McBride v. Houston County Health Care Authority et al

Filing 340

OPINION. Summary judgment will be entered in favor of defendant Rajendra Paladugu in all respects. As to the remaining defendants, summary judgment will be entered in their favor only in part as set forth in this opinion. An appropriate judgment will be entered accordingly. Signed by Honorable Judge Myron H. Thompson on 6/24/2015. (dmn, )

IN THE DISTRICT COURT OF THE UNITED STATES FOR THE
MIDDLE DISTRICT OF ALABAMA, SOUTHERN DIVISION

COURTNEY McBRIDE,

)
)
Plaintiff,
)
)
v.
)
)
HOUSTON COUNTY HEALTH CARE )
AUTHORITY d/b/a Southeast )
Alabama Medical Center,
)
et al.,
)
)
Defendants.
)

CIVIL ACTION NO.
1:12cv1047-MHT
(WO)

OPINION
Plaintiff Courtney McBride developed a rare skin
disease after receiving treatment at a county hospital
followed by her subsequent discharge to a local jail.
She

brings

this

lawsuit

against

the

following

defendants: Houston County Health Care Authority; Drs.
Dinesh Karumanchi and Rajendra Paladugu; the City of
Dothan;

and

Dothan

City

Jail

Correctional

Officers

Mamie McCory and Stephanie Johnson.

She asserts that

the Health Care Authority and the doctors committed
medical malpractice in violation of Alabama law and
that the City of Dothan and its correctional officers
were deliberately indifferent to her medical needs in
violation of the United States Constitution and were
negligent in violation of Alabama law.

The court has

jurisdiction pursuant to 28 U.S.C. § 1343(a)(3) (civil
rights) and § 1367 (supplemental).
The

case

is

now

before

this

court

defendants’ motions for summary judgment.

on

the

The motions

will be granted in part and denied in part.

I. LEGAL STANDARD
“A

party

may

move

for

summary

judgment,

identifying each claim or defense--or the part of each
claim or defense--on which summary judgment is sought.
The court shall grant summary judgment if the movant
shows

that

there

is

no

genuine

2

dispute

as

to

any

material fact and the movant is entitled to judgment as
a matter of law.” Fed. R. Civ. P. 56(a).

The court

must view the admissible evidence in the light most
favorable
reasonable
Matsushita

to

the

non-moving

inferences
Elec.

in

Indus.

party

favor

Co.

Ltd.,

and

of
v.

draw

that
Zenith

all

party.
Radio

Corp., 475 U.S. 574, 587 (1986).

II. BACKGROUND
This case arises out of McBride’s development of a
severe rash that peeled off large parts of her skin.
Specifically,

she

brings

medical-malpractice

claims

against the Houston County Health Care Authority as
well

as

the

doctors

practicing

deliberate-indifference and

there,

and

negligence claims against

the City of Dothan and the correctional officers at the
Dothan City Jail.

As the defendants have moved for

summary judgment, the facts are taken in the light most
favorable to McBride.

3

The facts can
McBride’s

be divided
period

initial

into three parts: (A)
the

in

Southeast

Alabama

Medical Center, which is run by Houston County Health
Care Authority; (B) McBride’s time in jail; and (C)
McBride’s subsequent admissions to the medical center
at the end of her jail stay and after she was released.

A. McBride’s Initial Period
in Southeast Alabama Medical Center
On

June

21,

2012,

a

municipal

court

revoked

McBride’s bond on a pending domestic-violence charge
and ordered her to jail.

After she had a psychological

breakdown in the courtroom, she was transported to the
behavioral medical unit of Southeast Alabama Medical
Center.
While

at

the

medical

center,

Dr.

Karumanchi

conducted several psychiatric evaluations of McBride.
The day after
with

major

she arrived, Karumanchi diagnosed

depressive

social anxiety.

disorder,

alcohol

abuse,

her
and

During a subsequent evaluation, on
4

June 25, he diagnosed her with bipolar disorder and
bulimia,

as

well

alcohol abuse.

as

other

mental-health

issues

and

Along with other drugs for depression,

Karumanchi prescribed one 25mg Lamictal1 tablet twice a
day, for a total of 50mg of Lamictal per day, in order
to treat the bipolar disorder.

He also anticipated

that she would eventually move to a higher dosage of
Lamictal.

Both

parties

agree

that

Karumanchi

instructed McBride not to stop taking Lamictal suddenly
without consulting a doctor because a sudden withdrawal
might cause seizures.
that

he

warned

Karumanchi’s medical notes state

McBride

about

the

possibility

of

a

lethal rash and that he instructed the nurse to provide
information about Lamictal to McBride.

The notes do

not mention a warning that Lamictal at higher dosages
is more likely to lead to a severe skin disease.

The

parties dispute whether Karumanchi in fact told McBride
1.
Lamictal is the brand name for lamotrigine.
Lamictal
is
used
throughout
this
opinion
for
consistency.
5

about

the

possibility

rash--specifically
its

more

of

a

severe

skin

Stevens-Johnson Syndrome (SJS), or

virulent

form,

Toxic

Epidermal

Necrolysis

(TEN)--that can develop from taking Lamictal at all, as
well as whether he was required to tell her about the
increased

risk

of

SJS

or

TEN

from

higher

initial

dosages of Lamictal.
As background, SJS occurs when less than 10 % of
the skin is affected with blisters.
more than 30 % is affected.

TEN occurs when

Between 10 % and 30 %,

there is a hybrid diagnosis of SJS/TEN.

At least one

expert, Dr. Robert Auerbach, testified that two mucous
membranes should also be involved for an SJS or TEN
diagnosis.

These

membranes

can

include

the

mouth,

throat, and vaginal area, among other areas.
Although

Karumanchi

remained

the

psychiatrist

on

the case until McBride was discharged to the jail on
July 4, several other medical professionals saw McBride
during that span.

6

First, after Karumanchi prescribed Lamictal on the
afternoon of June 25, Herminia Coppage, a nurse at the
hospital, had the responsibility of administering the
medication.

Coppage knew that that the standard of

care

administer

was

to

two

dosages

of

Lamictal

at

12-hour intervals, but because Karumanchi’s order to
administer two doses came during the afternoon, Coppage
administered both dosages of Lamictal within two and a
half hours of each other in the late evening.

She

stated that she followed the doctor’s orders giving the
dosages at this interval.2

2.
McBride contends that Coppage gave up to four
doses of Lamictal to McBride that night, relying on
billing records, which show four Lamictal pills
purchased on June 25.
Billing Records (doc. no.
201-10) at 3. However, billing records do not indicate
how many of those pills Coppage gave to McBride, and
the medical records indicate that Coppage gave only two
pills to McBride. Houston County Medical Records (doc.
no. 131-1) at 504.
Moreover, neither McBride nor her
experts stated in their testimony that McBride received
four doses. Even taking the evidence in the light most
favorable to McBride, the court concludes that Coppage
gave only two doses.
7

The

parties

dispute

whether

Coppage

also

gave

McBride a warning about a severe rash as a potential
side effect of Lamictal.

There is a signed page in the

record from June 25 where McBride acknowledged the side
effects, including “yellowing of the eyes or skin” for
some drug.
131-1)

at

Houston County Medical Records (doc. no.
644.

The

signed

page,

though,

does

not

mention Lamictal, and no other pages are included.
Second, while McBride remained in the hospital, Dr.
Paladugu, a psychiatrist, covered for Karumanchi the
weekend of June 30 to July 1.

He did not change the

prescription for Lamictal but did add a prescription
for an anti-psychotic drug.

McBride testified that she

does not remember if Paladugu warned her about side
effects

of

Lamictal

but

claims

that

she

would

have

heard a warning about a potentially fatal side effect
and its symptoms.
Karumanchi returned after the weekend and was the
doctor responsible when the medical center discharged

8

McBride to the jail on July 4.

Karumanchi maintains

that he told the officer who transported McBride to
jail

that

if

her

conditioned

worsened,

she

should

return to the hospital; the officer denies that he was
told any information.3

B. McBride’s Time in Jail
McBride arrived in the Dothan City Jail on July 4.
Dothan had several policies at the jail relevant to
this case regarding medical care for prisoners.
because

the

jail

did

not

have

medical

First,

personnel

on

3.
In summary judgment, the evidence is taken in
the light most favorable to the non-moving party.
Here, whether Karumanchi informed the transporting
officer can cut both ways for McBride. If he did, then
it
eliminates
a
theory
of
malpractice
against
Karumanchi
but
bolsters
McBride’s
deliberate-indifference claim against the City of
Dothan and its correctional officers; if he did not,
then, vice-versa.
McBride should not be put at a
disadvantage at summary judgment by having to guess
which defendant is telling the truth.
The court
therefore interprets the evidence in the light most
favorable to McBride against each defendant in summary
judgment and will let the jury at trial decide which of
these defendants is telling the truth.
9

staff, the city had a policy of transporting prisoners
to the hospital should a medical issue arise.
the

supervisor

treating

would

ensure

that

had

passed

to

doctor

any
the

Second,

message

the

transportation

officer would be communicated to any other officer that
“is going to have any interaction with the detainee.”
McCory Dep. (doc. no. 172-17) at 43:21-45:23.
When

McBride

arrived

at

the

jail,

the

jailing

officers put her in a holding cell near the front of
the jail, noting her potential suicide risk.

The jail

also filled McBride’s Lamictal prescription, and she
continued to take the drug during her time in jail.
On the next day, McBride began to feel ill.
lips became chapped, and she was freezing.
two

days

horrible.

after

she

reported

feeling

On the same day, she had a follow-up

appointment

facility,

arrived,

By July 6,

She could not eat and had difficulty getting

out of bed.
medical

she

Her

scheduled

presumably

for

10

at

a

separate

mental-health

medical

treatment.

During that trip, she did not mention a skin rash or
any

kind

of

sickness

to

either

the

officer

that

transported her to the appointment or to the medical
personnel.
Over

the

next

four

continued to deteriorate.

days,

McBride’s

condition

Every day, she screamed for

people to help her and banged on the door of her cell
when she had energy.

At some point while in jail, she

spoke with Correctional Officer Johnson, a detention
lieutenant at the jail, about her condition.
point,

McBride’s

lips

were

peeling

off.

At that
Although

Johnson brought her Vaseline and water, she did not
take her to the hospital, as per the city’s policy of
providing medical care.
her medication.

Johnson also brought McBride

Correctional Officer McCory, the other

individual defendant, was the jail administrator and
worked at least three days when McBride was screaming.
She could hear McBride’s shouting from her office, but
did nothing to help her.

11

Finally, on July 10, when McBride complained of a
sore

throat

and

refused

to

eat

breakfast,

the

jail

transported her back to the medical center.

C. McBride’s Subsequent Trips to the Medical Center
When McBride arrived at the medical center on July
10, she first had an initial screening.

The medical

records note that, although she “appear[ed] well” and
was “in no distress,” she also was “malnourished,” had
sunken

eyes,

and

her

throat

pain

was

a

“10/10.”

CliniCare July 10 Evaluation (doc. no. 172-3) at 4.4
She had a 101.5 degree fever, difficulty breathing,
extremely dry and cracked lips and mouth, and “very dry
and ashy skin.”

Id.

She also had dark splotches of

skin on her face. Although the nurses wrote in the

4. McBride later stated in the emergency room that
the pain was a “9/10.” Houston County Medical Records
(doc. no. 131-1) at 400. Either way, McBride reported
severe pain.
12

medical

records

that

McBride

was

not

taking

any

medicine, she was still taking Lamictal.
After this initial screening, McBride was sent to
the emergency room.
taking Lamictal.

She told the nurse that she was
After an examination, McBride was

diagnosed with a sore throat, a fever, mouth ulcers,
and a rash.5

Houston County Medical Records (doc. no.

131-1) at 399.

Despite being told McBride was taking

Lamictal, the nurse did not put it on McBride’s chart.
McBride was given medication and later released back to
the Dothan City Jail.

That night she was released from

jail.
After McBride returned home on July 10, she had
trouble urinating.

Her ears hurt, she had a headache,

and she still had splotches on her skin.

She went to

5.
In its section of undisputed material facts,
the Health Care Authority stated that, while McBride
reported a rash, the physician’s assistant did not
actually find one. This fact is clearly disputed. The
medical records list rash under the “diagnosis” and
“discharge instruction” on the discharge form for
McBride’s July 10 visit to the emergency room. Houston
County Medical Records (doc. no. 131-1) at 399.
13

the emergency room the following day, July 11, and was
diagnosed

with

vaginitis

by

the

doctor.

The

physician’s assistant did not see a rash, and McBride
was not diagnosed with any serious medical condition.
Although

McBride’s

mother

brought

in

her

bag

of

medications, none of the nurses or doctors asked about
Lamictal.

The nurses also did not annotate McBride’s

medical charts to indicate she was taking Lamictal.
The night of July 11 and the following morning, the
splotches on McBride’s face started appearing on her
back and chest.

Her eyes became extremely bloodshot,

and her body was aching.

The next day, when her mother

attempted to remove one of McBride’s earrings, all of
the skin on her ear peeled off.

Her mother immediately

took her back to the emergency room for the third time
in as many days.
Paladugu, who had been the covering physician for
one

weekend

during

her

previous

stay,

attended

to

McBride on that day and realized what was occurring.

14

He ordered her to stop taking Lamictal and told her
that she had SJS caused by Lamictal.

In the medical

record, Paladugu diagnosed her with SJS and stated:
“Her

symptoms

are

most

likely

due

to

Lamictal.

Stevens-Johnson syndrome is one of the side effects of
Lamictal.”

Medical Records (doc. no. 131-1) at 68.

McBride was then transferred to the intensive-care
unit at the medical center. For the next four days,
rashes covered 99 % of her body, and over 30 % of the
top layer of her skin peeled off.
that she could die from the condition.

Doctors told her
On July 16, she

was transferred to the University of Alabama-Birmingham
hospital, which has additional expertise in the area.
Her

diagnosis

upon

transfer

received treatment for

was

SJS

and

TEN.

She

nine days and was eventually

released.

15

III. DISCUSSION
There are several distinct sets of claims in this
case.

The

court

will

first

address

the

state-law

claims of medical malpractice against the Health Care
Authority and the doctors and then move to the federal
constitutional

claims

and

the

state-law

negligence

claims against the City of Dothan and the correctional
officers.

A. Alabama Medical Liability Act
To

prevail

on

her

medical-malpractice

claim,

McBride must prove by substantial evidence that the
health care provider “failed to exercise ... reasonable
care”

and

that

“such

injury ... in question.”
6-5-549.

failure

probably

caused

the

1975 Ala. Code §§ 6-5-548,

Substantial evidence means that the evidence

“would convince an unprejudiced thinking mind of the
truth of the fact to which the evidence is directed.”
1975

Ala.

Code

§ 6-5-542(5).

16

The

court

will

first

address

two

overarching

objections

to

expert

Paladugu’s,

and

the

issues:

several

reports

Houston

and

County

defendants’

Karumanchi’s,

Medical

Center’s

(healthcare defendants) general challenge to McBride’s
argument that a 50mg starting dosage of Lamictal can
cause SJS and TEN in general and did so in her case.
It will then address whether a reasonable factfinder
could find that each individual defendant breached the
duty of care, and, if so, that that violation caused
McBride’s condition.

1. Expert Reports6
Defendant

Karumanchi

contends

that

Dr.

Carla

Rodgers’s testimony should be disregarded, and all the

6.
The court addressed the methodology and
reliability of the expert opinions in its earlier
Daubert opinion. McBride v. Houston Cnty. Health Care
Auth., 2015 WL 3648995, at *10 (M.D. Ala. 2015)
(Thompson, J.) (denying defendant Karumanchi’s motion
to exclude).
This section concerns whether to
disregard the reports based on procedural issues.
17

healthcare defendants contend that Dr. Allan Nineberg’s
testimony should be disregarded.

The court disagrees.

Karumanchi first contends that Dr. Rodgers’s report
should be excluded because her affidavit is not based
on personal knowledge.

This argument fails because

expert reports do not have to be based on personal
knowledge.

See

Fed.

R.

Evid.

602,

703;

see

also

McKinney v. Kenan Transp., LLC, 2015 WL 1100736, at *1
(M.D.

Ala.

2015)

(Albritton,

J.)

(stating

that

expert-witness testimony does not have to be based on
personal knowledge);

Voter Verified, Inc. v. Premier

Election Solutions, Inc., 2010 WL 3123129, at *4 (M.D.
Fla. 2010) (Fawsett, J.) (same); Hamilton v. Silven,
Schmeits & Vaughan, 2013 WL 2318809, at *4 (D. Or.
2013) (Simon, J.) (same).
To the extent the personal-knowledge requirement in
Federal

Rule

of

Civil

Procedure

56(c)(4)

can

be

reconciled with Federal Rule of Evidence 602’s explicit
exemption

of

expert

testimony

18

from

the

personal-knowledge requirement, it has been interpreted
to mean that an “expert must have actually engaged in
an examination of the case and its issues but may,
unlike a fact witness, rely on posited facts or on
inadmissible

material

(such

as

scholarly

work

or

empirical data that is technically hearsay), if it is
the type of material on which such experts reasonably
regularly rely.”

11-56 Moore's Federal Practice-Civil

§ 56.94; see also NAACP-Montgomery Metro Branch v. City
of Montgomery, 188 F.R.D. 408, 413 (M.D. Ala. 1999)
(DeMent,

J.)

personal-knowledge

(finding
requirement

that

expert

because

she

set

met
forth

the facts underlying her opinion); Pauls v. Green, 816
F. Supp. 2d 961, 978 (D. Idaho 2011) (Winmill, J.)
(“Experts

may

satisfy

the

personal-knowledge

requirement if they provide affidavits containing an
opinion formed within their area of expertise and based
on their own assessment or analysis of the underlying
facts or data.”).

19

Here, Rodgers clearly identified the documents on
which she relied in the first part of her report, and
there is no indication she did not personally examine
these

documents.

Therefore,

personal-knowledge

requirement

even

if

applies,

the

Rodgers’s

report meets it.
Karumanchi
declaration
hearsay.

is

next

objects

unsworn

These

and

arguments

that

Dr.

constitutes
are

Rodgers’s

inadmissible

meritless.

Rodgers

signed and dated her report under penalty of perjury,
which substitutes for a sworn affidavit.
§ 1746.
[the]

See 28 U.S.C.

Additionally, her report can be “reduced to

admissible

form”

of

her

testimony

at

trial.

Pritchard v. S. Co. Servs., 92 F.3d 1130, 1135 (11th
Cir. 1996) amended on reh’g in part on other grounds,
102

F.3d

1118

(11th

Cir.

1996).

If

Karumanchi

is

arguing that the report is hearsay because it relies on
data or interviews from other studies, that argument is
foreclosed

by

Federal

Rule

20

of

Evidence

703

and

is

likewise meritless.

See Fed. R. Evid. 703 (“If experts

in the particular field would reasonably rely on those
kinds of facts or data in forming an opinion on the
subject, they need not be admissible for the opinion to
be admitted.”).
As for Dr. Nineberg, the healthcare defendants move
to

disregard

as

untimely

and

prejudicial

his

third

expert report, which was filed as part of McBride’s
opposition

to

summary

judgment.

See

Declaration (doc. no. 203-14) at 2.
three

reports

in

this

case.

Nineberg

Nineberg has filed

The

magistrate

judge

warned that the first report, filed in May 2014, was
deficient under Rule 26 and mandated that he update the
report.
Auth.,
(Moorer,

See
2014

McBride
WL

M.J.).

v.

Houston

4373187,

at

Soon

after,

*10

Cnty.

in

early

Supplemental Report (doc. no. 210-2).

21

Care

Ala.

(M.D.

Nineberg filed an supplemental report.

followed in late September.

Health

2014)

September,

See Nineberg
His deposition

McBride then submitted his

third

report,

in

opposition brief.
210-3).

December,

as

an

exhibit

to

her

See Nineberg Third Report (doc. no.

This new report contained descriptions of a

number of journal articles that show a purported link
between increased dosage of Lamictal and SJS and TEN,
as

well

as

routinely

the

additional

prescribed

statement

Lamictal

to

that

patients

Nineberg
in

his

practice.
Under Federal Rule of Civil Procedure 26(a)(2)(B),
an expert’s written report must contain “a complete
statement of all opinions the witness will express and
the basis and reasons for them,” “the facts or data
considered by the witness in forming them,” and the
“witness’s qualifications,” among other

requirements.

The court can impose sanctions for failure to comply
with this rule, “unless the failure was substantially
justified or harmless.”

Fed. R. Civ. P. 37(c)(1).

An

untimely report is harmless “when there is no prejudice
to

the

party

entitled

to

22

receive

the

disclosure.”

Hewitt v. Liberty Mut. Grp., Inc., 268 F.R.D. 681, 683
(M.D. Fla. 2010) (Baker, J.).

The party that fails to

comply with the requirements bears the burden of proof
to show the late disclosure was justified or harmless.
Id.
Here,

regardless

untimely,

it

was

of

whether

harmless.

the

Nineberg

report
expressed

was
a

consistent opinion over his second and third reports
that

an

excessive

starting

dosage

of

Lamictal

can

increase the risk of SJS and TEN, and he referenced the
title of every article cited in the third report at his
deposition.

He later supplied a copy of these articles

to the defendants, save one, over which there seems to
be confusion.

At this point, the court declines to

disregard any of the articles.

The doctors and the

Health Care Authority had the title of each article
from the deposition and copies of all but one, and they
cross-examined Nineberg about each in the deposition.
The articles used in this case should not have come as

23

a surprise.

Regarding the one article not yet supplied

to the healthcare defendants, the court gives McBride
the

benefit

of

the

doubt

that

there

is

genuine

confusion and that she is not intentionally withholding
it from defense counsel.7
As to Dr. Nineberg’s addition in the third report
that

he

prescribed

Lamictal

in

his

practice,

harmless, even assuming it was untimely.
second

report

made

clear

that

he

is

it

is

Nineberg’s
a

practicing

psychiatrist and included descriptions of Lamictal and
its potential side effects as well as his opinions on
whether the doctors’ prescription of Lamictal breached
the

standard

of

care

because

it

increased risk of a serious rash.

could

create

an

This report put the

doctors and the Health Care Authority on notice that
Nineberg

would

be

speaking

to

a

psychiatrist’s

7.
Should the article not be turned over to
defense counsel or should this become a pattern, the
court will welcome additional requests to disregard the
evidence.
24

considerations

when

prescribing

Lamictal.

In

other

words, the report provided sufficient information for
any defendant

to ask Nineberg about his familiarity

with Lamictal either from his own practice or reading
the literature.

2. General and Specific Causation: Lamictal and SJS
Each of the three healthcare defendants argues that
there is no scientific proof that Lamictal causes SJS
and TEN in general or caused these diseases in this
particular

case.

McBride,

however,

has

presented

enough expert testimony to create a genuine dispute of
material fact.
The healthcare defendants first argue that Lamictal
is only one of several possible causes of McBride’s SJS
and TEN rather than the probable cause.

See Lyons v.

Vaughan Reg'l Med. Ctr., LLC, 23 So. 3d 23, 28 (Ala.
2009) (“To present a jury question, the plaintiff [in a
medical-malpractice action] must adduce some evidence

25

indicating
caused

that

the

the

alleged

injury.

insufficient.”)

negligence

A

mere

(emphasis

quotation marks omitted).

in

...

probably

possibility

original)

is

(internal

In particular, they point to

the drug Flagyl, an infection or virus, or idiopathic
causes

as

healthcare

possible
defendants’

alternatives.
expert

echoed

Although
this

the

sentiment,

McBride’s experts gave clear testimony that Lamictal
probably

caused

confronted
Nineberg

with

and

her
other

Auerbach

SJS

and

TEN.

possible
did

not

Indeed,

causes,

when

both

hesitate

but

stated that Lamictal was the probable cause.

Drs.
rather

Although

they could not completely rule out another cause, just
as they could not completely rule out the sun would not
rise tomorrow, they did state that Lamictal probably
caused
standard

McBride’s

injury.

requires.

That

The

is

all

disagreement

the

between

legal
the

experts establishes a genuine dispute of material fact
on this issue.

26

The healthcare defendants next contend that there
is no scientific study showing that a higher initial
dosage of Lamictal causes SJS or TEN.

The court’s

earlier Daubert opinion covers this issue at length, so
it will not be covered in full here.

See McBride v.

Houston Cnty. Health Care Auth., 2015 WL 3648995.

The

basic two points are that (i) double-blind scientific
testing on humans is not required where such testing
would be unethical and (ii) McBride’s two experts and
numerous articles linking her higher initial dosages of
Lamictal to SJS and TEN, in lieu of such a study, is
enough to raise a genuine dispute of material fact as
to

whether

the

higher

starting

dosage

of

Lamictal

probably caused her SJS and TEN.
In

sum,

healthcare
issue.

with

their

defendants

argument

obfuscate

a

on

causation,

relatively

the

simple

McBride took a dosage of Lamictal that several

experts and several studies say causes SJS and TEN.
Although another drug or another environmental factor

27

might cause SJS or TEN in the absence of this high
starting
here.

dosage,

it

is

the

most

likely

explanation

The main question for the jury will be whether

one or more of the healthcare defendants’ negligence
caused McBride’s disease or whether it was a tragic
situation
efforts.

in

spite

of

the

these

defendants’

best

The court now turns to that question.

3. Evaluation of Each Healthcare Defendant
Each healthcare defendant argues that he, or it,
did not violate the standard of care, and, even if he,
or

it,

did,

those

actions

did

not

probably

cause

McBride to develop SJS and TEN.

a.

Defendant Karumanchi

McBride argues that defendant Karumanchi violated
the standard of care by (i) failing to obtain informed
consent to administer Lamictal at all and to administer
it at a higher than recommended dosage; (ii) failing to

28

warn

McBride

about

the

risks

of

Lamictal;

(iii)

prescribing medications at too high a dose and/or too
frequently; (iv) failing to give instructions to the
jail on how to care for her; (v) failing to obtain a
complete

history

of

McBride’s

previous

medical

treatment and medications; and (vi) discharging her to
the

jail

even

though

it

was

known

the

jail

was

inadequately staffed and trained to care for McBride.
Karumanchi objects to each theory, arguing that he did
not violate the standard of care and that any alleged
violation did not cause McBride’s medical condition.
The court finds that there is a genuine dispute of
material fact as to the first four theories (failure to
obtain informed consent; failure to warn; administering
too

high

a

instruction)

dosage;
but

and

grants

failing

to

give

summary

judgment

the
in

jail
favor

defendant Karumanchi as to the last two theories.

It

will first discuss McBride’s theories on how Karumanchi

29

breached

the

standard

of

care

and

then

turn

to

causation.

i.

Informed Consent8

As a threshold, this case raises the question of
the difference between informed consent and failure to
warn.

The court interprets the informed-consent theory

as whether McBride would have taken Lamictal in the
first place if she knew the risks and interprets the
failure-to-warn theory as whether McBride would have
stopped taking Lamictal once she started to see a rash
or

feel

certain

side

effects

had

she

received

an

adequate warning.
As
that

to

there

informed
is

no

consent,
genuine

8.

Karumanchi

dispute

of

first

argues

material

fact

As McBride points out in supplemental briefing,
the
Alabama
Supreme
Court
has
considered
informed-consent claims in the context of prescribing
medication.
See Nolen v. Peterson, 544 So. 2d 863
(1989) (holding that involuntary commitment to a mental
institution does not ipso facto bar a patient from
raising
an
informed-consent
claim
about
taking
potentially harmful antipsychotic medications).
30

regarding informed consent because the record indicates
that he informed McBride of the risks of Lamictal.
court

finds

whether

that

there

Karumanchi

is

a

genuine

obtained

dispute

informed

The

as

consent

to
to

prescribe Lamictal at a starting dosage of 50mg per
day; however, it rejects the claim regarding informed
consent

to

give

McBride

the

normal

25mg

dosage

of

Lamictal.
“To prove lack of informed consent, [McBride] will
need to establish [i] what disclosure of information is
required

by

the

standard

of

care

applicable

to

a

hospital, [ii] establish what she was in fact told, and
[iii]

prove

that

had

she

been

given

certain

inappropriately withheld information she would not have
submitted

to

the

medical

treatment

in

question.”

Houston Cnty. Health Care Auth. v. Williams, 961 So. 2d
795, 814 (Ala. 2006).
The

standard

of

care

required

Karumanchi

to

disclose to McBride the same risks as would any “other

31

reasonably competent physicians practicing in the same
general neighborhood and in the same general line of
practice.”

Fain v. Smith, 479 So. 2d 1150, 1152 (Ala.

1985) (internal quotation marks omitted).
does

not

dispute

that

he

should

Karumanchi

tell

patients

prescribed Lamictal of the risk of skin rash; indeed,
he maintains he did tell McBride.
to

argue

that

a

reasonable

However, he appears

doctor

would

not

have

informed McBride about the risk of a higher starting
dosage because there is no proven link between a higher
dosage and development of severe skin rashes.
McBride

produced

scientific

studies

that

Yet,
caution

doctors about starting at a higher-dosage level based
on the increased risk of skin rash.

Experts Nineberg

and Rodgers also stated in their reports, depositions,
and the Daubert hearing that Karumanchi’s failure to
inform

McBride

about

the

risks

breached the standard of care.

of

a

higher

dosage

Based on these sources,

there is a genuine dispute of material fact whether a

32

doctor should disclose to a patient the risk of taking
an initial dosage of Lamictal higher than 25mg once per
day.
The next element--what Karumanchi told McBride--is
disputed.

McBride

claims

that

Karumanchi

discussed

only the potential for weight gain and the need to
avoid suddenly quitting Lamictal based on the risk of
seizure.

Pointing to his medical notes, Karumanchi

responds that he told her of the risk of severe skin
rash.
the

Even though Karumanchi did make a notation in

medical

notes,

a

reasonable

juror

could

still

believe McBride’s testimony and find that Karumanchi
either lied in the medical record or included rashes in
the notation out of habit when prescribing Lamictal but
forgot to tell McBride.

Moreover, the medical notes do

not state whether Karumanchi told McBride about the
higher risk of skin rash from the 50mg starting dosage.
Finally,

while

there

is

a

genuine

dispute

of

material fact over whether McBride would have refused

33

to take the 50mg dosage had she been informed of the
risk of severe skin rash at this higher level, there is
no genuine dispute about whether she would have taken
Lamictal

at

all.

Alabama

has

adopted

an

objective

standard for this test: Would a reasonable patient in
McBride’s position have consented had she known the
material

information

the

doctor

failed

to

provide?

Fain, 479 So. 2d at 1153; see also Gregory Cusimano and
Michael Roberts, Alabama Tort Law § 17.04.
testimony

may

be

considered

conclusive of the issue.

but

A patient’s

cannot

alone

be

Fain, 479 So. 2d at 1154; see

also Alabama Tort Law § 17.04 (describing how Fain can
be

seen

as

testimony

allowing
is

a

hybrid

material

test

and

where

relevant

patient’s
but

not

dispositive).
McBride

has

not

presented

evidence

that

a

reasonable patient would not take the standard starting
dosage of Lamictal even if the patient had a warning
about the potential for severe, but rare, side effects.

34

McBride’s

experts,

Nineberg

and

Rodgers,

routinely

prescribe Lamictal, and neither testified to patients
refusing

treatment

at

the

normal

dosage.

Indeed,

numerous drugs have severe, but rare, side effects, and
yet

many

patients

routinely

take

them.

Although

McBride stated that she would never have taken the drug
at

even

the

normal

more, is not enough.

dosage,

that

statement,

without

On the other hand, a reasonable

patient likely would not take a higher starting dosage
of a drug if she knew that the higher dosage was linked
to a much higher incidence of a potentially deadly skin
disease.

This is especially true if the higher dosage

is not needed, as Drs. Nineberg and Rodgers contend.
In sum, there is a genuine dispute of material fact
whether Karumanchi violated the standard of care

by

failing to inform McBride of the dangers of a 50mg
starting dosage of Lamictal.

35

ii.
McBride

also

Failure to Warn

contends

that

defendant

Karumanchi

should be held liable for failing to warn her about the
potential severe skin rash from taking Lamictal at a
higher

dosage.

This

theory

resembles

the

informed-consent theory because both boil down to what
Karumanchi

told

McBride

before

medicine.9

Thus, for the reasons described above with

regards

to

the

genuine

dispute

informed-consent
of

material

he

prescribed

theory,

fact

there

regarding

the

is

a

whether

Karumanchi warned McBride about the potential risk of

9. However, as discussed above, the two theories
pose different questions regarding causation. Informed
consent asks whether McBride would have consented to
taking the medication in the first place whereas
failure to warn asks whether McBride would have stopped
taking the medication had she been warned of the
potential severe side effects of a 50mg-starting dosage
and been able to connect her symptoms to those effects.
These issues will be addressed in the causation section
below.
36

SJS

and

TEN

from

an

increased

starting

dosage

of

Lamictal.10

iii. Prescribing Medication at Too High a Dosage
As discussed above, there is a genuine dispute of
material

fact

as

to

whether

defendant

Karumanchi’s

decision to start Lamictal at 50mg a day breached the
standard of care.

Although Karumanchi contends that he

prescribed the 50mg starting dose because of McBride’s
diagnosed bulimia and her past use of Lamictal without
incident, both Drs. Nineberg and Rodgers reject

the

decision to increase the initial dosage based on these
conditions.

As such, this is a jury question.

10.
Dr. Rodgers also opined that defendant
Karumanchi breached the standard of care by giving an
inadequate warning to a patient known to have bipolar
disorder because he did not ensure she understood the
warning. Because there is a genuine dispute on whether
he warned her at all, the court need not address this
alternative ground for denying summary judgment.
37

iv.

Failure to Give Instructions to the Jail
on How to Care for McBride

McBride

also

argues

that

defendant

Karumanchi

breached the standard of care by failing to provide the
jail’s

transporting

officer

information

about

her

treatment and the warning that she should return to the
hospital if her condition deteriorated.

Dr. Rodgers,

one of McBride’s experts, notes that failure to pass on
this information would be a breach of the standard of
care.

Rodgers’s Report (doc. no. 173-4) at 4.

Karumanchi’s only response appears to be that he
warned

the

jail.

Because

the

transporting

officer

disputes this fact, McBride has established a genuine
dispute

of

material

fact

as

to

whether

Karumanchi

breached his duty of care by failing to inform the jail
of McBride’s condition.

38

v. Failure to Obtain McBride’s Medical History
Defendant Karumanchi next contends that McBride has
not presented any evidence that the failure to obtain
past medical history breaches the standard of care.
The court agrees for two reasons.

First, despite

Karumanchi moving for summary judgment on all grounds,
McBride did not address this theory in his opposition
briefing

and

therefore

has

abandoned

the

claim.

Resolution Trust Corp. v. Dunmar Corp., 43 F.3d 587,
599 (11th Cir. 1995).
does

not

point

out

Second, in any case, McBride

any

expert

testimony

on

how

a

reasonable doctor in Karumanchi’s position would obtain
a patient’s records.
necessary

in

a

“Expert testimony is generally

claim

under

the

Alabama

Medical

Liability Act, as the particular standard of care and
its breach must be identified by one with knowledge of
the area.”

Bozeman v. Orum, 199 F. Supp. 2d 1216, 1235

(M.D. Ala. 2002) (Thompson, J.) on reconsideration in
part sub nom. Bozeman ex rel. Estate of Haggard v.

39

Orum, 302 F. Supp. 2d 1310 (M.D. Ala. 2004) and aff’d,
422

F.3d

grounds

1265
by

(11th

Cir.

Kingsley

2005),

v.

abrogated

Hendrickson,

on

other

2015

WL

2473447, --- S. Ct. ----, at *4 (2015).
For these two reasons, summary judgment is granted in
favor of defendant Karumanchi on this theory.

vi. Discharging McBride to Jail Even Though
It Was Known to Be Inadequately Staffed
McBride’s final theory for defendant Karumanchi’s
malpractice

is

that

he

should

not

have

discharged

McBride to the local jail on July 4 when he knew it was
inadequately

staffed

to

care

for

McBride.

Summary

judgment will be granted in favor of Karumanchi on this
theory.
First,

McBride

again

testimony on this issue.
at

1235.

depositions

Neither
describe

fails

to

present

expert

See Bozeman, 199 F. Supp. 2d

the

expert

whether

and

reports
to

what

nor

the

degree

a

physician sending a patient to a jail should inquire
40

about

the

Karumanchi

staffing
did

of
meet

not

the

jail,

that

much

why

Second,

standard.

less

as

described below, McBride has not put forth sufficient
evidence to establish that the City of Dothan had an
informal custom, in violation of its official policy,
of failing to care for inmates at the jail.

Thus, even

if a physician had a duty to investigate the adequacy
of

staffing

before

releasing

an

inmate

to

a

jail,

McBride has failed to show that Karumanchi would have
identified a problem.

Accordingly, this claim fails.

vii. Causation
Defendant Karumanchi last argues that even if he
breached

the

standard

of

care

on

the

remaining

theories--prescribing high starting dosages, failing to
obtain informed consent, failing to warn, and failing
to provide instructions to the jail--none of these acts
probably caused McBride to develop SJS or TEN.

41

These four remaining theories can be thought of as
the root cause of the problem (prescribing the higher
dosage),
problem

and
was

subsequent
not

mistakes

prevented.

As

that

ensured

discussed

the

above,

evidence suggests that prescribing the higher dosage
probably caused SJS and TEN.

The evidence supports the

following conclusions: the alleged failure of informed
consent about the higher dosage compounded this root
cause because there is a genuine dispute as to whether
McBride would have taken the Lamictal at the 50mg level
to start with had she known the potential consequences;
Karumanchi’s

alleged

failure

to

warn

her

about

the

early onset symptoms of SJS and TEN, combined with his
warning her not to stop taking the medicine for fear of
seizures, likewise compounded the prescribing error by
causing McBride to continue taking the Lamictal when
she experienced the early onset symptoms in her jail
cell and preventing her from identifying the problem to
subsequent doctors; and the alleged failure to tell the

42

jail about McBride’s condition ensured the correctional
officers did not recognize McBride’s symptoms and take
her immediately to the doctor.11
McBride therefore has presented sufficient evidence
to create a genuine dispute regarding whether these
breaches probably caused her illness.

b.
McBride
malpractice

argues
when,

Defendant Paladugu
that
as

Defendant

the

covering

Paladugu

committed

psychiatrist,

he

11.
To the extent Karumanchi, or any defendant,
argues that another party’s negligence vitiates his
negligence, combined and concurring negligence applies
in the medical-malpractice context and precludes this
argument.
Breland ex rel. Breland v. Rich, 69 So. 3d
803, 827 (Ala. 2011).
This basic tort theory
recognizes that, “[i]f one is guilty of negligence
which concurs or combines with the negligence of
another and the two combine to produce injury or
damage, each negligent person is liable for the
resulting injury or damage, and the negligence of each
would be deemed the proximate cause of the injury.”
Marsh v. Green, 782 So. 2d 223, 227 (Ala. 2000)
(internal quotation marks omitted).
Put differently,
an actor earlier in the long chain of events in this
case cannot successfully assert there is no causation
by pointing to a later actor’s negligence.
43

failed to warn her about the possibility of a severe
skin rash from taking Lamictal.
he

did

not

causation

have

a

because

Paladugu’s warning.
sufficient

evidence

duty

to

McBride

Paladugu responds that
warn

did

and

not

there
hear

is
any

no
of

Because McBride does not present
to

establish

that

Paladugu’s

failure to warn her about the risk probably caused her
SJS and TEN, summary judgment will be granted in favor
of Paladugu.
The underlying breach for Paladugu, according to
McBride, is not that he failed to give a warning, but
rather that, once he started giving McBride a warning
about

Lamictal,

he

had

to

give

a

complete

one,

including a warning of getting a severe skin rash from
a high starting dosage.

McBride’s causation

theory

appears to be that she assumed the warning given by
Paladugu was the full warning, did not realize that
there were other potential side effects such as SJS or
TEN, and failed to recognize the symptoms of SJS and

44

TEN

when

she

started

experiencing

them.

Put

differently, she relied on Paladugu, and he led her
astray.
The problem with this theory is that McBride did
not hear any warning from Paladugu--that is, she never
relied on him to give her the full warning because she
never thought he was giving her a warning at all.

This

makes the situation as if Paladugu gave no warning at
all, which all parties agree would not have breached
the standard of care. In sum, there is no causation
because McBride never relied on Paladugu at all, and
her

only

theory

for

breach

was

reliance

on

an

inadequate warning.12

12. If Paladugu had a general duty to warn, as did
Karumanchi, the result here could be different. Simply
because a patient does not remember receiving a warning
does not mean that she would not have heard an adequate
warning about a severe side effect. Indeed, an average
patient may not remember the warning about a headache,
but would likely hone in on the possibility of a skin
rash that can cause skin to slough off and potential
death as side effects.
45

c.

Houston County Health Care Authority

McBride argues that defendant Houston County Health
Care Authority committed malpractice based on vicarious
liability for the actions of defendants Karumanchi and
Paladugu,
McBride

psychiatric
in

the

nurse

behavioral

Coppage,
medical

who

treated

unit,

and

the

emergency-room nurses who treated McBride starting on
July 10.

The Health Care Authority acknowledges that

it would be vicariously liable for the actions of these
doctors

and

theories.
below,

the

nurses,

but

disputes

liability

on

all

Karumanchi and Paladugu are covered above;
court

addresses

the

actions

of

the

behavioral-medical-unit and emergency-room nurses.

i. Behavioral-Medical-Unit Nurse
McBride
malpractice

claims
when

that

treating

nurse
McBride

Coppage
in

the

committed
behavioral

medical unit by (i) failing to obtain informed consent

46

to administer Lamictal at a higher than recommended
dose;

(ii)

effects

failing

of

to

warn

Lamictal;

McBride

(iii)

about

failing

the

to

side

document

McBride’s medication; (iv) failing to administer and
monitor

medication

properly;

(v)

administering

medications at too high a dose; and (vi) administering
medications too frequently.

The Health Care Authority

argues that Coppage did not breach the standard of care
on the first three theories and that any breach on the
latter

three

theories

did

condition.

The

court

judgment

the

Health

for

not

agrees
Care

cause

and

McBride’s

grants

Authority

as

summary
to

any

liability based on Coppage’s actions.
First,

the

Health

Care

Authority

contends

that

nurses do not have a duty to obtain informed consent or
to warn patients of the side effects of a drug the
doctor prescribed.
1034,

1039

(Ala.

In Wells v. Storey, 792 So. 2d
1999),

the

Alabama

Supreme

Court

explicitly “decline[d] to create an independent duty

47

that

requires

hospitals

and

nurses

informed consent from a patient.”
that,

even

procedure,

if
a

a

nurse

nurse

can

“does

The court reasoned

assist

not

to ... obtain

a

doctor

necessarily

with

have

a

the

requisite knowledge of a particular patient’s medical
history, diagnosis, or other circumstances which would
enable

the

[nurse]

to

fully

information to the patient.”
quotation marks omitted).
assumes

that

doctors

disclose

all

pertinent

Id. at 1038 (internal

In other words, Alabama law

have

knowledge

inform a patient that nurses lack.

or

training

to

While one could

disagree with the Alabama Supreme Court’s logic that
nurses do not have a duty to obtain informed consent,
it

is

the

Coppage,

law

that

therefore,

this
do

court

not

have

must
a

apply.
duty

to

Nurse
obtain

informed consent.
The same logic precludes a failure-to-warn theory.
Under this logic, even if a nurse gets a patient to
sign

a

form

with

warnings

48

about

a

medication,

the

doctor would presumably know more details about the
different

drug

options

associated with each.

for

a

patient

and

the

risks

Given that the Alabama Supreme

Court declined to create overlapping duties for nurses
and doctors in the informed-consent context in Wells,
it is unlikely that that court would find the same
overlapping duties in a failure-to-warn context.13
Second, McBride’s contention that Coppage failed to
document her medications cannot go forward either.

She

provides neither expert testimony nor any argument as
to how she can proceed on this theory.
As
failure

to
to

McBride’s

last

administer

the

three

theories

medication

about

the

properly,

too

frequently, or at too high a dose, McBride has failed
to

establish

that

these

actions

had

any

causal

13. McBride also argues that, even if Coppage had
no obligation to obtain informed consent, once she
decided to inform McBride of any potential side
effects, she had an obligation to tell her about the
rash as well. McBride has not cited, nor has the court
found, any case law carving out this exception for
nurses.
49

relationship with her illness.

Although the

Health

Care Authority and McBride agree there is a genuine
dispute of material fact on the breach of the standard
of care by giving McBride her first two doses of 25mg
Lamictal within two and a half hours rather than at
twelve-hour

intervals,

there

is

no

expert

testimony

that this caused McBride to develop SJS or TEN.

In the

Daubert hearing, Dr. Auerbach testified that these two
doses were like any other 50mg daily dosages--dangerous
because of the amount taken in one day.
prompting,
interval

however,

between

he

the

did

not

dosages

say

on

that

the

Even after
the

first

short

day

of

several weeks of taking Lamictal caused or contributed
to McBride’s SJS or TEN.

ii.
McBride

Emergency-Room Nurses

contends

that

the

emergency-room

nurses

breached the standard of care on July 10 and July 11 by
failing to take steps to prevent TEN; failing to review

50

records

from

McBride’s

prior

admissions;

failing

to

obtain an accurate and complete medical history; and
failing to timely and accurately chart medications that
McBride

had

been

administered

and

prescribed.

Health Care Authority rejects each theory.

The

While there

is a genuine dispute of material fact as to whether the
nurses

breached

the

standard

of

care

by

failing

to

chart McBride’s medications timely and accurately and
whether that breach caused McBride’s illness, summary
judgment will be granted in favor of Houston County
Health Care Authority on the rest of these theories.
McBride’s first theory--that the nurses failed to
take steps to prevent the development of TEN--appears
to

be

more

of

an

umbrella

characterization

than

a

separate theory of how the nurses breached the standard
of care.

Put differently, the other three theories

describe how the nurses’ breach of the standard of care
led to the end result of TEN.
rejects this umbrella theory.

51

The court therefore

Next, the Health Care Authority argues that failure
to

review

records

in

an

emergency-context

breach the standard of care.
examine

records

from

a

does

not

While the failure to

month

earlier

does

seem

concerning, McBride does not mention this theory in her
opposition brief, much less point to expert testimony
to

establish

the

standard

of

care.

McBride

has

therefore abandoned this theory, and summary judgment
will be granted in favor of the Health Care Authority.
See Resolution Trust Corp., 43 F.3d at 599.
McBride’s third theory is that the nurses breached
the standard of care by failing to ask about McBride’s
medication.

However,

as

the

Health

Care

Authority

contends, there is no factual dispute on this issue.
In her deposition, McBride testified that she does not
remember if the emergency-room nurses asked her about
her medication.
235:1-11;
other

See McBride Dep. (doc. no. 175-5) at

267:20-268:6.

hand,

testified

The

intake

that

they

52

nurses,
did

ask

on

the

about

medication.

See Hillary Lott Dep. (doc. no. 131-4) at

61:11-61:15;

Hunter

21:16-18.

Clark

Dep.

(doc.

inability

established
Moreover,

the
even

medication,

to

recall,

existence
if

McBride

the

of

nurses

testified

no. 175-5) at 235:9-11.
failure
heard

to

ask

from

McBride

a

has

factual

did
that

“everybody I’m taking Lamictal.”

nurses

131-6)

at

Given the nurses’ definitive answers and

McBride’s

the

no.

not
she

not

dispute.
ask

about

always

told

McBride Dep. (doc.

This moots any argument about

about
McBride

Lamictal
that

she

because,
was

if

the

prescribed

Lamictal, then the failure to ask about Lamictal could
not have caused her development of SJS and TEN.
There, is, however a genuine dispute of material
fact about what the nurses did with the information
that McBride was taking Lamictal--that is, whether they
breached

the

standard

of

care

by

failing

McBride’s medications in the medical charts.

to

put

Although

McBride does not present her own expert on this issue,

53

one of the emergency-room nurses for the medical center
testified that, if a patient were to tell a nurse about
her medication, the nurse would breach the standard of
care if she did not include that in the chart.

See

Nicole Fennell Dep. (doc. no. 175-4) at 56:17-57:19.
Here, the parties agree that the charts do not include
Lamictal, but there is a genuine dispute of material
fact whether the reason is that McBride never told the
nurses about her medication, as the nurses maintain, or
the nurses failed to chart it, as McBride contends.
Taking

the

McBride,

evidence

the

court

in

the

concludes

light
that

most

favorable

McBride

told

to
the

nurses about Lamictal and their failure to chart this
information constitutes a breach of the standard of
care.
The Health Care Authority argues that it should be
granted summary judgment because, even though one of
its nurses testified that failure to chart medications
would be a breach of the standard of care, this nurse

54

never

said

actually

that

any

breached

of

this

the

emergency-room

standard.

It

nurses

points

to

precedent requiring an expert to establish both the
standard of care and its breach.
Supp. 2d at 1235.

See Orum, 199 F.

The court rejects this argument.

Although a plaintiff in a medical-malpractice suit
generally

has

to

use

expert

testimony

to

establish

breach and causation, Alabama courts have acknowledged
exceptions where a plaintiff provides other assurances
that

her

theory

of

negligence

pulled out of thin air.

and

causation

is

not

Such assurances can include

common sense, such as when a foreign object is found in
a

patient’s

body

post-surgery,

or

where

an

authoritative textbook on the issue makes an expert
unnecessary.

Id.

While a lay jury would not know intuitively that it
is the standard of care to chart medications, it could
understand evidence of a breach--that is, a chart that
does not list the medication--without an expert. If, as

55

in this case, both parties agree that a certain action,
which is not technically complicated, would violate the
standard of care, and all that is left is a factual
question whether the nurses took this action, there is
no need for a separate expert to opine on the issue.
In

other

words,

the

jury

may

need

an

expert

to

establish the standard of care for charting medications
but does not need an expert to apply it in this case.
The

logic

behind

the

exception

treatises bolsters this reasoning.

for

medical

As noted above,

Alabama law allows an exception to expert testimony
where the plaintiff can identify an authoritative text
or treatise that establishes the proper procedure.

Of

course, the text or treatise does not comment on the
case at issue; instead, courts are willing to allow the
text or treatise in lieu of an expert on the standard
of care and then let the jury decide if this standard
was violated.

When the standard is comprehensible,

courts do not require a second expert on breach.

56

See,

e.g., Complete Family Care v. Sprinkle, 638 So. 2d 774,
776 (Ala. 1994) (establishing standard of care, and
holding that a doctor violated that standard, based on
instructions in a pregnancy kit and the defendant’s own
admission about what constitutes the standard of care).
Similarly, an emergency-room nurse who works for the
defendant medical center established the standard of
care in this case, and the jury can interpret whether
the nurses breached that standard of care without an
expert.
Finally, the Health Care Authority contends that
the actions of the emergency-room nurses did not cause
McBride’s
nurses
chart

condition

breached
that

the

McBride

to

deteriorate.

standard
was

of

taking

care

However,
by

these

failing

Lamictal,

and

to

that

failure could have easily led the doctors to miss the
potential diagnosis of SJS or TEN because the doctors
could

not

symptoms,

make

the

Lamictal,

correct
and

the

57

connections
resulting

among

SJS

or

her
TEN.

There

is

therefore

a

genuine

dispute

whether

this

failure to chart probably caused a delay in diagnosis
of McBride’s SJS and TEN.

B. Deliberate-Indifference Claim
Pursuant to 42 U.S.C. § 1983 and the Fourteenth
Amendment, McBride asserts that Correctional Officers
Johnson

and

violated

McCory

her

as

well

as

constitutional

the

City

rights

of

Dothan

by

being

deliberately indifferent to her serious medical needs
while in custody. See City of Revere v. Mass. Gen.
Hosp.,

463

U.S.

constitutional
detainees).
demonstrate

239,

right

to

244-45

(1983)

medical

care

(establishing
for

pretrial

To prevail on this claim, McBride must
“(1)

a

serious

medical

need;

(2)

the

defendant’s deliberate indifference to that need; and
(3)

causation

between

plaintiff’s injury.”

that

indifference

and

the

Youmans v. Gagnon, 626 F.3d 557,

563 (11th Cir. 2010).

58

McBride

sues

Correctional

Officers

Johnson

and

McCory in their individual capacities, as well as the
City of Dothan for its custom or policy of denying or
delaying

treatment

to

inmates

with

serious

medical

needs.

1. Individual Defendants: Qualified Immunity
Correctional Officers Johnson and McCory raise the
defense

of

qualified

them.

However,

immunity

for

the

to

the

reasons

claim

described

against
below,

McBride has established a genuine dispute of material
fact regarding their entitlement to qualified immunity.
The

doctrine

of

qualified

immunity

insulates

government agents from individual liability for money
damages for actions taken in good faith pursuant to
their discretionary authority.

Harlow v. Fitzgerald,

457 U.S. 800 (1982); Greason v. Kemp, 891 F.2d 829, 833
(11th

Cir.

1990).

The

test

for

qualified

immunity

turns primarily on the objective reasonableness of the

59

official’s

conduct

in

light

of

established

law:

“governmental officials ... generally are shielded from
liability for civil damages insofar as their conduct
does

not

violate

constitutional

rights

would have known.”
law

was

clearly

clearly

of

established
which

a

statutory

reasonable

person

Harlow, 457 U.S. at 818.
established,

the

immunity

or

If the
defense

fails, since “a reasonably competent public official
should know the law governing his conduct.”

Id.

On

the other hand, if the law was not clearly established
at the time of the challenged action, the defendant is
entitled to qualified immunity.

Id. at 807; Stewart v.

Baldwin County Bd. Of Educ., 908 F.2d 1499, 1503 (11th
Cir. 1990).
“To invoke qualified immunity, the official first
must establish that he was acting within the scope of
his discretionary authority” when the alleged violation
occurred.
Cir. 2009).

Case v. Eslinger, 555 F.3d 1317, 1325 (11th
This issue is not in dispute here.

60

Once

“the court concludes that the defendant was engaged in
a discretionary function, then the burden shifts to the
plaintiff to show that the defendant is not entitled to
qualified

immunity.”

Holloman

ex

rel.

Holloman

Harland, 370 F.3d 1252, 1264 (11th Cir. 2004).
plaintiff

must

...

show

that:

(1)

the

v.

“[T]he

defendant

violated a constitutional right, and (2) this right was
clearly

established

violation.”

at

the

time

of

the

alleged

Id.

a. Violation of Right
The correctional officers first contend that they
were not deliberately indifferent to McBride’s serious
medical needs while she was in jail.
“In
such

regard

basic

to

providing

necessities

as

pretrial
food,

detainees

living

space,

with
and

medical care the minimum standard allowed by the due
process

clause

is

the

same

as

that

allowed

eighth amendment for convicted persons.”

61

by

the

Wallace v.

Jackson, 667 F. Supp. 2d 1267, 1273 (M.D. Ala. 2009)
(Thompson, J.) (quoting Belcher v. City of Foley, Ala.,
30

F.3d

1390,

quotation

marks

1396

(11th

omitted).

Cir.
To

1994))

(internal

prevail

on

her

denial-of-medical-care claim, McBride must demonstrate
both that she had a “serious medical need” that, if
left unattended, posed “a substantial risk of serious
harm” and that “the response made by [the] officials to
that need was poor enough to constitute an unnecessary
and

wanton

accidental

infliction
inadequacy,

of

pain,

negligence

and
in

not

merely

diagnosis

or

treatment, or even medical malpractice actionable under
state law.”

Taylor v. Adams, 221 F.3d 1254, 1258 (11th

Cir. 2000) (internal quotation marks and alterations
omitted).
A “serious medical need is considered one that 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

62

for

a

doctor’s

attention.”

Farrow v. West, 320 F.3d 1235, 1243 (11th

Cir. 2003) (internal quotation marks omitted).

“When

prison guards ignore without explanation a prisoner’s
serious medical condition that is known or obvious to
them,

the

trier

indifference.”

of

fact

may

infer

deliberate

Bozeman, 422 F.3d at 1273 (11th Cir.

2005) (internal quotation marks omitted).
In

this

case,

McBride’s

psychiatrist,

defendant

Karumanchi, knew her condition and, taking the evidence
in the light most favorable to McBride on this claim,
told the jail officer that she should be brought back
to

the

another

hospital
way,

condition,

if

the

were

her

condition

physician

it

to

found

worsen,

worsened.
that

would

be

“Put

[McBride’s]
a

serious

medical need requiring treatment.”

Rykard v. City of

Dothan,

(M.D.

2011

WL

6813001,

at

*3

Ala.

2011)

(Thompson, J.) (finding a serious medical need because
the treating physician discharged the plaintiff “with
instructions

to

return

if

63

things

worsened”

and

the

plaintiff’s

condition

subsequently

McBride’s condition worsened.

worsened).

Here,

She could not eat, had

difficulty getting out of bed, and screamed for help
every day in jail.
took

her

to

the

After five days, jail staff finally
hospital.

When

she

arrived,

the

hospital staff noted that she had a 101.5 degree fever,
difficulty breathing, extremely dry and cracked lips
and mouth, and ashy skin.
The

next

question

is

whether

the

correctional

officers were deliberately indifferent to her serious
medical

need.

McBride

“can

prove

deliberate

indifference either by producing evidence demonstrating
that

necessary

medical

treatment

was

delayed

for

non-medical reasons or by showing that public officials
knowingly

interfered

course of treatment.”
omitted) (quoting

with

a

physician’s

prescribed

Id. (internal quotation marks

Bingham v. Thomas, 654 F.3d 1171,

1176 (11th Cir. 2001)).

64

Johnson

and

McCory

argue

that

they

were

not

personally aware of McBride’s serious medical need and
that, even if they had been, the jail took McBride to
doctor’s appointments whenever she requested.

As these

defendants point out, “imputed or collective knowledge
cannot serve as the basis for a claim of deliberate
indifference.

Each individual Defendant must be judged

separately and on the basis of what that person knows.”
Burnette
2008)

v.

Taylor,

(internal

evidence

in

however,

both

533

F.3d

citations

the

light

Johnson

1331

favorable

McCory

McBride’s screams in the jail.

(11th

Cir.

Taking

omitted).

most
and

1325,

the

to

would

McBride,

have

heard

Johnson saw McBride and

gave her Vaseline and water for her lips but did not
take her to the hospital even though she requested to
go.

McCory heard McBride screaming from her office and

therefore

was

deteriorated
assume

at

aware

but

this

that

McBride’s

did

nothing.

stage

that,

65

The
based

situation
court

on

the

must

had
also

City

of

Dothan’s policy that the jail supervisor should inform
staff about a doctor’s instructions, Johnson and McCory
knew that the doctor ordered McBride to return to the
hospital if her condition worsened.

In other words,

Johnson and McCory knew they had to return McBride to
the hospital in compliance with the doctor’s orders but
did not.

The evidence supports the conclusion that

this is deliberate indifference to a serious medical
need.14
This court’s previous decision in Rykard bolsters
this conclusion.

In Rykard, the plaintiff experienced

a hand injury while in the same city jail at issue in
this case, and she was eventually transported to the
14.
Even without the doctor’s instructions, the
court would find that McBride put forth substantial
evidence
that
the
officers
were
deliberately
indifferent to a serious medical need.
A layperson
would certainly recognize that a person who was
screaming for help for days, could not eat, had
difficulty getting out of bed, had a high fever, and
had difficulty breathing warrants medical attention,
and the officers failure to seek such medical attention
constitutes deliberate indifference.
See Farrow, 320
F.3d at 1246; Bozeman, 422 F.3d at 1273.
66

medical center for treatment.

2011 WL 6813001, at *1.

The medical center diagnosed her with a contusion and
“discharged her with instructions to return if things
worsened.”

Id.

Her hand worsened over the next few

days, and it swelled to the point where the Velcro on
the plaintiff’s splint would not fasten and blisters
soon

appeared.

Id.

*2.

condition,

deteriorating

at

the

In

response

plaintiff

to

called

this
the

guards every 30 minutes, but the guards refused to take
her to the hospital and instead gave her a cream for
her hand.

Id. at *2.

This court held that the jail’s

refusal to return Rykard to the hospital, as required
by

the

doctor’s

indifference.
Augusta

Ga.,

orders,

constituted

deliberate

Id. at *4; see also Young v. City of
59

F.3d

1160,

1171

(11th

Cir.

1995)

(noting that treatment in jail contrary to a doctor’s
orders could have made out a claim against individual
jailers,

but

granting

67

summary

judgment

on

municipal-liability

claim

due

to

lack

of

custom

or

policy).
This case bears a striking resemblance to Rykard.
Here, as in Rykard, the treating doctor told the jail
to return the patient to the hospital if her condition
deteriorated.

Here, as in Rykard, the patient pleaded

with the jail staff to return her to the hospital when
the condition in fact deteriorated--in this case, when
McBride could not eat and had difficulty getting up,
ashy skin, and a high fever.

And here, as in Rykard, a

member of the jail staff, Johnson, provided a makeshift
treatment--water
the

doctor’s

and

orders

Vaseline--rather
to

return

than

following

the

patient

in

the

to

the

hospital.15
Last,

taking

the

evidence

light

most

favorable to McBride, the court concludes that there is
a

genuine

dispute

of

material

fact

as

to

whether

Correctional Officers Johnson and McCory’s deliberate

15.

McCory did not even do that much.
68

indifference
injuries.
constitute

to

McBride’s

While

a

delay

deliberate

medical
in

needs

medical

indifference,

caused

her

treatment

can

“an

inmate

who

complains that delay in medical treatment rose to a
constitutional violation must place verifying medical
evidence in the record to establish the detrimental
effect

of

delay

in

medical

treatment

to

succeed.”

Lepper v. Nguyen, 368 Fed. App’x 35, 39-40 (11th Cir.
2010).
Johnson’s

The

question,

failure

to

then,

take

is:

McBride

Did
to

McCory
the

and

hospital

earlier than July 10 make her medical condition worse?
According to McBride’s expert, Dr. Auerbach, the answer
is yes.

In the Daubert hearing, he testified that,

assuming the hospital was not negligent, it could have
recognized McBride’s early symptoms of SJS and TEN,
made the proper diagnosis, and started adjusting her
treatment

if

the

jail

had

brought

her

in

earlier.

April 13 Daubert hearing (doc. no. 263) at 43:14-24.

69

Therefore,

McBride

has

established

a

genuine

dispute of material fact as to whether the correctional
officers violated her constitutional rights.

The court

next addresses whether there is clearly established law
that

Johnson

and

McCory’s

actions

violated

her

constitutional rights.16

b.
For

the

law

Clearly Established Law
to

be

clearly

established,

“[t]he

contours of the right must be sufficiently clear that a
16.
McBride also argues that Johnson and McCory
are liable in their individual capacities under a
theory
of
supervisory
liability.
“It
is
well
established in this circuit that supervisory officials
are not liable under § 1983 for the unconstitutional
acts of their subordinates unless the supervisor
personally participates in the alleged constitutional
violation or there is a causal connection between
actions of the supervising official and the alleged
constitutional deprivation.”
Doe v. Sch. Bd. of
Broward Cnty., Fla., 604 F.3d 1248, 1266 (11th Cir.
2010) (internal citations and quotation marks omitted).
The court has already found that Johnson and McCory
participated in the alleged violation by failing to
respond to what they knew was McBride’s serious medical
need.
Accordingly,
it
need
not
address
the
supervisory-liability theory at this time.
70

reasonable official would understand that what he is
doing violated that right.”

Lowe v. Aldridge, 958 F.2d

1565, 1570 (11th Cir. 1992).

“This is not to say that

an official action is protected by qualified immunity
unless the very action in question has previously been
held unlawful, but it is to say that in the light of
preexisting law, the unlawfulness must be apparent.”
Id.; see also Ashcroft v. al-Kidd, 131 S. Ct. 2074,
2083 (2011) (“We do not require a case directly on
point,

but

existing

precedent

must

have

placed

the

statutory or constitutional question beyond debate.”).
The Eleventh Circuit “recognize[s] three sources of law
that

would

put

a

government

official

on

notice

of

statutory or constitutional rights: specific statutory
or

constitutional

provisions;

principles

of

law

enunciated in relevant decisions; and factually similar
cases already decided by state and federal courts in

71

the relevant jurisdiction.”

Goebert v. Lee Cnty., 510

F.3d 1312, 1330 (11th Cir. 2007).17
As

a

threshold,

any

reasonable

official

would

understand that a constitutional violation may occur
when “officials knowingly interfere with a physician’s
prescribed course of treatment.”
1176.

Bingham, 654 F.3d at

Indeed, the Eleventh Circuit has noted that its

“earlier deliberate indifference decisions have stated
that when jailers are aware of serious medical needs
they may not ignore them or provide grossly inadequate
care”

and

that

“decisions

in

this

area

of

law

are

enough to make the right violated clearly established.”
Danley v. Allen, 540 F.3d 1298, 1313 (11th Cir. 2008),
overruled on other grounds by Ashcroft v. Iqbal, 556
U.S.

662

(2009).

The

Eleventh

Circuit

has

also

explicitly held that withholding medical care against a
doctor’s orders is deliberate indifference.

Bauer v.

17.
The facts underlying this case occurred in
2012. Therefore the court looks to caselaw before that
date.
72

Kramer, 424 Fed. App’x 917, 919 (11th Cir. 2011) (per
curiam) (citing Young v. City of Augusta, Ga., 59 F.3d
1160 (11th Cir. 1995) for the proposition that a jail
employee could have been held liable on a deliberate
indifference claim had she “ignored the doctor’s orders
and

...

not

administered

the

medication”

as

instructed); see also Rykard, 2011 WL 6813001, at *3-*4
(same).
As
McBride

explained

above,

screaming

and

Johnson

did

not

and

McCory

return

her

heard
to

the

hospital immediately when her condition deteriorated.
Such knowing interference with a doctor’s prescribed
course of treatment--to return her to the hospital--is
a

constitutional

violation

under

clearly

established

law.

Therefore, there is a genuine dispute of material

fact

regarding

whether

Johnson

and

McCory

should

receive qualified immunity.18

18. It is also clearly established that failing to
provide medical care to a prisoner with a serious
medical need, even without a doctor’s orders, is a
(continued...)
73

2.
The

City

of

City of Dothan

Dothan

moves

for

summary

judgment,

arguing that McBride has not created a genuine dispute
of material fact as to whether its provision of medical
care to inmates constituted an unconstitutional policy
or

custom.

judgment

The
in

court

favor

agrees
of

and

the

grants

city

on

summary
this

deliberate-indifference claim.
To

hold

a

municipality

liable

under

§ 1983,

a

plaintiff must show that the municipality had a policy
or

custom

of

unconstitutional

activity.

Monell

v.

Dep’t of Soc. Servs. Of City of New York, 436 U.S. 658
(1978).

A single incident is generally not enough to

support a policy or custom; instead, there either must
be an official policy that is unconstitutional or the
violation of that prisoner’s right.
See Danley, 540
F.3d at 1313; Bozeman v. Orum, 422 F.3d at 1273.
As
such, the officers would likewise not be entitled to
qualified immunity even if they did not receive the
doctor’s orders.
74

relevant practice must be so widespread “as to have the
force of law.”

Craig v. Floyd Cnty., Ga., 643 F.3d

1306, 1310 (11th Cir. 2011).
McBride maintains that the City of Dothan has three
customs that are unconstitutional: (i) the city does
not

provide

medical

for

adequate

personnel

in

funding

the

jail;

and

staffing

(ii)

the

of
city

inadequately trains jailers to recognize and respond to
medical

needs

or

prisoners;

and

(iii)

the

city

routinely fails to take prisoners to the medical center
when they need treatment.
The first two theories are easily rejected.
the

first

theory,

“it

is

difficult

to

As to

see

what

constitutional guarantees are violated” by the policy
of taking inmates to a hospital for medical treatment
rather than having on-site medical personnel.

City of

Canton,

(1989).

Thus,

Ohio

the

v.

bare

Harris,
argument

489
that

U.S.

378,

387

the

city

should

have

staffed or paid for medical personnel at the jail fails

75

as

a

matter

of

law.19

To

the

extent

that

McBride

contends that the city understaffed or underfunded the
jail in general, she provides no evidence for such a
contention or explanation of how such understaffing or
underfunding

caused

her

injury.

McBride’s

inadequate-training theory is likewise deficient.

She

does not provide any evidence of how the guards are
trained to recognize a serious medical need or how such
training is constitutionally unacceptable.
McBride’s final theory is that, even though the
city had an official policy of taking prisoners in the
city jail to the hospital for medical needs, it had a
custom of failing to do so.

To show a custom, McBride

first points to the affidavit of a prisoner, jailed in
June and July 2012, that states, “I have observed other
detainees of the City of Dothan Jail in clear need of
medical attention and who requested medical attention
19. Of course, if a plaintiff could show that the
policy led to unacceptably long delays in provision of
treatment, such as where a jail is hours from the
nearest hospital, that would be another story.
76

from

jailers

and

administrators,

administrators.

however,

ignored

Jail

these

staff

request

and
[sic]

for medical attention. ... This was common practice and
custom of the jail.”
172-5).

Aff. of Aquanda Critten (doc. no.

This affidavit fails to provide any details

about how many prisoners were not taken to the hospital
or the severity of the prisoners’ conditions.

“To have

any probative value, affidavits must be supported by
specific facts, not conclusory allegations.”

Cornelius

v. Home Comings Fin. Network, Inc., 293 Fed. App’x 723,
728

(11th

Cir.

2008)

(citing

Evers

v.

Gen.

Corp., 770 F.2d 984, 986 (11th Cir. 1985)).

Motors
While a

prisoner should not be expected to know the names of
all other prisoners or their diagnoses, McBride cannot
rely

on

bare

assertions,

such

as

those

in

this

affidavit, at summary judgment.
In addition to the affidavit, McBride also cites
four legal complaints about the Dothan City Jail over
the past eight years.

Two of these have nothing to do

77

with medical care.

Compl. of Terence Pouncey (doc. no.

172-7) at 3-4 (contending that McCory placed him in a
cell

where

danger);
172-8)

had

known

enemies,

of

Andrew

Keith

Compl.

at

because

he

he

3

(alleging
was

being

cruel

court-ordered payments).

him

in

Berkley

(doc.

unusual

and

jailed

putting

punishment

for

failing

to

no.

make

That leaves two cases with

facts from 2006 and 2008, in which the judges held on
summary judgment that there was a genuine dispute of
material

fact

regarding

whether

the

city

failed

to

provide adequate medical treatment to prisoners in the
local jail.

See Calhoun v. Banks, 2009 WL 1765261, at

*9 (M.D. Ala. 2009) (Fuller, J.) (adopting report and
recommendation) (finding that 2006 incident where jail
failed

to

treat

bleeding

head

injury

of

inmate

constituted deliberate indifference); Rykard, 2011 WL
6813001, at *3-*4 (finding deliberate indifference in
2008 incident in which a jail failed to treat bad hand
injury

in

violation

of

doctor’s

78

instructions,

but

granting summary judgment on municipal-liability claim
due to lack of custom or policy).
jail

staff

were

deliberately

Even assuming that
indifferent

to

a

prisoner’s serious medical need in 2006 and 2008, the
court cannot conclude that two events that were six and
four years before McBride’s respectively are enough to
establish a policy or custom of deliberate indifference
by the City of Dothan.

See Hawk v. Klaetsch, 522 Fed.

App’x 733, 735 (11th Cir. 2013) (holding that three
incidents over five years was not enough to establish
rampant abuse for supervisory liability); see also Ott
v. City of Mobile, 169 F. Supp. 2d 1301, 1311 (S.D.
Ala.

2001)

(Butler,

C.J.)

(four

meritorious

excessive-force cases over five years, including only
two in the previous four years, were not enough to show
custom or policy).

79

Because McBride has not shown a policy or custom of
deliberate indifference, her § 1983 claim against the
City of Dothan fails.20

20.
McBride also argues that the city jail’s
policy on filling prescriptions constitutes deliberate
indifference by the city.
The potential violation is
that the city refuses to fill needed prescriptions for
prisoners; however, the jail filled McBride’s Lamictal
prescription in this case, so there is no causal
connection between this theory and McBride’s injury.
See Bd. of Cnty. Comm'rs of Bryan Cnty., Okl. v. Brown,
520 U.S. 397, 404 (1997).
Though it does not bear on the analysis in this
case, the court notes that the policy on filling
prescription medication is disturbing.
According to
the jail administrator, Mamie McCory, the policy is to
fill prescriptions only for life-sustaining medication.
McCory Dep. (doc. no. 172-17) at 30:16-21.
That, of
course, begs the question: Who determines what is
life-sustaining?
According to McCory, the jail need
only
take
one
of
three
actions
to
make
this
determination: (i) looking in the “MVR” (which is not
defined in the deposition); (ii) calling the pharmacy;
or (iii) ‘Googling’ the medication. Id. at 59:10-23.
To repeat, it is the policy or custom of the city
that guards at the city jail, with no medical training,
can ‘Google’ medications to make the determination
whether they are life-sustaining. Indeed, that is what
McBride contends happened here. While the jail filled
McBride’s prescription, it is easy to imagine a
situation
in
which
a
prison
guard
without
the
appropriate expertise decides by a quick internet
(continued...)
80

C.

Negligence

The City of Dothan, McCory, and Johnson also move
to

dismiss

the

negligence

claim,

arguing

that

they

provided the proper treatment to McBride and that, even
if they had, it did not cause her injury.
To the extent that McBride contends that the city’s
and the correctional officers’ failure to give McBride
Lamictal at the right time or that their failure to
provide her other medications caused her injury, the
claim fails.

McBride does not point to any evidence

indicating that the city’s failure to fill other pills
besides
Lamictal

Lamictal
at

the

or

its

right

failure

time

to

caused

give
her

McBride

health

to

deteriorate.

search that an inmate does not need a prescribed
medication because it is not “life-sustaining,” and the
inmate dies or has a serious mental- or physical-health
episode as a result. Such a careless attitude towards
the lives of those under the government’s control is
deeply troubling.
81

However,

the

argument

that

the

city

and

its

correctional officers were negligent by failing to take
McBride to the hospital survives.

This claim mirrors

the deliberate-indifference claim discussed above.

As

discussed above, taking the evidence in the light most
favorable to McBride, jail staff, including Johnson and
McCory, did not follow the doctor’s orders and this
delay worsened her injury.

***
Summary

judgment

will

be

entered

in

favor

defendant Rajendra Paladugu in all respects.

of

As to the

remaining defendants, summary judgment will be entered
in

their

opinion.

favor
An

only

in

part

appropriate

as

set

judgment

forth

will

be

in

this

entered

accordingly.
DONE, this the 24th day of June, 2015.
/s/ Myron H. Thompson___
UNITED STATES DISTRICT JUDGE