Correctional Nurse Legal Briefs: Prison Litigation Reform Act (PLRA)

Recently I was contacted by the wife of an inmate about his poor medical care. He is currently in a state prison. She wanted to interest a legal firm in taking on the case and was wondering what information she would need to gather. One of the first things I asked was about the actions her husband had already taken to remedy the situation. For example, had he already requested treatments through the normal sick call process or submitted grievances about his medical care?

Legal recourse is a common place to go when inmates are not receiving needed healthcare. A 205 survey sited in this article found medical care to be the number one litigation topic in both jails and prisons.

The Prison Litigation Reform Act (PLRA) was passed in 1996 to require preliminary actions before a legal claim is heard by the court. This legislation was originally proposed to limit frivolous inmate lawsuits regarding their conditions of confinement and is limited to civil cases (not medical malpractice). See an earlier post on Section 1983 (Civil Rights) cases.

Key Points of PLRA

  • Exhaustion of Administrative Remedies – An inmate must first use the internal grievance system to the full extent (including any appeals process) before taking legal action on a claim
  • Mental or Emotional Injury – cannot be claimed without first showing physical injury
  • Screening and Dismissal – PLRA allows a case to be screened by the court and dismissed as frivolous even before the defense is required to reply.
  • Three-Strikes Clause – Upfront filing fees are generally waived or greatly decreased for inmates due to poverty. However, after three prior lawsuits dismissed as “frivolous, malicious, or failing to state a claim for relief”, this waiver is exhausted. Further filings will require the full fee be paid upfront.

The number of lawsuits filed by inmates greatly increased from 1970 to 1995. More than 40,000 inmate claims clogged the legal system in 1995. The PLRA aimed to reduce frivolous and unnecessary inmate lawsuits by creating some boundaries on the types and frequency of legal claims. Lawsuits filed by inmates have been reduced to around 25,000 per year.

What has been your experience with PRLA? Do you think it is a good idea?


Correctional Nurse Legal Briefs: Section 1983

Subpoenas have been issued at your jail for an inmate claim that his continuing headaches were ignored and he was denied necessary treatment of his ‘serious medical need’. Your risk manager and legal counsel will be meeting with staff members involved in the case, including nurses involved in triaging the sick call slips. They are referring to this as a Section 1983 case…..

Although all nurses should have an understanding of nursing malpractice and the legal basis of their profession, correctional nurses have an added need to understand law. When I first entered the specialty I knew little about the importance of various constitutional amendments or civil rights legislation and my work actions. When I first heard the term “1983 Case” I made a mental note to check out that year and see what had happened that was so important. I was in nursing school in 1983. That was a long time ago and I didn’t remember much that was going on. However, 1983 is not a year but a section of US Civil Rights Act of 1871. This act was created to protect those who were being harassed by the Ku Klux Klan following the Civil War. Section 1983 of this act is the means through which US citizens can bring forward a civil claim that their constitutionally protected rights have been violated.

Section 1983 legal claims include false arrest, unreasonable searches, equal protection, and excessive force. For correctional nursing practice, Section 1983 claims involve abridgement of the 8th or 14th Amendment to the constitution as it relates to health care provision of prisoners or detainees. In Estelle v Gamble (1976) the Supreme Court ruled that denial of adequate medical care constituted “cruel and unusual punishment” as was protected against by the 8th amendment to the constitution. Jail detainees are not yet prisoners being ‘punished’ and technically are not addressed in the 8th amendment. However, Bell v Wolfish (1979) established this same need of adequate healthcare for unconvicted detainees under the 14th amendment which protects due process for criminal conviction. In this case, the Supreme Court ruled that failure to provide medical care was a form of punishment imposed on an individual who had not been convicted of a crime. So, although unconvicted jail detainees and prison inmates have medical rights based on two different constitutional amendments, their medical care rights are essentially the same and legal claims of injustice are brought to court through Section 1983 of the Civil Rights Act.

So, a Section 1983 case is a civil rights case rather than a medical malpractice case and comes with a few peculiarities. Instead of looking to determine if the standard for nursing care was provided, a Section 1983 case is looking at the primary determinants of deliberate indifference to a serious medical need.  See my prior posts for more details on deliberate indifference and serious medical need. Although a Section 1983 case can be tried in either a state or federal court, plaintiff lawyers with background in these cases tend to lean toward federal courts as federal judges are receptive to claims of constitutional rights violations. Section 1983 claims also have a longer shelf-life as medical malpractice claims are governed by state law and can have a shorter timeframe for filing. In addition, plaintiff attorneys like Section 1983 cases because their fees, if they prevail, must be covered by the defendant (if reasonable). This element of the law allows for the pursuit of ‘smaller’ claims that might not otherwise be considered.

Have you heard the term ‘Section 1983’ or ‘1983 Case’ in your practice of correctional nursing? Share your experiences in the comments section of this post.

Photo Credit: © Matthew Benoit –

Correctional Nurse Legal Briefs: Understanding Deliberate Indifference

Inmate Barto is suing the medical director and nurses at your jail facility for not treating his leg ulcer that later developed osteomyelitis after release. He is charging deliberate indifference to his condition. While being confined to the jail for 10 days he did not mention the leg ulcer to any medical staff and left the facility before the required 14 day physical assessment. Does he have a case?


Unlike the majority of other nursing specialties, correctional nursing practice has been molded by the legal system. A body of judgments and class action cases has grown over the last four decades with escalation following the Supreme Court decision on Estelle vs. Gamble in 1976. Texas prisoner J. W. Gamble injured his back working on the prison farm. He contended he was not given medical treatment and even punished for his inability to work. His suit was against W. J. Estelle, then the director of the state department of corrections. The case moved through the lower courts and came before the Supreme Court where it was judged a violation of the Eighth Amendment’s prohibition of ‘cruel and unusual punishment’ to not provide necessary health care to prisoners. This court decision established the standard of ‘deliberate indifference to serious medical needs’ as a breach of the Eighth Amendment.

Deliberate Indifference

The term deliberate indifference seems almost an oxymoron. Can you really be deliberately indifferent to something? This created phrase, however, is in standard usage in correctional healthcare and needs understood as it relates to nursing practice. Deliberate Indifference defined: When a professional knows of, and disregards, an inmate’s serious medical need.

Components of deliberate indifference:
• There must be a serious medical need
• Staff must know about the serious need
• Staff must intentionally and deliberately fail to provide required treatment for that need
• This failure to treat caused the inmate unneeded pain or suffering or similar harm

In the case above, staff were not aware of the leg ulcer while Mr. Brown was in custody and there is no indication that staff deliberately or intentionally refused to treat his condition. It is unlikely that his case will prevail.

Serious Medical Need

This phrase in the court decision also need consideration. A serious medical need Is one that, if left untreated, has a risk of serious harm to the patient and can be one of two categories:

• Diagnosed by a physician as requiring treatment
• Is a need so obvious that even a lay person would know it needed medical attention

Again, the case above does not meet either of the standards for serious medical need. Claims of this type are more common than you might think in our particular clinical specialty. Have you been named in a correctional lawsuit of this type? Most are brought by the inmate without legal counsel and are referred to as ‘pro se’ cases.

Some information in this post was obtained from a presentation by Stacy M. Blackman, Esq., Chief Legal Officer, CorrectHealth Companies, during a session of the 2012 ACHSA conference in San Antonio, TX.

Photo Credit: © Matthew Benoit –

Top Correctional Health Care News from 2010

Top Correctional Health Care News from 2010This article was originally published by

Editor’s note: This article is part of the 2010 CorrectionsOne End of the Year Report. Please visit the main page for the end of the year report here.

Several correctional health care news stories top the list as we near the end of the first decade of the 21st century. These stories define the year past and help frame the year ahead. Here are my picks for the top four news stories in correctional health care this year.

#1 – California Prison System at the Bench
California’s Prison system (CDRC), the largest in the nation at over 150,000 inmates, has been embroiled in a legal battle that spans two decades and culminated in a hearing by the Supreme Court this fall. At issue is the flagging healthcare provided by the CDRC. Prior court rulings have focused on reducing the prison population in order to allow for better provision of healthcare based on available resources. But a solution to the California case requires creativity. Balance is needed between the demand for public safety and the necessity for humane treatment of inmates. Every state and county system is struggling to maintain this balance as trends show an increasing healthcare burden in the correctional system.

Why is this important? Although seems like a local issue, the final decision on the constitutionality of the healthcare delivered to this state’s prison population will affect all US correctional systems. Correctional healthcare practices have been court-driven since the landmark 1976 Estelle v. Gamble, when the Supreme Court ruled that lack of medical care constituted cruel and unusual punishment prevented by the 8th Amendment. Since that time, case law has fleshed out the parameters of required medical and mental health care for citizens behind bars.

#2 – It’s All in Your Head
Mental health takes the number two slot this year with increasing reports of deficient mental health care in jails and prisons across the country. Social advocates suggest that, too often, America has decided to criminalize mental conditions rather than treat them. This year, a national report chronicled the distressing news that our largest mental health facilities are now jails. Mental health care is expensive, requiring increased staff support and medications. Seriously mentally ill inmates are a management issue and can be extremely difficult to handle in the general population. Small facilities are particularly vulnerable to these challenges. As the inmate population ages (See news story #3 below) new concerns such as dementia and organic brain disease emerge. Add to this mix the growing awareness of Post Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) as contributing factors to criminality, and we have the makings of a major news story for this year and the next.

Why is this important? Our society and our corrections systems must grapple with how to handle mental illness as a component of criminal activity. Custody officers need to understand underlying mental illness to effectively manage inmate behavioral problems. Specialized mental hospitals, closed in the 1980’s, may be revitalized to handle nonviolent mentally ill offenders. Mental health courts are advocated in many sectors.

#3 – Another Day Older and Deeper in Debt
It is no secret that the US inmate population is getting older, and inmate population statistics show marked growth in the over-50 segment. The PEW report, published a little over a year ago, documents aged federal prison inmates as a third of total population. Similar numbers exist at state and local facilities. This year, much media attention was placed on the high cost of caring for elder inmates and possible options for alleviating the financial burden or creatively managing their health care. From sea to shining sea, correctional systems are adding assisted living complexes, in-prison oncology units and hospice facilities. Some systems are looking at ways to reduce the burden of end-of-life medical care, such as relaxing medical parole requirements.

Why is this important? Managing aging inmates with increasing chronic conditions and terminal illness will consume a greater portion of resources in coming years. This may mean expanding medical units, building specialized facilities for older inmates, or creatively involving community services to provide needed care.

#4 – Suicides are Down!
After years of effort and attention, suicides in US jails are down and prisons suicides remain at a low. A national study, released this year by the National Center for Institutions and Alternatives (NCIA), documents a near three-fold decrease in jail suicide rate from 20 years prior. This extraordinary improvement is attributed to increased awareness, staff training and enhanced intake assessment of vulnerable detainees. Prison suicide rates have remained stable at 15 per 100,000, only slightly higher than the general population figures (11 per 100,000).
Why is this important? This significant decrease in jail suicides and stability of a low rate of prison suicides indicates that prevention efforts are working. With all the bad news we read over the course of a year, it is a delight to see positive change in a significant health and legal risk. Of course, there is always room for improvement. The jail study findings indicate a shift in suicide attempts from the first 24 hours to the 2-14 day period of confinement. It is recommended that further prevention efforts focus on this time period.

The coming New Year promises to continue to provide significant correctional health care news. We live in most interesting times!

Is there a significant correctional healthcare news story I missed? Add your picks to the comments on this post.

Legal History of Correctional Nursing – Part I

Where were you in November, 1976? Maybe not even born yet…but probably not thinking about healthcare in prisons and jails. However, November, 1976 could be deemed the official start of the profession of correctional nursing. This is the date of the landmark Estelle v GambleSupreme Court decision which established heathcare as a constitutional right for US inmates based on the 8th Amendment (Cruel and Unusual Punishment).

According to Mary Muse, RN, MSN, in an article on the Evolution of Correctional Nursing Practice published in CorrectCare, organized correctional healthcare was rare. “Before the 1970s, much inmate health care was provided by other inmates, correctional officers and the occasional physician. The first documentation of correctional nursing may be a 1975 article by Rena Murtha, a director of nursing for a large correctional system. In her account, nurses were “a tool of the warden, a slave of the physician and an unknown to the patient.”

The Estelle v Gamble ruling established three basic rights for inmates because they are not free to seek care on their own.

#1 – The right to access to care

This is the primary and fundamental right established by the court decision. There must be capacity to deal with medical emergencies and provide needed healthcare, including continuation of medical management established prior to incarceration.

#2 – The right to care that is ordered

As a follow-up to access to care, once treatment is ordered by a health care professional, that care is to be provided without undue delay.

#3 – The right to a professional medical judgement

The concept of access to care involve the nature and timing of the care such that is is provided by qualified individuals using appropriate equipment, in conducive locations, and for purely medical reasons. Rold, in his excellent article “Thirty Years After Estelle v. Gamble: A Legal Retrospective”citres as example a 1974 case in which an inmate with a severed ear was treated by having the ear removed and the stump stitched.

The establishment of these three basic healthcare rights for US inmates became the foundation of healthcare delivery and therefore nursing practice in the corrections environment.