having a complete picture of a patient's background and condition, a doctor would not be in a position to properly evaluate the patient to make a determination as to the proper course of treatment and therapy, and that this could increase the risk of harm to a patient. Id. at 24:5-12. Dr. Thomas also testified that, in certain cases, a patient who is incarcerated for the first time like Mr. Barbaros is at an increased risk of suicide. Id. at 24:16-22. He conceded that when a patient has been off a medication like Paxil for several days or a week there is a chance of suicide. Id. at 26:12-18. Finally, Dr. Thomas acknowledged that he should have asked how long Mr. Barbaros had been off his medication because certain actions might need to be taken until the medication is further built up in the patient's system. Id. at 44:12-17. For example, in certain circumstances, the patient should be placed under observation until Dr. Thomas was able to come into the facility to meet with that patient. Id. at 38:8-39:2.

         On the evening of March 20, 2009, Mr. Barbaros received his first (and only) dose of Trazodone while at the MCCF. Sept. 8, 2016 Trial Tr. at 44:12-17. This was slightly less than 72 hours after he first entered the MCCF at 3:00 a.m. on March 18.

         On March 21, 2009, Mr. Barbaros received his first and only dose of Paxil at approximately 9:00 a.m. He did not receive Paxil the evening before because it is a medication prescribed to be taken in the mornings. Despite medical orders from a physician's assistant, there is no record that any medical personnel at the MCCF checked Mr. Barbaros' blood pressure this day. That morning Mr. Barbaros also spoke with his wife, Plaintiff Miryem Barbaros. He informed her that he would make bail and would be able to leave the MCCF on Thursday March 26. Sept. 6, 2016 Trial Tr. at 203:21-23-204:1-4.

         7. William Buffton

         When Nurse Bauer was unable to verify Mr. Barbaros' medications on Wednesday March 18, she placed him on line to see a psychologist. On the afternoon of Saturday March 21, Mr. Barbaros met with William Buffton, a psychological services associate. Sept. 9, 2016 Trial Tr. at 55:10-12. Mr. Buffton is a Psychological Services Associate, which is a Civil Service Master's Level Psychologist. He is not a licensed doctoral psychologist. Id. Mr. Buffton previously worked for over ten years at the Pennsylvania State Department of Corrections as a Psychological Services Specialist, a Grade 8 Master's Level position. He testified that when he is functioning as a Psychological Services Associate he is required to work under the supervision of a licensed and doctoral level psychologist. Id. at 56:10-14.

         Mr. Buffton was employed by Forensic Counseling Services, an independent contractor hired by PrimeCare to provide psychological services to inmates at the MCCF. He was given the title “Mental Health Worker” by PrimeCare, ostensibly obviating the need for PrimeCare to supervise him. Id. at 56:15-21. However, Mr. Buffton testified that he was acting as a psychologist and providing psychologist services at th[2]e MCCF without any supervision from a licensed psychologist or psychiatrist.[] Id. at 57:8-15; 59:21-23; 62:8-11. He testified that, as he himself contracted with Forensic Counseling Services, he did not concern himself with who supervised him. Id. at 62:3-20.

         As a Mental Health Worker at the MCCF, Mr. Buffton worked approximately 12.5 hours per week at the MCCF. He also possessed the ability to place inmates on suicide watch or monitoring. Id. at 64:24-65:5. The decision, though, was not his final call. Id. He did not receive any training from PrimeCare on suicide prevention and was unfamiliar with PrimeCare's policies and procedures on suicide watch and monitoring. He testified he was unfamiliar with the policies and procedures because PrimeCare did not require him to be familiar with those policies and procedures. Id. at 77:12-14.

         On the afternoon of March 20, 2009, Mr. Buffton briefly met with Mr. Barbaros for approximately ten to eighteen minutes (at most). His notes from the meeting described Mr. Barbaros as a recently arrested first-time inmate acting timid, subdued, emotional, and with a history of treatment for anxiety and depression for which he took Paxil and Trazodone. Id. at 68:6-10; 73:14-20. Throughout the meeting, Mr. Barbaros was turned away from Mr. Buffton, staring at the floor and not making any eye contact. Id. at 81:8-83:2. Mr. Barbaros only responded to Mr. Buffton's questions with short answers and mumbling. Id. At his deposition, Mr. Buffton described Mr. Barbaros as “looking like a cornered rat” and appearing “very, very fearful.” Id. at 67:15-18. Although he acknowledged that many of these behaviors indicate suicidal tendencies, Mr. Buffton noted that Mr. Barbaros became more relaxed and animated as time went by.[23] Id. at 68:11-13; 88:23-6.

         Like the other medical staff at the MCCF, Mr. Buffton did not review Mr. Barbaros' medical chart and did not discuss his physical condition with anyone. Id. at 70:8-72:15. He testified he did not do this because in the limited time he had to meet with Mr. Barbaros he understood his role as simply assessing whether Mr. Barbaros required further services. Id. at 72:6-15. Mr. Buffton's notes stated “rule out depression and rule out adjustment disorder.” This meant that he suspected Mr. Barbaros was suffering from depression and/or adjustment disorder. Id. at 67:24-68:5. Mr. Buffton intended to refer Mr. Barbaros to a psychiatrist. Id. at 68:14-15.

         Mr. Buffton's notes contain no record that he conducted a suicide assessment of Mr. Barbaros and did not document any information indicative of suicide risks. Despite this lack of documentation, Mr. Buffton testified that he conducted a suicide assessment and that Mr. Barbaros' symptoms and conduct “did not scream suicide.” Id. at 85:17-86:3. Instead, they “indicated that he was under a lot of pressure, they indicated he was anxious, they indicated he was fearful.” Id. at 85:17-86:3.

         Mr. Buffton's meeting with Mr. Barbaros is his last known interaction with any of the medical staff at the MCCF. On the evening of March 21, he was scheduled to receive his Trazodone. The medical records, though, indicate he was never provided this medication.

         8. Correctional Officers Cleary and Ryan

         Two MCCF correctional officers, Christine Cleary and Jonathan Ryan, testified at trial. Id. at 109:25-157:7. In 2009, Officer Cleary worked the second shift from approximately 7:20 a.m. to 5:20 p.m. Id. at 113:18-25. In March, she was stationed in the B Unit at the MCCF (also known as the segregated housing unit). Id. at 11:2-119:18. She had observed and recorded Mr. Barbaros' behaviors over the course of three days and did not document any unusual behaviors. Id. at 118:12-122:4-7. However, on the afternoon of March 21 she observed Mr. Barbaros pacing in his cell and documented this on a behavioral observation form. She testified this would have been out of character for Mr. Barbaros which is why she made a notation. Id. at 121:25-126:2.

         In 2009, Officer Ryan was also stationed in the B Unit. He worked the third shift between approximately 4:40 p.m. and 12:40 a.m. Id. at 142:10-143:10. Officer Ryan did not identify or document any unusual behaviors exhibited by Mr. Barbaros during the prior days he had observed and recorded his behaviors. Id. On the evening of March 21, he observed and documented that Mr. Barbaros was exhibiting “bizarre behavior.” Id. at 146:20-148:16. The “bizarre behavior” was that Mr. Barbaros had removed all of his clothing and was in his underwear. Id. Officer Ryan recalled briefly speaking to Mr. Barbaros that evening. He testified that at no time did he believe that Mr. Barbaros should have been monitored or was a suicide risk. Id. at 152:23-153:2. Officer Ryan's final note observed that at 11:21 p.m. Mr. Barbaros was alive.

         For the next seven hours Mr. Barbaros was not monitored or observed by any correctional officer or medical staff. On Sunday March 22, at approximately 6:19 a.m., he was found dead in his cell. An autopsy was performed and a fifteen centimeter long object consisting of tightly rolled remnants of a t-shirt that had been fabricated into the shape of a tubular plug was found wedged in Mr. Barbaros' posterior oropharynx. The cause of death was identified as “choking on a foreign object” and “suicide.”

         C. Expert Witnesses

         At trial Plaintiffs called four expert witnesses: Kathryn Wild, Dr. Peter Breggin, David Hopkins, and Dr. Lorene Sheren. The PrimeCare Defendants and Dr. Thomas also presented expert testimony from: Terry Fillman, Dr. Lawrence Mendel, Dr. Lawrence Guzzardi, Dr. Cheryl Wills, and Dr. Susan Rushing.

         1. Kathryn Wild

         Kathryn Wild was offered, and accepted, as an expert in nursing and correctional health care. Nurse Wild is a RN and Certified Health Care Professional. Sept. 8, 2016 Trial Tr. at 199:9-201:14. She previously worked as Senior Nurse at the Orange County Correctional Facility in California and as the Health Services Administrator of the San Bernadino Sheriff's Department for fifteen years. Id. at 200:16-201:17. In her capacity as Health Services Administrator of the San Bernadino Sheriff's Department, she oversaw the health care program for four prison facilities with an inmate population of approximately 6, 000 and also supervised the nursing staff. Id. at 201:19-203:7.

         After leaving this position, Nurse Wild worked as Deputy Director in charge of Correctional Health Care for Orange County. Id. at 204:9-25. She is also the former President of the California Chapter of the American Correctional Health Services Association. Id. at 208:20-209:11. She has received training and is familiar with the standard of care for nursing in correctional healthcare and has experience treating patients on psychiatric medications. She is also familiar with the appropriate policies and procedures in the correctional healthcare setting and withdrawal symptoms and has received training in these respects. Id. at 211:9-216-13.

         Nurse Wild testified, to a reasonable degree of nursing certainty, that the care rendered by each of the individual PrimeCare Defendants (Paul James, Patricia Bauer, Christina Rowe, Grace Ramos, and Wendy Johnson) fell below the applicable standard of care for nurses and healthcare professionals in a correctional setting. Id. at 227:6-12; 258:4-10. She also testified that all of the individual PrimeCare Defendants were subjectively aware that delaying or denying Mr. Barbaros his medications could cause him to suffer withdrawal or some other risk of harm. Id. at 258:25-259:7.

         With respect to Nurse James, Nurse Wild opined his handling of Mr. Barbaros' intake fell below the applicable standard of care and was neither sufficient nor complete. Id. at 227:15-228:8. She testified the failure to obtain accurate and complete information about a patient's psychiatric medications puts a patient at risk of harm. Id. at 228:11-229:9. She described Nurse James' multiple misspellings of Mr. Barbaros' name as “careless and sloppy.” Id. at 285:1. She also explained that with medications like Paxil there is a risk to stopping a patient “cold turkey.” Id. at 229:8-17. In her opinion, Nurse James' failure to properly conduct the intake screening “set the stage, if you will” for the substandard care received by Mr. Barbaros and the MCCF placed him at risk of harm. Id. at 229:22-230:12.

         Nurse Wild referred to the acts and omissions of Nurse Bauer as “well outside the standard” of care. Id. at 230:16-232:25. She opined that Nurse Bauer's single attempt to verify Mr. Barbaros' medications and her lack of follow up “very much” puts a patient like Mr. Barbaros at risk of harm. Id. at 231:7-8. As for Nurse Rowe, it was Nurse Wild's opinion that her handling of Mr. Barbaros' sick call was insufficient, inappropriate, and breached the standard of care and put Mr. Barbaros at risk of harm. Id. at 233:8-240:6.

         She also testified that Wendy Johnson, after reviewing Mr. Barbaros' medical chart and knowing that he had not received his medications in over 48 hours, “at a minimum, she should have called him down to see how he's doing, and then call a provider with that information.” Id. at 240:7-22. She also said that Wendy Johnson at least should have communicated this information to Nurse Ramos. Id. at 241:9-13. These acts and omissions, among others, led Nurse Wild to conclude that Wendy Johnson's acts and omissions were a breach of the standard of care and increased the risk of harm to Mr. Barbaros. Id. at 243:5-6.

         Nurse Wild conceded that Nurse Ramos “did a good job on calling CVS and getting the information that Nurse Bauer couldn't get with the same information.” Id. at 243:11-16. It was her opinion, however, that Nurse Ramos should have reviewed Mr. Barbaros' medical chart and informed the on-call psychiatrist about the length of time Mr. Barbaros had been off his medications and whether he had any signs or symptoms of withdrawal. Id. at 244:1-11.

         Nurse Wild opined that each of the individual PrimeCare Defendants were subjectively aware that not having medications like Paxil or Prozac could cause withdrawal, and that denying or delaying Mr. Barbaros access to his psychiatric medication was a delay in the treatment of his serious medical need. Id. at 244:12-245:2. She also testified that the symptoms Mr. Barbaros was exhibiting, including headaches, high blood pressure, fear, and anxiety, suggested withdrawal and that “those are all red flags that something is going on with our patient.” Id. at 249:8-18. According to Nurse Wild, the combination of Mr. Barbaros' symptoms and his failure to receive his medications meant that “he should have been put on some type of observation or some type of watch, where people were monitoring these symptoms” and that the individual PrimeCare Defendants' failure to do so breached the standard of care and placed Mr. Barbaros at an increased risk of harm. Id. at 250:1- 253: 19.

         Nurse Wild conceded that the policies and procedures PrimeCare had in place in 2009 met the appropriate standard of care. She testified, however, that this was not the issue. Id. at 250:8-11. Rather, she opined that the issue was the lack of supervision of the medical staff and the lack of follow-through to ensure the staff followed the policies and procedures in place at the facility. Id. at 250:12-19. When asked whether PrimeCare and Wendy Johnson were properly supervising the staff at the MCCF she said “obviously not, ” and referred to, among other things, Nurse Rowe's statement that it was “very common” to assess patients without reviewing their medical charts. Id. at 250:20-251:2. Nurse Wild also testified that in certain respects PrimeCare's LPNs were acting outside the scope of their authority. Id. at 235:15-25. According to Nurse Wild, the acts and omission of each of the PrimeCare Defendants increased the risk of harm to Mr. Barbaros and contributed to his death. Id. at 251:12-253:12.

         2. Dr. Peter Breggin

         Plaintiffs also offered Dr. Peter Breggin as an expert. Dr. Breggin was offered, and accepted, as an expert in psychiatry, psychopharmacology, and Paxil. Sept. 9, 2016 Trial Tr. at 226:9-10. Dr. Breggin received his undergraduate degree from Harvard College and his medical degree from Case Western Medical School. After medical school he interned at SUNY Upstate Medical Center in Syracuse. Id. at 192:4-23. He ran a private psychiatry practice in Maryland for over forty years. Since 2002, he has been in private practice in Ithaca, New York. He is licensed to practice in New York State. Id. at 194:4-9.

         Dr. Breggin is the author of numerous peer-reviewed articles and books, including books on the adverse effects of psychiatric drugs on the brain and psychiatric drug withdrawal. Id. at 195:7-196:10; 198:9-18; 199:6-23; 200:5-23. He has taught graduate level courses in counseling and psychological services at the University of Maryland, Johns Hopkins, and SUNY Oswego. Id. at 197:2-13. Dr. Breggin has also testified before Congress about psychiatric drugs, specifically, SSRIs including Paxil and their effect on military personnel. Id. at 206:4-207:5.

         Dr. Breggin opined that Dr. Thomas' conduct “was not anywhere near the standard of care, not even close.” Id. at 228:9-17; 277:7-13. He also testified that the treatment provided by Mr. Buffton fell below the applicable standard of care. Id. at 228:18-23; 246:3-250:6; 277:7-13.

         It was Dr. Breggin's opinion that Dr. Thomas' conduct, specifically, prescribing psychiatric medications without knowing any information about the patient, fell below the standard of care. Id. at 234:5-236:5; 241:3-242:23. He referred to his acts and omissions as “not even practicing medicine.” According to Dr. Breggin, “you can't prescribe that way. These are very powerful drugs, that have important adverse effects, which, at times, have a toxic effect, and they have very important withdrawal effects.” Id. at 236:10-14. Dr. Breggin testified, consistent with Dr. Thomas' own testimony, that when a doctor starts a patient on Paxil they need to be aware about the risk of suicide and that Paxil is the most likely SSRI to cause a serious adverse reaction. Id. at 236:10-25. According to Dr. Breggin, Dr. Thomas should have placed Mr. Barbaros on monitoring, should have started him on a lower dose of Paxil, and at least explained to him the adverse side effects of Paxil. Id. at 242:14-23; 244:5. Had Dr. Thomas acted differently, he could have prevented Mr. Barbaros' suicide. Id. at 274:13-24. The same holds true for Dr. Breggin's opinion of William Buffton: that is, had Mr. Buffton behaved differently, it would have been less likely that Mr. Barbaros would have committed suicide. Id. at 274:25-275:13.

         Dr. Breggin also testified about the care Mr. Barbaros received from the medical staff at the MCCF. He opined that “the care and treatment he received, starting at the very beginning, contributed to his suicide.” Id. at 233:21-234:4; 277:14-19. It was his opinion, to a reasonable degree of medical certainty, that Mr. Barbaros' suicide was preventable and that the first time Mr. Barbaros' death could have been prevented is the night he came into the MCCF. Id. at 268:25-271:9. He testified that had Mr. Barbaros promptly received his medications on either March 18 or 19, this could have prevented, and at least would have softened, Mr. Barbaros' withdrawal. Therefore, his suicide could have been prevented. Id. at 271:17-22; 272:25-274:14.

         Dr. Breggin testified that when a patient like Mr. Barbaros is prescribed medications like Paxil, the need to continue that medication or monitor the patient is a serious medical need. Id. at 244:23-245:19. It was his opinion that Dr. Thomas knew there was a risk of suicide when prescribing Mr. Barbaros the Paxil, but nevertheless failed to take any action. Id. at 245:20-246:2. Specifically, Dr. Breggin testified that the available literature on Paxil, including warnings from the manufacturer, show that Dr. Thomas should have been aware that restarting Mr. Barbaros on Paxil without monitoring could cause suicide. Sept. 12, 2016 Trial Tr. at 145:23-147:9. He also described several studies linking Paxil to “bizarre” suicides like that of Mr. Barbaros.

         Dr. Breggin testified, to a reasonable degree of medical certainty, that Mr. Barbaros was suffering from withdrawal in the days before he first received the Paxil prescribed by Dr. Thomas. Id. at 256:7-259:24. It was his opinion that restarting Mr. Barbaros on 30 milligrams of Paxil, after he been without the drug for at least several days and was exhibiting symptoms of withdrawal, was inappropriate and contributed to his death. Id. at 260:24-261:12; 264:7-268:24; 271:23-24; Sept. 12, 2016 Trial Tr. at 147:10-152:22. Regardless of whether the Paxil was at a high enough dose to cause him to commit suicide, Dr. Breggin opined that, at a minimum, Mr. Barbaros should have been monitored due to the way Paxil is prescribed, his symptoms, and the nature and circumstances of his first incarceration. Id. at 153:4-14. He also testified that had Mr. Barbaros received his Trazodone as scheduled, or been monitored on the night of March 2, it could have prevented him from committing suicide. Id. at 152:23-153:3.

         3. Dr. Lorne Sheren

         Dr. Lorne Sheren was offered, and accepted, as Plaintiffs' expert in anesthesiology and pain and suffering. Dr. Sheren is an anesthesiologist and currently the Director of Jefferson Medical Center in Charlestown, West Virginia. He graduated from State University of New York Downstate Medical Center and completed his anesthesiology residency at Columbia Presbyterian Hospital in New York City. He is Board certified in internal medicine and anesthesiology and licensed to practice in New York, New Jersey, and West Virginia. Sept. 9, 2016 Trial Tr. at 160:1-172:4.

         Dr. Sheren testified, to a reasonable degree of medical certainty, about the conscious pain and suffering Mr. Barbaros would have experienced. Specifically, Dr. Sheren described death by suffocation in a manner like Mr. Barbaros experienced as something “extremely unpleasant, ” “painful, ” “essentially the equivalent of torture, ” and “undoubtedly . . . took some amount of time.” Id. at 177:19-182:4. It was his opinion that Mr. Barbaros would have been conscious for approximately five to seven minutes before his death. However, he acknowledged it could have been slightly less or more depending on whether Mr. Barbaros took a breath before ingesting the object and how long it took for the object to completely obstruct his airway. Id. at 184:2-15.

         4. David Hopkins

         Plaintiffs also presented the testimony of David Hopkins, an actuarial economic consultant. Mr. Hopkins received his Bachelor's Degree from the Wharton School of Business at the University of Pennsylvania and a Master's Degree in actuarial science from Temple University. Sept. 12, 2016 Trial Tr. at 200:5-203:6.

         Mr. Hopkins provided an expert report calculating what he described as “an appropriate measure of economic loss for an individual in these kinds of circumstances” and testified that “the largest part of a person's economic value is something that we call their earnings capacity.” Id. at 203:15-18. Earnings capacity, Mr. Hopkins testified, “refers to the amount of earnings that a person could expect to receive, given their background, prior work history, skills, even given their interests, what it is they might choose to do, but it's a measure of their economic value.” Id. at 203:19-23. Mr. Hopkins testified that, depending on a number of factors, Mr. Barbaros' lost earnings capacity would in the range of $540, 486 to $810, 735.[24] Id. at 215:19-217:19.

         5. Terry Fillman

         The PrimeCare Defendants offered, and the Court admitted, Terry Fillman as an expert in correctional nursing. Nurse Fillman is a RN and the Health Services Administrator for the San Bernadino County Sherriff's Department. Kathy Wild, Plaintiffs' correctional nursing expert, served as his boss for 15 years and also hired him for his current job at the San Bernadino County Sheriff's Department. Nurse Fillman's responsibilities include coordinating the medical and dental care for approximately 6000 inmates and providing daily health care. His position as Health Services Administrator is defined by the NCCHC as the “responsible health authority” with responsibility for staffing, teaching, updating policies and procedures on an annual basis, and providing medical, dental, and mental health care. As the Health Services Administrator, he is also responsible for reviewing the CQI process in order to utilize data to evaluate policies and procedures for improvement. He is an educator for the NCCHC, the organization that sets accreditation standards for correctional facilities. Sept. 12, 2016 Trial Tr. at 227:7-241:4.

         It was Nurse Fillman's opinion that the PrimeCare Defendants all met the appropriate standard of care and acted in accordance with what a reasonable nurse and prison healthcare provider would do under the circumstances. Id. at 245:6-15. He testified the conduct of Nurse James, Nurse Ramos, Nurse Johnson, Nurse Bauer, Wendy Johnson, and Nurse Rowe all met the appropriate standard of care. Id. at 277:9-18. He also testified that PrimeCare itself met the appropriate standard of care for the provision of medical care in a prison environment (including its policies and procedures for access to care, suicide screening, and verification of medications). Id. at 276:24-277:8. He noted that PrimeCare's access to mental health care policies and procedures satisfied the standard of care because Mr. Barbaros was referred to a mental health worker within 3-4 days of admission and had non-emergent issues. Id. at 273:1-274:4. He testified that although a LPN was supervising the nursing staff at the MCCF, the nursing staff was performing functions he would expect them to perform and that were common in a correctional environment. Id. at 265:16-24.

         On cross-examination, Nurse Fillman acknowledged that NCCHC standards place responsibility on a Health Services Administrator “to ensure that the staff complies with policies and procedures.” Id. at 279:19-22. He also acknowledged that the purpose of establishing policies and procedures, and following those policies and procedures, is to ensure that patients are treated properly and to keep them as safe as possible. Id. at 279:23-280:13. He conceded that when a nurse does not follow policies and procedures they can potentially be putting their patients at risk.[25] Id. At trial, Plaintiffs' counsel also read a portion of Mr. Fillman's deposition wherein he admitted that if a nurse does not accurately complete intake documents, it can impact the information available to the health services staff. Specifically, he acknowledged that if something is not properly documented, a nurse could miss a symptom that he or she otherwise would have recognized. Id. at 286:20-287:21.

         Nurse Fillman acknowledged that PrimeCare's policies and procedures at the MCCF were based on NCCHC standards (which set the minimum acceptable standard of care in a correctional environment). Id. at 288:4-9. He conceded that Nurse James violated PrimeCare's policies and procedures, and acknowledged that if a patient is taking psychiatric medications it is important to know how long he or she has been on or off the medications. He agreed that Nurse James' intake form was missing important information. Id. at 289:20-292:1.

         Nurse Fillman conceded that Nurse Rowe's conduct of performing an assessment on Mr. Barbaros without the benefit of his medical chart violated PrimeCare's policies and procedures. He noted, however, that it was the responsibility of the night nurse (i.e., Paul James) to collect this information and pass on the sick call slip to ensure the nursing staff has all the available information. Id. at 297:15-299:6. He testified that if Nurse Rowe's statement that it was “very common” to assess patients without the benefit of their medical chart was true, it would be a violation of PrimeCare's policies and procedures, but stated that “whoever is gathering these medical records and not providing the chart they're violating policies and procedures.” Id. at 299:23-301:12.

         Nurse Fillman acknowledged that PrimeCare's policies and procedures in place at the time were “the minimum standard of care, nothing beyond” and conceded that the nursing staff failed to comply with numerous policies and procedures on multiple occasions. Id. at 301:13-17. It was his opinion that it was a “combination” of Mr. Barbaros' failure to give accurate and complete information to Nurse James and Mr. Barbaros' failure to provide any information about the dosages which led to the delay in obtaining his medications. Id. at 304:19-305:25. When asked if he was aware that Nurse James testified that he never asked for dosage information because PrimeCare's intake form at the MCCF does not ask for it, Nurse Fillman testified “no.” Id. at 305:22-306:1.

         Mr. Fillman conceded that the nursing staff's failure to follow medical orders and take Mr. Barbaros' blood pressure was “not acceptable” because it is incumbent upon the nursing staff to follow medical orders because the reason for the medical order is to protect the patient and ensure he or she receives the care he or she needs. Id. at 306:2-307:23. He would not, however, concede that this breaches the standard of care. When asked if the failure to follow medical orders puts a patient at increased risk of harm he testified “not necessarily.” Id. at 307:2-308:2. However, Nurse Fillman acknowledged that if a medication like Trazodone is prescribed to an inmate, but not given to him, it is not acceptable nursing care. Id. at 308:3-13. Nurse Fillman also testified that it is incumbent upon a nurse to make sure he or she is familiar with, and able to provide, all relevant information to a physician when he or she calls the physician after verification of a patient's medication. Id. at 312:5-24. Finally, despite acknowledging the repeated violations of PrimeCare's policies and procedures, which are based on the minimal acceptable standard of care, Nurse Fillman testified to a reasonable degree of nursing certainty that all the PrimeCare Defendants acted within the applicable standard of care. Id. at 313:8-17.

         6. Dr. Lawrence Mendel

         The PrimeCare Defendants also called Dr. Lawrence Mendel as an expert in the field of correctional medicine. Sept. 13, 2016 Trial Tr. at 28:5-35:21. Dr. Mendel is the Medical Director of the Leavenworth Detention Center. Id. He previously worked as an accreditor surveyor for the NCCHC and is one of twenty fellows at the Society of Correctional Physicians. Id. Dr. Mendel has previously been retained by PrimeCare and testified on its behalf “probably” more than 10 times, “possibly more” than 20 times, but “probably not” more than 30. Id. at 35:25-40:25.

         Dr. Mendel opined, to a reasonable degree of medical certainty, that the access to care provided by the PrimeCare Defendants to Mr. Barbaros was appropriate and met the standard of care. Id. at 44:6-9. He also testified that PrimeCare's policies and procedures for the verification of medications met the standard of care, id. at 48:2-11, and noted that he was not aware of any national standard that requires an inmate who is potentially going through withdrawal/SSRI discontinuation syndrome to be monitored, id. at 55:10-14. It was his opinion that none of the PrimeCare Defendants breached the duty of care and that their acts and omissions did not increase the risk of harm to Mr. Barbaros or contribute to his suicide. Id. at 41:2-48:11.

         On cross-examination, Dr. Mendel conceded that when diagnosing a patient a doctor has an obligation to obtain sufficient information in order to decide what treatment is appropriate for a patient. Id. at 57:1-59:1. A portion of Dr. Mendel's deposition was also read wherein he testified that the responsibilities of a doctor conducting an examination and prescribing medication over the telephone are no different from a doctor actually sitting in the room with the patient. Id. at 60:15-63:13. He acknowledged that in the practice of medicine in a correctional setting it is generally recognized that if something is not written down, then it did not happen. Id. at 62:14-20.

         Dr. Mendel conceded that failure to complete an intake chart in its entirety could put a patient at risk of harm, and acknowledged that one factor to consider in determining whether a prison healthcare provider has adequate policies and procedures in place is whether there is a failure to follow those policies and procedures. Id. at 74:1-75:1. He acknowledged that PrimeCare's policies and procedures were based on the minimum standard of care set forth in the NCCHC. He also testified that if a patient comes into the facility on psychiatric medications, and the medications cannot be verified, a nurse should call the on-call provider. Id. at 83:23-83:5. He did not, however, consider any of the individual PrimeCare Defendants' failure to comply with the policies and procedures in place as breaching the standard of care. Finally, when asked whether LPNs should be supervising LPNs he testified that “ideally” a LPN should not be supervising other LPNs. Id. at 91:1-14.

         7. Dr. Lawrence Guzzardi

         Dr. Lawrence Guzzardi also testified on behalf of the PrimeCare Defendants as an expert in medical toxicology. Dr. Guzzardi graduated from Boston College with a degree in chemistry and obtained his medical degree from Jefferson Medical College in Philadelphia. Id. at 228:24-231:14. He completed his residency at the University of Kentucky, where he taught and obtained a Master's Degree in toxicology. Id. He is the former director of the emergency department at York Hospital in York, Pennsylvania. Id.

         Dr. Guzzardi testified that the level of Paxil in Mr. Barbaros' blood following his death (130 nanograms) was within the therapeutic range. Therefore, there was Paxil in Mr. Barbaros' system that was not related to the Paxil he received at the MCCF. He opined that it would be impossible to have this amount of Paxil in your bloodstream from a single 30 mg dose. Id. at 242:1-17. Based on his review of the medical records he testified that “[i]t would be highly, highly, highly unlikely that [Mr. Barbaros] would have gone through SSRI discontinuation syndrome, given the amount of Paxil that was present in his blood at the time of autopsy.” Id. at 243:17-24. According to Dr. Guzzardi, Mr. Barbaros' blood work also established that he did not have a toxic level of Paxil in his system at the time of his death. Id. at 244:22-25.

         On cross-examination, Dr. Guzzardi acknowledged that Dr. Thomas' psychiatry expert, Dr. Susan Rushing, authored a report stating that with a single 30 mg dose of Paxil it was possible to have a up to 147 nanograms in your bloodstream, depending on a person's metabolism. Id. at 245:24-248:17. He, however, strongly disagreed with her opinions and conclusions. Id. Dr. Guzzardi also made a series of errors in his report and testimony regarding the factual circumstances of this case. Id. at 251:1-255:18.

         8. Dr. Cheryl Wills

         The PrimeCare Defendants also presented testimony from Dr. Cheryl Wills, who was offered, and accepted, as an expert in correctional psychiatry. Dr. Wills is the head of Child and Adolescent Forensic Psychiatry at University Hospital Case Medical Center in Cleveland, Ohio. She obtained her undergraduate degree at Barnard College, Columbia University, and her medical degree from State University of New York in Syracuse. Id. She completed her residency in general and child psychiatry at the University of Pittsburgh and then completed a fellowship at Case Western Reserve University. She is Board certified in General Psychiatry, Child and Adolescent Psychiatry, and has a subspecialty certification in Forensic Psychiatry. Dr. Wills is licensed to practice in Pennsylvania, Ohio, Louisiana, and New York. She has worked in a correctional facility providing care to patients, and was a former monitor for the United States Department of Justice. In that capacity, she observed correctional facilities and assessed conditions of confinement (including access to mental healthcare) to determine whether a facility's policies and procedures meet a minimally acceptable standard of care. Sept. 14, 2016 Trial Tr. at 3:21- 15:14.

         Dr. Wills testified, to a reasonable degree of medical certainty, that PrimeCare and Mr. Buffton's treatment of Mr. Barbaros met the appropriate standard of care. Id. at 16:5-18; 29:10-17. She also opined that PrimeCare's policies and procedures at the MCCF met the appropriate standard of care, highlighting the MCCF's NCCHC certification. Id. at 16:11-15. She testified that the policies and procedures in place at the MCCF were “above and beyond” what “we” ideally would like to see in all jails. Id. at 19:6-10. As for Mr. Buffton, she testified that his assessment notes were appropriate and suggested that Mr. Barbaros did not need to be monitored. Specifically, she highlighted that, according to Mr. Buffton's note, Mr. Barbaros became more animated as time went by which “shows that he has the capacity to calm down” and also suggests that Mr. Buffton “made a good effort to engage him” and that Mr. Barbaros was in a better emotional state than when he and Mr. Buffton initially met. Id. at 27:9-15.

         It was Dr. Wills' opinion that Mr. Buffton had no reason to suspect Mr. Barbaros was suicidal at the time of the assessment. She noted that Mr. Barbaros' behavior had changed during the assessment, was future-oriented, and that he was planning to see a psychiatrist the following day. Id. at 29:24-9. She did not believe simply because an inmate who is incarcerated for the first time has an increased risk of suicide that every first time inmate should be placed on monitoring or suicide watch. Id. at 24:15-25. It was Dr. Wills' opinion that Mr. Barbaros committed suicide due to a “number of things, ” id. at 33:1-11, including among other things that “he was incarcerated for the first time in his life . . . the number of charges kept increasing, [and] they were published in the newspaper, which had implications for his business, ” id. at 33:7-34:9. Therefore it was her opinion, to a reasonable degree of medical certainty, that nothing about the care provided to Mr. Barbaros by PrimeCare and Mr. Buffton caused him to commit suicide. Id. at 34:10-19.

         On cross-examination, Dr. Wills acknowledged that an inmate who is incarcerated for the first time is at an increased risk of suicide. Id. at 37:23-25. She also agreed that as part of an initial assessment it is important to find out when a patient last took his or her medication. She testified that the nursing staff had an obligation to investigate when Mr. Barbaros last took his medication. Id. at 38:5-39:22. She further acknowledged that withdrawal is a potential side effect if a person abruptly stops taking medications like Paxil, that suicidal ideations have been associated with individuals who abruptly stop taking SSRIs like Paxil, and that this is something the medical staff should be aware of. Id. at 40:13-42:19. When asked if Mr. Barbaros' symptoms, including headaches, hypertension, increased pulse, abdominal pain, increased anxiety, and depression could be signs that he was suffering from withdrawal, Dr. Wills testified “That's one possibility, yes.” Id. at 43:5-11. She conceded that the nursing staff's failure to check Mr. Barbaros' blood pressure was unfortunate and “pretty bad” because without this information they could not assess his medical condition. Id. at 43:12-25. For example, without this information they could not know if his blood pressure continued to increase, decrease, or stay the same, which could have alerted the medical staff to a serious medical issue. Id. at 44:5-11.

         Dr. Wills acknowledged that Mr. Buffton did not document that he conducted a suicide assessment of Mr. Barbaros and did not ask Mr. Barbaros if he was experiencing any physical symptoms since arriving at the MCCF. Id. at 45:3-46:3. She acknowledged, consistent with Mr. Buffton testimony, that if Mr. Buffton had asked about Mr. Barbaros' physical symptoms he should have written it down in his note. Id. at 46:3-20. When asked whether, logically, Mr. Buffton's failure to document that he conducted a suicide assessment meant that he failed to conduct a suicide assessment of Mr. Barbaros, Dr. Wills was unsure. Id. at 47:19-48:3. She testified that Mr. Buffton's failure to document “any information about lethality, whether he was having thoughts of harming himself or others, it was an oversight on Mr. Buffton's part.” Id. at 28:5-11. She went on to testify that “a suicide assessment is a requirement for a social worker, but physical symptoms is not . . . so if he went above and beyond, that's great, but that is not what he's required to do.” Id. at 48:4-13. She conceded that, as a psychologist, he would be aware that physical symptoms can impact the mental state. Id. at 48:14-16. When asked whether it would be important to know that a first time detainee who is being assessed for the first time by a mental healthcare worker is experiencing physical symptoms or other aggravating factors she testified that “it would be helpful to know, yes.” Id. at 48:14.

         Throughout her testimony Dr. Wills repeatedly referred to Mr. Buffton as a social worker, but conceded that at the MCCF he was acting as a Master's level psychologist and, as such, NCCHC standards required him to be supervised by a qualified mental health professional. Id. at 49:10-25. It was her belief that, although Mr. Buffton was not a licensed psychologist, because he had a master's degree he was permitted to “work for someone else, under their supervision.” Id. at 17:6-19:2. She later acknowledged that the person supervising Mr. Buffton was not a psychologist, but also a social worker like Mr. Buffton. Id. at 50:12-16. Dr. Wills testified that although PrimeCare did not provide Mr. Buffton with any training, including training on suicide prevention, she was “not sure that is required” under the circumstances. Id. at 55:18-22. She acknowledged that, in her opinion, PrimeCare's actions with respect to Mr. Buffton did not cause Mr. Barbaros' suicide, was “more likely than not” and “roughly 51%.” Id. at 59:23-60:4. In her expert report, part of which was read to the jury, she wrote: “Dr. Breggin's past work on side effects to Selective Serotonin Reuptake Inhibitor SSRI medications, which are used to treat depression and anxiety, and what pharmaceutical companies have disclosed has had important implications for the medical field.” Id. at 60:20-61:8.

         9. Dr. Susan Rushing

         Dr. Thomas presented testimony from one expert, Dr. Susan Rushing, who was offered, and accepted, as an expert in psychiatry. Sept. 13, 2016 Trial Tr. at 133:14-15. Dr. Rushing is a psychiatrist in private practice in Haverford, Pennsylvania and holds a clinical teaching appointment at the University of Pennsylvania. She teaches residents and medical students in forensic psychiatry. Id. at 112:2-9. She received her undergraduate degree in neuroscience from the Massachusetts Institute of Technology, her medical degree from the Yale School of Medicine and her Juris Doctorate from Stanford Law School. Id. She completed an internship in pediatrics at the Children's National Hospital in Washington D.C. and her psychiatry residency at the University of Pennsylvania. Id. She, like Dr. Breggin, has never worked as a psychiatrist in a correctional facility. Id. at 124:20-127:1.

         Dr. Rushing testified that Mr. Barbaros was not suffering from SSRI discontinuation syndrome or withdrawal. Id. at 149:18:24. She opined that Dr. Thomas' conduct met the standard of care and was appropriate. According to Dr. Rushing, the standard of care “absolutely” does “not” require Dr. Thomas to speak with Mr. Barbaros prior to prescribing him medication. Id. at 151:19-152:11. She also testified that the standard of care did not require Dr. Thomas to review Mr. Barbaros' medical records prior to prescribing him psychiatric medication. Id. It was her opinion that the standard of care also did not require Dr. Thomas to place Mr. Barbaros on monitoring. Id. at 152:12-17. Nor did Dr. Rushing believe the standard of care required Dr. Thomas to restart Mr. Barbaros on a lower dosage of Paxil. Id. at 153:9-154:4. It was her opinion, to a reasonable degree of medical certainty, that Dr. Thomas' acts and omissions did not cause Mr. Barbaros to commit suicide. Id. at 160:24-162:24. Rather, it was her opinion that Mr. Barbaros committed suicide due to a certain level of distress over his incarceration, including, among other things, recently learning that his charges and bail had been increased. Id. at 162:7-21.

         On cross-examination, Dr. Rushing acknowledged that if a physician is going to prescribe a patient Paxil, then he or she should be familiar with the potential side effects of the medication. She conceded that some studies suggest that Paxil causes significantly more discontinuation symptoms than other SSRI medications. Id. at 177:25-180:23. She also acknowledged that the studies she relied on which formed the basis of her opinions (which found an increase in suicidal ideations in children and adolescents on Paxil, but not adults) were conducted in settings where the individuals being studied were under close observation and monitoring, which she acknowledged is significant when it comes to suicide and suicidal ideation. Id. at 194:10-195:1. She testified that it is important for psychiatrists to diagnose a deteriorating mental condition as early as possible because early recognition results in an increased likelihood of avoiding injury to a patient. She conceded that one way for a psychiatrist to accomplish this goal is by having a complete picture of his or her patient and reviewing the patient's medical records. Id. at 198:22-199:17.

         Dr. Rushing also testified about the distinctions between LPNs and RNs, in terms of both training and education. She acknowledged that LPNs “certainly have less experience” than other medical professionals. Id. at 202:15-204:6. Regardless, she testified that it is the responsibility of the doctor to make sure he has all available information about a patient so he can make an informed medical decision when prescribing medications for a patient. Id. at 204:11-19. Dr. Rushing acknowledged that in her clinical practice she asks patients how long they have been on or off a particular medication when prescribing. Id. at 204:20-205:25. When asked whether Mr. Barbaros would have been able to commit suicide had he been monitored, she did not answer the question. Instead, Dr. Rushing testified that such a practice would have been outside the standard of care. Id. at 219:5-220:19. Consistent with the testimony of the other expert witnesses, she testified that the nature of Mr. Barbaros' suicide was “unusual, ” “incredibly rare, ” and “something I have not previously seen.” Id. at 222:3-223:8.

         III. STANDARD OF REVIEW

         A. Motion For Judgment as a Matter Of Law

         Federal Rule of Civil Procedure 50 governs motions for judgment as a matter of law. The rule provides, in relevant part:

(a) Judgment as a Matter of Law.
(1) In General. If a party has been fully heard on an issue during a jury trial and the court finds that a reasonable jury would not have a legally sufficient evidentiary basis to find for the party on the issue, the court may:
(A) resolve the issue against the party; and
(B) grant a motion for judgment as a matter of law against the party on a claim or defense that, under the controlling law, can be maintained or defeated only with a favorable finding on that issue.
(2) Motion. A motion for judgment as a matter of law may be made at any time before the case is submitted to the jury. The motion must specify the judgment sought and the law and facts that entitle the movant to the judgment.
(b) Renewing the Motion After Trial; Alternative Motion for a New Trial. If the court does not grant a motion for judgment as a matter of law made under Rule 50(a), the court is considered to have submitted the action to the jury subject to the court later deciding the legal questions raised by the motion. No later than 28 days after the entry of judgment-or if the motion addresses a jury issue not decided by a verdict, no later than 28 days after the jury was discharged-the movant may file a renewed motion for judgment as a matter of law and may include an alternative or joint request for a new trial under Rule 59. In ruling on the renewed motion, the court may:
(1) allow judgment on the verdict, if the jury returned a verdict;
(2) order a new trial; or
(3) direct the entry of judgment as a matter of law.
(c) Granting the Renewed Motion; Conditional Ruling on a Motion for a New Trial.
(1) In general. If the Court grants a renewed motion for judgment as a matter of law, it must also conditionally rule on any motion for a new trial by determining whether a new trial should be granted if the judgment is later vacated or reversed. The court must state the grounds for conditionally granting or denying the motion for a new trial.
(2) Effect of Conditional Ruling. Conditionally granting the motion for a new trial does not affect the judgment's finality; if the judgment is later reversed, the new trial must proceed unless the appellate court orders otherwise. If the motion for a new trial is conditionally denied, the appellee may assert error in that denial; if the judgment is reversed, the case must proceed as the appellate court orders.

         Fed. R. Civ. P. 50(a)-(c).

         “Entry of judgment as a matter of law is a sparingly invoked remedy.” Marra v. Philadelphia Housing Auth., 497 F.3d 286, 300 (3d Cir. 2007) (internal citation and quotation marks omitted). Because the jury returned a verdict in favor of the Plaintiffs, the Court “must examine the record in a light most favorable to the plaintiff, giving her the benefit of all reasonable inferences, even though contrary inferences might reasonably be drawn.” In re Lemington Home for the Aged, 777 F.3d 620, 626 (3d Cir. 2015) (internal citation and quotation marks omitted).

         The Court can only address issues raised in a Rule 50(b) motion which were first properly raised in a Rule 50(a) Motion. See Lightning Lube, Inc. v. Witco Corp., 4 F.3d 1153, 1172 (3d Cir. 1993) (“In order preserve an issue for judgment pursuant to Rule 50(b), the moving party must timely move for judgment as a matter of law . . . pursuant to Rule 50(a), and specify the grounds for that motion.”). Where issues raised in a Rule 50(b) motion have been properly preserved, the Court may grant the motion “only if, viewing the evidence in the light most favorable to the nonmovant and giving it the advantage of every fair and reasonable inference, there is insufficient evidence from which a jury reasonably could find liability.” Id. at 1166. The Court “may not weigh the evidence, determine the credibility of witnesses, or substitute its version of facts for the jury's version.” Id. Judgment as of matter of law following return of a jury verdict is only appropriate when “if, as a matter of law, the record is critically deficient of that minimum quantity of evidence from which a jury might reasonably afford relief.” Trabal v. Wells Fargo Armored Serv. Corp., 269 F.3d 243, 249 (3d Cir. 2001) (internal citation and quotation marks omitted). “The question is not whether there is literally no evidence supporting the party against whom the motion is directed but whether there is evidence from which the jury could properly find a verdict for that party.” Jaasma v. Shell Oil Co., 412 F.3d 501, 503 (3d Cir. 2005) (internal citation and quotation marks omitted).

         B. Motion For a New Trial; Remittitur

         Federal Rule of Civil Procedure 59 governs motions for a new trial. The Rule provides, in relevant part, “[t]he court may, on motion, grant a new trial on all or some of the issues- and to any party. . . after a jury trial, for any reason for which a new trial has heretofore been granted in an action at law in federal court. . . .” Fed.R.Civ.P. 59(a)(1)(A). The Court may grant a new trial “purely on a question of law” or to correct a previous ruling “on a matter that initially rested within the discretion of the court, e.g. evidentiary rulings . . . or prejudicial statements made by counsel.” Klein v. Hollings, 992 F.2d 1285, 1289-90 (3d Cir. 1993) (internal citation and quotation marks omitted). The Court may also grant a new trial where it “believes the jury's decision is against the weight of the evidence.” Id. at 1290. However, a Court “should do so only when ‘the great weight of the evidence cuts against the verdict and . . . [ ] a miscarriage of justice would result if the verdict were to stand.'” Leonard v. Stemtech Int'l Inc., 834 F.3d 376, 386 (3d Cir. 2016) (quoting Springer v. Henry, 435 F.3d 268, 274 (3d Cir. 2006)). “A district court's power to grant a new trial is limited to ensure that it does not substitute its judgment of the facts and the credibility of the witnesses for that of the jury.” Id. (internal citation and quotation marks omitted).

         “The applicable standard for ordering a new trial where the verdict was against the weight of the evidence differs from the standard for granting a motion” for judgment as a matter of law. Agere Sys., Inc. v. Atmel Corp., No. Civ. A 02-CV-864, 2005 WL 2994702, at *15 (E.D. Pa. Aug. 17, 2005). “A court should only order a new trial when, in its opinion, the verdict is contrary to the ‘great weight of the evidence.'” Id. (quoting Roebuck v. Drexel Univ., 852 F.2d 715, 736 (3d Cir. 1988)). In determining whether a new trial should be granted “a court is permitted to consider the credibility of the witnesses and to weigh the evidence.” Id. Although “a party who fails to move for judgment as a matter of law under Rule 50(a) at the close of all evidence wholly waives the right to mount any post-trial attack on sufficiency of evidence grounds. . . [w]here a challenge is made to the weight of the evidence, as opposed to its sufficiency, a court may exercise its discretion and grant a new trial regardless.” Id. at *16 (citing Greenleaf v. Garlock, 174 F.3d 352, 365 (3d Cir. 1999)).

         “A court may grant a new trial or a remittitur ‘only if the verdict is so grossly excessive as to shock the judicial conscience.'”[26] Wright v. Cacciutti, No. 3:12-CV-1682, 2015 WL 3654553, at *20 (M.D. Pa. June 11, 2015) (quoting Williams v. Martin Marietta Alumina, Inc., 817 F.2d 1030, 1038 (3d Cir. 1987)). “The fact that a court finds an award to be extremely generous or would have found the damages to be considerably less is not sufficient to shock the conscience.” Id. (internal citation and quotation marks omitted). Both the Third Circuit and the Pennsylvania Supreme Court have set a high bar for determining what “shocks the judicial conscience.” See, e.g., Motter v. Everest & Jennings, Inc. 883 F.2d 1223, 1230 (3d Cir. 1989) (in order to disturb a jury verdict “the damages assessed by the jury must be so unreasonable as to offend the conscience of the Court”); Haines v. Raven Arms, 536 Pa. 452, 455, 640 A.2d 367 (1994) (“Judicial reduction of a jury award is appropriate only when the award is plainly excessive and exorbitant. The question is whether the award of damages falls within the uncertain limits of fair and reasonable compensation or whether the verdict so shocks the sense of justice as to suggest the jury was influenced by partiality, prejudice, mistake, or corruption.”) (citations omitted). If a Court reduces a jury award because it believes the amount of the award is inconsistent with the evidence, “the court must offer a new trial as an alternative to a reduction in the award in order to avoid depriving the plaintiff of his/her Seventh Amendment right to a jury trial.” Cortez v. Trans Union, LLC, 617 F.3d 688, 716 (3d Cir. 2010).

         IV. MOTION FOR JUDGMENT AS A MATTER OF LAW

         A. 42 U.S.C § 1983 - Adequate Medical Care

         Plaintiffs pursued claims under 42 U.S.C § 1983, alleging that each of the individual PrimeCare Defendants and Dr. Thomas violated Mr. Barbaros' Fourteenth Amendment right to adequate medical care by acting, or failing to act, with deliberate indifference to his serious medical needs.[27] The jury found each of these Defendants, with the exception of Wendy Johnson, liable under section 1983. Plaintiffs also alleged, and the jury found, that PrimeCare had a policy, practice, or custom of deliberate indifference to the serious medical needs of inmates at the MCCF, and that this policy, practice, or custom caused Mr. Barbaros' suicide. The jury awarded Plaintiffs $1, 057, 334 in compensatory damages.

         1. The Individual PrimeCare Defendants

         The individual PrimeCare Defendants each timely moved for judgment as a matter of law pursuant to Federal Rule of Civil Procedure 50(a) at the close of Plaintiffs' case-in-chief. Sept. 13, 2016 Trial Tr. at 9:15-14:3. The Court deferred ruling on the motions. At the close of the evidence the individual PrimeCare Defendants renewed their motions. Sept. 14, 2016 Trial Tr. at 62:14-17. The Court again deferred ruling on the motions and submitted the case to the jury.[28] The individual PrimeCare Defendants timely renewed their motions for judgment as matter of law pursuant to Federal Rule of Civil Procedure 50(b). (Doc. 354).

         Plaintiffs' theory of deliberate indifference, as reflected in the jury charge, was that each of the individual PrimeCare Defendants “ignored a diagnosed medical condition that required Mr. Barbaros to take the medication Paxil, ignored and/or disregarded obvious symptoms that showed Mr. Barbaros was suffering from medication withdrawal, failed to ensure proper dosing when restarting Mr. Barbaros' medication, and failed to monitor Mr. Barbaros.” Jury Charge § 13(B). The jury was instructed in accordance with the Third Circuit's Model Jury Instruction § 4.11.1 (Denial of Adequate Medical Care), with slight modifications to indicate that because Mr. Barbaros was a pretrial detainee, Plaintiffs' claimed deprivation of his constitutional right to adequate medical care arose under the Fourteenth Amendment, not the Eighth Amendment.[29] After deliberating for a period of time, the jury submitted a written question to the Court: “Could you provide us with a better definition of deliberate indifference?” After discussing the appropriate response with counsel, the Court referred the jury back to the instructions. The jury later returned its verdict.

         Plaintiffs' claims arise under 42 U.S.C. § 1983. Section 1983 is not an independent source of substantive rights, but merely “provides a remedy for deprivations of rights established elsewhere in the Constitution or federal laws.” Kopec v. Tate, 361 F.3d 772, 775-76 (3d Cir. 2004). To establish liability under section 1983, a plaintiff must prove by a preponderance of the evidence that: (1) he was deprived of a federal right; and (2) the person who deprived him of that right acted under color of state law. Burella v. City of Philadelphia, 501 F.3d 134, 139 (3d Cir. 2007).

         The state action element of Plaintiffs' claim was not in dispute. The PrimeCare Defendants conceded that, as a corporation contracting with the state to provide constitutionally required medical services to inmates, both the corporation and its employees qualified as state actors for purposes of section 1983. See West v. Atkins, 487 U.S. 55-56, 108 S.Ct. 42, 101 L.Ed.2d 40 (1988) (“It is the physician's function within the state system, not the precise terms of his employment, that determines whether his actions can fairly be attributed to the state.”); see also Donnell v. Corr. Health Servs, Inc., 405 F. App'x 617, 621 n.5 (3d Cir. 2010) (“[W]e do not think there is any dispute that the [defendants], though not directly employed by the state, acted under color of state law in providing medical services . . . at the Ocean County Jail.”). The jury was instructed, consistent with the proposed jury instructions submitted by the PrimeCare Defendants, (Doc. 333), that this element of Plaintiffs' claim had been satisfied. The question for the jury to decide, then, was whether Plaintiffs proved by a preponderance of the evidence that any of the individual PrimeCare Defendants violated Mr. Barbaros' Fourteenth Amendment right to adequate medical care and, if so, whether these acts and omissions caused Mr. Barbaros to commit suicide.

         “While the Eighth Amendment prohibits the infliction of cruel and unusual punishment upon prisoners, it applies only ‘after [the State] has secured a formal adjudication of guilt in accordance with due process of law.'” Natale v. Camden Cnty. Corr. Facility, 318 F.3d 575, 581 (3d Cir. 2003) (quoting City of Revere v. Massachusetts Gen. Hosp., 463 U.S. 239, 244, 103 S.Ct. 2979, 77 L.Ed.2d 605 (1983)). Accordingly, because Mr. Barbaros was a pretrial detainee, not a convicted prisoner, his claims arose under the Fourteenth Amendment's due process clause.[30] Id. at 582. In order to prove a constitutional violation of Mr. Barbaros' Fourteenth Amendment right to adequate medical care, Plaintiffs must show: “(i) a serious medical need, and (ii) acts or omissions by prison officials that indicate deliberate indifference to that need.” Natale, 318 F.3d at 582. The Court will first address whether the evidence was sufficient for a reasonable jury to conclude that Mr. Barbaros had a “serious medical need.”

         In denying the PrimeCare Defendants' motion for summary judgment, the Court noted that they “do not challenge whether Barbaros had a serious medical need.” (Doc. 175 at n.10). At trial while moving for judgment as a matter of law pursuant to Rule 50(a), counsel for the PrimeCare Defendants stated: “Specifically, in this particular matter, I think, at least, at this point, [it] has to be conceded that Mr. Barbaros had a serious medical condition, he was diagnosed when he came into the prison with anxiety, and he received medications for it. So I think that certainly meets the first prong.” Sept. 13, 2016 Trial Tr. at 10:6-10. The PrimeCare Defendants in their brief in support of their post-trial motion, though, attempt to disavow their own counsel's statements:

Initially, it must be stated that PrimeCare Defendants do not concede Barbaros suffered from a serious medical condition. He was a generally healthy male who received mental health medications from his family physician. There was nothing about his history which indicated he suffered from a serious medical condition or that any of the PrimeCare Defendants should have been subjectively aware of any serious medical condition.

         (Doc. 377, at 21). The PrimeCare Defendants not only failed to move for judgment as a matter of law pursuant to Rule 50(a) on the basis that Mr. Barbaros did not have a serious medical need; they explicitly conceded that he did. Under the circumstances, the PrimeCare Defendants have waived this issue and may not now claim in their Rule 50(b) motion that the evidence was insufficient for a reasonable jury to conclude that Mr. Barbaros had a serious medical.[31] The Court need only address then, whether viewing the evidence in the light most favorable to the Plaintiffs, no reasonable jury could conclude that any of the individual PrimeCare Defendants acted, or failed to act, with deliberate indifference to Mr. Barbaros' serious medical need.

         A prison employee acts with deliberate indifference to an inmate's serious medical need when he or she “knows of and disregards an excessive risk to inmate health or safety; the official must both be aware of facts from which the inference could be drawn that a substantial risk of serious harm exits, and he must also draw that inference.” Farmer v. Brennan, 511 U.S. 825, 837, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994). “This requirement of actual knowledge means that ‘the official must both be aware of facts from which the inference could be drawn that a substantial risk of serious harm exists, and he must also draw the inference.'” Beers-Capitol v. Whetzel, 256 F.3d 120, 131 (3d Cir. 2001) (quoting Farmer, 511 U.S. at 837). “[D]eliberate indifference is a stringent standard of fault, requiring proof that a municipal actor disregarded a known or obvious consequence of his action.” Bd. Of Cnty. Comm'rs of Bryan Cnty. Oklahoma v. Brown, 520 U.S. 397, 410, 117 S.Ct. 1382, 137 L.Ed.2d 626 (1997).

         Plaintiffs, however, “need not show that a prison official acted or failed to act believing that harm actually would befall an inmate; it is enough that the official acted or failed to act despite his knowledge of a substantial risk of serious harm.” Farmer, 511 U.S. at 842. A defendant's knowledge of a substantial risk of serious harm “can be proved indirectly by circumstantial evidence” and a jury may reasonably find that a defendant “knew of a substantial risk from the very fact that risk was obvious.” Beers-Capitol, 256 F.3d at 131 (internal citation and quotation marks omitted). In addition, a defendant “who is actually aware of the risk to the prisoner can avert liability by showing that he responded reasonably to the risk, even if the ultimate harm was not avoided.” Id. at 132.

         It is apparent that “[t]he knowledge element of deliberate indifference is subjective, not objective knowledge, meaning that the official must actually be aware of the existence of the excessive risk; it is not sufficient that the official should have been aware.” Id. at 133. There must, therefore, be sufficient evidence from which a jury could reasonably conclude that each of the individual PrimeCare Defendants “knew or were aware of and disregarded an excessive risk to [Mr. Barbaros'] health and safety, and they can show this by establishing that the risk was obvious.” Id. at 135.

         The Third Circuit has found acts and omissions amounting to deliberate indifference to a serious medical need in a number of contexts “including where (1) prison authorities deny reasonable requests for medical treatment, (2) knowledge of the need for medical care is accompanied by the intentional refusal to provide it, (3) necessary medical treatment is delayed for non-medical reasons, and (4) prison authorities prevent an inmate from receiving recommended treatment for serious medical needs.” Pearson v. Prison Health Serv., 850 F.3d 526, 538 (3d Cir. 2017) (citations omitted). It is well-established that evidence that prison medical personnel negligently failed to diagnose or properly treat a medical condition, without more, is insufficient to demonstrate deliberate indifference. See, e.g., id. at 535 (“[T]he mere receipt of inadequate medical care does not itself amount to deliberate indifference - the defendant must also act with the requisite state of mind when providing the inadequate care.”); Rouse v. Plantier, 182 F.3d 192, 197 (3d Cir. 1999) (“It is well-settled that claims of negligence or medical malpractice, without some more culpable state of mind, do not constitute deliberate ...


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