Bevan v. Santa Fe County et al

Filing 224

MEMORANDUM OPINION AND ORDER by District Judge Kenneth J. Gonzales granting 163 Defendant Santa Fe County's Motion for Summary Judgment. (tah)

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEW MEXICO
AIMEE BEVAN, as Personal
Representative of the Estate of Desiree
Gonzales, deceased,
Plaintiff,
vs.

Civ. No. 15-73 KG/SCY

SANTA FE COUNTY, GABRIEL VALENCIA,
Youth Development Administrator, Individually,
MATTHEW EDMUNDS, Corrections Officer,
individually, JOHN ORTEGA, Corrections Officer,
MOLLY ARCHULETA, Corrections Nurse,
Individually, ST. VINCENT HOSPITAL, and
NATHAN PAUL UNKEFER, M.D.,
Defendants.
MEMORANDUM OPINION AND ORDER
This matter comes before the Court upon Defendant Santa Fe County’s Motion for
Summary Judgment (Motion for Summary Judgment), filed April 15, 2016. (Doc. 163).
Plaintiff filed a response on May 17, 2016, and filed exhibits on May 19, 2016. (Docs. 181 and
186). Defendant Santa Fe County (County) filed a reply on June 22, 2016. (Doc. 205). Having
considered the Motion for Summary Judgment, accompanying briefing, and relevant evidence,
the Court grants the Motion for Summary Judgment.
A. Background
This case involves, in part, whether Desiree Gonzales received adequate medical care
while incarcerated at the Santa Fe Youth Development Program (YDP), a program operated by
the County. Just prior to Gonzales’ incarceration at the YDP on the night of May 7, 2014,
Gonzales was treated for a heroin overdose at St. Vincent Hospital and medically cleared for

incarceration. It is undisputed that no nurse was present at the YDP that night and that several
hours later Gonzales stopped breathing. It is also undisputed that when Gonzales stopped
breathing and became nonresponsive non-medical YDP staff began CPR and called 911. Several
hours later, Gonzales died at St. Vincent Hospital. The Office of the Medical Investigator
determined that the cause of death was “Toxic effects of heroin.” (Doc. 145-4) at 1.
1. The Complaint for Wrongful Death (Complaint) (Doc. 1) at 4-19
In Count Two of the Complaint, Plaintiff brings 42 U.S.C. § 1983 claims against the
County for violations of Gonzales’ rights under the Fourteenth and Eighth Amendments. (Doc.
1) at 14-15, ¶¶ 73-78. Plaintiff clarifies in her response to the Motion for Summary Judgment
that the County adopted the following unconstitutional custom or practice: “After hours, when
nurses were not on shift, residents suspected of intoxication or withdrawal were not appropriately
screened pursuant to the receiving screening policy, were not appropriately evaluated pursuant to
the intoxication and withdrawal policy, and instead, were allowed to ‘sleep it off’ under the
watch of untrained eyes as long as they had a medical clearance from a doctor or hospital.”
(Doc. 181) at 30. Plaintiff further alleges that the County did not implement its medical
receiving screening policy, and failed to train its YDP officers on (1) the receiving screening
policy, (2) recognizing the signs and symptoms of heroin intoxication and withdrawal, and (3)
monitoring residents for signs and symptoms of heroin intoxication and withdrawal. Id. at 29, ¶
14.
In Count Three of the Complaint, Plaintiff alleges two New Mexico Tort Claims Act
(NMTCA) claims against the County. First, Plaintiff alleges that the County, through its
employees, was negligent by failing to provide adequate medical care to Gonzales. (Doc. 1) at
15, ¶ 82. Plaintiff cites NMSA 1978, § 41-4-12 of the NMTCA which provides waiver of

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immunity “when law enforcement officers cause wrongful death through the deprivation of
rights, privileges and immunities secured by the U.S. Constitution or New Mexico Constitution.”
Id. at 15, ¶ 80. Second, Plaintiff alleges that the County was negligent in the manner it operated
the YDP. Id. at 15, ¶ 83.
The County moves for summary judgment on all claims against it. Plaintiff opposes the
Motion for Summary Judgment in its entirety.
2. Facts Relevant to the Motion for Summary Judgment1
a. Summary of Facts Related to Gonzales’ Incarceration at the YDP
Gonzales received care for a heroin overdose at St. Vincent Hospital, which included the
administration of naloxone, “a short acting antagonist of the effects of heroin,” and lorazepam, a
central nervous system depressant like heroin. (Doc. 163-14) at 2. As a central nervous system
depressant, lorazepam has an additive effect to heroin. Id. In fact, “the co-administration of
lorazepam … changes the opioid treatment scenario complicating treatment and adding
pharmacologic risk.” Id. at 4.
Gonzales was discharged from St. Vincent Hospital at 9:52 p.m. with a medical clearance
noting “No further cares [sic].” (Doc. 166-1); (Doc. 166) at 2. Gonzales arrived at the YDP at
10:35 p.m. (Doc. 166) at 2. Defendant Gabriel Valencia (Valencia) and YDP staff member
Esmeralda Coronado (Coronado) interacted with Gonzales in the booking process. Coronado
indicated on Gonzales’ Intake Checklist that a medical screening form was completed and placed
in the medical box so that a nurse could review it in the morning. (Doc. 186-5) at 3. No medical

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Unless otherwise noted, the factual summary reflects the evidence viewed in the light most
favorable to Plaintiff.
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screening form, however, was completed and staff, instead, relied on the medical clearance to
accept Gonzales. Id.
While Gonzales was alert, oriented, and coherent during the booking process, she was
also nauseous, “a little fogy,” and tired. (Doc. 67-13) ; (Doc. 166-2) at 3, depo. at 34-35; (Doc.
166-3) at 2, depo. at 31-32; (Doc. 166-4); (Doc. 185-6) at 5, depo. at 151. After Coronado
dressed Gonzales out and finger printed her, Gonzales was added “to board and count at 10:55
pm and escorted … to the Anasazi C-pod living unit ….” (Doc. 166-4). Once at the Anasazi Cpod, Gonzales telephoned her mother and spoke with her for about five minutes. Id.
About that same time, Defendant Matthew Edmunds (Edmunds) arrived at the Anasazi
C-pod to accept Gonzales. Id. Edmunds “immediately” concluded that Gonzales “was not in a
normal state of mind,” had “groggy” looking eyes, and had slurred speech. (Doc. 166-6).
Because no nurse was on duty at the YDP during the night, Edmunds called Defendant Nurse
Molly Archuleta (Nurse Archuleta) to advise her of Gonzales’ “state” and ask questions about
the medical clearance. Id. Nurse Archuleta told Edmunds “to keep an [sic] very close eye on
[Gonzales] and to notify her of any changes.” Id. Nurse Archuleta specifically told Edmunds to
monitor Gonzales’ breathing. (Doc. 145-1) at 1; (Doc. 185-7) at 4, depo. at 90. Nurse Archuleta
later acknowledged that not being in a normal state of mind, having groggy eyes, and slurring
speech would have been “red flags” to her. (Doc. 176-5) at 3, transcript at 37.
Based on the telephone conversation with Nurse Archuleta, Edmunds and Valencia
placed Gonzales in a “boat” or bed in the dayroom of the Anasazi C-pod. (Doc. 166-4). To
comply with Nurse Archuleta’s instruction to monitor Gonzales’ breathing, Edmunds and
Defendant John Ortega (Ortega), who arrived at the Anasazi C-pod at 11:40 p.m., conducted 15
minute checks on Gonzales, including “extra checks.” (Doc. 166-6); (Doc. 166-8). The checks

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“were conducted through the window of the dayroom, and horseshoe,” which placed Edmunds
and Ortega 2 to 3 feet from Gonzales. Id.; (Doc. 185-4) at 4, depo. at 68. Edmunds kept a door
unsecured because of Gonzales’ “unusual breathing.” (Doc. 166-6). The checks included
shaking Gonzales, shining a light in her eyes once, 2 and asking her if she was okay, without
getting a verbal response. (Doc. 185-2) at 6, transcript at 33; (Doc. 206-6) at 3-4, depo. at 55-57.
Valencia evidently left the Anasazi C-pod around the time Gonzales went to sleep at
about 11:15 p.m., and checked on her at least one other time at about 11:55 p.m. (Doc. 166-2) at
3, depo. at 37; (Doc. 185-2) at 6, transcript at 33; (Doc. 171) at 23:55:35 to 23:56:09. After
Plaintiff went to sleep, Edmunds and Ortega noted “unusual breathing,” “breathing difficulties,”
“awkward” breathing, and “gasping” by taking “deep breaths follow[ed] by extended period [sic]
of no breathing repeatedly.”3 (Doc. 145-3); (Docs. 166-6, 166-7, and 166-8).
Valencia at some point went to clean the front lobby. (Doc. 166-4). At about 1:52 a.m.,
Edmunds radioed Valencia to inform him that Gonzales stopped breathing. Id. Edmunds and
Ortega then began CPR while Valencia called the Interim Youth Service Administrator at 1:54
a.m. and then called 911 at 1:55 a.m. Id. Emergency personnel arrived at 2:05 a.m. Id.
Edmunds went with Gonzales to St. Vincent Hospital, where she died several hours later. (Doc.
166-7).

2

Gonzales only verbally responded, briefly, when Ortega shone a light in her eyes. (Doc. 206-6)
at 3, depo. at 55-56.
3

Edmunds later characterized Gonzales’ breathing as “snoring.” (Doc. 166-5) at 2, depo. at 37.
Ortega subsequently stated that the “awkward” breathing began later, at 1:00 a.m., and
characterized the breathing as “real loud snoring.” (Doc. 166-8); (Doc. 185-2) at 3, transcript at
23.
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b. The County’s Policies
In 2014, the County had policies which it adopted from the 2011 “Standards for Health
Services in Juvenile Detention and Confinement Facilities,” authored by the National
Commission on Correctional Health Care. (Docs. 163-1 and 163-2). The policies covered
subjects like health training for staff, receiving screening, health assessments, emergency
services, nursing assessment protocols, intoxication and withdrawal, and alcohol and other drug
problems. Id. (Policy numbers Y-C-04, Y-E-02, Y-E-04, Y-E-08, Y-E-11, Y-G-06, and Y-G08).
The County’s receiving screening policy required that nursing personnel perform the
receiving screening and that they document the screening on a form. (Doc. 186-4) at 2. That
policy, however, indicated that residents referred to St. Vincent Hospital who return to the YDP
“are accepted if there is a written medical clearance….” Id. If someone other than a nurse
performs the receiving screening, “[a] [n]urse will review the completed receiving screening
form and the resident within 12-hours of the resident’s admission to” the YDP. Id. at 3. Another
policy, the intoxication and withdrawal policy, required “constant observation when severe
withdrawal symptoms are observed.” (Doc. 186-3) at 2.
c. The County’s Training
The New Mexico Administrative Code § 8.14.14.10, as amended in 2011, requires that
New Mexico juvenile detention centers certified by the Children, Youth, and Families
Department provide training in first aid, CPR, and “intake criteria/and reporting.” NMAC §
8.14.14.10 (D) (13) and (16). The County had a policy establishing minimum staff training
requirements. (Doc. 186-13). The policy included training on first aid, CPR, and policies. Id.

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The County provided evidence that, prior to Gonzales’ death, Valencia, Edmunds,
Ortega, Coronado, and Nurse Archuleta received various trainings including basic academy
trainings, basic orientation trainings, in-service trainings, training in medical
emergencies/urgencies, instruction on narcotics, and training on CPR, first aid, and on the use of
automated external defibrillators (AED). See (Doc. 163-3) at 8-9; (Doc. 163-5) at 1-2, and 5;
(Doc. 163-6) at 6-7 and10; (Doc. 163-7) at 1and 9; (Doc. 163-8) at 1 and 7; (Doc. 163-9) at 1, 3,
and 7-8; (Doc. 163-10) at 2, 5, and 6; (Doc. 163-12) at 6; (Doc. 205-7) at 1-3, 5-9, 13-16, and 1819.
An objective of the medical emergencies/urgencies training was to “[r]ecognize some
signs and symptoms of illnesses or injuries that require immediate and urgent medical attention.”
(Doc. 205-4) at 1. The training reviewed checking for breathing which includes asking whether
the resident is on drugs or withdrawing from drugs. Id. at 2. The training noted that there was a
separate course on opiate and drug overdoses, but directed activation of the incident management
system if staff suspects an opiate or drug overdose, and that staff watch respiratory rates and
watch for “difficulty in arousing” the resident. Id. at 3.
Two other County trainings were entitled, “Alcohol, Drugs, and Narcotics” and “NMCD
Addiction Services.” (Doc. 205-5); (Doc. 163-15). The trainings listed as an objective
identifying or recognizing “the primary symptoms associated with the use of various
drugs/substances.” (Doc. 205-5) at 1; (Doc. 163-15) at 8. The trainings also listed the
physiological effects of narcotic use like nausea, “Mental Fogginess,” “Blurred vision,” and
“Reduced physical activity.” (Doc. 205-5) at 2; (Doc. 205-3) at 3. These trainings further listed
heroin or opiate withdrawal symptoms. (Doc. 205-5) at 3; (Doc. 205-3) at 3.

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County lesson plans created prior to Gonzales’ death included those on medical
urgencies, narcotics recognition, substance abuse, drugs and narcotics, and policies. (Doc. 2056) at 1-4, and 7-8. The County also had a “Basic Book” entitled “Drug Use and Recognition.”
(Doc. 163-15) at 9.
Furthermore, Nurse Archuleta trained life skills staff on signs and symptoms of opioid
intoxication. (Doc. 204-1) at 4, depo. at 54. That training included monitoring the person’s
breathing by watching the chest rise and fall. Id. at 4, depo. at 54-56. It is unclear, however,
whether this training occurred prior to Gonzales’ death.
d. Evidence From YDP Staff Concerning Customary Practices and Training
(1) Valencia
Valencia testified at his deposition that when a resident arrived at the YDP after hours
and no nurse was present, staff would determine whether the resident was coherent and able to
understand questions before accepting them into the YDP. (Doc. 186-6) at 3, depo. at 24-25. If
the resident was under the influence of drugs, i.e., not coherent, that resident would be taken to
the hospital. Id. at 3, depo. at 24. Valencia stated in his deposition testimony that even if a
resident had a medical clearance, he would make sure that the resident was coherent before
accepting the resident and that, if called for, he would not accept a resident even if the resident
had a medical clearance. (Doc. 205-1) at 3, depo. at 26-27.
Valencia understood that the shift supervisor should call 911 if the shift supervisor
believes a resident is under the influence of drugs or unable to breathe, and that a shift supervisor
should call Nurse Archuleta if a staff member reports that a resident is having trouble breathing.
(Doc. 185-7) at 3, depo. at 22; (Doc. 206) at 11-12. Valencia also knew that a heroin overdose
can result in difficulty breathing. (Doc. 185-7) at 4, depo. at 90. Valencia, however, did not

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have any training on the symptoms of drug intoxication or withdrawal. (Doc. 186-6) at 2, depo.
at 18. He agreed that neither a shift supervisor nor a life skills worker is qualified to perform
medical assessments. Id. at 2, depo. at 19.
(2) Edmunds
Edmunds knew that when nursing personnel was not present at night, the nurse would
conduct a medical assessment in the morning. (Doc. 186-2) at 2, depo. at 7-9. Edmunds noted
in his deposition testimony that it was the custom at the YDP to let residents “sleep off” drugs or
alcohol if they had been medically cleared, and to call the nurse if there was a concern. Id. at 45, depo. at 141-42. Edmunds also noted a marked increase in the number of residents with
heroin addiction. Id. at 6, depo. at 161.
Edmunds knew that a difficulty breathing is a serious condition and that medical
personnel should be called immediately in that situation. (Doc. 185-6) at 2, depo. at 55-56.
Edmunds was trained to call the on-call nurse when a resident had a health need, any time a
resident had a medical clearance, or if there was a question of whether a resident was under the
influence of drugs. (Doc. 186-2) at 2, depo. at 7-8. On the other hand, Edmunds stated in his
deposition testimony that he was not trained on the symptoms of a heroin overdose. (Doc. 1862) at 3, depo. at 111 and 112. Edmunds was also not trained in conducting medical assessments,
but he testified that he was trained to watch for potential issues that may involve the medical
condition of a resident. Id. at 2, depo. at 9; (Doc. 205-10) at 3, depo. at 5-6.
(3) Ortega
Ortega indicated that it was the practice, when a nurse was not present at the YDP at
night, to accept an alert and functioning resident with a medical clearance, place the resident in a
day room to sleep in a boat, check on the resident every 15 minutes through the night, and then

9

have medical personnel check on the resident in the morning. (Doc. 186-12) at 3-4, depo. at 2630. If the resident was intoxicated, then the YDP would not accept the resident. Id. at 3, depo. at
26.
Ortega, likewise, knew that difficulty breathing is a serious condition and that one should
immediately call medical personnel or 911 if a resident has breathing difficulties. (Doc. 185-4)
at 2, depo. at 20-21. Ortega also knew that in monitoring Gonzales, he was monitoring her
breathing. Id. at 3, depo. at 63. Even so, Ortega testified at his deposition that he did not have
training on opioid or heroin overdose signs and symptoms, or training on how to monitor a
resident who recently experienced a heroin overdose. (Doc. 186-12) at 2, depo. at 18. Ortega,
however, was trained not to accept residents who, if intoxicated, are not coherent, and he was to
trained to know that signs of being under the influence of drugs and alcohol include slurred
speech, not being mentally alert, and being unable to stay awake. (Doc. 205-8) at 3-4, depo. at
16-17. Ortega further knew that medical personnel should be called when a resident exhibits
signs and symptoms of being under the influence of drugs. Id.
(4) Coronado
Coronado testified at her deposition that if a resident is incoherent, she should notify her
supervisor, who would call medical personnel. (Doc. 186-7) at 2, depo. at 11. Coronado stated
she was trained on intake to look at a resident’s speech and mobility, but she was not trained on
drug intoxication symptoms or on how to help a resident who was intoxicated. Id. at 2, depo. at
12-13. Nonetheless, Coronado testified at her deposition that with her first aid training she could
recognize the physical condition of a resident and determine whether that person should be
accepted at the YDP. (Doc. 205-9) at 2, depo. at 63-64. There is no documentation that
Coronado received any training on the receiving screening policy. (Doc. 186-5) at 4.

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(5) Archuleta
At her deposition, Nurse Archuleta testified that she recognized that drug withdrawal can
be a problem at a youth detention center and that residents under the effects of drugs, even if
they can walk and talk, should be sent to a hospital. (Doc. 186-1) at 2, depo. at 38 and 41. Nurse
Archuleta also agreed that there was a policy of constant observation when a resident is at risk of
progressing to a more severe level of withdrawal or intoxication. (Doc. 186-1) at 3-4, depo. at
97-98. Nurse Archuleta testified at her deposition that, because Gonzales was medically cleared,
she did not feel that staff should keep Gonzales under constant observation, nor did she feel that
Gonzales needed an immediate assessment. Id. at 4, depo. at 98-99, 101.
B. Standard of Review
Summary judgment is appropriate if the moving party shows “there is no genuine dispute
as to any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P.
56(a). Once the moving party meets its initial burden of demonstrating the absence of a genuine
issue of material fact, the burden shifts to the nonmoving party to set forth specific facts showing
that there is a genuine issue for trial. See Schneider v. City of Grand Junction Police Dep't, 717
F.3d 760, 767 (10th Cir. 2013). A dispute over a material fact is “genuine” only if “the evidence
is such that a reasonable jury could return a verdict for the nonmoving party.” Anderson v.
Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). The Court views the facts in the light most
favorable to the nonmoving party and draws all reasonable inferences in the nonmoving party’s
favor. Tabor v. Hilti, Inc., 703 F.3d 1206, 1215 (10th Cir. 2013).

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C. Discussion
1. Count Two: Section 1983 Claims
Government or municipal liability under Section 1983 attaches only to the actions “for
which the municipality is actually responsible,” i.e., municipal liability does not encompass
liability under the doctrine of respondeat superior. Schneider, 717 F.3d at 770 (citation
omitted). For a governmental entity to be subject to liability under Section 1983, a plaintiff must
show “three elements: (1) official policy or custom, (2) causation, and (3) state of mind.” Id. at
769.
a. The “Sleep it Off” Custom
Plaintiff argues that the County did not implement its receiving screening policy during
the night when a nurse was not present at the YDP. Rather, Plaintiff asserts that the County’s
actions
all culminated into an unconstitutionally dangerous policy, custom, and practice at the
facility wherein inmates suspected of intoxication or withdrawal were not appropriately
screened pursuant to the receiving screening policy, were not appropriately evaluated
pursuant to the intoxication and withdrawal policy, and instead, were allowed to ‘sleep it
off’ under the watch of untrained eyes so long as they had a medical clearance from a
doctor or hospital.
(Doc. 181) at 21. Plaintiff maintains that this unconstitutional custom caused the County’s
employees to violate Gonzales’ rights under the Fourteenth and Eighth Amendments, and that
the County’s custom reflected deliberate indifference on the part of the County.
The first element of municipal liability, an official policy or custom, includes “a wellsettled custom or practice.” Schneider, 717 F.3d at 770. A municipality’s inaction, like failing
to implement a policy, can constitute a custom. Triplett v. District of Columbia, 108 F.3d 1450,
1453 (D.C.Cir.1997) (noting “inaction giving rise to or endorsing a custom” can be basis of
Section 1983 liability); Garcia v. Salt Lake Cty., 768 F.2d 303, 307 (10th Cir. 1985) (finding that
12

sufficient evidence supported jury’s conclusion that despite policy statements county had
unconstitutional custom on medical care). A custom is an act that “has such widespread practice
as to have the force of law.” Carney v. City & Cty. of Denver, 534 F.3d 1269, 1274 (10th Cir.
2008). “In order to establish a custom, the actions of the municipal employees must be
‘continuing, persistent and widespread.’” Id. (citation omitted). Most commonly, plaintiffs
demonstrate the existence of a “continuing, persistent and widespread custom” by “offer[ing]
evidence suggesting that similarly situated individuals were mistreated by the municipality in a
similar way.” Id.
The evidence, even when viewed in the light most favorable to Plaintiff, shows three
YDP staff members testified at depositions that the custom at the YDP in receiving residents at
night when a nurse was not present was to (1) determine whether the resident had a medical
clearance, (2) determine, nonetheless, whether the resident was coherent and mobile, (3) if the
resident had a medical clearance and was coherent and mobile, place the resident in a boat in a
day room where staff could check on the resident every 15 minutes as the resident slept, and (4)
ensure a nurse would check on the resident in the morning. From this evidence, a reasonable
jury could possibly find that the “sleeping it off” custom was “continuing, persistent and
widespread.” Plaintiff, however, has not presented evidence from which a reasonable jury could
find that the custom necessarily had “the force of law.”
Assuming that Plaintiff has established such a custom, the next inquiry is whether
Plaintiff has shown that the “sleeping it off” custom violated the Fourteenth or Eighth
Amendments, which prohibit deliberate indifference to a prisoner’s serious medical needs.4 The

4

Plaintiff does not specify in the Complaint if she considered Gonzales a pre-trial detainee or a
post-conviction inmate. The County and Plaintiff, however, only refer to the Eighth Amendment
in the Motion for Summary Judgment and accompanying briefing. Whether Plaintiff brings the
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Court notes that if a plaintiff alleges that a custom is unconstitutional on its face, as Plaintiff
seems to allege here, causation and state of mind are shown by “simply proving the existence of
the unlawful policy.” Barney v. Pulsipher, 143 F.3d 1299, 1307 (10th Cir. 1998) (citation
omitted).
Plaintiff cites Garcia v. Salt Lake Cty. as an analogous case wherein the Tenth Circuit
upheld the jury’s finding that the county’s custom violated a prisoner’s Eighth Amendment right
to adequate medical care. 768 F.2d at 307 (holding that sufficient evidence existed to support
jury’s finding that county’s “practice on medical care violated the established constitutional
standard”). In Garcia, the county sheriff had a written policy of not allowing deputies to take
semi-conscious or unconscious prisoners to the jail. Id. at 306 . Despite this written policy,
there was a custom of taking semi-conscious or unconscious persons suspected of being
intoxicated to the jail. Id. 306-07 (“there was proof that the Salt Lake County jail personnel
implemented the policy or custom of admitting to the jail persons in an unconscious condition
who were suspected of being intoxicated ….”). The Tenth Circuit concluded that the custom
itself was unconstitutional under the Eighth Amendment. Id. at 307.
In making the Eighth Amendment deliberate indifference determination, the Tenth
Circuit relied on the following facts. First, “there was no physician present at the jail most of the
time,” “[a] nurse was at the jail ‘four to five hours five days a week,’” and “[a] medical
technician was on duty from 5 a.m. until 1 p.m. and from 1 p.m. until 9 p.m.” Garcia, 768 F.2d
at 308. Second, when the jail was full, it could house “[a]s many as 400 inmates.” Id. Third,

Section 1983 claim under the Fourteenth or Eighth Amendment, the same deliberate indifference
standard applies. See Martinez v. Beggs, 563 F.3d 1082, 1088 (10th Cir. 2009) (holding that
deliberate indifference standard applies to pre-trial detainees under Fourteenth Amendment);
Hunt v. Uphoff, 199 F.3d 1220, 1224 (10th Cir. 1999) (holding that deliberate indifference
standard applies to post-conviction inmates under Eighth Amendment).
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officers found Garcia semi-conscious outside a hospital. Id. at 305. Fourth, the doctor at the
hospital released Garcia to officers when they said the jail staff could observe him. Id. Fifth,
when Garcia was booked into the jail, the medical technician instructed that Garcia be checked
every 15-20 minutes. Id. at 308. Sixth, Garcia was only actually checked on about every 30
minutes by a “search and print officer” and once by the medical technician. Id. Finally, “[n]o
medical personnel were present in the” jail when Garcia stopped breathing approximately six
hours after having been booked into the jail. Id.
The Tenth Circuit concluded that
the jury's finding against the County is supported by sufficient evidence of gross
deficiencies and deliberate indifference in staffing and procedures to monitor persons
admitted to the jail in an unconscious condition who are suspected of being intoxicated.
The record supports the conclusion that the County's policy of admitting to jail
unconscious persons suspected of being intoxicated, carried out with the described
deficiences and indifference, caused a violation of Garcia's constitutional rights.
The Tenth Circuit further noted a single incident of unconstitutional activity arising from an
unconstitutional custom, like in Garcia, is sufficient to show municipal liability if the
unconstitutional custom caused the incident and the unconstitutional custom can be attributed to
a municipal policy maker. Id. at 308 n. 4 (“Proof of a single incident of unconstitutional activity
is not sufficient to impose liability under Monell, unless proof of the incident includes proof that
it was caused by an existing, unconstitutional municipal policy, which policy can be attributed to
a municipal policymaker.”) (quoting City of Oklahoma City v. Tuttle, 471 U.S. 808, 823-24
(1985)). The Tenth Circuit determined that the unconstitutional custom at issue in Garcia could
be attributed to the county sheriff, a chief elected county official who was in charge of the jail,
and who, therefore, was a municipal policy maker. Id.
Garcia is factually distinguishable from this case in several ways. The custom in Garcia
was to book semi-conscious or unconscious prisoners, a custom easily reflecting deliberate
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indifference to the serious medical needs of prisoners. In this case, the custom was to accept
residents who were at least coherent and mobile at the time of booking. Also, there is no
evidence in this case suggesting that the number of residents housed at the YDP at any one time
came close to as many as 400. Additionally, the medical clearance in this case noted that no
further care was required while in Garcia the prisoner was released from the hospital with the
understanding that the jail staff would observe him. Finally, the evidence here indicates that
Edmunds and Ortega, in fact, checked on Gonzales every 15 minutes, unlike the staff in Garcia.
Moreover, considering that Plaintiff relies on a single incident to demonstrate municipal
liability based on an unconstitutional custom, Plaintiff has failed to come forward with any
evidence to show that the “sleep it off” custom can be attributed to a municipal policymaker, like
an YDP administrator or warden. For this reason alone, a reasonable jury, viewing the evidence
in the light most favorable to Plaintiff, could not find, even if there was a “sleep it off” custom,
that liability could be assigned to the County on the basis of that custom. Accordingly, the
County is entitled to summary judgment on the Section 1983 municipal liability claim premised
on the “sleep it off” custom.
b. Failure to Train
Plaintiff argues that the County’s failure to train officers on the receiving screening
policy, how to recognize the signs and symptoms of heroin intoxication and withdrawal, and how
to monitor residents for signs and symptoms of heroin intoxication and withdrawal directly
caused Gonzales’ respiratory distress and subsequent death. The first element of municipal
liability, an official policy or custom, includes either inadequate training or failure to train.
Schneider, 717 F.3d at 770 (observing that official policy or custom element of municipal

16

encompasses “deliberately indifferent training.”). The Court will, thus, address the causation and
state of mind elements related to Plaintiff’s failure to train claims.
(1) Causation
When municipal liability is based on inadequate training, “rigorous standards of
culpability and causation must be applied to ensure that the municipality is not held liable solely
for the actions of its employee.” Id. (citation omitted). “That a particular officer may be
unsatisfactorily trained will not alone suffice to fasten liability on the city, for the officer's
shortcomings may have resulted from factors other than a faulty training program,” like
negligent administration of “an otherwise sound program….” City of Canton, Ohio v. Harris,
489 U.S. 378, 390-91 (1989). “[S]howing merely that additional training would have been
helpful in making difficult decisions does not establish municipal liability.” Connick v.
Thompson, 563 U.S. 51, 68 (2011). Additionally, “adequately trained officers occasionally make
mistakes; the fact that they do says little about the training program or the legal basis for holding
the city liable.” Canton, 489 U.S. at 391.
With respect to training on the receiving screening policy, a reasonable jury viewing the
evidence in the light most favorable to Plaintiff could find that, despite trainings on “policies,” it
is unclear from that label whether training included the receiving screening policy. Specifically,
Gonzales’ Intake Checklist indicates that a medical screening form was completed and placed in
the medical box so that a nurse could review it in the morning. This fact demonstrates that staff
was trained to follow the receiving screening policy’s provision regarding how to proceed when
a nurse is unavailable to complete a screening at the time of booking. Moreover, a reasonable
jury, viewing the evidence in the light most favorable to Plaintiff, could infer that despite
knowing she should complete medical screening forms, Coronado failed to complete Gonzales’s

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medical screening form. Such a mistake, however, “says little about the training program or the
legal basis for holding the city liable,” especially since Gonzales had a medical clearance, which
was enough to book Gonzales under the receiving screening policy. Canton, 489 U.S. at 391.
Next, with respect to training on the recognition of signs and symptoms of heroin
intoxication and withdrawal and training on monitoring residents for signs and symptoms of
heroin intoxication and withdrawal, it is undisputed that the County provided Valencia,
Edmunds, Ortega, and Coronado training on narcotics recognition, substance abuse, and medical
emergencies/urgencies. The training included recognizing narcotic/opiate symptoms like nausea,
“mental fogginess,” “blurred vision,” and “reduced physical activity.” (Doc. 205-3) at 3; (Doc.
205-5) at 2. Consistent with this training, Ortega testified at his deposition that he was trained
that signs of drug use include slurred speech, not being mentally alert, and being unable to stay
awake. The training further described symptoms associated with heroin or opiate withdrawal.
(Doc. 205-3) at 3; (Doc. 205-5) at 3. Additionally, the training recognized that drug use or
withdrawal can lead to breathing issues which require staff to monitor breathing, including
watching respiratory rates, and monitoring for “difficulty in arousing” the resident. (Doc. 205-4)
at 2-3. Valencia verified this training when he testified at his deposition that he knew that a
heroin overdose can result in difficulty breathing.5

5

The deposition testimony refers at times to “training” the deponents received and at other times
it refers to what the deponents “knew,” like Valencia knowing that a heroin overdose can result
in difficulty breathing, knowledge which would be consistent with training on narcotic
overdoses. Plaintiff does not assert that this kind of knowledge was not obtained through
training, although Plaintiff has the burden of showing that training was inadequate. See Barney,
143 F.3d at 1308 (holding that plaintiff must “come forward with evidence pertaining to the
adequacy of the instruction” received in training and that without that evidence courts “have no
reason to conclude that [a defendant] received constitutionally deficient training”). As such, the
Court will construe “knowledge” deposition testimony as knowledge gained through training.
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Despite this training, Valencia, Edmunds, Ortega, and Coronado stated in their respective
depositions that they were not trained on the signs and symptoms of a heroin overdose or
withdrawal. This contradictory deposition testimony shows that these particular YDP staff
members were perhaps unsatisfactorily trained, could have used additional training, or were
adequately trained but simply made mistakes the night Gonzales was incarcerated at the YDP.
Such situations alone are insufficient to establish municipal liability.
Even if one assumed that Valencia, Edmunds, Ortega, and Coronado did not receive any
training on the signs and symptoms of a heroin overdose or withdrawal or on monitoring for
signs and symptoms of a heroin overdose or withdrawal, Valencia, Edmunds, and Ortega,
nevertheless, all admitted that if a resident exhibited difficulty breathing, whatever the cause,
they knew to call 911 or medical personnel, which they eventually did. Coronado further
testified at her deposition that she had sufficient first aid training to recognize the physical
condition of a resident and to determine whether that person should be accepted at the YDP. She
also testified that she was trained on intake to examine a resident’s speech and mobility, and to
call a supervisor if a resident is incoherent. Valencia testified at his deposition that if a resident
was under the influence of drugs, i.e., incoherent, he would not accept the resident and, instead,
send the resident to the hospital, regardless of a medical clearance. Edmunds testified at his
deposition that he was trained to call the nurse if a resident has a health need, if a resident has a
medical clearance, and if he has questions about whether a resident was under the influence of
drugs. Edmunds further testified that he was trained to watch for potential issues associated with
the medical condition of a resident. In addition, Ortega knew to call medical personnel when a
resident exhibited signs and symptoms of being under the influence of drugs and he was trained
not to accept incoherent residents. Ortega testified at his deposition that staff would monitor

19

residents every 15 minutes through the night if they had been accepted with a medical clearance
and that he knew that in monitoring Gonzales he was checking on her breathing.
Based on this evidence, a reasonable jury, having viewed the evidence in the light most
favorable to Plaintiff, could not find that the County inadequately trained or failed to train YDP
staff when to seek medical attention if a resident appeared to be in physical distress, and could
not find that the County did not adequately train or failed to train YDP staff to monitor residents
every 15 minutes if they are accepted with a medical clearance. Under the circumstances of this
case, had YDP staff heeded their training regarding residents in physical distress, Gonzales
would not have become unresponsive while in their care. In other words, YDP staff’s failure to
follow this training caused harm to Gonzales, not any lack of training specific to recognizing the
signs and symptoms of heroin overdose and withdrawal, or monitoring a resident for signs and
symptoms of heroin overdose and withdrawal.
In sum, applying a rigorous causation standard, a reasonable jury viewing the evidence in
the light most favorable to Plaintiff could not find that the County’s alleged inadequate training
or lack of training caused harm to Gonzales. Nevertheless, assuming arguendo that Plaintiff has
shown the requisite causation, the Court will address the deliberate indifference requirement of
Plaintiff’s failure to train claims.
(2) Deliberate Indifference
The third element, state of mind, requires that when the theory of municipal liability, like
failure to train, relies on a “facially lawful” policy, like a training policy, a plaintiff must
demonstrate that “the municipal action was taken with ‘deliberate indifference’ as to its known
or obvious consequences.” Schneider, 717 F.3d at 770 (citation omitted). “The deliberate
indifference standard may be satisfied when the municipality has actual or constructive notice

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that its action or failure to act is substantially certain to result in a constitutional violation, and it
consciously or deliberately chooses to disregard the risk of harm.” Id. at 771 (citation omitted).
Although notice can usually “be established by proving the existence of a pattern of tortious
conduct,” in some “narrow range of circumstances, … deliberate indifference may be found
absent a pattern of unconstitutional behavior if a violation of federal rights is a highly predictable
or plainly obvious consequence of a municipality's action or inaction[.]” Id. (citation omitted).
In the case of a failure to train claim, “even a showing of gross negligence by the municipality is
inadequate to meet the state-of-mind requirement.” Blueberry v. Comanche Cty. Facilities Auth.,
672 F. App'x 814, 817 (10th Cir. 2016).
Specific or extensive training may not be necessary, however, for a jailer to know that
certain conduct is inappropriate. Sexual assault is a clear example of conduct that a jailer would
know is unlawful, regardless of training. Barney, 143 F.3d at 1308 (“Specific or extensive
training hardly seems necessary for a jailer to know that sexually assaulting inmates is
inappropriate behavior.”). Furthermore, although failure to recall training “may reflect upon the
quality of the training, deficiencies in the training of particular officers” do not put the
municipality “on notice of the need for better training.” Johnson v. Dixon, 666 F. App'x 828,
831 (11th Cir. 2016).
In this case, Plaintiff does not provide evidence of a “pattern of tortious conduct” to
establish notice on the part of the County. Plaintiff argues, instead, that the violation of
Gonzales’ federal rights was “a highly predictable or plainly obvious consequence of” the
County’s failure to train. Indeed, Plaintiff presents general evidence that juveniles in detention
centers who are under the influence of narcotics and who may be suffering from narcotic
withdrawal is a recurring problem that is highly predictable. Plaintiff argues that “despite

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recognizing the obvious potential that its offices would routinely encounter young persons
intoxicated with or withdrawing from heroin, YDP did not prepare its officers for those
encounters.” (Doc. 181) at 37. To support this argument, Plaintiff cites several cases wherein
courts found either no training on a mental health condition, superficial training on alcohol
withdrawal signs and symptoms, or inadequate training inferred from the wrongful conduct of
jail staff. Olsen v. Layton Hills Mall, 312 F.3d 1304, 1319 (10th Cir. 2002) (finding that
appellant alleged facts that “County manifested deliberate indifference by failing to train its jail’s
prebooking officers to recognize [obsessive compulsive disorder (OCD)] and handle sufferers
appropriately”); Trujillo v. Management and Training Corporation, et al., Civ. No. 15-544
WJ/SMV, (Doc. 56) at 16, filed April 15, 2016 (stating that reasonable juror could infer that
failure to correctly fill out health care request form was result of inadequate training); M.H. v.
City of Alameda, 62 F.Supp. 3d 1049, 1083-84 (N.D. Cal. 2014) (finding that plaintiff produced
evidence of cursory or no training on alcohol withdrawal signs and symptoms including training
logs that did not describe training content).
The cases Plaintiff cites, however, are distinguishable from this case and so lack
persuasive authority. Indeed, Plaintiff concedes that in Olsen, the “officers ‘received absolutely
no training on OCD….”’ (Doc. 181) at 37. Here, the undisputed evidence shows, at the very
least, that YDP staff received some training on drug intoxication and withdrawal as well as on
monitoring. Plaintiff admits that in Trujillo Judge Johnson made his ruling “based solely on the
wrongful conduct of the jail officers” without “specifically consider[ing] the jail’s training
policies or evidence regarding same.” Id. at 35. Evidence regarding YDP’s training policies is,
in fact, a subject of this Motion for Summary Judgment. The plaintiff in M. H. produced
evidence from an officer “designated the County’s person most knowledgeable” about training

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who characterized training on alcohol withdrawal signs and symptoms as “very little” and
“cursory,” as well as evidence from a staff member who was unable to recall such training and
from training logs that did “not describe their content.” 62 F.Supp.3d at 1083-84. In this case,
there is no evidence from a “knowledgeable” County official regarding the training at issue, let
alone a County official describing the training as somehow cursory. Moreover, the County has
provided evidence of the content of the various trainings reported in the training logs and
certificates.
Notwithstanding these cases, Plaintiff fails to present evidence, pertinent to this case,
from which a reasonable jury could find that it is “highly predictable and plainly obvious” that
receiving residents with medical clearances after being treated for heroin overdoses will result in
denying those residents of the right to adequate medical services. Indeed, in this case, the
administration of lorazepam, a drug that complicates opioid treatment and adds pharmacologic
risk, could have altered the typical situation faced by YDP staff when a resident arrives with a
medical clearance that requires no further care. Nonetheless, a reasonable jury, considering the
evidence in the light most favorable to Plaintiff, could not find that specific or extensive training
is necessary for YDP staff to know that medical personnel should be called when a resident is
nauseous, not in a right state of mind, groggy eyed, slurring speech, tired, and having difficulty
breathing. Furthermore, the failure by three particular YDP staff members to recall training on
the signs and symptoms of heroin overdose and withdrawal does not necessarily indicate that the
County was on notice of a need for better overall training.
In this case, it is undisputed that YDP staff knew, presumably through relevant trainings,
whether formal or informal, to accept residents with medical clearances, to turn away residents
who are not coherent and mobile, to monitor residents with medical clearances every 15 minutes

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through the night until a nurse assesses them in the morning, and to call for medical assistance if
a resident is generally in physical distress or is having difficulty breathing. Considering the
above evidence even in the light most favorable to Plaintiff and considering the rigorous standard
of culpability to be employed in the failure to train context, a reasonable jury could not find that
the County’s alleged failure to train amounted to deliberate indifference to the constitutional
right to adequate medical care. Hence, the County is entitled to summary judgment on the
failure to train claims. In sum, the Count Two claims against the County will be dismissed with
prejudice.
2. Count Three: NMTCA Claims
The County argues that it is also entitled to summary judgment on the NMTCA negligent
failure to provide adequate medical care claim, brought under Section 41-4-12 of the NMTCA,
and the negligent operation of a building claim, brought under Section 41-4-6 of the NMTCA.
The County specifically argues, with respect to Section 41-4-12, the NMTCA provision waiving
immunity for law enforcement officers who violate a person’s constitutional rights, that Plaintiff
has not shown that negligence by the County caused YDP staff members to violate Gonzales’
constitutional right to receive adequate medical care. As discussed above, a reasonable jury
could not find that the County’s actions or inactions caused a County employee to violate
Gonzales’ constitutional right to receive adequate medical care.
Even so, Plaintiff contends that simple negligence by the County, acting through its
employees, in providing adequate medical care waives immunity for law enforcement officers.
However, it is well-established in New Mexico “that under Section 41-4-12, ‘immunity is not
waived for negligence standing alone.’” Lessen v. City of Albuquerque, 2008-NMCA-085, ¶ 35,
144 N.M. 314 (citation omitted). Rather, to proceed under Section 41-4-12, a plaintiff must

24

allege that negligence caused a specified tort or violation of rights enumerated in Section 41-412. Id. (“[T]he negligence complained of must cause a specified tort or violation of rights.”)
(quoting Caillouette v. Hercules, Inc., 1992-NMCA-008, ¶ 18, 113 N.M. 492).
Plaintiff further contends that negligence alone is enough under Section 41-4-12 if a duty
is owed. The New Mexico Supreme Court in Methola v. Eddy Cty., indeed, noted a common law
duty for a custodian, like a jailer, “to exercise reasonable and ordinary care for the protection of
the life and health of the person in custody.” 1980-NMSC-145, ¶ 23, 95 N.M. 329 (quoting City
of Belen v. Harrell, 1979-NMSC-081, ¶ 15, 93 N.M. 601 (1979)). The New Mexico Supreme
Court then stated that the NMTCA is in derogation of such common law rights to sue for
negligence and so the NMTCA must be construed strictly. Id. Considering that the NMTCA is
in derogation of the common law and considering the legislative intent behind the 1977
amendments to the NMTCA,6 the New Mexico Supreme Court in Methola concluded “that the
Legislature intended ‘caused by’ in Section 41-4-12 to include those acts enumerated in that
section which were caused by the negligence of law enforcement officers while acting within the
scope of their duties.” 1980-NMSC-145, at ¶ 24. Accordingly, negligence alone, i.e., Plaintiff’s
allegation that the County was negligent by failing to provide adequate medical care, does not
suffice to waive immunity under Section 41-4-12. The County, thus, is entitled to summary
judgment on the Count Three claim brought under Section 41-4-12.
Regarding waiver of immunity for negligent operation of a building, the New Mexico
Supreme Court has ruled that the waiver extends to “dangerous conditions created by the
negligence of public employees in the ‘operation or maintenance’ of public buildings,” including

6

“The 1977 amendments, under Section 41-4-12 removed immunity of law enforcement officers
for ‘personal injury ... caused by (them)’ ….” Methola, 1980-NMSC-145, at ¶ 13.

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“safety policies necessary to protect the people who use the building.” Upton v. Clovis Mun.
Sch. Dist., 2006-NMSC-040, ¶ 9, 140 N.M. 205, as revised (Sept. 12, 2006). A single discrete
administrative decision affecting only one inmate does not fall within the Section 41-4-6 waiver.
Id. at ¶ 20 (observing that Section 41-4-6 waiver applies where “dangerous condition based on
more than just a single administrative decision affecting only one inmate….”). The question,
then, is whether the County, through its employees, made “a single, discrete administrative
decision affecting only a single person, as opposed to a dangerous condition affecting the
general” population at the YDP. Id. at ¶ 17.
Plaintiff contends that the County’s actions or inactions pertained to the provision of
medical care which affects all residents at the YDP. However, even viewing the evidence in the
light most favorable to Plaintiff, a reasonable jury could not find that the “sleep it off” custom is
attributable to the County and that the County failed to provide adequate medical/narcotics
training. Hence, a reasonable jury could not find that the County’s actions or inactions adversely
affected the health of the general population at the YDP. Instead, the decisions of the YDP staff
in this case occurred on one occasion affecting only one resident, Gonzales. Consequently,
Section 41-4-6 does not provide waiver of immunity regarding Plaintiff’s allegation that the
County negligently operated the YDP building. The County, therefore, is entitled to summary
judgment on the Section 41-4-6 claim brought under Count Three. For the foregoing reasons,
Count Three will be dismissed with prejudice as it relates to the County.
IT IS ORDERED that
1. Defendant Santa Fe County’s Motion for Summary Judgment (Doc. 163) is granted;
2. summary judgment will be entered in the County’s favor on all claims brought by
Plaintiff; and

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3. those claims will be dismissed with prejudice, thereby terminating the County as a
Defendant in this matter.

_______________________________
UNITED STATES DISTRICT JUDGE

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