                                                                            FILED
                                                                    Feb 24 2020, 5:36 am

                                                                            CLERK
                                                                        Indiana Supreme Court
                                                                           Court of Appeals
                                                                             and Tax Court




ATTORNEYS FOR APPELLANTS                                   ATTORNEYS FOR APPELLEE –
Mary Jane Lapointe                                         INDIANA DEPARTMENT OF
Daniel Lapointe Kent                                       CORRECTION
Lapointe Law Firm, P.C.                                    Curtis T. Hill, Jr.
Indianapolis, Indiana                                      Attorney General of Indiana

                                                           Frances Barrow
                                                           Deputy Attorney General
                                                           Indianapolis, Indiana

                                                           ATTORNEYS FOR APPELLEES –
                                                           CORIZON, INC. AND THE
                                                           CORIZON MEDICAL
                                                           EMPLOYEES
                                                           Carol A. Dillon
                                                           Christopher Andrew Farrington
                                                           Bleeke Dillon Crandall, P.C.
                                                           Indianapolis, Indiana



                                            IN THE
    COURT OF APPEALS OF INDIANA




Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                           Page 1 of 43
      Sue Williams, Linda Wood, and                              February 24, 2020
      Claude Wood, as the Co-                                    Court of Appeals Case No.
      Personal Representatives of the                            19A-CT-1832
      Estate of Rachel A. Wood,                                  Appeal from the Marion Superior
      Deceased,                                                  Court
      Appellants-Plaintiffs,                                     The Honorable John M.T. Chavis,
                                                                 II, Judge
              v.                                                 Trial Court Cause No.
                                                                 49D05-1401-CT-1478
      Indiana Department of
      Correction, Corizon, Inc.,
      Georgeanne R. Pinkston, Dawn
      Renee Antle, Mary D. Grimes,
      Tina Icenogle, Daniel P. Rains,
      M.D., Richard M. Hinchman,
      M.D., and Vance Raham, M.D.,
      Appellees-Defendants.



      Najam, Judge.


                                         Statement of the Case
[1]   In April of 2012, Rachel A. Wood, then an inmate in the Indiana Department

      of Correction (“DOC”), died from complications relating to lupus and a blood

      clotting disorder. Her Estate, through its personal representatives (“the

      Estate”), sued the DOC; the DOC’s for-profit contractor for medical services at

      the DOC’s prisons, Corizon, Inc. (“Corizon”); and Corizon employees Dr.

      Richard M. Hinchman, Dr. Vance Raham, Dr. Daniel P. Rains, Nurse

      Practitioner Dawn Renee Antle, Nurse Practitioner Georgeanne R. Pinkston,

      Registered Nurse Mary D. Grimes, and Registered Nurse Tina Icenogle


      Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                  Page 2 of 43
      (collectively, “the Corizon medical employees”). 1 In its complaint, the Estate

      alleged, pursuant to 42 U.S.C. § 1983, that Corizon and the Corizon medical

      employees had violated Wood’s federal civil rights under the Eighth

      Amendment to the United States Constitution when they were deliberately

      indifferent to her serious medical conditions while she was in their care. The

      Estate further alleged that the DOC was negligent under Indiana law in failing

      to monitor its contractor. The trial court entered summary judgment for the

      DOC, Corizon, and the Corizon medical employees.


[2]   On appeal, the Estate raises four issues for our review, which we restate as

      whether genuine issues of material fact preclude the entry of summary

      judgment. We affirm the trial court’s entry of summary judgment for the two

      registered nurses—Nurse Grimes and Nurse Icenogle—as there is no designated

      evidence to show that they breached the standard of care relevant for registered

      nurses, let alone acted with deliberate indifference toward Wood. Accordingly,

      the trial court properly entered judgment as a matter of law for Nurse Grimes

      and Nurse Icenogle.


[3]   But the designated evidence most favorable to the Estate tells a much different

      story for the medical doctors and the nurse practitioners. For them, we hold

      that the designated evidence readily demonstrates genuine issues of material




      1
        The Estate does not appeal the trial court’s entry of summary judgment for Dr. Michael Mitcheff, Cassidy
      Anderson, Carolyn Barnes, Linda Benton, Carmel Billman, Jared Caudill, Deborah Cravens, Jana Cuffel,
      Sheilah Ferguson, Lynette Lees, Bruce Lelak, Jennie Mauck, Pamela Sue Moore, Tiffany Rutherford, Janell
      Sanders, Carmen Shilling, or Elizabeth Vinup.

      Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                          Page 3 of 43
      fact on the Estate’s claims of deliberate indifference. Indeed, this is not a close

      case under Indiana’s summary judgment standards. The designated evidence

      would support a reasonable inference and a finding that these medical doctors

      and nurse practitioners were actually aware of a substantial risk of serious harm

      Wood faced as a result of her serious medical conditions, yet they acted, in the

      words of the Estate’s medical experts, with “a severe and callous disregard for

      [Wood’s] clinical status” and rendered treatment that was “inappropriate,”

      “catastrophic,” showing “absolutely no interest” in Wood’s health, “quite

      suspect,” “dismiss[ive],” and “clearly . . . below the standard of care.”

      Appellant’s App. Vol. VI at 16-18, 24.


[4]   Accordingly, we reverse the entry of summary judgment for those Corizon

      medical employees, for Corizon, who has been sued under the doctrine of

      respondeat superior, and for the DOC, which failed to discover Wood’s facially

      inconsistent medical records, her nonexistent treatment plans, or Corizon’s

      “completely and totally inadequate” medical settings. Id. at 17. We therefore

      affirm in part, reverse in part, and remand for further proceedings consistent

      with this opinion.


                                  Facts and Procedural History
                                                    Background


[5]   Wood was twenty-two years old in June of 2010 when she was convicted of her

      first criminal offense, dealing in a controlled substance. She was incarcerated in

      the Huntington County Jail while she awaited her sentencing, and at her

      Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020       Page 4 of 43
      sentencing the court ordered her to serve a term of incarceration in the DOC.

      At all times during her ensuing incarceration, Corizon, a for-profit corporation,

      was under contract with the DOC to provide medical services at the relevant

      DOC correctional facilities.


[6]   That contract required Corizon to provide medically appropriate care to

      inmates; maintain records “for contract monitoring” by the DOC; and comply

      with the DOC’s written health care services directives. Appellant’s App. Vol. V

      at 231. The DOC’s health care services directives, in turn, required, among

      other things, that Corizon establish and maintain plans for the treatment of

      inmates, which were to be “formal written plans that identify serious health

      conditions referenced from [a master] problem list, describe goals and

      outcomes, list the planned interventions, and describe which professional

      discipline is responsible for carrying them out.” Appellant’s App. Vol. VI at

      129, 131. For “serious conditions,” treatment was to be “in a consistent and

      continuing fashion” with “a structured process.” Id. at 133.


[7]   In July of 2010, the county jail transferred Wood to the DOC. In doing so, the

      county jail submitted a summary of Wood’s medical records. And, upon intake

      with the DOC, Wood self-reported her medical history. Those documents

      demonstrated that Wood had a history of lupus, “a bleeding . . . [and] clotting

      disorder,” and kidney trouble, and she had been prescribed numerous




      Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020    Page 5 of 43
      medications related to those disorders. Appellant’s App. Vol. III at 76, 82-83.

      In relevant part, Wood had been prescribed hydroxychloroquine 2 and warfarin. 3


[8]   Hydroxychloroquine is a prescription medication for lupus. Hydroxychloroquine

      (Oral Route), Mayo Clinic (Feb. 17, 2020), mayoclinic.org/drugs-

      supplements/hydroxychloroquine-oral-route/description/drg-20064216/

      [https://perma.cc/QB9C-WWAY]. Lupus is a “systemic autoimmune disease

      that occurs when your body’s immune system attacks your own tissues and

      organs.” Lupus, Mayo Clinic (Feb. 17, 2020), mayoclinic.org/diseases-

      conditions/lupus/symptoms-causes/syc-20365789/ [https://perma.cc/BXN6-

      SWMK]. Lupus is often indicated by “flares” of “unexplained rash[es],”

      especially on the face; “ongoing fever”; “persistent aching”; or “fatigue.” Id.

      Among other complications, lupus “can cause serious kidney damage,”

      including “kidney failure,” and it can affect the central nervous system: “[i]f

      your brain is affected by lupus, you may experience headaches, dizziness,

      behavior changes, vision problems,” or “have difficulty expressing” thoughts.

      Id. Lupus may also “lead to blood problems, including . . . increased risk of

      bleeding or blood clotting.” Id. Wood’s prescription for warfarin was, in turn,



      2
        Wood’s medical records often use the brand name Plaquenil to refer to the hydroxychloroquine
      prescription. See Hydroxychloroquine (Oral Route), Mayo Clinic (Feb. 17, 2020), mayoclinic.org/drugs-
      supplements/hydroxychloroquine-oral-route/description/drg-20064216/ [https://perma.cc/QB9C-
      WWAY]. Also, we reject Corizon and the Corizon medical employees’ arguments on appeal that we cannot
      take judicial notice of the Mayo Clinic’s website of general facts relating to diseases, their symptoms, and
      their common medications. See Ind. Evidence Rule 201(a)(1)(B).
      3
        Wood’s medical records often use the brand name Coumadin to refer to the warfarin prescription. See
      Warfarin (Oral Route), Mayo Clinic (Feb. 17, 2020), mayoclinic.org/drugs-supplements/warfarin-oral-
      route/description/drg-20070945/ [https://perma.cc/Z8C8-3UM9].

      Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                           Page 6 of 43
       “used to prevent or treat blood clots . . . .” Warfarin (Oral Route), Mayo Clinic

       (Feb. 17, 2020), mayoclinic.org/drugs-supplements/warfarin-oral-

       route/description/drg-20070945/ [https://perma.cc/Z8C8-3UM9].

                                            Rockville Correctional Facility


[9]    On July 9, 2010, the DOC received Wood at the Rockville Correctional Facility

       (“Rockville”). Corizon medical employees Dr. Raham and Nurse Practitioner

       Pinkston 4 were responsible for Wood’s medical care at Rockville.


[10]   Upon intake, Nurse Practitioner Pinkston acknowledged “[m]edical

       documentation received from Huntington County.” Appellant’s App. Vol. III

       at 87, 89. Nurse Practitioner Pinkston further acknowledged Wood’s history of

       “lupus” and the county jail’s summary of her specific prescriptions. Id. at 84-

       85, 89. However, Nurse Practitioner Pinkston only identified Wood’s

       prescription for warfarin as ongoing.


[11]   Four days later, Wood reported to Nurse Practitioner Pinkston that she “has

       [l]upus,” which “has affected [her] kidneys,” and that she “has been taking

       [hydroxychloroquine] 200 mg [twice daily].” Id. at 103. Nurse Practitioner

       Pinkston then restarted Wood’s hydroxychloroquine prescription.




       4
         There is no dispute that “[a] nurse practitioner is considered a provider, like a doctor. A nurse practitioner
       can prescribe medication, diagnose patients, order medical treatment, and develop a treatment plan for
       patients.” Medical Appellees’ App. Vol. IV at 78.

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                               Page 7 of 43
[12]   On October 5, 2010, Dr. Raham met with Wood about her being

       “noncompliant” with her hydroxychloroquine prescription. Id. at 138. Dr.

       Raham would later testify that he allowed Wood’s hydroxychloroquine

       prescription to “expire[]” in October of 2010 without “renewing” the

       prescription because Wood “had not taken her [hydroxychloroquine] for over a

       month and she had not had any lupus-related flare-ups or complications.”

       Appellant’s App. Vol. II at 174. According to Dr. Raham, although Wood had

       previously been permitted to keep her hydroxychloroquine on her person while

       at Rockville without any reports of improper use, “it was not medically sound

       to restart a medication that had known side effects if taken improperly.” Id.


[13]   Dr. Steven H. Neucks, a rheumatologist with the Rehabilitation Associates of

       Indiana, would later identify Dr. Raham’s decision to discontinue the

       hydroxychloroquine as “a catastrophic error” that was “clearly . . . below the

       standard of care.” Appellant’s App. Vol. VI at 18, 24. At the time Dr. Raham

       discontinued Wood’s hydroxychloroquine prescription, neither he nor Nurse

       Practitioner Pinkston counseled Wood about the importance of being

       compliant with that prescription even though lupus patients are often

       noncompliant with their medications due to the on-again, off-again nature of

       the disease. They also did not consult with a specialist or otherwise establish a

       long-term treatment plan for Wood’s lupus. Conversely, when Wood had been

       noncompliant with her warfarin prescription, Dr. Raham counseled her on why

       that prescription was important, and Wood resumed her compliance.




       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020    Page 8 of 43
[14]   Throughout her time at Rockville, Wood had numerous blood tests. Those

       blood tests frequently showed abnormal clotting results. See Prothrombin time

       test, Mayo Clinic (Feb. 17, 2020), mayoclinic.org/tests-procedures

       /prothrombin-time/about/pac-20384661/ [https://perma.cc/T3AS-ZG5G].

       On multiple occasions, the blood tests showed “panic” level slow clotting. E.g.,

       Appellant’s App. Vol. III at 143, 154, 167. However, the electronic medical

       records (“EMRs”) created by Dr. Raham and Nurse Practitioner Pinkston just

       as frequently failed to show any consistent provider response to Wood’s

       abnormal blood tests—often, a single EMR stated that Wood had been

       prescribed conflicting dosages of warfarin, one dosage that would have made

       sense only for quick-clotting blood and one dosage that would have made sense

       only for slow-clotting blood. E.g., id. at 136. It is frequently not clear from the

       EMRs what dosages of warfarin, if any, Wood actually received at any given

       time.

                                          Madison Correctional Facility


[15]   The DOC transferred Wood to the Madison Correctional Facility (“Madison”)

       on December 29, 2010. Wood again reported to the Madison medical staff that

       she had lupus and blood clotting issues as “[c]hronic care conditions.” Id. at

       191. Corizon medical employees Dr. Hinchman and Nurse Practitioner Antle

       were responsible for Wood’s medical care at Madison.


[16]   On January 14, 2011, Wood met with Dr. Hinchman and complained of lupus

       flare-ups. Following a blood test that showed increased inflammation, Dr.


       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020      Page 9 of 43
       Hinchman described Wood’s lupus as “symptomatic.” Id. at 207. He

       prescribed her a steroid but did not restart her hydroxychloroquine prescription,

       consult with a specialist, or establish a long-term plan of care for Wood’s lupus.

       Although Wood’s blood work over the next several months continued to show

       inflammation and Dr. Hinchman continued to recognize that her lupus was

       symptomatic, Wood’s medical records do not demonstrate that Dr. Hinchman

       or Nurse Practitioner Antle ordered any further treatment for Wood.


[17]   On May 22, Wood wrote a note to Corizon medical staff at Madison that stated

       she had “a butterfly rash” on her face from her lupus, and she had “been using

       hydrocortisone cream and it has not helped.” Id. at 228. Dr. Hinchman again

       only prescribed a steroid.


[18]   On June 4, Wood wrote another letter to Corizon medical staff at Madison

       complaining about the lupus-related butterfly rash on her face. Wood met with

       Nurse Practitioner Antle, who originally directed Wood to receive ibuprofen.

       However, that direction was “contraindicated with [the warfarin] therapy.” Id.

       at 241. Nurse Practitioner Antle then directed Wood to apply hydrocortisone

       to her rash.


[19]   Throughout her time at Madison, just as at Rockville, Wood had numerous

       blood tests. Those blood tests frequently showed abnormal clotting results. On

       multiple occasions, the blood tests showed “critical[ly]” slow clotting. E.g., id.

       at 220; Appellant’s App. Vol. IV at 128, 161. However, the EMRs created by

       Dr. Hinchman and Nurse Practitioner Antle just as frequently failed to show


       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020    Page 10 of 43
       any consistent provider response to Wood’s abnormal blood tests. Often, a

       single EMR stated that Wood had been prescribed conflicting dosages of

       warfarin, and it was frequently not clear what dosage of warfarin Wood

       actually should have been taking at any given time. E.g., Appellant’s App. Vol.

       III at 220. On multiple occasions, the EMRs indicated that, in response to

       Wood’s blood clotting more slowly than desired, Dr. Hinchman and Nurse

       Practitioner Antle either did nothing or erroneously identified Wood’s blood-

       clotting history as demonstrating “therapeutic” results. E.g., Appellant’s App.

       Vol. IV at 66.


[20]   In the fall of 2011, Wood’s health began to demonstrate a “constellation of

       symptoms very strongly suggestive of lupus activity.” Appellant’s App. Vol. VI

       at 25. Stasha Merchant, 5 Wood’s fellow inmate and “very close friend” at

       Madison, observed Wood “become really sick” shortly before Thanksgiving.

       Id. at 44. Wood “stopped eating,” “couldn’t get out of bed,” and “had bad

       headaches.” Id. Wood “was starting to lose some weight” and “was always

       tired.” Id. She “also broke out in a rash” and started “to get sores on her legs

       from where the rashes were and they would bleed. She also had nose bleeds




       5
         Corizon and the Corizon medical employees assert on appeal that the Estate “inappropriately use[s]
       portions of Affidavits” from Wood’s fellow inmates “that were stricken” by the trial court during the
       summary judgment proceedings. Medical Appellees’ Br. at 48 (bold removed). Corizon and the Corizon
       medical employees are simply wrong in their assessment; the Estate’s brief accurately tracks only those
       portions of the relevant affidavits that the trial court deemed admissible, as do we.

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                         Page 11 of 43
       sometimes.” Id. Around the turn of the month, Wood’s “gums were bleeding.”

       Id. at 45.


[21]   Over the next few months, Wood “was very weak.” Id. She could not get her

       own food; Merchant and other inmates would have to hold Wood up and walk

       her. She could not go to the bathroom by herself; again, her fellow inmates

       “would help her,” and “her urine smelled like death.” Id. Wood could not

       write her own requests for medical assistance; Merchant and other inmates

       “would write [the] requests for her and have her sign them” until “[i]t got to the

       point where she didn’t have enough strength to even sign her own name.” Id.

       Wood “couldn’t walk[,] feed herself, bathe herself, take her medication, or do

       her laundry; she could only lay in bed. Her deterioration was obvious . . . .” Id.

       Merchant took Wood “to medical” and recalled other prison officials observing

       Wood in this condition as well. Id. at 46.


[22]   Sasheena Bonner, another inmate at Madison and one of Wood’s “best friends”

       there, also observed Wood’s deterioration during that same timeframe. Id. at

       34. In December of 2011, Bonner observed that Wood “was very sick.” Id.

       Wood’s “skin color was yellowish and she was catching fevers” and “never got

       better.” Id. By February of 2012, Wood could not “move, get out of bed,

       drink, [or] eat, and “blood [wa]s coming out of [her] ears.” Id. at 35. Wood

       “would have blood in her underwear” that was not “from her menstrual cycle.”

       Id.




       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020   Page 12 of 43
[23]   Bonner “tried to get [Wood] help” but “no one wanted to listen.” Id. Wood’s

       “skin had these rashes” that Bonner could not “even describe. They were red

       and purple[] and covered three-fourths of her back and sides.” Id. But the

       Corizon medical employees at Madison only gave Wood “Claritin or

       Ibuprofen,” which Bonner then administered to Wood. Id. at 36. Bonner later

       recalled:


               They let her lay in bed incredibly sick for a month before they
               transferred her [to the Indiana Women’s Prison]. She couldn’t
               move, it hurt her to walk, she couldn’t eat, and she was bleeding
               from her mouth and ears.


               . . . [Wood] was bleeding from her mouth and ears while at
               Madison for over a month.


               . . . She could barely talk, she couldn’t lift her head, she could
               barely move, and [she] had a huge rash covering three-fourths of
               her back and sides.


       Id.


[24]   Near the end of Wood’s time at Madison, Nicole Marie Paul, another inmate

       and another of Wood’s “best friends” at Madison, observed the following in

       February and March of 2012:


               [Wood’s] health started to deteriorate rapidly in 2012. In
               February 2012, I remember [Wood] would just get tired a lot and
               did not feel well. . . . I noticed the rash on [Wood’s] body the
               first week of March in 2012, and I noticed the blood that started
               leaking from [Wood’s] gums and ears during the second week of
               March 2012.

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020    Page 13 of 43
       Id. at 39.


[25]   Like Merchant and Bonner, Paul would help Wood go to the cafeteria and,

       later, bring Wood food when Wood could no longer walk. Paul observed that

       Wood had “these blotches all over her arms, by her shoulders, and they were

       really bad. . . . [Wood] couldn’t get out of bed . . . and she lost so much weight,

       around 20 pounds . . . around the end of February or beginning of March.” Id.

       at 40-41. Paul observed prison staff seeing Wood in this condition and doing

       nothing. Paul observed Wood “constantly trying to contact the medical facility

       in the prison.” Id. at 40. “The majority of people there did not respond to

       her. . . . A couple of times she’d be gone” to medical “for a while, but usually

       they would just see her and send her back.” Id.


[26]   Around early March of 2012, Dr. Hinchman and Nurse Practitioner Antle sent

       Wood to The King’s Daughters’ Hospital (“KDH”) in Madison with concerns

       about swelling on Wood’s arm. After later reviewing Wood’s medical records

       and the testimony of those involved, Dr. Neucks would describe that sequence

       of events as follows:


               [T]here is a very poor hand off both from the prison to the ER
               and from the ER back to the prison. It appears quite clearly that
               the prison staff and nurse practitioners were quite concerned
               about [Wood’s] arm and that it was swollen and red suggesting a
               lupus flare . . . . However[,] the KDH [staff] deals only with an
               upper respiratory tract infection and sends her back. When this
               dichotomy was identified at the prison[,] there was no
               remediation taken. When [Wood] was returned . . . , Dr.
               Hinchman orders Tylenol, fluids, and vital signs, but does not see
               [Wood] . . . . There was no further investigation of the arm
       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020   Page 14 of 43
        swelling, no further request for consultation, no further input.
        The problem was just sort of dropped.


        By this time, [Wood] had fever, lethargy, pleuritic chest pain, low
        albumin, elevated globulins, rash, dropping hemoglobin, and 2+
        proteinuria. This constellation is very likely related to her lupus.
        Unfortunately, there is no attempt on the part of Dr. Hinchman
        to put these things together to suggest lupus. There is no request
        for further input from internal medicine, or rheumatology, or any
        other specialist to see whether these items might be related to
        lupus and thus require treatment. In fact, he says this did not
        constitute a lupus flare-up.


        When she was seen and had a [blood] sedimentation rate of 53,
        [which is an abnormally high result indicative of inflammation in
        the blood from lupus,] there was no follow-up recommended.
        There was no mention of a long-term plan. Dr. Hinchman and
        others . . . maintain the EMR document itself is a standing long-
        term care plan; however[,] there was no mention in the EMR of
        the long-term need to follow [Wood]. In fact[,] in spite of being
        on some brief [steroid] and having a sedimentation rate of 53 she
        was not seen again until routinely scheduled as required at three
        months.


        At the next visit we find that her sedimentation rate was 126, this
        time again strongly suggesting a lupus flare. Her sedimentation
        rate has risen almost 100 points since she has been incarcerated
        and there is absolutely no interest on the part of the various
        physicians to modify or implement her treatment.


        When she was eventually transferred to the Indiana Women’s
        Prison . . . [, Dr. Hinchman] says that the reason was that her
        condition had worsened and that she now required 24-hour
        monitoring; however[,] it is clear from 03/01/201[2] to
        03/19/201[2] when she was transferred that [Dr. Hinchman] did

Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020      Page 15 of 43
               not visit her for an office visit. It seems that if she
               required . . . 24-hour care that visits more than every three weeks
               would have been appropriate . . . making this analysis quite
               suspect.


       Id. at 16-17 (citations omitted).


[27]   Dr. Neucks would add that Dr. Hinchman’s treatment of Wood relied on

       “notoriously vague” standards; failed to account for “signal[s] of a more

       dangerous lupus complication”; and failed to account for the “two areas of

       system involvements that often lead to death in lupus” patients, renal system

       involvement and central nervous system involvement. Id. at 16. Dr. Neucks

       concluded that Dr. Hinchman’s treatment of Wood was “clearly . . . below the

       standard of care” and “a link of failure in the chain that eventually caused”

       Wood’s death. Id. at 18.


                                             Indiana Women’s Prison


[28]   On March 19, 2012, Dr. Raham, Dr. Hinchman, and Nurse Practitioner Antle

       decided that Wood’s blood-clotting levels required “close monitoring.” Id. at

       51. Accordingly, the DOC transferred Wood to the Indiana Women’s Prison

       in Indianapolis because “there is an infirmary” there.” Id. Wood had to be

       transported in a wheelchair. Corizon medical employee Dr. Rains was




       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020    Page 16 of 43
       responsible for Wood’s medical care at the Indiana Women’s Prison. Corizon

       medical employees Grimes and Icenogle, registered nurses, assisted Dr. Rains. 6


[29]   Wood spent four days at the Indiana Women’s Prison before being transported

       by ambulance to Terre Haute Regional Hospital due to hypoxia. After later

       reviewing Wood’s medical records and the testimony of those involved, Dr.

       Neucks would describe Dr. Rains’ treatment of Wood at the Indiana Women’s

       Prison as follows:


                Dr. Rains[’] evaluation [of Wood] is equally problematic [to Dr.
                Hinchman’s;] although she was only [at the Indiana Women’s
                Prison] briefly[,] there is documentation of the seriousness of her
                status. The nurses’ notes clearly state [Wood] is having marked
                difficulty walking. The nurses’ notes suggest that she was a max
                assist of two. [Dr. Rains] dismisses this as needing a little help to
                the bathroom; however[,] I believe max assist of two strongly
                suggest[s] [Wood] was unable to ambulate on her own. [Dr.
                Rains] never attempted to examine [Wood’s] ability to walk.
                This would have been a key to transferring her [to a hospital]
                sooner or initiating more aggressive therapy.


                Due to her low oxygen, a chest x-ray was ordered [the day after
                she arrived at the Indiana Women’s Prison], but [it was] never
                accomplished. There is no note in the chart as to why it was not




       6
         There is no dispute that, unlike a medical doctor or a nurse practitioner, a registered nurse is “unable to
       diagnose medical conditions, order medical treatment, prescribe medications, or make a treatment plan for a
       patient.” Medical Appellees’ App. Vol. IV at 126. Rather, registered nurses “triage patients and
       communicate their medical needs to the provider, i.e., the nurse practitioner or doctor, and then follow the
       provider’s orders.” Id. Further, a registered nurse is “able to provide first aid or life-saving medical care as
       needed, draw blood, administer medications, take vital signs, and other such nursing measures.” Id.

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                              Page 17 of 43
        done or any further attempt to get it done during her brief stay at
        that time.


Id. at 17 (citations omitted). Dr. Neucks continued:


        It is clear from [Dr. Rains’] records that [Wood’s] lupus flare had
        begun prior to her transfer [to the Indiana Women’s Prison].
        This is documented in several comments that he makes. At the
        time of her transfer which was “due to an elevated [test
        measuring her blood clotting]” he also noted the following[:]
        that she “had bleeding lips and gums”[;] that she also had
        “weakness and pain in her legs for a month”[;] and that she was
        “ill appearing[.”] . . . He treated this constellation of symptoms
        with Tylenol. . . . [H]e notes that “she reported that she had felt
        bad for a month or so with fevers and myalgias[.”]
        Additionally[,] he describes that she went to [KDH] for a rash
        and he himself documents a malar rash. . . . [H]e describes her as
        “in moderate distress and she was chronically ill appearing”[;]
        “[s]he had lost 20 pounds over the last month[.”] Her records
        clearly document a steady[,] slow[,] downhill course presumably
        caused by her lupus which is apparent from the clinical record
        and well documented eventually by her autopsy. This suggests
        her downhill course or lupus flare began as far back as four to six
        weeks prior to [her transfer to the Indiana Women’s Prison]. . . .
        [E]ven a cursory phone consult with [a] rheumatologist during
        this interval might have strongly and beneficially affected the
        course of [Wood’s] illness.


        . . . [T]he issue of [hydroxychloroquine] comes up on multiple
        occasions. Perhaps had she been treated with adequate steroid
        when she began to decline, and had the [hydroxychloroquine]
        been reinitiated as might have been standard of care for any
        rheumatology consult, this entire cascade of events might have
        been prevented. . . .



Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020     Page 18 of 43
       Id. at 22-23.


[30]   Regarding Wood’s transfer to Terre Haute Regional Hospital, Dr. Neucks

       stated as follows:


               Finally, . . . Dr. Rains discusses [Wood’s] transfer to Terre Haute
               Regional Hospital [on March 23]. He describes [Wood as
               having] a sedimentation rate of 136, arthralgias, myalgias, severe
               anemia, proteinuria, inability to walk, unexplained pains in her
               legs, hypoxia, and that she was not responding to steroids.
               However, he did not feel that this was a sufficient reason for her
               to be transferred as emergent. . . .


               [Wood] came to the [DOC] two years ago with the diagnosis of
               lupus. It seems quit[e] surprising to me this diagnosis yet eluded
               the Prison Medical System. . . . Additionally[,] there is some
               urgency in her transfer. When [Dr. Rains] arrived that morning
               [of March 23] he sees her quite early in the morning and notices
               that she is hypoxic. It is difficult to improve . . . hypoxia without
               high-levels of oxygen. This is certainly a dramatic change in her
               status. In addition to all of the symptoms listed this documents
               the severity of her illness. . . .


       Id. at 23. Dr. Neucks further stated:


               [Wood] was then transferred to Terre Haute Regional
               Hospital. . . . [T]here is quite a bit of consternation amongst the
               various [hospital] physicians and hospital records as to why she
               was transferred so far away. Dr. Raham in his deposition notes
               that there were contracts between the prison system and the
               various “regional” hospitals such that this case was deemed to be
               transferred to Terre Haute Regional Hospital. However[,] Dr.
               Raham also says in his deposition . . . [that] if there was a rule
               that a patient who was sick or emergent could be transferred to
               the most appropriate hospital . . . he says unequivocally yes this
       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020      Page 19 of 43
               is true. Since Methodist Hospital was literally up [the] street
               from [the Indiana Women’s Prison], it seems highly illogical that
               in an emergency situation [Wood] would be transported 70 miles
               to a regional hospital. . . . [W]hen she was admitted to Terre
               Haute Regional Hospital[,] she was transferred immediately to
               the intensive care unit and placed on a ventilator. This alone
               would strongly suggest[] that [Wood’s] clinical status was indeed
               emergent and strongly suggests that her transfer to [a r]egional
               [h]ospital 70 miles away was inappropriate.


               [Wood] was sent by ambulance to Terre Haute. Again[,] this
               appears to be somewhat of an oxymoron. If indeed it was
               necessary[,] which it obviously was, then transfer to a closer
               institution would have been appropriate. Additionally, [Dr.
               Rains] saw [Wood] at 08:26 in the morning, the ambulance was
               ordered at 10:20 in the morning, but she[] did not actually leave
               the [Indiana Women’s Prison] until 11:30. This suggests either a
               severe or callous disregard for the patient’s clinical status and that
               the infirmary setting itself was completely and totally inadequate
               for [Wood’s] care. She was catastrophically sick. She was
               transferred to a remote institution somewhat casually. These
               findings alone suggest that the care under Dr. Rains at the
               [Indiana Women’s Prison] was below the standard of care.


       Id. at 17 (citations omitted). As he said with respect to Dr. Raham and Dr.

       Hinchman, Dr. Neucks stated that Dr. Rains’ “care clearly f[ell] below the

       standard of care” and was “a link of failure in the chain that eventually caused

       the death of Rachel Wood.” Id. at 18.


[31]   After about three weeks at Terre Haute Regional Hospital, on April 13, 2012,

       Wood was discharged from the hospital and transported back “to prison” by

       “ambulance.” Appellant’s App. Vol. V at 9. However, at some point Corizon


       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020      Page 20 of 43
       directed the ambulance instead to transfer Wood to the Kindred long-term

       acute care hospital in Indianapolis. En route back to Indianapolis, Wood

       suffered from “gross hemoptysis”—“coughing up blood”—and died. Id. at 17;

       Coughing up blood, Mayo Clinic (Feb. 17, 2020), mayoclinic.org/symptoms/

       coughing-up-blood/basics/definition/sym-20050934/

       [https://perma.cc/6AAC-MT78].


[32]   According to Dr. Neucks:


               [I]n review of the autopsy . . . from the Marion County Coroner’s
               office[,] it suggests that her cause of death [was] “medical
               complications of pneumosepsis and coagulopathy. Contributory:
               Lupus erythematosus[.”] . . . The medical complications of
               pneumosepsis reported by the Marion County Coroner include
               “A” history of lupus with antiphospholipid antibody syndrome[,]
               “B” status post splenectomy due to idiopathic thrombocytopenic
               purpura, and “C” admitted to the hospital on 03/23/12 for acute
               respiratory failure, pneumonia, sepsis, renal failure, and
               hypoxemia. This documents the role of lupus in her
               pneumosepsis and clearly the role of lupus and coagulopathy,
               both of which contributed to her death. The bleeding which did
               occur [in the final ambulance ride] was a subsidiary or a
               downstream event from those processes and not the primary
               cause. . . .


       Appellant’s App. Vol. VI at 25. Dr. Neucks further discussed Corizon’s

       decision to transport Wood by ambulance from Terre Haute to Kindred as

       follows:


               Corizon made arrangements for Kindred long-term care facility
               to evaluate Ms. Wood . . . . This obviously . . . was a most
               disastrous suggestion. Once again[,] the long ride from Terre
       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020   Page 21 of 43
               Haute to Kindred undoubtedly strongly contributed to her acute
               demise. . . . [T]he autopsy makes entirely clear that the
               underlying cause of her death was from the lupus including its
               involvement due to her immunosuppression and her splenectomy
               all due to the lupus contributing pneumosepsis. As well
               the . . . antiphospholipid antibody causing her clotting, [h]er
               death may have been accelerated from the tracheal ulcerations
               with blood casts that partially coated the trachea and airways. . . .


               In reviewing the prior medical records we hear this unbelievable
               story of [Wood] being shackled to her ambulance bed [en route
               to Kindred] and coughing up blood. She would signal to the
               nursing staff and prison staff her difficulty breathing. They
               would unshackle her long enough to cough up blood and then
               reshackle her. The absurdity of this is further compounded by
               the fact that following the ambulance was a car full of guards.
               Remind yourself at this time that [Wood] could not walk.
               Perhaps if more effort had been expended to her medical
               attention or that she had been transferred to a care facility closer
               than the 70 miles [sic]. Finally, . . . we again see . . . [Corizon
               medical staff] suggest that the [EMRs are] in fact the long[-]term
               treatment plan . . . . I will point out that Dr. Rain[s], when he
               was seeing [Wood] for the few days she was in the [Indiana
               Women’s Prison,] analyzed her status as being moderately ill,
               febrile, short of breath, basically unable to walk (max assist of
               two), severe anemia, [and having a] high sedimentation rate, and
               his treatment plan was Tylenol. How this could pass for a long[-
               ]term treatment plan for a seriously ill lupus patient baffles me.


       Id. at 20-21.


                                                 Procedural History


[33]   The Estate filed its first amended complaint against the DOC, Corizon, and the

       Corizon medical employees in April of 2014. Thereafter, the DOC, Corizon,

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020     Page 22 of 43
       and the Corizon medical employees separately moved for summary judgment.

       After some technical and user-error issues with electronic filing, in March of

       2018 the trial court accepted as timely submitted the Estate’s responses to the

       DOC and the Corizon medical employees as well as portions of the Estate’s

       designated evidence. However, the trial court refused to accept the Estate’s

       response to Corizon on Corizon’s independent motion for summary judgment.

       Thereafter, the court entered summary judgment for the DOC, Corizon, and

       the Corizon medical employees. This appeal ensued.


                                       Discussion and Decision
                              1. Indiana’s Summary Judgment Standards

[34]   Summary judgment in Indiana is a “high bar” for a moving party to clear.

       Hughley v. State, 15 N.E.3d 1000, 1004 (Ind. 2014). As the Indiana Supreme

       Court has emphasized:


               Summary judgment is a desirable tool to allow the trial court to
               dispose of cases where only legal issues exist. But it is also a
               blunt instrument by which the non-prevailing party is prevented
               from having his day in court. We have therefore cautioned that
               summary judgment is not a summary trial, and the Court of
               Appeals has often rightly observed that it is not appropriate
               merely because the non-movant appears unlikely to prevail at
               trial. In essence, Indiana consciously errs on the side of letting
               marginal cases proceed to trial on the merits, rather than risk
               short-circuiting meritorious claims.


       Id. at 1003-04 (cleaned up).



       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020    Page 23 of 43
[35]   We review the trial court’s decision on summary judgment de novo. Id. at 1003.

       Although the nonmoving party “has the burden on appeal of persuading us that

       the grant of summary judgment was erroneous, we carefully assess the trial

       court’s decision to ensure that he was not improperly denied his day in court.”

       Id. (quotation marks omitted). In our review, we apply the same standard that

       the trial court should have applied: we look only to the designated evidence

       and the reasonable inferences therefrom that are most favorable to the

       nonmoving party. Id. We first consider whether the moving party

       “affirmatively negate[d] an opponent’s claim.” Id. (quotation marks omitted).

       If so, we then consider whether the nonmoving party has demonstrated that the

       designated evidence shows a genuine issue of material fact. Id. “A fact is

       material if its resolution would affect the outcome of the case, and an issue is

       genuine if a trier of fact is required to resolve the parties’ differing accounts of

       the truth . . . .” Id. (quotation marks omitted). Although the trial court here

       entered findings and conclusions in its summary judgment orders, such findings

       and conclusions are neither required under Indiana Trial Rule 56(C) nor

       binding on this Court in our review. E.g., Knighten v. E. Chicago Hous. Auth., 45

       N.E.3d 788, 791 (Ind. 2015).


                                             2. The Estate’s Claims

[36]   The Estate’s claims against the Corizon medical employees are premised on 42

       U.S.C. § 1983. That statute “provides a cause of action against any person who

       deprives an individual of federally guaranteed rights ‘under color’ of state law.”

       Filarsky v. Delia, 566 U.S. 377, 383 (2012) (quoting 42 U.S.C. § 1983). “Anyone

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020       Page 24 of 43
       whose conduct is ‘fairly attributable to the state’ can be sued as a state actor

       under § 1983.” Id. (citing Lugar v. Edmondson Oil Co., 457 U.S. 922, 937 (1982)).

       Corizon and the Corizon medical employees do not dispute that they were state

       actors for purposes of the Estate’s § 1983 claims.


[37]   According to the Estate, each of the Corizon medical employees was

       “deliberately indifferent” to Wood’s “serious medical needs, which constituted

       cruel and unusual punishment in violation of the Eighth Amendment to the

       United States Constitution.” 7 Appellant’s App. Vol. II at 167. The Estate then

       alleged that Corizon itself was liable “for the torts committed by [its] agents in

       the course of their employment under the doctrine of respondeat superior.” Id. at

       166.


[38]   The Estate also sued the DOC. According to the complaint, the DOC had “a

       duty under Indiana law to take reasonable steps to provide for the health and

       safety of inmates in its custody,” which steps the DOC “failed to take” on

       behalf of Wood. Id. In particular, the Estate alleged that the DOC failed “to

       ensure that . . . Corizon carried out its contractual duty to provide reasonable

       medical care” to Wood. Id. at 167.


                                    3. The Corizon Medical Employees

                                3.1. The Deliberate Indifference Standard




       7
         There is no dispute that the Eighth Amendment’s prohibition against cruel and unusual punishment is
       applicable against the DOC, Corizon, and the Corizon medical employees.

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                        Page 25 of 43
[39]   The Estate asserts that the Corizon medical employees were each deliberately

       indifferent to Wood’s serious medical needs. “[D]eliberate indifference to

       serious medical needs of prisoners constitutes the unnecessary and wanton

       infliction of pain proscribed by the Eighth Amendment.” Estelle v. Gamble, 429

       U.S. 97, 104 (1976) (citation and quotation marks omitted). As the Supreme

       Court of the United States has explained:


               [The Eighth] Amendment proscribes more than physically
               barbarous punishments. The Amendment embodies broad and
               idealistic concepts of dignity, civilized standards, humanity, and
               decency, against which we must evaluate penal measures. Thus,
               we have held repugnant to the Eighth Amendment punishments
               which are incompatible with the evolving standards of decency
               that mark the progress of a maturing society.


               These elementary principles establish the government’s
               obligation to provide medical care for those whom it is punishing
               by incarceration. An inmate must rely on prison authorities to
               treat his medical needs; if the authorities fail to do so, those
               needs will not be met. In the worst cases, such a failure may
               actually produce physical torture or a lingering death, the evils of
               most immediate concern to the drafters of the Amendment. In
               less serious cases, denial of medical care may result in pain and
               suffering which no one suggests would serve any penological
               purpose. The infliction of such unnecessary suffering is
               inconsistent with contemporary standards of decency . . . .


       Id. at 102-03 (cleaned up). “The Constitution does not mandate comfortable

       prisons, but neither does it permit inhumane ones . . . .” Farmer v. Brennan, 511

       U.S. 825, 832 (1994) (citations and quotation marks omitted).



       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020     Page 26 of 43
[40]   Deliberate indifference does not require a showing that the prison officials acted

       “maliciously and sadistically for the very purpose of causing harm.” Wilson v.

       Seiter, 501 U.S. 294, 305 (1991) (quotation marks omitted). But, while

       deliberate indifference requires showing more than “mere negligence, ” id., and

       “[m]edical malpractice does not become a constitutional violation merely

       because the victim is a prisoner,” Estelle, 429 U.S. at 106, it also does not

       require a plaintiff to show that he was “literally ignored” by prison medical

       staff. Hayes v. Snyder, 546 F.3d 516, 524 (7th Cir. 2008) (quotation marks

       omitted).


[41]   Instead, the Supreme Court of the United States has held that “acting . . . with

       deliberate indifference . . . is the equivalent of recklessly disregarding” a

       “substantial risk of serious harm to a prisoner.” Farmer, 511 U.S. at 836. Thus,

       for a prison medical official to be liable for the denial of adequate medical care,

       the prisoner must show that “the official knows of and disregards an excessive

       risk to inmate health or safety; the official must both be aware of facts from

       which the inference could be drawn that a substantial risk of harm exists, and

       he must also draw the inference.” Id. at 837.


[42]   In other words, “an Eighth Amendment claimant need not show that a prison

       official acted or failed to act believing that harm actually would befall an inmate;

       it is enough that the official acted or failed to act despite his knowledge of a

       substantial risk of serious harm.” Id. at 842 (emphases added). As the United

       States Court of Appeals for the Seventh Circuit has put it, the prisoner “must

       show only that the defendants’ responses to [his serious medical conditions]

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020        Page 27 of 43
       were so plainly inappropriate as to permit the inference that the defendants

       intentionally or recklessly disregarded his needs.” Hayes, 546 F.3d at 524.

       Conversely, a prison official may avoid liability under the deliberate-

       indifference standard if he can show that he “responded reasonably to the risk,

       even if the harm ultimately was not averted.” Farmer, 511 U.S. at 844.


[43]   “Whether a prison official had the requisite knowledge of a substantial risk is a

       question of fact subject to demonstration in the usual ways, including inference

       from circumstantial evidence . . . .” Id. at 842. Evidence of repeated examples

       of medical mistreatment or systemic deficiencies in medical treatment have

       been held to demonstrate deliberate indifference. As the United States Court of

       Appeals for the Second Circuit has said, “while a single instance of medical

       care denied or delayed, viewed in isolation, may appear to be the product of

       mere negligence, repeated examples of such treatment bespeak a deliberate

       indifference by prison authorities . . . .” Todaro v. Ward, 565 F.2d 48, 52 (2d

       Cir. 1977). And the Seventh Circuit has held that juries may conclude that a

       prisoner has been “effectively denied access to adequate medical care” from

       evidence of “systemic and gross deficiencies in staffing, the quality of personnel,

       and sick call procedures.” Bass by Lewis v. Wallenstein, 769 F.2d 1173, 1186 (7th

       Cir. 1985) (quotation marks omitted).


[44]   With those principles in mind, we turn to the Estate’s claims against the

       Corizon medical employees. We initially note, however, that there is no

       dispute that Wood suffered from serious medical conditions during her time in

       the DOC facilities. There is also no dispute that each of the Corizon medical

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020     Page 28 of 43
       employees was actually aware of her serious medical conditions. Thus, the

       dispute here turns on whether the designated evidence supports at least an

       inference that the Corizon medical employees “disregard[ed] an excessive risk

       to [Wood’s] health or safety.” See Farmer, 511 U.S. at 837. We divide our

       analysis of that question between the actual providers of Wood’s medical care

       and the registered nurses.


                                       3.2. Wood’s Medical Providers


[45]   Genuine issues of material fact preclude the entry of summary judgment for

       Wood’s medical providers—Corizon medical employees Dr. Raham, Dr.

       Hinchman, Dr. Rains, Nurse Practitioner Pinkston, and Nurse Practitioner

       Antle. A reasonable finder of fact could readily conclude from the designated

       evidence that Wood’s medical providers, individually or collectively, acted or

       failed to act despite their knowledge of a substantial risk of serious harm to

       Wood or otherwise were plainly inappropriate in their treatment of Wood’s

       serious medical conditions so as to permit the inference that those providers

       intentionally or recklessly disregarded her needs.


[46]   Dr. Neucks’ designated sworn statements include the following assessments of

       Dr. Raham’s treatment of Wood at Rockville:


               In [Dr. Raham’s deposition] he lists several organ systems that
               can be involved with lupus. He seems to be knowledgeable about
               lupus being a multiorgan system disease[;] however, when
               [Wood] had rashes, joint pain, kidney disease, and weakness he
               did not seem to think that any of these were related to her lupus,
               which they obviously were.

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020    Page 29 of 43
                                             ***


        [Lupus] is a disease . . . that can be dormant and then subject to
        flare up. Thus[,] often patients with lupus have a higher level of
        non[-]compliance [with their medications] because patients tend
        to get complacent when they are not having a flare up and stop
        taking their medication[s] . . . . Wood stopped taking her
        [hydroxychloroquine]. When she noted to [Dr. Raham] that she
        had stopped taking it, [he] discontinued the medication.


        I believe this was a catastrophic error . . . .


Appellant’s App. Vol. VI at 17, 24 (emphasis added). Dr. Neucks added:


        [Dr. Raham] does discuss that non[-]compliance with
        medications occasionally occurs both in the prison medicine and
        in standard medical practices. He notes that [Wood] was non[-
        ]compliant with her [hydroxychloroquine] and the medicine was
        eventually discontinued. He says that the discontinuation of
        [hydroxychloroquine] could have been part of the problem that
        she got so sick.


        I then beg to question as to why no one ever mentioned it in the
        chart, and it was never brought . . . up to the patient, and most
        certainly never restarted. I am quite confident that any
        consultation with rheumatology, even a cursory phone consultation,
        would have strongly suggested the re-implementation of
        [hydroxychloroquine]. [Wood] is originally non[-]compliant with
        her [warfarin], but after discussion with the physician becomes
        compliant . . . saying she did not realize it is important. This
        would suggest that the patient indeed would have been compliant
        with the [hydroxychloroquine] if it had been simply mentioned to
        her how important it was[,] especially as she became increasingly
        sick. This alone could have had a major beneficial impact.


Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020   Page 30 of 43
       Id. at 18 (emphasis added).


[47]   Dr. Dianne Sommers, another of the Estate’s designated experts, also provided

       sworn statements and agreed with Dr. Neucks’ assessment that Dr. Raham’s

       discontinuation of Wood’s hydroxychloroquine and failure to counsel Wood

       about that medication “shows a basic lack of understanding of [lupus] as a disease

       and how it is treated.” Id. at 29 (emphasis added). Although those sworn

       statements are explicitly in reference to Dr. Raham, a reasonable fact-finder

       could conclude they are just as applicable to Nurse Practitioner Pinkston, who

       also actually treated Wood at Rockville and shared responsibility for providing

       Wood’s medical care at that facility.


[48]   Regarding Dr. Hinchman’s treatment of Wood at Madison, Dr. Neucks’

       designated sworn statements include the following:


               [Despite the purported basis for transferring Wood to KDH,] the
               KDH [staff] deals only with an upper respiratory tract infection
               and sends her back. When this dichotomy was identified at the
               prison[,] there was no remediation taken. When [Wood] was
               returned . . . , Dr. Hinchman orders Tylenol, fluids, and vital signs, but
               does not see [Wood] . . . . There was no further investigation of the arm
               swelling, no further request for consultation, no further input. The
               problem was just sort of dropped.


               By this time, [Wood] had fever, lethargy, pleuritic chest pain, low
               albumin, elevated globulins, rash, dropping hemoglobin, and 2+
               proteinuria. This constellation is very likely related to her lupus.
               Unfortunately, there is no attempt on the part of Dr. Hinchman to put
               these things together to suggest lupus. There is no request for further
               input from internal medicine, or rheumatology, or any other specialist to

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020           Page 31 of 43
               see whether these items might be related to lupus and thus require
               treatment. In fact, he says this did not constitute a lupus flare-up.


               When she was seen and had a [blood] sedimentation rate of 53,
               [which is an abnormally high result indicative of inflammation in
               the blood from lupus,] there was no follow-up recommended. . . .


               At the next visit we find that her sedimentation rate was 126, this
               time again strongly suggesting a lupus flare. Her sedimentation rate
               has risen almost 100 points since she has been incarcerated and there is
               absolutely no interest on the part of the various physicians to modify or
               implement her treatment.


               When she was eventually transferred to the Indiana Women’s
               Prison . . . [, Dr. Hinchman] says that the reason was that her
               condition had worsened and that she now required 24-hour
               monitoring; however[,] it is clear from 03/01/201[2] to 03/19/201[2]
               when she was transferred that [Dr. Hinchman] did not visit her for an
               office visit. It seems that if she required . . . 24-hour care that visits more
               than every three weeks would have been appropriate . . . making this
               analysis quite suspect.


       Id. at 16-17 (emphases added; citations omitted). Although those statements

       are explicitly in reference to Dr. Hinchman, a reasonable fact-finder could

       conclude they are just as applicable to Nurse Practitioner Antle, who also

       actually treated Wood at Madison and shared responsibility for providing

       Wood’s medical care there.


[49]   Regarding Dr. Rains’ treatment of Wood at the Indiana Women’s Prison, Dr.

       Neucks’ designated sworn statements include the following:




       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020               Page 32 of 43
        Dr. Rains[’] evaluation [of Wood] is equally problematic [to Dr.
        Hinchman’s;] although she was only [at the Indiana Women’s
        Prison] briefly[,] there is documentation of the seriousness of her
        status. The nurses’ notes clearly state [Wood] is having marked
        difficulty walking. The nurses’ notes suggest that she was a max
        assist of two. [Dr. Rains] dismisses this as needing a little help to the
        bathroom; however[,] I believe max assist of two strongly suggest[s]
        [Wood] was unable to ambulate on her own. [Dr. Rains] never
        attempted to examine [Wood’s] ability to walk. This would have been
        a key to transferring her [to a hospital] sooner or initiating more
        aggressive therapy.


        Due to her low oxygen, a chest x-ray was ordered [the day after she
        arrived at the Indiana Women’s Prison], but [it was] never
        accomplished. There is no note in the chart as to why it was not
        done or any further attempt to get it done during her brief stay at
        that time.


Id. at 17 (emphases added; citations omitted). Dr. Neucks continued:


        It is clear from [Dr. Rains’] records that [Wood’s] lupus flare had
        begun prior to her transfer [to the Indiana Women’s Prison].
        This is documented in several comments that he makes. . . He
        treated this constellation of symptoms with Tylenol. . . . Her records
        clearly document a steady[,] slow[,] downhill course presumably
        caused by her lupus which is apparent from the clinical record
        and well documented eventually by her autopsy. This suggests
        her downhill course or lupus flare began as far back as four to six
        weeks prior to [her transfer to the Indiana Women’s Prison]. . . .
        [E]ven a cursory phone consult with [a] rheumatologist during this
        interval might have strongly and beneficially affected the course of
        [Wood’s] illness.


        . . . [T]he issue of [hydroxychloroquine] comes up on multiple
        occasions. Perhaps had she been treated with adequate steroid

Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020         Page 33 of 43
               when she began to decline, and had the [hydroxychloroquine] been
               reinitiated as might have been standard of care for any rheumatology
               consult, this entire cascade of events might have been prevented. . . .


       Id. at 22-23 (emphases added).


[50]   Dr. Neucks added that Dr. Rains’ decision to transport Wood seventy miles by

       ambulance when she was hypoxic, emergent, and “catastrophically sick” was

       “inappropriate,” an “oxymoron,” and represented “a severe or callous

       disregard for [Wood’s] clinical status.” Id. at 17. Dr. Neucks further added that

       the infirmary at the Indiana Women’s Prison “itself was completely and totally

       inadequate for [Wood’s] care.” Id.


[51]   Dr. Neucks also lamented the failure of Wood’s medical providers to establish a

       long-term treatment plan for her:


               There was no mention of a long-term plan. Dr. Hinchman and
               others . . . maintain the EMR document itself is a standing long-
               term care plan; however[,] there was no mention in the EMR of
               the long-term need to follow [Wood]. In fact[,] in spite of being
               on some brief [steroid] and having a sedimentation rate of 53 she
               was not seen again [by Dr. Hinchman] until routinely scheduled
               as required at three months.


                                                    ***


               In reference to her treatment plan . . . , [Dr. Raham] says that the
               [EMR] was her treatment plan. Again[,] there is just no
               documentation that this was used as an effective tool or to be in
               compliance with the prison system[’s] mandate of a treatment
               plan for chronically ill patients. . . .

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020             Page 34 of 43
               The necessity of a long-term treatment plan for lupus is quite
               obvious as this disease waxes and wanes. Vigilance for these
               needs to be undertaken. The fact [Wood] steadily declines and
               eventually dies, all without a plan, supports the inadequacy of the
               EMR as a plan.


               There is nothing in her chart that suggests long-term care of any
               kind. . . .


                                                    ***


               It is clear that use of the [EMR] order system as a long[-]term
               treatment plan for a lupus patient was completely and totally
               inadequate and falls well below the standard of care for any
               physician under these circumstances.


       Id. at 16, 18, 21.


[52]   Dr. Neucks summarized his assessment of Wood’s medical providers as

       follows: “all three physicians[’] care clearly falls below the standard of care.

       Each a link of failure in the chain that eventually caused the death of Rachel

       Wood.” Id. at 18. Again, while that statement was explicitly in reference to the

       three physicians, a reasonable fact-finder could conclude that it is equally

       applicable to the two nurse practitioners on this record.


[53]   In sum, the designated evidence shows that Wood’s medical providers rendered

       care that was described by other medical professionals as “callous,” “a

       severe . . . disregard for [Wood’s] clinical status,” “inappropriate,”

       “catastrophic,” showing “absolutely no interest” in Wood’s treatment, “quite

       suspect,” “dismiss[ive],” and “clearly . . . below the standard of care.” Id. at 16-
       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020     Page 35 of 43
       18, 24. The designated evidence shows that Wood’s medical providers’

       treatment of Wood “discontinued” essential medication; showed a “basic lack

       of understanding” of Wood’s lupus; repeatedly failed to make “even a cursory

       phone consultation” that “would have strongly suggested the re-

       implementation” of her lupus medication; took “no remediation” when

       learning of KDH’s failure to address specific medical concerns and instead “just

       sort of dropped” those concerns; addressed the “constellation” of lupus

       symptoms “with Tylenol”; repeatedly failed to recommend or undergo basic

       follow-up appointments; showed “absolutely no interest” in “modify[ing] or

       implement[ing]” appropriate treatment plans; had no clear or effective long-

       term plan in place, despite the “necessity” of such a plan for Wood;

       implemented no “long-term care of any kind”; and failed to appropriately

       transport her in emergent circumstances. Id. at 16-18, 22-24, 29. The Estate’s

       medical expert further explicitly testified that the failures of Wood’s medical

       providers were “link[s] . . . in the chain” that resulted in her death. Id. at 18.


[54]   A reasonable fact-finder could readily conclude from the designated evidence

       that the responses of Wood’s medical providers to her serious medical

       conditions “were so plainly inappropriate as to permit the inference that the

       defendants intentionally or recklessly disregarded [Wood’s] needs.” Hayes, 546

       F.3d at 524. The record does not suggest a single or isolated instance of

       medical mistreatment, nor does it suggest that Wood’s medical providers

       reasonably responded to her needs but simply failed to avert harm. The record

       instead shows systemic and gross deficiencies in her medical care throughout


       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020      Page 36 of 43
       her incarceration, which deficiencies the Estate’s expert directly connected to

       her cause of death. Genuine issues of material fact support at least an inference

       that the Wood’s medical providers “disregard[ed] an excessive risk to [Wood’s]

       health or safety.” Farmer, 511 U.S. at 837. Accordingly, the trial court erred

       when it entered summary judgment for Dr. Hinchman, Dr. Raham, Dr. Rains,

       Nurse Practitioner Antle, and Nurse Practitioner Pinkston.


                                          3.3. The Registered Nurses


[55]   Conversely, there is no evidence that the two registered nurses at the Indiana

       Women’s Prison—Nurse Grimes and Nurse Icenogle—breached the standard

       of care relevant for registered nurses, let alone acted with deliberate indifference

       toward Wood’s serious medical needs. To the contrary, the record is clear that

       at all relevant times Nurse Grimes and Nurse Icenogle were acting under the

       direction of Dr. Rains, and at all relevant times Dr. Rains, not Nurse Grimes or

       Nurse Icenogle, was responsible for Wood’s treatment and care. Thus, Nurse

       Grimes and Nurse Icenogle affirmatively negated the Estate’s showing that they

       acted in a plainly inappropriate manner, and they are entitled to judgment as a

       matter of law. We therefore affirm the trial court’s entry of summary judgment

       for Nurse Grimes and Nurse Icenogle.


              3.4. The Remaining Corizon Medical Employees’ Other Arguments


[56]   We briefly address the remaining Corizon medical employees’ other arguments

       on appeal. We initially note, however, that the substantial part of their

       argument on appeal takes one of two approaches: either the remaining Corizon

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020     Page 37 of 43
       medical employees simply disregard the designated evidence that is most

       favorable to the Estate, or they assert that the Estate’s expert testimony is

       insufficient as a matter of law. Regarding the first line of attack, we reject their

       attempt to disregard Indiana’s summary judgment standards—as shown above,

       the designated evidence most favorable to the Estate readily shows genuine

       issues of material fact precluding the entry of judgment as a matter of law.


[57]   As for the second line of attack, the remaining Corizon medical employees

       suggest that Dr. Neucks’ sworn statements are not sufficient to avoid summary

       judgment because he did not explicitly use the legal term-of-art “deliberate

       indifference” in his sworn statements. But the remaining Corizon medical

       employees cite no Indiana authority that requires an expert to invoke a specific

       term to avoid summary judgment in causes such as this. We instead look to the

       clear import of the designated evidence as a whole, in the light most favorable

       to the summary judgment nonmovant, and determine whether a finder of fact

       can infer the legal standard of deliberate indifference from that evidence.

       Again, as demonstrated above, we hold that that test is readily satisfied.

       Further, insofar as the remaining Corizon medical employees assert that the

       designated evidence shows medical malpractice but not deliberate indifference,

       we conclude that, on this record, that degree of difference is for the finder of

       fact.


[58]   The remaining Corizon medical employees also suggest that the trial court did

       not err in entering summary judgment because the Estate did a poor job citing

       the designated evidence in its brief to the trial court. Be that as it may, our

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020     Page 38 of 43
       standard of review in this appeal is de novo, and the Estate’s brief to our Court is

       more than adequate. We will not decide this appeal on those grounds.


                                                     4. Corizon

[59]   We next address the trial court’s entry of summary judgment for Corizon. As

       noted above, the Estate sued Corizon under the doctrine of respondeat superior—

       that is, on the theory that the corporate entity was responsible for the tortious

       acts of its employees when those acts occurred within the scope of their

       employment. E.g., Cox v. Evansville Police Dep’t, 107 N.E.3d 453, 460 (Ind.

       2018). In the trial court, Corizon moved for summary judgment independently

       of the Corizon medical employees. For various procedural reasons, the trial

       court concluded that the Estate failed to respond to Corizon’s motion for

       summary judgment and then entered summary judgment for Corizon. And, on

       appeal, the parties dispute whether the trial court erred when it refused to

       accept the Estate’s response to Corizon’s motion for summary judgment and

       treated Corizon’s motion for summary judgment as if it were unopposed.


[60]   But we need not decide those questions. Instead, we hold that the evidence

       designated by the parties with respect to the Estate’s claims against the Corizon

       medical employees is relevant and available against Corizon under the doctrine

       of respondeat superior. Indeed, in its summary judgment motion to the trial

       court, Corizon conceded that it can be liable under the doctrine of respondeat

       superior on a claim of deliberate indifference if the designated evidence were to

       show “systemic and gross deficiencies” such that “the inmate population is

       effectively denied access to adequate medical care.” Appellant’s App. Vol. V at
       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020     Page 39 of 43
       160-61 (quotation marks omitted). As we have already held, the designated

       evidence that was properly before the trial court on the Estate’s claims against

       the Corizon medical employees demonstrates that genuine issues of material

       fact exist as to whether such systemic and gross deficiencies existed here.

       Accordingly, the trial court erred when it entered summary judgment for

       Corizon.


                                                   5. The DOC

[61]   Finally, we address the trial court’s entry of summary judgment for the DOC.

       The Estate sued the DOC on the ground that the DOC had, under Indiana law,

       negligently failed to supervise its contractor. Specifically, the Estate asserts that

       the DOC negligently failed to discover that Corizon had no treatment plan for

       Wood and that Corizon had not met Wood’s medical needs. 8 As our Supreme

       Court has explained: “Prevailing on a negligence claim requires fulfillment of

       three elements: 1) duty owed to plaintiff by the defendant; 2) breach of duty by

       allowing conduct to fall below the applicable standard of care; and 3)

       compensable injury proximately caused by defendant’s breach of duty.” Ryan v.

       TCI Architects/Eng’rs/Contractors, Inc., 72 N.E.3d 908, 913 (Ind. 2017).




       8
        We need not consider the Estate’s additional argument that the DOC acted negligently when it placed
       Wood in shackles while she was being transported by ambulance on the date of her death.

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                       Page 40 of 43
[62]   There is no dispute that the DOC owed Wood a duty to ensure that Corizon

       provided appropriate medical care for Wood. See Appellant’s Br. at 59;

       Appellee Ind. Dep’t of Corr.’s Br. at 18-23. As we have stated:


               public policy considerations require that the DOC not be made
               an absolute insurer of prisoners’ safety. Although the DOC is
               not a guarantor, neither has it been relieved of all responsibility
               for safekeeping its charges. Rather, the DOC’s responsibility
               takes the middle ground: it has the duty “to take reasonable
               precautions to preserve the life, health, and safety of prisoners.”


       Cole v. Ind. Dep’t of Corr., 616 N.E.2d 44, 45-46 (Ind. Ct. App. 1993) (quoting

       Reed v. State, 479 N.E.2d 1248, 1254 (Ind. 1985)), trans. denied. “Because of the

       DOC’s unusual ability to control all aspects of its prisoners’ lives, the DOC’s

       duty to take reasonable precautions may include an obligation to control the

       conduct of third persons.” Id. at 46. The DOC’s contract with Corizon

       acknowledged that duty by requiring Corizon to maintain records “for contract

       monitoring” by the DOC and by requiring Corizon to comply with the DOC’s

       written health care services directives. Appellant’s App. Vol. V at 231.


[63]   As the question of the DOC’s duty to Wood is not an issue, we turn to the

       questions of breach and proximate causation. Unlike the existence of a duty,

       “[w]hether a party breached its duty is a factual question generally not

       appropriate for summary disposition.” Cole, 616 N.E.2d at 46 (quotation marks

       omitted). Likewise, “determining proximate cause in negligence cases . . . is a

       particularly fact-sensitive issue.” Cox, 107 N.E.3d at 464.



       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020         Page 41 of 43
[64]   Genuine issues of material fact preclude the entry of summary judgment for the

       DOC on the questions of breach and proximate causation. The designated

       evidence shows that the DOC required Corizon to establish and maintain

       treatment plans for inmates, which were to be “formal written plans that

       identify serious health conditions referenced from [a master] problem list,

       describe goals and outcomes, list the planned interventions, and describe which

       professional discipline is responsible for carrying them out.” Appellant’s App.

       Vol. VI at 129, 131. For “serious conditions” such as Wood’s lupus, treatment

       was to be “in a consistent and continuing fashion” with “a structured process.”

       Id. at 133.


[65]   As explained by Dr. Neucks, those requirements were simply never

       implemented for Wood, a multi-year inmate who suffered from serious medical

       conditions upon first arriving in the DOC’s care. Moreover, many of Wood’s

       EMRs are facially inconsistent, such as with her warfarin dosages. And Dr.

       Neucks’ sworn statements include his assessment that the infirmary at the

       Indiana Women’s Prison, where Wood was seen by Dr. Rains immediately

       prior to her transfer to Terre Haute Regional Hospital, was “completely and

       totally inadequate for . . . patient care.” Id. at 17. Further, regarding causation,

       Dr. Neucks stated that the lack of an appropriate treatment plan contributed to

       Wood’s death.


[66]   Accordingly, whether the DOC breached its duty to Wood by not sufficiently

       monitoring Corizon such that it might have discovered those failures is a

       question for the finder of fact. Likewise, whether the DOC could have avoided

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020    Page 42 of 43
       or mitigated harm to Wood with more effective monitoring of Corizon is an

       open question of material fact. Thus, the trial court erred when it entered

       summary judgment for the DOC. 9


                                                    Conclusion
[67]   In sum, while we affirm the trial court’s entry of summary judgment for Nurse

       Grimes and Nurse Icenogle, the record includes abundant designated evidence

       that should be considered by a trier of fact and therefore precludes summary

       judgment for Dr. Hinchman, Dr. Raham, Dr. Rains, Nurse Practitioner Antle,

       Nurse Practitioner Pinkston, Corizon, and the DOC. Accordingly, we affirm in

       part, reverse in part, and remand for further proceedings consistent with this

       opinion.


[68]   Affirmed in part, reversed in part, and remanded for further proceedings.


       Vaidik, J., and Tavitas, J., concur.




       9
         On appeal, the DOC asserts that it met its contractual duty to monitor Corizon and that, had the DOC
       discovered Corizon’s failures, the DOC’s only contractual remedy would have been to impose a financial
       penalty on Corizon. But those assertions are not dispositive on the Estate’s claim that the DOC negligently
       failed to discover Corizon’s failures, which breach of its duty to Wood proximately caused Wood’s death.

       Court of Appeals of Indiana | Opinion 19A-CT-1832 | February 24, 2020                           Page 43 of 43
