Michael Wilson, 32, was serving a two-week jail sentence in the San Diego Central Jail for violating his probation. At the time of his imprisonment, he had an enlarged heart, a serious condition that began when he was four to five months old. As a result, he needed four different cardiac medicines each day to prevent fluid accumulation in his body. The court issued a written notice to medical personnel at the jail about Wilson’s “serious medical needs.” But the jail nurses ignored the judge’s forewarning and when the medications were not available, he missed 36 doses of his meds in the first six days in jail, followed by three days where he received six doses of some of his medicines instead of the required 18. He died on the morning of his tenth day in jail.

Lawyers for the jail and the City of San Diego filed a motion for summary judgment that Presiding District Judge Ruth Bermudez Montenegro of the U.S. District Court for the Southern District of California granted it in part and denied it in part. Plaintiff Phyllis Jackson was the “successor-in-interest of his estate. She had cared for Wilson since he was three months old but never adopted him. She was termed his “equitably adopted mother.”

Jackson sued various jail and government defendants for six causes of action, including “deliberate indifference to serious medical needs,” failure to train, failure to supervise some of the jail’s medical staff and the county’s administrators, and negligence.

The county asserted “qualified immunity” for the San Diego government officials, which would shield them from liability if their conduct violated a “clearly established” constitutional right. Montenegro’s opinion cited Ninth Circuit precedents that “clearly establish that prison officials “may not deny, delay, or intentionally interfere with medical treatment.” In addition, “a prison official who is aware that an inmate is suffering from a serious acute medical condition violates the Constitution when he stands idly by rather than responding with reasonable diligence to treat the condition.” The judge denied the County’s motion for qualified immunity.

Three of Wilson’s nurses, Macy Germono, Marylene Ibanez, and Anil Kumar (the nurses) appealed the district court’s denial of the motion for summary judgment in a civil rights action that alleged violations of 43 U.S.C. §1983, and the Eighth Amendment. Section 1983 gives people the right to sue state government employees for civil rights violations, and the Eighth Amendment forbids cruel and unusual punishment.

In a unanimous 3-0 memorandum opinion of the Ninth Circuit Court of Appeals on September 11, Justices Sandra Ikuta, Michelle Friedland, and Kenneth K. Lee affirmed Montenegro’s ruling. The opinion said that patient Wilson “had a right to not be denied or delayed in receiving all of his prescribed cardiac medications by jail medical staff who knew of his severe cardiac issues and that he had missed doses of his essential cardiac medications.” They concluded, “The nurses do not meaningfully challenge this definition of the allegedly violated right.”

The opinion went on to provide factual support for the court’s decision. It said that each of the three nurses had examined Wilson’s medical records, and these reviews gave “rise to the inference” that they knew of the jail’s “failure to provide those medications.” They also “knew of the risk” Wilson faced without his required medicine. The opinion summarized that “a reasonable fact finder could conclude that the nurses’ failure to manage Wilson’s potentially fatal condition by providing him with medication for his serious medical needs was in disregard of a substantial risk to Wilson’s health.”

In addition, the Ninth Circuit said that the district court had rightly concluded that the nurses’ civil right to immunity was never established. Their inaction thus constituted “deliberate indifference.” Precedent established that a nurse who knew her patient was at serious risk but who failed to call paramedics would be denied summary judgment as would prison officials who failed to provide food to a diabetic.

The opinion summarized that the actions of the three nurses who failed to treat Wilson were comparable. The judges said that ignoring Wilson’s repeated requests for his “prescribed and necessary” treatment clearly violated his Eighth Amendment rights to avoid cruel and unusual punishment. The appellate court concluded that the district court’s lengthy description and analysis was “adequately specific” about the circumstances of each nurse and the district court “did not err” when it individualized the qualified immunity analysis of each nurse’s behavior.