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Braggs v. Dunn

United States District Court, M.D. Alabama, Northern Division

July 7, 2019

EDWARD BRAGGS, et al., Plaintiffs,
v.
JEFFERSON S. DUNN, in his official capacity as Commissioner of the Alabama Department of Corrections, et al., Defendants.

          PHASE 2A REMEDIAL OPINION ON IMMEDIATE RELIEF FOR SUICIDE PREVENTION

          MYRON H. THOMPSON, UNITED STATES DISTRICT JUDGE.

         In this long-standing lawsuit, the court previously found that the Alabama Department of Corrections (ADOC) has failed to provide adequate mental-health care to inmates in its custody in violation of the Eighth Amendment to the United States Constitution. See Braggs v. Dunn, 257 F.Supp.3d 1171 (M.D. Ala. 2017) (Thompson, J.), Braggs v. Dunn, No. 2:14CV601-MHT, 2019 WL 539050, __ F.Supp.3d __ (M.D. Ala. Feb. 11, 2019) (Thompson, J.). More recently, in the wake of 15 inmate suicides in a 15-month period, the plaintiffs asked for immediate suicide-prevention relief. For reasons that follow, the court concludes that these suicides, as well as other evidence in the record, show that ADOC continues to fail to provide adequate suicide-prevention measures and, thus, subjects inmates to a substantial risk of serious harm, including self-harm, continued pain and suffering, and suicide. The risk of suicide is so severe and imminent that the court must redress it immediately. Therefore, the court will grant the plaintiffs' motion for immediate relief by making permanent most provisions of an interim suicide-prevention agreement that the parties reached early in this litigation; by adopting, in large measure, the recommendations proposed by experts for both parties; and by requiring court monitoring that is limited to the immediate relief ordered here. By agreement of the parties, the issue of non-immediate suicide-prevention relief will be resolved by the court later.

         I. PROCEDURAL BACKGROUND

         The plaintiffs in this class-action lawsuit include a group of seriously mentally ill state prisoners and the Alabama Disabilities Advocacy Program (ADAP), which represents mentally ill prisoners in Alabama. During the liability trial, and in response to the suicide of class member Jamie Wallace just days after he testified, the parties agreed to a series of interim suicide-prevention measures. See Interim Agreement (doc. no. 1106-1). The court reduced this ‘interim agreement' to an order. See Interim Relief Order (doc. nos. 1106, 1106-1).

         In June 2017, the court issued a liability opinion in which it found that ADOC's mental-health care for prisoners in its custody was, “[s]imply put, ... horrendously inadequate” and violated the Eighth Amendment. Braggs, 257 F.Supp.3d at 1267. The court more specifically found that “ADOC's inadequate crisis care and long-term suicide-prevention measures have created a substantial risk of serious harm, including self-harm, suicide, and continued pain and suffering.” Id. at 1220. The “serious” suicide-prevention deficiencies identified by the court included ADOC's failure to provide crisis care to those who need it; placement of prisoners in crisis in dangerous and harmful settings, including unsafe crisis cells; inadequate treatment for prisoners in crisis care; inadequate monitoring of suicidal prisoners; inappropriate release of prisoners from suicide watch; and inadequate follow-up care for prisoners released from suicide watch. See Id. at 1218-31. Moreover, the court found that these risks are particularly heightened for prisoners with serious mental illnesses. “Serious mental illness” (SMI) is a term of art used in the field of psychiatry which refers to “a subset of particularly disabling conditions ... defined by the diagnosis, duration, and severity of the symptoms.” Id. at 1246. Certain conditions are always considered SMIs, such as schizophrenia, bipolar disorder, and major depressive disorder. See id. at 1186 n.6.

         Over a period of months, the court adopted several ‘remedial orders' regarding mental-health care that touched on suicide prevention.[1] To fashion a comprehensive suicide-prevention remedy, the parties agreed to, and the court accepted, a process whereby Drs. Mary Perrien and Kathryn Burns, the defendants' and plaintiffs' correctional mental-health experts, respectively, would “assess ADOC facilities and operations related to suicide prevention and provide a report with recommendations to resolve the constitutional violation determined by the Court in the Liability Opinion and Order.” Joint Notice (doc. no. 2014) at 1; Order (doc. no. 2020) (adopting the parties' plan for assessing suicide-prevention measures).

         On January 18, 2019, before the parties' experts completed their report, and in response to a series of suicides, the plaintiffs filed an emergency motion regarding the placement of high-risk prisoners in segregation. See Motion for Preliminary Injunction (doc. no. 2276) at 1. The court construed it as seeking permanent, albeit immediate, relief. See Order (doc. no. 2345).

         On March 8, the experts filed (1) a report with recommendations for relief, (2) a report identifying a subsection of those recommendations to be implemented immediately in light of the recent suicide crisis plaguing ADOC, and (3) case summaries of many of the recent suicides. See Joint Expert Report and Recommendations, Immediate Relief Recommendations, Joint Expert Case Summaries (doc. nos. 2416-1, 2416-4, 2416-2). Their reports were the product of an extensive and thorough study, in which they reviewed thousands of documents from ADOC, toured multiple facilities, and interviewed both prisoners and staff.

         In March and April, the court held a trial to determine whether immediate and non-immediate suicide-prevention relief is needed and, if so, what it should be. The parties and the court decided during the hearing that the portion of the hearing on non-immediate suicide-prevention relief would be continued to a future date. This opinion addresses only immediate relief in response to the ongoing substantial and pervasive inadequacies in ADOC's suicide-prevention efforts, exemplified by the 15 suicides that have occurred since December 2017.

         As immediate relief, the plaintiffs first request that the court enter an order making permanent most of the provisions of the interim agreement. The agreement addressed licensing of mental-health professionals; suicide-watch procedures, including inmates' placement on and discharge from suicide watch, follow-up appointments upon discharge, and documentation requirements; and suicide risk assessments, including a monthly evaluation of assessments.

         The plaintiffs also request that the court adopt as an order the experts' second report. This report identifies a subsection of their recommendations that should be implemented on an immediate and permanent basis. These ‘immediate relief recommendations' address suicide-watch follow-ups, referrals to higher levels of care, preventing discharge from suicide watch to segregation, training for staff, security checks in segregation, confidentiality, and immediate life-saving intervention. In addition, the plaintiffs seek interim monitoring of the immediate relief.

         Finally, the plaintiffs also argue that the defendants are placing mentally ill prisoners in units that, while not labelled as segregation or restrictive housing, impose equally severe restrictions on out-of-cell time, and the same accompanying risk of serious harm, particularly suicide. Therefore, they contend, the court's relief should extend to these “segregation like” settings.

         The court heard substantial evidence suggesting that prisoners in certain units receive very little out-of-cell time. However, the court needs more time to consider the evidence, and may decide to solicit additional input from the parties before deciding this critical issue. Therefore, the court's findings remain open as to this discrete issue, and the court will take it up after this opinion is issued.

         II. RECENT SUICIDES [2]

         Fifteen men in ADOC custody have committed suicide since December 30, 2017, an average of almost one suicide per month. An examination of their cases illustrates severe and systemic inadequacies in ADOC's suicide-prevention efforts. Many of the inadequacies, detailed in the 15 cases below, are instances of ADOC's pervasive and substantial noncompliance with the interim agreement and other remedial measures that they agreed to implement; that is, they are examples of what ADOC recognized are “systemic failures to comply with court orders.” Pls. Ex. 2710 at ADOC0475738.[3] Other inadequacies, while not necessarily constituting noncompliance with specific remedial orders to date, show ADOC's failure to live up to its obligations under the Eighth Amendment. In sum, both types of deficiencies summarized in the 15 cases below demonstrate that immediate relief is necessary to address the substantial risk of serious harm to which prisoners remain exposed.

         Rashaud Morrissette

         On March 8, 2019, Rashaud Morrissette hanged himself with a belt in the shower of a segregation unit at Fountain prison. See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 184; Pls. Ex. 2661 at ADOC0470542. ADOC's suicide-prevention failures in his case include that before entering segregation, he did not receive a critical preplacement screening for issues such as whether he was at risk of suicide or had a serious mental illness (SMI). See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 185; Burns Apr. 9, 2019, Rough Draft (R.D.) Trial Tr. at 191; see generally Pls. Ex. 2692.

         Matthew Holmes

         Matthew Holmes killed himself on February 14, 2019, roughly 12 hours after being transferred from mental-health observation (MHO) to segregation at Limestone prison. See Burns and Perrien Apr. 9, 2019, R.D. Trial Tr. at 169, 186. (MHO is a short-term placement that does not have the same level of protections as suicide watch.) ADOC's suicide-prevention failures in his case include (1) not placing him in suicide watch despite his being suicidal, and (2) placing him in segregation despite his having a SMI, and without adequately assessing his suicide risk or referring him for the emergency mental-health care he needed. Specifically:

• On February 11, 2019, Holmes was improperly placed in MHO, rather than suicide watch. See Defs. Ex. 3613 at SPA_13585. A “Psychiatrist/CRNP Progress Note” on February 12 indicates that he had recently become suicidal after being placed in segregation, and that he had twice attempted suicide in 2010. Id. at SPA_13582. As acknowledged by Deborah Crook, ADOC's Director of Mental Health Services, Holmes met the National Commission on Correctional Health Care (NCCHC)'s definition of nonacutely suicidal, and therefore, under the interim agreement, should have been placed on at least nonacute suicide watch (rather than MHO), at which point a suicide risk assessment would have been required. See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 55.[4]
• Because he was not placed on suicide watch, he did not receive a suicide risk assessment. See Id. at 55-56. Furthermore, the parties' experts, Drs. Burns and Perrien, flagged that while in MHO, Holmes's contacts with mental-health staff were conducted inside his cell, “rather than in a confidential area out of cell.” Joint Expert Case Summaries (doc. no. 2416-2) at 4; see also Defs. Ex. 3613 at SPA_13581-84.
• On February 14, he was ordered released from MHO to segregation per the order of a nurse practitioner who “wrote no note in the chart explaining the rationale for this decision or the level of risk assessed.” Joint Expert Case Summaries (doc. no. 2416-2) at 4. Holmes's February 13 treatment plan review had stated that he was “not making progress toward treatment plan goals, ” Defs. Ex. 3613 at SPA_13577; however, suddenly, the next day, the treatment plan review concluded that he had “completed treatment goal, ” id. at SPA_13576; see also Joint Expert Case Summaries (doc. no. 2416-2) at 4.
• The segregation pre-placement screening completed on February 14 at 11:45 a.m. noted that Holmes had a SMI, and that there were “yes” responses to the following three questions: (1) Are you feeling sad, hopeless, or depressed? (2) Have you ever intentionally hurt yourself or attempted suicide? (3) Have you had any serious problems with a significant other, family member or friend recently? See Defs. Ex. 3613 at SPA_13571. As noted by the parties' experts, despite these responses, Holmes “was not diverted from segregation placement and an ‘urgent' rather than ‘emergent' referral to mental health was made.” Joint Expert Case Summaries (doc. no. 2416-2) at 4.
• Later that night, he was discovered hanging from an overhead light fixture in his segregation cell. See id.
• Drs. Burns and Perrien concluded that his case “illustrates the problems with use of MHO rather than approved suicide watch levels, poor documentation of rationale for release from watch, failure to generate an emergency referral to mental health in response to a positive pre-placement screen and releasing SMI inmates from watch directly into segregation.” Id.

         Daniel Gentry

         Daniel Gentry hanged himself at the Donaldson prison Residential Treatment Unit (RTU) on February 6, 2019. ADOC's suicide-prevention failings include not placing him on suicide watch despite his making clear that he wanted to die, not conducting a suicide risk assessment when indicated, and inadequate review of his suicide. Specifically:

• A few weeks before his death, on January 24, 2019, a mental-health progress note reported that Gentry had asked a correctional officer to kill him. See Pls. Ex. 2314 at SPA_13258. In response, he was placed in MHO that day. See id. As plaintiffs' expert Dr. Burns testified, the MHO placement was inappropriate, because “with someone who's actively voicing the wish that someone kill him, you would expect to start a suicide watch, either acute or nonacute, but not just mental health observation status.” Burns Apr. 9. 2019, R.D. Trial Tr. at 94.
• Five days into his MHO placement, Gentry continued to report “auditory hallucinations and a desire for someone to kill him.” Pls. Ex. 2314 at SPA_13275. His records indicate that he did not receive a suicide risk assessment in relation to his MHO placement. See generally Pls. Ex. 2314.
• On January 31, 2019, Gentry was released from MHO to the RTU at Donaldson. See Id. at SPA_13235; Joint Expert Case Summaries (doc. no. 2416-2) at 3. A week later, on February 6, he was discovered hanging from a light fixture inside his cell during a security check. See Joint Expert Case Summaries (doc. no. 2416-2) at 3. The correctional officers waited several minutes for medical staff, who upon arriving, told them to remove the sheet from his neck and initiated CPR. See Id. Dr. Burns testified that this intervention was inadequate, as the officers should not have waited for medical staff to arrive before removing the noose and beginning CPR. See Burns Apr. 9, 2019, R.D. Trial Tr. at 204. Indeed, both Drs. Burns and Perrien noted with respect to Gentry's suicide that correctional officers “need additional training and drills regarding first aid and responding to hanging attempts.” Joint Expert Case Summaries (doc. no. 2416-2) at 3. This observation coincides with the experts' more general recommendation that ADOC policy and practice be revised to ensure that as soon as two security staff are present, “CPR should be immediately initiated while whatever method of suicide is eliminated.” Joint Expert Report and Recommendations (doc. no. 2416-1) at 29.
• In carrying out their suicide-prevention assessment, Drs. Burns and Perrien did not receive any medical or security reviews of the suicide, see Joint Expert Case Summaries (doc. no. 2416-2) at 3, even though, in their expert opinion, ADOC must conduct such reviews in cases of suicides, see Joint Expert Report and Recommendations (doc. no. 2416-1) at 34. Here, and in the other cases detailed in this section in which Drs. Burns and Perrien did not receive medical or security reviews, the court infers from ADOC's failure to provide the reviews that either the reviews were never conducted, or that--like the limited sample of documents reviewing suicides that they did receive--they were generally inadequate.[5]

         Paul Ford

         Paul Ford killed himself in segregation at Kilby prison on January 16, 2019, following two prior suicide attempts in segregation in 2018, and less than a month after being released from suicide watch. See Joint Expert Case Summaries (doc. no. 2416-2) at 3. ADOC's suicide-prevention failures in his case include inadequate (1) follow-up mental-health appointments after release from suicide watch, (2) suicide risk assessments, and (3) mental-health assessments while in segregation. Specifically:

• In April 2018, while in segregation, Ford set fire to his cell and attempted to hang himself. See id.; Pls. Ex. 2309 at SPA_9757. On July 30, he again attempted to hang himself while in segregation and was placed on suicide watch. See Pls. Ex. 2309 at SPA_9741.
• Following his release from suicide watch on August 2, he was placed in segregation, but records indicate that, following discharge from suicide watch, he did not receive the required three-, seven-, and 30-day follow-up appointments. See Id. at SPA_9730; see generally Pls. Ex. 2309.
• Ford's initial mental-health assessment in segregation failed to note his history of suicide attempts and left the “assessment” section blank. See id. at SPA_9728-29.
• On December 12, he cut his wrist while in segregation, for which he was charged with a disciplinary violation. See Id. at SPA_9670.
• Ford was placed on suicide watch on December 12. See Id. at SPA_9702. A suicide risk assessment on December 20 stated that he had no recent “suicidal/self-injurious” behavior or ideation, even though he had cut his wrist just eight days earlier. Id. at SPA_9674. He was released from suicide watch around December 21 and placed back in segregation at Kilby. See Pls. Ex. 2352 at ADOC0462881; Joint Expert Case Summaries (doc. no. 2416-2) at 3. Records indicate that, in contravention of the interim agreement, staff did not complete the follow-up appointments after his release from suicide watch. See generally Pls. Ex. 2309; Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 108; Burns and Perrien Apr. 9, 2019, R.D. Trial Tr. at 123-24.
• On January 16, 2019, Ford was found hanging from his segregation cell door. See Pls. Ex. at SPA_9656. Drs. Burns and Perrien did not receive medical or security reviews of his suicide. See Joint Expert Case Summaries (doc. no. 2416-2) at 3. While ADOC conducted a ‘quality improvement' (QI) assessment of the case, both Drs. Burns and Perrien testified that it did not constitute an adequate review of the suicide. See Burns and Perrien Apr. 10, 2019, R.D. Trial Tr. at 114-15.

         Roderick Abrams

         Roderick Abrams committed suicide on January 2, 2019, the same day he was placed in segregation. Rampant suicide-prevention failures plagued his case, including failing to place him on suicide watch when he expressed suicidality, repeatedly failing to screen him for mental-health issues prior to placing him in segregation, failing to complete mental-health appointments due to staffing and SPA_ce shortages, and failing to immediately initiate life-saving measures when he was found hanging in his cell. Specifically:

• Records indicate that Abrams was initially held in segregation between August 23 and December 4, 2018, see Pls. Ex. 2346 at ADOC0462894-95, without receiving a segregation preplacement screening, see generally Pls. Ex. 2304.
• A nursing record from September 3 reported that Abrams had suicidal thoughts and had told people he was going to hang himself. See Id. at SPA_9559. Despite being suicidal, Abrams remained in segregation instead of being placed on suicide watch, see Id. at SPA_9560, and did not receive a suicide risk assessment at that point, see Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 69.
• The segregation initial assessment conducted on September 4--several days after the seven-day timeframe in which it should have been completed--failed to mention that the day before, Abrams had told nursing staff that he was suicidal. See Pls. Ex. 2304 at SPA_9582-83.
• Records indicate that, while in segregation, SPA_ce and security staff shortages prevented Abrams from having his scheduled mental-health appointments on November 20, 27, and 30, and December 4. See Id. at SPA_9601; Joint Expert Case Summaries (doc. no. 2416-2) at 3.
• On approximately December 21, he was placed on suicide watch after stating that he was suicidal. See Pls. Ex. 2304 at SPA_9596, SPA_9599. Apparently, he had gone to the infirmary to have stab wounds checked on, and then felt increased anxiety about returning to a particular prison block. See Id. A mental-health progress note from December 26 also reported that he had safety concerns and wanted to change institutions because of a conflict he had with gang-affiliated inmates due to his sexuality. See Id. at SPA_9594. His records do not contain a single crisis treatment plan. See generally Pls. Ex. 2304.
• Abrams was released from suicide watch on December 26, see Id. at SPA_9571, and sometime between then and January 2, he was placed in segregation, see Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 181; Defendants' Response to Amended Chart (doc. no. 2500-1) at 14. The records indicate that he did not receive a segregation preplacement screening. See Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 181-82; see generally Pls. Ex. 2304. Nor did he receive a three-day follow-up after being discharged from suicide watch. See generally Pls. Ex. 2304. The parties' experts noted that despite his stay on suicide watch, he was not placed on the mental-health caseload. See Joint Expert Case Summaries (doc. no. 2416-2) at 3; Pls. Ex. 2305 at SPA_9791.
• The segregation duty post logs indicate that, during the week running up to his suicide, there were several times where there was an hour, or even two hours, between security checks, see Vail Apr. 3, 2019, R.D. Trial Tr. at 149, even though ADOC policy requires that security checks in segregation be conducted every 30 minutes.
• On January 2, 2019, at approximately 7:00 p.m., more than an hour after the last security check, see id., a correctional officer making a security check discovered Abrams hanging from a vent cover inside his cell, see Pls. Ex. 2307 at SPA_10451. At 7:11 a.m., he was cut down and medical staff initiated CPR, according to one officer's report. See Id. at SPA_10452. According to both experts, this emergency response time was “inadequate to save life, ” as “11 minutes from discovery to cut down is more than enough time for death to occur.” Joint Expert Case Summaries (doc. no. 2416-2) at 3.
• Drs. Burns and Perrien did not receive a medical review. See Id. at 3. ADOC's quality improvement report stated that there were no areas for improvement in mental-health treatment or institutional operation, and recommended no corrective actions. See Pls. Ex. 2305 at SPA_9792-93.[6]

         Ryan Rust

         On December 21, 2018, Ryan Rust was discovered in his segregation cell “sitting on [the] floor with one end of [a] belt around his neck and the other end tied to a bar in the window of the cell.” Joint Expert Case Summaries (doc. no. 2416-2) at 2. His case illustrates ADOC's failures to complete follow-up appointments after a crisis placement and to conduct timely security checks in segregation in the immediate lead-up to a suicide. Specifically:

• Rust was placed on suicide watch from approximately November 5 to 16, 2018, see Pls Ex. 2298 at SPA_9880-81, but his records indicate that he did not receive any follow-up appointments after his release, see generally Pls. Ex. 2298.
• Rust attempted to escape and was returned to segregation on December 20 or 21. See Id. at SPA_9869, SPA_9872; Joint Expert Case Summaries (doc. no. 2416-2) at 2. On December 21, shortly after his segregation placement, he was discovered hanging in his cell. See Joint Expert Case Summaries (doc. no. 2416-2) at 2.
• Prior to his death, Rust had received three separate segregation pre-placement screenings on December 20 and 21. See Pls. Ex. 2298 at SPA_9867-74. According to Drs. Burns and Perrien, the “reason for three pre-placement screenings was not clear. At best, the three completed screenings raise questions about inefficiencies in the system regarding redundant work and/or poor communication among nursing staff; at worst, they raise concerns regarding the authenticity and validity of the screenings.” Joint Expert Case Summaries (doc. no. 2416-2) at 2. As Dr. Burns elaborated, in the worst-case scenario, it represented “an attempt to say that the screening was done when the screening wasn't done, and still very poorly coordinated because they did it three times.” Burns Apr. 9, 2018, R.D. Trial Tr. at 190.
• Based on his review of the duty post logs, plaintiffs' expert Eldon Vail testified that about an hour passed from the last security check to the time Rust was discovered hanging. See Vail Apr. 3, 2019, R.D. Trial. Tr. at 151; see also Pls. Ex. 2662 at ADOC0469207 (duty post log indicating that more than an hour had passed).
• Drs. Burns and Perrien reported inadequate review of Rust's suicide. Specifically, they stated that they did not receive a medical review, and that the psychological autopsy was “limited” and did “not contain any psychological information.” Joint Expert Case Summaries (doc. no. 2416-2) at 2. They did receive a document labeled only “Ryan Chas Rust, ” whose authorship and purpose was unclear, but did “identify deficiencies in mental health follow-ups, treatment planning and logistics.” Id.

         Kendall Chatter

         On November 25, 2018, Kendall Chatter was discovered hanging from the ceiling of his cell in the temporary holding unit at Staton prison. ADOC's failures in his case include not transitioning him from acute to non-acute suicide watch prior to releasing him from suicide watch, not providing follow-up appointments after he was released from suicide watch, and not checking his cell even though he was intensely yelling and banging on his cell in the immediate lead-up to his suicide. Specifically:

• On November 16, 2018, Chatter cut his right wrist, possibly after being sexually assaulted. See Defs. Ex. 3577 at SPA_10176-81. He was placed on acute suicide watch that same day, see Id. at SPA_10180, and then released directly to MHO the next day, without any intervening period on non-acute suicide watch, see Id. at SPA_10178. He was released from MHO on November 20. See Id. at SPA_10164; Joint Expert Case Summaries (doc. no. 2416-2) at 2.
• His records indicate that he did not receive three- or seven-day follow-ups after being released from suicide watch. Crook Apr. 2, 2019, Trial Tr. (doc. no. 2488) at 35. Director of Mental Health Services Crook said that the failures to do the follow-ups were violations of the interim agreement, but that she did not immediately discover the violations because no one in her office did a detailed review of his mental-health records until February 2019, more than two months after he died. See Id. at 35-40.
• On November 25, Chatter loudly and intensely yelled and banged against his cell for a prolonged period of time. See Defs. Ex. 3577 at SPA_10200; Joint Expert Case Summaries (doc. no. 2416-2) at 2; Pls. Ex. 2401 at SPA_13483. The correctional shift supervisor instructed his officer to “just allow him to continue banging and being disruptive and he would get tired and stop, ” according to a written reprimand of the supervisor. Pls. Ex. 2401 at SPA_13483. Shortly after Chatter started making noise--according to one record, less than an hour later--a correctional officer distributing meals discovered him hanging from the ceiling by a sheet tied around his neck. See Id. at SPA_10200-01.
• ADOC's review of the suicide was inadequate. No medical or security reviews were provided to Drs. Burns and Perrien. See Joint Expert Case Summaries (doc. no. 2416-2) at 2. Furthermore, according to the experts, the “mental health QI review contained little information and no recommendations for improvement in spite of failing to provide follow-up after watch placement and failure to provide an actual mental health assessment after referral from security 11/14/18. ... The Psychological Autopsy states both that the treatment plan was up to date and included goals that were implemented but also states that there were no goals on the treatment plan because he wasn't on the mental health caseload.” Id.

         Mark Araujo

         Mark Araujo used a sheet to hang himself from a door in his segregation cell at Limestone prison on November 23, 2018. Inadequacies in his case include not properly responding to his request for mental-health attention after he was placed in segregation, and not adequately reviewing his suicide. Specifically:

• On October 29, 2018, during his initial mental-health assessment following placement in segregation, Araujo requested to be placed on the mental-health caseload and begin medication. See Pls. Ex. 2291 at SPA_10221-22. Yet, according to Drs. Burns and Perrien, he was not seen by mental-health staff prior to his death almost a month later. See Joint Expert Case Summaries (doc. no. 2416-2) at 2.
• Drs. Burns and Perrien noted that the “QI review contains no recommendations” and that the psychological autopsy also “contained little information--and neglected to note that he wanted [mental-health] help and asked for it 10/29/18 when seen in seg[regation].” Id.

         John Barker

         John Barker hanged himself from a vent cover in his cell at St. Clair prison on September 26, 2018. Deficiencies in his case include housing him in segregation despite his serious mental illness (SMI), and inadequate interventions to save his life after he was discovered hanging. Specifically:

• Despite being flagged as having a SMI, major depressive disorder, see Pls. Ex. 1758 at SPA_3343-44, Barker had been housed in segregation for several months in the lead-up to his suicide, see Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• On September 1, 2018, mental-health personnel recommended his administrative referral for removal from segregation due to his SMI diagnosis, see Pls. Ex. 1758 at SPA_3343-44, but records indicate that he was released from segregation on September 24, just two days before his suicide, see Joint Expert Case Summaries (doc. no. 2416-2) at 1.[7]
• On September 26 at 6:30 p.m., a correctional officer observed Barker hanging from a vent cover over a toilet in his cell. See Id. Troublingly, “[n]o actions [were] taken until 6:36 p.m. when medical [staff] arrived at which time [they] entered cell, cut prisoner down and began CPR.” Id. Drs. Burns and Perrien concluded that the correctional officer response was inadequate because, as explained above, security officers “must intervene and begin life-sustaining efforts rather than waiting for medical, ” and also because the medical emergency response time of six minutes was inadequate. Id.
• Drs. Burns and Perrien did not receive security or medical reviews of the suicide, and the mental-health review “was cursory and found no problems and no areas for improvement.” Id.

         Ross Wolfinger

         Ross Wolfinger was discovered hanging in his segregation cell at Fountain prison on August 22, 2018, less than a month after cutting his wrist and being placed in acute suicide watch. His case shows ADOC's failure to provide adequate treatment following release from suicide watch to segregation, the falsification of security logs and failure to conduct security checks in segregation in the time immediately leading up to his suicide, and the failure to initiate life-saving measures immediately when he was discovered. Specifically:

• Wolfinger's records state that on July 26, 2018, he was placed on acute suicide watch after attempting suicide by cutting his left wrist with a razor blade. See Pls. Ex. 1823 at SPA_4134, SPA_4187-90. He remained on acute suicide watch until July 31, see Id. at SPA_4167, when he was placed on nonacute suicide watch, id. at SPA_4153.
• On August 3, he was discharged from nonacute suicide watch to segregation. See Burns Dec. 7, 2018, Trial Tr. (doc. no. 2256) at 117; Pls. Ex. 1823 at SPA_4155, SPA_4163. The records indicate that he did not receive adequate follow-ups after his release from suicide watch. See Burns Dec. 7, 2018, Trial Tr. (doc. no. 2256) at 119; see generally Pls. Ex. 1823.
• According to Dr. Burns, Wolfinger's suicide risk was elevated by ADOC's failure to provide adequate treatment to him when he was returned to segregation. See Burns Dec. 7, 2018, Trial Tr. (doc. no. 2256) at 119.
• The night of Wolfinger's death, the correctional officer assigned to conduct security checks every 30 minutes in Wolfinger's area of segregation not only failed to do a single check, but also put false information in his duty post log indicating that he had completed the required checks, according to an ADOC memorandum discussing disciplinary action against the officer. See Pls. Ex. 2403 at SPA_13487. The memorandum states that the correctional officer's actions “resulted in” Wolfinger's death. Id. at SPA_13488.
• On August 22, around 1:00 a.m., Wolfinger was discovered hanging in his cell. See id. Drs. Burns and Perrien reported that the immediate intervention was inadequate: he was “discovered hanging at 12:57 a.m., ” but “there was no intervention except to call for assistance which arrived at 1:03 a.m. No intervention until others arrived and then he was cut down and taken to HCU [the health care unit], arriving there at 1:08 a.m. LPNs attempted CPR and ambulance was called.” Joint Expert Case Summaries (doc. no. 2416-2) at 2.
• Drs. Burns and Perrien also criticized the inadequate reviews of Wolfinger's suicide. No medical review was provided; the QI program review did not make any recommendations; the psychological autopsy provided no additional analysis or information. See id.

         Jeffery Borden

         On June 3, 2018, Jeffery Borden, who had been diagnosed with schizoaffective disorder, hanged himself on death row at Holman prison. See Pls. Ex. 1643 at ADOC0424844. His case is an example of ADOC failing to adequately intervene with potential life-saving measures and inadequately completing a suicide incident review. Specifically:

• Neither the correctional officers who originally found him hanging nor the nurse that later arrived at the scene attempted CPR or other life-saving efforts. See Joint Expert Case Summaries (doc. no. 2416-2) at 1; Pls. Ex. 1760 at SPA_2965.
• Drs. Burns and Perrien did not receive a medical or security review. See Joint Expert Case Summaries (doc. no. 2416-2) at 1.

         Timothy Chumney

         On May 12, 2018, “[w]ithin 1 day of being released from MHO to a housing unit where he expressed concern for his safety from other inmates, ” Timothy Chumney “was discovered hanging in his [segregation] cell having tied a bed sheet to a cell window and then around his neck.” Id. ADOC's failures in his case include inadequate treatment planning, not placing him on suicide watch even though he was found to have a moderate risk of suicide, and an inadequate review of his suicide. Specifically:

• On May 7, 2018, Chumney was determined to be at a “moderate” risk for suicide, after telling medical staff that he had suicidal ideation at night and would rather harm himself than have someone else harm him. Pls. Ex. 1646 at ADOC0425086. That same day, however, he was admitted to MHO instead of suicide watch. See Id. at ADOC0425042.
• On May 11, Chumney was discharged from MHO. See Id. at ADOC0425011. The next day, at approximately 3:05 a.m., correctional officers conducting security rounds discovered him hanging from his segregation cell window in Limestone prison. See Pls. Ex. 1780 at SPA_3144; Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• Dr. Burns and Perrien criticized that no “CPR, actual medical assessment or life-sustaining measures [were] attempted. LPN responding to the emergency said to leave him in the cell on the unit and called the physician to pronounce him dead. Hours later, the deputy coroner arrived and ‘confirmed inmate Chumney deceased.'” Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• ADOC also inadequately reviewed his suicide. Drs. Burns and Perrien did not receive medical or security reviews; the mental-health QI program review had no criticism or recommendation for anyone; the psychological autopsy revealed no additional or substantive information. See id.
• Drs. Burns and Perrien further criticized that there was “[n]o transitional care planned; treatment plan called only for a monthly contact with treatment coordinator and quarterly appointment with CRNP, ” and there was “[n]o plan to follow more closely (or intervene to prevent placement in [segregation] based on his anxiety and paranoia).” Id.

         Robert Martinez

         By the time Robert Martinez took his life on March 31, 2018, he had been in segregation at St. Clair prison for more than one year. Pls. Ex. 1493 at ADOC0420976-77. In his case, ADOC's failures included not conducting security rounds in segregation and not timely cutting him down when he was found hanging.

• Two weeks before his death, he told mental-health staff that he was “doing real bad” and needed to go to a psychiatric ward. Id. at ADOC0421023. ADOC left him in segregation and failed to connect him with mental-health staff.
• Correctional officers failed to conduct security checks in Martinez's unit for at least two hours during the morning of his suicide. See A.A. Apr. 23, 2018, R.D. Trial Tr. at 203-04.
• When ADOC staff discovered Martinez hanging from a sheet tied to a vent in his cell, they waited more than 30 minutes before cutting him down, a delay that, in the experts' words, was “inexcusable and inhumane.”[8] Joint Expert Case Summaries (doc. no. 2416-2) at 1.

         Billy Thornton Billy

         Thornton died on March 2, 2018, as the result of a head injury he sustained when attempting to hang himself in segregation at Holman prison on February 26. See Joint Expert Case Summaries (doc. no. 2416-2) at 1; Stewart Apr. 23, 2018, Trial Tr. (doc. no. 1797) at 57. The failures by ADOC in his case include not placing him on suicide watch after he was found attempting to hang himself and said he wanted to kill himself, and not completing suicide risk assessments or providing follow-up appointments after releasing him from crisis watch.

• A nursing record from December 27, 2017 reports that Thornton said he wanted to kill himself, had been found attempting to hang himself, had suicidal thoughts, and auditory hallucinations of “kill, kill yourself.” Pls. Ex. 1489 at ADOC0420855. Drs. Burns and Perrien testified that he should have been placed on suicide watch; however, the records show that he was improperly placed on MHO. See Id. at ADOC0420856; Burns and Perrien Apr. 9, 2019, R.D. Trial Tr. at 89-90.
• The records indicate that no suicide risk assessment was conducted at the time. See Burns Apr. 9, 2019, R.D. Trial Tr. at 90; see generally Pls. Ex. 1489.
• Records indicate that he did not receive adequate follow-up appointments after release from MHO on January 2 or 3, 2018, given that he actually should have been placed on suicide watch rather than MHO. See Joint Expert Case Summaries (doc. no. 2416-2) at 1; Burns and Perrien Apr. 9, 2019, R.D. Trial Tr. at 121; Stewart Apr. 23, 2018, Trial Tr. (doc. no. 1797) at 50-52; see generally Pls. Ex. 1489.
• Thornton was again transferred to crisis watch on February 22, and then released back to segregation on February 23. See Stewart Apr. 23, 2018, Trial Tr. (doc. no. 1797) at 6-8. The records indicate that Thornton did not receive follow-up attention after his release from crisis watch. See Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• On February 26, as a correctional officer was speaking to him in his segregation cell, Thornton “stepped onto his bed put a shoe string around his neck and was hanging from the light fixture, ” according to an incident report. Pls. Ex. 1488 at ADOC0421089. As the officer reached toward Thornton, the string broke, and Thornton fell and hit his head on the floor. See id.
• Officers put Thornton in a wheelchair and took him to the medical unit. See Id. According to Drs. Burns and Perrien, the “decision to place him in wheelchair after sustaining head/neck injury rather than a back board and/or calling for medical to respond requires further review and supports need for additional and on-going first aid training for correctional staff.” Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• Thornton died on March 2 as a result of the head injury. See id.; Stewart Apr. 23, 2018, Trial Tr. (doc. no. 1797) at 57; Pls. Ex. 1488 at ADOC0421089.
• ADOC's review of the incident leading to Thornton's death was inadequate. Drs. Burns and Perrien did not receive a medical or security review; and the mental-health QI review “did not identify any issues with mental health's failure to provide any follow-up to Mr. Thornton after crisis placements.” Joint Expert Case Summaries (doc. no. 2416-2) at 1.
• Ultimately, Dr. Burns testified that she believed ADOC's noncompliance with the interim agreement increased Thornton's risk of suicide, “because the risk was never measured and quantified, in spite of multiple crisis placements, ” and “there doesn't appear to be any effort to reduce that risk.” Burns Dec. 7, 2019, Trial Tr. (doc. no. 2256) at 106.

         Ben McClure

         On December 30, 2017, Ben McClure jumped to his death from the top tier of a dormitory at Limestone prison. See Incident Report (doc. no. 1966-25) at 2; Pls. Ex. 1669 at ADOC0424820. ADOC failed to initiate immediate life-saving measures. Namely, the officers who found McClure did not immediately conduct CPR, but rather waited until Licensed Practice Nurses arrived a few minutes later, according to ADOC reports. See Id. As stated above, Drs. Burns and Perrien emphasized that CPR should be initiated as soon as two security staff are present, regardless of whether medical staff has arrived. See Joint Expert Report and Recommendations (doc. no. 2416-1) at 29.

         III. DISCUSSION

         A. Permanent Injunction Requirements

         The plaintiffs' emergency motion seeks permanent, albeit immediate, relief. To obtain a permanent injunction, plaintiffs must show: (1) actual success on the merits; (2) that irreparable injury will be suffered without an injunction; (3) that the threatened injury outweighs any damage the proposed injunction may cause the opposing party; and (4) that the injunction, if issued, would not be adverse to public interest. See Klay v. United Healthgroup, Inc., 376 F.3d 1092, 1097 (11th Cir. 2004). As discussed below, the plaintiffs meet all these requirements.

         i. Success on the Merits: Eighth Amendment Violation

         The plaintiffs satisfy the first requirement for a permanent injunction because they have succeeded on the merits of their claim. To prevail on an Eighth Amendment challenge, plaintiffs must show that: (1) objectively, prisoners had serious medical needs and either had already been harmed or were subject to a substantial risk of serious harm; and (2) subjectively, the defendants acted with deliberate indifference to that harm or risk of harm; that is, they knew and disregarded an excessive risk to inmate health or safety. See Braggs, 257 F.Supp.3d at 1189. As the court held in 2017, the plaintiffs met this standard and therefore established an Eighth Amendment violation, given that ADOC's mental-health care for prisoners was, “[s]imply put, ... horrendously inadequate” Braggs, 257 F.Supp.3d at 1267. The court specifically found that ADOC's inadequate suicide prevention contributed to the Eighth Amendment violation. As the court explained, deficient suicide prevention--both alone and in combination with six other inadequacies--"subject[s] mentally ill prisoners to actual harm and a substantial risk of serious harm.” Id. at 1193. ADOC's suicide prevention was found to be deficient in multiple ways. These included inadequately identifying prisoners at risk of suicide, providing inadequate treatment and monitoring to at-risk prisoners, as well as inappropriately releasing prisoners from suicide watch and not giving them follow-up care. See Id. at 1220, 1231. Additionally, the court found that the “skyrocketing number of suicides within ADOC, the majority of which occurred in segregation, ” reflected the “combined effect” of inadequate screening for the impact of segregation on mental health, and inadequate treatment and monitoring in segregation units. Id. at 1245.

         As extensively detailed in the liability opinion, see Id. at 1194-1200, ADOC's “persistent and severe shortages” of mental-health and correctional staff significantly contributed to all these deficiencies. Id. at 1268. Since then, the court has repeatedly reaffirmed the centrality of mental-health and correctional understaffing to ADOC's mental-health care failings, and thus, Eighth Amendment violations. See Braggs, 2019 WL 539050, __ F.Supp.3d __ at *5, 9-10; Braggs v. Dunn, 2019 WL 78949, __ F.Supp.3d __ at *1 (M.D. Ala. Jan. 2, 2019) (Thompson, J.); Braggs v. Dunn, 2018 WL 5410915, __ F.Supp.3d __ at *1 (M.D. Ala. Oct. 29, 2018) (Thompson, J.).

         Now, in addition to the liability findings, the court further finds that the substantial and pervasive deficiencies identified in the 15 recent suicides demonstrate that ADOC's suicide-prevention efforts remain inadequate and continue to contribute to the ongoing Eighth Amendment violation originally found in the liability opinion. ADOC still has serious deficiencies in the identification of prisoners at risk of suicide, as well as in their treatment, monitoring, and follow-up care. The deficiencies include:

• Failing to place suicidal prisoners on suicide watch;
• Failing to conduct suicide risk assessments;
• Failing to appropriately monitor prisoners on suicide watch;
• Failing to put prisoners on the mental-health caseload when appropriate;
• Inadequate treatment planning; and
• Inadequate follow-up treatment after release from suicide watch.

         ADOC's segregation practices also continue to suffer from the serious flaws the court found in the 2017 liability opinion, including:

• Inadequate screening of prisoners for suicidality and SMIs prior to placing them in segregation;
• Placing prisoners with SMIs in segregation absent extenuating circumstances;[9] and
• Failing to conduct 30-minute security checks in segregation, and failing to make sure the checks are staggered.

         Given these serious inadequacies in segregation practices, it is unsurprising that, similar to the liability opinion's finding in June 2017 that the “majority” of suicides occurred in segregation, Braggs, 257 F.Supp.3d at 1245, ADOC recognized nearly two years later, in March 2019, that the “majority of inmates who committed suicide within ADOC have been men who were alone in a restrictive housing cell, [10] after being released from suicide watch.” Pls. Ex. 2706 (Mar. 21, 2019, Daniels's memorandum announcing directive).

         These continuing deficiencies are compounded by ADOC's repeated failure to initiate immediate life-saving measures. Although not identified in the liability opinion, this problem clearly exacerbates ADOC's inadequate suicide-prevention efforts, and illustrates that prisoners remain at substantial risk of serious harm.

         Critically, mental-health and correctional understaffing remains a driving force behind the suicide-prevention deficiencies putting prisons at risk. As of December 2018, ADOC reported that 62 % of correctional officer positions were vacant, see March 2019 Quarterly Staffing Report (doc no. 2386-1) at 3, and as of September 2018, 23.6 % of the mental-health positions were vacant, see December 2018 Quarterly Staffing Report (doc. no. 2378-1) at 9. Commissioner Dunn admitted that ADOC is currently “struggling” to comply with court orders because of inadequate staffing levels, Dunn Apr. 1, 2019, R.D. Trial Tr. at 145, and affirmed that understaffing remains one of the problems driving the spike in suicides. See id. at 154-55.

         In addition to showing that prisoners remain at a substantial risk of serious harm, the 15 suicides also demonstrate that ADOC continues to act with deliberate indifference. As found in the liability opinion, “the state of the mental-health care system is itself evidence of ADOC's disregard of harm and risk of harm: in spite of ... notice of the actual harm and substantial risks of serious harm posed by the identified inadequacies in mental-health care, those inadequacies have persisted for years and years.” Braggs, 257 F.Supp.3d at 1256. Almost two years since the court wrote those words, the inadequacies continue to persist, as evidenced by the problems pervading the recent suicides.

         Furthermore, many of the inadequacies in the 15 suicides constitute noncompliance with the interim agreement and other remedial orders that ADOC agreed to implement. ADOC's continued inability to carry out the terms of the interim agreement and other remedial measures thus far illustrates “a striking indifference by ADOC to a substantial risk of serious harm.” Id. at 1264.

         Finally, ADOC's inadequate internal review of the 15 suicides shows ongoing deliberate indifference, just like the court originally found deliberate indifference in part because ADOC had “done vanishingly little to exercise oversight of the provision” of mental-health care. Id. at 1257. ADOC's ongoing broader failures to self-monitor are also extensively detailed in the monitoring section below.

         ADOC has recently adopted some promising measures to improve suicide prevention, such as the March 21, 2019, announcement by ADOC Deputy Commissioner Charles Daniels of a directive generally prohibiting the release of inmates from suicide watch directly to segregation. See Pls. Ex. 2706. However, as elaborated below, the measures are insufficient to address the scope of a problem that is many years in the making, and, as they were implemented quite recently, it remains to be seen whether they will even be effectively implemented. In any case, several of the key measures came only after the spike in suicides had taken more than a dozen lives, and after the plaintiffs brought attention the problem by requesting emergency relief. Put differently, the measures have been too little, too late.

         To conclude, while the liability findings by themselves would justify the relief ordered here, the court's additional factual findings concerning inadequate suicide prevention in the 15 recent suicides underscores that the constitutional violation remains ongoing and requires immediate relief. Accordingly, the plaintiffs satisfy the first requirement for a permanent injunction.

         With this in mind, the court will now briefly discuss why the plaintiffs satisfy the remaining requirements for a permanent injunction.

         ii. Remaining Permanent Injunction Requirements

         The plaintiffs meet the remaining three requirements for a permanent injunction. As to the second requirement, the immediate and substantial risk of suicide, as reflected in the recent wave of suicides, satisfies the irreparable harm inquiry. As to the third, the threatened injury absent an injunction--a higher risk of suicides and suffering--outweighs any harm the injunction would cause, particularly because, as discussed below, the defendants agree with or claim to be already enacting most of the measures the plaintiffs seek. Finally, an injunction is not adverse to the public interest, for ...


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