by Douglas Ankney

On November 20, 2025, the U.S. Court of Appeals for the Fourth Circuit revived the 42 U.S.C. § 1983 suit of Juliana Swink, Administrator of the Estate of David Ray Gunter, that alleged, inter alia, claims of deliberate indifference under Monell v. Dept of Soc. Servs., 436 U.S. 658 (1978), and under the 14th Amendment to the federal constitution.

Pursuant to a bench warrant related to a charge of driving on a suspended license, Gunter was detained in the Davie County Detention Center (“DCDC”) from November 7, 2012, through November 15, 2012. On November 16, 2012, he was transferred to the Stokes County Detention Center (“SCDC”), where he remained until his release on November 21, 2012.

Approximately one week later, Gunter sought treatment for severe stomach pain at the Wake Forest Baptist Medical Center (“Medical Center”) on November 29, 2012. Doctors at the Medical Center surgically removed a blood clot and Gunter was discharged from the Medical Center on December 11, 2012. However, further complications developed and on January 18, 2013, Gunter was diagnosed with a second blood clot that required surgeons to resect a portion of his bowel. On December 27, 2016, Gunter filed the operative second amended complaint (“SEC”) alleging that the poor standard of care he had received at the DCDC and the SCDC caused his injuries.

Gunter named several Defendants, including Davie County, Stokes County, Southern Health Partners (“SHP”), Physician’s Assistant (“PA”) Manuel Maldonado, and Nurses Sandra Hunt and Fran Jackson. According to the SAC, Gunter had been diagnosed with a heart condition shortly after birth. At age 15, he had open-­heart surgery to replace his aortic valve with a mechanical valve. The mechanical valve necessitated Gunter’s taking daily dosages of Coumadin to regulate the thickness of his blood and to prevent clotting.

Upon his arrival at the DCDC on November 7, 2012, Gunter informed Jackson of his mechanical valve and need for his daily dosage of Coumadin. Jackson was DCDC’s Medical Team Administrator (“MTA”) for SHP—which is the private medical contractor for both the DCDC and the SCDC. The following day, Gunter’s family brought six Coumadin pills to the DCDC. But Jackson refused to dispense the medication, alleging it was “out of date.”

Instead, Jackson contacted Maldonado, who is a licensed physician’s assistant under contract with SHP charged with oversight of the medical care at DCDC and SCDC. Maldonado ordered a prescription of Coumadin for Gunter. But Gunter did not receive his first dosage until November 9, 2012. Consequently, Gunter was deprived of Coumadin for the two days of November 7 and November 8. Gunter received Coumadin daily up thru November 15, 2012. However, on Friday, November 16, he was transferred to the SCDC. He arrived late in the afternoon. And Hunt, who was SCDC’s MTA for SHP, had gone home for the weekend.

Pursuant to SCDC policy, a guard phoned Hunt at home to inquire about Gunter’s Coumadin. But Jackson had failed to transmit Maldonado’s prescription to SCDC. Hunt, unaware of any prescription, refused to authorize SCDC staff to dispense any medication to Gunter. Gunter was again deprived of Coumadin for the three days until Hunt returned to work on November 19.

Gunter received his daily dosage of Coumadin until his release from detention on November 21, 2012. Gunter alleged that, due to the policies of the Defendants, he was denied Coumadin for two days (November 7 and 8, 2012) while detained at the DCDC and for three days (November 16, 17, and 18, 2012) while detained at the SCDC, which resulted in his blood clots. The Defendants moved for summary judgment on various grounds. The district court, for reasons discussed below, granted summary judgment to the Defendants and Gunter appealed.

As relevant here, the Fourth Circuit observed that, with respect to Gunter’s § 1983 claim for deliberate indifference under the 14th Amendment, “the district court erred in finding that Gunter’s evidence did not ‘create a genuine dispute of material fact’ that [SHP, Maldonado, Hunt, and Jackson] ‘were deliberately indifferent to [Gunter’s] medical needs.’”

Because Gunter was a pretrial detainee, he “need only show that the challenged government action was ‘not rationally related to a legitimate nonpunitive purpose or [wa]s excessive in relation to that purpose’ to establish deliberate indifference.” See: Short v. Hartman, 87 F.4th 593 (4th Cir. 2023) (quoting Kingsley v. Hendrickson, 576 U.S. 389 (2015)). Applying the test enunciated in Short, the Court first asked whether Gunter had a serious medical condition. His heart condition qualified as “objectively serious.” Second, did “the defendant act or fail to act in the face of an unjustifiably high risk of harm that is either known or so obvious that it should be known?”

While Short clarified that, as a pretrial detainee, Gunter need not prove that each defendant had actual knowledge but only that they “should have known of that condition and risk,” in the instant case the record revealed that the SHP employees had actual knowledge of Gunter’s condition and medication needs. Finally, Gunter’s blood clots satisfied the third prong of the Short test.

That is, Short requires that a plaintiff “be harmed by the defendant’s action or inaction.” With regard to the Monell claim against Davie and Stokes Counties, the Court observed that “[l]ocal governing bodies (and local officials sued in their official capacities) can … be sued directly under § 1983 for monetary, declaratory, and injunctive relief in those situations where, as here, the action that is alleged to be unconstitutional implements or executes a policy statement, ordinance, regulation, or decision officially adopted or promulgated by those whose edicts or acts may fairly be said to represent official policy.”

“A policy or custom for which a municipality may be held liable can arise in four ways: (1) through an express policy, such as a written ordinance or regulation; (2) through the decisions of a person with final policymaking authority; (3) through an omission, such as a failure to properly train officers, that manifests deliberate indifference to the rights of citizens; or (4) through a practice that is so persistent and widespread as to constitute a custom or usage with the force of law.” See: Lytle v. Doyle, 326 F.3d 463 (4th Cir. 2003).

Additionally, a plaintiff must show that a municipality’s policies were “the moving force behind a deprivation of federal rights.” See: Washington v. Housing Auth. of Columbia, 58 F.4th 170 (4th Cir. 2023). In the instant case, both Davie County and Stokes County contracted with SHP “to provide for the delivery of all medical and dental services to inmates” at the DCDC and the SCDC. As such, those Counties may be held responsible for SHP’s “decisions.”

And “a governmental unit may create an official policy by making a single decision regarding a course of action in response to a particular circumstance so long as that governmental unit possessed final authority to create official policy.” See: Hunter v. Town of Mocksville, N. Carolina, 897 F.3d 538 (4th Cir. 2018).

The Counties’ “single course of action” in choosing to contract with SHP to provide medical care to their inmates “d[id] 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 rights.” See: West v. Atkins, 487 U.S. 42 (1988). The evidentiary record “suggest[ed] SHP had a custom and practice of taking days to get inmates their medication, and of not having a medical professional available to treat inmates during weekends…. A reasonable jury could find that these decisions were the ‘moving force’ behind Gunter not receiving adequate medical care and suffering serious injuries.”

Accordingly, the Court vacated the district court’s order granting summary judgment to the Defendants on the 14th-­Amendment-­deliberate-­indifference claim and the Monell claim and remanded for further proceedings. The Court also reversed the district court’s order granting summary dismissal of medical malpractice claims Gunter raised against SHP under North Carolina law. But because medical malpractice laws vary from state to state, readers are advised to read the instant opinion for the Court’s analysis.

A request for rehearing before the entire Fourth Circuit en banc was denied on December 16, 2025. Swink was represented before the Court by attorney David W. MacDonald of MacDonald Wright LLP in Greensboro. See: Swink v. So. Health Partners, Inc., 160 F.4th 438 (4th Cir. 2025); and 2025 U.S. App. LEXIS 32965 (4th Cir. 2025).  

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