“Still-Treating, Still Immune” – Spikes v. Wheat and the Fifth Circuit’s Clarification that Misdiagnosis Amid Continuous Care Does Not Constitute Deliberate Indifference

1. Introduction

Spikes v. Wheat, No. 22-30327 (5th Cir. June 24, 2025) is the latest pronouncement by the United States Court of Appeals for the Fifth Circuit on the intersection of prisoner medical care, the Eighth Amendment, and qualified immunity. The case arose after inmate Larce Spikes fractured his hip at Louisiana’s Rayburn Correctional Center (“RCC”) but was repeatedly treated only for a suspected muscle strain. He asserted 42 U.S.C. §1983 claims of deliberate indifference against three nurses (Paula Stringer, Robin Bowman, and Lesley Wheat) and the facility’s sole physician, Dr. Casey McVea (whose heirs were substituted after his death).

The district court denied summary judgment, holding that factual disputes precluded qualified immunity. On interlocutory appeal—after an earlier panel disposition and a remand for individualized analysis—the Fifth Circuit reversed, holding that, even if every factual dispute were resolved in Spikes’s favor, the defendants’ conduct amounted to negligence or misdiagnosis, not the “subjective recklessness” required for an Eighth-Amendment violation. Thus, the defendants were entitled to qualified immunity.

2. Summary of the Judgment

• The court applied the two-step Pearson / al-Kidd qualified-immunity framework.
• Assuming arguendo that the right to be free from deliberate indifference was clearly established, the panel held that no defendant violated the right.
• Key rationale: the medical staff consistently treated Spikes—providing pain medication, mobility aids, work restrictions, and eventually an X-ray. Their error was only an incorrect diagnosis, repeatedly deemed insufficient to show deliberate indifference under Supreme Court and circuit precedent.
• Result: district court reversed; defendants granted qualified immunity; Spikes’s §1983 claims dismissed.

3. Analysis

a. Precedents Cited and Their Influence

Estelle v. Gamble, 429 U.S. 97 (1976) – the foundational case distinguishing medical negligence from deliberate indifference. The Fifth Circuit treated the factual parallels (multiple visits, pain medication, delayed X-ray) as “highly instructive.” Estelle’s core lesson—that misdiagnosis alone is not cruel and unusual punishment—controlled the outcome.

Farmer v. Brennan, 511 U.S. 825 (1994) – supplied the “subjective recklessness” standard: the official must both perceive and disregard a substantial risk. The panel quoted Farmer to refute arguments that defendants “should have perceived” a fracture.

Domino v. Texas DOC, 239 F.3d 752 (5th Cir. 2001); Petzold v. Rostollan, 946 F.3d 242 (5th Cir. 2019) – reiterated that negligence, disagreement with treatment, or perfunctory evaluation is not enough.

Other supportive authorities: Cleveland v. Bell (deliberate-indifference elements), Johnson v. Treen (examples of wanton disregard), and recent circuit cases (Williams v. City of Yazoo, Ford v. Anderson County) distinguishing “symptoms-only” scenarios from obvious life-threatening risks.

Collectively, the cases provided a rigid framework: unless a medical provider refuses or intentionally withholds care in the face of obvious danger, qualified immunity applies. The panel used these precedents to treat every factual dispute (pain severity, wheelchair use, appointment delays) as immaterial.

b. The Court’s Legal Reasoning

1. Step-One (Constitutional Violation)
   – Deliberate Indifference requires: (i) awareness of facts showing substantial risk, (ii) actual subjective inference of that risk, (iii) disregard of the risk.
   – The nurses and physician’s conduct, even taken at its worst, reflected continuous treatment. Misreading or underestimating symptoms equals negligence—not “subjective recklessness.”
2. Role-by-Role Analysis
   – Nurse Stringer: two early visits; failure to note inability to ambulate, no hernia check; nevertheless provided medication and followed standing orders.
   – Nurse Bowman: mid-July visits; maintained treatment plan, documented symptoms, arranged bottom-bunk and no-duty status.
   – Nurse Wheat: late-July visit; added crutches, advised against strenuous activity; her disciplinary report did not block access to medical care.
   – Dr. McVea: reviewed all notes, altered medication, ordered labs and ultimately an X-ray; misdiagnosis did not equate to deliberate indifference.
3. Qualified-Immunity Overlay
   – Even if the nursing or medical judgment were poor, no clearly established law required earlier X-rays for non-traumatic hip pain where treatment was ongoing.
   – The court thus chose the first prong (no constitutional violation), rendering the “clearly established” inquiry moot, but noted the standard would fail there too.

c. Impact of the Judgment

• Reinforces a Strict Deliberate-Indifference Standard
  Spikes v. Wheat tightens the already high bar inmates face when suing for delayed diagnosis. Continuous albeit mistaken treatment effectively immunizes medical staff absent smoking-gun evidence of willful neglect.
• Emphasizes Individualized Qualified-Immunity Review
  The court’s insistence on role-specific analysis, prompted by the death of Dr. McVea, will shape future litigation where multiple staff members are sued collectively.
• Guidance to Prison Health Systems
  – Standing orders, chart reviews, and incremental treatment adjustments—if documented—create a robust defense.
  – Facilities should note that disciplinary measures (e.g., malingering reports) will not jeopardize qualified immunity so long as access to care continues.
• Ripple Effect Beyond Corrections
  The “continuous-treatment shield” resonates with municipal and emergency-room contexts, where misdiagnosis claims often surface under §1983.

4. Complex Concepts Simplified

• Qualified Immunity: A legal doctrine shielding officials from personal liability unless (1) they violated a constitutional/statutory right and (2) that right was clearly established at the time.
• Deliberate Indifference: More than negligence. The official must know of a serious risk and consciously disregard it—akin to criminal recklessness.
• Standing Orders: Pre-approved treatment protocols nurses follow when a physician is unavailable; usually cover routine ailments.
• Interlocutory Appeal: An appeal before final judgment, permitted here because qualified immunity is a defense from suit, not merely liability.
• Law of the Case / Mandate Rule: Earlier appellate rulings govern later proceedings unless vacated. Here, the first panel decision (Spikes I) was vacated; only Spikes II controlled.

5. Conclusion

Spikes v. Wheat cements a pragmatic, provider-friendly reading of the Eighth Amendment in the Fifth Circuit: as long as prison medical staff are trying—even if clumsily or incorrectly—they are “still treating” and therefore “still immune.” The decision underscores the difficulty of translating a delayed or wrong diagnosis into constitutional tort liability and instructs lower courts to parse each defendant’s role separately before stripping qualified immunity. For practitioners, the case is both a shield for correctional healthcare workers and a roadmap for plaintiffs seeking to overcome that shield—demanding concrete evidence of intentional disregard, not mere error.