REMEMBERING
IN ORDER TO PREVENT
SIMILAR TRAGEDIES FROM
HAPPENING AGAIN
JEFFREY CLARK
TIMOTHY SOUDERSGase 4:92-clt00110-RAE Document 2186 Filed 11/13/2006 Page 5 of 39
determined that T.S. was “floridly psychotic. Exhibiting symptoms consistent with his deseription
‘of manic episodes prior to incarceration. (Duffy Dep. Ex. 10.) Duffy thus referred T.S. to the
“CSP -id.-meaning the Crisis Stabilization Program that hospitalizes and treats mentally ill
prisoners at the Huron Valley Men’s Facility (a prison psychiatric hospital). (See Dufly Dep. 41
47.) Duffy had no expectation that T.S. would be transferred immediately, though, since he planned
to examine TS, the following day. (See Duffy Dep. Ex. 10.) The prior suicide attempts noted by
Duffy referred to a series of suicide attempts in the _alamazoo County Jail (T.S. stabbing himself
in the stomach and attempting hanging); the hanging was attempted while T.S. was housed in the
alamazoo Regional Psychiatric Hospital and nearly resulted in his death, (Walden Decl. 19.)
Duffy completed a referral form for T.S. on the morning of August 3, 2006 before examining
T.S. again later in the day. (Duffy Dep. 71.) The referral form was marked “Emergent and noted
that “Prisoner decompensated . . in detention cell . .. Prisoner remained agitated . .. Associations
loose, disintegrated. Unable to determine if prisoner is responding to internal stimuli... (Duffy
Dep. Ex. 9 at 1.) Duffy also noted that T-S.’s psychiatric medications could not be changed due to
the absence of an on-site psychiatrist. ( d. at 2.)
‘The same day Duffy received an email that the referral had been received. (Duffy Dep. 71.)
He later received an email that day that the referral had been approved. ( d. at 72.) T.S. was not
transferred that day, though. Defendants blame the failure to transfer upon a “transfer coordinator
(ecretary) at Huron Valley who failed to transmit the transfer order to IMF, together with the
scheduled leave of the transferring psychiatrist on Friday, August 4, 2006 and Mr. Dufly’s past
reliance on email correspondence to affect transfer orders. (See Def’.’ Resp., Dkt. No, 2177, at 5.)
Rule 22 (1): At every institution, there shall be available the services of at least one qualified medical officer
lwho should have some knowledge of psychiatry. The medical services should be organized in close relation-
Iship to the general health administration of the community or nation. They shall include a psychiatric service
lor the diagnosis and in proper cases, the treatment of states of mental abnormallity.” (Standard Minimum
Rules for the Treatment of Prisoners).