tanner in this appeal this appeal involves two primary issues both of them relate to the district courts grant qualified immunity to the defendants in this case and both aspects of that ruling that will discuss today represent a dangerous an unsupported expansion of qualified immunity in this district in the circuit the st issue was whether or not these defendants should even be entitled to assert to claim entitlement to qualified immunity is or not government actors these are defendants who are employees of a company called correct care solutions c c s is a private for profit company whose entire business model is to vigorously compete across the country with other companies like it who go for government contracts to provide medical services in prisons but these defendants were in fact in a state facility in a state prison in this case the supreme court's decision in richardson versus mcknight is still directly on point that case was not only limited to a company that randy private prison they were giving a test that has been used in other context as well to determine when private actors are entitled to qualified immunity they laid out the test to look at the history of immunity a common law and then look at the three policy factors behind qualified immunity d to see if they would apply that  in full our scheme we know that in a very different factual context the supreme court applied the exact same test so that the case was not limited to just them in that in that private prison setting here the fact that they are running the medical unit rather than the entire prison it does not make it just make a difference because it's undisputed that c c s was absolutely the final word on all medical decisions there was no county oversight about medical care for specific inmates the evidence is undisputed that timothy made murray one of the defendants in this case was the final word on that and so we believe that that is a distinction without a difference in this case i will say councilman the court and larceny specifically said when he was discussing richards that richardson was essentially intentionally mayor and then they sent out those elements that you were just discussing are factors and that st factor seems to me to be one that in most question and question here which is a private firm systematically organized to assume a major lane administrative task and then in parentheses managing an institution now managing an institution could have just been an example which was the facts and that came in richardson but does that perhaps narrow it to that particular circumstance and we know that that entity or defendants employees who are managing an institution every court that has considered the question you're asking every circuit has ruled that that current federal is not limited to that circumstance and has found that defendants just like c c s are not entitled every circuit to directly consider this question has applied richardson even but both before and after full are state and found no qualified immunity for defendants just like the defendants in this case were to say things are exactly on point which could because i'm sorry your honor in here is harrison vs actually in the th circuit that are involved correctional correctional medical services which was a large company westford has also been involved in these cases that was way they are a large company administrative only organized i'm sorry systematically organized to carry out a large task like this they do it all over the country in over two hundred facilities in thirty eight states for profit so we don't believe that they are entitled to qualified immunity at all as a legal matter his lieutenants circuit and any time into it as to what the proper resolution of the policy and legal dealing with one doctor who had been contracted to perform an execution it was a policy that just didn't point that direction and he was granted qualified immunity so it's not the same situation but the court was looking at how a single doctor like that should get the benefit of qualified immunity because those policy factors point the other direction so it's only through that inference but it would be an issue of st impression even if it were about a were but of the circuits what's the has also ruled against qualified immunity in that context you on the on the nd issue whether these if they were entitled to claim qualified immunity would it apply to them in this case the court the district court was required to you all the factors all facts in the in the plaintiff's favor if he had done so and is this court will do you want to know for review the evidence is simply overwhelming in the record of deliberate indifference to her medical needs supreme court has made very clear that this is a fast question that injury can infer conscious to regard disregard just from the fact that need was obvious and that the risk was obvious and if we look at what we know would have been obvious to these defendant and thirty one morning until over thirty hours later right before her baby dies in the final stages of labor at eleven o'clock the next day she's telling them my water has broken and believing bleeding through multiple pat i'm having cramping i'm having contractions i feel my baby's head starting to come out can you please check she's telling him this over and over and over every opportunity that she can every time to listen we also know that it was obvious they saw it with their own eyes they saw their clothing was soaking wet with amniotic fluid they saw the blood on the pads over and over they saw the blood clots in the toilet they saw that she was crying they saw that she was hyperventilating they saw that she was anxious we also know that they knew that this was a substantial risk because they had specific policies to address it both their policies and their nursing pathways which are more along the lines of procedures indicated that with any of these symptoms that transport was supposed to be immediate either send her to the hospital or get a doctor to look at her immediately they did neither of those things until they could even hear the baby's heartbeat a day later we know that after all of these complaints over and over what did they do what was the evidence of their conscious disregard st they wa luna defended luna waited over an hour to even see her she st said i'm too busy then when she finally did see her she over an hour later she spent six minutes with her she didn't even go through the pathway carefully that would have told her based on believing in cramping and broken water sent her to the hospital right then after she was done in his enchanted town or back to her cell she filled out the pathway from memory twenty minutes later if you check routine several an hour she said well dr got exploited when the pregnant and she called her a liar and called her a figure as john is crying and hyperventilating and saying please don't make me have this baby here and they walked back to the medical unit together when when sanchez took over sanchez knew what had been happening all day she knew about the bleeding she knew about the cramping she knew about the complaints of broken water sanchez didn't even check on seanna who was already in segregation didn't check on her show her st interaction was just by chance she saw her during a minute past she saw the blood she still didn't call the a mess later she gave her tylenol doctoring murray had known about this throughout the day as well was that because there had been any care at all that they were exercising their medical plans with oxendine unself together make clear that is not the test you can't just say that they attempted to render care and therefore it's that's the negligence round and not deliberate indifference the celtic or the court itself was very clear you have to go further and ask the question i don't care what they've already done in terms of care was it patently and reasonable and that's a fact question again and so the question of whether you give a woman water more pads and tylenol when she's standing in front of you soaking wet with amniotic fluid and blood and contractions that's a jury question of whether that is patently unreasonable the court ignored that analysis completely the district court did not even other than one footnote mentioning the self case didn't ask those questions in the self analysis is this patently unreasonable do they recognize their inability to treat it what even a layman who found this to be obvious and those same to decisions also make it clearly established as well in oxon being he was treated every day for a week but that doctor was not entitled to qualified immunity if i could here on earth like to reserve the remaining time for about a documentary with my limited time i'd like to go straight to discussion of this objective in clearly established brands of plaintiff deliberate indifference clean because whether or not this court chooses to dress the issue of qualified immunity  judgment can still be affirmed on either of these two grounds and with respect to the subjective pronk as the court is very well aware plaintiff was required to meet a high of a denture hurdle by presenting evidence that each of the individual defendants consciously and recklessly to me first the patient is in custody and therefore we have to look at this in that context this is a custodial pregnancy we can stow deal birth she couldn't disregard the advice of the nurse or disregard the advice of the prison attendants and run off to a doctor of her own choice or run off to a hospital of her own choice or provide the kinds of rational self relief that would normally be attended to this type of a case instead she is in custody i repeat and the facts are gross i mean i wouldn't want to have a child birth under those circumstances i can't conceive of a single woman who would either so what am i missing well  the plaintiff's own written declarations you know with with nurse luna for example plaintiff does not dispute that nurse luna responded to each of her three requests for medical assistance she does not further dispute that during each of these men it requests for medical assistance that her saloon examined mr tanner's sanitary pad confirm that there was only light spotting that miss turner utilized the fetal heart monitor to assess whether or not the findings and let dr murray decide whether or not further treatment was necessary and what dr murray did at that point with say you know based on what you're telling me that you believe she had a negative niter seem paper test which negative meaning that it did not confirm that there was any out of fluid and that there was only light spotting on the senate terry pat which again is undisputed if you look at tanner's written declaration she confirmed that it was a very light spotting if you and that her vital signs were normal that the pay that the fetus was in the upper left quadrant of miss tanner's abdomen had not quote unquote dropped and thus was not in in in labor that what dr murray did about point based on those that information was let's put her in the sheltered housing unit where she can be observed for if every fifteen minutes and if she a woman is in the hospital and she calls her doctor or the doctor does go see the woman he does it he doesn't examine the woman he it were dead be appropriate step out of chair well  well the question is respectfully are is not whether this was a medical marking this amounted to medical malpractise the question is whether the certain plaintiff has presented evidence of the subjective component which requires a showing which will not be met absent x an extraordinary degree of neglect and that cannot be said about the facts here with any of these three defendants especially with nurse who saw her and least four times over the course of her shift  it's the difference between seeing someone and and taking affective action all of them recognize they were not o b g y n all of them recognize this was above their pay grade in terms of competence and yet no one referred her to the hospital even though they have protocols that just think they should and it seems to me that that is what the the self the case in certain cases all about that you are deliberately indifferent if you recognize expertise is needed that you don't have look i don't think there is no evidence that they recognize that exadata special expertise were required at just as a matter of self evident if you were going to a brain surgeon or two of the diet risk or even to a g p and to please deliver my child they would in the real world say no that requires or should have an expert but  believe without having read all how many hundreds of pages of the record there is and of opinion i believe that there is evidence they recognize that this expertise will the nurses did not believe that she was in the midst of an upset trickle emergency or that she required emergent care well then a reasonable belief summary judgment taking the evidence  that particular test miss tanner continued to have all kinds of symptoms it didn't stop a nurse want to continue to treat her and then there sanchez and dr murray you know  what why didn't they have a responsibility to perform that gatekeeping function based on all of these all of these continuing symptoms you know you can't just say well one test that she it with the continuing nature of her symptoms they were stay were they were never getting worse until the following morning in fact they stayed relatively stable she always had very light spotting her vital signs were stable the fetal movement was always regular and so these nurses they did not believe that there was an emergent situation they require transfer to a hospital and what in an exercise in their gatekeeper function you had a nurse a little who contacted her supervising medical director dr mcmurray and and advised him of what her findings were of what the various diagnostic test results were and then he then decided to move her to a higher level area of the  assessments of her abdomen they were there were a nurse sanchez was counting whether she was having contractions i mean they were trying to determine whether or not this woman was in labor or was not or was just experiencing cramping were what the not to go forward with another type of diagnostic test that me amount to the medical negligence but that doesn't that doesn't necessarily establish deliberate indifference and you know whether that what the procedure of this case is is the eight not all reasonable inferences to the point of the number of times he didn't he eat declined to do so and i believe that had he given all reasonable inferences that it is likely that the opposite result a see that i'm right quickly running out of time and i would be remiss if i didn't address the clearly established prong as well because regardless of how the court does determine the subjective prong summary judgment can still be affirmed on the clearly established prong and plaintiff in their reply really relied on the olson the booker in the prado cases and argues that the issue here is simply that cantor was entitled to receive adequate care of her serious medical needs while incarcerated that that was the clearly established rule but this description of the alleged clearly established right improperly seeks to convert the rule of qualified immunity into a rule of virtual unqualified liability by alleging a violation of an extremely abstract like right right as recently as this month this court in quinn tanya held that the defense dispositive question is whether the violet of nature of the particular conduct is clearly established and so applied to the to the conflict that part of the despised question is really whether it was clearly established that denying a pregnant three trop pretrial detainees or requests for additional diagnostic testing or a otherwise very very similar they they recognize that this the doctors recognize this was normally would require an expert he knew that there was symptoms that were not progressing normally and yet you i'm looking at you i'm doing i'm suffering he tried to make the same argument you're making that it's not a deliberate indifference to medical treatment because he was providing plenty of medical treatment and we said that's not enough we said there that completely on point case but what i think we're what we are saying here is that there should be a case and there isn't one there hasn't been one sided in any thing as briefing below or before this court where you can you can hold one of these defend to to know that by jews by based on their evaluation of what they saw this taney and their the outcome of their diagnostic testing that it was clearly established that they would be violating her constitutional rights if they did not i think to meet that standard and this is why is because even she recognizes and admits that the defendants attempted to provide what they believed in good faith was appropriate care responsive to her complaints now she takes issue with that with what they actually did in the quality of those assessments but that is nothing more than our charging them with medical negligence not the type of extraordinary degree of neglect that's required to meet a deliberate indifference claims thank you thank you her a liar and left her alone without the treatment that she was asking for it wasn't that she needed a specific it wasn't a pelvic exams you need it per se she needed help she needed to know am i in labor and what's happening with my baby and what comes next nobody even looked that's the st thing you do when a pregnant woman says my water just broke erection of the hospital and you have someone look because then they can do what they need and that's exactly what would have saved the baby in this case he died at the very end of labor after thirty hours unmonitored because they haven't made that call that their policies said that they should make that their protocols and that they should make these defendants did not even use the pathway each time that they don't with your symptoms they didn't  nine in the morning the panel will take a but a ten minute recess and then will reconvene reply and that time thank you counsel mr room do we need anything