United States District Court, D. Maryland
SHARON BOST, individually and as the personal representative of the ESTATE OF FATIMA NEAL, Plaintiff,
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
L. HOLLANDER UNITED STATES DISTRICT JUDGE
case arises from the tragic death of Fatima Neal (“Ms.
Neal” or the “Decedent”) on November 4,
2012, at the age of 42. 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
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.
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; 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.
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. ¶¶
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. As to the Medical Defendants,
plaintiff also alleges medical malpractice. Id.
¶¶ 207-17. 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.
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. 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
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;
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
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.
Factual Background 
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
recalled that at approximately 2:00 a.m. on November 1, 2012,
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  from medical came
downstairs and took Fatima to medical[.]
ECF 225-11 at 1; see also ECF 228-8 at 11.
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]  . . . . 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.
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.
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.
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
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
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.”
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.
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
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
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.
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.
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.
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
Id. The following portion of Wiggins's
deposition transcript is pertinent, id. (bold in
Q Do you have any independent recollection of any of
your encounters with Fatima Neal as a patient at the
A No, ma'am.
Q Fair to say that you have no independent
recollection of how she appeared physically during your
A That is fair to say.
Q And you have no independent recollection of any
treatment that you - treatment or medications that you
A That is correct.
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
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).
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
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.
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.
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
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.”
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.
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).
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).
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).
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. 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
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. In the
medical record, Jamal wrote, id. at 26:
“Patient lied down all shift.” Jamal also wrote,
id. at 27:
Increase activity level
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).
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.
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. 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
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.
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.
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.
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.
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.
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.
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) 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).
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.
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.”
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
she never saw Ms. Neal receive any medical care while in the
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
[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.
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
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.
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.”
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
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”),  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.”
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.
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.
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  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,
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
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.
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.
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.
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
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).
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
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).
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.
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)
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.
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
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
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
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.
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.
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).
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
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.
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
Q. Was your general take-away that [Obadina] was not
showing enough concern for Fatima Neal?
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.
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
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
G. Additional care and pronounced dead approximately 0431
H. [A]ccute hemorrhage of the left parietal white matter
I. [S]econdary infarct of the left occipital, and temporal
cortices . . . .
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).
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
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.
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.”
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, ”
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;
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.
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 ...