Stanfill v. AEDEC International Inc et al

Filing 150

ORDER DENYING 54 Motion for Sanctions; DENYING 85 Motion for Partial Summary Judgment; and GRANTING 89 Motion for Summary Judgment. Ordered by Judge Marc Thomas Treadwell on 3/29/2012. (tlh)

IN THE UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF GEORGIA
MACON DIVISION

RAYMOND D. STANFILL,
Plaintiff,
v.
CULLEN TALTON, et al.,
Defendants.

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CIVIL ACTION NO. 5:10-CV-255(MTT)

ORDER
This case concerns the treatment of Robert Lewis Stanfill (“Stanfill”) by various
officers and medical personnel at the Houston County Detention Center (“HCDC”) on
July 2 and 3, 2008. Stanfill died while in HCDC custody on July 3, 2008. Plaintiff
Raymond Stanfill, Robert Stanfill’s father, brings this action individually and as the
administrator of his son’s estate, alleging that the Defendants violated his son’s rights
under the Eighth and Fourteenth Amendments. He also brings medical malpractice
claims under Georgia law against Defendant Southern Health Partners (“SHP”).1
This matter is before the Court on the Motion for Partial Summary Judgment of
Plaintiff Raymond Stanfill (Doc. 85) and the Motion for Summary Judgment of
Defendants Sheriff Cullen Talton, Major Charles Holt, Sergeant James Wheat,
Lieutenant David Carrick, Corporal Donald Lester, Officer Eddie Serrano, Corporal
Carol Oates, Deputy James Collins, and Lieutenant Michael Garrett (collectively
referred to as the “Houston County Defendants”) (Doc. 89). Also before the Court is the
1

Defendant AEDEC International, Inc., the manufacturer of the restraint chair involved in this
action, has been dismissed with prejudice. (Doc. 81).

Plaintiff’s Motion for Sanctions. (Doc. 54). For the reasons set forth below, the
Plaintiff’s Motion for Sanctions is denied, the Plaintiff’s Motion for Partial Summary
Judgment is denied, and the Defendants’ Motion for Summary Judgment is granted.
I. Factual Background
The relevant facts are taken from the Plaintiff’s Complaint (Doc. 1) and the
parties’ Statements of Material Facts and responses thereto (Docs. 126 &127).
Pursuant to Federal Rule of Civil Procedure 56(e) and Local Rule 56, all material facts
not specifically controverted by specific citation to the record are deemed admitted,
unless otherwise inappropriate.
A.

Parties/HCDC Chain of Command

Defendant Cullen Talton has served as the Sheriff of Houston County since
1973. As Sheriff, Talton sits at the top of the Houston County Sheriff’s Office chain of
command. Although Talton retains ultimate authority over the activities of the Sheriff’s
Office, he delegates authority over HCDC to Major Charles Holt and the officers
beneath Major Holt. (Doc. 127 ¶¶ 275-278). Holt has served as the primary
administrator of the Houston County Detention Center since 2000. In that capacity, he
is responsible for the overall supervision and operation of HCDC. Holt’s duties include
promulgating HCDC policies and procedures. During the events in question, neither
Talton nor Holt was present at HCDC, and neither interacted with Stanfill in the 24 hours
preceding his death.
In July 2008, Lieutenants David Carrick and Michael Garrett were shift
supervisors at HCDC. During their shifts, Carrick and Garrett had responsibility for the
overall operation of HCDC. Their duties included, but were not limited to, receiving and

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releasing inmates, surveillance of inmates, and supervision of other officers as they
interacted with inmates. Sergeant James Wheat was also a shift supervisor and had
been working as a jail officer for approximately 12 years. At the time of the incident,
Wheat was assigned to inmate housing, where he supervised the deputies and made
sure the housing units were properly operated. Corporal Donald Lester, Officer Eddie
Serrano, and Corporal Carol Oates were all detention officers with various
responsibilities. Deputy James Collins was a booking clerk rather than a detention
officer, and therefore had no law enforcement responsibilities and very limited
interaction with inmates. Collins’ duties were limited to entering data into the computer.
Defendant Southern Health Partners, Inc., is the independent contractor retained
to provide medical staff and treatment to inmates at HCDC. SHP provides HCDC with
licensed, qualified medical personnel and 24-hour access to basic medical care for
inmates. Ordinarily, inmates would provide SHP medical staff with prescription drug
information during the booking process, and it would then be SHP’s responsibility to
administer any medication. SHP has a mental health nurse on staff, and they also
coordinate mental health care with outside mental health providers. Mental health
services are only provided during the day shift, and, accordingly, mental health staff is
unavailable at night. HCDC officers are not tasked with supervision of medical
personnel, and, with very limited exceptions, are required to comply with all medical
directives of SHP staff regarding inmate medical care.
B.

The Incident

On June 30, 2008, Stanfill was arrested for burglary pursuant to a valid warrant
and booked into HCDC. (Doc. 127 ¶ 45). Stanfill had been incarcerated at HCDC on

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numerous prior occasions. (Doc. 127 ¶ 7). In addition to his criminal history, Stanfill
also had a history and reputation at HCDC of cutting his wrists and threatening suicide
and other self-harm. (Doc. 127 ¶ 8). Despite HCDC precautions, Stanfill was adept at
obtaining materials that could be used to cut himself or reopen old wounds, such as
buttons from his prison jumpsuit, pieces of broken light bulbs, and even his toenails.
(Doc. 127 ¶¶ 11-12, 30). Stanfill was also known to associate with other “cutter”
inmates in order to obtain cutting materials and to offer and receive “encouragement” for
his and their self-destructive acts. (Doc. 127 ¶¶ 13-16).
Stanfill treated HCDC staff with similar disregard. His “ordinary routine” was to
verbally abuse HCDC officers and medical personnel using profane language and
threats of physical harm to both himself and others. (Doc. 127 ¶ 33). When Stanfill had
to be restrained, he would spit on officers and become agitated, and on at least one
occasion, he attempted to throw blood on an officer. (Doc. 127 ¶¶ 34-36). Other times,
Stanfill would refuse to take his medication, and during one previous incarceration, he
falsely claimed he could not breathe. (Doc. 127 ¶¶ 37-39).
Because of his behavior, Stanfill was often placed on suicide watch pursuant to
HCDC policy requiring special precautions, such as preventative clothing and restraints,
for inmates with suicidal tendencies. (Doc. 127 ¶¶ 17-18). On one previous occasion,
Stanfill was restricted to a restraint bed for approximately 36 hours, with periodic
releases. (Doc. 127 ¶ 20). In addition to his ability to find ways to injure himself, Stanfill
was also adept at escaping from, or at least lessening the effect of, various restraints
and other protective devices used by HCDC. (Doc. 127 ¶¶ 23-27). Based on his prior

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incarcerations, most, but not all, HCDC officers and SHP medical personnel were
familiar with Stanfill’s tendencies. (Doc. 127 ¶ 52).
During the course of his booking on June 30, 2008, Stanfill was sent to speak
with the medical staff, but he refused to speak with Nurse Lily Green or the mental
health nurse. (Doc. 127 ¶¶ 46, 51). It is undisputed that neither Stanfill nor any
member of his family provided HCDC with any needed medication, nor is there any
evidence that Stanfill was prescribed any medication at or immediately preceding the
time of his June/July 2008 incarceration. (Doc. 127 ¶¶ 47-48, 50).2 Due to Stanfill’s
history of self-harm, at the time of his booking he was labeled a suicide risk and was
placed on suicide watch, which required officers to visually check Stanfill every 15
minutes. (Id. ¶¶ 54-55). These precautions lasted through the afternoon of July 2,
2008. (Doc. 127 ¶ 56).
On the afternoon of July 2, Stanfill was being housed in cell J-1, which the Court
notes for purposes that will become apparent, had a sink from which Stanfill could drink
freely. (Doc. 127 ¶ 57). At approximately 5:45 p.m., Sergeant James Wheat discovered
that Stanfill had placed a tourniquet around his arm and, with pieces of a metal button
from his prison jumpsuit, cut his arm. (Doc. 127 ¶ 59). For whatever reason, Stanfill
used the tourniquet to build up the blood and then released it, causing blood to spread
across the cell. (Doc. 127 ¶ 61). Medical staff was immediately alerted, and Stanfill
was taken to the medical area where his arm was bandaged and nurses assessed his
condition. (Doc. 127 ¶ 84). While in medical, Wheat discovered that Stanfill had
additional pieces of the metal button hidden in his mouth with which he presumably
2

There is evidence that during a prior incarceration in January/February 2008, Stanfill was
taking Wellbutrin and Seroquel, both medicines used to treat depression and other mental
disorders. (Kaplan Dep. at 123).
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intended to cut himself again. (Doc. 127 ¶ 85). Wheat was familiar with Stanfill from his
prior incarcerations, and was aware of one previous occasion in which Stanfill obtained
glass from another inmate and used the glass to cut his own arm. (Doc. 127 ¶ 79).
While Stanfill was washing the blood from his body in the shower, he allegedly told
Wheat that if given the opportunity, he would kill himself. (Doc. 127 ¶ 90). Despite
already being on suicide watch, Wheat concluded from this statement that Stanfill was a
serious suicide threat. However, because Wheat felt he was already taking the
necessary precautions to make sure Stanfill would not hurt himself further, Wheat did
not report the suicide threat to his superiors. (Doc. 127 ¶ 90). After his shower, Stanfill
was placed in a suicide smock, which is a “one-piece quilted material with Velcro
adjustments on the shoulders.”3 (Carrick Dep. at 93).
Lieutenant David Carrick was the night-shift supervisor on July 2 and 3, and in
that capacity had overall responsibility of HCDC from 6:00 p.m. on July 2 until 6:00 a.m.
on July 3. Due to Stanfill’s suicide threats and because he was known to reopen his old
wounds, Carrick ordered Wheat to place Stanfill in a restraint chair. (Doc. 127 ¶ 94).
This order was made sometime between 6:00 and 6:30 p.m. on the night of July 2.
When Stanfill was placed in the chair, he was in the medical area and in the presence of
a nurse, who apparently had no objections. (Carrick Dep. at 62). The chair Stanfill was
placed in was a “Prostraint Chair” manufactured by AEDEC International, Inc. (Doc.
127 ¶ 232). Although the record is unclear, Stanfill was secured to the chair using
several built-in straps: one strap crosses diagonally from above each shoulder across
the chest (forming an “X”) and buckles in near the waist, similar to a seat belt, and a
3

A suicide smock is made out of a heavy material that pretrial detainees cannot tear, ingest, or
use to choke themselves. As can be seen in the video, the smock does not pin Stanfill’s arms
to his side nor does it restrict leg movement in any way.
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third strap crosses over the lap. In addition, Stanfill’s wrists and ankles were placed in
Velcro straps and handcuffs and leg irons were applied for added security.4 (Wheat
Dep. 29-30). Another strap was placed around Stanfill’s shins. (Wheat Dep. at 109-10).
As a matter of practice, Wheat would always check to make sure the straps and cuffs
were not too tight, although he does not specifically remember doing so with Stanfill.
(Wheat Dep. at 69).
At the time in question, HCDC had no formal written policy governing when
restraint devices were to be used or how long an inmate should be restrained. (Doc.
127 ¶ 243). Instead, use of restraints was governed by informal “guidelines,” under
which officers were afforded discretion in deciding when and under what conditions
restraints should be utilized. (Doc. 127 ¶ 249). Most often, restraints were used when
inmates were combative or posed a risk of self-harm. (Doc. 127 ¶ 244). The general
practice was for inmates to be provided with water or toileting upon the inmate’s
request. (Doc. 127 ¶ 250). Aside from temporary releases, inmates would be released
from restraints when they were no longer at risk to attempt the behavior that caused
them to be placed in the restraints to begin with. (Doc. 127 ¶ 247). Necessarily, this
too required the exercise of some discretion.
After being secured in the chair, Stanfill was taken to cell J-14. J-14 is a nonpadded cell, with a glass-paneled door allowing those outside the cell to see in, and vice
versa, without having to physically enter the cell. Inside J-14, there is a sink, a toilet,
and a bed space. (Carrick Dep. at 41). Activity in J-14 is captured on a motionactivated camera and displayed on a monitor in the nearby intake area. Wheat and
4

According to Wheat, the handcuffs and leg irons were used because inmates have been
known to break free of the Velcro straps used to secure inmates’ hands and feet. (Wheat Dep.
at 64-65).
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Carrick concluded that because the intake area had multiple officers and because
everything would be caught on camera, Stanfill would be kept under close observation.
(Doc. 127 ¶ 100). Wheat ordered the detention officers on duty to check on Stanfill
every 15 minutes, and Corporal Donald Lester repeated this directive to the officers in
the intake area. (Doc. 127 ¶ 106).
To this point, the events of Stanfill’s incarceration are largely undisputed.
However, the events occurring after this time, from about 6:30 p.m. on July 2 until
approximately 6:30 a.m. on the morning of July 3, are almost entirely in dispute. The
reason for the factual dispute is that portions of the video recording from when Stanfill
was restrained in cell J-14 and from when he was later moved to cell J-15 are
unavailable. The subject of the missing video has been one of much disagreement
among the parties and one of concern and frustration for the Court.
After viewing those portions of the video that do remain, the Plaintiff filed a
Motion for Sanctions (Doc. 54) on June 20, 2011, alleging that the unavailable video
was the result of the Houston County Defendants’, Defendant Holt’s in particular, failure
to preserve the video.5 In short, the Plaintiff argues that Defendant Holt intentionally
destroyed the video or allowed the video to be destroyed because the evidence might
have portrayed events harmful to the Defendants’ case. As a sanction for the alleged
spoliation, the Plaintiff asks the Court to apply an adverse inference presumption when
ruling on the Motions for Summary Judgment and to infer that events the Defendants
claim occurred but that are not depicted on the existing video did not in fact occur. For
5

On September 9, 2011, the Court convened a hearing on the Plaintiff’s Motion for Sanctions.
(Doc. 75). At that hearing, counsel for the Plaintiff conceded that sanctions, if appropriate,
would apply only against the Houston County Defendants and not Southern Health Partners.
(Doc. 75 at 82-83).

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reasons discussed in more detail below, the Court finds that there was no spoliation of
evidence and that an adverse inference is not appropriate.6 Because the Plaintiff is not
entitled to an adverse inference, the Court will continue its factual analysis using the
materials available in the record, which include the existing video and the affidavits and
deposition testimony of the parties and additional witnesses. The Court will, of course,
still resolve all reasonable inferences in the Plaintiff’s favor.
While in J-14, Stanfill began trying to hit his head on both the back of the chair
and the sink. Wheat and Lester decided to place a foam helmet on Stanfill’s head to
prevent him from injuring himself. Because the chin strap was broken, the helmet was
secured to Stanfill’s head using medical tape. (Colston Dep. at 41).7 At approximately
8:40 p.m. on July 2, Stanfill was moved from J-14 to J-15, which is a padded cell with no
obstructions and, like J-14, has a glass-paneled door allowing those outside the cell to
see in without having to physically enter the cell. (Doc. 127 ¶ 120). During the move
from J-14 to J-15 and throughout the night, various officers heard Stanfill shouting, both
about his restraint in the chair and simply in conversation with other officers.8 (Oates
Dep. at 43-45). According to Nurse Colston, at approximately 10:00 p.m., she was
called by Sergeant Wheat to check on Stanfill. (Colston Dep. at 43). Although not
6

As will be discussed, even if the Court had found spoliation, the Plaintiff vastly overestimates
the scope of any adverse inference he would receive.
7

As an example of the Plaintiff’s misunderstanding of the adverse inference, the Plaintiff claims
that medical tape being used to secure the helmet “is not shown on the video and is subject to
the adverse inference,” yet he never explains what inference he wants drawn. (Doc. 127 ¶
110). Then, he later claims the helmet was taped to Stanfill’s head not for his protection, but
rather to punish him. Thus, on numerous occasions, the Plaintiff asserts the adverse inference,
but then later contradicts that assertion by using to his advantage the statement he claims is
“subject to the adverse inference.”
8

Deputy Collins remembered hearing Stanfill yell that he could not breathe and that he was
thirsty. (Collins Dep. at 13).
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shown on the video, Nurse Colston claims she checked Stanfill’s vital signs and
confirmed that the restraint straps and helmet did not impede Stanfill’s breathing.
(Colston Dep. at 95). Despite claiming that he could not breathe, Stanfill showed no
signs of abnormal breathing and was “alert, oriented, and cooperative.” (Colston Dep.
at 96). Nurse Colston did not document her medical findings from the 10:00 p.m. check.
From 10:00 p.m. until 12:00 a.m., officers performed their scheduled checks on
Stanfill, allegedly by looking into J-15 from outside the cell, four separate times. (Doc.
76-2). Although Wheat directed that checks be performed in 15-minute intervals,
occasionally over 45 minutes would pass between checks. (Doc. 76-2). Sometime
between 12:00 and 1:00 a.m. on July 3, Nurse Colston again checked on Stanfill by
looking in through the glass window. (Colston Dep. at 62). According to Colston, she
watched Stanfill for a few minutes, and he was sitting in the chair and seemed alert.
(Colston Dep. at 62).
At approximately 3:30 a.m., Wheat and Serrano responded to a call that Stanfill
claimed he had urinated and defecated on himself. Stanfill was removed from the
restraint chair, and Stanfill, the chair, and the cell were cleaned using a hose that
connects to a water faucet outside of J-15. According to Wheat, there was no evidence
that Stanfill had in fact used the bathroom as he had claimed. (Wheat Dep. at 80-81).
The actual “shower” is not shown on the video, but the subsequent cleaning of cell J-15
is. While the cell was being mopped, Stanfill can be seen lying naked on the floor of the
cell, stretching or moving his legs around. According to Wheat, Stanfill was out of the
chair for approximately 30 minutes. During this time, the foam helmet was still taped to
his head. (Stanfill Video 3 at 17:00-24:00). As can be seen on the video, Stanfill was

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then dressed in a clean suicide smock and placed back in the restraint chair by Wheat
and Serrano. Wheat then removed the helmet from Stanfill’s head and remained in the
cell for a few minutes while Stanfill drank water from a cup. (Stanfill Video 3 at 38:0042:00).
A few minutes later (at the 47:00 mark on Stanfill Video 3), Wheat re-entered the
cell with Nurse Colston. Wheat thought Stanfill’s speech may be slurred, and he
wanted Nurse Colston to determine if anything was medically wrong. (Doc. 127 ¶ 155).
Nurse Colston can be seen checking Stanfill’s blood pressure and pulse and, though
the video has no sound, apparently talking with Stanfill. Stanfill’s blood pressure was
120/60 and he had a pulse rate of 72, both within normal limits, and Colston detected no
slurred speech. (Colston Dep. at 59-60). In Nurse Colston’s presence, Wheat gave
Stanfill more water, which he drank with no difficulty. (Stanfill Video 3 at 50:00-51:35;
Colston Dep. at 59). Neither Wheat nor Serrano had any further interaction with Stanfill.
(Doc. 127 ¶ 170). Between 4:00 a.m. and 5:56 a.m., Stanfill was observed five separate
times by Officer Allysia Allen. (Doc. 76-2). At no point from 6:30 p.m. on July 2 when
Stanfill was first restrained up until the shift change at 6:00 a.m. on July 3 did any nurse
suggest to any of the Houston County Defendants that Stanfill be treated differently.
(Doc. 127 ¶ 167).
At approximately 6:00 a.m. on July 3, the night shift was relieved of duty and
Lieutenant Garrett came on duty as the day-shift supervisor. (Doc. 127 ¶ 182). Also
starting his shift was Detention Officer Chris Deaton, who is not a Defendant in this
action. Deaton observed Stanfill in J-15 at approximately 6:15 a.m. According to
Deaton, Stanfill appeared to be breathing, but his head was tilted forward and he looked

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as if he was sleeping. (Doc. 127 ¶ 184). At 6:30 a.m., Deaton again checked on Stanfill
and found him unresponsive in the chair.9 (Doc. 127 ¶ 185). After entering the cell,
Deaton nudged Stanfill with his foot and, when he did not respond, reached under
Stanfill’s chin and lifted his head. Stanfill’s head fell back down, and Deaton then
discovered that Stanfill was not breathing. (Doc. 127 ¶ 185). Deaton can be seen
calling out to Deputy James Collins, the booking clerk on duty and a trained first
responder (meaning he is trained in CPR and basic first aid). A moment later Collins
entered the cell and checked Stanfill’s carotid artery but did not detect a pulse. He then
checked Stanfill’s mouth for an obstruction but found nothing. While Stanfill lied
motionless in the chair, Collins and Deaton exited the cell, apparently waiting on a nurse
to arrive. One minute later, Nurse Sumler arrived with a defibrillator AED and a bagvalve mask, also known by the proprietary name Ambu bag. While Nurse Sumler
worked on Stanfill, Collins and another officer can be seen unfastening the restraint
chair straps, albeit slowly and unsuccessfully. During the first six minutes after finding
Stanfill unresponsive, he was never removed from the chair. Stanfill Video 1 ends just
as Nurse Sumler is applying the bag-valve mask to Stanfill. According to Collins, they
“bagged him” for several minutes but were unable to resuscitate. EMS arrived shortly
thereafter, but their efforts were also unsuccessful. Nurse Sumler concluded that
Stanfill was dead when she arrived. (Doc. 127 ¶ 192). Stanfill was pronounced dead at
6:39 a.m. on July 3, 2008. The medical examiner determined that Stanfill died of a
sudden cardiac dysrhythmia (a sudden heart attack), with dehydration and microcytic
anemia as contributing factors.
9

The discovery of Stanfill’s death and the initial resuscitation efforts were captured on camera
and appear on Stanfill Video 1.
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Major Holt was not at HCDC on July 2 or 3, and he had no direct involvement
with Stanfill during the events in question. Holt was first informed of Stanfill’s detention
and subsequent death on the morning of July 3. After learning of Stanfill’s death, Holt
contacted Sheriff Talton, who instructed Holt to follow the ordinary investigative
procedure. (Doc. 127 ¶ 281). Holt then alerted the Georgia Bureau of Investigation to
the incident, which arrived at HCDC shortly thereafter to begin its investigation.10 The
GBI ultimately determined that Stanfill’s death was not the result of any criminal action
or inaction.
II. Summary Judgment Standard
Summary judgment must be granted if the pleadings, the discovery and
disclosure materials on file, and any affidavits show that there is no genuine issue as to
any material facts and that the movant is entitled to judgment as a matter of law. Fed.
R. Civ. P. 56(c). “A factual dispute is genuine only if ‘a reasonable jury could return a
verdict for the nonmoving party.’” Info. Sys. & Networks Corp. v. City of Atlanta, 281
F.3d 1220, 1224 (11th Cir. 2002) (quoting United States v. Four Parcels of Real Prop.,
941 F.2d 1428, 1437 (11th Cir. 1991)). The district court must “view all evidence in the
light most favorable to the nonmoving party, and resolve all reasonable doubts about
the facts in its favor.” Id. The burden rests with the moving party to prove that no
genuine issue of material fact exists. Id.
If the moving party discharges this burden, the burden then shifts to the
nonmoving party to go beyond the pleadings and present specific evidence showing
that there is a genuine issue of material fact or that the moving party is not entitled to
10

The Court will discuss Major Holt’s actions involving the video recording system in more detail
below.
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judgment as a matter of law. Celotex v. Catrett, 477 U.S. 317, 323 (1986); Fed. R. Civ.
P. 56(e). This evidence must consist of more than mere conclusory allegations or legal
conclusions. See Avirgan v. Hull, 932 F.2d 1572, 1577 (11th Cir. 1991). Ultimately,
summary judgment must be entered when “the nonmoving party has failed to make a
sufficient showing on an essential element of [his] case with respect to which [he] has
the burden of proof.” Celotex, 477 U.S. at 323.
The standard of review for cross-motions for summary judgment does not differ
from the standard applied when only one party files a motion. Am. Bankers Ins. Group
v. United States, 408 F.3d 1328, 1331 (11th Cir. 2005). “Cross-motions for summary
judgment will not, in themselves, warrant the court in granting summary judgment
unless one of the parties is entitled to judgment as a matter of law on facts that are not
genuinely disputed.” United States v. Oakley, 744 F.2d 1553, 1555 (11th Cir. 1984).
The Court will consider each motion on its own merits, resolving all reasonable
inferences against the party whose motion is under consideration. Am. Bankers Ins.
Group, 408 F.3d at 1331.
III. Discussion
A.

Spoliation

As discussed above, the Plaintiff moved for sanctions alleging that the
unavailability of portions of video from when Stanfill was housed in J-14 and J-15 was
the result of the Houston County Defendants’, and Defendant Holt’s in particular, failure
to preserve the video. In short, the Plaintiff argues that Defendant Holt intentionally
destroyed the video or allowed the video to be destroyed because the evidence might
have portrayed events harmful to the Defendants’ case. As a sanction for the alleged

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spoliation, the Plaintiff has asked the Court to draw an adverse inference regarding the
missing video when ruling on the pending Motions for Summary Judgment.
Because the Plaintiff seeks spoliation sanctions against only the Houston County
Defendants, and because the Plaintiff’s claims against those Defendants are premised
on federal-question jurisdiction, federal law governs whether the imposition of sanctions
is appropriate.11
Spoliation is the “destruction or significant alteration of evidence, or the failure to
preserve property for another’s use in pending or reasonably foreseeable litigation.”
Graff v. Baja Marine Corp., 310 Fed. Appx. 298, 301 (11th Cir. 2009) (internal
quotations and citations omitted). Federal courts have broad discretion to impose
spoliation sanctions against litigants as part of their inherent power to manage their own
affairs.12 As the party seeking sanctions, the Plaintiff has the burden of proof. To meet
this burden, the Plaintiff must prove that the missing evidence existed at one time; that
the alleged spoliator had a duty to preserve the evidence; and that the evidence was
crucial to his case. In re Delta/AirTran Baggage Fee Antitrust Litig., 770 F. Supp. 2d
1299, 1305 (N.D. Ga. 2011). If it is found that evidence has in fact been spoliated, the

11

In Flury v. Daimler Chrysler Corp., 427 F.3d 939 (11th Cir. 2005), the Eleventh Circuit held
that federal law governs the imposition of sanctions in diversity-jurisdiction cases as well
because “spoliation sanctions constitute an evidentiary matter.” 427 F.3d at 944. The court,
however, relied on Georgia state spoliation law for “guidance” due to the lack of specific federal
precedent. Id.
12

The Defendants claim that Federal Rule of Civil Procedure 37 is dispositive of the spoliation
issue. Rule 37 provides another avenue for the imposition of spoliation sanctions. Under Rule
37(e), “a court may not impose sanctions … on a party for failing to provide electronically stored
information lost as a result of the routine, good-faith operation of an electronic information
system” absent extraordinary circumstances. However, the Plaintiff has not moved for
sanctions under Rule 37, and, in any event, the Plaintiff’s point is that the video was lost not as
a result of the “good-faith operation of an electronic information system,” but rather because of
Holt’s knowing failure to preserve the video before it was overwritten.

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Court must then decide whether sanctions are warranted and if so, what sanctions to
impose. In making this determination, the following five factors should be considered:
(1) whether the movant was prejudiced as a result of the destruction of evidence; (2)
whether the prejudice could be cured; (3) the practical importance of the evidence; (4)
whether the alleged spoliator acted in good or bad faith; and (5) the potential for abuse
if expert testimony about the evidence is not excluded. Flury, 427 F.3d at 945.
The degree or nature of bad faith necessary for the imposition of spoliation
sanctions is not entirely clear. The Eleventh Circuit has said that the “key to unlocking a
court’s inherent power [to sanction spoliation] requires a finding of bad faith.” Barnes v.
Dalton, 158 F.3d 1212, 1214 (11th Cir. 1998). Thus, even though other factors
supporting a finding of spoliation may be present, “an adverse inference is drawn from a
party’s failure to preserve evidence only when the absence of that evidence is
predicated on bad faith.” Bashir v. AMTRAK, 119 F.3d 929, 931 (11th Cir. 1997) (per
curiam). Yet in Flury, the Eleventh Circuit held that bad faith was only a factor to
consider, leading at least one district court to conclude that the Eleventh Circuit no
longer strictly requires proof of bad faith as an essential element of spoliation. See
Brown v. Chertoff, 563 F. Supp. 2d 1372, 1381 (S.D. Ga. 2008). Other district courts
have rejected this interpretation of Flury. See Managed Care Solutions, Inc. v. Essent
Healthcare, Inc., 736 F. Supp. 2d 1317, 1328 n.16 (S.D. Fla. 2010); Woodard v. WalMart Stores East LP, 801 F. Supp. 2d 1363, 1372 (M.D. Ga. 2011). While the degree of
bad faith necessary to impose sanctions may not be entirely clear, it is clear that simple
negligence is not enough but actual malice is not required. See, e.g., Mann v. Taser
Int’l, Inc., 588 F.3d 1291, 1310 (11th Cir. 2009) (noting that malice is not required for

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finding of bad faith); Bashir, 119 F.3d at 931 (holding that more than “mere negligence”
in losing or destroying evidence is required to sustain an inference of consciousness of
a weak case); Preferred Care Partners Holding Corp. v. Humana, Inc., 2009 WL 982460
at *7 (S.D. Fla. 2009) (finding even “grossly negligent” conduct insufficient to support
finding of bad faith).
As noted, the Eleventh Circuit in Flury looked to Georgia law for guidance in
defining the elements of spoliation and, in the process, arguably diminished the role of
bad faith in spoliation analysis. Subsequent to Flury, in AMLI Residential Props., Inc. v.
Ga. Power Co., 293 Ga. App. 358, 667 S.E. 2d 150 (2008), the Georgia Court of
Appeals held that spoliation sanctions may be appropriate even when the spoliator has
not acted in bad faith. Nevertheless, the court made clear that the relative culpability of
the parties is important. The court contrasted, on the one hand, “‘the accidental,
random, or unintended dissipation of evidence by persons having no interest in its
preservation,’” with, on the other hand, those cases in which “‘a party knowledgeable of
litigation strategy, tactics, and policies … acted unfairly to preclude the opportunity of an
adversary to be apprised of the existence of a defense to a plaintiff’s claims.’” AMLI,
293 Ga. App. at 363, 667 S.E. 2d at 155 (quoting N. Assurance Co. v. Ware, 145 F.R.D.
281, 284 (D. Me. 1993)). This would explain the Eleventh Circuit’s decision in Flury.
While the plaintiff in Flury may not have acted in bad faith when he destroyed the
automobile that was the subject of his products liability claim, he nevertheless unfairly
deprived the defendant of an opportunity to adequately defend its interests. See also
Graff, 310 Fed. Appx. at 301 (affirming the exclusion of the results of destructive testing

-17-

of critical evidence when the defendants were not present for the testing and, because
of its destruction, had no opportunity to perform their own tests).
As a practical matter, notice of the need to preserve the evidence is critical; it is
difficult to assign blame for the destruction of evidence when a party had no reason to
know the evidence needed to be preserved. Hence, it is common for lawyers to send
“spoliation letters” to potential adverse parties at the earliest possible moment. These
letters advise of the possibility of litigation and request the preservation of evidence.
Generally, it is difficult to argue good faith when evidence is destroyed after the receipt
of such clear notice.
The events surrounding the alleged spoliation are as follows. After Stanfill was
discovered unresponsive on the morning of July 3, 2008, Holt was contacted and
informed of Stanfill’s death. Holt then contacted Sheriff Talton, who instructed Holt to
follow the ordinary investigative procedure. (Doc. 127 ¶ 281). As part of the ordinary
investigative procedure, Holt alerted the Georgia Bureau of Investigation, and the GBI
arrived at HCDC at approximately 8:00 a.m. to begin its investigation.
At the September 9, 2011, sanctions hearing, Holt explained some details of the
HCDC recording system.13 The surveillance cameras in cells J-14 and J-15 are motion
activated. Both cameras feed into and are recorded onto a digital video recorder, or
DVR, which is located in the “central control” area. Major Holt then has the capability to
download from his personal computer in his office portions of the recordings that are
captured on the DVR, and then view and/or make copies of the downloaded videos.
The HCDC recording system automatically overwrites old video with new video. (Holt
Dep. at 30-31). Thus, any video not downloaded or otherwise preserved will be
13

A transcript of the spoliation hearing is located at Doc. 75.
-18-

overwritten and permanently lost within two to three months. (Holt Dep. at 111). HCDC
does not have in place any video retention policy requiring it to preserve certain
recordings for a specified period of time.
Once Holt arrived at HCDC on the morning of July 3, he went to his office and
began the process of downloading portions of the video of Stanfill from J-15 for the GBI
to use in its investigation. According to Holt, he had to choose a start and end point of
the video, and he did so, he claims, based on what he thought would be “relevant” to
the GBI’s investigation. (Doc. 75 at 44). The portions Holt claims he chose to download
were from approximately 8:00 or 10:00 p.m. on July 2 until Stanfill was found
unresponsive around 6:30 a.m. on July 3. After he downloaded certain portions of the
video to his personal computer, Holt reviewed the video with several GBI agents and
then copied two of the downloaded segments to a DVD, those identified as Stanfill
Video 1 and Stanfill Video 2, and provided the DVD to the GBI. A third segment of
video, identified as Stanfill Video 3, was not copied to DVD until later, and the GBI
finally picked up this DVD in December 2008. Stanfill Video 3 also contains several
technical abnormalities, such as split-screens and color irregularities. According to Holt,
the GBI never asked him for video recordings to begin with, nor did they ask for
additional video evidence other than what he gave them.14 The original video was lost
due to the system’s automatic overwriting function sometime in October 2008, a result
Holt admitted he knew would occur.
It is undisputed that there was no effort to preserve certain portions of the video
from when Stanfill was restrained. For example, Holt did not attempt to download video
from when Stanfill was in cell J-14 and the foam helmet was taped to his head—from
14

No party offered any testimony or evidence from the GBI with regard to the retention of video.
-19-

approximately 6:00 p.m. until 8:30 p.m.—or video after it was discovered Stanfill had
died at 6:30 a.m. the following morning. As noted above, Holt did not think these events
were relevant to the GBI’s investigation, as he “was concerned about the cause of
[Stanfill’s] death.” (Doc. 75 at 44). Also undisputed, and of particular concern to the
Court, is the fact that certain events the Defendants claim occurred during Stanfill’s
restraint are not depicted on the video that has been produced. Because the cameras
in J-14 and J-15 are motion-activated, it is understandable that there is not a continuous
12-hour recording of Stanfill from 6:30 p.m. until 6:30 a.m.15 However, Nurse Colston’s
alleged 10:00 p.m. medical check and Stanfill’s shower at 3:30 a.m. certainly produced
sufficient movement to activate the camera, yet these events do not appear on any of
the three segments of video. Holt did not offer an explanation for the shower not being
depicted. (Doc. 75 at 44). While the Plaintiff attributes the dearth of video to Holt’s
“cherry-picking” only the favorable portions of the video to provide to the GBI, there is
no direct evidence that Holt tampered with the evidence.
Here, although the Court recognizes the hardship and prejudice the Plaintiff
faces in not having potentially favorable video evidence to assist his case, there are
several issues that, when considered together, preclude the imposition of spoliation
sanctions in his favor. First, the Plaintiff has not established that the Houston County
Defendants had a duty to preserve any video, much less the additional video that was
not provided to the GBI and that was later overwritten. Generally speaking, a party has
a duty to preserve evidence only when litigation is pending or reasonably foreseeable.
Graff, 310 Fed. Appx. at 301. The Houston County Defendants claim they did not
reasonably anticipate civil litigation resulting from Stanfill’s death either at the time Holt
15

In total, there exists approximately one hour of video.
-20-

copied the video or any time before the video was overwritten in October 2008. Though
debatable, this argument has some merit. The Plaintiff did not file suit until June 30,
2010, almost two years after Stanfill’s unfortunate death, and the Defendants were not
served with process until July 7, 2010. Moreover, there is no evidence in the record that
the Plaintiff requested that the Defendants impose a litigation hold or provided the
Defendants any form of notice that litigation was imminent or even contemplated until
the lawsuit was actually filed. In other words, there was no spoliation letter. Though the
argument can be made that litigation is reasonably foreseeable any time an inmate dies
while in custody, that is clearly not always true, and the Court is unwilling to draw that
inference under the specific circumstances of this case. See Kraft Reinsurance Ir., Ltd.,
v. Pallets Acquisitions, LLC, 2011 WL 5386421 at *11 (N.D. Ga. 2011) (citing Georgia
state spoliation law for the proposition that, to be reasonably foreseeable, “litigation
must have been contemplated—mere awareness of potential liability is insufficient to
trigger a duty to preserve evidence”).
Second, even if there was a duty to preserve the video, the Plaintiff has not
established that that duty was owed to the Plaintiff. In In re Delta/Air Tran Baggage Fee
Antitrust Litig., the court rejected the plaintiffs’ “shifting duty” argument that a CID issued
to Delta by the DOJ to preserve and produce all relevant documents imposed upon
Delta a preservation duty that Delta owed not only to the DOJ but also to any potential
third party:
To be sure, upon receipt of the CID, Delta had a duty to the DOJ to
preserve and produce all relevant documents. However, the Court has
difficulty accepting the notion that at that time, as a matter of law Delta
immediately owed the same duty to Plaintiffs…. [W]hen Delta received
the CID, it cannot be said that Delta should have anticipated this lawsuit.
Consequently, Delta owed no preservation duty to Plaintiffs that it could
-21-

have breached. If Delta failed to comply with the CID, the DOJ—not
Plaintiffs—is the appropriate party to take action.
770 F. Supp. 2d at 1308 (emphasis in original).
Similarly, here, the Plaintiff claims the GBI investigation into Stanfill’s death
triggered a duty to preserve the video. The Court disagrees. Somewhat surprisingly,
there is no evidence that the GBI issued any type of litigation hold to Holt or anyone at
HCDC to preserve all potentially relevant evidence relating to Stanfill’s death. However,
like in In re Delta, even if Holt did have such a duty, that duty was likely owed only to the
GBI. The Plaintiff points to Holt’s admission that he was aware that the GBI
investigation could lead to a criminal prosecution as evidence that litigation was
reasonably foreseeable, but this alone does not establish that any duty was owed to the
Plaintiff. The mere investigation into Stanfill’s death, which apparently is routine
procedure following an in-custody death, does not necessarily mean that Holt should
have at that time anticipated litigation with the Plaintiff, nor does it mean that the Plaintiff
can take advantage of the duty to preserve evidence, if there was one, Holt owed to the
GBI.16 The Court is not aware of any decision by a court in this circuit adopting the
“shifting duty” argument urged by the Plaintiff, and on the facts here, this Court declines
the opportunity to be the first. See Point Blank Solutions, Inc. v. Toyobo Am., Inc., 2011
WL 1456029 at *24-26 (S.D. Fla. 2011) (rejecting the shifting duty theory as
“incompatible with the basic rule that a duty is owed to a specific party”).

16

In Swofford v. Eslinger, 671 F. Supp. 2d 1274 (M.D. Fla. 2009), the court stated in dicta that a
law enforcement investigation into an incident was relevant to whether the defendants had a
duty to preserve evidence. 671 F. Supp. 2d at 1278. However, in addition to the law
enforcement investigation, there was also a pending lawsuit, and the plaintiffs had issued
multiple requests to the defendants that all relevant evidence be preserved. Thus, while not
cited by either party, Swofford is distinguishable on these grounds.
-22-

Finally, even if the Houston County Defendants owed a preservation duty to the
Plaintiff, the Plaintiff has not met his burden of showing that Holt or any other Defendant
acted in bad faith. Even in the absence of a spoliation letter or other direct notice to
Holt to preserve the video, the evidence on this issue is not all in Holt’s favor. First, the
Court is not convinced that Major Holt is as naive as he portrayed himself to be at the
sanctions hearing. While the transcript of the hearing speaks for itself, as jail
administrator, the Court remains suspicious of Holt’s strained recollection of the events
leading up to and including Stanfill’s death, surely a memorable event, and of what
events are depicted on the remaining video. In addition, Holt’s claimed familiarity with
the HCDC recording system, which has been in place for almost ten years, is
elementary at best and, if true, is disconcerting. While the Court would not expect Holt
to be an expert on all the technical aspects of the recording system, as the jail
administrator, he should, and perhaps might, possess more than the novice
understanding he represented to the Court.
The Court is particularly concerned with Holt’s incriminating and cynical
testimony at the coroner’s inquest17 on October 15, 2009, when asked about the
absence of time and date stamps on the video:
JUROR: Well I would recommend that you get time stamps on that. They
even put time stamps on the 7-11 stores.
HOLT: That’s a great idea, but once again, I’m in the jail business and I
have a video system in house. It may not meet your standard or what you
think needs to be desired. I’d like to have that time too, but at that time,
that was the system I was working with, and if I ever get a bundle of

17

The Court is aware that coroner’s inquests are sometimes used, properly, to obtain
information in preparation for litigation. If the Plaintiff did that here, one would think there would
have been some indication to Holt that litigation was likely. However, the coroner’s inquest was
apparently initiated long after the video had been destroyed.
-23-

money, then we are going to make some changes that we are going to be
able deal with after. Then I’ll have the time.
JUROR: Well, I would think you need that just to prevent lawsuits. I
mean, it could be - HOLT: Well, I have got the video system and the way the law is practiced,
is if I don’t have video, then I don’t have a problem, but if I have got video,
I have got to use it. And I have got what I work with. And that’s what you
saw. And you are just going to have to trust me and about a dozen other
people who were there that evening that are here to testify that they can
give you the time line which you are inquiring about.
Unlike a convenience store, where the clerk may have been shot
and you are sitting there with a question of when did this happen, I have
got a multitude of people right outside the door that will raise their hand
and swear truthfully that they can tell you what time everything occurred
better than that video is going to show you. They can sit there and you
can question them and all of them will verify each other independently and
follow that same time line. So you feeling about the video would be a
good thing to have, but I have got something that I feel is probably better
than the video that supports and explains.
Doc. 79-4 at 7-8 (emphasis added).18 While Holt offered an explanation for his
statement that “the way the law is practiced, is if I don’t have video, then I don’t have a
problem, but if I have got video, I have got to use it,” the statement is certainly capable
of a less noble interpretation.
Also problematic to the Plaintiff’s request for spoliation sanctions is his failure to
clearly assert what adverse inference should be drawn from the missing video.
Although he asserts that certain factual elements of the case are “subject to the adverse
inference,” his summary judgment briefs do not clearly show how any adverse inference
should impact the Court’s summary judgment analysis. An adverse inference does not
amount to free reign to advance elaborate theories, unsupported by the available
evidence, of what the spoliated evidence may have shown. At most, the strongest
18

The juror’s question about the absence of time stamps on the remaining video is a good one,
particularly when a “still-shot” from the surveillance camera is time-stamped. Neither Holt nor
his lawyer was able to explain this to the satisfaction of the Court.
-24-

inference that could apply here would be that, if preserved, the video would not have
shown several activities the Houston County Defendants said occurred but that are not
depicted on the remaining video, e.g., the provision of water to Stanfill at 10:00 p.m. and
his removal from the chair and shower at 3:30 a.m. Thus, even applying an adverse
inference does not automatically get the Plaintiff by summary judgment.
Despite the Court’s significant concerns over the unavailable video, the Court is
nonetheless unable to conclude based on this very circumstantial evidence that Holt’s
conduct was sufficiently culpable to constitute spoliation of evidence. In the absence of
a spoliation letter from the Plaintiff or any other notice of the possibility of a claim by
Stanfill’s survivors, the only arguable relevance of the video at the time it was
overwritten was to assist the GBI in its criminal investigation. It is conceivable, and
perhaps even likely, that the scope of a GBI criminal investigation, and therefore what is
and is not helpful to such an investigation, is materially different than what would be
relevant or helpful in a civil case alleging various constitutional violations. Also
noteworthy is the GBI’s report from the day of Stanfill’s death that the medical examiner
had found no notable causes of death. (Doc. 77-4). Thus, notwithstanding the Court’s
skepticism regarding Holt’s coroner’s inquest testimony, his assertion that he was only
concerned with Stanfill’s cause of death and that he had no reason to anticipate future
litigation over the matter is worthy of some credence. Although Holt likely should have
ensured that the video was preserved in its entirety, his failure to do so suggests only
negligence, and mere negligence is insufficient to support spoliation sanctions in this
circuit. Bashir, 119 F.3d at 931. As noted, it is the Plaintiff’s burden to prove that he is

-25-

entitled to the extraordinary relief he seeks, and he has not carried his burden.
Accordingly, the Plaintiff’s Motion for Sanctions is denied.
B.

Official Capacity Claims and Eleventh Amendment Immunity

The Plaintiff asserts both official and individual capacity claims against each of
the Houston County Defendants. All of these Defendants contend that they are entitled
to Eleventh Amendment immunity for the section 1983 claims against them in their
official capacities. The Plaintiff did not address the issue of Eleventh Amendment
immunity in his response to the Defendants’ Motion.
Generally, absent a waiver by the State or valid congressional override, the
Eleventh Amendment bars suits against a State or one of its agencies, departments, or
officials when the State is the real party in interest or when monetary recovery would
essentially be paid from State funds. DeKalb Cnty. Sch. Dist. v. Schrenko, 109 F.3d
680, 688 (11th Cir. 1997). Under this principle, “a suit against a governmental officer in
his official capacity is the same as a suit against [the] entity of which [the] officer is an
agent.” McMillian v. Monroe Cnty., Ala., 520 U.S. 781, 785 n. 2 (1997) (internal
quotations and citation omitted) (alteration in original).
Under Georgia law, sheriffs are state officials for Eleventh Amendment purposes.
Manders v. Lee, 338 F.3d 1304, 1328 (11th Cir. 2003) (holding that the sheriff “in his
official capacity is an arm of the state, not [the] County, in establishing use-of-force
policy at the jail and in training and disciplining his deputies in that regard”). Thus,
Sheriff Talton is entitled to Eleventh Amendment immunity against official capacity
claims. Moreover, sheriff’s deputies, as employees of the sheriff, are entitled to the
same Eleventh Amendment immunity as the sheriff. Carr v. City of Florence, Ala., 916

-26-

F.2d 1521, 1527 (11th Cir. 1990). Accordingly, Defendants Holt, Wheat, Carrick,
Lester, Serrano, Oates, Collins, and Garrett are also entitled to Eleventh Amendment
immunity from claims brought against them in their official capacities.
C.

Individual Capacity Claims

The Plaintiff also brings claims under 42 U.S.C. § 1983 against the Houston
County Defendants in their individual capacities. Section 1983 provides that:
Every person who, under color of any statute, ordinance, regulation,
custom, or usage, of any State or Territory or the District of Columbia,
subjects, or causes to be subjected, any citizen of the United States or
other person within the jurisdiction thereof to the deprivation of any rights,
privileges, or immunities secured by the Constitution and laws, shall be
liable to the party injured in an action at law, suit in equity, or other proper
proceeding for redress.
42 U.S.C. § 1983. Section 1983 itself does not create any protected rights, but instead
provides a remedy for constitutional violations committed under color of state law. The
relevant inquiry under section 1983 then is whether a right secured by the Constitution
has been violated. Even if a constitutional violation has occurred, however, a defendant
may still be protected by qualified immunity. “Qualified immunity offers complete
protection for individual public officials performing discretionary functions ‘insofar as
their conduct does not violate clearly established statutory or constitutional rights of
which a reasonable person would have known.’” Sherrod v. Johnson, 667 F.3d 1359,
1363 (11th Cir. 2012) (quoting Harlow v. Fitzgerald, 457 U.S. 800, 818 (1982)). “The
purpose of this immunity is to allow government officials to carry out their discretionary
duties without the fear of personal liability or harassing litigation, protecting from suit all
but the plainly incompetent or one who is knowingly violating federal law.” Lee v.
Ferraro, 284 F.3d 1188, 1194 (11th Cir. 2002) (internal quotations and citation omitted).

-27-

A threshold determination in a qualified immunity analysis is whether the official
was acting within the scope of his discretionary authority when the alleged constitutional
violation occurred. Case v. Eslinger, 555 F.3d 1317, 1325 (11th Cir. 2009).19 If a
defendant establishes that he was performing a discretionary function, the burden shifts
to the plaintiff to demonstrate (1) that there was a violation of a constitutional right and
(2) that the constitutional right was clearly established at the time of the incident.
Saucier v. Katz, 533 U.S. 194, 201 (2001). The Supreme Court has stated that district
courts and courts of appeals have discretion in deciding which of these two prongs to
address first. Pearson v. Callahan, 555 U.S. 223, 236 (2009).20
Before addressing the substance of the Plaintiff’s claims and whether the
Defendants are entitled to qualified immunity, the Court must determine the appropriate
constitutional standard to apply. The Plaintiff’s Complaint and briefs invoke the
protections of both the Eighth and Fourteenth Amendments. Indeed, both the Eighth
and Fourteenth Amendments provide protection from the use of excessive force by
government officials. However, the Eighth Amendment applies only to individuals who
have been convicted of a criminal offense. Here, Stanfill was a pretrial detainee and
had not yet been convicted of any offense. The Eighth Amendment is therefore

19

Here, there is no dispute that the Houston County Defendants were acting within their
discretionary authority at the time of the incident.
20

The Supreme Court’s allowance of discretion in deciding which qualified immunity prong to
address first has no application in Fourteenth Amendment excessive force claims because the
qualified immunity analysis in excessive force claims involves only the first prong. Fennell v.
Gilstrap, 559 F.3d 1212, 1217 n. 6 (11th Cir. 2009). The reasoning for the abridged analysis is
that “the subjective element required to establish it is so extreme that every conceivable set of
circumstances in which [excessive force] occurs is clearly established to be a violation of the
Constitution….” Id. at 1217 (internal quotations and citation omitted).

-28-

inapplicable, and the Plaintiff’s claims will be analyzed under the Fourteenth
Amendment.
Under the Fourteenth Amendment, a pretrial detainee can state a claim (1) that
the defendants were deliberately indifferent to his serious medical needs, (2)
challenging the conditions of his confinement (which also involves a deliberate
indifference analysis), or (3) that the defendants used excessive force. It is not entirely
clear what types of claims the Plaintiff is asserting against the various Defendants.21
However, upon careful review of the Plaintiff’s Complaint and briefs, the Court construes
the Plaintiff’s Complaint as asserting the following claims: an excessive force claim
against Defendants Carrick and Wheat based on their initial placement of Stanfill in the
restraint chair (Doc. 1 ¶¶ 52-53); an excessive force claim based on the continued use
of the restraint chair (Doc. 1 ¶ 53); claims against Defendants Lester, Serrano, Oates,
Collins, and Garrett based on their alleged failure to intervene and remove Stanfill from
the restraint chair (Doc. 1 ¶¶ 55-58); claims against Defendants Carrick, Wheat, Lester,
Serrano, Oates, Collins, and Garrett for deliberate indifference to Stanfill’s serious
medical needs (Doc. 1 ¶ 54); and a claim against Defendants Talton and Holt based on
a theory of alleged failure to train and failure to institute appropriate policies and
procedures (Doc. 1 ¶¶ 46-47). Because the Defendants were acting within their

21

The Court is not obligated to “distill every potential argument that could be made based upon
the materials before it on summary judgment.” Resolution Trust Corp. v. Dunmar Corp., 43 F.3d
587, 599 (11th Cir. 1995). Moreover, grounds not raised in the Plaintiff’s Complaint or disclosed
during discovery but that are relied upon at summary judgment will not be considered. See
Hurlbert v. St. Mary’s Health Care Sys., Inc., 439 F.3d 1286, 1297 (11th Cir. 2006). Because
the Court “may not infer claims other than those that plainly appear on the face of the complaint
to defeat a defense of qualified immunity,” the Court relies primarily on the Plaintiff’s Complaint
to discern the factual basis of his claims. GJR Invs., Inc. v. Cnty. of Escambia, Fla., 132 F.3d
1359, 1367-69 (11th Cir. 1998).

-29-

discretionary authority at the time of the alleged constitutional violations, the Court’s
analysis begins with the first step in the qualified immunity analysis: whether there was
a constitutional violation. The Court will address each claim, or set of claims, in turn.
i.

Excessive Force Claims

The Plaintiff claims that Defendants Carrick and Wheat used excessive force in
their management of Stanfill during the night and early morning of July 2 and 3. “A
jailer’s use of force against a pretrial detainee is excessive under the Fourteenth
Amendment if it ‘shocks the conscience.’” Fennell v. Gilstrap, 559 F.3d 1212, 1217
(11th Cir. 2009) (citation omitted). “The use of force does not ‘shock the conscience’ if it
is applied ‘in a good-faith effort to maintain or restore discipline.’ However, if the force is
applied ‘maliciously and sadistically to cause harm,’ then it does ‘shock the conscience,’
and is excessive under the Eighth or Fourteenth Amendment.” Id. (quoting Hudson v.
McMillian, 503 U.S. 1, 7 (1992)).
In determining whether the force was applied maliciously and sadistically to
cause harm, courts are to consider a) the need for the application of force; b) the
relationship between the need and the amount of force that was used; c) the extent of
the injury inflicted upon the prisoner; d) the extent of the threat to the safety of staff and
inmates; and e) any efforts made to temper the severity of a forceful response. Whitley
v. Albers, 475 U.S. 312, 321 (1986); Hudson, 503 U.S. at 7. In making this
determination, courts are to “give a wide range of deference to prison officials acting to
preserve discipline and security.” Id. The determination “must not be made in the glow
of hindsight.” Griffin v. Troy State Univ., 128 Fed. Appx. 739, 742 (11th Cir. 2005)
(citation omitted). Instead, the relevant inquiry is whether the decision by the

-30-

government official was egregious, that is, conscience-shocking, at the time the official
made the decision. Id. “Unless it appears that the evidence, viewed in the light most
favorable to the plaintiff, will support a reliable inference of wantonness in the infliction
of pain … the case should not go to the jury.” Whitley, 475 U.S. at 322.
a.

Need for Application of Force

The Plaintiff argues that Carrick and Wheat’s restraint of Stanfill was
unnecessary because Stanfill posed no threat to the safety of other inmates or detention
officers. (Doc. 85-9 at 10). The Plaintiff claims the real reason Stanfill was placed in
the restraint chair was to “get him out of the way and try to keep him from being an
interruption to operations.” (Doc. 122-3 at 9). In making this argument, the Plaintiff fails
to appreciate that less than one hour before Stanfill was placed in the restraint chair, he
had tied a tourniquet around his arm, somehow removed a metal button from his prison
jumpsuit, cut his wrist or arm, and sprayed blood across his cell. Even discounting
Wheat’s claim that Stanfill expressly threatened suicide on July 2, given Carrick and
Wheat’s familiarity with Stanfill’s history of self-mutilation, coupled with his most recent
cutting incident on July 2, there was a need for the application of some force. Carrick
and Wheat’s decision to use force was not unreasonable under the circumstances. See
Campbell v. Sikes, 169 F.3d 1353, 1374-77 (11th Cir. 1999) (recognizing that use of “L”
shaped restraint and straightjacket was a permissible use of force on prisoner who had
taken affirmative acts towards harming herself and posed a serious threat of further selfharm).

-31-

b.

Relation Between Need and Amount of Force Used

The Plaintiff contends that the amount of force used—full restraints, including
handcuffs, leg irons, and the foam helmet—was disproportionate to the need. As the
Defendants point out, however, much of the Plaintiff’s argument rests on his claim that
other, less forceful measures could have been used to prevent any perceived risk of
harm. This argument is misplaced, as “courts must determine whether the evidence
goes beyond a mere dispute over the reasonableness of the particular use of force or
the existence of arguably superior alternatives.” Whitley, 475 U.S. at 322. As
discussed above, Carrick and Wheat reasonably perceived that Stanfill posed a serious
threat of injury to himself. During prior incarcerations, Stanfill had shown the ability to
escape from or lessen the effect of various restraints, and he had a tendency to reopen
old wounds. Moreover, inmates have been known to break free of the Velcro straps
used to secure their hands and feet, thus necessitating the use of handcuffs and leg
irons in addition to the straps built into the chair. Also, while in cell J-14, Stanfill had
attempted to bang his head, prompting Wheat to apply the foam helmet, which he
secured to Stanfill using medical tape. Based on these considerations, the force used
was not disproportionate to the need for force, and this factor weighs in favor of the
Defendants.
c.

Extent of Injury Inflicted

Although the “nature of the force rather than the extent of the injury” is the
relevant inquiry in Fourteenth Amendment excessive force cases, the extent of injury is
still a “factor that may suggest whether the use of force could plausibly have been
thought necessary in a particular situation.” Wilkins v. Gaddy, __ U.S. __, 130 S. Ct.

-32-

1175, 1176-78 (2010) (internal quotations and citation omitted). In most excessive force
cases, the extent of injury caused by the alleged excessive force is apparent. See
Skrtich v. Thornton, 280 F.3d 1295, 1302 (11th Cir. 2002) (prisoner suffered multiple rib
fractures, back injuries, lacerations to the scalp, and abdominal injuries as a result of
beating at the hands of prison officials). Here, the extent of injury inflicted by the
Defendants’ use of the restraint chair, the Plaintiff contends, is obvious. The Plaintiff
states in a conclusory fashion that the “extent of injury was death.” (Doc. 122-2 at 18).
To sustain such a theory, however, the Plaintiff must produce evidence that the alleged
constitutional violation he complains of caused Stanfill’s injuries. Hale v. Tallapoosa
Cnty., 50 F.3d 1579, 1584 (11th Cir. 1995).
The Plaintiff’s medical expert regarding cause of death is Dr. Melissa Sims. Dr.
Sims is the regional medical examiner for the Georgia Bureau of Investigation. She
performed an autopsy as part of the GBI’s routine procedure following an in-custody
death. After completing the autopsy, Dr. Sims concluded that Stanfill “died as a result of
a sudden cardiac dysrhythmia…. A history of microcytic anemia and dehydration [were]
contributory factors in th[e] death. As medical records document that the decedent’s
anemia was due to his repeated self-cutting, the manner of death in this case is best
classified as undetermined.”22 (Doc. 54-8 at 6). During her deposition, Dr. Sims stated
her opinion, expressed to a reasonable degree of medical certainty, that neither the fact
nor duration of Stanfill’s restraint played a role in his death. (Sims Dep. at 93).
According to Dr. Sims, Stanfill died a “sudden unexpected death.” (Sims Dep. at 54).

22

No party contests the methodology or accuracy of Dr. Sims’ conclusion regarding Stanfill’s
cause of death.

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Despite this potentially damaging testimony from his own cause-of-death expert, the
Plaintiff offers no medical evidence to the contrary.23
Dr. Sims did testify that, during the autopsy, she noted the presence of several
red abrasions on Stanfill’s left forearm arm that were likely consistent with restraints or
handcuffs used to secure Stanfill in the chair. (Sims Dep. at 45). While it is also likely
that being confined in the restraint chair caused Stanfill some physical discomfort and
emotional pain, there is little evidence that the restraints themselves caused Stanfill any
physical injury. Campbell, 169 F.3d at 1376. Thus, the extent of injury inflicted by the
Defendants’ use of the restraint chair was minimal and supports a finding that the use of
force was not excessive.24
d.

Extent of Threat to the Safety of Staff and Inmates

The Plaintiff claims that Stanfill “posed no threat whatsoever to any of the staff or
other inmates and, at most, was solely a threat to [himself].” (Doc. 122-2 at 18). The
Plaintiff’s attempt to downplay the threat Stanfill posed to himself is not persuasive.
Although perhaps not violent towards staff or other inmates, Defendants Carrick and
Wheat faced a difficult decision involving an unruly inmate with a known history of
severe self-mutilation. Under these circumstances, Carrick and Wheat obviously felt
that Stanfill needed to be restrained. If Stanfill had not been restrained, and if he

23

The Eleventh Circuit held in Wingster v. Head, 318 Fed. Appx. 809 (11th Cir. 2009), that mere
temporal proximity between an inmate’s death and the alleged excessive force was insufficient
to overcome the medical expert’s testimony that the inmate’s death was not the result of the
alleged assault or trauma. 318 Fed. Appx. at 815-16. However, the court did note that the
Plaintiff in Wingster only asserted a claim for the wrongful death of the inmate, and not for any
injuries suffered prior to his death, thus suggesting that the lack causation evidence alone may
not be fatal to such a claim. Id. at 815 n. 10.
24

Whether and to what extent Stanfill’s reported dehydration supports a claim for relief will be
resolved in the Court’s deliberate indifference analysis.
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followed through on his threat to commit suicide, the Defendants would have likely
faced the prospect of a lawsuit claiming they should have protected this suicidal inmate
from himself. As the Fourth Circuit stated, “prison officials must not be forced to walk a
tightrope and face the prospect of a lawsuit no matter which way they turn.” Grayson v.
Peed, 195 F.3d 692, 696 (4th Cir. 1999). It is in precisely these circumstances that
prison officials should be accorded deference in their decisions involving prison safety
and security. Accordingly, Stanfill posed a threat to his own safety sufficient to justify
Carrick and Wheat’s decision to impose restraints.
e.

Efforts Made to Temper the Severity of a Forceful Response

There is also evidence that Carrick and Wheat made some effort to temper the
severity of their use of force. After securing Stanfill in the chair, Wheat ordered
detention officers to check Stanfill every 15 minutes. Although the checks were not
performed at strict 15-minute intervals, there is evidence that, throughout the night,
officers performed visual checks on Stanfill approximately 30 times. (Doc. 76-2). Most
of these checks were done by peering in through the glass window on the door to the
cell. Thus, even if all of the video had been preserved, the checks would not be visible
by viewing the recorded video. Moreover, Nurse Colston, to whom the adverse
inference would not apply even if one was warranted, testified that she physically
checked on Stanfill once at approximately 10:00 p.m. on July 2, and then again at
approximately 4:00 a.m. on July 3. According to Nurse Colston, Stanfill’s vital signs
were normal during both medical checks and, despite his claims of difficulty breathing,
his respiration was not obscured. On multiple occasions between 3:30 and 4:00 a.m.,
Wheat gave Stanfill water from a Styrofoam cup, which Stanfill can be seen drinking

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with no apparent difficulty. (Stanfill Video 3 at 38:00-42:00 and 50:00-52:00). In short,
even applying an adverse inference, there is sufficient evidence that Carrick and Wheat
made a concerted effort to temper the severity of their forceful response.
Considering all these factors together, the Plaintiff has failed to produce evidence
that Carrick and Wheat’s placement of Stanfill in the restraint chair was anything other
than a good-faith effort to protect Stanfill from further self-harm. Stanfill’s penchant for
self-mutilation, as well as the specific incident that precipitated a forceful response on
July 2, are uncontroverted. Carrick and Wheat’s forceful response therefore does not
shock the conscience. When construed in the light most favorable to the Plaintiff, the
evidence does not support an inference that Carrick and Wheat acted with a malicious
and sadistic intent to cause harm. Accordingly, the Plaintiff has not met his burden of
proving unconstitutional excessive force, and it necessarily follows that Carrick and
Wheat are entitled to summary judgment on qualified immunity grounds.
With regard to the Plaintiff’s claim that the use of restraints continued beyond any
reasonable need for such measures, the analysis is slightly more complicated.
Generally, any continued use of force after the necessity for the application of force
ceases can violate the Fourteenth Amendment. Williams v. Burton, 943 F.2d 1572,
1576 (11th Cir. 1991) (rejecting claim that putting a violent inmate in four-point restraint
for twenty-eight and one-half hours was excessive force). However, “[t]he Constitution
does not require prison officials to release from restraint a dangerous inmate who has
lashed out … simply because he has stopped lashing out for the time being.” Scroggins
v. Davis, 346 Fed. Appx. 504, 506 (11th Cir. 2009). Rather, “[h]ow long restraint may
be continued calls for the exercise of good judgment on the part of prison officials.

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Once it is established that the force was applied in a good faith effort to maintain
discipline and not maliciously or sadistically for the purpose of causing harm, the courts
give great deference to the actions of prison officials in applying prophylactic or
preventive measures” to prevent the incidence of further disturbances. Williams, 943
F.2d at 1576. “It is by this observation and management that corrections officials judge,
in light of their experience and expertise, whether the plaintiff’s violent nature has
abated.” Id. “[F]ederal courts must defer in many matters to the expert judgment of
these administrators, particularly in matters of internal security and order.” Id. (internal
quotations and citation omitted).
Here, as instructed by the Eleventh Circuit, the Court must largely defer to the
expert judgment of the officers tasked with observing and managing Stanfill during his
restraint. Stanfill’s unfortunate history was no secret to the Houston County
Defendants. Wheat, who was aware of this history, had the most interaction with
Stanfill during the events leading up to his death, and likely would have been the one to
order his release, was entitled to exercise some discretion in determining when Stanfill
no longer posed a threat of self-harm. At approximately 4:00 a.m., Wheat exercised
discretionary judgment when he removed the foam helmet after sensing that Stanfill had
begun to calm down. (Wheat Dep. at 42-43). As Wheat explained, it “[w]as a give-andtake kind of thing…. I wanted to believe that he didn’t want to harm himself, but I wasn’t
sure, so I wanted to remove the helmet, you know, just back off a little bit at a time to
see how he was going to act and how he was going to respond, and like I said, we do
just one thing at a time, until finally, you know, he’s out of the restraints altogether, and

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hopefully by that time medical have had a chance to evaluate him and go from there to
do what they need to do to help him.” (Wheat Dep. at 42-43).25
In light of the Court’s finding that Stanfill’s initial restraint was prudent and proper,
the Court now extends that finding to Stanfill’s continued restraint. Stanfill posed a
serious risk of harm to himself, and the particular circumstances confronting the officers
justified the continued use of the restraints until they were reasonably assured that the
situation had abated. Although perhaps more could have been done to ensure that
Stanfill experienced no discomfort, the evidence must go “beyond a mere dispute over
the reasonableness of the particular use of force or the existence of arguably superior
alternatives.” Whitley, 475 U.S. at 322. In short, the tragedy of Stanfill’s essentially
unexplained death by itself does not render excessive the measures undertaken in
response to Stanfill’s behavior. Thus, to the extent the Plaintiff has asserted an
excessive force claim based on Stanfill’s continued restraint, the Defendants are entitled
to qualified immunity and summary judgment in their favor is appropriate.
The Plaintiff has also asserted a claim that Defendants Lester, Serrano, Oates,
Collins, and Garrett should have intervened to prevent the use of excessive force.
While the Plaintiff is correct that an officer who is present at the scene and who fails to
take reasonable steps to protect the victim of another’s use of excessive force can be
held personally liable for his nonfeasance, such a claim is dependent upon an initial
finding of excessive force. Crenshaw v. Lister, 556 F.3d 1283, 1294 (11th Cir. 2009).
Because the Plaintiff has failed to prove that the use of force was excessive, it

25

The Court recognizes the possibility for after-the-fact rationalizations, particularly in a case
such as this, where the Plaintiff is not available to dispute the Defendants’ testimony. However,
when the applicable standard involves the subjective intent of the alleged participants, testimony
from those participants is particularly relevant.
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necessarily follows that the Plaintiff’s claims against Defendants Lester, Serrano, Oates,
Collins, and Garrett based on their failure to intervene also fail.
ii.

Deliberate Indifference Claims

The Plaintiff has also asserted Fourteenth Amendment deliberate indifference
claims against the Houston County Defendants. Specifically, the Plaintiff contends that
the Defendants were deliberately indifferent to Stanfill’s physical and mental health
needs both prior to and during his restraint. Because it is not clear against whom this
claim is asserted, in an abundance of caution, the Court will address the claim as
though it were properly asserted against Defendants Carrick, Wheat, Lester, Serrano,
Oates, Collins, and Garrett. (Doc. 1 ¶¶ 52-58).
To prove his claim, the Plaintiff must prove that Stanfill had an objectively serious
medical need; that a Defendant acted with deliberate indifference to that need; and that
the Defendant’s deliberate indifference caused Stanfill’s injuries. Mann, 588 F.3d at
1306-07. A serious medical need is one that has been “diagnosed by a physician as
requiring treatment or one that is so obvious that a lay person would recognize the need
for medical treatment.” Id. To establish “deliberate indifference,” the Plaintiff must show
that a Defendant “(1) had subjective knowledge of a risk of serious harm; (2)
disregarded that risk; and (3) acted with more than gross negligence.” Harper v.
Lawrence Cnty., Ala., 592 F.3d 1227, 1234 (11th Cir. 2010).
The “subjective knowledge” component requires that a defendant was “both [ ]
aware of facts from which the inference could be drawn that a substantial risk of serious
harm exists, and he must also draw the inference.” Burnette v. Taylor, 533 F.3d
1325,1330 (11th Cir. 2008) (internal quotations and citation omitted). A defendant will

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not be held liable for his or her failure to alleviate a risk that should have been perceived
but was not. Id. at 1331. Thus, “imputed or collective knowledge cannot serve as the
basis for a claim of deliberate indifference.” Id. (internal quotations and citation
omitted). “Each individual defendant must be judged separately and on the basis of
what that person [knew].” Id. For reasons set forth in more detail below, the Plaintiff’s
deliberate indifference claims fail on multiple levels.
a.

Mental Health Need

The Plaintiff claims that Defendants Carrick and Wheat knew that Stanfill had a
severe mental illness and a habit of self-mutilation, yet they failed to adequately address
these psychological needs. The Plaintiff further alleges that certain unnamed
Defendants allegedly failed to adequately assess Stanfill’s mental health needs at the
time of his admission to HCDC, as required by HCDC policy. (Doc. 122-1 at 9).
Although he does not identify the particular Defendants who failed to abide by the
policy, according to the Plaintiff, “the failure to follow policy led to the cutting which, in
turn led to [Stanfill’s] restraint in the chair and, ultimately, his death.” (Doc. 122-1 at 10).
First, the only objectively serious medical need that Carrick and Wheat (and any
other individual Defendant for that matter) were aware of was Stanfill’s history of selfinflicted harm. It therefore follows that the only risk of serious harm these Defendants
were aware of was the possibility that Stanfill may try to hurt himself. Although there is
evidence that Stanfill had been treated for Adjustment Disorder and ADHD at Central
State Hospital in February 2008, the record does not support the Plaintiff’s argument
that Carrick and Wheat (or any of the Houston County Defendants) knew that Stanfill
had been diagnosed by a physician with any particular mental illness or that he had, in

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the past, been prescribed medication for that illness.26 Moreover, other than escorting
the nurses during their distribution of medication to inmates, jail officials are generally
unaware of inmates’ specific medication needs and they do not participate in the
diagnosis or treatment of inmate mental health conditions. (Carrick Dep. at 35-36; 4445). A Defendant cannot be deliberately indifferent to a risk of harm he is not aware of.
Accordingly, to the extent the Plaintiff claims that any of the Houston County
Defendants failed to provide appropriate medical care (in the form of medication or
other treatment) for Stanfill’s diagnosed mental disorders, the Defendants are entitled to
summary judgment.
Second, assuming that Stanfill’s history as a “cutter” constitutes a serious
medical need, the Plaintiff has not produced sufficient evidence that any of the Houston
County Defendants were deliberately indifferent to that need. As noted above, the only
risk of harm the Houston County Defendants were subjectively aware of was Stanfill’s
potential to injure himself. Despite his refusal to speak with medical staff upon arrival at
HCDC on June 30, Stanfill was immediately classified as a suicide risk due to his selfdestructive history and was placed on suicide watch. (Doc. 127 ¶ 268). For two days,
Stanfill remained on suicide watch in HCDC custody, whereby he was observed at least
every 15 minutes, without incident. Thus, from the time of his initial booking up until
approximately 5:45 p.m. on July 2, there is no evidence of any serious medical need,
other than that already being accounted for, warranting the Defendants’ attention, and,

26

The Plaintiff admits that neither Stanfill nor anybody from his family provided prescription
medication at the time of his June 2008 incarceration. (Doc. 127 ¶¶ 47-48). In fact, the Plaintiff,
Stanfill’s father, admitted that just prior to his incarceration Stanfill told him that he was not
taking any medications. (Stanfill Dep. at 53).
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resultingly, no evidence that Stanfill’s medical needs, both mental and physical, were
not attended to.
The evidence is just as lacking with regard to Stanfill’s treatment after he cut
himself on July 2. Following this incident, Stanfill was sent to medical where he was
observed by medical staff and his wound was bandaged. After taking a shower to rinse
the blood from his body, Stanfill was dressed in a suicide smock and placed in the
restraint chair in J-14. Again, at this time, the only “serious risk of harm” any of the
Houston County Defendants were subjectively aware of was Stanfill’s suicide potential,
as evidenced by his past and now most recent behavior. Because Carrick and Wheat
took immediate action to prevent this risk of harm from materializing by placing him in
restraints, it cannot be said that Carrick, Wheat, or anyone else who assisted in
restraining Stanfill disregarded that risk.
b.

Physical Medical Need

With regard to Stanfill’s physical medical needs, the Plaintiff claims Defendants
Wheat, Lester, Serrano, Oates, Collins, and Garrett knew at 3:30 a.m. “that [Stanfill]
was in a completely exhausted and dangerously weak condition and was not physically
or mentally fit to spend more time in the restraint chair,” but that they were “deliberately
indifferent to [his] serious condition and returned him to” or left him in the chair. (Doc. 1
¶¶ 54-58). As discussed above, a serious medical need is one that has been diagnosed
by a physician as requiring treatment or one that is so obvious that a lay person would
recognize the need for medical treatment. Because Stanfill had not been diagnosed by
a physician with any physical medical need requiring treatment, the Plaintiff may
proceed only under the latter definition. Though the Plaintiff does not identify the

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physical “condition” forming the basis of this claim, construed in the light most favorable
to him, the only possible conditions that could support the Plaintiff’s theory are
exhaustion, weakness, and dehydration.
Assuming these conditions constitute serious medical needs, there is insufficient
evidence that Wheat and Serrano (who placed Stanfill back in the chair at
approximately 3:45 a.m.) or Lester, Oates, Collins, and Garrett (who were on duty and
observed Stanfill in the chair at various times) were subjectively aware of Stanfill’s
medical conditions or the risk of serious harm that could result if left unattended. To
prove the subjective knowledge element, the Plaintiff must not only prove that a
Defendant was aware of facts from which the inference could be drawn that a
substantial risk of serious harm exists, he must also prove that that Defendant actually
drew the inference. While the Plaintiff points to the video of Stanfill lying on the floor in
J-15 and then being placed back in the chair around 4:00 a.m. as evidence of Stanfill’s
alleged obvious “condition,” the fact remains that nothing in the record suggests that the
Defendants actually drew the inference that Stanfill’s condition could lead to death if not
promptly treated.27 (Serrano Dep. at 41: “Q: But you didn’t see anything like that where
Stanfill was exhibiting any signs or symptoms that you needed to go get medical for? A:
No, sir.”; Wheat Dep. at 45: “Q: But did he also look to be fatigued? A: To me, no, sir …
it appeared to me that … he just seemed to be noncompliant.”; Greifinger Dep at 174:
“Q: [I]sn’t it fair to say that the jailers also didn’t know when [Stanfill] became dehydrated
that evening before they found him unresponsive? A: Correct.”). Whether a “medical
need might be recognizable by a trained medical professional, such as a nurse, is not
27

The Court notes that Stanfill’s appearance is not that of a healthy individual. However, it is
not clear whether Stanfill was exhausted or whether he was simply being noncompliant.
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enough. Instead, the need for immediate medical assistance must have been apparent
to the untrained eye of a layperson.” Youmans v. Gagnon, 626 F.3d 557, 564 n. 8 (11th
Cir. 2010).
Assuming that Stanfill’s alleged exhausted state and dehydration constitute
objectively serious medical needs and even assuming that the Defendants were
subjectively aware of a risk of serious harm, the evidence is similarly lacking that any
Defendant was deliberately indifferent to those needs. To the contrary, after Stanfill
was placed back in the chair, he was given water, and at approximately 4:00 a.m. Nurse
Colston, at Wheat’s request, took Stanfill’s blood pressure, checked his pulse and
breathing rate, and determined that Stanfill appeared in normal health and needed no
further medical care. After Nurse Colston’s 4:00 a.m. medical check, the helmet was
removed and Stanfill was given more water. All of these events are depicted on Stanfill
Video 3 and their occurrence cannot be argued.
The Plaintiff must produce evidence that, with knowledge of a substantial risk of
serious harm, a Defendant “knowingly or recklessly disregarded that risk by failing to
take reasonable measures to abate it.” Hale, 50 F.3d at 1583. This standard requires
more than accidental inadequacy, negligence in diagnosing or treatment, or even
medical malpractice actionable under state law. As the Eleventh Circuit stated in
Youmans v. Gagnon, the “best response to a serious medical need is not required by
federal law in these cases.” 626 F.3d at 564. Accordingly, even if, as the Plaintiff
argues, the Defendants should have taken steps to “involve appropriate medical
personnel and … transfer Stanfill to a [mental health] facility,” their failure to do so does
not rise to the level of deliberate indifference.

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Finally, as noted above, even if the Plaintiff could prove a Defendant’s deliberate
indifference to Stanfill’s medical needs (which the Court has found he has not), he must
also prove causation between that indifference and Stanfill’s injuries. Mann, 588 F.3d at
1306-07. The Plaintiff’s attenuated theory that “the failure to follow policy led to the
cutting which, in turn led to [Stanfill’s] restraint in the chair and, ultimately, his death” is
contradicted by the Plaintiff’s medical expert’s, Dr. Sims, opinion that Stanfill’s death
was not causally related to his restraint in the chair. To circumvent this testimony, the
Plaintiff cites Dr. Sims’ conclusion that dehydration was a contributing factor in Stanfill’s
death. The Plaintiff summarily attributes Stanfill’s dehydration to his being restrained in
the chair and not receiving sufficient fluids from the Defendants. Even allowing Plaintiff
the inference that Stanfill’s dehydration was caused by his restraint in the chair, which
the Plaintiff has not and cannot prove, he still lacks sufficient evidence to prove
causation.
As noted, dehydration is listed as a contributing cause of the sudden cardiac
dysrhythmia that led to Stanfill’s death. Importantly, however, Dr. Sims did not testify
that Stanfill would have survived had he not been dehydrated. (Sims Dep. at 72). In
fact, Dr. Sims did not offer an opinion on the degree or seriousness of Stanfill’s
dehydration, nor could she say with any certainty what caused Stanfill to become
dehydrated. (Sims Dep. at 62, 71-72). Although deliberate indifference claims do not
always require expert medical testimony, the medical causation issue here “presents a
technical and scientific issue that requires the specialized knowledge of an expert
medical witness.” Wingster, 318 Fed. Appx. at 815-16 (citation omitted). Mere temporal
proximity alone between Stanfill’s death and the Defendants’ alleged unconstitutional

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conduct is not sufficient to create a genuine issue of material fact as to the cause of
Stanfill’s injuries. Id. Accordingly, the Plaintiff has failed to produce evidence that
Stanfill’s injuries were caused by the Defendants’ alleged deliberate indifference.
Having failed to prove a constitutional violation, the Plaintiff has not met his burden of
establishing that these Defendants are not entitled to qualified immunity. Summary
judgment is therefore appropriate.28
Though the Defendants object to the Court considering the Plaintiff’s claim that
Defendant Collins is liable for his delay in performing CPR or other resuscitation efforts
once Stanfill was found unresponsive, this claim fails for the same reason. “To survive
summary judgment, a plaintiff must show that the delay attributable to the defendant’s
indifference likely caused the plaintiff’s injury. 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.” McDaniels v. Lee, 405 Fed. Appx. 456, 458-59 (11th Cir. 2010) (internal
quotations and citation omitted). The Plaintiff has failed to show, by way of medical
evidence (or any evidence, for that matter), that Collins’ alleged indifference likely
caused Stanfill’s death, and summary judgment is therefore warranted.29
28

It is well settled that the “moving party may support its motion for summary judgment with
affirmative evidence demonstrating that the non-moving party will be unable to prove its case at
trial.” Fitzpatrick v. City of Atlanta, 2 F.3d 1112, 1116 (11th Cir. 1993).
29

The Court notes that Collins’ “6 minute delay” in providing medical treatment, as the Plaintiff
calls it, does not rise to the level of deliberate indifference. As evidenced by Stanfill Video 1,
Collins enters cell J-15 at the 00:51 second mark and immediately checks for a pulse. Though
there is no sound in the video, a nurse is summoned shortly thereafter. Nurse Sumler enters
the cell at the 02:45 mark and, presumably, assumes medical responsibility for Stanfill. For the
remainder of the video, Collins and another officer can be seen attempting to remove Stanfill
from the restraint chair. Though the lack of resuscitative efforts on the video is concerning, the
Court does not attribute that delay in treatment to Collins or any other Houston County
Defendant.
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Even if the Plaintiff could prove that the Defendants were deliberately indifferent
to Stanfill’s serious medical needs, he has failed to establish that the law applicable to
the circumstances of this case was clearly established at the time of the alleged
violations. The Plaintiff has not identified a materially similar case from the United
States Supreme Court, the Eleventh Circuit, or the Georgia Supreme Court, nor is this
an obvious case in which the unlawfulness of the Defendants’ conduct was so apparent
that every objectively reasonable government official facing these circumstances would
know that the official’s conduct violated federal law. Vinyard v. Wilson, 311 F.3d 1340,
1351-52 (11th Cir. 2002). Accordingly, the Defendants are entitled to qualified immunity
on the Plaintiff’s deliberate indifference claims.
iii.

Claims against Sheriff Talton and Major Holt

The Court now turns to the Plaintiff’s claims against Sheriff Talton and Major
Holt. It is undisputed that neither Talton nor Holt had any direct contact with Stanfill
during his incarceration at HCDC from June 30 until July 3. (Doc. 127 ¶¶ 276, 288).
Instead the Plaintiff seeks to hold Talton and Holt liable for their failure to provide a
written policy or training to their subordinate officers on the proper use of the restraint
chair. (Doc. 1 ¶¶ 46-47). However, it is well established that supervisory officials
cannot be held individually liable under section 1983 based on a policy or lack thereof or
failure to train absent a finding that a subordinate official committed a constitutional
violation. Howell v. City of Lithonia, 397 Fed. Appx. 618, 621 (11th Cir. 2010); Beshers
v. Harrison, 495 F.3d 1260, 1264 n.7 (11th Cir. 2007); Rooney v. Watson, 101 F.3d
1378, 1381-82 (11th Cir. 1996). Thus, inextricably linked to the Plaintiff’s claims against
Talton and Holt are his claims that other Houston County Defendants violated Stanfill’s

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constitutional rights based on his initial and extended placement in the restraint chair.
Because the Court has already found that the Defendants are entitled to summary
judgment on the Plaintiff’s claims against the other Houston County Defendants, the
Plaintiff lacks the required underlying constitutional deprivation on which to base his
claims against supervisors Talton and Holt. Accordingly, Talton and Holt are entitled to
summary judgment.
IV. Conclusion
All parties can agree that Stanfill’s death was unfortunate, and that in hindsight,
perhaps more could have been done. Hindsight, however, is not an appropriate lens
through which to view the Defendants’ actions. The Plaintiff has failed to meet his
burden of proving that the Defendants violated Stanfill’s constitutional rights. The
Defendants are therefore entitled to qualified immunity. Accordingly, the Plaintiff’s
Motion for Partial Summary Judgment is denied, and the Houston County Defendants’
Motion for Summary Judgment is granted. The Plaintiff’s Motion for Sanctions is also
denied.
SO ORDERED, this 29th day of March, 2012.
S/ Marc T. Treadwell
MARC T. TREADWELL, JUDGE
UNITED STATES DISTRICT COURT

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