Juliana Swink v. Souothern Health Partners, Inc., et al.

Greensboro, North Carolina personal injury lawyer represents the Plaintiff on medical malpractice, wrongful death and civil rights claims.



David Ray Gsunter was diagnosed with a heart condition shortly after birth. At fifteen years old, to address his heart condition, Gunter underwent open-heart surgery to replace his aortic valve with a mechanical heart valve (“MHV”).

At this time, Gunter was also prescribed Coumadin, an anticoagulant or blood thinner, which reduces the formation of blood clots. Id. Gunter “faithfully and regularly took his Coumadin dosage at a set hour every day” and such regimen “was effective and [Gunter] did not suffer serious complications from his heart condition provided that he faithfully

observed his physicians’ instructions.”



Individuals with MHVs have a higher risk of blood clots than those without MHVs.

J.A. 2147. To ensure such patients are receiving the appropriate amount of Coumadin,

providers monitor the patient’s International Normalized Ratio (“INR”) range, which

indicates, amongst other things, the blood’s thickness and clotting factors. Id. It is

important for individuals with MHVs to maintain levels of anticoagulant within a

therapeutic range and that the levels of anticoagulant do not fall above or below the

therapeutic range. J.A. 245. An appropriate or “therapeutic” INR level for an individual

with an MHV is between 2.5 and 3.5. See J.A. 695, Deposition of Virginia Glover Yoder

(“Yoder Dep.”) 201:14–15; J.A. 1925 ¶ 5. An individual with an MHV that has an INR

level below the “therapeutic” range is at risk for clot formation, while an individual with

an MHV that has an INR level above the “therapeutic” range is at risk for excessive

bleeding. See J.A. 682, Yoder Dep. 78:4–2. Gunter typically took Coumadin once per day

in the evening. J.A. 674, Gunter Dep. 80:9–10. Over the years, Gunter’s daily dosage has

fluctuated between 5mg and 7mg per day due to various factors, including financial access

to medication, diet, and metabolism needs. J.A. 673, Gunter Dep. 74:19; see also J.A. 533.

In early 2012, Gunter was treated by Dr. Virginia Yoder at a Coumadin clinic in North

Carolina. J.A. 1977. Due to financial difficulties, Gunter had trouble securing reliable

transportation to his appointments, and subsequently, was discharged from the clinic on May

31, 2012 for failure to attend. J.A. 695, Yoder Dep. 201:4–7; see also J.A. 1977. Between

May 2012 and November 2012, Gunter asserts he provided lawn care services for a doctor,

who, in exchange for this labor, provided Coumadin and INR testing. See J.A. 1977, 2199.

On November 6, 2012, Gunter was arrested in Forsyth County pursuant to a bench

warrant and was temporarily placed at the Forsyth County local confinement facility. J.A.

245; see also J.A. 672, Gunter Dep. 54:13–20. When Gunter arrived at the Forsyth County

local confinement facility, “he completed a medical intake form, disclosing that he has a heart

condition and alerting that he takes Warfarin1 daily together with other medications and other

medical information.” J.A. 245.



On the morning of November 7, 2012, Gunter was transferred to Davie County

Detention Center (“DCDC”). J.A. 246. Upon his arrival, Gunter was screened by appellee

1 The generic brand of Coumadin is referred to as “Warfarin,” and both brands are

used interchangeably by the parties’ witnesses and district court. See J.A. 1218, Gunter

Dep. 36:12–15. For consistency purposes, this opinion will only refer to Gunter’s

prescribed medication as Coumadin.



Fran Jackson, a nurse and the Davie County Medical Team Administrator for appellee

Southern Health Partners, Inc. (“SHP”), the contracted medical care provider for DCDC. J.A.

94, 246, 566–77, 675, Gunter Dep. 81:7–14. Gunter advised Jackson that he had an MHV and

took Coumadin, which she noted in his medical record. J.A. 94, 532–33. Jackson further

noted that Gunter advised he would have his medications brought to DCDC if he was not

released and advised Jackson to call his doctors if he was not released. J.A. 533. Gunter states

Jackson was not “very nice” and “when she listened to [Gunter’s] heart clicking” stated “[j]ust

because your heart clicks doesn’t mean you have a mechanical heart valve.” J.A. 1228, Gunter

Dep. 88:17–25.



On the morning of November 8, 2012, Jackson contacted Gunter’s primary care

physician and pharmacist about his condition. J.A. 533. According to Jackson’s notes in the

medical records, the clinic where Gunter stated his primary physician worked had last seen

Gunter in June 2012 for a sick visit, but otherwise had not managed his INR levels since 2010.

Id. Jackson’s notes in the medical records further indicated the pharmacist informed Jackson

that Gunter had last filled a prescription for 1mg of Coumadin on October 19, 2012, and did

not have any prescriptions remaining. Id. Jackson also received a faxed medical record from

a clinic, which indicated Gunter reported taking 7mg of Coumadin by mouth daily.

That same day, Jackson consulted with appellee Manuel Maldonado, a licensed

Physician’s Assistant and independent contractor for SHP who oversaw medical care at DCDC

and Stokes County Detention Center (“SCDC”). J.A. 375; J.A. 648, Deposition of Manuel

Maldonado (“Maldonado Dep.”) 30:6–24. Maldonado ordered a prescription for 5mg of

Coumadin and arranged for Gunter to have an INR test completed on November 13, 2012. J.A.

1303–04, Maldonado Dep. 83:20–25, 84:1–5. Additionally, that same day, Gunter’s family

delivered Coumadin to DCDC—two 5mg pills and four 1mg pills. J.A. 540. Nothing in the

record suggests Gunter took or was permitted to take any of the Coumadin pills his family

brought for him. Gunter did not receive any Coumadin on November 7 or November 8 but

received 5mg of Coumadin each day from November 9 through November 14, pursuant to the

prescription ordered by Maldonado. See J.A. 1303, Maldonado Dep. 83:20–25; J.A. 537.

On November 13, 2012, Gunter had an INR test which showed that his levels were

1.07, well below the therapeutic range. J.A. 1304–5, Maldonado Dep. 87:2–5, 96:16–20. As

a result, Maldonado modified Gunter’s prescription to be increased to 7.5mg on November 15,

November 17, and November 19, and remain at 5mg on November 13, November 14,

November 16, and November 18. J.A. 1306, Maldonado Dep. 97:1–14. Jackson administered

Coumadin to Gunter in accordance with the new prescription on November 14 and November

15. See J.A. 606, Deposition of Francessia Robinson Jackson (“Jackson Dep.”) 46:19–25.

On November 15, 2012, Jackson prepared transfer paperwork for Gunter which

summarized Gunter’s condition and listed his treatment/medications. See J.A. 608–10,

Jackson Dep. 55:3–13; see also J.A. 539.



On November 16, 2012, a Friday afternoon, Gunter was transferred from DCDC to

SCDC. J.A. 627, Deposition of Sandra Hunt (“Hunt Dep.”) 27:23–25. SCDC contracts with

SHP for medical services. J.A. 578–92. Gunter arrived at the jail after appellee Sandra Hunt,

a nurse and the Team Administrator for SHP, had left for the weekend. J.A. 628, Hunt Dep.

28:1–2. In accordance with jail policy, a detention officer telephoned Hunt at home to notify

her of Gunter’s arrival and to answer her questions regarding Gunter’s medication. J.A. 628,



Hunt Dep. 28:15–23. Hunt states she was not aware of Maldonado’s order for Coumadin as

the detention officer did not relay that information to her. J.A. 629, Hunt Dep. 29:14–18.

Hunt did not direct the SCDC detention staff to dispense any medication to Gunter, including

the medicine Gunter obtained from his family,2 and absent specific authorization from Hunt,

SCDC detention staff were prohibited from dispensing medication to Gunter. See J.A. 631,

633, Hunt Dep. 33:10–18, 35:4–10. Gunter did not receive any Coumadin on November 16,

November 17, or November 18. See J.A. 635, Hunt Dep. 40:13–17.



On November 19, 2012, the following Monday when Hunt returned to work, Hunt

arranged for Gunter to receive the requisite Coumadin doses on November 19 and November

20. J.A. 1299, Hunt Dep. 69:14–18. Hunt asserts she never received the transfer paperwork

prepared by Jackson. J.A. 629, Hunt Dep. 29:21–23. Nothing in the record suggests Gunter

submitted any grievance forms or pursued any administrative remedies against DCDC or

SCDC related to their failure to provide him with his required dosages of Coumadin.

On November 21, 2012, Gunter was released from SCDC with only the six Coumadin

pills his family initially brought him when he was held at DCDC. Nothing in the record suggests

SCDC prepared a medication plan for Gunter or discharged Gunter with a medication plan.

On November 29, 2012, Gunter was admitted to Wake Forest Baptist Medical Center

(“Wake Forest”) for a blood clot. J.A. 746–47. At the time of his admission, his INR levels

were 1.7, well below the therapeutic range. J.A. 749. His medical records from Wake Forest

indicated that he began experiencing abdominal pain two days before seeking admission and

had been off his Coumadin since earlier that week. J.A. 746–47. Wake Forest surgically

removed the blood clot during Gunter’s stay, and Gunter was later discharged on December

11, 2012, with a therapeutic INR level of 3.16. J.A. 747. Gunter’s INR was subtherapeutic

on four of the five INR tests he received between December 14, 2012, and January 2, 2013.

On January 18, 2013, Gunter was diagnosed with a second blood clot requiring surgeons to

resect part of his bowel.



II.



A.



On December 27, 2016, Gunter filed the operative Second Amended Complaint

(“SAC”) against appellees Davie County, Stokes County, Andy Stokes, Cameron Sloan,

Mike Marshall, Eric Cone, Western Surety Company, and Ohio Casualty Company

(collectively, “Public Appellees”) and Southern Health Partners, Inc. (“SHP”), Jason

Junkins, Sandra Hunt, Fran Jackson, and Manuel Maldonado (collectively, “Medical

Appellees”) alleging that his injuries resulted from the care he received during his

detainment at DCDC and SCDC. See J.A. 222–63. As relevant here, Gunter alleged Public

Appellees and Medical Appellees acted with deliberate indifference toward his

constitutional right to adequate medical care. J.A. 252–53; J.A. 257–58. Gunter further

alleged a Monell claim against Davie and Stokes Counties, as well as a medical malpractice

claim against SHP, Jackson, and Maldonado. J.A. 252–62.



On July 6, 2020, Public Appellees filed a motion for summary judgment, arguing,

amongst other things, they are entitled to (1) qualified immunity, governmental immunity,

and public officer’s immunity, and (2) summary judgment with respect to Gunter’s

Fourteenth Amendment deliberate indifference claim and Gunter’s Monell claim under 42



U.S.C. § 1983. See J.A. 23 (Docket No. 125), 1840–63.



On March 15, 2021, the district court granted Public Appellees’ motion for

summary judgment and dismissed Gunter’s Fourteenth Amendment deliberate indifference

claim and Gunter’s Monell claim under 42 U.S.C. § 1983. Specifically, the district court

opined that “[p]retrial detainees alleging they have been subjected to unconstitutional

conditions of confinement” must allege (1) “the deprivation alleged was ‘objectively,

sufficiently, serious’” and (2) the “prison officials acted with deliberate indifference.” See

J.A. 1842–43 (collecting cases) (citations omitted).



The district court found the evidence did not create a “genuine dispute of material

fact as to whether a violation of [Gunter’s] constitutional rights occurred” for three reasons.

J.A. 1842. First, the district court stated even if the first prong was satisfied, Gunter’s

evidence does not show Public Appellees “were deliberately indifferent to [Gunter’s]

medical needs.” J.A. 1845. Specifically, the district court stated “there is no evidence on

the record that Public [Appellees] intended to prevent or delay [Gunter] from receiving

medical treatment or that Public [Appellees] ignored his medical needs” and the fact Gunter

“disagree[d] with the treatment he received or that a difference course of treatment might

have led to a better medical outcome, . . . is not evidence of a subjective intent by Public

[Appellees] to deprive [Gunter] of medical treatment, which is necessary to state a

constitutional violation.” J.A. 1846.



Second, the district court stated Gunter “ha[d] not presented evidence that Public

Defendants had the medical training necessary to make decisions regarding [Gunter’s] care

. . . and . . . this court does not find that Public Defendants should have understood whether

[Gunter’s] medical care was proper or that it should have been appropriate for Public

Defendants to intervene in [Gunter’s] medical care.” Seeing no constitutional

violations, the district court also disposed of Gunter’s Monell claim. Accordingly, the district court granted Public Defendants'’ motion for summary judgment as to Gunter’s constitutional claims. J.A. 1848–49.



Medical Defendants also filed a motion for summary judgment, which the district court

granted in part and denied in part on March 23, 2021. J.A. 23 (Docket No. 123); J.A. 31

(Docket No. 178). Gunter and Medical Defendants moved for reconsideration. On June 10, 2021, the district court granted Medical Defendants’ motion for reconsideration; granted in part and denied in part Gunter’s motion for

reconsideration; and reopened summary judgment.



On September 17, 2021, the district court struck its previous March 23, 2021

Memorandum Opinion and Order stating that “for purposes of maintaining a relatively clear

record, . . . one opinion and order addressing all summary judgment arguments and related

issues [wa]s appropriate.” That order only addressed claims and motions related to the case

against Medical Defendant

Reversed and remanded.