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Bost v. Wexford Health Sources, Inc.

United States District Court, D. Maryland

July 23, 2018

SHARON BOST, individually and as the personal representative of the ESTATE OF FATIMA NEAL, Plaintiff,
v.
WEXFORD HEALTH SOURCES, INC. ., Defendants. created by create timestamp modified by modify timestamp User ID Last Name First Name Credential created by create timestamp modified by modify timestamp User ID Last Name First Name Credential created by create timestamp modified by modify timestamp User ID Last Name First Name Credential created by create timestamp modified by modify timestamp User ID Last Name First Name Credential

          MEMORANDUM OPINION

          ELLEN L. HOLLANDER UNITED STATES DISTRICT JUDGE

         This case arises from the tragic death of Fatima Neal (“Ms. Neal” or the “Decedent”) on November 4, 2012, at the age of 42.[1] Ms. Neal suffered multiple strokes while detained at the Women's Detention Center (“WDC”), which is part of the Baltimore City Detention Center (“BCDC”). She died one day before she was due to have a probation violation hearing. ECF 212-2 (Declaration of Angel Maes, Assistant Manager, Clerk's Office, Circuit Court for Baltimore City) at 4, ¶ 6; see also ECF 233-5 (Autopsy Report, signed by Doctor Theodore King, Jr., Assistant Medical Examiner, Office of the Chief Medical Examiner, dated January 25, 2013) at 10. At the relevant time, Ms. Neal was receiving medical care from employees of Wexford Health Sources, Inc. (“Wexford”) at the WDC infirmary (the “Infirmary”).

         In the First Amended Complaint (ECF 56) (“Amended Complaint”), plaintiff Sharon Bost, the Decedent's mother, individually and as the personal representative of the Estate of Fatima Neal, filed suit against Wexford and numerous individuals: Anike Ajayi, R.N.; Elizabeth Obadina, R.N.; Ebere Ohaneje, R.N.; Najma Jamal, R.N.; Karen McNulty, R.N.; Andria Wiggins, P.A.; Getachew Afre, M.D.; Jocelyn El-Sayed, M.D.; Oby Atta, C.R.N.P.; and twenty-five unnamed medical service providers (collectively, the “Medical Defendants”). ECF 56, ¶¶ 29-39.[2]

         Plaintiff also sued the State of Maryland (“State”); BCDC; and various State employees: Shavella Miles, Security Chief; Captain Carol McKnight; Lieutenant Valerie Alves; Officer Cierra Ladson;[3] Gwendolyn Oliver, Assistant Warden of BCDC; Ricky Foxwell, Assistant Warden of BCDC; Carolyn Atkins, Assistant Commissioner, Department of Pretrial Detention and Services; Carol Harmon, Facility Administrator; and twenty-five unnamed “custody officers” (collectively, the “Custody Defendants”). Id. ¶¶ 40-48. All individual defendants were sued in their personal and official capacities. Id. ¶¶ 39, 49.[4]

         Plaintiff has asserted multiple claims. As to all defendants, plaintiff asserts a claim of denial of adequate medical care, pursuant to 42 U.S.C. § 1983, based on alleged violations of the Eighth and Fourteenth Amendments (ECF 56, ¶¶ 153-68); denial of adequate medical care under Article 24 of the Maryland Declaration of Rights (id. ¶¶ 187-206);[5] intentional infliction of emotional distress (“IIED”) (id. ¶¶ 226-37); and wrongful death, pursuant to Md. Code (2013 Repl. Vol., 2017 Supp.), §§ 3-901 through 3-904 of the Courts and Judicial Proceedings Article (“C.J.”). Id. ¶¶ 238-43.[6] As to the Medical Defendants, plaintiff also alleges medical malpractice. Id. ¶¶ 207-17.[7] Moreover, plaintiff alleges that Wexford is liable for the actions of its employees pursuant to the doctrine of respondeat superior. Id. ¶¶ 244-46. Further, plaintiff seeks indemnification from Wexford, BCDC, and the State for the actions of their employees. See Id. ¶¶ 247-50.

         The Custody Defendants have moved for summary judgment (ECF 212), supported by a memorandum of law (ECF 212-1) (collectively “Custody Defendants' Motion”), and a host of exhibits. See ECF 212-2 through ECF 212-23. The Medical Defendants have also moved for summary judgment (ECF 213), supported by a memorandum of law (ECF 213-1) (collectively “Medical Defendants' Motion”), and many exhibits. See ECF 213-3 through ECF 213-30; see also ECF 214 through ECF 214-3 (exhibits filed under seal by the Medical Defendants). Plaintiff has filed a consolidated response in opposition to the motions (ECF 228, “Opposition”). It is accompanied by more than 150 exhibits, some of which are redacted and some of which are filed under seal. See ECF 225-1 through ECF 225-159.[8] Both groups of defendants replied and submitted additional exhibits. See ECF 241 (“Custody Defendants' Reply”); ECF 241-1 through ECF 241-23 (additional Custody Defendant exhibits); ECF 245 (“Medical Defendants' Reply”); ECF 245-1 and ECF 245-2 (additional Medical Defendant exhibits).[9] In sum, the parties have filed more than 7, 200 pages of motions, memoranda, and exhibits. See ECF 212; ECF 213; ECF 214; ECF 225; ECF 228; ECF 233; ECF 235; ECF 241; ECF 245.[10]

         No hearing is necessary to resolve the summary judgment motions. See Local Rule 105.6. For the reasons that follow, I shall grant the Custody Defendants' Motion (ECF 212) as to all claims and all Custody Defendants, i.e., Miles, McKnight, Alves, Oliver, Atkins, Foxwell, Harmon, and the twenty-five unnamed custody officers. Additionally, I shall dismiss the case as to Ladson, although she has not appeared. Further, I shall grant the Medical Defendants' Motion (ECF 213) as to all claims against Atta and the twenty-five unnamed medical care providers. And, I shall grant the Medical Defendants' Motion as to the IIED claim.

         However, I shall deny the Medical Defendants' Motion as to the deliberate indifference claim predicated on the Eighth Amendment, the Fourteenth Amendment, and Article 24 of the Maryland Declaration of Rights, as to Ajayi, Obadina, Ohaneje, Jamal, McNulty, Wiggins, Afre, and El-Sayed. I shall also deny the Medical Defendants' Motion as to the medical malpractice and wrongful death claims lodged against Ajayi, Obadina, Ohaneje, Jamal, McNulty, Wiggins, Afre, and El-Sayed. Further, I shall deny the Medical Defendants' Motion as to plaintiff's assertion of respondeat superior liability as to Wexford. Because the claim for indemnification is premature, I shall not resolve that contention in the context of this Memorandum Opinion.

         I. Factual Background [11]

         The BCDC is a State correctional facility located in Baltimore City, operated by the Department of Public Safety and Correctional Services (“DPSCS”). See Md. Code (2017 Repl. Vol.), §§ 5-401(a), (b) of the Correctional Services Article (“C.S.”); see also ECF 212-1 at 17. BCDC consists of multiple buildings, one of which is the WDC. ECF 212-1 at 17. The Commissioner of DPSCS is the appointing authority for BCDC employees, who are paid by the State. See C.S. § 5-202(c)(4); see also Md. Code (2014 Repl. Vol., 2017 Supp.), § 12-101(a)(1) of the State Government Article (“S.G.”). See ECF 212-1 at 17.

         Wexford is a medical care provider “contracted by the State to provide around-the-clock care” at BCDC. ECF 228 at 14; see also ECF 212-1 at 10. In November 2012, registered nurses (“R.N.”) Ajayi, Obadina, Ohaneje, Jamal, and McNulty were employed by Wexford and worked at BCDC. See Id. at 52-57. At that time, Certified Registered Nurse Practitioner (“C.R.N.P.”) Atta, Physician Assistant (“P.A.”) Wiggins, and physicians (“M.D.”) Afre and El-Sayed were also employed by Wexford and worked at BCDC. Id.

         Stacey Shumway, a Wexford Charge Nurse, is identified in the Medical Defendants' Motion as an “R.N. Deposition Expert.” ECF 213-20 at 2-3. Shumway testified at her deposition (ECF 213-20) that in the fall of 2012, there were three shifts for Wexford staff working in the Infirmary. ECF 213-20 at 4. The day shift started at 8:00 a.m. and ended at 4:30 p.m. Id. The evening shift ran from 4:00 p.m. to 12:00 a.m. or 12:30 a.m. Id. And, the night shift began at 12:00 a.m. and ended at 8:00 a.m. or 8:30 a.m. Id.; see also ECF 213-26 (McNulty Deposition) at 3-4. According to Shumway, the Infirmary was “always staffed” by Wexford employees. ECF 213-20 at 3.

         Nurse McNulty testified at her deposition that during the day shift, the Infirmary was staffed by a doctor and either “two RNs” or an R.N. and a Licensed Practical Nurse (“L.P.N.”). ECF 213-26 at 3. According to McNulty, the nurses reported to the doctor on duty during the day shift. Id. at 4. During the evening and night shifts, the Infirmary was staffed either by “two RNs” or “one RN and one LPN.” Id. at 4. McNulty stated that doctors were “not typically” in the Infirmary during the evening shift and were never at the Infirmary during the night shift. Id. Additionally, McNulty averred that physician assistants and nurse practitioners were never staffed at the Infirmary during the evening and night shifts. Id.

         During the evening and night shifts, nurses working in the Infirmary reported either to a “PA or nurse practitioner” stationed in the BCDC “general population.” Id. And, during evening and night shifts, an “on-call” physician could be reached by telephone. See ECF 213-28 (Deposition of Getachew Afre, M.D.) at 4. According to Doctor Afre, the on call physician shift “starts around 4:30 p.m.” and lasts “until the morning, until 8 o'clock in the morning” the following day. See ECF 225-49 (Afre Deposition) at 29.

         A.

         Ms. Neal was arrested on September 7, 2012 (ECF 212-4 at 4, Trial Summary), and charged on September 8, 2012, with possession of marijuana, pursuant to Md. Code (2012 Repl. Vol., 2017 Supp.), § 5-601(a)(1) of the Criminal Law Article. See ECF 225-4 at 14 (Commitment Pending Hearing, dated September 8, 2012). As to the possession of marijuana charge, bond for Ms. Neal was set at $5, 000. See ECF 225-4 at 4.

         However, the Circuit Court for Baltimore City lodged a Detainer, ordering no bail for Ms. Neal as to “Bench Warrant No. 208149026.” See ECF 212-4 at 2 (Detainer of September 8, 2012); ECF 212-2 (Declaration of Maes) at 3, ¶ 7; ECF 212-3 at 2 (Circuit Court for Baltimore City Criminal Docket, listing “208149026” as the “Case Number” for Ms. Neal's criminal proceedings). The “CHARGE” for which Ms. Neal was to be detained was specified as “viol narc laws (FTA).” ECF 212-4 (capitals in original). The Detainer pertained to a Bench Warrant issued for Ms. Neal (ECF 212-4 at 12) after she failed to appear for a probation violation hearing on August 8, 2011. See id.; see also ECF 212-2 at 3, ¶ 5.

         Pursuant to the Detainer, Ms. Neal was held at WDC. See ECF 212-4 at 8 (Commitment Pending Hearing, dated September 10, 2012). She was housed in the “Post 83 dormitory.” See ECF 212-2 at 17; see also ECF 225-25 (Post 83 Logbook) at 9.

         As to the possession of marijuana charge of September 8, 2012, Ms. Neal was found guilty on October 26, 2012, and sentenced to time served. ECF 212-4 at 4 (Trial Summary). However, because of the Detainer (ECF 212-4 at 2), Ms. Neal was not released. See ECF 212-2 at 4, ¶ 6. With regard to Ms. Neal's alleged violation of probation, a hearing was set for November 5, 2012. ECF 212-2 at 4, ¶ 6.

         B.

         At the relevant time, Christina Sexton was Ms. Neal's bunkmate in the Post 83 dormitory of the WDC. See ECF 228 at 19; see also ECF 212-2 at 17; ECF 225-25 at 9. In a letter from Sexton to Bost, dated November 16, 2012 (ECF 225-1), Sexton recounted that on the “morning of” October 30, 2012, Ms. Neal “woke with a really bad headache and her vision was blurred.” Id. at 1. According to Sexton, Ms. Neal remained in bed “the whole day” and was “in pain.” Id.

         Natalie Saracino was also an inmate at WDC at the relevant time. At her deposition (ECF 225-8), Saracino stated that on October 31, 2012, she and Ms. Neal “were supposed to do Bible study” together, but Ms. Neal “kept complaining that her head was hurting and she couldn't read the book.” ECF 225-8 at 11. According to Saracino, Ms. Neal “kept saying her head was pounding.” Id.

         Sexton recalled that at approximately 2:00 a.m. on November 1, 2012, [12] Sexton awoke to Ms. Neal

walking into things . . . . She kept saying something[']s really wrong get the officer. She say [sic] her head hurt so bad and she couldn't see. I then dressed her and walked her to the door where we waited on medical. While waiting she fell out in my arms[.] I placed her on the floor [and] she started sweating really bad and saying she was so cold so I wraped [sic] her in a blanket until Nurse Rachel [13] from medical came downstairs and took Fatima to medical[.]

ECF 225-11 at 1; see also ECF 228-8 at 11.

         Officer Tanaya Collins, a BCDC employee working in the Post 83 dormitory during the early morning hours of November 1, 2012 (see ECF 212-1 at 17), wrote in the Post 83 Logbook, ECF 213-8: “0220 . . . Christina Sexton . . . advised me of issues being had by . . . Tammy Fallen [sic] [14] . . . . She advised that Ms. Fallen [sic] was having trouble breathing and that she seem[ed] dizzy. When I asked Ms. Fallen [sic] what was wrong she replied she don't know. I noticed that she was breathing rapidly and looked to be in distress. Supervisor and medical staff was notified 0232 medical staff (Nurse Rachel) arrived on post 83 to escort Ms. Fallen [sic] to the clinic.” ECF 213-8 at 3; see also ECF 225-26 (Deposition of Ajayi) at 7.

         Ajayi testified at her deposition (ECF 225-26; ECF 213-23; ECF 212-1) that on November 1, 2012, she was working as a triage nurse at the WDC. ECF 213-23 at 22; see also ECF 213-1 at 7. In the “early morning hours” on that date, she responded to “a call” and went “to a dorm where [she] saw” Ms. Neal sitting down, wrapped in a blanket. ECF 213-23 at 2, 5. Ms. Neal appeared to be “weak” (ECF 225-26 at 17) and told Ajayi that “she had a headache.” ECF 213-23 at 6.

         Ajayi took Ms. Neal's “vital signs” and listened to Ms. Neal's lungs. Id. at 7. Ajayi then helped Ms. Neal walk to a wheelchair. Id. As Ms. Neal walked to the wheelchair, Ajayi noticed that Ms. Neal's face “showed pain” and she was “frowning.” ECF 213-23 at 20. However, Ajayi claimed that Ms. Neal's “gait was normal” with “no one-sided weakness.” Id. at 12. Ajayi did not recall Ms. Neal, or anyone else, reporting that Ms. Neal had been walking into walls, had blurred vision, had been confused or disoriented, had fallen into Sexton's arms, had been sweating, had lost consciousness, or that Ms. Neal had stayed in bed for most of the previous day. ECF 225-26 at 17-18. Ajayi escorted Ms. Neal to the Infirmary “triage area.” ECF 213-23 at 9; ECF 225-26 at 7; ECF 212-1 at 3.

         Plaintiff and the Medical Defendants provided the Court with Ms. Neal's medical records during the time she was housed in the Infirmary. See ECF 233-6; see also ECF 214.[15] According to the medical record “generated” by Ajayi at 2:51 a.m. on November 1, 2012, Ajayi assessed Ms. Neal at 2:42 a.m. on that date. See ECF 233-6 (Medical Record of November 1, 2012, 2:51 a.m.) at 1-2.[16] Ajayi reported that Ms. Neal told her: “‘[M]y head is pounding and I feel cold. i took 2 motrins and it is not helping.'” Id. at 1. Ajayi also stated that the cause of Ms. Neal's headache was unknown, and that Ms. Neal had a “knowledge deficit.” Id. Additionally, Ajayi stated Ms. Neal was “ambulatory but weak, ” “move[d] all extremities, ” and “follow[ed] command.” Id.

         Ajayi also wrote that she contacted a physician “for treatment and orders, ” and “notified pa wiggins for further eval.” ECF 233-6 at 2. However, Ajayi failed to identify the physician she claimed to have contacted. Nor is there any indication that Ms. Neal was examined by a doctor until later during the morning of November 1, 2012.

         The Medical Defendants submitted Wexford's “November 2012 Provider On-Call Schedule”, which lists the physicians who were on call the nights of November 1-2, 2012, November 2-3, 2012, and November 3-4, 2012. See ECF 213-9 (the “On-Call Schedule”). But, the On-Call Schedule fails to identify the physician who was on call between 4:30 p.m. on October 31, 2012, through 8:00 a.m. on November 1, 2012, the shift during which Ms. Neal arrived at the Infirmary. Id.; see also ECF 233-6 at 1-3; ECF 213-20 at 4; ECF 213-26 at 3-4; ECF 225-49 at 29.[17]

         In the medical record created by Ajayi at 2:51 a.m. on November 1, 2012, she further stated that “after report given to infirmary rn and officers pt transferred to infirmary in a stable condition.” ECF 233-6 at 2. Additionally, Ajayi wrote, id.: “Referred to provider - condition not responding to protocol.” See also ECF 225-26 (Ajayi Deposition) at 27. Ajayi also noted that “pa wiggins arrived to clinic.” ECF 233-6 at 2.

         In addition, Ajayi noted in the medical record that Wiggins decided “to admit [Ms. Neal] for 24 hr obserbation [sic].” ECF 233-6 at 2; see also ECF 225-26 at 27. Wiggins indicated she was “concerned about -- you know, wanted to see what was going on with [Ms. Neal's] headache.” ECF 225-26 at 27.

         Ajayi testified at her deposition that when P.A. Wiggins arrived, Ajayi “presented [her] assessment” of Ms. Neal, including vital signs. ECF 225-26 at 24. In particular, Ajayi stated that she informed Wiggins that Ms. Neal had “an ongoing headache”, that Ms. Neal was “cold”, and that Ms. Neal “was a little weak[.]” Id. According to Ajayi, Wiggins “did the further assessing and questioning” of Ms. Neal. Id.

         Jamal explained that an inmate is admitted to the Infirmary for observation so that Wexford staff can monitor the inmate's medical condition. See ECF 225-47 (Jamal Deposition) at 56. According to Isaias Tessema, M.D., Wexford's Regional Medical Director, “only the sickest [inmates] go to the infirmary.” ECF 225-53 (Tessema Deposition) at 45.

         Wiggins stated at her deposition that she did not remember communicating with Ajayi about Ms. Neal. See ECF 225-43 (Wiggins Deposition) at 5. Indeed, she did not recall Ms.

         Neal. Id. The following portion of Wiggins's deposition transcript is pertinent, id. (bold in original):

Q Do you have any independent recollection of any of your encounters with Fatima Neal as a patient at the WDC?
A No, ma'am.
Q Fair to say that you have no independent recollection of how she appeared physically during your encounters?
A That is fair to say.
Q And you have no independent recollection of any treatment that you - treatment or medications that you prescribed; correct?
A That is correct.

         Nurse Obadina “generated” a medical record for Ms. Neal at 3:34 a.m. on November 1, 2012. See ECF 233-6 at 3. The “VISIT TYPE” was described as “Admission Note.” Id. Doctor Afre was listed as Ms. Neal's “Provider.” Id. There is no indication that Doctor Afre was called to the Infirmary when Ms. Neal was first admitted. Rather, Obadina stated that Ms. Neal was “to be seen by MD in am.” Id.

         In the medical record (ECF 233-6 at 3), Obadina stated that Ms. Neal “was admitted from TRIAGE AT 3.00AM with C/O of HEADACHE.” Id. Obadina also stated that Ms. Neal “walked from Triage to infirmary”; that Ms. Neal “refused vitals on admission”; and that Obadina would “continue to monitor pt for safety and comfort.” Id. Additionally, Obadina wrote that Ms. Neal was admitted “in stable condition although [she] was a bit weak. No further complaints noted.” Id. Obadina also wrote, id.: “Musculoskeletal: . . . . No weakness.” (Bold in original).

         At 6:59 a.m. on November 1, 2012, Obadina “generated” another medical record for Ms. Neal. ECF 233-6 at 6. The “VISIT TYPE” was listed as “Skilled care” and Doctor Afre was identified as Ms. Neal's “Provider.” Id. Obadina stated that Ms. Neal “continued to be restless” and that an unidentified “PA came to see” Ms. Neal. Id. According to Obadina, Ms. Neal “refused vital signs.” Id. Obadina stated that she would “continue to monitor pt for safety and comfort.” Id.

         P.A. Wiggins “generated” a medical record for Ms. Neal at 7:32 a.m. on November 1, 2012 (ECF 233-6 at 4-5), in which Wiggins was identified as Ms. Neal's “Provider.” Id. at 5. Wiggins stated: “Reason(s) for visit . . . Pt states that her head ache [sic] started 30 minutes ago.” Id. at 4 (bold in original). Yet, Wiggins also wrote: “No . . . headaches.” Id. at 5. Additionally, Wiggins wrote: “Pt reports that she took 2 tablest [sic] that she received for [sic] another inmates [sic] in the dorm whic [sic] she thinks is motrin. Pt denies any othe [sic] nausea, vomnitngm [sic] dizziness.” Id. at 4. According to Wiggins, Ms. Neal had no “vision changes” and was “[a]lert and oriented.” Id. at 5.

         At 10:06 a.m. on November 1, 2012, Doctor Afre “generated” a medical record for Ms. Neal. See ECF 233-6 at 7-9. The “VISIT TYPE” was for “Skilled Care” (id. at 7), and Afre was listed as Ms. Neal's “Provider.” Id. at 9 (capitals in original). Afre wrote, inter alia, id. at 7: “According to the PA's note, the patient complaines [sic] of severe headache of about 30 minutes duration and was behaving irraticaly [sic]. However, after admission patient took her [medication] and slept quietly.” Doctor Afre stated that he “tried to talk to the patient but her answer was only ‘I don't know.' She did not want to be disturbed and wanted to continue sleeping.” He also wrote, id. at 9: “Patient at this time look[s] drawzy [sic] which is probably due to the [medication]. Her vital signs are within normal limits.” Additionally, Afre prescribed “motrin 600 mg” every “8 hrs. . . . for the headache” and stated that he would “continue to observe patient.” Id. No medical tests were ordered.

         Nurse Ohaneje “generated” a “HEALTH ASSESSMENT” for Ms. Neal at 12:30 a.m. on November 2, 2012. See ECF 233-6 at 10-11 (capitals in original). In that assessment, Doctor Afre was listed as Ms. Neal's “Provider.” Id. at 11. Ohaneje stated, inter alia, that Ms. Neal was “stable no issue to report.” Id. at 10. She also said, id. at 10-11: “No vision changes or headaches. No hearing loss. . . . No dizziness, no emotional disturbances.”

         At 6:56 a.m. on November 2, 2012, Nurse Obadina “generated” another medical record for Ms. Neal. See ECF 233-6 at 12-13. The “VISIT TYPE” was for “Skilled Care” (id. at 12), and Doctor Afre was listed as Ms. Neal's “Provider.” Id. at 13 (capitals in original). Obadina stated that Ms. Neal “ate breakfast” and that “no complaint [was] noted.” Id. at 12. However, Obadina also wrote, id.: “pt still weak. MD to be notified.” Additionally, Obadina stated “Musculoskeletal: . . . . No weakness.” Id. (bold in original). In the medical record, Obadina indicated that Ms. Neal was not experiencing dizziness, and that Obadina would “continue to monitor pt for safety and comfort.” Id.

         About 24 hours after Doctor Afre first saw Ms. Neal, he saw her again. Doctor Afre “generated” a medical record for Ms. Neal at 10:20 a.m. on November 2, 2012. See ECF 233-6 at 14-16. The “VISIT TYPE” was for “Skilled Care” and he was listed as Ms. Neal's “Provider.” Id. at 14, 16. Doctor Afre wrote that Ms. Neal “was admitted by the PA because of severe headache” and that Ms. Neal told Afre “she still has the headache.” Id. at 14. He also stated that Ms. Neal “denies nausea, vomiting, or blurring of vision. She denies dysphagia, diarrhea or cough.” Id. Further, Afre wrote that Ms. Neal was “awake & alert, irritable but consolable, no acute distress.” Id. Notably, Afre discontinued the prescription of “motrin 600 mg” and prescribed “Tylenol-codeine No. 3.” Id. at 16.

         At 9:34 p.m. on November 2, 2012, Nurse Jamal “generated” a medical record for Ms. Neal. See ECF 233-6 at 17-18. The “VISIT TYPE” was “Skilled Care” (id. at 17) and Doctor Afre was listed as Ms. Neal's “Provider.” Id. at 18 (capitals in original). Jamal wrote, inter alia, id. at 17: “Patient remained in bed all evening. She did not get up for vital signs. V[ital] S[igns] were stable. No new complaints voiced. No nausea or vomiting this shift. No medications due. Patient in stable condition. She did get up around 9:00pm [sic] and was interacting with other peers in the dorm. Will continue to monitor patient.” Jamal also wrote that Ms. Neal had “No vision changes or headaches. No hearing loss. . . . No dizziness, no emotional disturbances.” Id. Further, Jamal wrote, id. at 18: “Neurological: Alert and oriented.” (Bold in original).

         Nurse Jamal “generated” a medical record for Ms. Neal at 5:18 a.m. on November 3, 2012. See ECF 233-6 at 19-20. The “VISIT TYPE” was for “Skilled Care” (id. at 19) and Doctor Afre was listed as Ms. Neal's “Provider.” Id. at 20. Jamal wrote, id. at 19: “No changes in condition reported. Patient slept well. No episodes of diarrhea or nausea. V[ital] S[igns] were stable. Patient did not have any night shift medications. Will continue to monitor patient.” Jamal also wrote: “No vision changes or headaches. No hearing loss. . . . No dizziness, no emotional disturbances. . . . No weakness.” Id. at 19. Further, Jamal wrote, id. at 20: “Neurological: Alert and oriented.” (Bold in original).

         At 7:27 a.m. on November 3, 2012, Doctor El-Sayed “generated” a medical record for Ms. Neal. See ECF 233-6 at 21-22. The “VISIT TYPE” was for “Skilled Care” and El-Sayed was listed as Ms. Neal's “Provider.” Id. El-Sayed wrote, id. at 21: “Patient was admitted because of severe headache. No complaints of headache this AM. No nausea, no lightheadedness.” Additionally, El-Sayed wrote: “Constitutional: No apparent distress” and “Pain management: On Tylenol # 3.” Id. (bold in original).

         At 3:02 p.m. on November 3, 2012, Nurse McNulty started writing a “HEALTH ASSESSMENT” for Ms. Neal, listing Doctor Afre as Ms. Neal's “Provider.” See ECF 233-6 at 23-25. McNulty completed the assessment of Ms. Neal at 3:17 p.m. Id. at 25.[18] Notably, McNulty wrote, id. at 23: “Risk for Injury R/T hx of Falls, Impaired Health Maintenance, Altered Nutritional Intake.” (Bold in original). But, McNulty did not elaborate on the meaning of that statement. McNulty also said, id.: “Pt has been lying in bed throughout the day mostly sleeping and no distress is present. Pt needs encouragement/assistance with getting up to eat and getting cleaned up. Pt reports that she is visually impaired and is not wearing any glasses, will continue to monitor closely.” Additionally, McNulty wrote, id. at 24: “Comments for eyes: Pt c/o headache 10/10 this am and is ordered for Ibuprofen and Tylenol #3. . . . Gastrointestinal: Comments: Pt is not eating, however, is drinking water with meds and recently drank some juice and ate some crackers with the assistance [of] other inmates in her dorm. . . . Musculoskeletal: Comments: Pt has no complaints of musculoskeletal pain, however, states that she has had trouble ambulating but has not fallen since she has been here in the infirmary.” (Bold in original). According to McNulty, Ms. Neal's “Pain Score” was “10/10.” Id. (underlining in original). McNulty wrote that she had “continued MD orders” as to Ms. Neal's treatment. Id. at 25. She did not describe those orders.

         At 9:09 p.m. on November 3, 2012, Jamal began to write a medical record for Ms. Neal, indicating that Jamal's “VISIT TYPE” was to provide “Skilled Care” and that Doctor Afre was Ms. Neal's “Provider.” See ECF 233-6 at 26-27. Jamal completed the medical record at 9:18 p.m. on that same date. Id. at 27.[19] In the medical record, Jamal wrote, id. at 26: “Patient lied down all shift.” Jamal also wrote, id. at 27:

Status
Completed
Order
Increase activity level

         According to Jamal, Ms. Neal “was able to ate [sic] some food as she was encouraged by her room mates [sic]. No nausea or vomiting. Patient did get her Tylenol #3 which she took without difficulty. V[ital] S[igns] were stable. Will continue to monitor patient.” Moreover, Jamal stated that Ms. Neal's “Condition” was “Unchanged.” Id. (bold in original). Jamal also wrote, id. at 26: “No vision changes or headaches. No hearing loss. . . . No dizziness, no emotional disturbances. . . . No weakness.” And, Jamal wrote, id. at 27: “Constitutional: No apparent distress. Well nourished and well developed. . . . Neurological: Alert and oriented.” (Bold in original).

         C.

         The Infirmary contained three inmate dormitories, which Ajayi referred to as “Dorms 1, 2, and 3.” ECF 225-26 at 32. Ms. Neal was in “Dorm 3, ” which was an “open dorm” that housed multiple detainees. Id. According to a document signed by Officer Ladson (ECF 225-55), Dorm 3 contained eight inmate beds.

         Photographs of Dorm 3 were submitted as exhibits to the Opposition. See ECF 225-56 (photographs taken by Sergeant Carolyn Murray, dated November 4, 2012); ECF 233-4 at 14 (same). The photographs indicate that Dorm 3 consisted of a single room containing multiple beds, a table located in the center of the room, and a communal shower located in a corner of the room. ECF 225-56.[20] Dorm 3 was flanked by two rooms: the “Officer's Control Center” and the “Nurse's Station.” Id. Glass windows provided a view into Dorm 3 from the “Officer's Control Center” and the “Nurse's Station.” Id.

         The glass windows allowed medical staff and BCDC officers to see the inmates in Dorm 3, according to Ajayi. ECF 225-26 at 32. However, Alves testified at her deposition that “basically the nursing window, it's like you can't see out of that window. You can't really see out of it. They have stuff, papers and cabinets and all kinds of stuff in there . . . partially” obstructing the view into Dorm 3. ECF 212-20 at 8. BCDC correctional officers and Wexford medical staff could enter Dorm 3 “through [a] little doorway.” ECF 212-20 at 9.

         Inmate Saracino testified that a hallway adjoined Dorm 3, and passersby could see into Dorm 3. See ECF 225-8 at 9-10. Saracino also stated that the lights in Dorm 3 were “always on”, even in the middle of the night. Id. at 43.

         Kiearra Blair, a WDC inmate, was in the Infirmary when Ms. Neal “arrived” at Dorm 3 during the early morning hours of November 1, 2012. See ECF 225-29 (Declaration of Blair) ¶ 5. And, Blair remained in the Infirmary with Ms. Neal “for days after she arrived.” Id. During that period of time, Blair “was able to see and hear what was happening” to Ms. Neal in the Infirmary. Id. Blair averred, id. ¶ 6:

When [Ms. Neal] arrived at the infirmary, it looked like she had suffered from a stroke. She was sluggish on one side of her body and was having trouble walking. During the entire time that [Ms. Neal] was in the infirmary . . . she was having trouble moving one side of her body. She was in lots of pain. It was obvious that she needed medical help badly the entire time that she was in the infirmary.

         Blair also recalled that on an unspecified date, Ms. Neal “would try to get up and walk, but she repeatedly fell and hit her head.” ECF 225-29, ¶ 7. She added, id. ¶ 10: “Eventually, [Ms. Neal] could not get out of bed and could not eat.” Moreover, Blair averred in her Declaration, id. ¶ 8: “Every day, on every shift, I and many other women in the infirmary would tell nurses, guards, and other individuals that [Ms. Neal] needed emergency medical help and needed to go to the hospital.” Blair claimed that she personally “informed every nurse who came in to pass medications that [Ms. Neal] needed emergency medical help and needed to go to the hospital.” Id. Additionally, Blair stated that Ms. Neal “repeatedly told nurses and guards that she needed to go to the hospital. We told the staff these things for days before [Ms. Neal] died.” Id. According to Blair, the “staff” said Ms. Neal “was faking her problems to get medication.” Id. ¶ 9.

         Mary Betch, a WDC inmate housed in the Infirmary with Ms. Neal, stated in her Declaration (ECF 225-38) that on November 2, 2012, Ms. Neal was “dragging the right side of her body . . . she was also incontinent, and she could not get up to use the bathroom[.]” Id. ¶ 6. Betch averred: “Numerous times I told the nurses that [Ms. Neal] needed help.” Id. ¶¶ 7-8. According to Betch, unidentified medical staff “kept saying that [Ms. Neal's] vitals were fine and that [Ms. Neal] just wanted attention. They also said that she was supposed to be released very soon, and said a number of times that she was not going to be there much longer.” Id. ¶ 8.

         Moreover, Betch averred, id. ¶ 7: “Pretty much the whole time that [Ms. Neal] was in the infirmary, it was obvious that something was really wrong and that she badly needed medical help.” Betch also stated: “When the nurses came in, [Ms. Neal] kept telling them that her head felt like it was going to explode, and she would have tears in her eyes.” ECF 225-38, ¶ 7.

         In Sexton's letter to Bost (ECF 225-11), Sexton stated that on November 3, 2012, she was in the Infirmary working as an “Observation Aid.” Id. at 2-3. Sexton claimed that on that date Ms. Neal “looked so sickly. . . . She had no idea what was going on . . . . She kept saying ‘her head'” and “‘something[']s really wrong.'” Id. at 2. Additionally, Sexton stated that “nurse Ms. M- (Indin lady) [21]only checked on Fatima one time and said . . . that [Ms. Neal was] fine because her vitals [were] normal she just need[ed] to eat. Then [Sexton] told that [nurse] that if they didn't do something to send [Ms. Neal] to the hospital she was going to die.” Id. at 3 (internal quotation marks omitted).

         Further, Sexton asserted that she spoke with Nurse Ajayi on November 3, 2012. Id. According to Sexton, Ajayi and “Nurse Ms. M -” told her that they did not “know what[']s wrong” with Ms. Neal. Id. Additionally, Sexton stated that “Nurse Ms. M -” said that “nurses can only do what they are told no more or no less they can't make the call to send [Ms. Neal] out to a hospital.” Id. (internal quotations omitted). Additionally, Sexton stated: “To [her] and everyone other then [sic] the medical staff . . . at WDC we could see that Fatima was not here self [sic] something was really wrong with her.” Id. at 1.

         Inmate Kelly Frye was housed with Ms. Neal in the Post 83 dormitory. See ECF 225-24 (Declaration of Kelly Frye, dated January 18, 2017) ¶ 3. Frye continued to see Ms. Neal when she went to the Infirmary to “pick up medication” and when she worked in the Infirmary “on suicide watch.” Id. ¶ 4. Frye stated that when Ms. Neal was in the Infirmary, she “exhibit[ed] . . . very bad headaches, vomiting, diarrhea, blurry vision, impaired vision, and difficulty walking. From what [Ms. Neal] was saying and doing, it was obvious to [Frye] that [Ms. Neal] badly needed medical help. [Frye] and the other detainees repeatedly called out to the staff to get [Ms. Neal] help and to take her to the hospital.” ECF 225-24, ¶ 5. According to Frye, “detainees had to help [Ms. Neal] get dressed, because she physically could not do so on her own.” Id. ¶ 8. Further, Frye stated that she “saw [Ms. Neal] struggling to walk. She was dragging one side of her body and appeared to have weakness on one side of her body. It looked to me as though she had had a stroke. [Frye] could see that just by looking at her.” Id.

         Inmate Saracino testified at her deposition (ECF 225-8) that she was in the Infirmary “every morning” to receive medications and that she also worked in the Infirmary when Ms. Neal was there. Id. at 3-4. According to Saracino, Ms. Neal needed help from an unidentified nurse to walk, because she “couldn't move her leg and arm on one side of her body[.]” Id. at 14.[22] And, she never saw Ms. Neal receive any medical care while in the Infirmary. Id.

         Notably, Saracino wrote a letter to Bost on November 4, 2012. ECF 225-10; ECF 233-3. She recalled, ECF 225-10 at 1-2; ECF 233-3 at 3-4:

[Ms. Neal] talked about her head hurting so bad[.] She had trouble seeing out her eyes, didn't know much of what was going on. She thought she was home sometimes & other times thought she was on her way home . . . . [Ms. Neal] was really sick . . . . She wasn't eating, nor getting up to shower. The few ladies that were with her in her dorm had to help her go to the rest room[, ] wash up, drink, walk . . . . We watched her just go down hill in a matter of days. She was a vegetable. . . . We all spoke up & said something to the nurses that she wasn't OK and she needed to go to the hospital. The jail did nothing. Everytime [sic] I spoke to a nurse they said “her vitals were fine.” That was Nurse Rachel . . . . I observed the nurses on duty sleeping[.] When I seen how [Ms. Neal] couldn't walk I said to the nurse “see she getting worse.” Nurse told me I wasn't a doctor. Fatima had no movement on the one side of her body. Her foot was dragging & her arm was hanging. She was drewling [sic] from her mouth, she started going to the bathroom on herself, wouldn't eat & was just gone. . . . The dorm . . . had a window that the officers & nurses could see her [through] and they watched her for days just go down hill & they did nothing. [Ms. Neal] kept saying over & over “my head hurts bad, my head hurts bad” . . . . [T]he nurses or doctors anybody, no body listened to her. She cried out for help best way she knew how.

         In Saracino's Declaration of February 15, 2017 (ECF 225-30; ECF 233-3), she stated, ECF 225-30, ¶¶ 6-12:

[Ms. Neal] kept crying out for help every day in the infirmary, but the nurses, doctors, and officers did not help her. Fatima talked about her head being in extreme pain. She kept saying, over and over, that her head hurt bad.
While she was in the infirmary Fatima also had trouble seeing and understanding what was going on. She did not seem to know where she was at all times.
Fatima drooled, urinated, and defecated on herself. But, she was not physically able to get up to take a shower.
Fatima was not able to eat properly. She could not walk around, or get a drink without getting help from me and the other detainees.
The nurses and officers could see Fatima being helped by me and the other detainees.
I witnessed Fatima struggling to walk. She could not move one side of her body, and her foot was dragging and her arm was hanging. These things were easy to see just from looking at her. I also pointed this out to the nurse on duty, but the nurse did not take any action to help Fatima.
I tried to get the nurses to help Fatima, and I observed many of the other detainees do the same. But the nurses did not. One of the nurses that I talked to about . . . Fatima . . . was Nurse Rachel.
The Infirmary had a window, through which the nurses and officers could see Fatima and the other detainees in the infirmary at all times. But the medical staff and officers did nothing to help her.

         Inmate Monica Brown provided a statement on November 4, 2012. ECF 233-4 at 26. She claimed that Ms. Neal “received little to no attention from medical staff even though they were alerted many times to . . . her condition by the other inmates[.]” Brown also wrote a letter to Bost on November 5, 2012. ECF 225-12. She said, in part, that she “told the medical staff” that Ms. Neal “kept on saying that her headache [was] so bad . . . but they did nothing for her . . . and the inmates was . . . the[] only ones that help . . . her.”

         Other inmates also provided statements at the relevant time. See ECF 233-4 at 22 (Inmate Statement of Ernestine Williams, dated November 4, 2012) (“Medical staff seemed not to care at all.”); ECF 233-4 at 24 (Inmate Statement of Donnetta Bennett, dated November 4, 2012) (“Staff was told on numerous occasions of [Ms. Neal's] condition [but] there was little or no response.”).

         According to an undated report written by Sergeant Murray for the Internal Investigative Unit (“IIU”) of the DPSCS (ECF 225-37) (hereinafter, the “Initial IIU Report”), [23] detainees who were in the Infirmary with Ms. Neal provided statements to the effect that Ms. Neal “remained in the bed, would not eat or drink, and began walking with her right side slumped and dragging her right leg, since Friday (11/2/2012).” Additionally, Sergeant Murray reported that three of the detainees stated that “they believed [Ms. Neal] had a stroke.” Id.

         D.

         On November 4, 2012, “Staff discovered [Ms. Neal] unresponsive at 0025 Hrs.”, i.e., 12:25 a.m. ECF 225-14 at 12-13 (IIU Duty Officer's Checklist) at 12 (hereinafter, “Duty Officer's Checklist”); see also ECF 225-14 at 5, 10. The Duty Officer's Checklist does not identify the “staff” member who discovered Ms. Neal. More than three hours passed before Ms. Neal was transported to Johns Hopkins Hospital (“JHH” or the “Hospital”). See ECF 233-6 at 28, 30.

         Based on a document signed by Officer Ladson on November 4, 2012, six of the eight beds in Dorm 3 were occupied by inmates during the early morning hours on that date. See ECF 225-55. Lieutenant Alves stated at her deposition (ECF 212-20) that on November 4, 2012, she was the supervisor responsible for BCDC correctional officers stationed in the WDC, and Captain McKnight was the Shift Commander to whom Alves reported. Id. at 3.

         According to a “Serious Incident Report” created by Alves at approximately 3:22 a.m. on November 4, 2012 (ECF 233-4 at 17-20), Ladson informed Alves that she (Ladson) “had just completed a security round when she returned to the security office [where] she was alerted by several detainees in [the Infirmary] by tapping on the window that [Ms. Neal] was gasping for air. Officer Ladson immediately notified Nurse Elizabeth Obagine [24] and the two went into the dorm area to assist [Ms. Neal] who was experiencing difficulty breathing.” ECF 233-4 at 17; see also ECF 212-24 (Post 93 Logbook, C-Shift) at 3 (entries made by Ladson between 3:22 a.m. through 4:00 a.m. on November 4, 2012).

         Alves stated at her deposition (ECF 212-20) that in the early morning hours of November 4, 2012, she was in the Correctional Officers' room adjacent to Dorm 3 (id. at 7-8) when inmates housed in Dorm 3 “[k]nocked on the officer's window.” Id. at 8. She explained that the inmates knocked on the officer's window because, inter alia, “the officer is the one who is supposed to respond to incidents, ” not the nursing staff. Id. She added that the inmates “know they would have got a response quicker” by knocking on the “officer's window.” Id. Alves also stated that the “medical staff . . . ain't expedient.” Id.[25]

         Alves looked through the “officer's window” into Dorm 3, where she saw Ms. Neal “tossing and turning and looking like she couldn't breathe.” ECF 212-20 at 7. Alves then walked to the nurses' station. The nurse “was awake” and Alves “told the nurse, let's go, something is wrong.” Id. at 8.

         At 4:00 a.m. on November 4, 2012, BCDC Assistant Warden Oliver called Officer Ladson. She asked Ladson to “report the situation to” Oliver. ECF 212-24 at 3.

         Inmate Kelly Frye saw Ms. Neal on November 4, 2012. ECF 225-24 (Declaration of Frye) ¶ 10. According to Frye, Ms. Neal was “lying in her own feces, drooling, and foaming at the mouth. She was incoherent and looked . . . as if she was in a vegetative state.” Id. Frye claimed that she “banged on the nurses' station to get help for [Ms. Neal], but the nurse on duty was asleep with her feet propped up on a chair. Despite [Frye's] banging, [the nurse] did not get up right away.” Id. ¶ 11; see also ECF 233-4 at 21 (Inmate Statement of Vanessa Dow, dated November 4, 2012) (“I observed Dorm 3 women trying to get the nurse['s] attention but she was sleeping so I nock [sic] on the window[.]”). According to Frye, “[w]hen the nurse finally got up, she acted as if she did not want to touch [Ms. Neal]. She then made multiple phone calls. The detainees in the infirmary were told to leave the room.” ECF 225-24, ¶ 12.

         Nurse Oby Atta worked with the “general population” of inmates on the fourth floor of BCDC. ECF 225-59 (Oby Atta Deposition) at 4. At 4:42 a.m. on November 4, 2012, Nurse Atta began to write a medical record for Ms. Neal, which she completed at 8:54 a.m. See ECF 233-6 at 28-29; see also ECF 225-59 at 65; ECF 225-114 (Jamal Deposition) at 57; ECF 245-2 (Miller Deposition) at 12. In the medical record, Atta was listed as Ms. Neal's “Provider.” See ECF 233-6 at 28-29.[26] Nurse Atta wrote, id. at 28:

Called by Nurse at about 3:22 am to evaluate a 42 year old AA Female with a history of . . . Headaches . . . . [S]he was found unresponsive. Patient was admitted to the Infirmary because of severe headache.On [sic] arrival Pt was unresponsive to stimuli but was breathing and secretions from her mouth. Per report her appetite was poor.He [sic] Oxygen SAT room air was 30%, heart rate 120's and breathing 12 - 14/min. She was started on Oxygen therapy face mask, suctionedl [sic], 911 activated.O2 [sic] SAT increased to 90%, hr [sic] 70's the Infirmary Nurse called the MD on call Dr. Kulam but no response, Dr[.] Tewede was called and she left messages for return call.She [sic] also called the Nurse Supervisor Ms[.] Stacey who was notified of the plan to sent [sic] the Pt to ER for evaluation and she agreed with the plan. Dr[.] Tewede called back and agreed with the plan to sent [sic] the Pt to ER.At [sic] about 3:50 AM the Pt stopped breathing and no pulse and CPR was started HR 50.911 [sic] came at about 3:53AM and left 3:55AM.

See also ECF 233-4 at 29 (Progress Note written by Atta at 3:22 a.m. on November 4, 2012); ECF 233-35 (same).

         At 5:29 a.m. on November 4, 2012, Nurse Obadina “generated” a medical record for Ms. Neal, indicating that the “VISIT TYPE” was for “Skilled care/Ermergency [sic] sent out by 911”, and that Doctor Afre was Ms. Neal's “Provider.” See ECF 233-6 at 30.[27] Obadina wrote, id.:

At 3.22am, [sic] pt was found to by [sic] inresponsive [sic] to stimuli. The Nurse Practitioner was called. pt [sic] was breathing, B/p 80/60 ..unresponsive [sic] to stimuli, with secretions from her mouth.oxygen [sic] SAT was 30%, heart rate was 120, and breathing was 12-14/min.she [sic] was started on oxygen therapy by face mask, sunctioed [sic], 911 activated.O2 [sic] increased to90%.HR [sic] was 70. all [sic] efforts to get on call doctor failed. Dr. Tewede was contacted. he [sic] eventually responded. Charge nurse was informed. at [sic] 3.50am, [sic] pt stopped breathing.no [sic] pulse and CPR was started.HR [sic] was 50. . . .

See also ECF 233-4 at 27 (Progress Note written by Obadina at 7:30 a.m. on November 4, 2012).

         Nurse Jamal wrote and signed a document on November 4, 2012 (ECF 233-4 at 28) at an unspecified time. She recounted that she “was called by c/o to help . . . a patient in dorm three.” Jamal stated that she “placed 02 on the patient.” According to the Initial IIU Report (ECF 225-37), the “On-Call doctor” whom Atta, Obadina, and Jamal attempted to contact “never answered the call or called the nurse[s] back.” ECF 225-37. The medical record created by Nurse Atta indicated that “Dr. Kulam” was the on call doctor. ECF 233-6 at 28. Because Doctor Kulam could not be reached, the “nursing staff” subsequently called the regional nursing manager, “who gave permission to send [Ms. Neal] out to the hospital (via ambulance - 911).” ECF 225-37; see also ECF 225-15 (Murray Deposition) at 11; ECF 233-6 (medical records) at 30.

         A 911 crew arrived at the Infirmary at 3:53 a.m. on November 4, 2012. ECF 233-6 at 28, 30. According to Frye, when “paramedics and emergency medical technicians arrived[, o]ne of them assessed [Ms. Neal] and said that [she] had been dead for a while.” ECF 225-24 (Declaration of Frye) ¶ 13.

         Alves stated at her deposition that when the 911 crew arrived, she “went into the office” and called Captain McKnight, asking McKnight to provide “two . . . weapons qualified officers” to accompany Ms. Neal from the Infirmary to the Hospital. ECF 212-20 at 12. McKnight followed “protocol” by calling the IIU, alerting Detective Mark Forrest as to Ms. Neal's situation. ECF 212-18 at 9; see also ECF 225-14 at 5.

         According to the medical records “generated” by Atta (ECF 233-6 at 28) and Obadina (id. at 30), the 911 crew left the Infirmary with Ms. Neal at 3:55 a.m. on November 4, 2012. Ms. Neal was transported to JHH. See ECF 233-5 (Autopsy Report) at 10. When Ms. Neal arrived at the Hospital, she had “[n]o pulse” and “[n]o respiration.” ECF 233-11 (JHH medical record) at 2. The Hospital medical record further noted, id. at 3: “Cardiopulmonary arrest with long down time.” Ms. Neal was pronounced dead at 4:31 a.m. on November 4, 2012. See ECF 225-14 at 9; see also ECF 233-5 at 10.

         In Saracino's handwritten letter to Bost of November 4, 2012 (ECF 225-10), Saracino wrote, id. at 1; see also ECF 233-3 at 3 (same): “[T]his jail did not help [Ms. Neal] or do anything for her. . . . They let her die.”

         E.

         Sergeant Murray wrote a Criminal Investigation Report for the IIU, dated June 5, 2013. See ECF 225-14 at 1-11 (hereinafter, the “Final IIU Report”). Murray interviewed various health care providers and WDC detainees. I need not restate the information obtained from parties or witnesses whose statements were obtained through other means, and already recounted. However, Monica Brown's statement to Ms. Murray was more detailed than the information previously recounted.

         Brown told Murray that Ms. Neal “stayed in the bed, kept sleeping”, “barely spoke”, and “would talk incoherently . . . about a book and a girl, and was also asking [other detainees] to close the door.” ECF 225-14 at 8. According to Brown, “what [Ms. Neal] was saying did not make sense.” Id. Further, Brown stated that Ms. Neal “was walking like something was wrong with her right side, ” “urinated in her bed approximately three (3) times, ” “began sweating approximately two (2) days prior and was hot and cold at the same time.” Id.

         Brown related that on the morning of November 4, 2012, she saw “Acid white” bubbles coming out of [Ms. Neal's] mouth” and that Ms. Neal “was breathing hard, gasping for air.” Id. According to Brown, Ms. Neal “sat up on the side of her bed and was talking out of her head.” Id. At that point, Brown “banged on the nurses' station window and observed the nurse asleep.” Id. Brown “continued banging on the window until the nurse woke up.” Id. Brown “told the nurse that they needed her help” and the “nurse came into the infirmary and began treating” Ms. Neal. Id.

         The Final IIU Report concluded, inter alia, that the “interviews with the detainees housed in the infirmary established that the detainees were familiar with [Ms. Neal] and their statements that they were concerned for and helping [Ms. Neal] were consistent.” ECF 225-14 at 8 (emphasis in original).

         The following portions of Murray's deposition are pertinent, ECF 225-15 at 20-22 (bold in original):

Q. In addition, did you ever raise any concerns with anybody about the quality of medical care that Fatima Neal received at the BCDC?
A. Yes, sir.
Q. And who did you raise those concerns with?
A. My supervisor, Director Ballard. Lieutenant Daniel Morrow and Director Jesse Ballard, III.
Q. And so my question is, generally speaking, to the best of your memory, what concern did you raise with Mr. Morrow?
A. That there were medical issues that I believe our department needed to ensure were appropriate, as far as the care certain inmates were receiving.
Q. Do you remember in general terms what you raised with Director Ballard?
A. Just the fact that I observed that there were some questionable issues regarding medical care inmates received and someone needed to ensure that it was properly looked into.
Q. Was your general take-away that [Obadina] was not showing enough concern for Fatima Neal?
A. Yes.

         F.

         Doctor Theodore King, Jr., the Assistant Medical Examiner for the Office of the Chief Medical Examiner for the State of Maryland, conducted a postmortem examination on November 4, 2012, and wrote an Autopsy Report as to his findings. See ECF 233-5 (Autopsy Report). He concluded that the cause of Ms. Neal's death was “intracerebral hemorrhage (stroke) with complications.” Id. at 10; see also Id. at 1.

         The Autopsy Report contained a “Pathologic Diagnosis”, which stated, inter alia, id. at 9:

I. [I]ntracerebral hemorrhage with complications
A. Admission to institution infirmary with complaints of headache (11/1/12)
B. In infirmary with institutional personnel supervision and detainees who reported that she walked with her right side slumped and dragging her right leg since 11/2/12
C. [R]eceived acetaminophen for headache, at 0900 hrs. and 2100 hrs. 11/3/12
D. [A]dditional complaints of headache at 0200 hrs. 11/4/12
E. “[F]oaming from the mouth” and unresponsive with no pulse 0225 hrs. 11/4/12
F. Emergency medical personnel transport to local Maryland hospital
G. Additional care and pronounced dead approximately 0431 hrs. 11/4/12
H. [A]ccute hemorrhage of the left parietal white matter
I. [S]econdary infarct of the left occipital, and temporal cortices . . . .

         The Autopsy Report also included a “Neuropathology Report.” See ECF 233-5 at 6-8. It revealed a 3/8 inch hemorrhage on Ms. Neal's medial right frontal subgaleal scalp, and a 3/8 inch hemorrhage on her lateral right frontal subgaleal scalp. Id. at 3. An “opening” was “noted in the left posterior parietal region” of the brain, “through which it [was] possible to identify an intracerebral hematoma.” Id. at 6. Additionally, a “4.5 x 3.0 x 3.0 cm” hematoma was observed in the “white matter of the left parietal lobe.” Id. The “significant mass” of the second hematoma had caused “left uncal herniation.” Id. The report also noted an “[a]cute hemorrhagic infarct . . . in the left occipital lobe and mesial temporal lobe.” Id. The ventricular system of the brain “appear[ed] collapsed.” Id. The “midbrain show[ed] marked compression on the left side and the aqueduct [was] collapsed.” Id. Additionally, there was swelling of the left cerebral hemisphere, causing asymmetry between the cerebral hemispheres. Id.; see also ECF 225-18 (Affidavit of Doctor King, dated July 24, 2017).

         Plaintiff submitted the Expert Report of Laura Pedelty, M.D., Ph.D., a board-certified neurologist with subspecialty certifications in vascular neurology, neurosonology, and behavioral neurology. See ECF 225-20 (Pedelty Report of March 14, 2017) at 1. She also holds a Ph.D. in Cognition and Communication from the University of Chicago. See Id. at 8. Notably, Doctor Pedelty explained some of the terms used in the Autopsy Report. See ECF 225-20 (Pedelty Report of March 14, 2017). Doctor Pedelty stated, id. at 3: “Intracerebral hemorrhage . . . occurs when a blood vessel leaks, resulting in bleeding into a region of the brain.” An “Ischemic stroke occurs when an artery supplying blood to a region of the brain is occluded (blocked) and that region of the brain is deprived of nutrients and oxygen.” ECF 225-20 at 3. Further, Doctor Pedelty explained, id.: “Both ischemic and hemorrhagic strokes can cause swelling of the brain in areas around the immediate damage. Brain swelling (edema) usually develops over several days following a stroke . . . . The swelling can block large and small blood vessels, leading to further strokes. If the swelling is severe, it can force regions of the brain out of its firm covering (the dura mater) or even out of the cranial vault (skull), a phenomenon known as herniation.” She added, id.: “Herniation of the brain hemispheres onto the brainstem (‘uncal herniation') can damage crucial brain structures supporting vital functions and is rapidly fatal if not treated.”

         Doctor Pedelty also stated, id.: “Fatima came to medical attention on the night of October 31-November 1, complaining of . . . severe headache and impaired vision, and as having difficulty walking. This is consistent with the initial left parietal hematoma, resulting in right-sided weakness and difficulty seeing or attending to the right” side of her body. (Citations omitted). According to Doctor Pedelty, the Autopsy Report “is explained by a sequence of events starting with a hemorrhagic stroke of the left brain hemisphere, followed by brain swelling leading to blockage of blood vessels supplying structures in the back of the brain resulting in ischemic strokes, and by ongoing swelling ultimately leading to brain herniation and death.” Id. at 3-4.

         Plaintiff's expert, Nathaniel R. Evans, II, M.D., a board certified internist and certified Correctional Health Care Provider (ECF 233-44), submitted a report dated June 19, 2017. ECF 225-19. He opined, id. at 5: “By all clinical indications (sudden onset severe headache, drowsiness, weakness, confusion), a first stroke - a significant, serious neurological event - occurred no later than 11/01/2012 . . . . and the progressive effect of the bleed was to cause death of other parts of her brain (left occipital and left parietal) leading to her death.”

         Peter Pytel, M.D., another plaintiff's expert, is a board certified neuropathologist. He stated in a report dated June 19, 2017, ECF 225-22: “[T]he available clinical information also suggests that the decedent suffered from asymmetric neurologic deficits that can potentially be localized to the left side of the brain starting on 11/1/12 or 11/2/12. This history and the early histologic changes including macrophage infiltration would both be consistent with or suggest that the decedent developed ischemic changes before the events of 11/4/12.” Id. at 2. At his deposition (ECF 225-35), Doctor Pytel said, id. at 22: “Based on the literature and teachings, people typically say that macrophages show up after two, three - some people say after five days of the injury, ” i.e., stroke.

         Doctors Pedelty and Evans agree that, given the symptoms presented by Ms. Neal during the early morning hours of November 1, 2012, she required urgent transfer to a hospital where she could receive appropriate medical care. See ECF 225-19; ECF 225-20.

         Doctor Evans opined that a “severe sudden onset of headache, . . . associated with weakness and confusion should signal [to] a medical provider that the patient may have an intracranial bleed and may need to be evaluated with brain imaging. . . . If a stroke or neurological crisis cannot be ruled out, the standard of care requires prompt . . . transfer to a hospital for evaluation.” ECF 225-19 at 3; see also ECF 225-20 at 5.

         Moreover, Doctor Pedelty opined that “Fatima Neal's progression to cardiopulmonary arrest and death was due to a failure to consider, investigate, and obtain appropriate medical care for a diagnosis ...


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