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Carlos v. York County

United States District Court, M.D. Pennsylvania

December 9, 2019

YORK COUNTY, et al., Defendants



         I. Introduction

         The plaintiff, Angela Carlos (“the plaintiff”), has brought a federal civil rights survival and wrongful death action under 42 U.S.C. §1983, and also raises supplemental state-law claims. The action, proceeding via an amended complaint (Doc. 36), arises out of the death of the plaintiff's daughter, Tiombe Kimana Carlos (“Carlos”), who committed suicide in October 2013 at York County Prison (“YCP”) where she was being held as an immigration detainee. Presently before the court is Magistrate Judge Joseph F. Saporito Jr.'s report and recommendation (Doc. 94) addressing three motions (Docs. 65, 68, and 74) for summary judgment filed by various defendants. The plaintiff has filed multiple objections (Doc. 101) to the report and recommendation, and York County, one of the defendants moving for summary judgment, has also filed an objection (Doc. 97) to the report and recommendation. For the reasons that follow, the court will sustain in part, and overrule in part, the objections.

         II. Factual Background and Procedural History

         A. Defendants Named in the Instant Action

         The plaintiff's amended complaint names a multitude of institutional and individual defendants, each of whom is alleged to have played a role in failing to prevent Carlos's suicide at YCP. Considering the numerosity of named defendants, it may be helpful to list all of the defendants at the outset because many of them will be referenced in the factual recitation below. The defendants are as follows: (1) York County; (2) PrimeCare Medical, Inc. (“PrimeCare”); (3) Pamela Rollings-Mazza, M.D. (“Dr. Rollings-Mazza, ” “Rollings-Mazza, ” or “the Doctor”); (4) Patrick Gallagher, Licensed Professional Counselor (“LPC Gallagher” or “Gallagher”); (5) Aimee Leiphart, LPN (“Nurse Leiphart” or “Leiphart”); (6) Medical John Does 1-10; (7) Corrections Officer John Does 1-10; (8) Deputy Warden Clair Doll (“Deputy Warden Doll” or “Doll”); (9) Corrections Officer Erika Collins (“CO Collins” or “Collins”); (10) Corrections Counselor Janet Jackson (“Counselor Jackson” or “Jackson”; (11) Corrections Officer Grissell Santos-Heredia (“Santos-Heredia”); (12) Corrections Counselor McNicholas (“McNicholas”); (13) Corrections Counselor Crist (“Crist”); (14) Corrections Counselor Nadeau (“Nadeau”); (15) Corrections Counselor Trig (“Trig”)[1]; (16) Captain Carl Neeper (“Captain Neeper” or “Neeper”); (17) Holly A. Snyder, RN (“Nurse Snyder” or “Snyder”); and (18) Robert Davis, M.D. (“Dr. Davis” or “Davis”).[2]

         B. Events Leading to Carlos's Incarceration at York County Prison

         Carlos, who was born in Antigua and Barbuda in 1978, immigrated to the United States with her parents in 1983. Carlos maintained lawful permanent resident status, but unlike her parents, she never became a naturalized citizen. Since her teenage years, Carlos suffered from mental health problems, including paranoia and hallucinations, for which she was prescribed medication and hospitalized on numerous occasions since 1994.

         Around 2003, Carlos was involved in an altercation with police officers in a Connecticut bar for which she was arrested, convicted of an aggravated felony, and sentenced to a term of incarceration in a Connecticut state prison. Because Carlos was a non-citizen, her conviction of an aggravated felony rendered her removable from the United States. In 2008, Immigrations and Customs Enforcement (“ICE”) took custody of Carlos, however she remained incarcerated in the Connecticut prison while removal proceedings were initiated. Subsequently, Carlos assaulted a corrections officer in the Connecticut prison, and her custody was turned back over to the Connecticut State authorities. In 2011, after an additional period of incarceration, Carlos was again released into ICE custody, and in April of 2011, she was transported to York County Prison (“YCP” or “the Prison”) in York, Pennsylvania, for detention pending completion of removal proceedings.

         C. YCP - An Overview of the Facility's Mental Health Protocol and Policy at the Time of Carlos's Incarceration

         1. YCP's Official Suicide-Prevention Policy Circa 2011-2013

         According to the YCP suicide prevention policy, (see Doc. 85-2), effective at the time of Carlos's incarceration, [3] each county prison employee and contracted employee was to receive two hours of initial suicide prevention training followed by one hour of annual training to be provided by the Prison's training department in cooperation with the Prison's mental health department. (Id. at 2). All inmates, immediately upon admission to YCP, were to be screened for suicidal tendencies. (Id.) If an inmate was deemed suicidal upon admission or at any time thereafter during incarceration, any staff member could order that the inmate be placed on a designated level of observation[4] in suicide resistant housing quarters.[5] (Id.) Furthermore, pursuant to established YCP practice, inmates on psychotropic medications who became involved in an altercation were automatically to be placed on a suicide watch regardless of whether they otherwise exhibited suicidal tendencies. (Docs. 85-14 at 14; and 85-15 at 8, 12). Any inmate placed on a suicide observation level was to remain on that level of observation until seen by a mental health counselor. (Doc. 85-2 at 2). The mental health counselor would then assess the inmate and determine whether the inmate should remain on that level of observation, be stepped down to a lower level of observation, or be removed from observation altogether. (Doc. 85-15 at 7).

         The policy also provided that in the event of a suicide or suicide attempt, all staff involved in the discovery and intervention must submit reports relaying their full knowledge of the inmate and incident. (Id. at 3). Furthermore, the policy dictated that every completed suicide, as well as every “serious suicide attempt, ” must be examined by a “mortality review”[6] committee. (Id.)

         2. YCP's Mental Health Department and Protocol

         Individuals from YCP's mental health department remain as defendants in the instant action. Also named as a defendant is PrimeCare, the company with which YCP has contracted to provide mental-health services.

         YCP's mental health department consists of six individuals who are responsible for providing mental health services at the Prison: one psychiatrist, three mental health counselors, and two mental health nurses. (Doc. 85-19 at 8). YCP's psychiatrist is defendant Dr. Rollings-Mazza, [7] an employee of PrimeCare. As YCP's psychiatrist, Dr. Rollings-Mazza's primary responsibility is “medication management.” (Id. at 7, 9). She performs initial evaluations on individuals who are already on mental health medications when they arrive at the Prison, and after the initial evaluation, she then follows up with patients with respect to medication management by conducting periodic medication checks to ensure that an inmate is stable on his or her current medication. (Id. at 8-9). For inmates that appear to be mentally stable on their medication, the Doctor will conduct medication checks every four to eight weeks, and for inmates that appear to be unstable, the Doctor will conduct checks on a weekly basis. (Id. at 9). The Doctor may conduct a medication check sooner than planned if an inmate complains that his or her medication is not working. (Id.) At each medication check, the Doctor conducts a suicide-risk assessment by asking inmates a series of questions to determine whether they would likely hurt themselves. (Id. at 34). While Dr. Rollings-Mazza's primary responsibility is medication management, she may also refer an inmate to a mental health counselor if she believes that psychotherapy may be beneficial. (Id. at 10).

         The prison's mental health department also includes three mental health counselors. One of those three counselors is defendant LPC Gallagher, who also serves as the Prison's Mental Health Coordinator. (Doc. 85-15 at 5). Gallagher's first task each workday is to visit inmates who recently have been placed on a suicide observation level and assess whether they should remain on a suicide observation level, be stepped down to psychiatric observation, or be removed from observation altogether. (Id. at 6-7). During the timeframe of Carlos's detention, any segregated inmate on constant observation status or suicide precaution status was seen by Gallagher on a daily basis. (Id. at 28). Once Gallagher stepped a segregated inmate down to psychiatric observation status, he would check that individual on a weekly basis.[8] (Id. at 9). In addition to regularly seeing segregated inmates on observation statuses, Gallagher also may see inmates for counseling on a request or referral basis. (Id. at 19). Gallagher also was part of the Program Review Committee (“PRC”) Team, a group of individuals[9] who regularly met with inmates in segregation to evaluate their status and determine whether their placement is still appropriate based on multiple factors. (See Doc. 85-14 at 22).

         Finally, the Prison's mental health department employs two mental health nurses. At the time of Carlos detention, they were defendants Nurse Leiphart and Nurse Snyder. During this time, some of the primary responsibilities of the mental health nurses were to conduct weekly checks of inmates in segregated housing, check on mental health inmates who put in sick-call slips, assist Dr. Rollings-Mazza on the days that she was at the Prison, and attend ICE meetings to discuss immigration detainees experiencing specific mental health problems. (Doc. 85-17 at 5-6, 8). Mental health nurses also have a general familiarity with suicide risk factors, and they have the authority to place an inmate on constant watch or suicide precaution. (See id. at 7).

         3. YCP Administrators and Corrections Employees

         At all times relevant to the instant action, the Prison's Deputy Warden of Treatment was defendant Doll. Doll's responsibilities include overseeing the Prison's corrections staff, education department, religious services, work release program, and inmate grievance system. (Doc. 85-14 at 11). Doll's daily interaction with inmates is fairly limited, but he may have contact with inmates when taking part in PRC reviews or when dealing with an inmate's appeal through the grievance system. (Id. at 12). Of the contact Doll has with inmates, little pertains to mental health treatment issues unless individuals from the mental health department call him for assistance in formulating some sort of plan or to ensure that they are comporting with a policy. (Id.) Doll has the authority to place inmates in certain segregation units, and if a particular inmate has a mental health concern, he will consult with a mental health counselor before placing that inmate in segregation. (Id. at 13, 25). Doll has frequent interactions with mental health staff, including psychiatrists and mental health counselors. (Id. at 12-13). Doll and LPC Gallagher have occasionally discussed what type of things could be provided to assist segregated inmates in occupying their time. (Id. at 12).

         Corrections officers such as defendants Collins and Santos-Heredia are responsible for conducting rounds by performing alternating tours of their assigned housing block and periodically checking on inmates. (Doc. 85-13 at 8). As for segregated inmates on psychiatric observation, suicide precaution, or medical observation, corrections officers are required to check on those inmates every fifteen minutes and sign a sheet explaining what the inmate was doing at the time of the check. (Id. at 10-11). Inmates who were not on any observation status (i.e., they did not have a “sign” on their cell) would only be checked every thirty minutes. (Id. at 10). Additionally, specific corrections officers were assigned to continuously observe each individual on constant watch. (Id. at 9-10). When corrections officers are first hired by the Prison, they are taught risk factors for inmate suicide, and are trained as to what signs they should look for. (Id. at 11).

         YCP's corrections counselors are responsible for conducting intake interviews of inmates upon their arrival to the Prison and for performing monthly “contact reviews” with inmates to whom they are assigned. (Doc. 85-16 at 4). Carlos's assigned corrections counselor was defendant Counselor Jackson. According to Counselor Jackson, her responsibilities at monthly contact reviews with regard to Carlos were to check in on her and make sure she was provided with clothing, writing utensils, communication with family, and contact with immigration services. (Id. at 9). If an inmate needs assistance between monthly contact reviews, the inmate can send a request slip to the corrections counselor, which the counselor would answer by writing on the request slip and returning it to the inmate. (Id.) A corrections counselor may authorize that an inmate be moved from one cell to another, unless the inmate is on an observation status, in which case the corrections counselor would have to consult with mental health staff prior to authorizing a move. (Id. at 19).

         D. Carlos's Detention at YCP

         Given the duration of Carlos's detention at YCP and the chain of events underlying the instant action, it is helpful to separate the operative facts into three specific time periods: (1) April 14, 2011, to August 13, 2013; (2) August 13, 2013, to October 23, 2013; and (3) October 23, 2013, and thereafter.

         1. April 14, 2011 to August 13, 2013

         a. Carlos's Arrival at YCP

         Carlos arrived at YCP on April 14, 2011, and she was seen by LPC Gallagher upon arrival. (Doc. 85-15 at 12). Because of Carlos's agitation, Gallagher placed her on psychiatric observation status. (Id. at 12-13). Due to her aggressive behavior and behavior during transport to the Prison, she was placed in segregated housing conditions in the Behavioral Adjustment Unit (BAU) pod of the Prison's female maximum security block.[10] (Doc. 85-6 at 2-3). On April 15, 2011, nonparty Corrections Counselor Schneider conducted an intake of Carlos. According to Counselor Schneider, Carlos did not understand why she was at the Prison, and she did not remember getting into trouble. (Doc. 85-6 at 3). Carlos was classified under Security Level III[11] due to her confusion and her mental health status. (Id.)

         On, April 20, 2011, Carlos was removed from psychiatric observation status per LPC Gallagher's recommendation, and she was transferred to a cell in general population. (Id.) On April 25, 2011, Carlos was seen by psychiatrist Dr. Rollings-Mazza for the first time. (See Doc. 85-11 at 5). It was conveyed to the Doctor that Carlos had previously been diagnosed with schizophrenia and that she had been prescribed Haldol Decanoate (“Haldol”) injections which she received every two weeks. (Doc. 85-19 at 14, 17). The Doctor diagnosed Carlos with “likely [ ] schizoaffective disorder” and reported that Carlos was stable on her meds, exhibited no overt psychosis, and denied suicidal ideation. (Doc. 85-11 at 5).

         b. Carlos's Disruptive Behavior

         Throughout the first twenty-eight months of her detention at YCP, Carlos repeatedly engaged in disruptive behavior.[12] As a result of this behavior, Carlos spent much of her time on either BAU status or Intensive Custody Unit (ICU) status.[13] During the period of April 14, 2011, to early August 2013, she was housed in disciplinary segregation on eight separate occasions, and she was on ICU status for one extended period of time-from January 23, 2013 to June 7, 2013. (Docs. 85-6 at 6; 85-9 at 13). Moreover, in accordance with YCP's policy of automatically placing mental health inmates on suicide precaution after involvement in an altercation, Carlos was placed on suicide precaution on four specific dates during that time period: June 8, 2011; November 11, 2012; December 13, 2012; and July 11, 2013. (Doc. 85-9 at 11). Each of the four times that she was placed on suicide precaution following an altercation, she was stepped down to psychiatric observation status the very next day by LPC Gallagher. (See Doc. 85-6 at 3, 6-7).

         c. Defendants' Interactions with Carlos

         Many of the individual defendants named in the instant action observed Carlos on a regular basis throughout the first twenty-eight months of her detention. Those observers reported varying accounts as to Carlos's mood and behavioral tendencies.

         Dr. Rollings-Mazza typically conducted a medication check on Carlos every four to eight weeks. (Doc. 85-19 at 9). Dr. Rollings-Mazza recalled that Carlos was “remarkably stable” on her Haldol shots, and Carlos never exhibited any psychotic symptoms when the Doctor observed her. (Id. at 14). Additionally, the Doctor recalled that on the majority of occasions where she observed Carlos, Carlos was engaged in terms of conversation. (Id.) Dr. Rollings-Mazza also spoke with Carlos frequently on a social, non-evaluative basis because Carlos was often housed in a segregation area that was directly across from Dr. Rollings-Mazza's office. (Id. at 4). The Doctor recalled that Carlos expressed frustration about three things: (1) lack of contact with her family; (2) confusion about her deportation status; and (3) being housed in a segregated environment. (Id. at 4, 11).

         Although Dr. Rollings-Mazza was aware that Carlos engaged in disruptive behavior from time to time, she did not believe that the disruptions were caused by her schizophrenia, and she elected not to make any changes to her medication regimen. (Id. at 32). The Doctor acknowledged that there were some occasions where Carlos refused her Haldol shot, but according to the Doctor's recollection, Carlos usually received the shot within a day thereafter. (Id. at 4, 14). The Doctor did not recall any exacerbation of Carlos's psychiatric symptoms on the occasions that her shot was delayed, and the Doctor testified that a delay of a day or two should not cause any problems. (Id.)[14]

         Each time Carlos was housed in segregation due to her behavior, defendant LPC Gallagher saw her at her cell on a weekly basis to review her mental health status until he believed she could be removed from psychiatric observation status. (Doc. 85-15 at 13). Gallagher would also see Carlos intermittently on other occasions when she requested him or simply needed support; on those occasions, when he could, Gallagher would pull Carlos out for counseling sessions (which lasted between twenty and thirty minutes) in the female mental health office. (Id.) When talking with Gallagher, Carlos frequently expressed concerns about deportation, and she often complained about her placement in segregated housing. (Id. at 11-12). On one occasion, Carlos expressed distress over the fact that her parents were having relationship problems. (Id. at 12). Gallagher reported that Carlos's mood fluctuated; Gallagher recalled that sometimes, Carlos could be “very reasonable” and at other times, she would be “difficult to handle.” (Id. at 14). Gallagher expressed that Carlos was not the “easiest compliant inmate in the [Prison], ” but she was generally “workable.” (Id.) According to Gallagher, there was an attempt at one point to have Carlos participate in an anger-management class, but she was unable to participate because of her illiteracy. (Id. at 13).

         Gallagher testified that in his many personal assessments of Carlos between April 2011 and August 2013, he observed nothing that led him to believe Carlos may be at risk for harming herself, and none of his interactions with her led him to believe that he should talk to Dr. Rollings-Mazza about a possible medication change. (Id. at 11, 13). Gallagher recalled that there were occasions where Carlos refused her Haldol injection and her treatment was briefly delayed, but like Dr. Rollings-Mazza, Gallagher did not observe any changes in Carlos's behavior when the treatment was delayed. (Id. at 13-14).

         Any time that Carlos was in segregation, she would also be seen by a mental health nurse on a weekly basis for a mental health check. The nurse that saw Carlos most frequently was defendant Nurse Leiphart, but Carlos was also seen occasionally by defendant Nurse Snyder.[15] (See Doc. 85-21 at 8). According to Nurse Leiphart, Carlos frequently was involved in altercations with other inmates and staff and would easily become agitated at times. (Doc. 85-17 at 8). When speaking with Nurse Leiphart, Carlos would often complain about being locked up in segregation, but Leiphart had no authority to move Carlos to different housing quarters. (Id. at 12). Although Carlos was difficult for many Prison staff members to deal with, Nurse Leiphart believed that she and Carlos had established a rapport, and Carlos was more cooperative with her than with other staff. (Id. at 6, 9). On occasions where Carlos refused her Haldol shot from other staff, Nurse Leiphart could usually convince Carlos to receive the shot shortly thereafter. (Id. at 9-10).

         Defendant Deputy Warden Doll did not personally speak with Carlos until he became part of the PRC around June or July of 2013 and began observing Carlos as a part of that Committee. (Doc. 85-14 at 23). Although Doll did not actually speak with Carlos until 2013, he had been previously aware that she was involved in altercations and was “difficult to manage.” (Id.) Doll also recalled that he had placed Carlos on ICU status on at least one occasion and that he had consulted with Gallagher before doing so. (Id. at 13). Doll was also aware that Carlos refused her Haldol shot on various occasions, but it was his understanding that she was stable on her medication. (Id. at 25). At various times prior to August 2013, Doll spoke with Joe Dunn, Assistant Field Director for ICE, to recommend that Carlos be moved out of YCP and into a different facility because Doll knew that Carlos was concerned about her immigration status, and he believed that she may have benefited from a “change in scenery.” (Id.) Doll also discussed this matter with Gallagher who similarly “believe[d] [Carlos] would have been better off in some other type of environment” because she was “getting tired of being where she was.” (Doc. 85-15 at 15). ICE did not accept Doll's recommendations, however, and Carlos remained detained at YCP. (Doc. 85-14 at 25).

         Defendant Jackson was Carlos's assigned corrections counselor at YCP. (Doc. 85-16 at 4). As Carlos's assigned corrections counselor, one of Counselor Jackson's primary responsibilities was to conduct a monthly contact review at which she would check to make sure Carlos had clothing, writing utensils, communication with family, and contact with immigration services. (Id. at 9). Like many other defendants, Jackson recalled that Carlos expressed concern about her immigration case, and that she wanted to stay in the United States because she did not want to be separated from her family. (Id. at 14). Jackson recalled that she usually did not observe Carlos more than once a month, and, therefore, she did not observe Carlos's behavior on a daily basis. (Id.)

         The record reflects that many interactions between Jackson and Carlos were unamiable, and contact reviews were often unproductive due to Carlos's behavior. After one contact review, Jackson reported that Carlos refused to listen, was “very frustrating to speak with, ” and would not let Jackson “get a word in.” (Id. at 12). At other contact reviews, Jackson reported that Carlos would “wast[e] time, ” repeatedly ask questions that had already been answered, argue, and refuse to talk to Jackson in a respectful manner. (Id. at 14-15). Jackson also recalled that Carlos said some “very colorful things” at the contact reviews and that she once accused Jackson of “not lik[ing] black people.” (Id. at 7). On another occasion, Jackson reported that Carlos “[was] always needing something or complaining about something.” (Id. at 17). Jackson also recalled that Carlos would sometimes engage in interruptive and “attention-grabbing” behavior, but she stated that such behavior is common among inmates. (Id. at 7).

         Defendant CO Collins, who began working at YCP in October 2011, often worked in the prison block on which Carlos was housed, and she had frequent contact with Carlos. (Doc. 85-13 at 3-4). Collins was not aware of Carlos's specific mental health diagnosis, but she could tell that something was “a little off” with her. (Id. at 5). According to Collins, Carlos acted mentally immature in some ways and would sometimes talk in a child-like manner in an attempt to “get what she wanted.” (Id. at 4). Collins did not personally have any significant problems with Carlos, as Carlos was very comfortable with her and respectful to her. (Id. at 4, 12). Collins recalled, however, that Carlos was verbally assaultive with and problematic for other corrections officers and inmates. (Id. at 12-13). Collins testified that Carlos would get agitated very easily and that she could “fly off the handle” when she became agitated. (Id. at 12). Collins remembered that the factors which agitated Carlos most were other inmates and frustration surrounding her lengthy stay at the Prison. (Id. at 14). Collins did not recall talking to Carlos about the status of her immigration case, but Carlos had informed her that she was from Antigua. (Id. at 13). When Carlos became agitated, corrections officers, including Collins, would try to talk to her, calm her down, and divert her mind away from whatever was agitating her. (Id. at 14). This would be effective for “certain officers, ” including Collins. (Id.)

         2. August 13, 2013 to October 23, 2013

         On August 10, 2013, Carlos was removed from BAU status, after having been placed on that status on July 11, 2013. (Doc. 85-6 at 7). On August 13, 2013, however, three days after she was removed from BAU status, Doll placed her on ICU status due to her “continued assaultive behavior.” (Id.) Later that same day, Carlos was found in her cell attempting to hang herself from a window by tying a sheet around her neck. (Doc. 76-12 at 2). Security staff members cut her down to the floor to assess her, and according to a medical chart note from nonparty medical nurse Angela Schmuck, Carlos began crying and saying, “It's not fair, I don't wanna live.”[16] (Id.) Carlos was taken to the Prison's medical department, and then ultimately to an outside hospital for further treatment. (Id.)

         Dr. Rollings-Mazza and Nurse Leiphart were both near Carlos's cell when the August 13, 2013 suicide attempt occurred. Carlos was being housed in the female maximum security area's “A” pod, which is located directly across from Nurse Leiphart's office. (Doc. 85-17 at 10). Nurse Leiphart ran over to Carlos's cell after she heard officers yelling that there was a medical emergency. (Id.) By the time Nurse Leiphart arrived, Carlos had been cut down and was on the ground and “pretty alert.” (Id.) Although Dr. Rollings-Mazza was not present on the A pod at the time of the incident, she was working close enough that she could hear a “commotion” in the area of that pod.[17] (Doc. 85-19 at 20). The Doctor recalled Leiphart emerging from the A pod and informing her that Carlos had attempted suicide. (Id.) Leiphart also told the Doctor that Carlos had been very upset, and was yelling and screaming that she wanted to talk to somebody about her deportation status. (Id.) According to Nurse Leiphart, Dr. Rollings-Mazza decided to place Carlos on constant observation status and put her in “four-point” restraints upon her return from the hospital. (Doc. 85-17 at 12).

         Gallagher was at the Prison when Carlos attempted suicide, but he was not located in the area in which the attempt occurred. (Doc. 85-15 at 15). Doll, Collins, and Santos-Heredia did not recall being at the Prison at the time of the suicide attempt, but they learned of it shortly afterwards. (Docs. 85-14 at 26; 85-13 at 13; and 85-20 at 10). Jackson testified that she “vaguely” remembered the suicide attempt, but she did not discuss the attempt with Carlos at subsequent contact reviews because she felt such discussions would be more appropriate for mental health staff. (Doc. 85-16 at 8-9, 11). Snyder, McNicholas, Crist, Nadeau, and Trig all assert that they were unaware of Carlos's suicide attempt. (Docs. 85-21 at 7-8; 76-23 at 3; 67-7 at 3; 67-8 at 3; and 67-9 at 2).

         On August 14, 2013, one day after her suicide attempt, Carlos returned from the hospital to YCP, where she was placed on ICU status and on constant observation. On that day, Carlos was seen by both Dr. Rollings-Mazza and Gallagher. Dr. Rollings-Mazza observed that Carlos was uncooperative, refused an evaluation, and refused to take her medication. (Doc. 85-19 at 25; Doc. 76-13 at 48). The Doctor directed that Carlos's current medication regimen continue and that she be seen again by a psychiatrist in one week. (Doc. 76-13 at 48). Carlos also refused an interview with Gallagher, who assessed her to be a suicide risk and kept her on constant observation. (Id.) On August 15, 2013, Carlos was again uncooperative with Gallagher, and he kept her on constant observation. (Id. at 47-48).

         When Gallagher saw Carlos on August 16, 2013, Carlos exhibited a “normal” mood, but her insight and judgment were limited, and she was “unable to commit to safety.” (Id. at 47). As a result, Gallagher ordered that she remain on constant observation. (Id.)

         On August 17, 2013, Carlos was seen by nonparty Shannon M. Taylor, LPC. Taylor noted that Carlos exhibited little cooperation and was unable to commit to safety, and, therefore, she was kept on constant observation. (Id.)

         On August 18, 2013, Carlos was again kept on constant observation after being seen by another nonparty, Jeff Leer. (Doc. 76-14 at 4). According to Leer, Carlos stated that she was “OK, ” but she would not come to her cell door. (Id.)

         On August 19, 2013, Carlos was seen by Gallagher, and for the first time since her suicide attempt, Gallagher stepped her down from constant observation to suicide precaution status. (Id. at 3). Gallagher noted that she was “appropriate and cooperative, ” and that she “contracted for safety”[18] and agreed to cooperate with treatment. (Id.)

         On August 20, 2013, Carlos was seen by both Gallagher and former defendant Dr. Davis. When she saw Dr. Davis, Carlos was “animated” and “angry” about her deportation case, but she was goal-oriented and maintained good eye contact. (Id.) Dr. Davis ordered that Carlos maintain her current treatment plan, and that she be seen again by a psychiatrist in eight weeks. (Id.) When Carlos saw Gallagher on the same day, she was “appropriate and cooperative, ” she denied suicidal ideations, and her mood was normal. (Id.) Gallagher stepped Carlos down from suicide precaution to psychiatric observation, and she remained on ICU status. (Id.)

         After she was stepped down to psychiatric observation on August 20, 2013, Carlos remained on that observation level for more than a month, during which time Gallagher saw her at her cell on an approximately once-per-week basis. (See id. at 1-3). On most visits during this time period, Gallagher observed that Carlos's mood was normal, her thought process was intact, and she denied suicidal ideation. (See id.) When Gallagher saw Carlos on September 19, 2013, she was cooperative and denied suicidal thoughts, but she exhibited an anxious and depressed mood, expressing that she could no longer handle being on ICU status. (Id. at 2). Gallagher explained to her that he did not have the authority to take her off of ICU status, and he suggested some ways that she could mitigate the anger she felt. (Doc. 85-15 at 21).

         On September 30, 2013, Carlos saw Dr. Rollings-Mazza for a follow-up psychiatric evaluation. Finding that Carlos was stable with no overt psychosis, the Doctor ordered that her medication regimen be continued and that she be seen by a psychiatrist again in six weeks. (Doc. 76-14 at 1). This was the last time that Dr. Rollings-Mazza saw Carlos for a clinical evaluation. (Doc. 85-19 at 26).

         On October 2, 2013, Gallagher saw Carlos at her cell. Carlos's mood was normal, but she told Gallagher that she was tired of being on psychiatric observation because it made other people think that she was “crazy.” (Doc. 85-15 at 21). Gallagher told Carlos that he would be willing to recommend her removal from psychiatric observation if she would continue to work with him to move forward on her mental health progress; Carlos agreed to do so. (Id.) After consulting with various PRC members, including Doll, Gallagher decided to take Carlos off psychiatric observation;[19] Carlos, however, remained on ICU status. (Id.) Gallagher believed that taking Carlos off psychiatric observation would give him more room to work with her because she would perceive that he was being supportive of her. (Id.) Once Carlos was taken off psychiatric observation, Gallagher made no arrangements for further clinical evaluations, but he did make arrangements to see her for weekly meetings with the PRC Team. (Id.) Gallagher did not recall anything worrisome about Carlos in those PRC meetings. (Id. at 21-22). Doll, who also took part in the PRC meetings with Carlos, perceived that the meetings had been positive, and he believed that Carlos “was actively engaged in moving back to general population.” (Doc. 85-14 at 30).

         Nurse Leiphart also testified about her interactions with Carlos in the weeks following the August 2013 suicide attempt. Leiphart recalled that during that time, Carlos was more agitated than usual, and on various occasions, Carlos refused her Haldol shot when medical nurses attempted to give it to her. (Doc. 85-17 at 9, 14). Generally, when Carlos refused her Haldol shot initially, Nurse Leiphart could convince her to take it later on the same day. (Id. at 9-10). Leiphart testified that she was not concerned that Carlos's increased agitation would cause her to harm herself, and she did not specifically recall talking to anyone about Carlos's increased agitation. (Id.)

         3. Carlos's Suicide - October 23, 2013

         At around 8:30 p.m. on the night of October 23, 2013, Officer Collins was on a routine shift at the Prison when she heard screaming coming from one of the pods on the female maximum security block. (Doc. 85-13 at 17, 19). Collins entered “A” pod and observed that Carlos and another inmate two cells over, Janette Cruz-Rivera, were yelling at each other and arguing about the television. (Id. at 16-17). The argument culminated with Cruz-Rivera saying to Carlos, “why don't you kill yourself?” (Id. at 17). In response, Collins said to Cruz-Rivera, “Why would you say that to her?” (Id.) Collins then turned to Carlos and began speaking with her. (Id.) Collins told Carlos to ignore Cruz-Rivera and to sit down and listen to her radio. (Id.) Immediately following the argument, Carlos was very upset, but after Collins talked with her for about five minutes, it appeared that Carlos had calmed down, and Collins departed from “A” pod for the time being. (Id. at 17-18). According to Collins, because Carlos appeared to have calmed down, Collins did not think of having Carlos speak to someone from the mental health department, and she did not suggest that anyone go back to check on Carlos to see if she was okay. (Id. at 18).

         At around 9:00 p.m. on the same evening, Officer Santos-Heredia, while conducting her rounds, checked on Carlos. (Doc. 85-20 at 15). Santos-Heredia observed that Carlos was sitting at the end of her bunk, and it appeared as if she was preparing to go to bed. (Id. at 14-15). Then, at 9:17 p.m., while conducting rounds, Officer Collins found Carlos with a bed sheet tied to the window and around her neck, and she was hanging from a bar on her cell window. (Docs. 85-13 at 16, 19; and 85-9 at 22). Carlos was taken to York Hospital where she was pronounced dead. (Doc. 76-12 at 1). None of the defendants other than Collins and Santos-Heredia were in the prison at the time that Carlos's suicide occurred. (See Docs. 85-19 at 28; 85-17 at 14; 85-16 at 10; 85-15 at 22; 85-14 at 30). Rollings-Mazza, Gallagher, Leiphart, Doll, and Jackson all stated that they were surprised when they learned of Carlos's suicide. (Docs. 85-19 at 28; 85-17 at 15; 85-16 at 10; 85-15 at 22; and 85-14 at 30). Similarly, Collins recalled that nothing stood out to her about her encounters with Carlos in the days leading up to the suicide. (Doc. 85-13 at 16).

         On October 21, 2013, two days prior to the suicide, Counselor Jackson had authorized Carlos's movement from a cell in “D” pod to a cell in “A” pod because the “D” pod cell, which was close to the medical department, was needed for an inmate with a medical appliance. (Docs. 85-16 at 11; and 85-15 at 23). Counselor Jackson did not consult with mental health staff before authorizing Carlos's move because Carlos was not on psychiatric observation at the time. (Doc. 85-16 at 18-19). Deputy Warden Doll testified that the cell to which Carlos was moved was “an exact copy” of the cell that she had been in previously. (Doc. 85-14 at 32). Similarly, Gallagher averred that the two cells were “mirror images, ” and that Carlos could have committed suicide in the “D” pod cell just as easily as in the “A” pod cell. (Doc. 85-15 at 23). Doll acknowledged that Carlos was not in a suicide-resistant cell when she committed suicide, but stated that her placement into such a cell was allowable because she had been removed from psychiatric observation. (Doc. 85-14 at 41).

         E. Post-Suicide Investigations and Reports

         Two federal investigations were conducted subsequent to Carlos's death. The first investigation, which was conducted by Lindsay M. Hayes (“Hayes”) for the Office of Civil Rights and Civil Liberties of the U.S. Department of Homeland Security, engaged in a review of YCP's suicide prevention practices. After that investigation, on April 1, 2014, Hayes issued a report (Doc. 85-11) which consisted of a summary of his observations, conclusions, and suggested remedies in regard to suicide prevention practices within YCP. Judge Saporito summarized Hayes' findings as follows:

[Hayes'] report found a number of deficiencies in the implementation of suicide prevention programs by York County Prison and PrimeCare, including inadequate guidance with respect to training, problematic housing of inmates in cells that were not suicide-resistant, and failure of mental health personnel to comply with suicide prevention requirements set out in the written policies. The report also noted an ICE policy requirement that a mortality review be conducted following any detainee suicide attempt, but it deferred making any findings due to lack of documentation.

(Doc. 94 at 31) (internal citations omitted). The Hayes report also found that YCP mental health staff “are not developing any treatment plans, ” as required for all inmates on suicide precautions greater than 24 hours. (Doc. 85-11 at 28). Moreover, Hayes found that “mental health staff continue to utilize ‘contracting for safety' when discharging detainees from suicide precautions and/or psychiatric observation.” (Id.) Hayes averred that this practice is problematic and should be discontinued because “[w]hile there may be some positive therapeutic aspects to safety contracts, most experts agree that once a patient becomes suicidal, their written or verbal assurances are no longer sufficient to counter suicidal impulses.” (Id.)

         The second federal investigation pertaining to Carlos's death was conducted by the ICE Office of Professional Responsibility, Office of Detention Oversight (“ODO”). On July 17, 2014, the ODO issued a report (Doc. 85-9) pertaining to its investigation. Judge Saporito summarized the findings of that report as follows:

This [ODO] report found York County Prison to be deficient in following various ICE standards, including inadequate documentation of administrative segregation orders, untimely segregation reviews, a failure to collect incident reports from all staff who responded to Carlos's October 2013 suicide and her August 2013 suicide attempt, a failure by medical staff [including LPC Gallagher and Dr. Rollings-Mazza] to document any treatment plan for Carlos during her thirty months of detention, and a failure to prepare a psychiatric alert report following Carlos's August 2013 suicide attempt.

(Id. at 31-32) (internal citations omitted).

         In addition to the two federal investigations, Dr. Raymond F. Patterson, a Board certified forensic psychiatrist and retained expert of the plaintiff, issued a forensic psychiatric report (Doc. 85-22) on June 23, 2015, and, thereafter an addendum (Doc. 85-23) dated September 30, 2016. Of particular relevance, Dr. Patterson concluded in his original report (which was issued prior to the initiation of the instant action) that “to a reasonable degree of medical certainty . . . the mental health care, treatment, and management provided by PrimeCare Inc., and the York County Prison did not meet the standard of care for mental health care in similar situations and institutions, and indeed reflected negligence and deliberate indifference.” (Doc. 85-22 at 11). Moreover, in the report, Dr. Patterson found “to a reasonable degree of medical certainty that [Carlos's] suicide was foreseeable and preventable” if she had been housed in a better environment, had her mental health treatment increased, and been provided with comprehensive treatment planning and formal suicide risk assessment and management. (Id. at 14-15).

         In the September 30, 2016 addendum to his original report, Dr. Patterson concluded that he reviewed the discovery materials and deposition testimony from this case- including the deposition transcripts of LPC Gallagher, Dr. Rollings-Mazza, and Nurse Leiphart-and that those materials supported the opinions he expressed in his initial report. (Doc. 85-23 at 4-5). Moreover, in the addendum, Dr. Patterson expressly endorsed the opinions that Hayes had previously presented in his own report from April 1, 2014. (See id. at 4).

         F. Procedural History of ...

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