Reference Number: 
CTAS-1370

It is the duty of the county legislative body to provide medical attendance for all prisoners confined in the county jail. The county legislative body shall authorize the compensation of the county jail physician, as agreed upon in writing between the county and the attending jail physician, or as may be fixed by the county legislative body. T.C.A. § 41-4-115(a). The Tennessee Supreme Court has recognized that it is the statutory duty of the county legislative body to furnish the services of a physician to treat illnesses of inmates. George v. Harlan, 1998 WL 668637, *4 (Tenn. 1998). See also Manus v. Sudbury, 2003 WL 22888883, *4 (Tenn. Ct. App. 2003) (“By statute, county legislative bodies alone have the power and duty to provide medical care to prisoners confined in their jail.”). Cf. County Hosp. Auth. v. Bradley County, 66 S.W.3d 888, 889 (Tenn. Ct. App. 2001); Leach v. Shelby County Sheriff, 891 F.2d 1241, 1250 (6th Cir. 1989) (“Contracting out prison medical care does not relieve the State of its constitutional duty to provide adequate medical treatment to those in its custody, and it does not deprive the State's prisoners of the means to vindicate their Eighth Amendment rights.”); Willis v. Barksdale, 625 F.Supp. 411 (W.D. Tenn. 1985) (medical needs); Andrews v. Camden County, 95 F.Supp.2d 217, 228 (D. N.J. 2000). See also West v. Atkins, 487 U.S. 42, 108 S.Ct. 2250, 101 L.Ed.2d 40 (1988).

Pursuant to state regulations, provision of medical services for the jail is to be the responsibility of a designated medical authority such as a hospital, clinic, or physician. There shall be an agreement between the county and the designated medical authority  responsible for providing the medical services. The designated medical authority must be notified in instances where an inmate may be in need of medical treatment and the jail must document this notification. Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(1). The health authority shall meet with the Sheriff and/or facility administrator at least annually. Note: Contracting out jail medical care does not relieve the county of its constitutional duty to provide adequate medical treatment to those in its custody. Leach v. Shelby County Sheriff, 891 F.2d 1241, 1250 (6th Cir. 1989). Clinical decisions are the sole province of the responsible clinician and shall not be countermanded by non-clinicians. Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(2)

All health care professional staff shall comply with applicable state and federal licensure, certification, or registration requirements. Verification of current credentials shall be available upon request from the provider. Health care staff shall work in accordance with profession specific job descriptions approved by the health authority. If inmates are assessed or treated by non-licensed health care personnel, the care shall be provided pursuant to written standing or direct orders by personnel authorized to give such orders. Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(3)

In Chattanooga-Hamilton County Hospital Authority v. Bradley County, 33 TAM 11-1, 3/10/2008, Ramsey was shot by an off-duty Bradley County law enforcement officer and was transported to Chattanooga-Hamilton County Hospital Authority for treatment.  The hospital was notified by a law enforcement officer to hold Ramsey.  The Hospital Authority filed suit against Bradley County for Ramsey’s medical bills pursuant to T.C.A. 41-4-115.  The Trial Court awarded hospital judgment for the amount of bill representing time from admittance of Ramsey until the requested hold was removed.  The Tennessee Court of Appeals affirmed the trial court’s decision.  The Tennessee Supreme Court reversed and dismissed the case holding that simple notification by a county law enforcement agency asking a hospital to secure a patient until time of release from treatment does not operate to establish liability of a county for medical expenses under T.C.A. 41-4-115

In Cornett v. Mathes, 2008 WL 5110795 (E.D. Tenn., 2008) a prisoner's federal civil rights claim was dismissed for failure to state a claim for which relief could be granted. The prisoner alleged that the prison and several other defendants violated his Eighth Amendment right not to be subjected to cruel and unusual punishment when he was denied medical care in regards to an injured rib. By the prisoner's own allegation, however, he was seen by a medical provider, escorted to the emergency room for xrays, and later seen by a physician. While the prisoner's contentions may have stated a claim for medical malpractice, no Eighth Amendment claim is stated by allegations that a medical condition has been negligently diagnosed or treated. U.S.C.A. Const.Amend. 8; 42 U.S.C.A. § 1983.

In Crawley v. Bragg, 2008 WL 5111116 (M.D. Tenn., 2008), the U.S. District Court of Middle Tennessee determined that a prison did not deny an inmate medical care in violation of the Eighth Amendment. The inmate did not suffer from a serious medical need. Further, even if the inmate had had a serious medical need, the prison did not act with deliberate indifference as the inmate was examined, blood work was done, and he was referred for follow-ups. U.S.C.A. Const.Amend. 8.

“The right to adequate medical care is guaranteed to convicted federal prisoners by the Cruel and Unusual Punishment Clause of the Eighth Amendment, and is made applicable to convicted state prisoners and to pretrial detainees (both federal and state) by the Due Process Clause of the Fourteenth Amendment.”Johnson v. Karnes, 398 F.3d 868, 873 (6th Cir. 2005).

The Eighth Amendment's proscription of the failure to provide medical care to prisoners was delineated by the United States Supreme Court in Estelle v. Gamble, 429 U.S. 97, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976), as follows:

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 as manifested in modern legislation codifying the common-law view that “(i)t is but just that the public be required to care for the prisoner, who cannot by reason of the deprivation of his liberty, care for himself.”        

We therefore conclude that deliberate indifference to serious medical needs of prisoners constitutes the “unnecessary and wanton infliction of pain,” proscribed by the Eighth Amendment. This is true whether the indifference is manifested by prison doctors in their response to the prisoner's needs or by prison guards in intentionally denying or delaying access to medical care or intentionally interfering with the treatment once prescribed. Regardless of how evidenced, deliberate indifference to a prisoner's serious illness or injury states a cause of action under § 1983.

Id. at 103-105, 97 S.Ct. at 290-291 (citations and footnotes omitted).

Although the Eighth Amendment's protections apply specifically to post-conviction inmates, the Due Process Clause of the Fourteenth Amendment operates to guarantee those same protections to pretrial detainees as well.  Where any person acting under color of state law abridges rights secured by the Constitution or United States laws, including a detainee's Eighth and Fourteenth Amendment rights, 42 U.S.C. § 1983 provides civil redress.

The Supreme Court has adopted a mixed objective and subjective standard for ascertaining the existence of deliberate indifference in the context of the Eighth Amendment: [A] prison official cannot be found liable under the Eighth Amendment for denying an inmate humane conditions of confinement unless 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 serious harm exists, and he must also draw the inference. The objective component of the test requires the existence of a "sufficiently serious" medical need. A sufficiently serious medical need is predicated upon the inmate demonstrating that he or she "is incarcerated under conditions imposing a substantial risk of serious harm."

The subjective component, by contrast, requires a showing that the prison official possessed "a sufficiently culpable state of mind in denying medical care." Deliberate indifference requires a degree of culpability greater than mere negligence, but less than "acts or omissions for the very purpose of causing harm or with knowledge that harm will result." The prison official's state of mind must evince "deliberateness tantamount to intent to punish."  "Knowledge of the asserted serious needs or of circumstances clearly indicating the existence of such needs, is essential to a finding of deliberate indifference." Thus, "an official's failure to alleviate a significant risk that he should have perceived but did not, while no cause for commendation, cannot under our cases be condemned as the infliction of punishment."

Miller v. Calhoun County, 408 F.3d 803, 812-813 (6th Cir. 2005) (citations omitted). See also Butler v. Madison County Jail, 109 S.W.3d 360, 366 (Tenn. Ct. App. 2002) (“When a prisoner suffers pain needlessly and relief is readily available, they have a cause of action against those whose deliberate indifference is the cause of suffering.”).

“Mere negligence, mistake or difference of medical opinion in the provision of medical care to prisoners do not rise to an Eighth Amendment deprivation under the Estelle standard.” Dawson v. Kendrick, 527 F.Supp. 1252, 1306 (D.C. W.Va. 1981). See also Butler v. Madison County Jail, 109 S.W.3d 360, 366 (Tenn. Ct. App. 2002) (Neither negligence nor gross negligence will support a § 1983 claim.). Moreover, officials are “entitled to rely on the professional judgment of trained medical personnel with regards to a prisoner's medical history and the need for medical care.” Miltier v. Beorn, 896 F.2d 848, 854-855 (4th Cir. 1990). “A prisoner's difference of opinion with prison physicians regarding the type of treatment he should receive does not rise to the level of a constitutional violation.” Rauh v. Ward, 112 Fed.Appx. 692, 695 (10th Cir. 2004); LaFlame v. Montgomery County Sheriff's Department, 3 Fed.Appx. 346 (6th Cir. 2001) (Jail inmate’s difference of opinion with doctor over his diagnosis and treatment does not state an Eighth Amendment claim.); Westlake v. Lucas, 537 F.2d 857, 860 n. 5 (6th Cir.1976) (same).

Furthermore, not all inadequate medical treatment rises to the level of an Eighth Amendment violation. “Thus, a complaint that a physician has been negligent in diagnosing or treating a medical condition does not state a valid claim of medical mistreatment under the Eighth Amendment. Medical malpractice does not become a constitutional violation merely because the victim is a prisoner. In order to state a cognizable claim, a prisoner must allege acts or omissions sufficiently harmful to evidence deliberate indifference to serious medical needs.” Estelle, 429 U.S. at 106, 97 S.Ct. at 292. A plaintiff must prove "objectively that he was exposed to a substantial risk of serious harm," and that "jail officials acted or failed to act with deliberate indifference to that risk," which requires actual knowledge and deliberate disregard. Victoria W. v. Larpenter, 369 F.3d 475, 483 (5th Cir. 2004) (citation omitted). See also Butler v. Madison County Jail, 109 S.W.3d 360, 366 (Tenn. Ct. App. 2002) ("In order to state a cognizable claim, a prisoner must allege acts or omissions sufficiently harmful to evidence deliberate indifference to serious medical needs.”) (citation omitted).

Inmates are not entitled to “unqualified access to health care.”Hudson v. McMillan, 503 U.S. 1, 9, 112 S.Ct. 995, 1000, 117 L.Ed.2d 156 (1992). Nor are they entitled to a medical program that caters to their every whim. Meadows v. Woods, 1994 WL 267957, *2 (W.D. Tenn. 1994). “The right to treatment is ... limited to that which may be provided upon a reasonable cost and time basis and the essential test is one of medical necessity and not simply that which may be considered merely desirable.” Bowring v. Godwin, 551 F.2d 44, 47-48 (4th Cir. 1977). See also Dean v. Coughlin, 804 F.2d 207, 215 (2d Cir.1986) ("The Constitution does not command that inmates be given the kind of medical attention that judges would wish to have for themselves....”) (citation omitted); Woodall v. Foti, 648 F.2d 268, 272 (5th Cir. 1981) (“[T]he essential test is one of medical necessity and not one simply of desirability.”); Feliciano v. Gonzalez, 13 F.Supp.2d 151, 208 (D.C. P.R. 1998) (Under the Eighth Amendment, the standard of care for inmates does not include the most sophisticated care that money can buy, but only that which is reasonably appropriate within modern and prudent professional standards in the field of medicine and health.). Cf. Nicholson v. Choctaw County, 498 F.Supp. 295, 308 (S.D. Ala. 1980) (The county is under no duty to provide prosthetic devices such as eyeglasses or dentures, or to provide routine diagnostic care for inmates. These services are not provided by the county to its free world citizens, and a person does not gain a greater right to services or benefits upon being convicted of a criminal offense.). But see Newman v. Alabama, 349 F.Supp. 278, 286-288 (M.D. Ala. 1972) (Upholding the right to prosthetic care for inmates in a long-term facility.).

Budgetary constraints do not justify the intentional withholding of necessary medical care. Jones v. Johnson, 781 F.2d 769, 770-72 (9th Cir. 1986). However, the county is required only to furnish inmates with routine and emergency medical care.  The county is not required to furnish other and additional elective medical care, which is not essential to the immediate welfare of the inmates and the lack of which poses no threat to life or limb. See Kersh v. Bounds, 501 F.2d 585, 588-589 (4th Cir. 1974); Jackson v. Fair, 846 F.2d 811, 817 (1st Cir.1988) (“Although the Constitution does require that prisoners be provided with a certain minimum level of medical treatment, it does not guarantee to a prisoner the treatment of his choice.”). See also Buckley v. Correctional Medical Services, Inc., 125 Fed.Appx. 98 (8th Cir. 2005) (Inmate failed to establish that 20-month delay in scheduling elective elbow surgery after it was recommended was deliberate indifference to inmate's serious medical need, as required to support inmate's § 1983 action against medical provider.); Grundy v. Norris, 26 Fed.Appx. 588 (8th Cir. 2001) (Delay in shoulder surgery did not amount to constitutional violation where medical evidence showed that the surgery was elective and the delay was not of great concern.); Olson v. Stotts, 9 F.3d 1475 (10th Cir. 1993) (An 11-day delay in elective heart surgery did not constitute deliberate indifference.); Cook v. Hayden, 1991 WL 75648, *3 (D. Kan. 1991) (“[T]he mere delay of elective surgery does not establish a violation of an inmate's protected rights.”). But see McCabe v. Prison Health Services, 117 F.Supp.2d 443, 450 (E.D. Pa. 1997) (The fact that a surgery is elective "does not abrogate the prison's duty, or power, to promptly provide necessary medical treatment for prisoners."); Delker v. Maass, 843 F.Supp. 1390, 1400 (D. Or. 1994) (“Where surgery is elective, prison officials may properly consider the costs and benefits of treatment in determining whether to authorize that surgery, but the words ‘elective surgery’ are not a talisman insulating prison officials from the reach of the Eighth Amendment. Each case must be evaluated on its own merits.”).

Continuity of care is required from admission to transfer or discharge from the facility, including referral to community-based providers, when indicated. When health care is transferred to providers in the community, appropriate information shall be shared with the new providers in accordance with consent requirements. Prior to release from custody or transfer, inmates with known serious health conditions shall be referred to available community resources by the jail’s health care provider currently providing treatment.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(4).

All intersystem transfer inmates (transferred from one confinement facility to another within the same county’s jurisdiction) shall receive a health screening by health-trained or qualified health care personnel, which commences on their arrival at the facility. All findings are recorded on a screening form approved by the health authority. At a minimum, the screening includes the following:

Detoxification from alcohol, opiates, hypnotics, and other stimulants shall be conducted under medical supervision in accordance with local, state, and federal laws.  When performed at the facility, detoxification shall be prescribed in accordance with clinical protocols approved by the health authority. Specific criteria shall be established for referring symptomatic inmates suffering from withdrawal or intoxication for more specialized care at a hospital or detoxification center.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(14)

Informed consent standards of the jurisdiction shall be observed and documented for inmate care in a language understood by the inmate.  In the case of minors, the informed consent of a parent, guardian, or a legal custodian applies when required by law.  Inmates routinely have the right to refuse medical interventions.  When health care is rendered against the inmate’s will, it shall be in accordance with state and federal laws and regulations.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(20)

The use of inmates in medical, pharmaceutical, or cosmetic experiments is prohibited.  This does not preclude inmate access to investigational medications on a case-by-case basis for therapeutic purposes in accordance with state and federal regulations.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(22).

When an inmate is paced in segregation for health concerns, health care personnel shall be informed as soon as practical and provide assessment and review as indicated by the protocols established by the health authority.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(25).

Medical/dental instruments and supplies (syringes, needles, and other sharp instruments) shall be inventoried, securely stored, and use shall be controlled.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(26).

Pregnant inmates shall have access to obstetrical services (prenatal, partum, and post-partum care) by a qualified health care provider.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(27)

Inmates with chronic medical conditions, such as diabetes, hypertension, and mental illness shall receive periodic care by a qualified health care provider in accordance with individual treatment plans that include monitoring of medications and laboratory testing.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(28)

The health authority shall develop and approve protocols for identifying and evaluating major risk management events related to inmate health care, including inmate deaths, preventable adverse outcomes, and serious medication errors.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(31).

Medical Emergencies

In case of medical emergencies, there shall be specific information readily accessible to all employees such as telephone numbers and names of persons to be contacted, so that professional medical care can be received.  There shall also be available the names and telephone numbers of persons to contact in case of death.  Rules of the Tennessee Corrections Institute, Rule 1400-1-.13(23).