                                     REVISED APRIL 9, 2002

                        IN THE UNITED STATES COURT OF APPEALS

                                    FOR THE FIFTH CIRCUIT

                                      _____________________

                                           No. 00-11078
                                      _____________________


BRENT LAWSON,

                                                                                Plaintiff - Appellee,

                                                     v.

DALLAS COUNTY; JIM BOWLES,
in his official capacity as Dallas County Sheriff;
JAMES R. FARRIS, in his official capacity as
Dallas County Chief Medical Officer,

                                                          Defendants - Appellants.
______________________________________________________________________________

                        Appeal from the United States District Court for the
                           Northern District of Texas, Dallas Division

______________________________________________________________________________
                                 March 28, 2002

Before GARWOOD, JOLLY and DAVIS, Circuit Judges.

E. GRADY JOLLY, Circuit Judge:

       We withdraw our prior opinion in this case, and substitute the following. This appeal arises

out of inmate Brent Lawson’s claims that the acts and omissions of jail medical personnel caused him

to develop severe decubitus ulcers on his lower back and buttocks. After a bench trial, the district

judge entered a judgment for Lawson in the amount of $250,000. The questions presented are: (1)


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whether the district court’s factual findings were clearly erroneous; (2) whether the district court

erred in concluding, based on the factual findings, that the defendants violated Lawson’s Eighth

Amendment right to adequate medical care; and (3) whether Dallas County should be held liable for

these violations.

                                                  I

       We review a district court’s findings of fact for clear error. Crawford v. Falcon Drilling Co.,

Inc., 131 F.3d 1120, 1124 (5th Cir. 1997). The parties do not challenge the district court’s factual

findings, and we do not find any clear error. Therefore, we base our opinion on the findings of fact

by the district court, which we summarize briefly.

       Lawson is a paraplegic who is paralyzed from the chest down. He was arrested for a parole

violation on September 13, 1993 while in the care of Dr. Benavides at Tri-City Hospital, and was

transferred to the Lew Sterrett Justice Center (“the jail”). Lawson was in good health when he

entered the jail. However, without proper medical care paraplegics such as Lawson are at risk of

developing decubitus ulcers, caused by unrelieved pressure on the body, which can be life-threatening.

Various medical equipment and personal assistance used to prevent decubitus ulcers are part of basic

medical training for doctors and nurses and are standard medical procedure in caring for paraplegics.

       When Lawson left Tri-City for the jail, his doctor, Dr. Benavides, telephoned Dr. Farris, the

Dallas County Chief Medical Officer, and expressed his concern that the jail could not adequately care

for Lawson. On Lawson’s hospital patient transfer form, Dr. Benavides stated that Lawson required

range of motion exercises twice per day, turning of his body once per hour, various medications,

dressing changes twice per day, and frequent cleaning and diaper changes.

       Nurse Pat McCormack, the supervising nurse when Lawson came through intake at the jail,


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objected to Lawson’s detention at the jail because she believed that the jail could not adequately meet

his medical needs. However, the Sheriff’s Department overruled her decision. During intake, Nurse

Diane Lynn was unable to read Dr. Benavides’ instructions on the medical transfer form. In

accordance with jail policies: Nurse Lynn did not contact Tri-City to clarify the orders, resulting in

Lawson’s medical orders being improperly recorded; no mobility assessment of Lawson was done;

and no alternative placement was considered.

        Lawson was placed in an infirmary cell with a bed that had a three-inch mattress lain on top

of a cement slab overlaid with ceramic tiles. The mattress often slipped off, and Lawson fell out of

bed. On October 2, 1993, after he fell off the bed he called out to the officer on duty for assistance,

who refused to help him. Lawson filed a grievance which the Lew Sterrett Tower Division rejected,

noting that generally inmates had to assist each other in moving from beds to wheelchairs.

        On November 3, Dr. John Kimmons, a doctor at the jail, saw Lawson and diagnosed him with

Stage II decubitus ulcers, a break in the outer skin that requires immediate attention because the

tissue has begun to rot and die. Dr. Kimmons recorded this diagnosis in Lawson’s jail medical

records and ordered the jail nurses to perform wet-to-dry dressing changes three times per day. The

nurses did not follow these orders, however, because the jail policy was to provide dressing changes

only twice per day. Lawson sometimes did not receive dressing changes this often if he did not make

it to the door of the cell in time, as required by jail policy.

        On November 6, Nurse Lynn transferred Lawson to a solitary cell because other inmates had

begun to complain about his stench of urine and feces. The solitary cell had no mobility supports, and

on several occasions Lawson fell to the floor and lay there for extended periods. The district court

found that by this time the jail nurses and doctors were aware of Lawson’s ulcers, but jail policy


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prevented them from doing anything more than changing his dressings twice daily and giving him

medications.

        Nurses saw Lawson on November 3, 5, 6, and 8. On November 8, Dr. Kimmons diagnosed

Lawson with two large decubitus ulcers, noting that they had worsened since November 3 and were

now at least Stage III. The jail staff scheduled an appointment for Lawson at Parkland Hospital on

December 28, about fifty days later. Lawson received no dressing changes for the following nine

days. The jail medical records indicate that Lawson “refused” dressing changes, but the district court

found this characterization to be suspect because the medical staff considered an inmate’s physical

failure to arrive at the cell door for a dressing change a “refusal.”

        On November 13, the jail medical staff sent Lawson to Parkland for a urinary tract infection.

The Parkland doctors diagnosed Lawson with Stage III and IV decubitus ulcers. Lawson was

returned to the jail with “medically necessary” orders calling for wet-to-dry dressing changes three

times per day, turning every two hours, and use of a pressure-reducing mattress, which Parkland

supplied. The jail medical staff did not follow the instructions because they contravened jail policies.

Also pursuant to jail policy, the nurses did not advise Parkland they could not follow these orders or

seek alternative placement for Lawson.

        Lawson was returned to Parkland on November 19, 1993, because the ulcers on his hips and

buttocks had worsened rapidly. Parkland returned Lawson to the jail the same day, with mandatory

medical orders that mirror those of November 13. The jail medical staff did not provide the

prescribed treatments, seek alternative placement for Lawson, or monitor the progression of his

wounds. On November 28, 1993, a member of the jail’s medical staff sent Lawson back to Parkland.

Parkland diagnosed Lawson with three large decubitus ulcers, two of which were Stage IV, exposing


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dead tissue and bone. Hospital staff concluded that “the patient has not been cared for properly in

the interim” between visits to Parkland. On November 30, Parkland physician Dr. J. Donald Smiley

determined that the jail could not effectively treat Lawson and refused to release Lawson back to the

jail.

        On January 8, 1994, Lawson was transferred to the custody of the Texas Department of

Corrections, and then to the John Sealy Hospital in Galveston. Over the next six months, Lawson

underwent two surgical debridements to remove dead tissue in the ulcer regions and treat the

osteomyelitis that had developed as a result of the ulcers. He also underwent three flap surgeries to

attempt to close the holes exposing his left and right trochanter bones. Lawson suffered extensive

scarring and disfigurement over his lower back and buttocks regions, as well as severe mental anguish

and physical and emotional pain. Following each of these surgeries, Lawson was confined to his bed

for weeks. Lawson underwent another surgery on May 1, 1995. Lawson still suffers from chronic

pain in his hip and lower back regions. No pain relief measure has been effective.

        On November 11, 1995, Lawson filed this lawsuit against Dallas County, Jim Bowles in his

official capacity as Sheriff, and James Farris in his official capacity as Chief Medical Officer of the

Dallas Co unty Jail, alleging that defendants were liable under 42 U.S.C. § 1983 for violating

Lawson’s right to adequate medical care under the Eighth Amendment. After a bench trial, the

district court entered judgment for the plaintiff and awarded him $250,000 for past and future pain

and suffering and mental anguish. Defendants now appeal.

                                                   II

        The defendants first argue that the district court erred in finding that any of the jail officials

violated Lawson’s right to adequate medical care under the Eighth Amendment. We review the


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district court’s conclusions of law on this issue de novo. Ran-Nan Inc. v. General Acc. Ins. Co. of

America, 252 F.3d 738, 739 (5t h Cir. 2001). Although the defendants argue that they provided

adequate medical care under the circumstances and that their policies were reasonable, there is

sufficient evidence to the contrary that would support the district court’s findings.

        The Eighth Amendment prohibition against cruel and unusual punishment forbids deliberate

indifference to the serious medical needs of prisoners. Estelle v. Gamble, 429 U.S. 97, 104 (1976).

The plaintiff must prove objectively that he was exposed to a substantial risk of serious harm. Farmer

v. Brennan, 511 U.S. 825, 834 (1994). Additionally, the plaintiff must show that jail officials acted

or failed to act with deliberate indifference to that risk. Id. at 834. The deliberat e indifference

standard is a subjective inquiry; the plaintiff must establish that the jail officials were actually aware

of the risk, yet consciously disregarded it. Id. at 837, 839.

        The district court found that it is common medical knowledge that a paraplegic who is not

properly cared for is at substantial risk of developing serious, even life-threatening, decubitus ulcers.

This is not in dispute. However, the defendants contend that the district court improperly applied the

Farmer deliberate indifference test to the collective knowledge and collective response of the jail

medical staff as a whole, rather than focusing on specific employees. To apply the Farmer test, each

individual’s subjective deliberate indifference must be examined separately. See Stewart v. Murphy,

174 F.3d 530, 537 (5th Cir. 1999). It is clear from reading the opinion that the district court believed

that all the nurses who primarily treated Lawson, including Nurses McCormack and Lynn, had actual

knowledge of the risk posed by the development and worsening of Lawson’s ulcers. The nurses

changed Lawson’s dressings on several occasions and must have observed first-hand the large holes

developing in Lawson’s skin. The jail medical staff were aware of pressure sores on Lawson’s back


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as early as November 6, 1993. Moreover, the district court found that “[e]ach time Mr. Lawson was

sent to Parkland . . . the jail [was] put on notice that it was providing inadequate care for him.”

Reading the district court’s opinion as a whole, then, it is apparent that the district court found that

the nurses who treated Lawson, including McCormack and Lynn, were aware of the risk of Lawson’s

condition and responded to it by: disobeying doctor’s orders; placing him in a solitary cell; not

providing him with adequate mobility equipment; not personally assisting him in turning himself,

bathing, or moving; not providing necessary dressing changes; and not seeking alternative placement

for Lawson. The district court’s findings of fact on this issue are sufficient.

        The defendants next argue that these responses do not rise to the level of deliberate

indifference. Deliberate indifference requires actual knowledge and conscious disregard of the risk

of harm to the plaintiff. Farmer, 511 U.S. at 834. Deliberate indifference cannot be inferred from

a prison official’s mere failure to act reasonably, i.e., it cannot be inferred from negligence alone.

Hare v. City of Corinth, 74 F.3d 633, 649 (5th Cir. 1996) (en banc).

        The evidence in this case suppo rts the district court’s finding that the medical personnel

treating Lawson had actual knowledge of the risk to Lawson’s health, but consciously disregarded

that risk. The nurses who changed Lawson’s dressings saw his ulcers. The doctors at Tri-City and

Parkland (on each of three visits), and Dr. Kimmons all agreed that Lawson required dressing changes

three times per day and regular medication. Doctors at Tri-City and Parkland sent specific mandatory

orders to the jail medical staff to turn Lawson every one or two hours, provide Lawson with a foam

mattress, and conduct hydrotherapy. The jail nurses did not follow these instructions, despite their

actual knowledge of the seriousness of Lawson’s condition. The district court’s findings that the jail

medical staff exhibited deliberate indifference to Lawson’s serious medical needs, on these facts, are


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not defective as a matter of law.

                                                  III

       The defendants next argue that the district court erred in finding that Dallas County (“the

County”) was liable for any violation of Lawson’s constitutional rights. A municipality is liable under

§ 1983 only if three requirements are met. First, the municipality must have “an official policy,

practice, or custom” which could subject it to § 1983 liability. Monell v. Dep’t of Soc. Servs., 436

U.S. 658, 690-94 (1996). Second, the official policy must be linked to the constitutional violation.

Id. Finally, the official policy must reflect the municipality’s deliberate indifference to that injury.

Hare, 74 F.3d at 649 n. 4, citing Farmer, 511 U.S. at 841. The evidence here was sufficient to show

that the County’s policies were linked to the deprivation of Lawson’s Eighth Amendment rights and

that the policies reflected the county’s deliberate indifference.

       The defendants argue that there was no “official policy” at work in Lawson’s case because

the County had never before received a complaint like Lawson’s from a paraplegic. This argument

is without merit. An “official policy” for § 1983 purposes may be eit er a writ ten policy or “a
                                                                    h

persistent widespread practice of city officials or employees, which, although not authorized by

officially adopted and promulgated policy, is so common and well settled as to constitute a custom

that fairly represents municipal policy.” Webster v. City of Houston, 735 F.2d 838, 841 (5th Cir.

1984) (en banc). The defendants do not dispute that the practices at issue in this case were

consistently applied to paraplegic inmates. The failure of anyone else to complain would not seem

to undermine the existence of a policy. Nevertheless, t he district court discredited the County’s

assertion that it had never had any other complaints from paraplegic inmates.

       Secondly, there must be evidence establishing a direct causal link between the official policy


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and the constitutional violation. The policy must be the “moving force” behind the constitutional

violations. Piotrowski v. City of Houston, 237 F.3d 567, 578 (5th Cir. 2001). In this case, the

district court found that the following official policies restricted the nurses’ ability to care for Lawson:

initial health and mobility assessments for paraplegics are not routine; dressing changes are allowed

only twice per day, and diaper changes and showers must also be completed during this time; nurses

are not allowed to enter a prisoner’s cell except, if at all, under limited circumstances; nurses are not

allowed to help inmates in the shower; foam mattresses are not allowed; mobility supports are not

provided; hospital policies that conflict with jail policies are disregarded; and alternative placements

for paraplegics are not considered. Had these policies not been in effect, it is reasonable to expect

that Lawson would have received much more personal assistance from the nurses at the jail. For

example, the nurses who treated Lawson pointed to these jail policies to explain why they did not

follow Parkland’s orders. The district court did not err in finding that the County’s policies were the

“moving force” behind any constitutional violation.

        Finally, the municipality must maintain its official policy with deliberate indifference to a

constitutionally protected right. Unlike the deliberate indifference standard applied to individual

employees, this standard is an objective one; it considers not only what the policymaker actually

knew, but what he should have known, given the facts and circumstances surrounding the official

policy and its impact on the plaintiff’s rights. Farmer, 511 U.S. at 841; Hare, 74 F.3d at 643 n. 4.

Therefore, constructive notice is adequate. Id.

        Although the defendants contend they could not have known that a constitutional violation

would occur in this case because they have never before received a report similar to Lawson’s, the

district court did not credit this assertion, because it was made by the same people who had no


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memory of Lawson’s condition even though some had personally interacted with him. The district

court found that the jail’s medical records could not be credited to support the defendants’ assertion

because Lawson’s own medical records did not reflect the severity of his condition. The orders from

doctors at Tri-City and Parkland and Dr. Benavides’ personal conversation with Dr. Farris, the Dallas

County medical officer, support the finding that the County should have been aware of the danger

its policies posed to Lawson. Lawson’s own official complaint made to the jail authorities also

indicates that the County had constructive knowledge of Lawson’s inability to care for himself. The

district court’s finding, on these facts, is not reversible as a matter of law.

                                                   IV

        For the reasons discussed above, the judgment of the district court is

                                                                                        AFFIRMED.




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