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Estate of Watson v. Cumberland County

United States District Court, D. New Jersey

January 9, 2020

THE ESTATE OF JON LEON WATSON by and through its Administrator ad Prosequendum, HELEN RAY LLOYD, and HELEN RAY LLOYD, in her own right, Plaintiffs,
CUMBERLAND COUNTY, et al., Defendants.



         This matter is before the Court on Motions for Summary Judgment filed by Defendants (1) CFG Health Systems, Inc. [Dkt. No. 124]; (2) Cumberland County and Warden Robert Balicki (collectively “Cumberland County Defendants”) [Dkt. No. 126]; and a Motion for Summary Judgment filed by Plaintiff, the Estate of Jon Leon Watson [Dkt. No. 125]. The Court has considered the written submissions of the parties, as well as the arguments advanced at the hearing on December 10, 2019. For the reasons stated on the record that day, as well as those that follow Cumberland County Defendants' and Defendant CFG's Motions will be granted and Plaintiff's Motion will be denied.

         I. Background

         This case deals with the circumstances surrounding the unfortunate suicide of Mr. Jon Leon Watson (“Mr. Watson”) while he was incarcerated at the Cumberland County Jail on June 3, 2016. This action is brought on behalf of Helen Ray Lloyd, the mother of Mr. Watson's children, as duly appointed Administrator of Mr. Watson's Estate (“Plaintiff”). Plaintiff brings this action against Cumberland County Jail (“Cumberland County”); CFG Health Systems, Inc (“CFG”), the provider of health services at Cumberland County Jail; and Warden Robert Balicki (“Warden Balicki”), the Warden of the Cumberland County Jail while Mr. Watson was in custody (collectively the “Defendants”). The following facts are relevant to the motions pending before the court.[1]

         A. Mr. Watson's Experience & Medical Record while at the Cumberland County Jail

         “Decedent, Jon Watson, was committed to the Cumberland County Jail on May 18, 2016. His New Admittance Initial Intake Medical Screening was completed by Corrections Officer Shin-an at 11:15 p.m.” (Pl. SMF ¶ 1). During the intake process, officers question new inmates utilizing a questionnaire form to assist their observations of the new inmate. (Cumberland Defs. SMF ¶30-42). When Mr. Watson was asked these questions, he responded yes to (1) having a serious illness; (2) taking medication; and (3) having a mental disability. (Pl. SMF ¶ 2). Early the next day, “Advanced Practice Nurse April Munson issued Orders related to Watson's alcohol and opioid withdrawal at 4:35 am.” (CFG SMF ¶ 23). At 10:30am, Mr. Watson's "Intake Mental Health Screening and Assessment," was completed, which showed Mr. Watson was anxious, afraid, or angry and was acting and/or talking in a strange manner. (Pl. SMF at ¶¶ 6-7). The Nurse conducting the assessment, Ms. Fedd, noted in “summary” mental health problems required follow up and, in “disposition, ” referred Mr. Watson for Mental Health Housing “ASAP.” (Id.). She commented: “Depression, Bipolar, Schizophrenia.” (Id.). That same day, Mr. Watson was seen by a psychiatrist Dr. Khalid Bajwa (“Dr. Bajwa”). Dr. Bajwa placed Mr. Watson on Suicide Watch Level 2-watch level 2 entails 30 minute checks on the inmate-and proscribed him 2 mg of Risperdal and 50 mg Benadryl. (Id. at ¶ 8).

         Later that night, Dr. Bajwa reevaluated Mr. Watson, reduced his suicide watch to Level 3, and diagnosed Mr. Watson with mood disorder, psychosis NOS and alcohol and opioid dependence.[2] (CFG SMF ¶ 34). Mr. Watson reported no suicidal or homicidal ideation or plan, and denied any history of suicide attempts to Dr. Bajwa. Between May 22, 2016 and June 1, 2016, Mr. Watson was examined and revaluated on multiple occasions. (Id. at ¶ 28). According to CFG records, “he was seen up to three times per day on May 19, 21, 22, 23, 24, 25 and 26 for check of vital signs --blood pressure (standing and sitting), pulse, respirations and temperature--and hydration.” (Id.). In monitoring his drug and alcohol withdrawal, Mr. Watson was asked on a number of occasions “if he was having difficulty adjusting to jail, felt overwhelmed, hopeless or had thoughts of hurting himself.” (Id. at ¶ 30).

         On May 21, 22, 24 and 25 Mr. Watson reported complaints “ranging from blood in the stool to possible seizure to dizziness” to CFG personnel. (Id. at ¶ 39; Cumberland Defs. SMF ¶¶ 96-102). On each of those occasions, Cumberland County personnel sent him to Medical. (Cumberland Defs. SMF ¶¶ 96-102). Following an incident of possible seizure on May 21st, Mr. Watson was seen and cleared by medical. On May 22, 2016, Dr. Bajwa saw Mr. Watson at approximately 8:50 am. At that time, Dr. Bajwa noted that Mr. Watson was in good spirits and stated that his current medicines were helping, he denied any suicidal intent or plan. (CFG SMF ¶ 36). Dr. Bajwa withdrew Mr. Watson from Level 3 Suicide Watch and cleared him for general population, continuing his medication. (Id. at ¶ 37). Mr. Watson was then seen by Dr. Larry Pettis for a physical assessment on May 23rd. (Id. at ¶ 38).

         On May 25, 2016, medical was called to Mr. Watson's cell for a possible seizure. When nurses arrived, Mr. Watson was sitting upright, he showed no signs of a seizure or distress. Mr. Watson was taken to medical and housed in infirmary. (J.L. Watson CCCF 30, interdisciplinary progress notes). Medical was called back to his cell later that day for another potential seizure and taken to medical for an assessment. There, Mr. Watson stated he was going to get into a fight with another inmate so he “faked it.” (Id.). Mr. Watson also reported hearing voices and “underwent a suicide screening, it was noted that he was seen by mental health and placed on suicide watch level 1 (‘S/W Level 1') with 15-minute checks.” (CFG SMF at ¶ 40). Mr. Watson stated that the voices told him they were coming to get him, and his suicide screening form specifies that he said: “he don't want to kill himself but he will if that would save the world.” (CC [Watson] - 00281, 300). The same day, Cumberland County Personnel observed Mr. Watson banging his head on the door of his cell and yelling, he was taken to medical for trying to hurt himself. (JL Watson CCCF 28, interdisciplinary notes; CC [Watson] - 00394). According to Cumberland County's Incident Report, when Mr. Watson returned to his B-Pod (on level I watch) he continued to bang his head. Cumberland County officers proceeded to place Mr. Watson in the restraint chair. (CC [Watson] - 00394-405). Mr. Watson “calmly sat in the chair and allowed officers to properly restrain him.” (Id.). He remained in the restraint chair for about three hours. (Id.)

         Cumberland County Sargent observed Mr. Watson again continually banging his head and proceeded to pepper spray him to “stop him from hurting himself.” (Pl. SMF ¶ 17). Mr. Watson was sent to medical, where his eyes were flushed with water. He was then placed into the restraint chair without incident, where he remained for approximately three and a half hours. (Id. at ¶¶ 17-18). He was put back into the restraint chair later that day. (Id. at ¶ 20). “Watson was evaluated every 15 minutes while in the restraint chair.” (CFG SMF n.2). “On May 27, 2016, Dr. Bajwa provided a telephone order for immediate (“STAT”) doses of Haldol 5 mg and Benadryl 50 mg as well as doses twice per day for 30 days (“BID x 30 days”).” (Id. at ¶ 43). Dr. Bajwa evaluated Mr. Watson on the morning of May 29, 2016; her notes acknowledge that Mr. Watson “was pepper sprayed and placed in a restraint chair by custody. . . . had been placed on 1:1 suicide watch and had reported auditory hallucinations.” (Id. at ¶¶ 45-46). Dr. Bajwa also noted that Mr. Watson denied any current suicidal or homicidal ideation, intent or plan, and reported no hallucinations or medication side effects. (Id. at ¶ 47). Mr. Watson reported to Dr. Bajwa that he had a problem with another inmate but that he “feels better now.” (Id. at 48). Dr. Bajwa removed Mr. Watson from 1:1 suicide watch but he continued on Level 1 suicide watch. (Id. at ¶ 49).

         Dr. Bajwa saw Mr. Watson again the following day, at which time he denied suicidal or homicidal ideation, intent or plan, and further denied any hallucinations or delusions. Dr. Bajwa placed Mr. Watson on Level 2 Suicide Watch. (Id. at 73-74). On May 31, 2016, psychologist JoAnne Gonzalez, Ph.D., met with Mr. Watson. At that time, she noted that Mr. Watson had no suicidal or homicidal intent or plan, and denied hallucinations or delusions. (Id. at ¶¶ 75-76). Dr. Gonzalez's discontinued Level 2 Suicide Watch, switching Mr. Watson to Level 3 Suicide Watch and continuing his medications. (Id. at 77). The next day, Dr. Gonzalez decided to clear him for general population and lock down from recent charges, he was to continue his medications. Medical again assessed Mr. Watson on June 2nd and 3rd. On June 2, 2016, Mr. Watson “was seen by CFG for another apparent seizure, where he stated he felt dizzy and fell but no injuries were found.” (Cumberland Defs. SMF ¶ 124). Mr. Watson indicated he stood up too fast and was “not suicidal or homicidal.” (J.L. Watson CCCF 35). On June 3, 2016, Mr. Watson reported another alleged seizure after returning from his court appearance that morning. Specifically, while a CFG nurse was administering his medication, she saw Mr. Watson lying on the ground with “foot and hand twitching.” (J.L. Watson CCCF 34). LPN Fedd thought, based on her observations and experience, that Mr. Watson performed a fake seizure. (Id.). He was taken to medical where he was evaluated and was found to be stable. Mr. Watson mentioned being at court earlier that morning and stated that it “wasn't good.” When asked if he felt suicidal, he indicated that he did not. (CC [Watson] - 00027). At some point Mr. Watson was brought back to his cell.

         On that same day, June 3, 2016 at 12:01 p.m., “Inmate Luis Colon walked past Mr. Watson's cell while distributing lunch trays. In his statement, Inmate Colon testified that he saw Mr. Watson hanging and that he gestured to Officer Rowe and told Officer Rowe that Mr. Watson was “hanging out.'” (Pl. SMF 33). After five minutes, Officer Rowe looked into Mr. Watson's cell, at 12:06 p.m. (Id. at ¶ 34). At that moment, Officer Rowe radioed a code. He entered the cell but did not initiate CPR, he “panicked”. (Id. at 35-36). CFG medical staff reported to Mr. Watson's cell with emergency equipment. (J.L. Watson CCCF 34). They performed CPR until EMT arrived on scene (Id.). Mr. Watson was pronounced deceased, and his death was ruled a suicide by hanging.

         Mr. Watson's mother testified that he loved his children and his girlfriend. (Dep. 30). She did not know of any reason that Mr. Watson would commit suicide, though she believed he was at risk of suicide. She did not believe that he would commit suicide in jail, in 2016. Mr. Watson's girlfriend, Hellen Ray Lloyd (“Ms. Lloyd”) testified that he had been to the psych ward, she had “him committed two times, ” around 2005 and again in 2009 at Inspira hospital. (Lloyd Dep. 62). Ms. Lloyd also testified that in 2009 Mr. Watson was “talking suicidal.” (Id. at 64). She does not know of any attempts of suicide. (Id. at 63).

         B. Cumberland County Jail's Policies & Officer Training

         Relevant to the Court's discussion is Cumberland County's restraint chair policy, Policy Number 10.22, which establishes how and when the restraint chair may be utilized. (Ex. D to [Dkt. No. 125] Policy 10.22). The Cumberland County Jail policy on the use of the restraint chair mandates that a shift commander can approve use of the restraint chair on a temporary basis only and must get approval from the Warden or Captain.” (Pl. SMF ¶ 21). It allows for the restraint of an inmate when the inmate (1) is combative and shows signs of imminent violence, (2) is inflicting wounds upon themselves and will not stop the behavior, (3) has attempted suicide and it is clear that they will continue to take their own life; and (4) has destroyed government property and will not stop the behavior. (Id.). According to the policy, “[a]ll incidents involving the use of the Inmate Restraint Chair must be carefully documented and video recorded unless it is determined by the Shift Commander that a delay would constitute a serious hazard to the inmate or staff or would result in major disturbance with serious property damage.” (Ex. D to [Dkt. No. 125] Policy 10.22). Once the inmate is placed into the restraint chair, medical's responsibility was to assess the inmate's condition and check vital signs. The inmate is placed on a 1 on 1 level watch while in the chair, offered 3 meals and opportunity to use the bathroom. “Recommendation for release from the Inmate Restraint Chair must be made by the Shift Commander, Physician or Mental Health Staff.” But the “Inmate shall not be removed . . . without approval from the Warden Captain.” (Id.).

         CFG also maintains a policy addressing restraint and seclusion, Policy I-01. (Pl. Ex. G to [Dkt No. 125] CFG Policy I-01). The purpose of the policy is as follows: “To differentiate the use of restraints as ordered by custody from restraints or seclusion as ordered by clinical and to define the role of health care personnel at the Cumberland County Department of Corrections [CCDOC] in monitoring inmate/ patients while restrained.” (Id.). According to the policy, the health care staff does not use medial restraints, and the mental health clinical staff does not allow the use of physical restraints. In the case where any patient is threatening staff, other inmates, or themselves or others, the Department of Corrections staff will escort them to Inspira ER for evaluation; CFG mental health staff “will order the transfer of the inmate/patient to the Emergency Room.” (Id.). The use of restraints by security staff, however, “is governed by approved correctional policies and procedures.” (Id.). The policy provides that (1) the “health record is reviewed for any contraindications to use and/or required accommodations which are reported to custody staff and (2) if restraints are improperly utilized and are jeopardizing the health of the inmate/patients, health staff will communicate their concerns to custody staff as soon as possible.” (Id.).

         “The ‘emergency situations' category of the[Cumberland County] jail policy includes a suicide precaution/prevention.” (Cumberland Defs. SMF ¶ 40). The “Suicide Precautions” policy, Number 11.7, is in place in “order to ensure the safety and well-being of inmates who may pose a suicide risk.” (Dkt. No. 127, Ex. 12, Cumberland County jail policy 11.7). Pursuant to this policy, inmates were to be interviewed four times within 2 weeks, beginning at intake for suicide screening purposes. (Id.). IT provided that when an inmate “is placed on suicide watch, close observation, or special watch by a staff member, a written detailed report must be submitted to the Shift Commander. The suicide levels are defined as follows: (1) “Level 1: 15-minute checks are performed on inmates, who are only provided a suicide gown and finger foods;” (2) “Level 2: 30-minute checks are performed on inmates, who are provided with standard jail uniform, bedding and finger foods;” (3) “Level 3: 30-minute checks are performed on inmates, who are issued standard jail uniform, bedding and receive regular food tray and eating utensils; and” (4) “1 on 1 Observation: inmates monitored at all times and are provided suicide safe gown and finger foods for all meals.” (Id; Pl. SMF ¶ 53). “Only a qualified mental health professional may remove an inmate from suicide watch at the jail.” Id. Finally, the Cumberland County Policy Number 11.7 details procedures to follow in the event that an officer discovers an inmate attempting suicide and when an inmate is pronounced dead as a result of suicide.

         “All correction officer hires are required to undergo 120 hours of training with the Police Training Commission prior to attending the Academy, which included 80 hours of classroom training and 40 hours of on the job training.” (Cumberland Defs. SMF ¶ 25). Warden Balicki testified that officers were trained on CPR. (Balicki Dep. 18:6-13). He testified that newly hired officers are provided with a training manual. (Cumberland Defs. SMF ¶ 32-33). Warden Balicki did not have a way of testing officers on the manual. [Dkt. No. 136-1 at ¶ 33].

         II. Summary Judgment Standard

         “Summary judgment is proper if there is no genuine issue of material fact and if, viewing the facts in the light most favorable to the non-moving party, the moving party is entitled to judgment as a matter of law.” Pearson v. Component Tech. Corp., 247 F.3d 471, 482 n.1 (3d Cir. 2001) (citing Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986)); accord Fed.R.Civ.P. 56 (a). Thus, the Court will enter summary judgment in favor of a movant who shows that it is entitled to judgment as a matter of law, and supports the showing that there is no genuine dispute as to any material fact by “citing to particular parts of materials in the record, including depositions, documents, electronically stored information, affidavits or declarations, stipulations . . . admissions, interrogatory answers, or other materials.” Fed.R.Civ.P. 56 (c)(1)(A).

         An issue is “genuine” if supported by evidence such that a reasonable jury could return a verdict in the nonmoving party's favor. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). A fact is “material” if, under the governing substantive law, a dispute about the fact might affect the outcome of the suit. Id. In determining whether a genuine issue of material fact exists, the court must view the facts and all reasonable inferences drawn from those facts ...

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