Mitchell Wayne Smothers Jr. died while incarcerated in the Walker County Jail due to septic shock and organ failure, conditions that arose from a lack of adequate medical care. His mother, Pamela Smothers, sued the county and its medical contractor under 42 U.S.C. § 1983, alleging that Walker County violated Mitchell's Eighth Amendment rights by adopting a policy of contracting exclusively with Preemptive Forensic Health Solutions. Preemptive, led by a registered nurse without a medical degree, provided substandard care, including drastically reducing medication and outside medical referrals, which led to the deaths of at least eleven inmates over several years. Although the county sheriff, Nick Smith, campaigned on improving care and subsequently directed officers to bypass the contractor for outside treatment, the county refused to terminate the contract with Preemptive, citing contractual limitations that required county commission approval. The district court granted summary judgment for the county, ruling that Alabama law limited the county's duty to merely funding care, not providing it. The Eleventh Circuit reversed, finding that the county's own policy choices created federal liability.
The Eleventh Circuit applied the framework established in Monell v. Department of Social Services, which requires a plaintiff to prove that a municipality's official policy or custom caused a constitutional violation. The court rejected the county's argument that Alabama Code § 14-6-19, which assigns healthcare administration to sheriffs, immunized the county from liability. The court reasoned that while state law may assign administrative duties, it cannot abrogate federal constitutional protections. The court found that Walker County had a policy of contracting with Preemptive despite knowing the provider was incompetent and that inmates were dying. The county's refusal to renew the contract with a qualified provider or to allow the sheriff to cancel the agreement, even after the sheriff raised specific complaints about the lack of physicians and the deaths of inmates, demonstrated deliberate indifference. The court emphasized that the county retained the authority to control the contract and chose to maintain a policy that resulted in inadequate care. Citing Estelle v. Gamble, the court held that deliberate indifference to serious medical needs constitutes cruel and unusual punishment. The evidence showed a direct causal link between the county's policy of maintaining the contract with Preemptive and Mitchell's death, as the provider failed to treat his known conditions, including a severe infected wound and liver disease.
The case is remanded to the district court for trial. Walker County can no longer rely on state statutes to claim immunity from federal Section 1983 liability for its healthcare policies. The decision clarifies that counties remain liable under Monell if they adopt or maintain policies that result in deliberate indifference to inmate health, regardless of whether state law assigns specific administrative duties to sheriffs. The ruling leaves open the factual question of whether the county's specific actions in this instance were the 'moving force' behind Mitchell's death, a determination now left for a jury.