Caseflicks

Court of Appeals for the Ninth Circuit • 2004

Toguchi v. Soon Hwang Chung

391 F.3d 1051 | 2004 U.S. App. LEXIS 25465

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Takeaway

In short, this case underscores that poor medical judgment or malpractice in prison does not establish deliberate indifference without evidence that the provider actually recognized and consciously disregarded a substantial risk to the inmate’s health.

Background

Keane Toguchi, an incarcerated man with extensive mental-health diagnoses, a history of illicit drug use, and Wolff-Parkinson-White Syndrome, came under Dr. Soon Hwang Chung’s care at Halawa Correctional Facility in late 1998. After returning to prison following methamphetamine use and several days without his prescribed medications, Keane was initially stabilized. He later began behaving irrationally, and Dr. Chung changed his medications, attributed his symptoms to a likely methamphetamine flashback, and ordered restraints when she viewed him as an imminent danger to himself.

Dr. Chung checked on Keane after he was restrained and recorded that he was asleep. A nurse reported at 3:00 p.m. that he had stopped breathing. CPR and other emergency efforts were unsuccessful. The medical examiner concluded that Keane died from combined toxic effects of sertraline (Zoloft) and diphenhydramine (Benadryl), at lethal and toxic blood levels respectively, though it was unclear how he had ingested those quantities.

Keane’s parents brought a § 1983 action against Dr. Chung and another prison physician, alleging deliberate indifference to Keane’s serious medical needs under the Eighth Amendment and interference with their liberty interest in their son’s companionship. Their experts criticized Dr. Chung’s diagnosis, medication choices, failure to account for possible drug interactions and withdrawal, and failure to perform a differential diagnosis. The district court granted summary judgment for the defendants. The parents did not contest summary judgment as to the other doctor, Dr. Paderes, and appealed the judgment for Dr. Chung.

Issues

Issue #1

Whether the evidence could support a finding that Dr. Chung was deliberately indifferent to Keane Toguchi’s serious medical needs in violation of the Eighth Amendment.

Holding

No. The parents did not produce evidence from which a jury could find that Dr. Chung actually knew of and consciously disregarded a substantial risk of serious harm to Keane.

Reasoning

An Eighth Amendment medical-care claim has both an objective and a subjective component. The official must deprive the prisoner of a basic necessity, and must act with deliberate indifference. Deliberate indifference is a demanding subjective standard: the official must know facts showing a substantial risk of serious harm, must actually draw that inference, and then must disregard the risk. Negligence, medical malpractice, and even gross negligence do not suffice.

The court found no triable issue concerning Cogentin. Although the record raised some uncertainty about whether Dr. Chung had read a 1995 report describing a negative reaction to the drug, she testified that she disagreed with that report’s causal conclusion and did not consider Cogentin a serious risk. Keane had also received Cogentin under her care in 1997 without apparent harm. Her possible medical error in discounting the earlier report did not prove that she subjectively recognized and disregarded an excessive risk.

The decision to discontinue Seroquel and prescribe Trilafon likewise did not establish deliberate indifference. A disagreement between medical professionals over alternative treatments is not enough. The parents needed evidence that the selected treatment was medically unacceptable under the circumstances and that Dr. Chung selected it in conscious disregard of an excessive risk. Their evidence showed, at most, a dispute over medical judgment.

The record did not support the claim that Dr. Chung was deliberately indifferent during Keane’s respiratory arrest. On learning that he had stopped breathing, she ran to assist him; CPR was already underway, and emergency personnel arrived shortly thereafter. The parents offered no evidence that Dr. Chung could have performed an additional procedure that would have revived him. The failed resuscitation effort therefore did not demonstrate conscious disregard.

The alleged restraint-monitoring failure also did not create a material factual dispute. Although the monitoring sheet had no entries at 2:00 or 2:15 p.m., the applicable policy assigned fifteen-minute checks to authorized correctional staff, and the sheet was completed by nurses rather than physicians. More importantly, Dr. Chung testified without contradiction that she personally returned every fifteen minutes to see how Keane was doing. A missing notation did not establish that she knowingly failed to monitor him.

There was no evidence that Dr. Chung knew Keane faced a substantial risk from Klonopin withdrawal. The premise that he had taken Klonopin continuously for nineteen years was undermined by evidence that he had not taken it for five or six months before his April 1998 parole and had been stable on other medications. Dr. Chung relied on her past treatment of Keane, and nothing showed that she actually perceived withdrawal as a serious danger.

The parents’ expert opinion concerning the combined effects of Zoloft, Benadryl, and Cogentin did not establish Dr. Chung’s subjective state of mind. The expert asserted that she disregarded known risks, but did not identify evidence that she herself knew those drugs posed a life-threatening risk to Keane and chose to proceed anyway. His criticism that she failed to assess Keane adequately or account for withdrawal symptoms described possible negligence, not the required conscious disregard. A contrary expert view of the diagnosis and medication regimen was also only a difference of medical opinion.

Finally, Dr. Chung’s failure to conduct a differential diagnosis did not meet the constitutional standard. Based on her extended experience treating Keane, his history, and his behavior, she concluded that he was experiencing an ice flashback and did not believe he had access to contraband drugs in prison. Even if those assumptions or the resulting diagnosis were unreasonable, the Eighth Amendment required proof that she actually knew he might be suffering an overdose or another grave condition and deliberately ignored that risk. The parents supplied no such evidence.

Viewed favorably to the parents, the record showed that Dr. Chung repeatedly responded to Keane’s condition and made treatment decisions that might be challenged as medically unsound. But it did not show that she denied, delayed, or intentionally interfered with treatment, or that she knowingly disregarded a substantial risk of serious injury. Summary judgment on the § 1983 claim was therefore proper.

Issue #2

Whether Keane’s parents could recover under § 1983 for deprivation of their constitutional liberty interest in the companionship and society of their son.

Holding

No. Because the evidence did not show conduct beyond negligence, it could not support a due-process violation.

Reasoning

Parents have a protected liberty interest in the companionship and society of their children, and state interference with that interest may be actionable under § 1983. But negligent conduct is categorically below the constitutional threshold for a due-process claim.

The parents’ due-process theory rested on the same alleged failures in diagnosis, treatment, medication management, and monitoring that supported their Eighth Amendment claim. Since that evidence failed to show Dr. Chung’s subjective awareness and conscious disregard of a serious risk, it showed no more than possible negligence. The district court thus properly granted summary judgment on this claim as well.