KOUKOS et al v. CHESTER COUNTY et al

Filing 20

MEMORANDUM SIGNED BY HONORABLE GERALD J. PAPPERT ON 2/7/17. 2/8/17 ENTERED AND COPIES E-MAILED. (va, )

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF PENNSYLVANIA
CHRISTOPHER KOUKOS, et al.,
Plaintiffs,

CIVIL ACTION
NO. 16-4602

v.
CHESTER COUNTY, et al.,
Defendants.
PAPPERT, J.

February 7, 2017
MEMORANDUM

Plaintiffs Christopher Koukos, a former inmate of Chester County Prison, and his wife
Carly sued Chester County, PrimeCare Medical Inc., Prison Warden D. Edward McFadden,
Prison Deputy Warden of Treatment Ronald M. Phillips, Medical Assistant Jenice Abney, Nurses
Amanda Hines and Samantha Budynkiewcz, Medical John Does 1–101 and Correctional John
Does 1–7.2 Koukos alleges, inter alia, that Defendants provided inadequate medical care in
violation of his rights under 42 U.S.C. § 1983 and the Eighth Amendment to the United States
Constitution. Currently before the Court is a motion to dismiss for failure to state a claim filed
by Chester County, McFadden, Phillips and Correctional Does. As explained below, the Court
grants in part and denies in part the Defendants’ motion.
I.
On August 20, 2014, Christopher Koukos was sentenced by the Chester County Court of
Common Pleas to nine to twenty-three months of incarceration. (Pls.’ Am. Compl. ¶ 27, ECF
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Medical John Does 1-7 were medical professionals employed by PrimeCare assigned to provide medical
services at Chester County Prison. Plaintiffs do not presently know the names of Defendants but will seek leave to
amend the complaint after initial discovery. (Pls.’ Am. Compl. ¶ 10.)
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Likewise, Correctional John Does 1-10 are yet unidentified correctional officers or supervisors employed
by Chester County to work at CCP. (Id. ¶ 13.)

1

No. 10, Ex. 1.) Prior to his sentencing, Koukos was being treated for various medical conditions
for which he was prescribed several medications. Specifically, he was taking diazepam,
metoprolol, oxycodone, oxycontin, paroxetine, prilosec, paxil and klonopin for ailments which
included tachycardia, neck and shoulder pain, migraines, numbness in his extremities and posttraumatic stress disorder. (Id. ¶¶ 18–19.) In anticipation of his incarceration, Koukos consulted
with his physicians and obtained from them a summary of his medical history, treatment and
prescribed medications, together with the actual medications in their prescription bottles
(“medical needs package”) to bring with him for presentation to the appropriate prison medical
personnel. (Id. ¶ 20.) He took his last dose of medication at 11:00 a.m. on the day of his
sentencing. (Id.) He was sentenced at 1:00 p.m. and arrived at Chester County Prison (“CCP”)
at approximately 3:00 p.m. (Id. ¶¶ 17, 21.)
Upon his arrival, he presented his medical needs package to Correction Doe 1, a young
African American male correctional officer. (Id. ¶ 21.) Koukos alleges that Correction Doe 1
wrongfully informed him that his package would be transferred to PrimeCare, the private
company that provides health services to CCP inmates, for consideration and distribution.
Koukos contends that Correction Doe 1 knew or should have known that his package would be
destroyed. (Id. ¶ 21.) At approximately 8:00 p.m. he was seen by a PrimeCare Medical
Assistant Jenice Abney, for what he later learned was an initial intake medical examination. (Id.
¶ 22.) During the examination, Koukos requested that he be permitted to take a dose of his next
scheduled medication, an opiate, because he had already missed one dose. (Id. ¶ 23.) According
to Koukos, Abney informed him that all of the medication he had brought into the prison would
be destroyed and that she was unable to provide him any of his prescribed medications, since any

2

medications would need to be prescribed by a PrimeCare doctor. There was, however, no doctor
regularly at the prison. (Id.)
At the conclusion of the examination, Abney noted in prison records that Koukos was at
risk for opiate and benzodiazepine withdrawal and that he had a heart condition. (Id. ¶ 24.) She
also noted that for medical reasons, Koukos should be assigned to a bottom bunk. (Id.) Amanda
Hines, a licensed practical nurse employed by PrimeCare, reviewed Abney’s notes prior to the
conclusion of the examination and was therefore also aware of Koukos’s medical needs. (Id. ¶
25.) Koukos alleges that neither Abney nor Hines informed him of his “right” to a bottom bunk
assignment or took any actions to ensure that Koukos would thereafter be monitored or evaluated
while undergoing opiate and benzodiazepine detoxification. (Id. ¶¶ 24, 25, 27.)
His intake examination concluded around 10:00 p.m. At that time, Koukos alleges that
Correctional Does 2 and 3 were “either not personally advised of and/or in any event ignored the
[ ] medical designation and instead assigned [Koukos] to occupy the top bunk in a cell, placing
him at serious, foreseeable, and known risk of falling and sustaining serious bodily injury or
death.” (Id.) By 10:15 p.m., as a result of having been without his prescription medication for
approximately eleven hours, Koukos began to experience debilitating physical and psychological
withdrawal symptoms, including prolonged spasms, shaking and profuse sweating. (Id. ¶ 28.)
He informed Correctional Doe 4 that he had not received his necessary medication and was
feeling ill, to which Doe 4 allegedly responded, “Get away from me, you’re making me nervous.
Medical is closed.” (Id. ¶ 29.) Koukos immediately requested and filled out a medical request
slip indicating that he was suffering from opiate and benzodiazepine withdrawal and that the
prison had failed to provide him with the appropriate detox medication as well as his prescribed
medication for tachycardia. (Id. ¶ 30.) He then tried to sleep but was unable to due to

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increasingly severe withdrawal symptoms, which in turn began to exacerbate his tachycardia.
(Id. ¶ 31.)
On August 21 Koukos went to breakfast but was unable to eat due to nausea, stomach
cramping and his other ongoing symptoms of withdrawal. (Id. ¶ 32.) At that time, he spoke to
Correctional Doe 5 and requested to be sent to the medical department to be evaluated and
receive treatment for his symptoms of profuse sweating, shaking and disorientation, which he
alleges were or should have been apparent to Doe 5. (Id.) According to Koukos, Correction Doe
5 denied his request and sent him back to his cell. (Id. ¶ 33.) Koukos then completed another
medical request slip seeking attention for his worsening symptoms of opiate withdrawal and
tachycardia. (Id.)
Koukos was similarly unable to eat lunch so he submitted another medical request slip
seeking treatment, this time to Correction Doe 6. (Id. ¶ 34.) That request was also denied and he
was taken to his cell. (Id.) As a result, Koukos’s symptoms further intensified, exacerbating his
heart condition and causing him to shake and sweat uncontrollably. (Id. ¶ 37.) He claims
Correctional Does continued to ignore these observed symptoms and he was left in his top bunk
and denied medical attention. (Id.)
In the early morning hours of August 22, allegedly as the result of his withdrawal
symptoms, sleeplessness and uncontrollable spasms, Koukos fell from the upper bunk. (Id. ¶
38.) His face struck the cell’s steel desk and his body slammed into a metal chair. (Id. ¶ 38.) He
landed face first on the floor of the cell and sustained various injuries, including a concussion
with loss of consciousness, nasal swelling, rib fractures, right hip bruising, abrasions to his ribs
and knees, a right orbital rim fracture, soft tissue hemorrhage, left pleural effusion, bibasal lung

4

atelectasis and damage to his right optical nerve. (Id.) He was taken to the Chester County
Hospital emergency room. (Id. ¶¶ 38–39.)
Koukos was discharged a few hours later with instructions to take antibiotics, apply ice to
his face every twenty minutes to reduce swelling and to receive an evaluation at Ear, Nose and
Throat Associates of Chester County (“ENTACC”) within two to three days. (Id. ¶ 41.) Despite
these instructions, Koukos alleges that Defendants failed to provide him with antibiotics, ice and
pain medication, leaving him in excruciating pain for many days. (Id. ¶ 42.) Upon his return
from the hospital, he was placed in solitary confinement on the medical block where he could,
ostensibly, be observed for ongoing complications. (Id. ¶ 43.) However, he alleges he was not
actually monitored for any further post-concussion or withdrawal symptoms and Defendants
continued to withhold the antibiotics, pain medication and ice for his injuries. (Id.)
On August 23 Koukos was seen by Medical Doe 1, who represented that he/she was a
physician assistant. Doe 1 told Koukos he would be transferred to a regular cell without further
treatment or monitoring. (Id. ¶ 44.) After the transfer, Koukos requested from Correctional Doe
7 that he be provided with ice packs; however, despite observing Koukos’s injuries, Doe 7 denied
his request “in direct violation of the treatment regime prescribed by the physician and medical
staff at Chester County Hospital.” (Id. ¶¶ 45–46.)
Despite the discharge instruction that Koukos be seen within two to three days of his
release from the ER, he was not taken to ENTACC to be examined for the ongoing pain in his
right eye until September 8, 2014. (Id. ¶ 47.) At that time, he was examined by a doctor and
underwent a diagnostic nasal endoscopy. (Id.) Koukos alleges that the delayed diagnostic
testing and the passage of time prevented further treatment from being an option. (Id.) He was

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instructed to return for a follow-up exam in one month. (Id. ¶ 48.) Defendants ignored this order
and did not bring him back to ENTACC. (Id.)
Koukos alleges that despite medical directives, Defendants withheld reasonable,
necessary and prescribed care, failed to ensure that he received the appropriate follow-up
treatment for his injuries and allowed him to remain in significant pain for approximately nine
months until he was able to seek treatment after his release. (Id. ¶ 49.) Koukos further alleges
that as the result of his fall, and subsequent denial of medical care, he has suffered permanent
injury: he can no longer read for more than ten minutes; experiences ongoing tenderness in his
right cheekbone which disrupts sleep; suffers from chronic pain in his right hip which affects his
mobility and experiences migraines and scarring under his right eye. (Id. ¶ 40.)
II.
To survive a motion to dismiss under Rule 12(b)(6), a plaintiff must plead factual
allegations sufficient “to raise a right to relief above the speculative level . . . on the assumption
that all the allegations in the complaint are true (even if doubtful in fact).” Bell Atl. Corp. v.
Twombly, 550 U.S. 544, 555 (2007). The “mere possibility of misconduct” is not enough.
Ashcroft v. Iqbal, 556 U.S. 662, 679 (2009). The court must construe the complaint in the light
most favorable to the plaintiff. See Connelly v. Lane Constr. Corp., 809 F.3d 780, 790 (3d Cir.
2016) (citations omitted). However, a court need not accept as true inferences drawn by the
plaintiff that are unsupported by facts. See Cal. Pub. Emps.’ Ret. Sys. v. Chubb Corp., 394 F.3d
126, 143 (3d Cir. 2004).
“While a complaint attacked by a Rule 12(b)(6) motion to dismiss does not need detailed
factual allegations, a plaintiff’s obligation to provide the ‘grounds’ of his ‘entitlement to relief’
requires more than labels and conclusions, and a formulaic recitation of the elements of a cause

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of action will not do.” Bell, 550 U.S. at 555 (2007) (citations and alterations
omitted); see Iqbal, 556 U.S. at 678 (2009) (“Threadbare recitals of the elements of a cause of
action, supported by mere conclusory statements, do not suffice.”). A court should “consider
only the allegations in the complaint, exhibits attached to the complaint, matters of public record,
and documents that form the basis of a claim.” Lum v. Bank of Am., 361 F.3d 217, 221 n.3 (3d
Cir. 2004). Whether a complaint states a plausible claim for relief is a context-specific task that
“requires the reviewing court to draw on its judicial experience and common sense.” Iqbal, 556
U.S. at 679 (citations omitted).
III.
In Count I, Koukos asserts claims pursuant to § 1983 for inadequate medical treatment
under the Eighth Amendment. To establish a prima facie case under § 1983, Koukos must first
demonstrate that a person acting under color of law deprived him of a federal right. See Groman
v. Twp. of Manalapan, 47 F.3d 628, 633 (3d Cir. 1995). Koukos must also show that the person
acting under color of law “intentionally” violated his constitutional rights or acted “deliberately
indifferent” in violation of those rights. See, e.g., Cty. of Sacramento v. Lewis, 523 U.S. 833,
843–44 (1998); Brower v. Cty. of Inyo, 489 U.S. 593, 596 (1989) (citing Hill v. California, 401
U.S. 797, 802–05 (1971)); see also Berg v. Cty. of Allegheny, 219 F.3d 261, 269 (3d Cir. 2000).
“The Eighth Amendment’s prohibition against cruel and unusual punishment protects
prisoners against the ‘unnecessary and wanton infliction of pain.’” Hamilton v. Leavy, 117 F.3d
742, 746 (3d Cir. 1997) (quoting Whitley v. Albers, 475 U.S. 312, 319 (1986)). Accordingly, “the
treatment a prisoner receives in prison and the conditions under which he is confined are subject
to scrutiny under the Eighth Amendment.” Farmer v. Brennan, 511 U.S. 825, 832 (1994)
(quoting Helling v. McKinney, 509 U.S. 25, 31 (1993)). The prohibition against cruel and

7

unusual punishment “requires prison officials to provide basic medical treatment to those whom
it has incarcerated.” Rouse v. Plantier, 182 F.3d 192, 197 (3d Cir. 1999).
A.
Koukos purports to bring Eighth Amendment claims against all Defendants, including
Chester County, Prison Warden McFadden and Prison Deputy Warden of Treatment Phillips, in
both their individual and official capacities. However, a suit against the county is analyzed under
the Monell framework, and suits against state officers in their official capacity are “only another
way of pleading an action against an entity of which an officer is an agent.” Kentucky v.
Graham, 473 U.S. 159, 165–66 (1985) (quoting Monell v. Dep't of Soc. Servs. of City of New
York, 436 U.S. 658, 690 n.55 (1978)); see also Brown v. Montgomery Cty., No. 08-4259, 2010
WL 742818, at *2 (E.D. Pa. Feb. 24, 2010) (holding that claims asserted against government
officers in their official capacity “effectively merge with claims against, the real party in interest,
[the] County”). Because Koukos also sued the County, his claims against McFadden and
Phillips in their official capacities are redundant, and the Court will only analyze the purported
claims against them in their individual capacities.
To establish an Eighth Amendment claim for inadequate medical treatment against
McFadden, Phillips and Correctional Does 1–7, Koukos must show that (1) Defendants were
deliberately indifferent to his medical needs and (2) those needs were serious. Rouse, 182 F.3d at
197. Defendants do not dispute that Koukos’s medical needs were serious. See generally (Defs.’
Mot. to Dismiss, ECF No. 11). The only issue is whether Defendants were “deliberately
indifferent” to those needs.
“It is well-settled that claims of negligence or medical malpractice, without some more
culpable state of mind, do not constitute ‘deliberate indifference.’” Rouse, 182 F.3d at 197.

8

Rather, deliberate indifference “requires obduracy and wantonness . . . which has been likened to
conduct that includes recklessness or a conscious disregard of a serious risk.” Id. (citation and
quotation omitted). Additionally, “[w]here a prisoner has received some medical attention and
the dispute is over the adequacy of the treatment, federal courts are generally reluctant to second
guess medical judgments and to constitutionalize claims which sound in state tort law.” Ascenzi
v. Diaz, 247 F. App’x 390, 391 (3d Cir. 2007) (quoting United States ex rel. Walker v. Fayette
Cty., 599 F.2d 573, 575 n.2 (3d Cir. 1979)). The Third Circuit has “found ‘deliberate
indifference’ in a variety of circumstances, including where the prison official (1) knows of a
prisoner’s need for medical treatment but intentionally refuses to provide it; (2) delays necessary
medical treatment based on a non-medical reason; or (3) prevents a prisoner from receiving
needed or recommended medical treatment.” Rouse, 182 F.3d at 197 (citations omitted).
“A prison official acts with deliberate indifference to a prisoner’s medical needs only if
he or she ‘knows of and disregards an excessive risk to inmate health or safety.’” Wall v.
Bushman, 639 F. App’x 92, 94 (3d Cir. 2015) (quoting Farmer, 511 U.S. at 837). “However,
subjective knowledge on the part of the official can be proved by circumstantial evidence to the
effect that the excessive risk was so obvious that the official must have known of the risk.”
Beers-Capitol v. Whetzel, 256 F.3d 120, 133 (3d Cir. 2001). Deliberate indifference is also
satisfied when prison authorities “deny reasonable requests for medical treatment . . . and such
denial exposes the inmate to undue suffering or the threat of tangible residual injury.” Spruill v.
Gillis, 372 F.3d 218, 235 (3d Cir. 2004). “[W]here knowledge of the need for medical care is
accompanied by the intentional refusal to provide that care,” deliberate indifference is present.
Id. Deliberate indifference may be manifested by “intentionally denying or delaying access to

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medical care or intentionally interfering with treatment once prescribed.” Estelle v. Gamble, 429
U.S. 97, 104–105 (1976).
The deliberate indifference analysis, however, is slightly different when the defendant is a
non-medical prison official. See Donnell v. Corr. Health Servs., Inc., 405 F. App’x 617, 622 (3d
Cir. 2010). The Third Circuit has stated that “[i]f a prisoner is under the care of medical
experts . . . a non-medical prison official will generally be justified in believing that the prisoner
is in capable hands.” Spruill, 372 F.3d at 236. “Prison officials cannot be held to be deliberately
indifferent merely because they did not respond to the medical complaints of a prisoner who was
already being treated by the prison medical staff.” Spencer v. Courtier, 552 F. App’x 121, 124
(3d Cir. 2014) (citing Durmer v. O’Carroll, 991 F.2d 64, 69 (3d Cir. 1993)). In Spruill, the Third
Circuit affirmed dismissal of a non-medical defendant, stating that a non-medical prison official
is not chargeable with the Eighth Amendment scienter requirement of deliberate indifference
“absent a reason to believe (or actual knowledge) that prison doctors or their assistants are
mistreating (or not treating) a prisoner.” Spruill, 372 F.3d at 236.
i.
With respect to Koukos’s claims against McFadden and Phillips in their individual
capacities, Koukos fails to state a claim. “To establish personal liability in a § 1983 action,
[plaintiff must] show that the official, acting under color of state law, caused the deprivation of a
federal right.” Graham, 473 U.S. at 167. “More particularly, the plaintiff must allege that the
defendant was personally involved in the deprivation.” Johnson v. Derose, 349 F. App’x 679,
681 (3d Cir. 2009). Although Koukos alleges that McFadden and Phillips were responsible for
insuring that inmates received adequate medical care and drafting and implementing CCP’s
policies related to such care, (Pls.’ Am. Compl. ¶ 12), he does not allege that either of them had

10

personal awareness of, or direct involvement with, either the allegedly inadequate medical care
he received or any of the alleged decisions that rendered the care inadequate. Koukos’s
allegations are thus insufficient to state a claim against McFadden and Phillips in their individual
capacities. See, e.g., Brown v. Deparlos, 492 F. App’x 211, 214–15 (3d Cir. 2012); Atkinson v.
Taylor, 316 F.3d 257, 271 (3d Cir. 2003) (holding that defendants in § 1983 civil rights actions
“must have personal involvement in the alleged wrongs . . . shown through allegations of
personal direction or of actual knowledge and acquiescence”).
ii.
Koukos also purports to bring claims against several unidentified, non-medical
correctional officers. Correction Doe 1 informed Koukos that his medical needs package would
be transferred to medical for consideration and distribution. Koukos claims that Correctional
Doe 1 in fact knew or should have known that his package would be destroyed. Even
disregarding the conclusory nature of this allegation and taking it as true, it is insufficient to
plead that Correctional Doe 1 acted with reckless disregard to Koukos’s serious medical needs.
Next, Koukos alleges that Correction Does 2 and 3 assigned him a top bunk despite the
medical designation that he should be assigned a bottom bunk. Koukos concedes that he does
not know whether the correctional officers were made aware of the medical designation. He
alleges that either the doctors failed to make the officers aware of the designation and the officers
assigned him a top bunk without any knowledge of the restriction or the officers were made
aware of the restriction and knowingly ignored it. If the former is true, Correctional Does 2 and
3 were not deliberately indifferent. If the latter is true, however, Correctional Does 2 and 3 may
have been deliberately indifferent. For this reason, Koukos’s claim against them should not be
dismissed at this stage. See Interwave Tech., Inc. v. Rockwell Automation, Inc., No. 05-398, 2005

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WL 3605272, at *13 (E.D. Pa. Dec. 30, 2005) (“When two or more statements are made in the
alternative and one of them if made independently would be sufficient, the pleading is not made
insufficient by the insufficiency of one or more of the alternative statements. A party may also
state as many separate claims or defenses as the party has regardless of consistency and whether
based on legal, equitable, or maritime grounds.”).
Koukos’s allegations with respect to Correctional Does 4–6 are essentially that he
approached them while experiencing evident physical symptoms (profuse sweating and
uncontrollable shaking), requested that he be permitted to go to the infirmary to receive medical
treatment and informed them, whether orally or by way of written statements contained in
medical request slips that he submitted to them, that he was experiencing opiate withdrawal and
had not been given the proper medication or necessary treatment by medical personnel.
Although “[p]rison officials cannot be held to be deliberately indifferent merely because they did
not respond to the medical complaints of a prisoner who was already being treated by the prison
medical staff,” Spencer, 552 F. App’x at 124 (citing Durmer, 991 F.2d at 69), Koukos has plead
sufficient facts to plausibly allege that the officers had “a reason to believe (or actual knowledge)
that prison doctors or their assistants [were] mistreating (or not treating) a prisoner.” Spruill, 372
F.3d at 236; see also Gravley v. Tretinik, 414 F. App’x 391, 394 (3d Cir. 2011) (Plaintiff’s
allegation that he submitted a written complaint stating that he was not being treated for his
injuries to a non-medical prison official stated a cognizable claim). Whether the officers had
sufficient knowledge to render them deliberately indifferent is a determination that should be
made when the record is more complete with respect to what Koukos said to each officer, what
was written on the medical request slips, what process correctional officers are supposed to

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follow with respect to those medical request slips and, most significantly, when and whether
Koukos was seen and treated by medical staff during the relevant timeframe.3
Finally, Koukos contends that after he was discharged from the hospital, seen by a
PrimeCare physician assistant and transferred to a new cell, he requested from Correctional Doe
7 that he be provided with ice packs to treat the pain from his fall. (Id. ¶ 45.) Koukos alleges
that despite observing his injuries, Doe 7 denied his request “in direct violation of the treatment
regime prescribed by the physician and medical staff at Chester County Hospital.” (Id. ¶ 46.)
Koukos, however, does not allege that Correctional Doe 7 was aware of the prescribed treatment
regime or any facts from which the Court could reasonably draw such a conclusion. Even if he
had known, such a failure to provide ice would not rise to the level of a constitutional violation.
Moreover, since this occurred shortly after Koukos was seen by a medical professional,
Correctional Doe 7 was “justified in believing that the prisoner [was] in capable hands.” Spruill,
372 F.3d at 236. Correctional Doe 7’s refusal, absent any knowledge that Koukos had been
directed to apply ice to his injuries or that he had subsequently been precluded from doing so by
the medical staff, cannot be said to constitute an intentional interference with prescribed
treatment and thus did not constitute deliberate indifference. Cf. Estelle, 429 U.S. at 104–105
(holding that deliberate indifference may be manifested by “intentionally denying or delaying
access to medical care or intentionally interfering with treatment once prescribed”).
B.
The Court analyzes Koukos’s claims against the County, asserted in Count II of the
amended complaint, under the standard for municipal liability set forth in Monell v. Dep’t of Soc.
3

While Koukos alleges he was not seen or treated by prison medical staff between his August 20 intake
examination and his August 22 early-morning fall from his bunk, Defendants contend that he was treated at least
four times on August 21. See (Defs.’ Mot., at 10). If Defendants’ contentions are true, the correctional officers were
likely “justified in believing that the prisoner [was] in capable hands.” Spruill, 372 F.3d at 236. However, taking
Koukos’s allegations as true, as the Court must at this stage in the proceedings, dismissal is inappropriate.

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Servs. of City of New York, 436 U.S. 658 (1978). Generally, a municipality will not be held
liable under the doctrine of respondeat superior for the misconduct of its employees. See
Andrews v. City of Philadelphia, 895 F.2d 1469, 1480 (3d Cir. 1990). Rather, a municipality can
only be liable under § 1983 when a constitutional injury results from the implementation or
execution of an officially adopted policy or informally adopted custom. See Beck v. City of
Pittsburgh, 89 F.3d 966, 971 (3d Cir. 1996) (citing Monell, 436 U.S. 658).
A policy “is made when a decisionmaker possess[ing] final authority to establish
municipal policy with respect to the action issues an official proclamation, policy, or edict.”
Andrews, 895 F.2d at 1480 (citation and quotation omitted). “A course of conduct is considered
to be a ‘custom’ when, though not authorized by law, such practices of state officials are so
permanent and well settled as to virtually constitute law.” Id. (citations and quotation omitted).
“In either instance, a plaintiff must show that an official who has the power to make policy is
responsible for either the affirmative proclamation of a policy or acquiescence in a well-settled
custom.” Bielevicz v. Dubinon, 915 F.2d 845, 850 (3d Cir. 1990) (citing Andrews, 895 F.2d at
1480). Finally, a supervisor or policymaker may be liable for failing to act affirmatively if an
existing practice creates an unreasonable risk of Eighth Amendment injury and the supervisor
was aware of and indifferent to that risk. See Beers–Capitol, 256 F.3d at 134.
A successful Monell claim must therefore establish: (1) an underlying constitutional
violation; (2) a policy or custom attributable to the municipality; and (3) that the constitutional
violation was caused by the municipality’s policy or custom. See Monell, 436 U.S. at 658. To
show causation where the alleged policy or custom does not facially violate constitutional rights,
the plaintiff “must demonstrate that the municipal action was taken with ‘deliberate indifference’
as to its known or obvious consequences.” Bd. of Cty. Comm'rs of Bryan Cty. v. Brown, 520 U.S.

14

397, 407 (1997). “A showing of simple or even heightened negligence will not suffice.” Id. In
other words, custom “requires proof of knowledge and acquiescence by the decisionmaker.”
McTernan, 564 F.3d at 658.
Koukos alleges four different “customs” which purportedly caused the violation of his
rights. First, he claims the County had a policy of placing “unreasonable and inhumane
limitations on admissions to the infirmary as well as limitations on inmate hospitalizations in an
effort to reduce medical costs.” (Pls.’ Am. Compl. ¶ 97.) Second, the County failed to establish
policies and procedures to ensure that inmates undergoing detoxification from opiate dependency
receive appropriate monitoring and/or treatment. (Id. ¶¶ 56–67, 75.) Third, Koukos alleges that
CCP maintained a policy of “deliberately ignoring inmates’ requests for medical care when they
believed inmates to be addicted to opioids” and for this reason failed to submit his medical
request slips. Fourth, Koukos alleges a custom of “deliberately ignoring the orders of outside
doctors regarding the need for medical treatment.” (Id. ¶ 51.) He claims that consistent with this
practice, Defendants ignored the orders of Chester County Hospital and ENTACC regarding
follow-up care Koukos should receive, causing him pain and permanent injury. (Id. ¶ 52.) In
addition, Koukos contends that the County is liable under a failure to train theory because it
failed to train correctional officers to identify the symptoms of opioid withdrawal. (Id. ¶¶ 108–
109); see also (Pls.’ Resp. in Opp’n, at 11, ECF No. 13).
i.
Koukos’s first allegation fails to state a claim under Monell. Koukos claims that the
County had a policy or practice of placing “unreasonable and inhumane limitations on
admissions to the infirmary as well as limitations on inmate hospitalizations in an effort to
reduce medical costs.” (Id. ¶ 97.) His claims, however, are conclusory and he fails to explain

15

“what basis he has for thinking that ‘policies to save money’ affected his medical treatment” or
“what specific treatment he was denied as a result of these policies.” See Winslow v. Prison
Health Servs., 406 F. App’x 671, 674 (3d Cir. 2011) (upholding the district court’s dismissal
under Rule 12(b)(6) when prisoner claimed he was harmed because the defendant treated his
hernia with a belt instead of surgery due to a “policy to save money”); see also Sims v. Wexford
Health Sources, 635 F. App’x 16, 19 (3d Cir. 2015) (upholding district court’s dismissal under
Rule 12(b)(6) when prisoner alleged a policy of deliberate indifference in order to save money).
Moreover, it is perfectly acceptable for the County to consider costs. “[T]he naked
assertion that [d]efendants considered cost in treating [Plaintiff’s injuries] does not suffice to
state a claim for deliberate indifference, as prisoners do not have a constitutional right to
limitless medical care, free of cost constraints under which law-abiding citizens receive
treatment.” Id.; see also Reynolds v. Wagner, 128 F.3d 166, 175 (3d Cir. 1997) (“[T]he deliberate
indifference standard of Estelle does not guarantee prisoners the right to be entirely free from the
cost considerations that figure in the medical-care decisions made by most non-prisoners in our
society). Because it is not a violation of federal law to consider costs, Koukos must plead facts
that meet the deliberate indifference standard. Bd. of Cty. Comm’rs, 520 U.S. at 407. He has
failed to do so. Without more, Koukos’s assertion that the County had a policy or custom of
limiting or altering medical treatment to inmates based on cost-savings cannot survive
Defendants’ motion to dismiss. See e.g., Sims, 635 F. App’x at 19; Simonds v. Delaware Cty.,
No. 13-7565, 2014 WL 3030435, at *5 (E.D. Pa. July 1, 2014).
ii.
Next, Koukos alleges that the County failed to establish policies and procedures to ensure
that inmates undergoing detoxification from opiate dependency receive appropriate monitoring

16

and/or treatment. (Id. ¶¶ 56–67, 75.) He identifies McFadden and Phillips as the municipal
decisionmakers responsible for ensuring inmates received adequate medical care and drafting
and implementing CCP’s policies related to such care. (Id. ¶ 12.) Koukos contends that due to
the lack of procedures regarding the treatment of opiate-dependent inmates, his prescription
medications were confiscated and not replaced, he was prevented from seeing a doctor to obtain
suitable replacements, he was not monitored or assessed properly while undergoing opiate and
benzodiazepine detoxification, he was not given appropriate medication to guard against the
known risks of detoxification or alleviate his withdrawal symptoms and the appropriate steps to
ensure that he was assigned to a bottom bunk were not taken.
Opiate-dependent individuals detoxifying from opiate use due to sudden termination of
usage present significant medical issues and risks. (Pls.’ Am. Compl. ¶ 59.) Moreover, although
detoxification for individuals who are otherwise healthy is not dangerous when it takes place
with proper monitoring and treatment, Koukos claims that detoxification is known to have
several dangerous and potentially fatal medical consequences for those with chronic health
conditions. (Id. ¶¶ 60, 61.) These consequences include dehydration, electrolyte imbalance,
neurological arrhythmia or cardia arrhythmias leading to sudden cardiac arrest. (Id. ¶ 62.)
For these reasons, Koukos alleges that basic standards of correctional healthcare require
that people admitted to correctional facilities who openly admit opiate use and dependence, inter
alia, “be consistently monitored, have their vital signs assessed at regular intervals, and be
administered medications designed to reduce the risk of health dangers, physical responses to
withdrawal and the pain associated therewith and caused thereby.” (Id. ¶ 63.) These measures
are allegedly necessary to ensure that an inmate undergoing opiate detoxification is not at risk for
the more serious medical consequences outlined above. Koukos alleges that reasonably trained

17

correctional policymakers are aware of the significant medical issues posed by opiate
detoxification and withdrawal due to sudden termination and thus privy to the need to monitor
the process. (Id. ¶¶ 59, 66.)
A medical assistant who withholds prescription medication, knows that a patient will
undergo opiate detoxification as a result, knows that such a process can pose serious risks, and
possesses information about the patient’s health history that suggests an increased likelihood of
serious risks, but does not take sufficient precautionary measures to monitor the patient or guard
against known risks is arguably acting with a mental state of recklessness. See Farmer, 511 U.S.
at 836 (“[A]cting or failing to act with deliberate indifference to a substantial risk of serious
harm to a prisoner is the equivalent of recklessly disregarding that risk.”). Both Abney and
Hines possessed this information, yet Koukos alleges that neither medical professional arranged
for Koukos to return to the infirmary for assessment or informed medical or correctional staff
that Koukos required such monitoring. At the very least, Koukos’s allegations are sufficient to
suggest that Abney and Hines had “knowledge of the need for medical care,” (Koukos’s need to
be monitored, have his vital signs assessed and/or be administered appropriate medication), and
intentionally refused to provide it. See Spruill, 372 F.3d at 235. Koukos has thus successfully
alleged a constitutional violation.
Koukos has also successfully alleged a custom attributable to the County. See BeersCapitol, 256 F.3d at 134 (“[T]o hold a supervisor liable because his policies or practices led to an
Eighth Amendment violation, the plaintiff must identify a specific policy or practice that the
supervisor failed to employ and show that: (1) the existing policy or practice created an
unreasonable risk of the Eighth Amendment injury; (2) the supervisor was aware that the
unreasonable risk was created; (3) the supervisor was indifferent to that risk; and (4) the injury

18

resulted from the policy or practice.” (citing Sample v. Diecks, 885 F.2d 1099 (3d Cir. 1989))).
According to Koukos, reasonably trained correctional and healthcare policymakers are “aware of
the patterns of increased use of opiate-based controlled substances, particularly for chronic
health conditions,” and are “particularly attuned to patterns of opiate use and abuse due to the
disproportionately high number of opiate-dependent individuals typically present in the
correctional population.” (Pls.’ Am. Compl. ¶¶ 57–58.)
Koukos alleges that the County was aware of this particular medical issue (common to
the inmate population), of the serious risks associated with detoxification, the need to monitor
inmates admitted to correctional facilities with histories of opiate abuse and the need to establish
specific policies and guidelines for their employees regarding the care of such inmates. (Id. ¶¶
65–67.) Specifically, he claims that “reasonable steps” should be taken to monitor, “evaluate,
diagnose, and treat individuals who had a history of [opiate use or dependency], including the
symptoms of withdrawal therefrom which [are] known to place the withdrawing subject at
considerable discomfort, at serious risk of medical conditions that could foreseeably result in
serious injury or even death.” (Id. ¶ 56.) Koukos has adequately alleged that the County was
deliberately indifferent in failing to establish any such policies or procedures.
Finally, Koukos alleges that the County’s failure to establish appropriate policies and
procedures for the monitoring and treatment of inmates undergoing detoxification after
admission in turn led to the failure of the individual Defendants to adequately monitor, assess
and treat him. These allegations are sufficient to state a claim. See Natale v. Camden Cty. Corr.
Facility, 318 F.3d 575, 584 (3d Cir. 2003) (holding that a reasonable jury could conclude that
failing to establish a policy to address the immediate medication needs of inmates with serious
medical conditions constituted deliberate indifference on the part of a prison health system);

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Ramos-Vazquez v. PrimeCare Med., Inc., No. 09-00364, 2010 WL 3855546, at *8–9 (E.D. Pa.
Sept. 30, 2010) (holding that plaintiff’s allegations were sufficient where he alleged that pursuant
to defendants’ customs, he was denied his medication and not treated despite defendants’
knowledge that failure to treat his disorder could have serious consequences).
iii.
Koukos also alleges that the County “maintained an unconstitutional policy or practice of
deliberately ignoring inmates’ requests for medical care when they believed inmates to be
addicted to opioids” and, pursuant to this practice, the Correctional Doe Defendants
“intentionally failed to submit [his] medical request slips with deliberate indifference to [his]
obvious and increasing need for medical attention.” (Pls.’ Am. Compl. ¶¶ 35–36.) Koukos has
not plead facts sufficient to raise an inference that a municipal policymaker, such as McFadden
or Phillips, was aware of or acquiesced in a practice of intentionally failing to submit medical
requests from suspected opiate addicts, to the extent that one existed. For this reason, his
allegations are insufficient to state a Monell claim. See Bielevicz, 915 F.2d at 850 (holding that
“a plaintiff must show that an official who has the power to make policy is responsible for either
the affirmative proclamation of a policy or acquiescence in a well-settled custom.” (citing
Andrews, 895 F.2d at 1480)).
iv.
Finally, Koukos alleges that either the County has a custom of “deliberately ignoring the
orders of outside doctors regarding the need for medical treatment” or has “failed to have a
policy or procedure in place to follow up on Doctors’ orders and provide seriously injured
inmates medical care and treatment.” (Pls.’ Am. Compl. ¶¶ 51–53.) He alleges that the
policymaking agents of CCP (and PrimeCare), McFadden and Phillips included, maintained “an

20

informal custom of limiting inmate hospitalizations and follow up care” and acquiesced in this
custom despite “severe problems with denial or delay of medical care for inmates in the past.”
(Id. ¶¶ 54–55.) Koukos contends that pursuant to this custom (or lack thereof), Defendants
ignored the orders of Chester County Hospital, failed to provide him with prescribed antibiotics,
pain medication and ice, failed to comply with the doctor’s instructions of obtaining care from
the ENTACC specialists within two to three days and, upon bringing him to the ENTACC
appointment, failed to comply with their instructions regarding a follow-up visit. (Id. ¶¶ 41–42,
47–48, 51–55.) He claims that as a direct result of Defendants’ practice of ignoring the
instructions of outside doctors, the medical staff failed to ensure he obtained appropriate follow
up treatment, denied and delayed prescribed treatment and caused him to endure needless pain
and suffer permanent injuries. (Id. ¶¶ 40, 49.)
Accepting Koukos’s allegations as true, Defendants failed to follow medical directives
from outside providers on several occasions and prevented Koukos from receiving “needed or
recommended medical treatment.” Rouse, 182 F.3d at 197; see also Estelle, 429 U.S. at 104–
105. These allegations are sufficient to state a claim. See Green v. Wexford Health Sources,
Inc., No. 16-3630, 2016 WL 7239891, at *6 (E.D. Pa. Dec. 14, 2016) (plaintiff’s allegations that
defendants ignored recommendations of outside medical providers and denied him adequate
treatment were sufficient to state a Monell claim); Stewart v. Wenerowicz, No. 12-4046, 2015
WL 5092865 at *16 (E.D. Pa. Aug. 27, 2015) (holding that alleging customs of preventing
inmates from receiving necessary and recommended medication and medical treatment and
policies of denying medical treatment for non-medical reasons satisfies the policies or customs
prong of Monell).

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v.
Koukos has also asserted claims against the County under a failure to train theory, which
are “analyzed as a species of ‘custom or practice’ liability.” Owens v. City of Philadelphia, 6 F.
Supp. 2d 373, 387 (E.D. Pa. 1998). Under this theory, “a policy or custom may also exist where
the policymaker has failed to act affirmatively at all, [though] the need to take some action to
control the agents of the government is so obvious, and the inadequacy of existing practice so
likely to result in the violation of constitutional rights, that the policymaker can reasonably be
said to have been deliberately indifferent to the need.” Natale, 318 F.3d at 584 (quotations
omitted). First, Koukos alleges generally that Defendants have maintained “either no system or
an inadequate system of review of the medical care of inmates, which has failed to identify
instances of deliberate indifference to serious medical needs or failed to discipline or closely
supervise or train prison staff who are deliberately indifferent to inmates’ serious medical
needs.” (Pls.’ Am. Compl. ¶ 107.) Next, he contends that Defendants maintained “a system of
grossly inadequate training pertaining to the treatment of inmates suffering with opiate
withdrawal” with respect to the correctional officers. (Id. ¶ 108.) He claims that correctional
officers should be properly trained in “identifying symptoms of opioid withdrawal” and “how to
handle an inmate who is experiencing” such symptoms. (Pls.’ Resp. in Opp’n, at 11.)
Koukos’s allegations regarding a generally inadequate system of review and training to
identify and prevent instances of deliberate indifference are too general to constitute a policy.
See, e.g., Colburn v. Upper Darby Twp., 946 F.2d 1017, 1028 (3d Cir. 1991) (“Only where a
municipality’s failure to train its employees in a relevant respect evidences a ‘deliberate
indifference’ to the rights of its inhabitants can such a shortcoming be properly thought of as a
city ‘policy or custom’ that is actionable under § 1983. . . . Only where a failure to train reflects a

22

‘deliberate’ or ‘conscious’ choice by a municipality—a ‘policy’ as defined by our prior cases—
can a city be liable for such a failure under § 1983.”); see also id. (“A § 1983 plaintiff pressing a
claim of this kind must identify a failure to provide specific training that has a causal nexus with
his or her injury.”). Moreover, “to sustain a claim based on a failure to train theory, ‘the
identified deficiency in [the] training program must be closely related to the ultimate
[constitutional] injury.’” Id. (quoting City of Canton v. Harris, 489 U.S. 378, 391 (1989)). Here,
the alleged deficiency is too attenuated from Koukos’s alleged injuries.
Koukos’s allegations regarding inadequate training with respect to the care of inmates
undergoing opiate detoxification and withdrawal are sufficiently specific and connected to his
injuries to plausibly state a claim. However, “the inadequacy of police training may serve as the
basis for § 1983 liability only where the failure to train amounts to deliberate indifference to the
rights of persons with whom the police come into contact.” City of Canton, Ohio v. Harris, 489
U.S. 378, 388–89 (1989). To plead the element of deliberate indifference for a failure to train
claim, Plaintiff must ordinarily allege a “pattern of similar constitutional violations by untrained
employees.” Thomas v. Cumberland Cty., 749 F.3d 217, 223 (3d Cir. 2014) (quoting Connick v.
Thompson, 563 U.S. 51, 62 (2011)). A plaintiff may also assert a failure to train claim premised
on a single incident. To do so, however, a plaintiff must show that the need to train officers was
“so patently obvious” that the municipality’s failure to train constituted deliberate indifference to
the “highly predictable consequence” that failing to train would result in constitutional
violations. Connick, 563 U.S. at 62 (citing Canton, 489 U.S. at 390; Bd. of Cty. Comm’rs, 520
U.S. at 398); see also Buoniconti v. City of Philadelphia, 148 F. Supp. 3d 425, 440 (E.D. Pa.
2015) (“While it is possible to establish deliberate indifference based on a single incident[,] . . .
this showing is available in a very narrow range of circumstances. To find deliberate

23

indifference from a single-incident violation, the risk of injury must be a highly predictable
consequence of the municipality’s failure to train and supervise its officers.” (quotations and
citations omitted)).
Koukos’s amended complaint does not contain facts that could support a “pattern of
similar constitutional violations by untrained employees.” Connick, 563 U.S. at 62. It does,
however, contain enough facts to state a claim under the single incident method. He has
identified a specific type of training that should have been provided to correctional officers—
training to educate correctional officers on the symptoms of opiate withdrawal, the medical
needs of individuals experiencing them and the appropriate course of action. He has alleged a
causal nexus to his injury—had officers been trained accordingly, they would have recognized
Koukos’s symptoms, known that he needed immediate medical attention and permitted him to
obtain it (by submitting his medical request slips or allowing him to go to the infirmary). See
(Pls.’ Am. Compl. ¶¶ 32–37, 74–76, 108–109). And he has pleaded facts suggesting that the
need for this type of training was or should have been obvious. See (Pls.’ Am. Compl. ¶¶ 56–
67). Although this will ultimately be a difficult showing to make absent a pattern of violations,
Koukos’s allegations are sufficient, at this early stage, to state a claim for failure to train. See
Berg v. Cty. of Allegheny, 219 F.3d 261, 276 (3d Cir. 2000) (“Although it is possible to maintain
a claim of failure to train without demonstrating such a pattern, the Bryan County Court made
clear that the burden on the plaintiff in such a case is high.”); see also Reynolds v. Municipality
of Norristown, No. 15-0016, 2015 WL 4450979, at *12 (E.D. Pa. July 17, 2015) (plaintiff’s
allegation that his injury resulted from failure to train officers in identifying individuals
experiencing a medical emergency was sufficient to state a claim); Hall v. Raech, No. 08-5020,
2009 WL 811503, at *5 (E.D. Pa. Mar. 25, 2009) (plaintiff’s allegation that his injury resulted

24

from failure to train officers in identifying symptoms of diabetic episode and taking appropriate
action was sufficient to state a claim).
IV.
For the reasons discussed above, Defendants’ motion to dismiss is granted with respect to
Koukos’s claims against Correctional Doe 1, Correctional Doe 7, McFadden and Phillips. Under
Federal Rule of Civil Procedure 15(a), “courts may grant. . . amendments ‘when justice so
requires.’” Fraser v. Nationwide Mut. Ins. Co., 352 F.3d 107, 116 (3d Cir. 2004) (citing Fed. R.
Civ. P. 15(a)). While Rule 15 states that “leave to amend should be ‘freely given,’ a district
court has discretion to deny a request to amend if it is apparent from the record that (1) the
moving party has demonstrated undue delay, bad faith or dilatory motives, (2) the amendment
would be futile, or (3) the amendment would prejudice the other party.” Id.; see also Grayson v.
Mayview State Hosp., 293 F.3d 103, 108 (3d Cir. 2002) (citing Foman v. Davis, 371 U.S. 178
(1962)). “Futility” means that the amended complaint would fail to state a claim upon which
relief could be granted. Shane v. Fauver, 213 F.3d 113, 115 (3d Cir. 2000) (citing In re
Burlington Coat Factory Sec. Litig., 114 F.3d 1410, 1426 (3d Cir. 1997)). The Third Circuit
Court of Appeals has left the decision whether to grant or deny leave to amend within the sound
discretion of the district court. Cureton v. Nat’l Coll. Athletic Ass’n, 252 F.3d 267, 272 (3d Cir.
2001) (citations omitted). Because amendment of Koukos’s claims against Correctional Does 1
and 7, McFadden and Phillips would be futile, they are dismissed with prejudice.
An appropriate order follows.
BY THE COURT:

/s/ Gerald J. Pappert
GERALD J. PAPPERT, J.
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