Estate of Brian Heath Roundtree v. Correct Care Solutions, Et Al.

Case 1:19-cv-00167 Document 1 Filed 01/18/19 USDC Colorado Page 1 of 27
IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF COLORADO
Civil Action No. 19-cv-167
THE ESTATE OF BRIAN HEATH ROUNDTREE

by and through its personal representative Dennis Roundtree;
H.R., a minor, by and through mother and next friend Nicole Roundtree;
C.R., a minor, by and through mother and next friend Tricia Baker;
B.R., a minor, by and through mother and next friend Tricia Baker;
O.S., a minor, by and through mother and next friend Sarah Schultz
Plaintiffs,
v.
CORRECT CARE SOLUTIONS, LLC;

BOARD OF COUNTY COMMISSIONERS FOR THE COUNTY OF ARAPAHOE,
COLORADO;
TYLER BROWN, in his official capacity as Arapahoe County Sheriff;
SHAUNDIVA GARRETT, individually;
BRANDON DUGAN, individually;
Defendants.
______________________________________________________________________________
COMPLAINT AND JURY DEMAND
Plaintiffs, by and through their attorneys of HOLLAND, HOLLAND EDWARDS &
GROSSMAN, PC, complain against Defendants as follows and request a trial by jury.
I. INTRODUCTION
1. Brian Roundtree was booked into the Arapahoe County Detention Facility as a
pre-trial detainee on January 17, 2018.
2. He was immediately put on suicide watch by security personnel for a number of
reasons, including a recent suicide attempt and an express suicidal threat he made to
investigators earlier that evening while being interviewed before going to jail.
3. However, despite numerous red flags indicating that Mr. Roundtree was acutely
and severely suicidal, he was negligently and recklessly “cleared” and removed from suicide
watch the next morning on January 18, 2018. This was due to ACDF and CCS’s practice of
clearing suicidal inmates for Court without a valid medical basis, and with no requirement for
their immediate restoration to suicide watch upon their return to jail.
4. Returning to the jail after his arraignment hearing, where the Judge increased Mr.
Roundtree’s bond in part because of his obvious and severe suicide risk, Mr. Roundtree was not
put back on suicide watch where he belonged, but was recklessly placed in a general population
cell, alone, unmonitored, and with the means to hang himself.
5. At approximately 9:45 p.m. on January 18, 2018, Mr. Roundtree was found by
another inmate, hanging by a bed sheet from his bunk.
6. Brian Roundtree was only 43 years old when he died. He leaves behind his four
minor children, and numerous other family members and friends devastated by this preventable
death.
II. JURISDICTION AND VENUE
7. This action arises under the Constitution and laws of the United States, including
Article III, Section 1 of the Constitution and 42 U.S.C. § 1983 and 42 U.S.C. § 1988. The
Jurisdiction of this Court is further invoked pursuant to 28 U.S.C. §§ 1331, 1343, 2201.
8. This case is instituted in the United States District Court for the District of
Colorado pursuant to 28 U.S.C. §1391 as the judicial district in which all relevant events and
omissions occurred and in which Defendants maintain offices and/or reside.
9. Supplemental pendent jurisdiction is based on 28 U.S.C. §1367 because the

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violations of federal law alleged are substantial and the pendent causes of action derive from a
common nucleus of operative facts.
10. Pursuant to the Colorado Governmental Immunity Act (CGIA), sovereign immunity
is waived for Plaintiffs’ claims against the Arapahoe County Defendants for the acts and omissions
complained of herein. See §§24-10-106(1)(b), (e), and § 24-10-118, C.R.S. On July 2, 2018
Plaintiffs filed a timely written notice of claim, pursuant to § 24-10-109, C.R.S.
11. Defendant CCS is a private corporation not entitled to immunity under the Colorado
Governmental Immunity Act.
III. PARTIES
12. At all times relevant hereto, the decedent, Brian Heath Roundtree, was a citizen of
the United States of America and a resident of the State of Colorado.
13. At all times relevant hereto, Plaintiff Dennis Roundtree was a citizen of the
United States of America and a resident of the State of Colorado. Plaintiff Dennis Roundtree is
the father of decedent Brian Roundtree and the Personal Representative of the Estate of Brian
Heath Roundtree.
14. At all times relevant hereto, Plaintiff H.R., minor child of the decedent Brian
Roundtree, has been a citizen of the United States of America and a resident of the State of
Colorado. Plaintiff H.R. is represented by her mother and next friend Nicole Roundtree.
15. At all times relevant hereto, Plaintiff C.R., minor child of the decedent Brian
Colorado. Plaintiff C.R. is represented by her mother and next friend Tricia Baker.
16. At all times relevant hereto, Plaintiff B.R., minor child of the decedent Brian
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Colorado. Plaintiff B.R. is represented by his mother and next friend Tricia Baker.
17. At all times relevant hereto, Plaintiff O.S., minor child of the decedent Brian
Colorado. Plaintiff O.S. is represented by her mother and next friend Sarah Schultz.
18. The Defendant Board of County Commissioners of the County of Arapahoe,
Colorado a/k/a “Arapahoe County” (hereinafter “BOCC”) is a governmental entity chartered
under the laws of the State of Colorado. Defendant BOCC represents, oversees, and sets policy
for Arapahoe County Colorado. Among other things, Arapahoe County operates the Arapahoe
County Detention Center (hereinafter ACDF), located at 7375 S. Potomac St., Centennial CO,
80112. Defendant BOCC also contracted with Defendant CCS to provide health care to the
inmates at the ACDF. Under COLO. REV. STAT. § 30-11-105, the BOCC is the proper party in an
action against Arapahoe County.
19. Defendant Tyler Brown, in his official capacity, is the Arapahoe County Sheriff and
a final policymaker for Arapahoe County with respect to all matters concerning the Arapahoe
County Sheriff’s office and all of its divisions, including the ACDF.
20. Defendant BOCC and Defendant Brown are hereinafter collectively referred to as
the “Arapahoe County Defendants.”
21. Arapahoe County Defendants are liable under state law for negligence in the
operation of a correctional facility pursuant to CO ST. § 24-10-106.
22. Defendant Correct Care Solutions, LLC (“CCS”) is a foreign corporation doing
business in the State of Colorado, with its principal street address located at 1283 Murfreesboro
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Pike, Suite 500, Nashville, TN 37217. Its registered agent of service is located at 155 East
Boardwalk, #490, Fort Collins, CO 80525.
23. Defendant CCS is sued vicariously for the negligence of its employees and
directly for its own negligent training, as well as its policies and practices regarding known
suicidal inmates at ACDF.
24. At all times relevant hereto, Defendant Shaundiva Garrett was a citizen of the
United States and a resident of Colorado. Defendant Garrett was employed by Defendant CCS
and acting within the scope of her employment.
25. At all times relevant hereto, Defendant Brandon Dugan was a citizen of the
United States and a resident of Colorado. Defendant Dugan was employed by Defendant CCS
and acting within the scope of his employment.
26. Defendants Garrett and Dugan are collectively referred to as the “Individual
Defendants.”
IV. STATEMENT OF FACTS
27. Suicide is a well-understood and serious health risk in local jails like ACDF.
28. According to a 2010 study by the Department of Justice’s National Institute of
Corrections (NIC), suicide is the leading cause of death in local jails in the United States.
29. Per the 2010 NIC study, the suicide rate of local jail detainees is several times
higher than that of the general population.
30. In response to this worsening national problem, corrections officials have
developed a well-understood profile of local jail detainees/inmates, who present a heightened
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risk of suicide: middle-aged white males with a history of mental illness, particularly depression,
like the decedent here.
31. Additionally, there are a number of well-known red flags that all reasonably
trained jail staff look for to indicate high suicide risk in a detainee/inmate, including: detainees
with previous suicide attempts; detainees with a history of alcohol or substance abuse, and;
detainees who have been recently incarcerated or recently had a court date where they received
bad news about their prospective legal status.
32. According to the 2010 NIC study, 93% of local jail suicides were committed by
hanging; 66% of the victims used bedding to hang themselves; and the majority of detainees who
committed suicide were in single-occupancy cells, or were similarly isolated in the days leading
up to their deaths.
33. These common methods of local jail suicide are well understood by reasonably
trained jail staff, including deputies and health care professionals.
34. Arapahoe County Detention Facility has had a particular problem with
detainee/inmate suicide in recent years.
35. At least five detainees/inmates at this jail have committed suicide since 2010,
including four suicides by hanging.
36. Recently, in 2015, Tyler Hawkins hanged himself in his cell at ACDF, using his
towel as a noose.
37. In 2016, Jared Maes committed suicide at ACDF by the exact same method Mr.
Roundtree would later use; he hanged himself in his cell with a bedsheet.
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Brian Roundtree Was Booked Into ACDF As A Known and Severe Suicide Risk
38. Mr. Roundtree went to the Arapahoe County Detention Facility (ACDF) on
January 17, 2018, as a pre-trial detainee.
39. In the months preceding his arrest, Mr. Roundtree experienced a number of
serious emotional setbacks, including a recent divorce, financial problems, and major depression.
40. Although he was in psychological treatment, in the weeks preceding his arrest, he
had temporarily stopped seeing his therapist and abruptly stopped his prescription anti-
depressant medication.
41. Under severe emotional strain and clearly not thinking rationally, Mr. Roundtree
committed a string of robberies using a mask and a BB gun.
42. While no one was physically hurt, Mr. Roundtree stole from several different
local businesses, not far from where he lived, each time taking varying amounts of money.
43. Given his amateurish tactics, disguises, and obvious mental health issues, Mr.
Roundtree quickly caught the attention of local law enforcement.
44. As he stopped for gas on the evening of January 17, 2018, Mr. Roundtree was
detained and taken to Arapahoe County Sheriff’s Office (ACSO) headquarters for questioning.
45. Mr. Roundtree gave an extensive interview to a Littleton Police Department
detective and to Arapahoe County Sheriff’s Office Investigator True, during which Mr.
Roundtree confessed entirely to this bizarre string of robberies.
46. Mr. Roundtree told investigators he was “struggling and desperate.”
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47. He stated that he had been in treatment for severe depression, was supposed to be
on prescription psychiatric medications, but had abruptly stopped going to therapy and taking his
medications a few weeks earlier.
48. During his interview, Mr. Roundtree was visibly despondent at the prospect of
significant jail time.
49. He was also visibly ashamed of what he had done, and the effect it would have on
his kids, saying that he had let his kids down, “forever.”
50. Mr. Roundtree also made an overtly suicidal statement, describing his plan to
commit “suicide by cop” if he had been caught during a robbery.
51. These investigators recognized that Mr. Roundtree was acutely suicidal.
52. These investigators told ACDF staff that Mr. Roundtree was extremely suicidal,
specifically warning them about Mr. Roundtree’s explicit threats to commit “suicide by cop.”
53. Mr. Roundtree was immediately placed on suicide watch by ACSO security staff.
54. His suicide watch documents demonstrate ACDF/CCS personnel’s understanding,
not only that Mr. Roundtree had suicidal ideation, but that he had made explicit threats to
commit “suicide by cop.”
55. These documents further demonstrate that ACDF/CCS personnel knew about Mr.
Roundtree’s recent suicide attempt—a little over three months prior—where he drove drunk and
crashed his car into another parked car, going 60 miles per hour.
56. ACDF/CCS personnel also knew that Mr. Roundtree was suffering from severe
depression and anxiety, that he was getting mental health treatment from Kaiser, and that he was
on psychiatric medication.
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57. ACDF/CCS personnel further understood that Mr. Roundtree had stopped taking
his psychiatric medications a month earlier when his prescription ran out.
58. ACDF/CCS personnel’s express understanding of Mr. Roundtree’s severe suicide
risk was further underscored by this jail’s previous experience with him.
59. In March 2016, Mr. Roundtree was incarcerated for a brief period at ACDF.
During this time he explained to jail medical personnel that he was feeling suicidal, and that he
had previously attempted suicide eight months earlier.
60. ACDF security staff thus had very good reason to place Mr. Roundtree on suicide
watch early at 12:15 a.m. on the morning of January 18, 2018.
61. He needed to be supervised and monitored on a regular basis, and he was, every
15 minutes, for the rest of the night.
Mr. Roundtree Was Baselessly “Cleared” and Removed From Suicide Watch Hours Later
62. Shortly after 9 a.m. the morning of January 18, 2017, the 15-minute checks on
Mr. Roundtree ended with a cursory note in his suicide-watch observation log: “cleared.”
63. As of 9 a.m., less than nine hours after he was initially placed on suicide watch,
nothing about Mr. Roundtree’s acute suicidality had changed.
64. He was still a known suicide risk: he made overtly suicidal statements less than 24
hours previously; he had attempted suicide more than once, most recently a little more than three
months ago; he was severely depressed; he had recently divorced and had a recent history of
alcohol abuse; he was also facing the possibility of an extended prison sentence for his
amateurish string of robberies; and, by his own account, he had let his kids down “forever.”
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65. In short, Mr. Roundtree remained an extremely high suicide risk, just as he had
nine hours before.
66. The only circumstance that had changed by 9:00 a.m. had nothing to do with Mr.
Roundtree, and everything to do with a reckless policy maintained by ACDF and CCS of
clearing suicidal inmates for Court without a valid medical basis, and with no requirement for
their immediate restoration to suicide watch upon their return to ACDF.
67. Mr. Roundtree was scheduled to appear in court for his advisement hearing later
that morning at 9:30 a.m.
68. Thus, Defendant CCS’s employee, Shaundiva Garrett, a mental health
professional, recklessly “cleared” Mr. Roundtree from suicide watch with a cursory note in his
suicide watch observation log.
69. There is no record of any examination of Mr. Roundtree conducted by Defendant
Garrett or anyone at ACDF before he was negligently and recklessly “cleared” and removed
from suicide watch so he could appear in court without being on watch.
70. Mr. Roundtree was then taken to his 9:30 a.m. advisement hearing by ACSO
Deputy Johnson.
71. At this hearing, the prosecutor asked the Judge to increase Mr. Roundtree’s bond,
relying in part on Mr. Roundtree’s statements to investigators, only hours before, that he was
severely suicidal and had a plan to commit “suicide by cop.”
72. The prosecutor further stated that he “believe[d] that Mr. Roundtree [was] a
severe risk to his own safety…” that “[h]is life seems to have fallen off the cliff right now,” and
that he was “extremely concerned for [] him….”

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73. The prosecutor also represented that he could seek a lengthy prison sentence for
Mr. Roundtree.
74. Persuaded in part by Mr. Roundtree’s obvious severe risk of self-harm, the Judge
increased Mr. Roundtree’s bond to $1,000,000, specifically stating: “I am concerned regarding
the safety of the community, the likelihood of conviction based upon the record made by Mr.
McKinzie, and candidly, the safety of this Defendant. And although that certainly sounds
counterintuitive every time I say it from here to keep somebody in jail, the jail is the best place
for me to ensure this Defendant doesn't harm himself.”
75. Mr. Roundtree was then transported back to ACDF by Deputy Johnson.
76. Mr. Roundtree, now contemplating a possible long stint in prison, was now more
suicidal, not less so, when he was taken back to ACDF.
Mr. Roundtree Was Negligently and Recklessly “Screened” For Suicide Risk Upon Returning
From Court
77. When Mr. Roundtree returned from Court on January 18, 2017, one day after he
was first booked into jail, he was still a known suicide risk: he had made overtly suicidal
statements less than 24 hours previously; he had attempted suicide more than once, most recently
a little more than three months ago; he was severely depressed; he had recently divorced and had
a recent history of alcohol abuse; he was facing the possibility of an extended prison sentence for
his amateurish string of robberies; and, by his own account, he had let his kids down “forever.”
78. Things had only gotten worse for him and his acute suicidal mindset was
compounded by the bad legal news he received at this advisement hearing, where he learned that
the prosecutor would likely seek a lengthy prison term and set a $1,000,000 bond.
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79. And in fact, his obvious suicidality was a primary reason for such a high bond.
80. Deputy Johnson, after having heard how suicidal he was from the advisement
hearing, including the judge’s belief that “the jail is the best place” “to ensure this Defendant
doesn't harm himself,” negligently did not have him immediately placed on suicide watch after
he transported him back to the jail.
81. Then, instead of just putting an obviously suicidal detainee back on suicide watch,
particularly given the fact that he was only cleared for the purpose of attending court, individual
Defendants Garrett and Defendant Brandon Dugan, a Registered Nurse, validated the earlier
negligent and reckless decision to “clear” him from suicide watch.
82. Defendant Garrett, a professional counselor, conducted a “Suicide Watch Initial
Assessment” at 11:48 a.m., January 18, 2017, two hours after she had already “cleared” Mr.
Roundtree so he could go to court, and immediately after he returned to jail from the advisement
hearing where he learned he faced lengthy prison time.
83. Defendant Garrett documented that she understood that Mr. Roundtree told
investigators only hours before that he wanted to die via “suicide by cop.”
84. She also understood that Mr. Roundtree had attempted suicide little more than
three months ago, on October 6, 2017, when “he drove a car 60 mph into a parked car while
drunk,” suffering critical injuries including a fractured skull, face, and vertebrae.
85. Defendant Garrett thus also understood that Mr. Roundtree had a recent history of
substance abuse.
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86. Defendant Garrett further understood that Mr. Roundtree was receiving mental
health treatment at Kaiser for depression and anxiety, and that he was prescribed Citalopram, an
anti-depressant, which he had abruptly stopped taking.
87. Defendant Garrett understood that security personnel had placed Mr. Roundtree
on suicide watch because of his known suicide risk less than 24 hours earlier.
88. However, Defendant Garrett inexplicably downplayed his suicide risk—ignoring
these known and glaring present red flags of Mr. Roundtree’s potential for self harm.
89. Assessing him for the well-understood factors that indicate suicide risk,
Defendant Garrett falsely charted that Mr. Roundtree did not have any “New legal issues,” or
“Bad news,” despite his day-old arrest for a bevy of felony robbery charges made fresh by that
morning’s advisement hearing, resulting in a $1,000,000 bond.
90. Defendant Garrett falsely charted that Mr. Roundtree did not present
“Hopelessness, feelings of guilt or worthlessness,” despite Mr. Roundtree’s clear feelings of
hopelessness, guilt, and shame over letting his kids down “forever,” which were readily apparent
to ACSO investigators the night before and to a Judge earlier that morning.
91. Defendant Garrett falsely charted that Mr. Roundtree was not “Impulsive,” even
as he told her about his suicide attempt, roughly three months prior, where he impulsively tried
to kill himself by ramming his car at high speed, while drunk, into a parked car.
92. Defendant Garrett falsely charted that Mr. Roundtree did not present a “Major
Depressive/manic episode,” despite knowing that he recently received treatment at Kaiser for
depression and anxiety, was prescribed Citalopram, and was marked in his jail medical record as
someone with a chronic problem of “major depressive disorder.”

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93. Defendant Garrett falsely checked “N/A” in response to a worksheet question
about whether or not the suicidal inmate being assessed was medication compliant, despite
knowing that Mr. Roundtree was not compliant with his anti-depression medications.
94. Instead of taking seriously these numerous red flags of acute and severe suicide
risk, Defendant Garrett appears to have relied solely on Mr. Roundtree’s purported statements
that he “denie[d] SI/HI/SH,” and “states that he feels safe going to GP.”
95. Even if Mr. Roundtree did deny that he was presently suicidal, all reasonable
mental health professionals understand that such denials are commonplace among mentally-ill
people who are actively suicidal, and all reasonable mental health professionals know that Mr.
Roundtree’s observable behavior and other known recent and immediate history— including his
suicidal ideation and planning, his prior suicide attempts, his recent divorce and alcohol abuse,
and his serious legal jeopardy—continued to present a severe risk of suicide.
96. Nevertheless, Defendant Garrett recklessly concluded that Mr. Roundtree did not
need to be on suicide watch or even frequent monitoring.
97. Defendant Garrett further recklessly put Mr. Roundtree alone in a cell with a
bedsheet and double bunk, where he was obviously unsafe with respect to self-harm.
98. Defendant Garrett did not even order a follow-up consult with a psychiatrist or
other mental health professional.
99. Defendant Nurse Dugan also “screened” Mr. Roundtree for suicide risk after Mr.
Roundtree returned from his advisement hearing, and thus also had the opportunity to place Mr.
Roundtree back on suicide watch, where he clearly belonged.
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100. Instead, like Defendant Garrett, Defendant Dugan conducted a negligent and
reckless “screening” of Mr. Roundtree, with a heavy thumb on the scale in favor of declaring an
obviously suicidal detainee “safe” for a general population cell.
101. When he conducted his assessment, Defendant Dugan also knew that Mr.
Roundtree had been placed on suicide by security staff watch only hours before because of his
stated threat to die via “suicide by cop.”
102. Defendant Dugan also knew that Mr. Roundtree had attempted suicide on October
6, 2017, little more than three months ago.
103. Defendant Dugan further understood that Mr. Roundtree was suffering from a
serious psychiatric illness: “major depressive disorder.”
104. Defendant Dugan understood that Mr. Roundtree was getting mental health
treatment from Kaiser, but had stopped going.
105. Defendant Dugan knew that Mr. Roundtree was on anti-depressant medication,
Citalopram in particular, but that Mr. Roundtree had abruptly stopped taking this medication
roughly a month prior.
106. Notwithstanding all of his knowledge of these various red flags of suicide risk,
Defendant Dugan falsely charted in his “screening” of Mr. Roundtree that the
arresting/transporting officers who brought Mr. Roundtree to jail did not think he was a suicide
risk, when in fact these exact officers demanded that Mr. Roundtree be put on suicide watch.
107. Defendant Dugan falsely charted that Mr. Roundtree did not express thoughts
about killing himself, when in fact, he had a plan only hours before to die via “suicide by cop.”
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108. Defendant Dugan falsely charted that Mr. Roundtree was not worried about major
problems in his life, despite the fact that Mr. Roundtree had just returned from the advisement
hearing where he faced a lengthy prison sentence and was issued a high bond.
109. Defendant Dugan falsely charted that Mr. Roundtree did not use alcohol.
110. Defendant Dugan falsely charted that Mr. Roundtree had no history of outpatient
mental health treatment, even as he faxed Kaiser to verify Mr. Roundtree’s prescription for the
anti-depressant Citalopram.
111. Defendant Dugan further falsely charted “no” to various questions about Mr.
Roundtree’s emotional outlook and mental health status, such as that he did not seem hopeless
about the future, was not showing signs of depression, was not anxious, afraid, or showing
unusual and obvious embarrassment and shame.
112. Defendant Dugan also did not place Mr. Roundtree on suicide watch, close
monitoring, or refer Mr. Roundtree for an immediate mental health evaluation.
113. Like Defendant Garrett, Defendant Dugan appears to have solely relied on Mr.
Roundtree’s purported claims that he didn’t feel suicidal at that moment.
114. All reasonably trained nurses at jail understand that such self-reported denials are
common among mentally ill people who are actively suicidal, and all reasonably trained nurses
know that such purported denials do not trump a person’s observable behavior and recent
history.
115. Mr. Roundtree’s severe suicide risk was clear to the investigators who took Mr.
Roundtree’s statements on the evening of January 17, to the officers who transported Mr.
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Roundtree to ACDF early in the morning of January 18, and to the prosecutor and Judge who
saw Mr. Roundtree during later that same morning at his advisement hearing.
116. Disregarding Mr. Roundtree’s observable behavior and recent history full of red
flags indicating serious suicide risk, Defendant Garrett and Defendant Dugan both concluded he
was “safe” to be placed in general population.
117. As Defendants Garrett and Dugan understood when they authorized Mr.
Roundtree to be housed in a general population cell, he would have all the common jail tools he
needed to hang himself, including a bedsheet and a double bunk.
118. As Defendants Garrett and Dugan knew when they authorized Mr. Roundtree to
be housed in a general population cell, he would no longer be supervised or monitored on any
kind of regular basis, much less the 15-minute interval checks he would have gotten had he been
put back on suicide watch.
119. As Defendants Garrett and Dugan understood when they authorized Mr.
Roundtree to be housed in a general population cell, he could be in a cell by himself, because
detainees routinely rotated in and out as part of the booking and bonding-out process.
Mr. Roundtree Was Placed In General Population And Given The Means to Hang Himself
120. After he was classified to be safe for a general population cell on January 18,
2017, Mr. Roundtree was housed in a cell by himself, with a bedsheet and a double bunk.
121. Mr. Roundtree was not monitored or checked on by any member of Arapahoe
County Defendants’ security staff or Defendant CCS’s medical staff.
122. Mr. Roundtree received no mental health care or counseling.
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123. Per ACSO’s post-death investigation review of surveillance cameras, Mr.
Roundtree was in the dayroom of his pod at 6:52 p.m., when he retreated back into his cell,
alone, and shut the door.
124. No one at the jail ever saw him alive again.
125. Some time after Mr. Roundtree went back into his cell and shut the door at 6:52
p.m., Mr. Roundtree used his bedsheet and bunk bed apparatus to hang himself.
126. He was found hanging by another inmate, Josh Pankoff, at approximately 9:45
p.m.
127. Mr. Pankoff was the dayroom cleaner for Mr. Roundtree’s pod and was making
the rounds cleaning empty cells prior to lockdown.
128. As Mr. Pankoff passed by his cell, he looked through the window and saw Mr.
Roundtree hanging from his bunk by a sheet.
129. Mr. Pankoff immediately ran downstairs to get help.
130. ACSO Deputies and CCS nurses arrived to cut him down at 9:50 p.m.
131. ACDF and CCS staff attempted various measures to resuscitate Mr. Roundtree,
but at that point it was too late: he had no shockable heart rhythm.
132. He was pronounced dead shortly thereafter, at 10:08 p.m., on January 18, 2017.
133. The Coroner’s report confirmed his death by hanging, noting his “known prior
and recent suicidal ideation and prior suicide attempts.”
134. Notwithstanding his troubles during the months leading up to his incarceration at
ACDF, Brian Roundtree, pictured below, was a beloved member of his family and community.
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135. He graduated from Smoky Hill High School and became a successful and
respected professional in the local publishing and real estate industry.
136. Mr. Roundtree was also a devoted father to his four biological kids, Plaintiffs
H.R., C.R., B.R., and O.S. and for his two-step children.
137. He was only 43 years old when he died.
138. As his father Dennis described in a “Letter to my son,” read to the large
community gathered at Mr. Roundtree’s funeral, his son struggled with “the Darkness”—mental
illness and substance abuse—for certain periods of his life.
139. But then Brian Roundtree turned his life around.
140. He worked for the Denver Post and was the production manager for 5280
Magazine for several years.
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141. At the time of his death, Mr. Roundtree was a well-liked and award-winning
member of the South Metro Denver Realty Association’s staff.
142. As his father Dennis eloquently explained in his “Letter to my son,” Mr.
Roundtree had struggled mightily through “the Darkness” to become, in Dennis’s words, “the
father I wish I had been, the artist I never was…” someone “I looked up to in admiration and
pride.”
143. Mr. Roundtree’s children have been devastated by this preventable death. They
have lost forever a devoted and loving father, and a man who was, despite his flaws, a model of
struggle and redemption.
V. CLAIMS FOR RELIEF
FIRST CLAIM FOR RELIEF

Violation of 42 U.S.C. § 1983 – Fourteenth Amendment
Denial of Medical Care
(Plaintiff Estate against Defendant Garrett and Defendant Dugan)
144. Plaintiffs hereby incorporate all other paragraphs of this Complaint as if fully set
forth herein.
145. 42 U.S.C. § 1983 provides that:
Every person, who under color of any statute, ordinance, regulation, custom or
usage of any state or territory or the District of Columbia subjects or causes to be
subjected any citizen of the United States or other person within the jurisdiction
thereof to the deprivation of any rights, privileges or immunities secured by the
constitution and law shall be liable to the party injured in an action at law, suit in
equity, or other appropriate proceeding for redress . . .
146. Brian Roundtree was a citizen of the United States and Defendants to this claim
are persons for the purposes of 42 U.S.C. § 1983.
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147. Each Defendant to this claim, at all times relevant hereto, was acting under color
of state law.
148. Mr. Roundtree was protected from deliberate indifference to his known serious
medical needs by the Fourteenth Amendment.
149. There is no qualified immunity for private actors working in a jail.
150. As a result of the allegations contained in this Complaint, Individual Defendants
are liable under 42 U.S.C. § 1983 for the violation of Mr. Roundtree’s rights under the
Fourteenth Amendment by acting with deliberate indifference to his serious medical needs and
disregarding the excessive risks associated with his known and obvious suicidality, despite being
expressly aware of Plaintiff’s condition and obvious need for treatment and close monitoring for
the same.
151. Under the Fourteenth Amendment, Individual Defendants also violated Plaintiff’s
rights by engaging in conduct that was not rationally related to a legitimate nonpunitive
governmental purpose, and making intentional decisions that put him at substantial risk of
suffering harm, and by not taking reasonable available measures to abate that risk, even though a
reasonable actor in the circumstance would have appreciated the high degree of risk involved, as
set forth in Kingsley v. Hendrickson, 135 S. Ct. 2466, 2473 (2015).
152. The acts or omissions of these Defendants were the legal and proximate cause of
Mr. Roundtree’s injuries, losses and death.
153. As a direct and proximate result of these Defendants’ unlawful conduct, Plaintiff
Estate has suffered injuries and losses, including the death of Mr. Roundtree, entitling it to
recover his compensatory and special damages, including for loss of constitutional rights, loss of
21
enjoyment of life, pain and suffering, loss of relationships, and permanent lost earnings and
earnings capacity for the expected productive working lifetime of Mr. Roundtree, all in amounts
to be proven at trial.
154. Plaintiff is also entitled to punitive damages against these Defendants, in that their
actions were taken maliciously, willfully or with a reckless or wanton disregard of the
constitutional rights of the deceased Brian Roundtree.
155. Plaintiff is entitled to attorneys’ fees and costs pursuant to 42 U.S.C.§1988, pre-
judgment interest and costs as allowable by federal law.
SECOND CLAIM FOR RELIEF

(Wrongful Death)
(Plaintiffs H.R., C.R., B.R., and O.S. Against Defendant Garrett, Defendant Dugan, and
Defendant CCS)
forth herein.
157. Defendant CCS is a private corporation that contracts with Arapahoe County to
provide medical care and health services to inmates at ACDF.
158. CCS and Individual Defendants are private ‘persons’, not governmental actors,
and are therefore not entitled to any immunity under the CGIA.
159. CCS is vicariously liable for the negligent acts and omissions by their agents
and/or employees, including but not limited to, Individual Defendants and other medical
workers, whether or not they are defendants to this claim.
160. At all times relevant to this action, Mr. Roundtree was under the medical
responsibility, care, and treatment of Defendants hereto.
22
161. Individual Defendants and other individual medical workers at ACDF had a duty
to provide medical and mental health care to detainees at ACDF, including Mr. Roundtree. This
includes a duty to provide reasonable care to prevent inmates known to be at risk for suicide
from committing suicide, a duty to properly classify such detainees and house them accordingly,
and a duty to properly supervise and monitor these detainees at risk of self harm.
162. All CCS employees who interacted with Mr. Roundtree during his incarceration at
ACDF, including, but not limited to Defendants Garrett and Dugan, had doctor-patient,
counselor-patient or nurse-patient relationships with Mr. Roundtree, and were acting within the
scope of their employment.
163. Defendant Garrett, Defendant Dugan, and Defendant CCS and its employees,
owed Mr. Roundtree a duty to exercise the degree of care, skill, caution, diligence, and foresight
exercised by and expected of medical and health care professionals in similar situations.
164. Through their actions and omissions, Individual Defendants and potentially other
CCS employees breached their standards of care and were negligent in failing to properly assess,
monitor, treat, and care for Mr. Roundtree, including, but not limited to the following:
a. failing to properly classify Mr. Roundtree as high suicide risk, and failing to put him
back on suicide watch after his return from his advisement hearing;
b. failing to remove all the items in Mr. Roundtree’s cell which could be used for self
harm;
c. failing to ensure that Mr. Roundtree had a cell-mate so he would not be further
isolated;
d. failing to adequately supervise and monitor Mr. Roundtree in his cell;
23
165. These duties of care are informed by state law. Under C.R.S. § 16-3-401,
“prisoners arrests or in custody shall be treated humanely and provided with adequate food,
shelter, and, if required, medical treatment.” The provision of adequate medical treatment and
humane care is a statutory obligation.
166. Defendant CCS also had a duty to exercise reasonable care in the training and
supervision of its employees and breached its duty of care, including failing to reasonably train
their employees to recognize the well-known red flags indicating a suicidal detainee, and in
acting to place such a suicidal detainee in an incarceration setting where he could not act out his
suicidal impulses.
167. CCS also willfully participated in a negligent and reckless policy maintained by
ACDF and CCS, which cleared suicidal inmates for Court without a valid medical basis, and
with no requirement for their immediate restoration to suicide watch upon their return to ACDF.
168. As a direct and proximate result of these Defendants’ unlawful acts and
omissions, Plaintiffs H.R., C.R., B.R., and O.S. have suffered damages, losses and injuries in an
amount to be determined by the jury at trial. These damages include inter alia funeral expenses,
lost earnings and financial benefits they would have reasonably been expected to receive from
their father had he lived, pain and suffering, upset, grief, loss of their father’s companionship,
anger, depression, and all other damages as allowed under state law.
169. Although not required, Plaintiffs hereby give notice that they may seek to amend
the Complaint to add punitive damages against these Defendants because the injuries complained
of are attended by circumstances of fraud, malice or willful and wanton conduct engaged in by
their employees and agents.

24
THIRD CLAIM FOR RELIEF

(Negligence In The Operation Of A Jail Causing Wrongful Death)
(Plaintiffs H.R., C.R., B.R., and O.S. Against Arapahoe County Defendants)
forth herein.
171. Pursuant to the Colorado Governmental Immunity Act, CO ST. § 24-10-106,
governmental immunity is waived for any action by a pre-trial detainee for injuries, which lie in
tort or could lie in tort, resulting from the negligent operation of any correctional facility or jail.
172. At all times relevant hereto, Mr. Roundtree was incarcerated at ACDF based on
allegations that had not yet been adjudicated, and thus was being held as a pre-trial detainee.
173. Arapahoe County Defendants are vicariously liable for the negligent acts and
omissions by their agents and/or employees, including but not limited to, Deputy Johnson and
other deputies, who were acting in the scope of their employment.
174. At all times relevant to this action, Mr. Roundtree was in the custody and care of
ACDF staff.
175. The operation of a correctional facility for purposes of the CGIA includes
adequate provision of medical and mental health care necessary for basic health, and adequate
provision of protection from self-harm.
176. Arapahoe County Defendants had a duty to provide reasonable care to prevent
inmates known to be at risk for suicide from committing suicide, a duty to properly classify such
detainees and house them accordingly, and a duty to properly supervise and monitor these
detainees at risk of self harm.
25
177. As alleged herein, Arapahoe County Defendants breached these duties by their
negligent acts and omissions, including, but not limited to the following:
a. Having a policy or practice of “clearing” detainees and inmates from suicide watch in
order to attend court hearings without a valid medical basis, and with no requirement
for their immediate restoration to suicide watch upon their return to ACDF;
b. “Clearing” or allowing Mr. Roundtree to be cleared from suicide watch despite

knowing that he was still actively suicidal;
c. failing to properly house Mr. Roundtree after his return from his advisement hearing,
including Deputy Johnson’s failure to require Mr. Roundtree be put on suicide watch
given his personal knowledge from the advisement hearing that Mr. Roundtree was
still actively suicidal;
d. failing to remove all the items in Mr. Roundtree’s cell which could be used for self
harm;
e. failing to ensure that Mr. Roundtree had a cell-mate so he would not be further
isolated;
f. failing to adequately supervise and monitor Mr. Roundtree in his cell, and;
g. failing to exercise reasonable care in the training and supervision of its employees,
including training regarding recognizing the well-known red flags indicating a
suicidal detainee, and in acting to place such a suicidal detainee in an incarceration
setting where he could not act out his suicidal impulses.
178. As a direct and proximate result of these Defendants’ unlawful acts and
omissions, Plaintiffs H.R., C.R., B.R., and O.S. have suffered damages, losses and injuries in an
amount to be determined by the jury at trial. These damages include inter alia funeral expenses,
lost earnings and financial benefits they would have reasonably been expected to receive from
their father had he lived, pain and suffering, upset, grief, loss of their father’s companionship,
anger, depression, and all other damages as allowed under state law.
VI. PRAYER FOR RELIEF
26
Plaintiffs pray that this Court enter judgment for the Plaintiffs and against each of the
Defendants and enter the following relief:
(A) All available compensatory damages, including, but not limited to, all available
damages for pain and suffering, physical, mental and emotional distress, loss of life, loss of
earnings and earning capacity, and all other non-economic and economic damages available
under the law;
(B) Punitive damages on all federal claims as allowed by law and in an amount to be
determined at trial against individual defendants;
(C) Punitive damages on state law claims upon suitable amendment after completion
of substantial discovery;
(D) Attorneys’ fees and costs;
(E) Pre- and post-judgment interest as appropriate; and
(F) Any further relief at law or equity that this Court deems just and proper, including
declaratory and injunctive relief with respect to the challenged policies and customs.
PLAINTIFFS RESPECTFULLY REQUEST TRIAL BY JURY.
/s/ Erica T. Grossman

Erica T. Grossman
John R. Holland
Anna Holland Edwards
Dan Weiss
HOLLAND, HOLLAND EDWARDS & GROSSMAN, PC
1437 High Street
Denver, CO 80218
27

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Case 1:19-cv-00167 Document 1 Filed 01/18/19 USDC Colorado Page 1 of 27

IN THE UNITED STATES DISTRICT COURT

Civil Action No. 19-cv-167

THE ESTATE OF BRIAN HEATH ROUNDTREE

CORRECT CARE SOLUTIONS, LLC;

COMPLAINT AND JURY DEMAND

Plaintiffs, by and through their attorneys of HOLLAND, HOLLAND EDWARDS &

pre-trial detainee on January 17, 2018.

2. He was immediately put on suicide watch by security personnel for a number of

their immediate restoration to suicide watch upon their return to jail.

cell, alone, unmonitored, and with the means to hang himself.

another inmate, hanging by a bed sheet from his bunk.

II. JURISDICTION AND VENUE

omissions occurred and in which Defendants maintain offices and/or reside.

9. Supplemental pendent jurisdiction is based on 28 U.S.C. §1367 because the

common nucleus of operative facts.

Plaintiffs filed a timely written notice of claim, pursuant to § 24-10-109, C.R.S.

Governmental Immunity Act.

the United States of America and a resident of the State of Colorado.

18. The Defendant Board of County Commissioners of the County of Arapahoe,

Colorado a/k/a “Arapahoe County” (hereinafter “BOCC”) is a governmental entity chartered

action against Arapahoe County.

the “Arapahoe County Defendants.”

operation of a correctional facility pursuant to CO ST. § 24-10-106.

Boardwalk, #490, Fort Collins, CO 80525.

suicidal inmates at ACDF.

and acting within the scope of her employment.

and acting within the scope of his employment.

IV. STATEMENT OF FACTS

28. According to a 2010 study by the Department of Justice’s National Institute of

higher than that of the general population.

30. In response to this worsening national problem, corrections officials have

developed a well-understood profile of local jail detainees/inmates, who present a heightened

like the decedent here.

bad news about their prospective legal status.

trained jail staff, including deputies and health care professionals.

detainee/inmate suicide in recent years.

including four suicides by hanging.

January 17, 2018, as a pre-trial detainee.

committed a string of robberies using a mask and a BB gun.

Roundtree quickly caught the attention of local law enforcement.

45. Mr. Roundtree gave an extensive interview to a Littleton Police Department

Roundtree confessed entirely to this bizarre string of robberies.

46. Mr. Roundtree told investigators he was “struggling and desperate.”

medications a few weeks earlier.

significant jail time.

commit “suicide by cop” if he had been caught during a robbery.

54. His suicide watch documents demonstrate ACDF/CCS personnel’s understanding,

commit “suicide by cop.”

58. ACDF/CCS personnel’s express understanding of Mr. Roundtree’s severe suicide

had previously attempted suicide eight months earlier.

watch early at 12:15 a.m. on the morning of January 18, 2018.

15 minutes, for the rest of the night.

nothing about Mr. Roundtree’s acute suicidality had changed.

nine hours before.

their immediate restoration to suicide watch upon their return to ACDF.

that morning at 9:30 a.m.

68. Thus, Defendant CCS’s employee, Shaundiva Garrett, a mental health

suicide watch observation log.

69. There is no record of any examination of Mr. Roundtree conducted by Defendant

from suicide watch so he could appear in court without being on watch.

severely suicidal and had a plan to commit “suicide by cop.”

that he was “extremely concerned for [] him….”

increased Mr. Roundtree’s bond to $1,000,000, specifically stating: “I am concerned regarding

for me to ensure this Defendant doesn't harm himself.”

suicidal, not less so, when he was taken back to ACDF.