The evidence at trial showed that on the morning of Saturday, August 25, 2018, NaphCare, Inc.’s (“NaphCare”) nurse Hannah Neill-Gubitz (“Gubitz”) found Cindy Lou Hill (“Hill”) lying shirtless on the floor of her cell and screaming in pain at the Spokane County Jail (“the Jail”). Hill’s cellmate told Gubitz that Hill was experiencing severe abdominal pain, and Hill continued to lie in the fetal position and repeat “I’m sick, I’m sick.” Gubitz examined her for five and a half minutes, determined that Hill was experiencing severe abdominal pain, and then asked corrections officers to transfer Hill in a wheelchair to the “medical watch” area of the Jail. Around 3:00 p.m., Gubitz stood outside Hill’s cell for under two minutes and recorded that Hill had no signs of medical distress. At approximately 5:25p.m., a corrections officer realized that Hill was unconscious and began CPR. Hill was transferred to a hospital and pronounced dead. Her autopsy revealed that her cause of death was “acute bacterial peritonitis due to ruptured duodenal-liver adhesions with perforation of duodenum.” The jury found that Gubitz’s actions amounted to a failure to provide Hill with adequate medical care. The jury awarded $2.475 million in compensatory damages and $24 million in punitive damages against NaphCare.
The Estate established that NaphCare had a policy or custom of “using medically untrained jail guards to monitor NaphCare patients in need of medical monitoring by medical professionals.” At trial, the Estate demonstrated NaphCare’s use of the Jail’s “medical watch” area, in which corrections officers briefly observe inmates through a small window in the cell door every 30 minutes and check for signs of life. The officers document their observations, but are not instructed to ask the patients how they feel, check for symptoms, or otherwise investigate medical conditions. The Estate argued at trial that NaphCare put inmates in need of professional medical care in the Jail’s “medical watch” instead of providing them with necessary care.
The United States Court of Appeals for the Ninth Circuit stated in its Memorandum filed on April 14, 2025: “The Estate’s evidence at trial was sufficient to prove such a policy or custom … the jury could have reasonably concluded from this evidence that NaphCare routinely sent people with serious, potentially fatal, conditions to medical watch for monitoring by medically untrained guards … The Estate also introduced sufficient evidence from which a reasonable jury could conclude that NaphCare acted with deliberate indifference to Hill’s constitutional right to adequate medical care … Finally, there was sufficient evidence introduced at trial from which a reasonable jury could conclude that NaphCare’s policy was the moving force behind the deprivation of Hill’s constitutional right to adequate medical care. … On this record, there is “evidence adequate to support the jury’s conclusion, even if it is also possible to draw a contrary conclusion.””
“Under de novo review, we conclude, however, that the jury’s punitive damages award against NaphCare is excessive under the Due Process Clause … Where, as here, the amount of compensatory damages is significant, the ratio of punitive to compensatory damages should not exceed four to one unless the defendant’s behavior was particularly “egregious” or “reprehensible.
There are five factors that are considered when analyzing the reprehensibility of a defendant’s conduct: [1] the harm caused was physical as opposed to economic; [2] the tortious conduct evinced an indifference to or a reckless disregard of the health or safety of others; [3] the target of the conduct had financial vulnerability; [4] the conduct involved repeated actions or was an isolated incident; and [5] the harm was the result of intentional malice, trickery, or deceit, or mere accident.
The federal appellate court held: “Here, the first two factors favor finding egregiousness because NaphCare’s conduct caused physical—and deadly—harm in reckless disregard of Hill’s safety. The third factor is less relevant in the context of “a mostly noneconomic damages case like this one.” Id. at 973–74. As for the fourth and fifth factors, the record does not show that NaphCare repeatedly caused such harm, or that it did so intentionally. On balance, we hold that NaphCare’s conduct was not sufficiently reprehensible to justify the imposed punitive damages award. We accordingly vacate the decision of the district court and remand for the district court to reduce the ratio of punitive to compensatory damages not to exceed four to one.”
Source Estate of Cindy Lou Hill v. NaphCare, Inc., No. 23-2741.
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