Ponzini v. PrimeCare Medical, Inc. (269 F. Supp. 3d 444, 2017)

MEMORANDUM OPINION

Robert D. Mariani, United States District Judge

TABLE OF CONTENTS

I. INTRODUCTION AND PROCEDURAL HISTORY.. .470

II. STATEMENT OF FACTS... 472

A. PrimeCare Medical, Inc.... 472

B. March 18, 2009-March 22, 2009...476

1. Paul James... 476

2. Patricia Bauer.. .477

3. Christina Rowe.. .478

4. Wendy Johnson.. .480

5. Grace Ramos.. .482

6. Dr. Alex Thomas... 483

7. William Buffton... 485

8. Correctional Officers Cleary and Ryan...486

C. Expert Witnesses... 487

1. Kathryn Wild.. .487

2. Dr. Peter Breggin.. .489

3. Dr. Lome Sheren.. .490

4. David Hopkins... 491

5. Terry Fillman... 491

6. Dr. Lawrence Mendel.. .493

7. Dr. Lawrence Guzzardi., .494

8. Dr. Cheryl Wills.. .494

9. Dr. Susan Rushing.. .496

III. STANDARD OF REVIEW... 498

A. Motion for Judgment as a Matter of Law.. .498

B. Motion for a New Trial; Remitti-tur. . .499

IV. MOTION FOR JUDGMENT AS A MATTER OF LAW.. .500

A 42 U.S.C. § 1983-Adequate Medical Care.. .500

1. The Individual PrimeCare Defendants/. .501

a. Paul James... 506

b. Patricia Bauer... 508

c. Christina Rowe... 510

d. Grace Ramos... 513

e. The Individual PrimeCare Defendants Did Not Violate Mr. Barbaros’ Constitutional Right To Adequate Medical Care... 515

2. . Dr. Aex Thomas... 517

3. PrimeCare Medical, Inc.... 522

a. PrimeCare’s Policy, Practice, or Custom.. .524

i. Failure to Adopt Needed Policy. . .525

ii. Failure to Train/Supervise ...525

b. Section 1983 Causation.. ,529

4. Conditional Ruling on Motion for New Trial.. .530

B. Negligence... 532

1. The PrimeCare Defendants... 532

2. Dr. Aex Thomas... 538

C. Punitive Damages... 540

V.MOTION FOR NEW TRIAL... 546

A. The PrimeCare Defendants... 546

1. Jury Instructions... 548

a. Negligence Per Se Jury Instruction and Agument.'. .548

b. Direct Causation and Increased Risk of Harm... 553

c. Unpreserved Claims of Error. . .555

i. Inconsistent Verdicts... 556

ii. Double Recovery.. .557

iii. Vicarious Liability-Punitive Damages... 558

2. Evidentiary Rulings... 561

a. The Criminal Charges Filed Against Barbaros... 561

b. Preclusion of Alleged Statement Made to Correctional Officer Ryan...565

c. Permitting Evidence of the Misspelling of' Mr. ■ Barbaros’ First Name.. .567

d. Permitting Mumtaz Barbaros to Testify. ..569

e. Preclusion of Testimony Regarding Alleged Misconduct of Correctional Officer Jesse Cleare... 572

f. Unpreserved Claims of Error. . .573

3. Weight of The Evidence... 574

a. The Individual PrimeCare Defendants ...575

b. Wiliiam Buffton... 581

c. PrimeCare Medical, Inc.., 582.

i. Respondeat Superior.,, 582

ii. Liability for Negligence of Independent Contractors.. .583

iii. Corporate Negligence.,. 585

B. Dr. Alex Thomas... 589

1. Permitting Dr. Breggin to Testify...589

2. Failure to Include Agency Question on Verdict Sheet... 592

3. Weight of the Evidence... 593

VI. MOTION FOR' NEW TRIAL-DAMAGES/REMITTITUR ... 595 ■

A. Wrongful Death Damages... 596

B. Survival Action Damages.., 598

C. New Trial-Compensatory Damages. . .600

VII. MOTION FOR DELAY DAMAGES... 600

VIII. CONCLUSION... 604

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

I. INTRODUCTION AND PROCEDURAL HISTORY

This case arises from the circumstances surrounding the death of Mumun Barba-ros, a pretrial detainee at the Monroe County Correctional Facility (the “MCCF”). Plaintiffs Peter Ponzini and Mi-ryem Barbaros, as Co-Administrators of the Estate of Mumun Barbaros (“Plaintiffs”), commenced this action on March 3, 2011 pursuant to 42 U.S.C. § 1Í983 and Pennsylvania’s Wrongful Déath and Survival statutes, 42 PA. CONS.STAT.ANN. §§ 8301, 8302. (Doc. 1). The amended complaint alleged that the PrimeCare Defendants, Dr. Thomas, and Monroe County and various County officials violated Mr. Barbaros’ Fourtéenth Amendment right to adequate medical care. The amended complaint also alleged, inter alia, that the PrimeCare Defendants and Dr. Thomas were negligent in their treatment, of Mr. Barbaros, and that their negligence caused Mr. Barbaros’ death. (Doc. 43).

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

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

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

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

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

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

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

II. STATEMENT OF FACTS

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

A. PrimeCare Medical, Inc.

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

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

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

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

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

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

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

There are important distinctions between a LPN and a RN. A LPN is qualified to undertake “thé performance of selected nursing acts under the direction of a Licensed Professional Nurse, a Licensed Physician, or Licensed Dentist which do not require specialized skill, judgment and knowledge required in Professional Nursing.” Id. at 165:9-168:2. In contrast, a RN, also known as a Licensed ■ Professional Nurse, “assesses human responses and plans, .implements, and evaluates nursing care for individuals.” Id. at 149:10—150:11. In order to become a RN, an individual is required to engage in more training and schooling than a LPN, Id. at 153:23-154:6. Thus, if an individual is going to provide nursing care as a LPN, that individual is required to be supervised by either a RN, licensed physician, dentist, or psychiatrist. Id. at 160:14-18. At the MCCF, however, a LPN was supervising other LPNs.

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

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

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

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

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

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

B. March 18, 2009—March 22, 2009

1. Paul James

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

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

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

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

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

2. Patricia Bauer

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

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

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

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

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

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

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

3. Christina Rowe

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

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

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

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

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

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

4. Wendy Johnson

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

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

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

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

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

5. Grace Ramos

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

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

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

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

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

6. Dr. Alex Thomas

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

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

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

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

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

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

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

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

7. William Buffton

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

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

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

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

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

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

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

8, Correctional Officers Cleary and Ryan

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

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

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

C. Expert Witnesses

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

1. Kathryn Wild

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

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

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

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

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

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

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

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

Nurse Wild conceded that the policies and procedures PrimeCare had in place in 2009 met the appropriate standard of care. She testified, however, that this was not the issue. Id. at 250:8-11. Rather, she opined that the issue was the lack of supervision of the medical staff and the lack of follow-through to ensure the staff followed the policies and procedures in place at the facility. Id. at 250:12-19. When asked whether PrimeCare and Wendy Joh