United States District Court, M.D. Pennsylvania
ANGELA CARLOS, as ADMINISTRATRIX of the ESTATE OF TIOMBE KIMANA CARLOS, Plaintiff
YORK COUNTY, et al., Defendants
MALACHY E. MANNION UNITED STATES DISTRICT JUDGE
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.
Factual Background and Procedural History
Defendants Named in the Instant Action
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”); (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
Events Leading to Carlos's Incarceration at York
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.
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.
YCP - An Overview of the Facility's Mental Health
Protocol and Policy at the Time of Carlos's
YCP's Official Suicide-Prevention Policy Circa
to the YCP suicide prevention policy, (see Doc.
85-2), effective at the time of Carlos's incarceration,
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 in suicide resistant housing
quarters. (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).
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” committee. (Id.)
YCP's Mental Health Department and Protocol
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.
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,  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).
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. (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 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).
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).
YCP Administrators and Corrections Employees
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).
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).
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).
Carlos's Detention at YCP
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
April 14, 2011 to August 13, 2013
Carlos's Arrival at YCP
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. (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 due to her confusion and
her mental health status. (Id.)
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
Carlos's Disruptive Behavior
the first twenty-eight months of her detention at YCP, Carlos
repeatedly engaged in disruptive behavior. As a result
of this behavior, Carlos spent much of her time on either BAU
status or Intensive Custody Unit (ICU) status. 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).
Defendants' Interactions with Carlos
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
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).
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.
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
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).
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. (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).
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).
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.)
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
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
August 13, 2013 to October 23, 2013
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.” (Id.) Carlos was taken to the
Prison's medical department, and then ultimately to an
outside hospital for further treatment. (Id.)
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. (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).
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).
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).
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.
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.
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
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” and agreed to cooperate
with treatment. (Id.)
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.
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).
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).
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; 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).
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.)
Carlos's Suicide - October 23, 2013
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).
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).
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).
Post-Suicide Investigations and Reports
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.”
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).
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.
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).
Procedural History of ...