United States Court of Appeals
For the First Circuit
No. 06-1761
ANGELINA RUIZ-ROSA,
Plaintiff, Appellant,
v.
JOHNNY RULLÁN, SECRETARY OF THE DEPARTMENT OF HEALTH
OF THE COMMONWEALTH OF PUERTO RICO, ET AL.,
Defendants, Appellees.
ON APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF PUERTO RICO
[Hon. Carmen Consuelo Cerezo, U.S. District Judge]
Before
Torruella and Lipez, Circuit Judges,
and DiClerico, Jr.,* District Judge.
José R. Olmo-Rodríguez for appellant.
Susana I. Peñagarícano-Brown, Assistant Solicitor General,
Department of Justice, with whom Salvador J. Antonetti-Stutts,
Solicitor General, and Maite D. Oronoz-Rodríguez, Deputy Solicitor
General, were on brief for appellees.
April 24, 2007
____________________
* Of the District of New Hampshire, sitting by designation.
DICLERICO, District Judge. Angelina Ruiz-Rosa brought
suit against officials of the Puerto Rico prison system and prison
medical personnel after her eighteen-year-old son, Jose Luis
Machuca-Ruiz, died of septicemia while being detained at the
Bayamón 1072 Correctional Complex (“BCC”). In her amended
complaint, Ruiz alleged violations of the Fifth, Eighth, and
Fourteenth Amendments, actionable under 42 U.S.C. § 1983, and
medical malpractice under Puerto Rico law. The district court
dismissed her suit as a sanction for failing to comply with its
order to allege her claims as directed, and alternatively, granted
summary judgment in the defendants’ favor on the federal claim, and
declined supplemental jurisdiction as to the malpractice claim,
which was dismissed without prejudice.
Background1
Jose Luis Machuca-Ruiz was incarcerated at BCC beginning
on September 19, 2001. On November 21, 2001, he reported to sick
call, requesting medical care for a skin infection on his upper
right thigh. He was evaluated and given topical medication. The
infection worsened, and Machuca was seen in the prison’s emergency
room on December 5 when the attending doctor found a mass in his
upper right thigh area, ordered a complete blood count (“CBC”), and
1
The facts are taken from the record and are undisputed unless
otherwise stated.
-2-
prescribed Tylenol. Another doctor examined Machuca in the
emergency room later in the day and noted swollen lymph nodes
(adenopathy), with high fever and pain. Machuca was discharged
from the emergency room early in the morning of December 6 before
the results of the CBC were available.
The prison received the results of Machuca’s CBC test
later in the day on December 6. The results showed that he had an
elevated white blood count, including elevated readings for
neutrophils. He was given an antibiotic, which his mother contends
was not effective to fight the type of infection that he had. On
December 8, Machuca returned to the prison emergency room because
of pain. The infection site showed signs of worsening, as his leg
was tender, swollen, and red. The next day, Machuca was diagnosed
with cellulitis in his right thigh. On December 10, another doctor
in the prison emergency room diagnosed Machuca with a right thigh
abscess and referred him to the prison infirmary.
Dr. Pichardo, the prison’s part-time surgeon, was
consulted about Machuca’s case. Dr. Pichardo drained the abscess,
ordered a culture of the abscess discharge, and ordered a second
antibiotic. After the surgery, Dr. Pichardo, who worked at the
prison only two days each week, did not do a follow up evaluation.
On December 12, Machuca began to experience headaches and the wound
site was secreting pus. During the night of December 12, Machuca
began to experience respiratory problems. Early in the morning of
-3-
December 13, Machuca was transferred to Bayamón Regional Hospital,
where he died the next day.
Angelina Ruiz-Rosa brought suit on her own behalf and on
behalf of her deceased son on April 12, 2004. She alleged federal
civil rights claims based on violations of the Fifth, Eighth, and
Fourteenth Amendments and claims under Puerto Rico law of
negligence and medical malpractice. Ruiz brought her claims
against the Puerto Rico Administrator of Corrections, Victor Rivera
González; the Secretary of the Department of Health, Johnny Rullán;
the Chief Health Care Coordinator for Puerto Rico, Aida Guzmán-
Font; the Medical Director at BCC, Hector Mena; medical doctors at
BCC, including Rafael Pichardo; unnamed nurses at BCC; the unnamed
Superintendent of BCC; and unidentified insurance companies.
The defendants filed a motion to dismiss in July of 2004
and also filed an answer to Ruiz’s complaint. During the fall of
2004 and the winter of 2005, Ruiz moved to substitute some named
parties for the John Doe defendants and to extend the deadlines for
discovery and for identifying other defendants. With their motion
to dismiss still pending, the defendants moved for summary judgment
on March 15, 2005. On March 21, 2005, the district court denied
the defendants’ motion to dismiss but found that “the complaint
jumbles the allegations pertaining to the constitutional tort with
those partaking of a medical malpractice, and imputes all
defendants with liability under either legal theory.” The court
-4-
ordered Ruiz to file an amended complaint, on or before April 18,
to “separate the factual allegations corresponding to each legal
theory of liability, and . . . also define which defendants are
liable under each of the theories, and for what actions.” The
court also warned Ruiz that failure to file an amended complaint as
ordered would result in dismissal of her case. The court denied
Ruiz’s motions to substitute parties and to extend discovery
deadlines.
Ruiz filed an amended complaint within the time allowed.
The amended complaint named several new defendants in place of John
Doe defendants. Ruiz also moved to dismiss all claims against
Victor Rivera González. The court dismissed the claims against
Rivera and against Hector Mena. The defendants supplemented their
motion for summary judgment after the amended complaint was filed,
and Ruiz filed a response. On February 15, 2006, the court
dismissed the defendants who had been named as John Does but were
then identified by name in Ruiz’s amended complaint. On February
28, 2006, the court found that Ruiz’s amended complaint did not
comply with the order to separate her allegations as to each of her
theories of liability and as to each defendant and dismissed all of
Ruiz’s claims as a sanction for noncompliance. At the same time,
the court granted the defendants’ motion for summary judgment on
Ruiz’s federal claim and declined supplemental jurisdiction as to
-5-
her malpractice claim under Puerto Rico law, which was dismissed
without prejudice.
Discussion
Ruiz appeals the district court’s order that dismissed
her claims as a sanction and alternatively granted summary judgment
in the defendants’ favor on her federal claims.2 She contends that
dismissing her claims as a sanction was inappropriate and that the
district court erred in granting summary judgment in the
defendants’ favor on her federal claim. The remaining defendants,
Johnny Rullán, Aida Guzmán-Font, and Rafael Pichardo, defend the
district court’s decision to dismiss Ruiz’s claims as a sanction
and argue that summary judgment was properly granted.3
2
Ruiz does not appeal the district court’s decisions denying
Ruiz’s motions to substitute named defendants for the John Doe
defendants and dismissing additional defendants named in the
amended complaint. Ruiz also does not challenge the district
court’s decision to decline supplemental jurisdiction over her
malpractice claim.
3
The defendants also argue that sovereign immunity provided by
the Eleventh Amendment bars Ruiz’s claims against them, which is a
theory that the district court rejected. The defendants did not
file a cross appeal to address this issue. To the extent the
Eleventh Amendment implicates the court’s jurisdiction, see Hudson
Savings Bank v. Austin, --- F.3d ---, 2007 WL 642007, at *5 (1st
Cir. Mar. 5, 2007) (noting issue of whether Eleventh Amendment is
jurisdictional doctrine is unresolved), which the court is required
to consider sua sponte, see Doyle v. Huntress, Inc., 419 F.3d 3, 6
(1st Cir. 2005), we are satisfied that the Eleventh Amendment does
not provide immunity to the defendants here, who were sued in their
individual capacities, see Dasey v. Anderson, 304 F.3d 148, 153
(1st Cir. 2002).
-6-
A. Dismissal as Sanction
In response to a defendant’s motion, a court may dismiss
an action “[f]or failure of the plaintiff to prosecute or to comply
with . . . any order of court.” Fed. R. Civ. P. 41(b). A
dismissal entered to sanction a party for failure to comply with a
court’s order or for failure to prosecute the case is reviewed for
abuse of discretion. Malot v. Dorado Beach Cottages Assocs., ---
F.3d ---, 2007 WL 549110, at *3 (1st Cir. Feb. 23, 2007). In
determining whether an abuse of discretion has occurred, “we must
fairly balance the court’s venerable authority over case management
with the larger concerns of justice, including the strong
presumption in favor of deciding cases on the merits.” Id.
Dismissal with prejudice, along with contempt, are the
most severe penalties that may be ordered against a recalcitrant
party. Benitez-Garcia v. Gonzalez-Vega, 468 F.3d 1, 4 (1st Cir.
2006). We therefore reserve dismissal with prejudice for egregious
misconduct that is measured by considering all aspects of the case,
including “‘the severity of the violation, the legitimacy of the
party’s excuse, repetition of violations, the deliberateness vel
non of the misconduct, mitigating excuses, prejudice to the other
side and to the operations of the court, and the adequacy of lesser
sanctions.’” Id. at 5 (quoting Robson v. Hallenbeck, 81 F.3d 1, 2-
3 (1st Cir. 1996)). In addition, procedural fairness mandates that
-7-
the plaintiff be afforded an opportunity to explain her
noncompliance or to advocate for a lesser sanction. Id. at 7.
In this case, the district court found Ruiz’s original
complaint wanting, but instead of dismissing her claims, the court
granted her an opportunity to file a more clearly stated complaint.
Ruiz filed an amended complaint within the time the court allowed.
As directed, Ruiz separated her claims into separate causes of
action, alleging deliberate indifference to serious medical needs
under federal law as her first claim and medical malpractice under
Puerto Rico law as her second claim. Ruiz alleged particular
actions and conduct by each defendant, including the newly named
defendants, in support of her federal claim. For her malpractice
claim, however, Ruiz adopted by reference all of the allegations
made in support of the federal claim and stated that those “acts
and omissions, also amount to gross negligence and/or fault under
Puerto Rico” law.
The district court found Ruiz’s amended complaint
deficient, concluding that she “utterly failed to comply with our
Order of March 21, 2005.” In particular, the court faulted Ruiz
for “once again jumbl[ing] the allegations pertaining to the
constitutional violation based on denial of medical care with those
which would sustain a tort for medical malpractice, and unabashedly
reassert[ing] that all defendants are liable under both legal
theories.” The court also found it unacceptable that Ruiz adopted
-8-
by reference all of the facts alleged in support of her federal
claim to support her malpractice claim.4 The court concluded that
Ruiz’s medical malpractice claim against the defendants who were
alleged to have “purely administrative deficiencies” was “patently
frivolous.”
To satisfy Federal Rule of Civil Procedure 8(a), a
plaintiff must allege claims in a way that gives the defendants
fair notice of what the claims are and the grounds for those
claims. Calvi v. Knox County, 470 F.3d 422, 430 (1st Cir. 2006).
The complaint “must ‘at least set forth minimal facts as to who did
what to whom, when, where, and why.’” Id. (quoting Educadores
Puertorriquenos en Accion v. Hernandez, 367 F.3d 61, 66 (1st Cir.
2004)). Civil rights cases do not impose a heightened pleading
standard. Asociación De Suscripción Conjunta Del Deguro De
Responsabilidad Obligatorio v. Flores Galarza, --- F.3d ---, 2007
WL 613719, at *17 (1st Cir. Mar. 1, 2007).
The defendants’ counsel conceded at oral argument that
Ruiz’s amended complaint put the defendants on notice of what her
claims were and the grounds for those claims and agreed that the
4
The reason for the district court’s aversion to Ruiz’s
adoption of allegations by reference is not clear. Because that is
a commonly-used pleading shortcut, that procedure, standing alone,
cannot be a basis for the court’s sanction. See, e.g., Mass.
Nurses Ass’n v. N. Adams Reg’l, 467 F.3d 27, 32 (1st Cir. 2006);
Gulf Coast Bank & Trust Co. v. Reder, 355 F.3d 35, 38 (1st Cir.
2004); In re Colonial Mortgage Bankers Corp., 324 F.3d 12, 14 (1st
Cir. 2003); Conway Chevrolet Buick, Inc. v. Travelers Indem. Co.,
136 F.3d 210, 214 (1st Cir. 1998).
-9-
amended complaint satisfied the requirements of notice pleading.
The defendants’ counsel argued, however, that the district court’s
sanction was within its discretion because Ruiz’s amended complaint
did not meet the more exacting requirements set forth in the
district court’s order. We disagree.
In its March 21 order, the district court required more
than is necessary to satisfy the notice pleading standard of the
federal rules. The district court then dismissed Ruiz’s claims as
a sanction for failing to comply with the court-imposed standard.
It is far from clear that Ruiz failed to comply with the court’s
order, much less that any deficiency in the amended complaint was
a sufficient basis to support the harsh sanction of dismissal.5
The court’s decision to dismiss the complaint as a sanction was an
abuse of discretion. We turn to the alternative basis for the
district court’s decision, summary judgment.
B. Summary Judgment
On appeal, we review summary judgment de novo, employing
the same standard that governed consideration of the motion below.
See Salem Hosp. v. Mass. Nurses Ass’n, 449 F.3d 234, 237 (1st Cir.
5
To the extent the district court dismissed Ruiz’s claims as
frivolous or for failing to state a cause of action, as opposed to
imposing dismissal as a sanction, that result is also disfavored
and would not have been appropriate here. See, e.g., Cepero-Rivera
v. Fagundo, 414 F.3d 124, 130 (1st Cir. 2005); Chute v. Walker, 281
F.3d 314, 319 (1st Cir. 2002); Gonzalez-Gonzalez v. United States,
257 F.3d 31, 36-37 (1st Cir. 2001).
-10-
2006). We therefore examine all of the material facts of record
and resolve all reasonable inferences in favor of the non-moving
party. N.H. Ins. Co. v. Dagnone, 475 F.3d 35, 37 (1st Cir. 2007).
Summary judgment is appropriate when the properly supported facts
of record “show that there is no genuine issue as to any material
fact and that the moving party is entitled to a judgment as a
matter of law.” Fed. R. Civ. P. 56(c).
The district court granted the defendants’ motion for
summary judgment on Ruiz’s federal claims and declined supplemental
jurisdiction over her malpractice claim, which was dismissed
without prejudice. In doing so, the court noted that Machuca’s
illness was a serious medical need but agreed with the defendants
that evidence was lacking to support the deliberate indifference
prong of Ruiz’s federal claim. Ruiz argues that she alleged
sufficient facts to allow a jury to conclude that the defendants
were deliberately indifferent to her son’s serious medical needs
and, to a lesser extent, contends that record facts support her
claim.
Because Ruiz’s son, Machuca, was a pretrial detainee
rather than a convicted inmate, the Fourteenth Amendment governs
his claim. Surprenant v. Rivas, 424 F.3d 5, 13 (1st Cir. 2005).
The Fourteenth Amendment provides at least as much protection for
pretrial detainees as the Eighth Amendment provides for convicted
inmates. Revere v. Mass. Gen. Hosp., 463 U.S. 239, 244 (1983).
-11-
Generally, the standard applied under the Fourteenth Amendment is
the same as the Eighth Amendment standard.6 Burrell v. Hampshire
County, 307 F.3d 1, 7 (1st Cir. 2002).
For medical treatment in prison to offend the
Constitution, the care “must involve ‘acts or omissions
sufficiently harmful to evidence deliberate indifference to serious
medical needs.’” Feeney v. Corr. Med. Servs., Inc., 464 F.3d 158,
161 (1st Cir. 2006) (quoting Estelle v. Gamble, 429 U.S. 97, 105-06
(1976)). Deliberate indifference in this context may be shown by
the denial of needed care as punishment and by decisions about
medical care made recklessly with “actual knowledge of impending
harm, easily preventable.” Id. at 162 (internal quotation marks
omitted). Deliberate indifference means that “a prison official
subjectively ‘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.’” Burrell, 307 F.3d at 8 (quoting
Farmer v. Brennan, 511 U.S. 825, 837 (1994)). Therefore,
substandard care, malpractice, negligence, inadvertent failure to
provide care, and disagreement as to the appropriate course of
treatment are all insufficient to prove a constitutional violation.
Feeney, 464 F.3d at 161-62.
6
The parties and the district court considered the claim under
the Eighth Amendment.
-12-
Ruiz primarily relies on the allegations in her complaint
to oppose summary judgment, and such reliance does not satisfy the
Rule 56 standard. In contrast, the defendants cite to the medical
record, deposition testimony, and their declarations submitted in
support of the motion for summary judgment. See Fed. R. Civ. P.
56(c). A party opposing a properly supported motion for summary
judgment must present competent evidence of record that shows a
genuine issue for trial. See Anderson v. Liberty Lobby, Inc., 477
U.S. 242, 256 (1986). Allegations made in a plaintiff’s complaint,
standing alone, are not enough to oppose a properly supported
motion for summary judgment. Velazquez-Garcia v. Horizon Lines of
P.R., Inc., 473 F.3d 11, 15 (1st Cir. 2007).
As presented, the record provides no evidence of
deliberate indifference on the part of any of the defendants.
Ruiz’s expert witness, Dr. Carlos Eduardo Ramirez Gonzalez,
criticized the care Machuca received, stating that he was given
ineffective antibiotics, that doses of the antibiotics which were
prescribed were missed, that the staff failed to keep adequate
medical records, and that the staff failed to respond when
Machuca’s condition worsened. Dr. Ramirez stated that in his
opinion the prison medical staff was indifferent to Machuca’s need
for care because they saw that his condition was deteriorating but
failed to take any action.
-13-
The record establishes that Dr. Pichardo treated Machuca
by draining the abscess, ordering a culture, and prescribing a
second antibiotic. Although Ruiz disagrees with the treatment Dr.
Pichardo provided, Dr. Ramirez’s opinion does not provide evidence
that Dr. Pichardo was aware that the antibiotic he prescribed was
ineffective and would pose a substantial risk of harm to Machuca.
Ruiz also faults Dr. Pichardo for failing to monitor Machuca’s
condition after he treated him. The record shows, however, that
Dr. Pichardo only worked at the prison two days each week. Ruiz
provides no evidence that Dr. Pichardo was aware that his failure
to monitor Machuca after treating him would subject Machuca to a
substantial risk of harm.
Ruiz has shown only that her expert witness disagrees
with Dr. Pichardo’s choice of antibiotic and the course of
treatment Dr. Pichardo provided, which might be evidence of
malpractice (a matter on which we express no opinion), but is
insufficient to show deliberate indifference. See Feeney, 464 F.3d
at 162-63. In addition, Ruiz, the party with the burden of proof,
cannot rely on speculation or conjecture and must present “more
than a mere scintilla of evidence in [her] favor.” Invest Almaz v.
Temple-Inland Forest Prods. Corp., 243 F.3d 57, 76 (1st Cir. 2001).
Ruiz argues that Dr. Rullán, who was Secretary of the
Puerto Rico Department of Health, and Dr. Guzmán, who was Chief
Health Care Coordinator for the Correctional Health Services
-14-
Program, knew of the substandard medical treatment provided at BCC
and failed to remedy the problem. Specifically, Ruiz contends that
Dr. Rullán and Dr. Guzmán knew that failing to treat sepsis
properly with antibiotics puts patients’ lives at risk and that the
practice of having a surgeon available only two days each week puts
patients’ lives at risk. She further contends that the risk of
harm from inadequate medical treatment at BCC was obvious.
Although Ruiz alleges that Dr. Rullán and Dr. Guzmán knew of these
practices and their consequences, she provided no evidence of such
knowledge.
While proof of deliberate indifference by prison
officials does not require evidence that the officials were aware
of the risk of a specific harm, the plaintiff must show that the
officials had “knowledge of facts from which the official[s] can
draw the inference that a substantial risk of serious harm exists.”
Calderon-Ortiz v. Laboy-Alvarado, 300 F.3d 60, 65 (1st Cir. 2002).
In some circumstances, “a fact-finder may conclude that a prison
official knew of a substantial risk from the very fact that the
risk was obvious.” Burrell, 307 F.3d at 8. The risk, however,
must have been obvious to the particular officials who are
defendants. Id.
The record establishes that Dr. Guzmán was appointed by
the federal court in Puerto Rico to coordinate compliance with the
Medical Health Care Plan and the Mental Health Plan in the Puerto
-15-
Rico prison system. She had no involvement with medical care for
individual inmates at BCC and knew nothing about Machuca’s case
until Ruiz filed suit. As Secretary of Health in Puerto Rico, Dr.
Rullán had no involvement in the medical treatment provided to
Machuca “or any other patient.” He did not supervise the medical
staff at BCC. Like Dr. Guzmán, Dr. Rullán became aware of
Machuca’s case only after Ruiz filed suit. Nothing in the record
shows or even suggests that either Dr. Guzmán or Dr. Rullán knew of
inadequate medical care at BCC, or that an inadequacy, which would
permit the inference that inmates were at substantial risk of
serious harm, was obvious.7 Therefore, no factual issue exists to
avoid summary judgment on whether Dr. Guzmán and Dr. Rullán were
deliberately indifferent to a substantial risk of harm to Machuca.
Conclusion
The district court abused its discretion in dismissing
Ruiz’s claims as a sanction for failing to comply with the
heightened pleading standard imposed by the court’s order. In the
absence of a genuine issue of material fact on the question of the
defendants’ deliberate indifference to Machuca’s serious medical
needs, however, summary judgment was appropriately granted in the
defendants’ favor on Ruiz’s federal claim. Ruiz does not appeal
7
Indeed, Ruiz concedes as much, stating in her brief that
“there is not much in the record regarding defendants’ knowledge of
the risks of harm that existed at [BCC].”
-16-
the district court’s decision not to exercise supplemental
jurisdiction over her malpractice claim. Therefore, that part of
the district court’s decision that dismissed Ruiz’s claim as a
sanction is harmless error.8 The district court’s decision
granting summary judgment in favor of the defendants on the federal
claim and declining supplemental jurisdiction over the malpractice
claim, which was dismissed without prejudice, is affirmed.
8
In addition, although the district court ordered that
judgment enter dismissing the complaint as a sanction for failing
to comply with the court’s previous order, the judgment entered the
same day dismissed the federal claims, with prejudice, and
dismissed the tort claims under Puerto Rico law without prejudice.
-17-