Brett Fields v. Prison Health Service

Filing

Opinion issued by court as to Appellant Corizon Health, Inc.. Decision: Affirmed. Opinion type: Non-Published. Opinion method: Per Curiam.

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[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
____________
No. 11-14594
____________
D.C. Docket No. 2:09-cv-00529-JES-DNF
BRETT FIELDS,
Plaintiff-Appellee,
versus
CORIZON HEALTH, INC.
f.k.a. Prison Health Services, Inc.,
Defendant-Appellant.
_____________
Appeal from the United States District Court
for the Middle District of Florida
______________
(September 6, 2012)
Before DUBINA, Chief Judge, JORDAN, and ALARCÓN,* Circuit Judges.
PER CURIAM:

*

The Honorable Arthur L. Alarcón, United States Circuit Judge for the Ninth Circuit, sitting
by designation.

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Brett Fields sued Prison Health Services, Inc.,1 the provider of medical services
for Lee County jails, as well as two Prison Health employees (Bettie Joyce Allen and
Joseph Richards), for their allegedly unconstitutional refusal to furnish the medical
care that he urgently needed. This refusal, said Mr. Fields, constituted cruel and unusual
punishment. The case went to trial, where a jury found that Prison Health, through its
policy or custom, refused to provide Mr. Fields proper medical attention in violation
of the Eighth Amendment. Prison Health moved for judgment as a matter of law and,
in the alternative, for a new trial. The district court denied these requests, and Prison
Health now appeals the district court’s rulings.2 After reading the briefs, reviewing
the record, and considering the parties’ presentations at oral argument, we affirm.
I. FACTUAL BACKGROUND
When we review a district court’s denial of a Rule 50 motion for judgment as
a matter of law, we consider the whole record. But we “disregard all evidence favorable
to the moving party that the jury is not required to believe” and “give credence to the
evidence favoring the non-movant as well as that ‘evidence supporting the moving

1

Prison Health changed its name to Corizon Health, Inc. in June of 2011, hence the name
in the caption. The parties, however, refer to the entity as “Prison Health Services, Inc.” throughout
their briefs, and for simplicity’s sake we do the same.
2

Prison Health also seeks review of the district court’s denial of its summary judgment
motion. But, after a trial on the merits, we cannot review the denial of a summary judgment motion.
See Lind v. UPS, 254 F.3d 1281, 1285 (11th Cir. 2001).
2

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party that is uncontradicted and unimpeached.’” Reeves v. Sanderson Plumbing Prods.,
530 U.S. 133, 151 (2000). We also “draw all inferences in favor of the non-moving
party.” O’Brien v. Columbia Palms W. Hosp. Ltd., 490 F.3d 1302, 1308 (11th Cir. 2007).
With these standards in mind, we chronicle the facts that the jury was entitled to find.
A. MR. FIELDS’ INJURY
On July 6, 2007, Mr. Fields was being held in the Lee County jail after being
convicted of two misdemeanors. At the time, Mr. Fields was an athletic 24-year-old
man. He was by all accounts healthy, except for a bump about half the size of a tennis
ball that swelled in his left arm. The bump resulted from a spider bite, and Mr. Fields
had covered the bump and bite with gauze.
As soon as he entered the jail, Mr. Fields was sent to a concrete room. There
two corrections officers checked him for drugs and weapons. The officers forced Mr.
Fields to remove the gauze and then sent him to a nurse. The nurses and medical staff
at the jail all worked for Prison Health, a company that contracted with Lee County
to provide medical services to prisoners in the County’s jails. Mr. Fields was seen by
a nurse named Bettie Joyce Allen. Ms. Allen found Mr. Fields to be in good health.
This was the first time Mr. Fields met Ms. Allen, but it would not be the last time, nor
the most significant time.
The jail’s medical staff sent Mr. Fields to an isolated part of the jail, where they
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treated him for a staphyloccocal infection, which is commonly known as a staph
infection. The treatment did not work, however. The swollen arm remained swollen,
and so on July 14th Mr. Fields complained about his open lesion.
The reason for the treatment’s failure was simple. A staph infection is caused
by bacteria, which is generally treated by a form of penicillin called methicillin. But
Mr. Fields did not have the garden-variety bacteria that causes a staph infection. His
infection was caused, rather, by methicillin-resistant Staphylococcus aureus, commonly
known as MRSA. As its name implies, MRSA is resistant to treatment through
methicillin. So Mr. Fields’ treatment did not work.
Mr. Fields again requested treatment on July 24th. In a medical-request form,
Mr. Fields wrote that “the meds that were given to” him were “not helping the open
wound.” Trial Ex. 1 at 15. Apparently, the Prison Health medical staff eventually sent
Mr. Fields to a medical block at the jail that dealt with MRSA infections. It appears
that the Prison Health staff provided lax treatment, so that additional treatment also
did not work.
On August 6th Mr. Fields felt his back go sore and numb. At first, as the young
and healthy are apt to do, Mr. Fields swiped all concerns away. He believed that the
soreness resulted from a pinched nerve or something trivial. But his pain increased.
On August 7th uncontrollable twitching affected his legs. For six hours, Mr.
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Fields dealt with the pain. By a little after midnight on August 8th Mr. Fields could
no longer tolerate the pain. The cell had an emergency button, and Mr. Fields, as well
as his roommate, began to thump the button. Mr. Fields testified that he hit the button
hundreds of times.
A Prison Health employee—a nurse—eventually showed up, and Mr. Fields
explained the pain that he felt. The nurse did nothing, and told Mr. Fields that he would
have to wait until the morning, when a doctor could examine him. His legs twitching
uncontrollably, Mr. Fields continued to bang the emergency button to no avail. A
corrections officer eventually ordered Mr. Fields and his roommate to stop pressing
the button.
On the morning of August 8th Mr. Fields dragged himself to the shower. As
he tried to return to his cell, his legs gave out, and he collapsed. Using walls and tables
to counterbalance gravity, Mr. Fields hoisted himself to his cell, where he again
collapsed.
By now, Mr. Fields could not walk and his lower body felt numb. Prisoners
throughout screamed “man down,” a prisoner-created alarm that, in theory, informed
the medical staff of an emergency. Some corrections officers and nurses thereafter
appeared at Mr. Fields’ cell. They commanded Mr. Fields to get up, but he couldn’t.
Mr. Fields stayed on the floor until an officer brought a wheelchair. The officers lifted
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Mr. Fields from the floor and placed him on the wheelchair. They then rolled him to
the jail’s medical department.
A nurse examined Mr. Fields at 8:55 a.m. In her notes, she wrote that Mr. Fields
complained that he could not walk. See Trial Ex. 1 at 13. As soon as the nurse finished
her examination, Mr. Fields met Joseph Richards, a physician’s assistant who worked
for Prison Health. Now, August 8th was a Wednesday, and Mr. Richards did not
normally examine inmates on Wednesdays. But Mr. Fields’ case constituted a medical
emergency, Mr. Richards testified, and he therefore examined Mr. Fields. See R. Vol.
8:118 at 92–93. Mr. Fields recounted his symptoms, which included weakness,
numbness, muscle spasms, and pain. He described his pain as a ten on a ten-point scale.
Mr. Richards too wrote that Mr. Fields complained that he couldn’t walk. See Trial
Ex. 1 at 13.
Mr. Richards used a reflex hammer to test Mr. Fields’ patellar reflex, i.e., to test
his knee-jerk reaction. Nothing happened; Mr. Fields had no reflex at all. Mr. Richards
also scraped Mr. Fields’ feet with a pin. Although Mr. Fields could just feel the pin,
he had no reaction whatsoever.
Despite these warning signs, and his realization that there was a medical
emergency, Mr. Richards gave Mr. Fields only Tylenol before he left. A nurse and a
corrections officer took Mr. Fields back to his cell. It was now about 9:30 a.m. on
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August 8th, and a nurse recommend that Mr. Fields be housed in the medical block.
After fifteen minutes, Mr. Fields was thrown into the back of a van. Corrections officers
dragged him from the van, placed him in a wheelchair, and took him to the medical
block. The officers placed Mr. Fields on the floor in a new cell and took the wheelchair.
Still in pain and now exhausted from lack of sleep, Mr. Fields asked every Prison
Health nurse that came by his cell that day—about ten by Mr. Fields’ calculation—for
help. He informed them that he was exhausted, that his legs twitched without relent,
that his lower body was numb, that his legs were weak. Like clockwork, or maybe as
if by pact, all the nurses agreed on the same approach: they did nothing.
A little after midnight on August 9th, Mr. Fields attempted to use the bathroom
for the first time in days. He crawled to the toilet, but then he felt his intestines escaping
from his rectum. Mr. Fields panicked, and the inmates in his cell begin to holler “man
down.” Ms. Allen—the nurse who had checked Mr. Fields on his first day in jail—soon
appeared. The inmates begged Ms. Allen to take Mr. Fields to the hospital. After
corrections officers cleared the cell, Ms. Allen walked in. Mr. Fields explained that
his intestines were coming out, and Ms. Allen demanded that Mr. Fields roll over. Mr.
Fields, who was on the floor, explained that he couldn’t move the lower half of his
body. Ms. Allen jerked Mr. Fields’ body, obtained some K-Y Jelly, and pushed the
intestines back in.
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Once she finished, Ms. Allen pushed Mr. Fields’ legs back and forth. Mr. Fields,
however, did not react. When she was done, Ms. Allen called Mr. Fields a liar. Ms.
Allen stated that, if Mr. Fields had not gone to the bathroom for days, he would be in
severe pain as she moved his legs. Mr. Fields explained that he could not feel anything
below his stomach.
By now it was nearing 3:00 a.m. On Ms. Allen’s orders, the corrections officers
dragged Mr. Fields on top of a sheet and carried him on the sheet to an observation
room. His pleas having been rejected by Ms. Allen, Mr. Fields dragged himself around
the room, set up his bed, and tried to make himself comfortable. Ms. Allen, by her own
deposition testimony, which was read to the jury, did not examine Mr. Fields further
once he was placed in the observation room. In other words, there was no observation
of Mr. Fields in the observation room.
Mr. Fields lay in agony throughout the early hours of August 9th. While in the
observation room, Mr. Fields begged six Prison Health employees for help. Again,
none so much as lifted a finger.
Dr. Noel Dominguez, a doctor who worked for Prison Health, arrived at work
at the Lee County jail at 8:00 a.m. on August 9th—about 24 hours after Mr. Fields’
paralysis began. Incredibly, neither Ms. Allen nor the other six Prison Health employees
with whom Mr. Fields spoke informed Dr. Dominguez about Mr. Fields, despite the
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fact that August 9th was a relatively light work day. Dr. Dominguez (who as noted
was unaware of Mr. Fields’ condition) therefore did not see Mr. Fields until 10:30 a.m.
There is no explanation in the record for the two-and-a-half–hour delay, but the jury
certainly could have inferred that the delay was in part due to the Prison Health
employees’ lack of concern about Mr. Fields and failure to tell Dr. Dominguez about
Mr. Fields’ condition.
Upon seeing Mr. Fields, Dr. Dominguez asked him what was wrong. Mr. Fields
told him his symptoms. Dr. Dominguez then ran the same tests that Mr. Richards had
performed. Immediately, he thought that there was something seriously wrong with
Mr. Fields. Concluding that Mr. Fields needed an MRI, Dr. Dominguez commanded
that Mr. Fields be sent to a hospital’s emergency room right away.
Dr. Dominguez gave the command as soon as he finished his examination of
Mr. Fields, but no one called an ambulance until 12:23 p.m. See Trial Ex. 2 at 3. The
ambulance arrived within five minutes of being summoned.
Doctors at the hospital took an MRI of Mr. Fields’ spine. The MRI showed that
an abscess was compressing the spine. An abscess is a collection of pus that forms
around tissue to protect other tissue from bacterial infection. Mr. Fields’ abscess,
unfortunately, formed near his spine, and, as it grew, it damaged the nerves in his spinal
cord. This compression of his spine and damage to his nerves caused Mr. Fields’
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numbness and eventual paralysis. Within hours of Mr. Fields’ arrival at the emergency
room, Dr. Jaime Alvarez operated on him to relieve the compression.
Time is crucial where an abscess compresses the spine. According to Dr.
Dominguez, as well as Mr. Fields’ medical expert, a patient who has the abscess
removed within 24 hours of paralysis stands a good chance of recovery. That is, where
a patient afflicted by spinal compression has an operation within 24 hours of his
paralysis setting in, he or she is likely to walk again. But the odds plummet after those
initial 24 hours.
The record shows that paralysis (as compared to numbness) afflicted Mr. Fields
sometime after 8:30 a.m. on August 8th. Therefore, had Mr. Fields received treatment
around that time on August 9th—around 24 hours later—he could have averted
permanent damage to his legs. But he did not receive that treatment because Prison
Health delayed his treatment. Because of this delay, Mr. Fields missed the critical 24hour window. Though Mr. Fields can, after years of rehabilitation, now travel with
a walker, he is still partially paralyzed from the waist down.
B. PRISON HEALTH’S POLICIES
Remarkably, neither side introduced Prison Health’s policy manual at trial.
Instead, the parties introduced evidence of Prison Health’s medical policies through
the testimony of Ms. Allen and Prison Health’s corporate representative. Prison Health’s
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corporate representative testified that nurses and physicians could send inmates to
hospitals only in emergencies. See R. Vol. 8:118 at 187. Prison Health’s corporate
representative defined an emergency as a critical injury or life-threatening “injury or
illness,” but she never testified that this definition was communicated to the medical
staff. R. Vol. 8:118 at 187. Ms. Allen corroborated part of this testimony. Nurses, Ms.
Allen said, “weren’t trained to designate whether somebody” had “to go to the ER;”
to the contrary, “that’s a doctor’s job to do.” R. Vol. 8:118 at 71. Hence, Prison Health
allowed nurses to send inmates to the hospital only in an emergency, but then left them
to figure out what an emergency was. To Ms. Allen, an emergency was narrowly defined
as when someone is “dying any minute.” R. Vol. 8:118 at 71. Ms. Allen elaborated
on her definition by giving examples of “emergencies.” She, for instance, had called
ambulances where a man was beaten half to death and where a man had no pulse, but
had placed inmates with partial paralysis in an observation room. See R. Vol. 8:118
at 79–80, 86–87.
Prison Health enforced its restrictive policy against sending inmates to the
hospital. Ms. Allen testified that, at monthly nurses’ meetings, medical supervisors
“yelled a lot about nurses” sending inmates to hospitals. See Vol. 8:118 at 65.
Repeatedly, Prison Health instructed nurses to be sure that the inmate had an emergency
because it cost money to send inmates to the hospital. See Vol. 8:118 at 71. In fact,
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Ms. Allen remembered three separate supervisors who emphasized the policy to her.3
As noted above, the abscess presented life-changing consequences for Mr. Fields
if left untreated for more than 24 hours. It thus constituted an objective medical
emergency.
In fact, Mr. Richards—one of Prison Health’s own employees—saw Mr. Fields
because the situation was a medical emergency. Both Dr. Dominguez and Mr. Fields’
medical expert also testified that Mr. Fields had a medical emergency. After he tapped
Mr. Fields with the reflex hammer and saw no response, Dr. Dominguez believed that
Mr. Fields “needed to be sent to the emergency room right away.” R. Vol. 8:118 at
161. And Mr. Fields’ medical expert testified that there was no medical justification
for refusing to send Mr. Fields to a hospital once he could no longer walk. See R. Vol.
7:117 at 111. Dr. Alvarez, the surgeon, agreed with the other two doctors. “[A]ny
discovery of weakness in the legs,” he said, “warrants immediate attention, immediate

3

Because Prison Health’s policy manual was not introduced at trial, the jury never heard
evidence as to which definition of emergency—that provided by Prison Health’s corporate
representative or the more narrow one used by Ms. Allen and/or other Prison Health staff—was the
operative one. Prison Health introduced a written policy at the summary judgment stage and now
argues that we must consider it, even though it chose not to introduce that evidence at trial. This
argument is frivolous. The legal standard for a motion for judgment as a matter of law requires courts
to determine whether evidence introduced at trial supports the jury’s conclusion. See Bill John’s
Rests., Inc. v. NLRB, 461 U.S. 731, 745 n.11 (1983). It is incoherent to say that evidence that a jury
never saw somehow supports (or undermines) that jury’s conclusion. See Porter v. Am. Optical
Corp., 641 F.2d 1128, 1137 (5th Cir. Apr. 1981) (noting that in deciding a motion for judgment as
a matter of law courts look at the evidence introduced at trial).
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action, to find out what’s causing it.” R. Vol. 8:118 at 13. He bluntly said that it is
an emergency to find the cause of the legs’ weakness. See R. Vol. 8:118 at 14.
Finally, like Mr. Fields’ medical expert, Dr. Alvarez testified that, with Mr. Fields’
symptoms, no medical justification existed for not taking an MRI. See R. Vol. 8:118
at 24. “[I]f the paralysis is obvious, any nurse or physician’s assistant, any health-care
personnel with some training, would be able to recognize that.” R. Vol. 8:118 at 34.
Even Mr. Richards recognized that partial paralysis would result from tumors, trauma
to the spinal cord, or spinal compression. See R. Vol. 8:118 at 129. Significantly, there
was no contrary testimony from Prison Health: Prison Health’s medical expert testified
that back pain was not a dire emergency but did not opine that paralysis is not a medical
emergency.
Although these doctors testified that weakness in the legs requires, at the least,
an MRI, Ms. Allen incredibly testified that she would not send someone with paralysis
to the hospital. Prison Health had no MRI available in Lee County jails, but, when Ms.
Allen had encountered inmates with symptoms of partial paralysis, she had simply “put
them in an observation cell and put them down to see a doctor.” R. Vol. 8:118 at 86.
This was, Ms. Allen assured the jury, the norm. See R. Vol. 8:118 at 87. In light of
this testimony by Ms. Allen, the jury was entitled to reject the testimony of Prison
Health’s corporate representative as to what constituted an emergency and find that
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Prison Health had a custom or policy of not sending inmates with paralysis to the
hospital unless they were near death.
C. PROCEDURAL HISTORY
After four days of trial, the jury found that Mr. Richards and Ms. Allen had not
violated the Eighth Amendment. The jury, however, found that Prison Health had a
custom or policy that did violate Mr. Fields’ constitutional rights. Specifically, the jury
concluded that Mr. Fields had a serious medical need, that Prison Health was deliberately
indifferent to his serious medical need, and that Prison Health’s actions proximately
caused Mr. Fields’ damages. The jury awarded Mr. Fields $700,000 in economic
damages and $500,000 in punitive damages.
In post-trial motions, Prison Health asked the district court to grant it judgment
as a matter of law under Federal Rule of Civil Procedure 50(a). Prison Health argued
that there was insufficient evidence to show that it had a policy or custom of refusing
to send inmates to hospitals. Prison Health also argued that Mr. Fields had not shown
that its policy caused his injury. In the alternative, Prison Health requested a new trial
under Rule 59. A new trial should have been granted, Prison Health asserted, because
the jury did not follow the jury instructions, because the jury’s verdict was inconsistent,
and because the jury instructions were incorrect with regard to the punitive damages.
In a thorough 29-page order, the district court denied Prison Health’s motion
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for judgment as a matter of law or, alternatively, for a new trial. Prison Health appealed.
II. STANDARD OF REVIEW
We undertake de novo review of a district court’s denial of a motion for judgment
as a matter of law. See Lambert v. Fulton Cnty., 253 F.3d 588, 594 (11th Cir. 2001).
Nevertheless, we must affirm the jury’s decision “if there is evidence from which” the
jury “reasonably could have resolved the matter the way it did.” Rodriguez v. Farm
Store Grocery, Inc., 518 F.3d 1259, 1264 (11th Cir. 2008).
We reverse a district court’s decision on a motion for new trial only if the district
court abused its discretion. See Lambert, 253 F.3d at 595. A district court should grant
a new trial only where the “great weight” of evidence contradicts the jury’s verdict.
See Lipphardt v. Durango Steakhouse of Brandon, Inc., 267 F.3d 1183, 1186 (11th
Cir. 2001).
III. ANALYSIS
The Eighth Amendment to the United States Constitution states that “[e]xcessive
bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishment
inflicted.” U.S. CONST. amend. VIII. The prohibition against cruel and unusual
punishment applies to states under the Fourteenth Amendment. See Robinson v.
California, 370 U.S. 660, 666–67 (1962).
For years, courts have recognized that a prison staff’s deliberate indifference
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“to an inmate’s serious medical needs violates the inmate’s right to be free from cruel
and unusual punishment.” Waldrop v. Evans, 871 F.2d 1030, 1033 (11th Cir. 1989).
And a prisoner whose Eighth Amendment rights are violated may sue the prison staff
members who violated those rights under 42 U.S.C. § 1983. That statute also allows
the prisoner to sue the municipality—like a county—who runs the prison system. To
do so, the prisoner must show that the municipality had a “custom or policy that
constituted deliberate indifference to that constitutional right.” McDowell v. Brown,
392 F.3d 1283, 1289 (11th Cir. 2004). The prisoner must show too that the custom
or policy caused the constitutional violation, as respondeat superior liability is not
permitted. See id. Although Prison Health is not a governmental entity, “[w]here a
function which is traditionally the exclusive prerogative of the state (or here, county)
is performed by a private entity,” that private entity, like a municipality, may be held
liable under § 1983. Ancata v. Prison Health Servs., 769 F.2d 700, 703 (11th Cir. 1985).
A. SUFFICIENCY OF EVIDENCE AS TO POLICY OR CUSTOM
To show that the government denied him medical care in violation of his Eighth
Amendment rights, a prisoner must show an objectively serious medical need and show
that “the prison official’s response to that need was poor enough to constitute an
unnecessary and wanton infliction of pain.” Bingham v. Thomas, 654 F.3d 1171, 1176
(11th Cir. 2011) (per curiam) (internal quotation marks omitted). A medical need is
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serious if it “has been diagnosed by a physician as mandating treatment or one that
is so obvious that even a lay person would easily recognize the necessity for a doctor’s
attention.” Farrow v. West, 320 F.3d 1235, 1243 (11th Cir. 2003). The prisoner must
additionally demonstrate that the prison official or municipality acted with deliberate
indifference. See Taylor v. Adams, 221 F.3d 1254, 1258 (11th Cir. 2000). As noted
above, a municipality or entity like Prison Health is liable only where its custom or
policy causes the constitutional injury. See AFL-CIO v. City of Miami, 637 F.3d 1178,
1187 (11th Cir. 2011). “When a municipal policy itself violates federal law . . . resolving
issues of fault and causation is straightforward.” Id. (internal quotation marks omitted).
But, if the policy or custom is facially lawful, “the plaintiff must establish that the
municipal action was taken with deliberate indifference as to its known or obvious
consequences.” Id.
Prison Health does not dispute that Mr. Fields had a serious medical need. Instead,
Prison Health contends that Mr. Fields offered insufficient evidence to show that it
had a policy or custom (1) that was deliberately indifferent to Mr. Fields’ medical needs,
and (2) that violated Mr. Fields’ constitutional rights. After a review of the trial transcript
and the exhibits, we disagree and conclude that the jury “reasonably could have resolved
the matter the way it did.” Rodriguez, 518 F.3d at 1264.
Prison Health is a private entity that provides medical services to prisoners in
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Lee County’s place, and so it can be held liable only if it had a “custom or policy that
constituted deliberate indifference to [a] constitutional right.” McDowell, 392 F.3d
at 1289. “A policy is a decision that is officially adopted by the municipality, or created
by an official of such rank that he or she could be said to be acting on behalf of the
municipality.” Goebert v. Lee Cnty., 510 F.3d 1312, 1332 (11th Cir. 2007). A policy
may be deliberately indifferent if it is facially unconstitutional or where the policy is
implemented with “deliberate indifference as to its known or obvious consequences.”
McDowell, 392 F.3d at 1291.
We have repeatedly held that “deliberate indifference” includes “the delay of
treatment for obviously serious conditions where it is apparent that delay would
detrimentally exacerbate the medical problem,” where “the delay does seriously
exacerbate the medical problem,” and where “the delay is medically unjustified.” Harper
v. Lawrence Cnty., 592 F.3d 1227, 1235 (11th Cir. 2010) (quoting Taylor, 221 F.3d
at 1259–60). A delay of even hours may be deliberately indifferent given the “reason
for the delay and the nature of the medical need.” McElligott v. Foley, 182 F.3d 1248,
1255 (11th Cir. 1999). The evidence at trial supports the jury’s determination that Prison
Health had a policy that delayed treatment of serious medical problems.
Both Ms. Allen and Prison Health’s corporate representative testified that Prison
Health did not allow nurses or physician’s assistants to send inmates to hospitals, except
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in emergencies. See R. Vol. 8:118 at 70, 187. Prison Health’s representative defined
“emergency” as a critical injury or life-threatening injury or illness, but the definition
was not communicated to the medical staff, and the jury could have reasonably found
that Ms. Allen and the rest of the staff defined “emergency” much more narrowly.
According to Ms. Allen, under Prison Health’s definition, the word “emergency” was
restricted to a life-or-death situation. Except for those life-or-death situations, it was
for a doctor to send an inmate to the hospital. See R. Vol. 8:118 at 71. Given the failure
of Prison Health to introduce its policy manual, the jury could have accepted Ms. Allen’s
more-restrictive definition of emergency as the operative one.
The evidence at trial, moreover, supports Ms. Allen’s definition over the corporate
representative’s. The nurse’s reaction on the night that Mr. Fields hit the emergency
button hundreds of time and the refusal of over a dozen Prison Health medical staff
members to do anything in response to Mr. Fields’ pleas for help indicate that
“emergency” meant only a life-or-death situation. After all, the nurse told Mr. Fields
that he would have to wait until a doctor saw him, and the staff members who later
saw Mr. Fields or heard his pleas for help did absolutely nothing. Critically, Ms. Allen
further testified that the norm at Prison Health was to put inmates with partial paralysis
in an observation room and wait for a doctor to see them. It is, in fact, what she had
done the previous times that she had come across partially paralyzed inmates. See R.
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Vol. 8:118 at 86–87. And, as noted earlier, Prison Health never introduced a manual
or policy guide at trial that described any other policy. Nor did Prison Health introduce
anything in writing defining “emergency.”
Despite not being a life-or-death situation, Mr. Fields’ situation undoubtedly
constituted a serious medical need under the Constitution. For Eighth Amendment
purposes, the “medical need of the prisoner need not be life threatening.” Washington
v. Dugger, 860 F.2d 1018, 1021 (11th Cir. 1989). Accord Gayton v. McCoy, 593 F.3d
610, 620 (7th Cir. 2010) (“A medical condition need not be life threatening to be serious;
rather, it could be a condition that would result in further significant injury or
unnecessary and wanton infliction of pain if not treated.”). Thus, we have recognized
that injuries like fractured hips and broken feet—which are unlikely to cause death
and are far less serious than paralysis—constitute “serious medical needs.” See Brown
v. Hughes, 894 F.2d 1533, 1538 (11th Cir. 1990) (per curiam); Mandel v. Doe, 888
F.2d 783, 790 (11th Cir. 1989). Constitutionally, paralysis is a serious medical need;
medically, paralysis is a serious emergency.
At trial, the doctors testified without contradiction that any form of paralysis,
partial or total, or weakness of the legs constituted a medical emergency. Mr. Fields’
lack of reaction after being hit with a reflex hammer, Dr. Dominguez explained, was
an emergency. See R. Vol. 8:118 at 161. And the doctors testified that delay in treatment
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would “detrimentally exacerbate” Mr. Fields’ medical problems. Treatment within 24
hours was critical to anyone in Mr. Fields’ situation. Plus, anyone with any medical
training (and for that matter anyone without any medical training) should have realized
that Mr. Fields’ paralysis required transportation to a hospital. See R. Vol. 8:118 at
34. Given Prison Health’s extremely narrow definition of “emergency,” and given the
testimony presented at trial, the jury could reasonably conclude that Prison Health had
a policy that improperly delayed treatment of serious medical needs, like paralysis,
where such delay would detrimentally exacerbate an inmate’s condition.
The jury could also have reasonably concluded that the delay here was medically
unjustified. The doctors at trial testified that no medical justification existed for not
sending Mr. Fields to a hospital and that any person with medical training would have
known that Mr. Fields required medical help. See R. Vol. 7:117 at 111; R. Vol. 8:118
at 13–14, 24. And paralysis is such an uncommon, serious, and traumatic event that
even someone without any medical training would have recognized the situation as
requiring immediate care by a doctor. See Simmons v. Cook, 154 F.3d 805, 808 (8th
Cir. 1998) (noting that being wheelchair bound is a serious medical need to which even
laymen are aware); Blackmore v. Kalamazoo Cnty., 390 F.3d 890, 897 (6th Cir. 2004)
(quoting Taylor v. Franklin Cnty., 104 F. App’x 531, 538 (6th Cir. 2004)) (“Such
obvious signs of reoccurring incontinence and debilitating immobility were clear
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symptoms of a serious problem, even if Defendants did not choose to believe
Plaintiff.”)).
Mr. Fields’ objectively verified inability to walk, lack of reflexes, and
incontinence so alarmed his fellow inmates that they begged Ms. Allen to take Mr.
Fields to the hospital. Yet over a dozen Prison Health nurses ignored Mr. Fields’ pleas.
Mr. Fields also testified that Mr. Richards examined his reflexes and sensation—just
like Dr. Dominguez did—with a similar result. See R. Vol. 9:119 at 51–52. But, unlike
Dr. Dominguez, Mr. Richards did nothing except give Mr. Fields Tylenol. Mr. Richards
acknowledged that trauma, tumors, and spinal compression would cause partial
paralysis—all of which are weighty medical problems. See R. Vol. 8:118 at 129. A
reasonable jury could have concluded that no medical justification explained the delay.
The evidence, in sum, sufficed to permit a finding of deliberate indifference: “[I]f
necessary medical treatment has been delayed for non-medical reasons, a case of
deliberate indifference has been made out.” Ancata, 769 F.2d at 704. See also Brown,
894 F.2d at 1538 (“[A]n unexplained delay of hours in treating a serious injury states
a prima facie case of deliberate indifference.”).
Plus, if the jury did ask itself why Prison Health delayed treatment for Mr. Fields’
paralysis, it could have concluded that it delayed treatment to save costs. Ms. Allen
noted that the Prison Health supervisors yelled at nurses because the nurses sent inmates
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to hospital. See R. Vol. 8: 118 at 65. Although Ms. Allen mentioned that some nurses
sent inmates to hospitals when the inmates had no medical problems—testimony, by
the way, that the jury was free to reject given its lack of corroboration4—she also said
that Prison Health underscored that it cost “so much money” every time an inmate went
to the hospital. R. Vol. 8:118 at 70. Apparently, Ms. Allen heard this mantra from three
different Prison Health supervisors. See R. Vol. 8:118 at 70–72. The jury could have
thus concluded that Prison Health delayed treatment to save money, which is not a
medical justification. Although an entity like Prison Health can generally include cost
allocations in formulating its policies, see Craig v. Floyd Cnty., 643 F.3d 1306, 1312
(11th Cir. 2011), cost is not a factor which can justify the lack of timely medical
treatment for something as serious as paralysis: “Lack of funds for facilities cannot
justify an unconstitutional lack of competent medical care or treatment of inmates.”
Ancata, 769 F.2d at 705. See also Anderson v. City of Atlanta, 778 F.2d 678, 688 n.14
(11th Cir. 1985) (noting that lack of funds cannot justify unconstitutional treatment
of inmates).
4

Ms. Allen also testified that she acted properly because she did not believe Mr. Fields was
really in medical trouble. But the jury was not required to believe this portion of her self-serving
testimony. This is especially true because Ms. Allen requested that the corrections officers move Mr.
Fields to the observation room. As the Seventh Circuit wrote about a similar case, “why put him in”
an observation room “if this was all an act?” King v. Kramer, 680 F.3d 1013, 1019 (7th Cir. 2012).
Ms. Allen further testified that she had placed partially paralyzed inmates in observation rooms
before, and the jury could have found that this was how she dealt with such a serious medical
problem.
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To hold Prison Health liable, Mr. Fields had to prove as well that Prison Health
implemented its policy with “‘deliberate indifference’ as to [the policy’s] known or
obvious consequences.” AFL-CIO, 637 F.3d at 1187. Three doctors testified that Mr.
Fields faced dire consequences without timely medical treatment. Even Mr. Richards
testified that only trauma, tumors, or compression to the spine, all of which are obvious
dangers, would explain a healthy man’s inability to walk. Partial paralysis, according
to the medical testimony, would be an obvious emergency that required at the very
least an MRI. And yet Prison Health’s policy did not allow nurses to send inmates to
hospitals in this very situation, as reflected not only by what happened to Mr. Fields
but also by what Ms. Allen had done in prior cases of paralysis. Without prompt medical
attention, the medical testimony indicated, the likelihood of paralysis skyrocketed.
With this evidence, a jury could conclude that Prison Health implemented a policy
while knowing that the policy would exacerbate inmate’s paralysis.
Finally, a “plaintiff must prove causation by demonstrating that the municipality’s
‘deliberate conduct . . . was the “moving force” behind [his] injury.’” McDowell, 392
F.3d at 1292 (alterations in original) (emphasis omitted). See also Cuesta v. Sch. Bd.
of Miami-Dade Cnty., 285 F.3d 962, 967 (11th Cir. 2002) (“A plaintiff must demonstrate
a direct causal link between the municipal action and the deprivation of federal rights.”)
(internal quotation marks omitted). Here, Mr. Fields had a serious medical need that
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Prison Health’s policy did not recognize as sufficient to warrant hospital care. And
testimony at trial indicated that, had Prison Health sent Mr. Fields to the hospital earlier,
paralysis could have been averted. A jury could therefore reasonably conclude that
Prison Health’s policy restricting the transportation to hospitals of inmates with serious
medical needs was a direct cause of Mr. Fields’ injuries.
B. MOTION FOR NEW TRIAL
After the district court discharged the jury, Prison Health filed a written motion
for a new trial under Rule 59. Prison Health sought a new trial on three grounds. First,
the jury’s verdict was inconsistent. Second, the district court inadequately instructed
the jury on punitive damages. Third, the jury did not follow the jury instructions. Prison
Health now raises these arguments on appeal, but each of them fails.
1. INCONSISTENT VERDICTS
In its first argument, Prison Health notes that the jury found neither Mr. Richards
nor Ms. Allen liable but found Prison Health liable. The jury, Prison Health maintains,
thus rendered inconsistent verdicts. Whatever the merits of this argument, Prison Health
has forfeited it.
The verdict form, by Prison Health’s admission, was “unquestionably a general
verdict with answers to written questions.” Appellant’s Br. at 46. This type of verdict
form falls within the bounds of Federal Rule of Civil Procedure 49(b). “As a general
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rule, a party must raise a Rule 49(b) challenge to the form of the verdict and the jury’s
answers at the time they are announced . . . .” Wilbur v. Corr. Servs., 393 F.3d 1192,
1200 n.4 (11th Cir. 2004). If a party does not object before a jury is discharged, that
party forfeits the argument that the verdict is inconsistent. See, e.g., id.; Stancill v.
McKenzie Tank Lines, Inc., 497 F.2d 529, 534–35 (5th Cir. 1974). “The reason for this
particular raise-it-or-lose-it rule is that, if the inconsistency is raised before the jury
is discharged, the jury can be sent back for further deliberations to resolve the
inconsistency in its verdict or interrogatory answers. Once the jury is gone . . . that
is not possible.” Pensacola Motor Sales, Inc. v. E. Shore Toyota, LLC, 684 F.3d 1211,
1225 (11th Cir. 2012). Having failed to object to the inconsistent verdict before the
district court discharged the jury, Prison Health has forfeited this argument.
2. JURY INSTRUCTIONS
Prison Health next argues that the district court should have defined “malice”
in a certain way in its jury instructions. The verdict form asked the jury, when deciding
whether to award punitive damages, to consider whether Prison Health “acted with
malice or reckless indifference to” Mr. Fields’ “federally protected rights.” Prison Health
wanted the instruction to define the word “malice” as “evil intent.” The district court
did not do so, and Prison Health contends that it is therefore entitled to a new trial.
We disagree.
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Simply put, a district court “enjoys broad discretion to formulate jury instructions
provided those instructions are correct statements of the law,” United States v. Lebowitz,
676 F.3d 1000, 1014 (11th Cir. 2012) (per curiam), and we cannot conclude that the
district court abused its discretion here. To the contrary, Prison Health’s proposed
definition of malice—“evil intent”—is too restrictive. Indeed, the Supreme Court has
rejected the argument that “evil intent” is a prerequisite to an award of punitive damages
under § 1983, deciding instead that a “reckless or callous disregard” standard suffices.
See Smith v. Wade, 461 U.S. 30, 51 (1983).
3. THE JURY’S FAILURE TO FOLLOW INSTRUCTIONS
Finally, Prison Health asserts that it deserves a new trial because the jury did
not follow the jury instructions. Prison Health describes this argument as follows:
[T]he jury could not have followed the Jury Instructions
because it found that both Allen and Richards were not aware
of Fields’ serious medical need and, therefore, could not have
found that any PHS policy or custom causing [sic] them to
deny him necessary medical care for that serious medical
need.
Reply Br. at 11. If this is its argument, then Prison Health is again arguing that the jury
rendered an inconsistent verdict. But, as already explained above, Prison Health forfeited
that argument.

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IV. CONCLUSION
The judgment in favor of Mr. Fields and against Prison Health is affirmed.
AFFIRMED.

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