Swink v. Southern Health Partners: Objective Deliberate Indifference, Monell Liability for Contracted Jail Healthcare, and Expert Causation

I. Introduction

In Juliana Swink v. Southern Health Partners, Inc., the Fourth Circuit issued a published decision that significantly clarifies three important strands of law at the intersection of constitutional rights, jail medical care, and state medical malpractice:

• How Kingsley and Short v. Hartman’s objective standard for pretrial detainees’ claims applies to jail medical care and deliberate indifference.
• When counties that contract out jail healthcare to private vendors (like Southern Health Partners, “SHP”) can face Monell liability for those vendors’ practices.
• How federal courts should treat medical expert causation testimony and related evidentiary issues at the summary judgment stage in North Carolina medical malpractice suits.

The case arises from the medical treatment (and lack thereof) provided to David Ray Gunter, a pretrial detainee with a mechanical heart valve who required daily Coumadin (warfarin) and careful INR monitoring. During a roughly two-week period in county jails, he missed multiple doses and never reached a therapeutic INR. Within days of release he suffered serious blood clots requiring multiple surgeries. His estate, through administratrix Juliana Swink, sued:

• Medical Appellees: Southern Health Partners (SHP) and its personnel (nurses Fran Jackson and Sandra Hunt, PA Manuel Maldonado, Medical Director Dr. Junkins).
• Public Appellees: Davie County, Stokes County, certain county officials, and sureties.

The district court granted summary judgment to all defendants, principally on the ground that there was no constitutional “deliberate indifference” and no admissible expert evidence of causation for the state-law medical malpractice claims. On appeal, the Fourth Circuit (Judge Gregory writing, joined by Judge Benjamin; Judge Richardson concurring in part and dissenting in part) reversed substantial portions of that judgment.

This commentary explains the decision’s structure, the competing opinions, and the broader doctrinal and practical consequences, particularly for:

• Pretrial detainee medical-care claims under the Fourteenth Amendment.
• County liability when they rely on private correctional healthcare companies.
• Expert testimony and causation in North Carolina medical malpractice litigation.

II. Summary of the Opinion

A. Core Factual Background

Gunter had a mechanical aortic valve placed at age 15 and required lifelong anticoagulation with Coumadin to keep his INR within a therapeutic range (2.5–3.5). Before his November 2012 arrest:

• He had been followed at a specialized Coumadin clinic by Dr. Virginia Yoder.
• He struggled with transportation and was discharged from that clinic in May 2012, but continued to obtain Coumadin, including via emergency pharmacy fills and informal arrangements.

After arrest on November 6, 2012, Gunter cycled through three county facilities. The relevant period is his time in:

• Davie County Detention Center (DCDC): Intake by SHP nurse Fran Jackson, consultation with SHP PA Manuel Maldonado, initial delay in restarting Coumadin, and a late INR check showing a dangerously low INR of 1.07.
• Stokes County Detention Center (SCDC): Weekend arrival after SHP nurse Sandra Hunt had left; no nurse physically present; no Coumadin for three days; then partial dosing per Maldonado’s alternating regimen; no discharge medication plan.

Throughout this period, Gunter missed multiple Coumadin doses, had sub-therapeutic INR, and was not bridged with Lovenox. Eight days after release, he was admitted with abdominal pain, found to have a blood clot requiring bowel surgery, and later suffered a second clot requiring further resection.

B. Procedural Posture

In his Second Amended Complaint, Gunter alleged, among other things:

• § 1983 deliberate-indifference claims under the Fourteenth Amendment against both Medical Appellees and Public Appellees.
• Monell claims against Davie and Stokes Counties.
• North Carolina medical malpractice claims against SHP, Jackson, and Maldonado.

The district court:

• Granted summary judgment to Public Appellees on the constitutional and Monell claims.
• Granted summary judgment to SHP on medical malpractice for lack of expert proof that SHP as an entity violated a standard of care.
• Found factual disputes as to breach of the standard of care by Jackson and Maldonado but held plaintiff had no admissible expert causation evidence, and thus granted summary judgment to them on the med-mal claims.
• Rejected the deliberate-indifference claim against Medical Appellees for essentially the same reasons as the claim against Public Appellees.
• Granted the Medical Appellees’ motion to strike a post-deposition declaration by plaintiff’s expert Dr. Damian Laber as contradicting his deposition.
• Denied Gunter’s motion to compel a deposition of defense expert Dr. Julie Sease as untimely.

C. Holdings on Appeal

The Fourth Circuit:

1. Deliberate Indifference (Fourteenth Amendment)
   • Held that, under Short v. Hartman and Kingsley, pretrial detainees like Gunter are governed by an objective reasonableness standard, not the prior subjective “actual knowledge” standard used by the district court.
   • Concluded that, on the existing record, Gunter had presented sufficient evidence to proceed against the Medical Appellees on his Fourteenth Amendment deliberate-indifference claim; summary judgment for them was error.
2. Monell Liability (Davie and Stokes Counties)
   • Held that the Counties’ contracts with SHP delegated final authority over inmate medical care to SHP, so SHP’s practices could constitute County “policy” for Monell purposes.
   • Found a genuine dispute of fact as to whether SHP had customs such as multi-day delays in providing prescribed medications and lack of weekend medical coverage, and whether those customs were the “moving force” behind Gunter’s injuries.
   • Vacated and remanded the Monell claims against Davie and Stokes Counties for further proceedings.
3. Medical Malpractice (North Carolina Law)
   • Reinstated Gunter’s med-mal claim against SHP, holding that under North Carolina’s nondelegable duty doctrine, SHP is an agent of the state for purposes of providing medical care in jail and can be liable (under respondeat superior) for its employees’ negligent acts.
   • Held that the district court abused its discretion in excluding key causation evidence:
     • Evidence of Gunter’s access to medication and anticoagulation status before incarceration (pharmacy records, emergency fills, clinic fax).
     • Expert causation testimony from Dr. Yoder and Dr. Laber, which the district court wrongly labeled speculative and insufficiently “certain.”
     • Dr. Laber’s post-deposition declaration, which the court held did not contradict his deposition and thus should not have been struck as a “sham.”
   • Because that evidence, if credited, would allow a reasonable jury to find proximate causation, the court reversed summary judgment on the med-mal claims against Jackson and Maldonado and against SHP on a vicarious liability theory.
4. Discovery Motion
   • Affirmed the denial of Gunter’s motion to compel the deposition of defense expert Dr. Sease as untimely, finding no abuse of discretion.

Judge Richardson agreed that Short required reconsideration of the deliberate-indifference claim against Jackson and Maldonado and that expert causation testimony was wrongly excluded, but he:

• Would have remanded the deliberate-indifference claim for the district court to apply Short in the first instance rather than the majority’s more direct application.
• Would have affirmed dismissal of the Monell claims against the Counties, viewing plaintiff’s arguments as improperly attempting to impose respondeat superior liability on the Counties.
• Would have treated the vicarious med-mal claim against SHP as waived because he read the complaint as not having clearly pleaded respondeat superior against SHP.

III. Precedents and Authorities Cited

A. Constitutional Standards for Pretrial Detainees

• Kingsley v. Hendrickson, 576 U.S. 389 (2015)
  • Held that excessive-force claims by pretrial detainees are governed by an objective standard of reasonableness under the Fourteenth Amendment, not the Eighth Amendment’s subjective standard.
• Short v. Hartman, 87 F.4th 593 (4th Cir. 2023), cert. denied, 144 S. Ct. 2631 (2024)
  • Extended Kingsley to deliberate-indifference claims by pretrial detainees, including medical-care claims.
  • Articulated the governing test: the detainee must show a serious medical condition, that the defendant’s actions were objectively unreasonable in face of a risk that was known or so obvious it should have been known, and that the detainee was harmed.
• Farmer v. Brennan, 511 U.S. 825 (1994)
  • Established the Eighth Amendment’s subjective “deliberate indifference” standard for convicted prisoners—actual knowledge and disregard of a substantial risk of serious harm.

B. Monell and Municipal Liability

• Monell v. Department of Social Services, 436 U.S. 658 (1978)
  • Municipalities are not liable under § 1983 on a respondeat superior theory, but can be liable when an official “policy or custom” is the moving force behind a constitutional violation.
• Lytle v. Doyle, 326 F.3d 463 (4th Cir. 2003) and Carter v. Morris, 164 F.3d 215 (4th Cir. 1999)
  • Identify four recognized pathways to a “policy or custom”: express policy, decision by a final policymaker, deliberate indifference evident in omissions (e.g., failure to train), and persistent and widespread practices amounting to custom.
• Washington v. Housing Authority of Columbia, 58 F.4th 170 (4th Cir. 2023)
  • Emphasizes that municipal liability requires the policy or custom to be the “moving force” behind the constitutional deprivation.
• Hunter v. Town of Mocksville, 897 F.3d 538 (4th Cir. 2018)
  • Confirms that a single decision by a final policymaker can constitute official policy for Monell liability.
• West v. Atkins, 487 U.S. 42 (1988)
  • Holds that physicians under contract to provide medical services to prisoners act under color of state law, and that contracting out medical care does not relieve the state of its constitutional duty.
• King v. Kramer, 680 F.3d 1013 (7th Cir. 2012)
  • Held that a county could be liable where its contracted medical provider’s policies and practices led to inmates being “off prescribed medications without appropriate oversight,” a key analogy used by the Fourth Circuit.

C. North Carolina Medical Malpractice and Agency

• Weatherford v. Glassman, 129 N.C. App. 618 (1998)
  • Sets out the elements of medical malpractice in North Carolina: standard of care, breach, proximate cause, and damages.
• Medlin v. Bass, 327 N.C. 587 (1990)
  • Addresses respondeat superior: an employer may be liable for an employee’s torts committed within the scope of employment, in furtherance of the employer’s business.
• Medley v. N.C. Department of Correction, 330 N.C. 837 (1992)
  • Holds that providing adequate medical care to incarcerated persons is a nondelegable duty of the state.
  • Independent contractors engaged to perform that duty may be considered agents of the state for liability purposes.
• State v. Wilson, 183 N.C. App. 100 (2008)
  • Reinforces the principle that governmental entities retain responsibility for providing medical care to prisoners.

D. Federal Procedure and Evidence

• Anderson v. Liberty Lobby, Inc., 477 U.S. 242 (1986)
  • Clarifies that at summary judgment courts must not weigh evidence or assess credibility; they ask whether there is a genuine dispute on material facts for a jury to resolve.
• Guessous v. Fairview Property Investments, LLC, 828 F.3d 208 (4th Cir. 2016); Jacobs v. N.C. Administrative Office of the Courts, 780 F.3d 562 (4th Cir. 2015)
  • Reinforce the prohibition on weighing evidence and making credibility determinations at the summary judgment stage.
• Fed. R. Evid. 703 & Advisory Committee Note
  • Allow experts, including physicians and pharmacists, to base opinions on patient histories and a variety of sources reasonably relied upon in their field.
• Spriggs v. Diamond Auto Glass, 242 F.3d 179 (4th Cir. 2001)
  • Explains the limited “sham affidavit” rule: only clear-cut, bona fide inconsistencies justify striking a later declaration that contradicts earlier deposition testimony.
• Spencer Medical Associates v. Commissioner, 155 F.3d 268 (4th Cir. 1998)
  • Supports denying untimely discovery motions; mere lateness alone can justify denial.

IV. Legal Reasoning and Doctrinal Analysis

A. Objective Deliberate Indifference Under the Fourteenth Amendment

1. From Farmer to Kingsley to Short

For convicted prisoners, deliberate-indifference claims have long been governed by Farmer v. Brennan’s subjective test: the official must actually know of and disregard an excessive risk to inmate health or safety. Before Short, many courts applied this same test to pretrial detainees’ medical-care claims under the Fourteenth Amendment.

Kingsley (2015) broke from this by holding that pretrial detainee excessive-force claims are governed by an objective reasonableness standard. In Short v. Hartman (2023) the Fourth Circuit extended that approach to deliberate-indifference claims by pretrial detainees, including medical-care claims. Under Short, a pretrial detainee must show:

1. An objectively serious medical condition.
2. That the defendant acted or failed to act in the face of a risk of serious harm that was known or so obvious it should have been known, and that the conduct was objectively unreasonable.
3. That the detainee was harmed by that conduct.

Critically, the plaintiff need not show the official’s actual subjective awareness of the risk—only that the risk would have been apparent to a reasonable officer or provider.

2. District Court’s Error and the Fourth Circuit’s Application

The district court, ruling before Short, required Gunter to prove that the Medical Appellees were subjectively aware of and deliberately chose to ignore his medical needs. It concluded there was no evidence Jackson, Maldonado, or other SHP staff intended to deprive him of care, and thus granted summary judgment.

Applying Short, the Fourth Circuit held this was the wrong legal standard. It then went further than Short itself did; rather than simply remanding for the district court to reapply the correct test, the majority applied the objective deliberate-indifference standard directly:

• Serious medical condition: A mechanical heart valve plus the need for continuous anticoagulation is paradigmatically serious. Both the risk of clotting (if under-anticoagulated) and of catastrophic bleeding (if over-anticoagulated) are severe.
• Objective unreasonableness / obvious risk:
  • Jackson’s intake notes and the faxed clinic record acknowledged that Gunter was on Coumadin for his valve and that 7 mg/day was typical for him.
  • Maldonado knew Gunter was on Coumadin and ordered an INR test (showing 1.07—far below therapeutic) but still structured an alternating dose schedule and did not employ rapid-acting bridging anticoagulation.
  • At SCDC, Hunt knew he had a mechanical valve and was on Coumadin yet no Coumadin was provided for three days because there was no nurse physically present and the jail had no weekend coverage process that ensured continuation of prescribed medications.
• Harm: Within days of this period of under-anticoagulation, Gunter developed life-threatening clots requiring bowel resections.

The majority stressed a key principle:

“No legitimate nonpunitive goal is served by a denial or unreasonable delay in providing medical treatment where the need for such treatment is apparent.”

On that basis, the court held that a reasonable jury could find that SHP personnel acted in the face of an obvious, unjustifiably high risk of serious harm by not ensuring continuous Coumadin dosing, timely INR checks, and bridging anticoagulation. Thus, summary judgment for the Medical Appellees on the Fourteenth Amendment claim was improper.

Judge Richardson agreed that Short changed the governing law but would have remanded rather than have the appellate court apply the objective test to the record in the first instance.

B. Monell Liability for Counties that Contract Out Jail Medical Care

1. Delegation to SHP as “Policy” of the Counties

Under Monell, municipalities can only be liable when a constitutional violation is caused by their own policy or custom. Mere employment (or contracting) of a tortfeasor is not enough. The key question here: does a county’s decision to contract with a private healthcare provider like SHP, and empower that provider to run all inmate medical care, create a Monell-qualifying “policy” such that the county is responsible for SHP’s systemic practices?

The Fourth Circuit answered yes, aligning with approaches like the Seventh Circuit’s in King v. Kramer:

• The contracts showed that Davie and Stokes Counties expressly delegated to SHP final authority “to provide for the delivery of all medical, dental and mental health services to inmates” at their jails.
• In this posture, SHP’s decisions about staffing, medication procurement, and weekend coverage are effectively county policy in the Monell sense, because the counties chose to let SHP act as the final decision-maker in that domain.

Thus, SHP’s decisions and customs could ground county liability if they were the “moving force” behind Gunter’s injuries.

2. Evidence of SHP Practices and Causation

The court highlighted evidence that:

• SHP often took days to get medications to inmates even when the need was known.
• SHP did not ensure a nurse or qualified medical provider was available on weekends to evaluate and medicate incoming detainees.
• Although emergency medication orders from local pharmacies were possible, this was not standard procedure, and in Gunter’s case no such emergency ordering occurred despite known need for Coumadin.

Drawing on King v. Kramer, the majority reasoned that a jury could find those SHP practices led to detainees being “off prescribed medications without appropriate oversight.” That, in turn, could be found to be the “moving force” behind Gunter’s under-anticoagulation and subsequent clotting.

Judge Richardson dissented on this point. He viewed plaintiff’s Monell theory as an impermissible attempt to impose respondeat superior liability on the Counties for SHP’s errors. He would have required clearer evidence that county policymakers themselves adopted or ratified unconstitutional policies (as opposed to merely hiring SHP), and thus would have affirmed summary judgment on the Monell claims.

C. Medical Malpractice Against SHP: Nondelegable Duty and Agency

1. North Carolina’s Nondelegable Duty in Correctional Healthcare

Under Medley and related cases, North Carolina recognizes that government entities have a nondelegable duty to provide adequate medical care to incarcerated persons. Even if they hire an independent contractor, the responsibility remains. In this framework:

• An entity like SHP, hired to fulfill the government’s nondelegable duty, is treated as an agent of the state or county for that function.
• Acts of SHP’s employees in furnishing medical care in the jail are thus legally imputed to the government, or—conversely—SHP may be held vicariously liable under a respondeat superior theory for its employees’ negligent acts.

Applying this, the Fourth Circuit held:

• Davie and Stokes Counties had a nondelegable duty to provide medical care at their jails.
• They contracted that duty to SHP, making SHP an agent of the state as a matter of law for purposes of delivering jail medical care.
• Accordingly, SHP can be held liable under North Carolina medical malpractice law for negligent acts of its personnel who were acting within the scope of their duties for SHP.

2. Pleading and Waiver

Judge Richardson argued that the plaintiff had not clearly pleaded a respondeat superior med-mal theory against SHP and thus had waived that theory on appeal. The majority rejected this:

• The Second Amended Complaint expressly alleged a medical malpractice claim against SHP, noted that SHP was authorized to do business in North Carolina, and detailed how SHP contracted to provide jail medical services and then provided substandard care through its staff.
• These allegations were sufficient to put SHP on notice of a vicarious malpratice theory based on acts of its employees in the scope of that contractual relationship.

Thus, the court restored the med-mal claim against SHP premised on respondeat superior for Jackson’s and Maldonado’s alleged breaches of the medical standard of care.

D. Medical Malpractice Against Jackson and Maldonado: Proximate Causation

1. The District Court’s Approach

The district court accepted that Gunter had evidence of standard-of-care breaches by Jackson and Maldonado but found he failed to show that those breaches were the proximate cause of his blood clots and bowel injuries. It did so primarily by:

• Deeming evidence of Gunter’s pre-incarceration medication history “inadmissible” or unpersuasive.
• Characterizing Dr. Yoder’s and Dr. Laber’s causation opinions as speculative and not advanced with a “reasonable degree of medical certainty.”
• Excluding Dr. Laber’s supplemental declaration as a “sham” that contradicted his deposition.

Once that evidence was stripped away, the court concluded plaintiff lacked expert proof that the jail care caused the clots, and it granted summary judgment.

2. Pre-incarceration Medication Evidence and the Faxed Record

The Fourth Circuit held that the district court’s handling of the pre-incarceration evidence reflected prohibited weighing of evidence and resolution of factual disputes at summary judgment:

• Pharmacy records showed Gunter consistently filled his prescription in June–August 2012 and obtained several emergency fills thereafter. Combined with his testimony about leftover medication and informal doctor assistance, this evidence could support a jury inference that he was therapeutically anticoagulated when arrested.
• The district court instead credited defense expert Dr. Sease’s view that Gunter was not therapeutically medicated, labeling her opinion “unrebutted”—an improper credibility judgment at summary judgment.

Similarly, the clinic fax Jackson received on November 8, 2012, though not a formal prescription, stated that Gunter reported taking 7 mg of warfarin daily. The district court dismissed it as not proving that the clinic formally prescribed 7 mg or “specifically communicated” a 7 mg order to Jackson, and thus as irrelevant to causation.

The Fourth Circuit disagreed. Even if the fax did not prove a prescription, it was relevant because:

• Jackson received it the same day she consulted Maldonado about dosing.
• It tended to show that 7 mg was Gunter’s typical self-reported daily dose, information a reasonable nurse would consider highly material when consulting a PA on how to dose a mechanical-valve patient whose INR would not be checked for days.
• If Jackson ignored that information and allowed a lower dose (5 mg) to be ordered without closer monitoring or bridging, a jury could find this was part of the causal chain leading to under-anticoagulation and clotting.

3. Expert Testimony from Dr. Yoder

The district court deemed Dr. Yoder’s testimony speculative because she “assumed” Gunter was properly anticoagulated prior to incarceration, could not quantify Gunter’s percentage of fault, and supposedly rested primarily on a temporal association between incarceration and clotting.

The Fourth Circuit rejected each of these critiques:

• Assumption of compliance: Dr. Yoder had treated Gunter for years in a professional capacity. She testified she knew him to be consistently compliant with his Coumadin (“he has always taken his medication,” she had “never known him to just be off it”). This was not guesswork but a professional judgment grounded in her longitudinal clinical experience, permissible under Rule 703.
• Percentage of fault: When pressed by defense counsel to assign a numerical percentage of comparative fault to Gunter, she demurred, explaining that anticoagulation is “all about trends” and that she could not meaningfully convert that into a percentage. The Fourth Circuit rightly characterized this as both:
  • Irrelevant to whether she could opine with a reasonable degree of medical certainty about proximate causation (experts are not required to assign percentages), and
  • A legal, not medical, question (apportionment of fault), which should not be used to impeach her medical opinion.
• Beyond temporal correlation: Dr. Yoder’s causation opinion was based on multiple factors:
  • Her knowledge of Gunter’s historic medication adherence.
  • The number and pattern of missed doses in jail.
  • Lack of therapeutic INR and lack of bridging with Lovenox.
  • The timing and progression of symptoms and hospitalization.
  Temporal proximity was one factor, but not the only one; she was not simply equating correlation with causation.

In short, the court held she testified with a reasonable degree of medical certainty and that excluding her opinion was an abuse of discretion.

4. Expert Testimony from Dr. Laber

The district court similarly discredited Dr. Laber’s testimony because he could not pinpoint the exact time the clot formed, could not numerically quantify risk increases from missing specific numbers of doses, assumed pre-jail anticoagulation, and relied on the temporal relationship between under-anticoagulation in jail and clotting.

The Fourth Circuit again disagreed:

• Timing of clot formation: It is rarely possible in medicine to specify the exact moment a clot forms. Dr. Laber testified, consistent with medical reality, that clot formation is a process and likely occurred days or weeks before hospitalization, based on clinical and imaging findings. That level of specificity is commonly accepted as sufficient for expert causation testimony.
• Risk quantification: He testified that the risk of clotting increases exponentially the longer a patient’s INR remains below therapeutic, and noted that Gunter’s INR was never therapeutic during his incarceration. He was not required to produce a formula quantifying the risk increase for each missed day.
• Pre-incarceration anticoagulation: Like Dr. Yoder, he was entitled to rely on patient history and the supporting record in inferring that Gunter generally took his Coumadin before jail. In any event, the evidence of severe under-anticoagulation during incarceration could support a causation opinion regardless of his exact status on the arrest date.
• Temporal proximity with known mechanism: The majority implicitly endorsed a key evidentiary principle: where there is a well-understood causal mechanism (mechanical valve + prolonged under-anticoagulation → clot formation), temporal proximity between that under-anticoagulation and the onset of clot-related symptoms is probative of causation. It is not mere correlation when the medical literature and clinical experience recognize that temporal pattern as causally significant.

Thus, excluding Dr. Laber’s testimony was likewise an abuse of discretion.

E. The Laber Declaration and the “Sham Affidavit” Rule

After his deposition, Dr. Laber executed a declaration that emphasized that Gunter was “underdosed and/or not provided medication for nearly the entirety of his incarceration.” The district court struck this declaration as offering a new, inconsistent causation theory (underdosing), distinct from his deposition theory (allegedly “lack of anticoagulation generally”).

The Fourth Circuit held this was error under Spriggs:

• The declaration did not contradict but merely elaborated on his deposition testimony, in which he had already spoken about missed and insufficient doses (“some days were skipped. Some days were underdosed.”).
• The “lack of anticoagulation” in deposition plainly referred to lack or inadequacy of anticoagulation therapy (medication and monitoring), not some different mechanism.
• Therefore, there was no “clear-cut” bona fide inconsistency, and the sham affidavit rule did not apply.

The declaration should have been admitted as part of the summary judgment record.

F. Discovery Motion: Denial of Motion to Compel

Finally, the court affirmed the denial of Gunter’s motion to compel the deposition of defense expert Dr. Sease:

• The motion was filed 11 days after the close of discovery, following two prior extensions.
• The district court found no “excusable neglect” and noted it might have ruled differently had the motion been timely.

The Fourth Circuit held this was a classic exercise of discretion under Spencer Medical Associates; tardiness alone can justify denial, and nothing in the record indicated an abuse of that discretion.

V. Complex Concepts Simplified

A. Pretrial Detainees vs. Convicted Prisoners

• Pretrial detainees have not been convicted and are held under the Due Process Clause of the Fourteenth Amendment. The constitutional question is whether the government’s actions are reasonably related to a legitimate, nonpunitive objective.
• Convicted prisoners are protected by the Eighth Amendment. Claims of inadequate medical care require showing subjective deliberate indifference (actual knowledge and disregard of a substantial risk).
• In Swink, Gunter was a pretrial detainee, so the objective reasonableness standard of Kingsley/Short applies, not the subjective Farmer standard.

B. Deliberate Indifference (Objective Version)

Under the Short standard for pretrial detainees:

• It is not necessary to prove that a nurse or PA actually knew about the full extent of the medical risk.
• It is enough if the risk was so obvious—as with a mechanical heart valve and known need for anticoagulation—that a reasonable professional should have known and acted differently.
• Discontinuous medication or prolonged delay in known necessary care can be “objectively unreasonable” where it serves no legitimate nonpunitive purpose.

C. Monell Liability

Some key concepts:

• Policy or custom: An official rule, a widespread practice, a decision by a final policymaker, or a failure to train/supervise that shows deliberate indifference.
• Moving force: The policy or custom must causally drive the constitutional violation; there must be a real connection, not just background noise.
• Delegation to private providers: When a county gives a private entity like SHP final authority over inmate medical care, and that entity adopts systemic practices that unreasonably delay or deny necessary care, those practices can be treated as county policies for Monell purposes.

D. Nondelegable Duty and Respondeat Superior in Jail Healthcare

• A nondelegable duty means the government is responsible for ensuring performance of a duty even if it hires a contractor to carry it out. It cannot avoid liability by outsourcing.
• Under North Carolina law, correctional medical care is such a duty. A contractor like SHP is treated as an agent for that purpose.
• Under respondeat superior, an employer (or principal) is liable for torts committed by its employees (or agents) within the scope of their employment, in furtherance of the employer’s business.

E. Proximate Cause and “Reasonable Medical Certainty”

• In medical malpractice, the plaintiff must show the defendant’s breach was a proximate cause of the injury—i.e., a cause that, in natural and continuous sequence, produced the harm.
• Experts express this in terms of “reasonable medical certainty” or “probability”—that the defendant’s conduct was more likely than not a cause of the injury; they do not have to eliminate every other possible cause.
• Experts may rely on patient history, clinical records, known medical mechanisms, and the timing of events to form these opinions.

F. Sham Affidavits and Summary Judgment

• At summary judgment, courts must decide whether a reasonable jury could find for the non-moving party on the evidence, not whether the judge believes the evidence.
• A later affidavit that directly contradicts clear deposition testimony without explanation may be disregarded as a “sham” meant to fabricate a dispute. But minor clarifications, elaborations, or consistent restatements are permissible.

VI. Impact and Broader Significance

A. Constitutional Litigation and Jail Healthcare

• Reinforces Short: Swink operationalizes Short v. Hartman by squarely applying the objective reasonableness standard to a classic medical-care scenario, signaling to district courts that pretrial detainee medical claims are not to be run through a subjective Farmer lens.
• Lower bar to trial: Plaintiffs in the Fourth Circuit alleging inadequate jail medical care as pretrial detainees will find it easier to survive summary judgment where the record shows:
  • a clearly serious medical condition,
  • documented knowledge of that condition by jail medical staff, and
  • unjustified delays or lapses in obvious necessary treatment.
• Increased scrutiny of contracted healthcare: Private correctional healthcare companies and their county clients should expect closer judicial scrutiny of practices like weekend staffing gaps, medication delays, and inflexible bureaucratic hurdles to continuing prescribed medications.

B. County Liability Strategies

• Counties in the Fourth Circuit can no longer assume that contracting with a private correctional healthcare vendor insulates them from Monell liability. Delegating final authority over inmate medical care makes the vendor’s systemic practices potential county “policy.”
• Practically, counties should:
  • Review vendor contracts to ensure clear expectations regarding 24/7 coverage, emergency medication procurement, and intake/transfer procedures.
  • Monitor vendor performance and consider corrective measures where patterns of delay or denial emerge.

C. North Carolina Medical Malpractice Practice

• Expanded potential defendants: Swink confirms that private jail healthcare providers like SHP can be held liable in North Carolina medical malpractice actions via respondeat superior for negligent acts of their jail-based staff.
• Pleading guidance: Plaintiffs should clearly:
  • Identify the contractual relationship between the county and provider,
  • Allege that the provider’s staff acted within the scope of that relationship, and
  • Allege specific breaches and resulting injuries.

D. Expert Evidence and Summary Judgment Culture

• Reining in over-aggressive Daubert at summary judgment: The opinion sends a strong signal that trial courts should be cautious about excluding medical causation experts as “speculative” when their opinions are grounded in accepted medical reasoning, even if the record is incomplete or contested.
• Recognition of temporal analysis: It implicitly endorses the idea that temporal proximity plus a well-understood causal mechanism is legitimate evidence of proximate cause—not mere correlation.
• Respecting patient history: By emphasizing Rule 703 and the normal reliance of physicians on patient and family reports, the court reinforces that expert testimony need not rest exclusively on perfect documentary records to be admissible.

VII. Conclusion

Swink v. Southern Health Partners marks an important elaboration of three converging bodies of law in the Fourth Circuit:

• It confirms that pretrial detainees’ medical-care claims are governed by an objective deliberate-indifference standard under the Fourteenth Amendment, and it applies that test in a detailed, fact-intensive healthcare context.
• It clarifies that counties cannot contract away constitutional and tort responsibility for jail medical care: when they give private providers final authority, they potentially assume Monell exposure for the provider’s systemic practices, and under North Carolina law those contractors function as agents for purposes of a nondelegable duty.
• It reaffirms that medical expert causation testimony—grounded in clinical experience, patient history, known mechanisms, and reasonable inference—belongs before a jury, not terminated at summary judgment through overly stringent evidentiary gatekeeping.

For litigants and courts in the Fourth Circuit, Swink underscores a simple but profound theme: when the state confines someone whose survival depends on carefully managed medication, it must ensure that contracted systems and personnel act with objective reasonableness. When they do not, both constitutional and state-law accountability can follow, and disputes about what caused harm are for juries to resolve based on robust, not truncated, expert testimony.