Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca9-07-15572/USCOURTS-ca9-07-15572-1/pdf.json

Parties Involved:
Ryan Ashton
Appellee
City of Reno
Appellee
Charla Conn
Appellant
Dustin Conn
Appellant
David Robertson
Appellee

Document Text:

FOR PUBLICATION

UNITED STATES COURT OF APPEALS

FOR THE NINTH CIRCUIT

CHARLA CONN; DUSTIN CONN,  No. 07-15572

Plaintiffs-Appellants, D.C. No.

v. Cv-05-00595-HDM 

CITY OF RENO; RYAN ASHTON; ORDER AND

DAVID ROBERTSON, AMENDED

Defendants-Appellees. OPINION 

Appeal from the United States District Court

for the District of Nevada

Howard D. McKibben, District Judge, Presiding

Argued and Submitted

October 20, 2008—San Francisco, California

Filed July 24, 2009

Amended January 8, 2010

Before: Mary M. Schroeder, Dorothy W. Nelson and

Stephen Reinhardt, Circuit Judges.

Order;

Dissent to Order by Chief Judge Kozinski’

Opinion by Judge Reinhardt

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COUNSEL

Terri Keyser-Cooper, Reno, Nevada, and Diane K. Vaillancourt, Santa Cruz, California, for the plaintiffs-appellants.

John J. Kadlic, Reno City Attorney, Donald L. Christensen,

Deputy City Attorney, Reno, Nevada, for the defendantsappellees.

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ORDER

The majority opinion filed July 24, 2009, slip op. 9581, and

appearing at 572 F.3d 1047 (9th Cir. 2009), is hereby

amended as follows:

1. Slip op. at 9611, line 7: replace <No such policy

had been adopted and implemented as of April 26,

2005.> with <This is further evidence that as of

April 26, 2006 no such policy had been adopted and

implemented.>

2. Slip op. at 9611, line 8: after <This is further evidence that as of April 26, 2006 no such policy had

been adopted and implemented.>, insert the following footnote: <The evidence of the new policy is

admissible solely as evidence of the absence of an

earlier policy and not for the purpose of proving negligence or culpable conduct of any kind. See Fed. R.

Evid. 407.>

The panel has voted to deny the petition for rehearing en

banc.

The full court was advised of the petition for rehearing en

banc. A judge requested a vote on whether to rehear the matter en banc. The matter failed to receive a majority of the

votes of the nonrecused active judges in favor of en banc

reconsideration. FED. R. APP. P. 35. 

The petition for rehearing en banc is denied. No further

petitions for rehearing may be filed.

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Chief Judge KOZINSKI, with whom Judges

O’SCANNLAIN, KLEINFELD, TALLMAN, CALLAHAN,

BEA and IKUTA join, dissenting from the denial of rehearing

en banc.

Until this opinion came along, police officers weren’t

required to serve as babysitters, psychiatrists or social workers, and judges didn’t run suicide-prevention programs.

Responsibility for preventing suicide rested with the individual and the family, not the state. But the panel has discovered

that the Constitution demands a change in job description:

Judges will henceforth micromanage the police, who in turn

will serve as mental health professionals. The panel’s reasoning has no stopping point, and our decision to let it stand

threatens unprecedented judicial intervention in our local

institutions. 

At bottom, this case raises the question of whether the state

has a legal (as opposed to moral) obligation to provide for the

health of its citizens. We have repeatedly rejected the idea

that such an obligation exists. See, e.g., DeShaney v. Winnebago Cty. Dept. of Soc. Servs., 489 U.S. 189, 200 (1989). This

is in part because the benevolent welfare state is in tension

with our tradition of liberty and individual dignity: What the

state provides for you, you do not provide for yourself, and

as the sphere of public largesse grows, the realm of private

initiative retreats. It also reflects a judgment that any redefinition of the role of the state should occur under the supervision

of democratically elected officials, not unaccountable federal

judges. States may obligate themselves, but they should not

have novel duties thrust upon them by judicial fiat. 

We have recognized an exception to this rule when the state

places a person in jail, but that exception has been strictly limited by its rationale. “The affirmative duty to protect arises

not from the State’s knowledge of the individual’s predicament or from its expressions of intent to help him, but from

the limitation it has imposed on his freedom to act on his own

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behalf.” DeShaney, 489 U.S. at 200. A prisoner cannot feed

or clothe himself, and he cannot get himself to a doctor; it is

therefore incumbent on his keeper to do those things for him.

See, e.g., id.; Estelle v. Gamble, 429 U.S. 97, 103 (1976).

And, because the state creates the prisoner’s conditions of

incarceration, the state has a duty not to purposefully create

a risk of harm—for instance, by placing the prisoner in a cell

with a person who intends to do him ill. See, e.g., Farmer v.

Brennan, 511 U.S. 825, 832-33 (1994). Apart from that rationale, there is no free-floating obligation to safeguard prisoners’ health. Otherwise, the distinction between prisoners and

non-prisoners would become illusory, and we would be

forced to recognize a duty of care towards society as a whole.

The panel’s opinion is significant because it cuts the state’s

obligation loose from this tether and creates novel duties to

train and to report information that bear no relationship to the

fact of incarceration. In the process, it strips the guts out of

the deliberate indifference standard, as well as the requirement that plaintiffs show a violation of clearly established law

to defeat qualified immunity. In the panel’s hands, standards

that are meant to limit liability to all but the most extreme

cases become tools for imposing the policy preferences of

unelected federal judges. This combination of errors amounts

to a toxic recipe for judicial micromanagement of local institutions. 

1. In a brief portion of the opinion that will nevertheless

have far-reaching consequences, the panel finds the City of

Reno potentially liable for failure “to train its officers in suicide prevention and the identification of suicide risks.” Conn

v. City of Reno, 572 F.3d 1047, 1063 (9th Cir. 2009). To

avoid liability under our federal Constitution, police departments throughout the Ninth Circuit must now transform their

police officers into suicide prevention experts. This novel

holding creates a clear inter-circuit split and is irreconcilable

with the standard for liability fashioned by the Supreme Court

in City of Canton v. Harris, 489 U.S. 378 (1989). 

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When ordinary citizens go about their business, they are not

monitored by experts in suicide prevention. If you or I waltz

up to a government employee— perhaps a mail man, dog

catcher or meter maid—and announce, “today’s a good day to

kill myself,” the Constitution does not guarantee that our chosen confidant will be a Sigmund Freud or Jacques Lacan. If

we want to see a psychiatrist, we have to go see a psychiatrist.

We certainly don’t have a right to expect that every public

servant we encounter will be specially trained to cater to our

mental health needs. 

According to the panel, citizens who are arrested fall into

a different and more rarified class. When Brenda Clustka

announced her suicidal thoughts to the officers sent to arrest

her, she had the right to an audience trained in “suicide prevention and the identification of suicide risks.” Conn, 572

F.3d at 1063. Indeed, the failure to provide that audience was

“the functional equivalent of a decision by the city itself to

violate the Constitution.” Harris, 489 U.S. at 395 (O’Connor,

J., concurring in part and dissenting in part). But why? What

constitutional penumbra turns the bench of a paddy wagon

into a psychoanalyst’s couch? 

Plaintiffs are not the first litigants to seek to impose such

a novel and dangerous duty, but other courts have steadfastly

rejected similar claims. Manarite v. City of Springfield, 957

F.2d 953, 959 (1st Cir. 1992) (rejecting claim that city was

liable for failing to provide “training and education . . . in suicide detection and prevention”); Colburn v. Upper Darby

Twp., 946 F.2d 1017, 1029-30 (3d Cir. 1991) (rejecting claim

that jail was liable because it “failed completely to formally

train its staff in signs and symptoms of suicide,” including

“instruction to take all suicide threats seriously”) (emphasis

omitted); Popham v. City of Talladega, 908 F.2d 1561,

1564-65 (11th Cir. 1990) (no liability for “failure to train jail

personnel to screen detainees for suicidal tendencies”); Burns

v. City of Galveston, 905 F.2d 100, 104 (5th Cir. 1990) (no

liability for “[f]ailure to train police officers in screening proCONN v. CITY OF RENO 641

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cedures geared toward detection of detainees with suicidal

tendencies”); see also Harris, 489 U.S. at 396-97 (O’Connor,

J., concurring in part and dissenting in part) (“The claim in

this case—that police officers were inadequately trained in

diagnosing the symptoms of emotional illness—falls far short

of the kind of ‘obvious’ need for training that would support

a finding of deliberate indifference . . . .”). 

What Clustka surely did have was a right of access to medical treatment; because Clustka could not take herself to the

doctor, the city had an obligation to make psychiatric care

available to her. See Estelle, 429 U.S. at 103. The city more

than fulfilled that obligation. Right before her arrest, Clustka

was evaluated by a team of medics. At intake, she was examined by a nurse who received annual training in suicide prevention. She was then held in a detoxification cell that was

regularly monitored by jail staff and nurses. After discharge,

she was arrested a second time and brought by police to an

emergency room, where she was seen by a physician. And

when she was arrested a third time, she was booked into the

mental health unit of the jail, which is managed by a licensed

social worker and staffed around the clock. When Clustka

committed suicide, she was scheduled to meet with a psychiatric nurse later that day. And there is no reason to think that

Clustka would have been denied additional care if she had

requested it. 

Other circuits have rejected claims that the Constitution

requires the kind of routine intake screening that was provided by the City of Reno. See Colburn, 946 F.2d at 1029-30;

Popham, 908 F.2d at 1564; Burns, 905 F.2d at 104. Rightly

so: Such screening may be laudable, but it also provides a

benefit that prisoners could not reasonably expect to receive

if they had not been arrested. The measures taken by the city

therefore went far beyond anything the Constitution could

conceivably require. 

Against the backdrop of the city’s efforts, the panel’s holding that the city could be found deliberately indifferent is

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remarkable. “[F]ar from demonstrating deliberate indifference

to the mental health needs of . . . potentially suicidal detainees, . . . the policies implemented by the City [of Reno] demonstrate an effort to ensure the safety of persons like

decedent.” Manarite, 957 F.2d at 960; see also Liebe v. Norton, 157 F.3d 574, 579 (8th Cir. 1998) (“[T]he County’s policy cannot be both an effort to prevent suicides and, at the

same time, deliberately indifferent to suicides.”). The panel

isn’t just saying that the city has to be aware of and take steps

to address the problem of suicide. The city plainly did that,

and more. The panel is saying that the act of employing professionals to examine and care for inmates’ mental health

won’t suffice; the city has a duty to enlist police officers as

trained suicide-prevention experts. And, more broadly, the

city is obliged to run its suicide prevention program in whatever manner unelected federal judges think best. 

This is precisely the kind of micromanagement of local law

enforcement that the Supreme Court has instructed us to

avoid. See Harris, 489 U.S. at 392. The Court in Harris was

clear that deliberate indifference means more than negligence,

and that a high bar to liability is necessary to forestall “an

endless exercise of second-guessing municipal employeetraining programs”—both because federal judges are “illsuited” to such a role and because excessive judicial intervention would “implicate serious questions of federalism.” Id.

As an example of conduct that might satisfy the deliberate

indifference standard, the Court therefore pointed to a total

abdication of constitutional responsibility: A city that armed

its police but failed to train them in the use of deadly force.

Id. at 390 n.10. This is hardly that kind of case. The city

didn’t fail to address the problem of inmate suicide; it failed

to address the problem in the way my colleagues think best.

If that is enough to give rise to liability, I can’t imagine what

local institution is safe from judicial meddling, or what if anything is left of our tradition of local self-government. 

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2. In another troubling portion of the opinion, the panel

holds that clearly established law required the officers transporting Clustka to report any suicide threats made en route to

jail. Conn, 572 F.3d at 1062. On that basis, the panel withholds qualified immunity. Id.

To see why the panel’s holding is remarkable, consider the

context in which these defendants acted. The officers did not

take Clustka to the hospital after the events in question, but

they did take her to a prison where they knew she would be

seen upon arrival by a nurse trained in detecting and preventing suicide risks. They did not tell the nurse what Clustka said

after being arrested, and the care that Clustka received may

have been less effective as a result. But the officers did not

withhold psychiatric care or actively interfere with Clustka’s

treatment. Their alleged fault was in failing to pass on information that would be relevant to routine psychiatric screening

that the city should not be required to provide in the first

place. The panel’s denial of qualified immunity in these circumstances means that officers can no longer leave the treatment of medical issues to trained medical professionals.

Instead, they must actively assist those professionals by providing any information potentially relevant to a diagnosis. I

doubt such a duty exists, and I certainly don’t think it exists

under clearly established law. 

Once again, if ordinary citizens threaten suicide in front of

a government employee—be it a tax collector, tollbooth operator or member of the judiciary— they have no constitutional

right to have those statements communicated to their families

or their doctors. Our Constitution does not turn government

officials into the eyes and ears of the American Medical Association. So why should it be any different for citizens lucky

enough to go to jail? It’s true that prisoners can’t take themselves to the doctor, Estelle, 429 U.S. at 103, but the officers

here took Clustka to a place where she was seen by a medical

professional trained in suicide prevention. After the officers

put Clustka in the same (or better) position than she occupied

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before she was arrested, what in our federal Constitution

required anything more? I can’t imagine any answer that

would not apply with equal force to those of us not in jail. 

Our prior cases have rightly declined to acknowledge such

a duty to assist. In Wood v. Housewright, we rejected a prisoner’s claim that prison officials violated his constitutional

rights by failing to provide his medical records to medical

professionals. 900 F.2d 1332, 1334 (9th Cir. 1990). Judge

Reinhardt argued in dissent that failure to provide information

constitutes deliberate indifference because “treatment can . . .

best be prescribed if records are available for review,” id. at

1343 (Reinhardt, J., dissenting in part), just as he reasons

today that, although Clustka received medical care, her diagnosis “was never made by someone who had all the requisite

information about her psychological instability,” Conn, 572

F.3d at 1060 (emphasis omitted). In Wood, a majority of the

panel disagreed. See 900 F.2d at 1334 (Farris, J.); id. at 1336

(Hug, J., concurring). “Although Wood’s treatment was not as

prompt or efficient as a free citizen might hope to receive,

Wood was given medical care at the prison that addressed his

needs.” Id. at 1334 (Farris, J.); see also Ruvalcaba v. City of

Los Angeles, 167 F.3d 514, 525 (9th Cir. 1999) (prison doctor’s failure to take patient’s medical history, although negligent, did not support finding of deliberate indifference). That

was correct then, and it remains correct today. 

Despite this contrary precedent from our own court, the

panel reverses the district court’s grant of qualified immunity.

Conn, 572 F.3d at 1062. Of course, the cases the panel cites

to show a violation of clearly established law demonstrate

nothing of the kind. The only Ninth Circuit case, Cabrales v.

County of Los Angeles, involved a claim for “medical understaffing at the jail,” such that “psychiatric staff could only

spend minutes per month with disturbed inmates.” 864 F.2d

1454, 1461 (9th Cir. 1988). And in Colburn, although a suicidal inmate was held in prison without any medical attention

whatsoever (including no medical screening at intake), the

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Third Circuit found the officers not liable for their failure to

provide access to medical care. 946 F.2d at 1025. Both cases

are miles away from this one, and Colburn supports the

defendants rather than the plaintiffs. 

The closest case is Cavalieri v. Shepard, 321 F.3d 616 (7th

Cir. 2003), but it doesn’t support the panel’s conclusion

either. In that case, a police officer assured an arrestee’s

mother that her son would not be left alone while in jail but

failed to pass that information on to the son’s custodians. Id.

at 622. The Seventh Circuit emphasized that the mother might

“have gone directly to the [jail] if she had known that [the

officer] did not intend to inform anyone of their conversation.” Id. By contrast, Clustka’s family never asked these individual defendants for help, and they never promised to give

it. The only obligation they incurred when they took Clustka

into custody was to ensure that incarceration did not deprive

her of the care that she otherwise could have obtained for herself. See DeShaney, 489 U.S. at 200. The officers fulfilled that

obligation. 

Cities and police should be entitled to assign responsibility

for the treatment of mental illness to trained medical professionals; certainly, the Constitution should not forbid such a

division of responsibility. But the panel holds to the contrary:

From here on out, police must become active participants in

the treatment of mental illness. And, unable to rely on the

shield of qualified immunity, police will wait with trepidation

to see what other novel duties courts shift onto their shoulders. This will exact a cost: As police devote time and energy

to judicially-imposed obligations, they will have less time and

attention to devote to preventing crime, protecting their own

safety and avoiding other types of constitutional violations.

These are precisely the kinds of trade-offs that should be evaluated by elected officials, and not by federal judges who lack

expertise and local knowledge and who do not represent the

people directly affected by such decisions. 

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3. In yet another alarming portion of the opinion, the panel

holds that a jury could find that the officers’ failure to relay

information on April 26 was the actual and proximate cause

of Clustka’s suicide on April 28. Conn, 572 F.3d at 1058-62.

The panel’s lax approach to causation dismantles yet another

barrier to judicial intervention in local affairs. 

With respect to “actual” cause, we simply don’t know what

would have happened had the officers reported Clustka’s

statements to the jail. The prison’s health services administrator testified that the intake nurse would have considered the

statements along with “a variety of variables” when assessing

Clustka’s mental health needs. We therefore can’t know

whether Clustka would have received additional care, or

whether that care would have been effective. The best the

panel can say is that “Clustka’s suicide might well have been

prevented” by “intervention [that] would likely have

occurred.” Id. at 1060 (emphasis added). This falls far short

of showing that, “but for” the officers’ omission, Clustka

would not have committed suicide. White v. Roper, 901 F.2d

1501, 1505 (9th Cir. 1990). 

As for proximate cause, any conceivable connection

between the officers’ omission and Clustka’s suicide is far too

attenuated to support liability. Two full days passed between

Clustka’s statements and her suicide. In the interim, Clustka

was “served with a Temporary Protective Order (‘TPO’),

which her mother had earlier sought” and which “ordered

Clustka to stay away from her mother’s residence.” Conn, 572

F.3d at 1053. Clustka was also arrested twice, at least once

because her own mother called police, rather than a doctor,

“to report that Clustka was causing a disturbance.” Id. And

her mother wasn’t the only one who passed up a chance to

keep Clustka from taking her life. Clustka was taken to the

hospital, where she was examined by a physician and then

released. And she was seen by two intake nurses trained in

suicide prevention. 

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The requirement of causation—like the deliberate indifference standard and the doctrine of qualified immunity—limits

the ability of judges to micromanage local institutions. See

Harris, 489 U.S. at 391-92. So long as they are limited to

errors that actually caused plaintiffs’ injuries, judges sit to

decide concrete cases and do not superintend entire programs

and institutions. But, if judges can draw attenuated causal

connections of the sort at issue in this case, they can expand

their authority to encompass a much larger sphere of activity.

Any mistake by local officials, no matter how remote its consequences, will become a federal case, and no corner of local

activity will remain beyond judicial authority. The Butterfly

Effect becomes an engine for judicial intervention. This may

appeal to federal judges, who undoubtedly believe they know

how to run local law enforcement far better than police and

local officials, but it should make everyone else very uncomfortable. 

* * *

Untethered from the need to explain why the state should

owe any affirmative obligations to its citizens, and unconstrained by qualified immunity, causation and the deliberate

indifference standard, judges will henceforth be free to

intrude on the most minute aspects of local decisionmaking.

The Constitution will have become a “ ‘federal good government act’ for municipalities,” Harris, 489 U.S. at 396

(O’Connor, J., concurring in part and dissenting in part), and

little will be left of our tradition of local self-government.

Second-guessing suicide-prevention measures designed by

local officials, and turning police into psychiatrists’ assistants,

will be just the beginning of this brave new world of rule by

judiciary. This is a sweeping and dangerous precedent, and

we severely undermine the autonomy of local governments by

failing to correct the error through our en banc process. 

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OPINION

REINHARDT, Circuit Judge:

This story has no happy ending, and it was unhappy long

before the events in question transpired. For years before she

ultimately committed suicide in the Washoe County Jail,

Brenda Clustka (“Clustka”) struggled with alcohol abuse and

serious mental health problems, including suicidal ideation.

The longevity of her struggle and the persistence of her problems, however, do not absolve the defendants if they were

deliberately indifferent to her serious medical need and as a

result played a causal role in her death. 

While transporting Clustka to civil protective custody, two

Reno police officers witnessed her wrap a seatbelt around her

neck in an apparent attempt to choke herself and then scream

that they should kill her or else she would kill herself. The

officers failed to report the incident to jail personnel or take

her to a hospital. Clustka was released from protective custody a few hours later. The next day, she was again detained

on a misdemeanor charge. During this second detention, less

than 48 hours after the suicide threats, Clustka hanged herself

in her cell. 

When an individual is taken into custody and thereby

deprived of her liberty, the officials who hold her against her

will are constitutionally obligated to respond if a serious medical need should arise. If, with deliberate indifference, these

officials fail to respond appropriately and instead act in a

manner that will foreseeably result in harm, they violate her

due process rights. The same is true when a municipality, with

deliberate indifference, fails to train its law enforcement officers or fails to adopt and implement policies when it is highly

predictable that such inaction will result in constitutional violations. 

We hold that, on the facts presented, a reasonable jury

could find that the defendant police officers are liable under

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42 U.S.C. § 1983 for their deliberate indifference to Clustka’s

serious medical need, and that their actions were a cause in

fact and a proximate cause of her suicide. Likewise, a jury

could find the City of Reno liable for its failure to train its law

enforcement officers or to implement policies on suicide prevention and reporting. For these reasons, and as explained further below, we reverse the district court’s grant of summary

judgment in favor of the defendants and allow Clustka’s surviving children to bring their claims before a jury. 

I. BACKGROUND

A.

Petitioners Charla and Dustin Conn (“the Conns”) are the

surviving children of Brenda Clustka, who committed suicide

on April 28, 2005 while in custody and awaiting trial at the

Washoe County Jail.

Clustka had long struggled with mental health problems

and suicidal ideation. She also had a history of repeated

encounters with the law: she had multiple misdemeanor convictions, including for domestic violence, larceny, and driving

under the influence. Between 2001 and 2004, Clustka was

involuntarily committed to the Nevada Mental Health Institute (“NMHI”) on three separate occasions under a Legal 20001

for threatening or attempting suicide. Her mental health further deteriorated in 2005. 

On March 19, 2005, Clustka was arrested for domestic battery of her mother. Officer Ashton (“Ashton”), one of the

defendants in this case, was present during the arrest. Once in

custody, Clustka stated that she “[wouldn’t] make it in jail”

1A Legal 2000 is a procedure under Nevada law whereby people suffering from mental illness or who may be a danger to themselves or others

may be involuntarily committed to a mental health facility for up to 72

hours. 

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and was placed on prison suicide watch. She was detained for

just over one month and released on April 21, 2005.

A few days later, on April 25, 2005, Clustka relapsed into

suicidal ideation. She was taken to Washoe Medical Center

where she threatened to commit suicide in the emergency

room by overdosing on her medication. Clustka was evaluated

as suffering from “acute suicidal ideation” and transferred to

NMHI on a Legal 2000. Her NMHI intake assessment states

that she was at “serious risk of harm.” At 9:06 a.m. the next

morning, however, Clustka was medically evaluated and

released. According to the evaluating doctor, Clustka denied

that she had any suicidal thoughts; she said she was “feeling

‘tired’ but otherwise well” and was assessed to be only at a

“low risk of harm” at the time of discharge.

Several hours later on April 26, 2005, at 2:43 p.m., Ashton

and his co-defendant, Officer Robertson (“Robertson”), were

dispatched in response to a 911 call, which reported that

someone, who turned out to be Clustka, was passed out on the

sidewalk. The officers found Clustka in a “grossly intoxicated” state; she “had a difficult time walking without assistance.” Ashton, who had been one of the arresting officers

handling the domestic battery call a month earlier, recognized

Clustka on sight. The officers decided to take Clustka to

Washoe County Jail on Civil Protective Custody (“CPC”) for

her own safety until she sobered up. They ran a “wants and

warrants check” and were cautioned of Clustka’s “violent tendencies, [that she was] known to abuse drugs, [was an] alcoholic [and had] other mental health problems.” Ashton

admitted that he was aware of Clustka’s violent tendencies

and mental health problems; nevertheless, the defendants

chose not to handcuff her because she was being detained for

her own protection, not on a criminal charge. 

Clustka did not want to be taken to jail; she became agitated and uncooperative when told where she was going. Robertson then told Clustka, falsely, that they would take her,

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instead, to her residence. Robertson testified that he lied

because Clustka was belligerent, and because he wanted to

cajole her into the paddy wagon cooperatively, which he succeeded in doing.

En route to the jail, with her hands free, Clustka removed

her seatbelt. She began walking around the back of the paddy

wagon and tapping on the video surveillance camera to get the

officers’ attention. According to Ashton, he asked Robertson

if they should pull over to secure Clustka in her seat, but Robertson decided against it, as they were near the jail and he

wanted to avoid any further confrontation. Both officers

believed that there was a Reno Police Department policy and

a state law requiring the wearing of seatbelts.

As they neared the jail, Clustka realized where she was

being taken and became angry, belligerent, and uncooperative. As Ashton observed her through the surveillance camera,

Clustka returned to her seat and wrapped the seatbelt around

her neck, in an apparent attempt to choke herself. The officers

pulled over, unwrapped the seatbelt from her neck, and handcuffed her. Clustka was screaming as they did so. She yelled

something to the effect of, “You lied to me. Just kill me. I’ll

kill myself then.”

Both Ashton and Robertson testified that they interpreted

Clustka’s words and actions as a mere attempt to get their

attention and “to manipulate the situation,” and that they did

not believe Clustka’s threats to be serious. However, Ashton

admitted that he did not believe that wrapping the seatbelt

around her neck was a “joke.” Ashton, who had been on the

police force for only seven months, remembered asking Robertson, a nearly eighteen-year veteran, whether he should

write up a report on the incident, but that Robertson said no.

Robertson testified that he “told [Ashton] if he wanted to

report it, he could report it.” Ashton testified that he was

unaware of any written policy mandating the reporting of

such incidents. 

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When they arrived with Clustka at the jail, neither defendant notified jail personnel that Clustka had tried to choke

herself or that she had threatened to commit suicide. Instead,

Ashton told jail personnel that Clustka was disoriented. The

defendants did not write a report nor inform their supervising

sergeant about the incident that day. Both asserted that it did

not occur to them to report it.

Upon arrival at the jail, Clustka underwent a brief intake

assessment, was held in CPC at the Washoe County Jail for

nearly four hours, and was released without further inquiry

around 8:00 p.m. Upon her release, she was served with a

Temporary Protective Order (“TPO”), which her mother had

earlier sought and obtained on account of domestic battery.

The TPO ordered Clustka to stay away from her mother’s residence, where she had been living, and to retrieve her personal

belongings only in the company of police officers. There is no

indication whether any other place was available where

Clustka would be able to sleep.

That evening, notwithstanding the TPO, Clustka returned to

her mother’s house, and her mother called 911 to report that

Clustka was causing a disturbance. Clustka, again grossly

intoxicated, was taken to the emergency room, readmitted for

observation, and released around 3:00 a.m.

The next day, on April 27, 2005, Clustka again returned to

her mother’s residence to collect her belongings and was

arrested by two officers (not defendants) for violating the

restraining order. She was returned to Washoe County Jail. 

After Clustka was booked, she was medically screened by

the nurse on duty and recommended for assignment to the

general inmate population. Because Clustka had been on suicide watch during her previous detention in March, she was

placed in the mental health unit in a red jumper to alert staff

that she was a high risk detainee. She was not, however,

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placed on suicide watch at this time. As a result there was a

bed sheet available in her cell.

The following morning, on April 28, 2005, Clustka was

escorted to and from her video arraignment. On the way back

from the arraignment, at 8:35 a.m., she became upset and

started crying because she wanted to make a phone call. At

9:17 a.m., she did not respond to the roll call. A deputy went

to check on her and immediately called a Code 50.2 Clustka

had committed suicide by hanging herself with the bed sheet.

The morning of Clustka’s suicide, Ashton happened to be

present at the Washoe County Jail on an unrelated matter. He

recognized Clustka’s photograph and told a prison deputy that

“she tried to choke herself out in the back of the wagon on

Tuesday.” Ashton explained to another deputy that a few days

earlier, he had transported Clustka to CPC — without handcuffs — and that “she tried to hang herself in the wagon.” He

stated that his more senior partner had declined to document

the incident. Ashton said that he would now write up a report

and predicted that his “sergeant will be pissed.”

B.

From January 2004 through August 2005, six detainees in

Washoe County Jail committed suicide. Clustka’s suicide followed less than 30 days after that of another detainee.

On May 11, 2005, less than one month after Clustka’s suicide, the Reno Police Department, apparently for the first

time, presented a class on “handling the mentally ill” to better

explain the Legal 2000 procedures. In May 2005, a new suicide prevention policy was implemented. At intake, the arresting officer must now answer a series of questions concerning

the detainee’s mental health, including questions about sui2Code 50 is a jail response when an inmate attempts suicide. Officers

and medical personnel rush to the scene. 

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cide risk. This policy was not adopted until after Clustka’s

death.

C.

After Clustka committed suicide, her surviving children,

the Conns, filed suit in the District of Nevada under 42 U.S.C.

§ 1983. They sued Officers Robertson and Ashton for deliberate indifference to Clustka’s serious medical need — her suicide risk — which, they alleged, resulted in her death. They

also sued the City of Reno under § 1983 for, inter alia, its

failure to train its law enforcement officers and to implement

policies on suicide prevention and reporting. The district court

found that the Conns had presented insufficient evidence to

raise a genuine issue of material fact as to whether the officers

were deliberately indifferent to a serious medical need by failing to report the choking incident and suicide threat and

whether such failure to report was the proximate cause of

Clustka’s death. Consequently, the district court concluded

that there was no basis on which a jury could find either individual liability or municipal liability and granted the defendants’ motion for summary judgment. The Conns appeal, and

we reverse.

II. STANDARD OF REVIEW

We review a grant of summary judgment by the district

court de novo. McDonald v. Sun Oil Co., 548 F.3d 774, 778

(9th Cir. 2008). We examine all evidence in the light most

favorable to the non-moving party, id.; Fed. R. Civ. P. 56, and

“do[ ] not weigh the evidence or determine the truth of the

matter, but only determine [ ] whether there is a genuine issue

for trial,” Balint v. Carson City, 180 F.3d 1047, 1054 (9th Cir.

1999) (en banc). “A dispute as to a material fact is genuine

if there is sufficient evidence for a reasonable jury to return

a verdict for the non-moving party.” Long v. County of Los

Angeles, 442 F.3d 1178, 1185 (citing Anderson v. Liberty

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Lobby, Inc., 477 U.S. 242, 248 (1986)). If such is the case,

“summary judgment will not lie.” Anderson, 477 U.S. at 248.

III. DISCUSSION

A. Individual Liability

[1] The Eighth Amendment protects inmates from cruel and

unusual punishment, which includes the denial of medical

care. Estelle v. Gamble, 429 U.S. 97, 102-03 (1976). Pretrial

detainees, by contrast, are protected under the Due Process

Clause of the Fourteenth Amendment. Or. Advocacy Ctr v.

Mink, 322 F.3d 1101, 1120 (9th Cir. 2003). Although courts

have borrowed from Eighth Amendment jurisprudence in giving shape to pretrial detainees’ substantive due process rights,

see Frost v. Agnos, 152 F.3d 1124, 1128 (9th Cir. 1998), that

amendment establishes only “a minimum standard of care,”

Mink, 322 F.3d at 1120 (emphasis in original).3

[2] The Eighth and Fourteenth Amendments both guarantee

that inmates and detainees receive constitutionally adequate

medical and mental health care. Doty v. County of Lassen, 37

F.3d 540, 546 (9th Cir 1994). An official’s deliberate indifference to a substantial risk of serious harm to an inmate —

including the deprivation of a serious medical need — violates the Eighth Amendment, and a fortiori, the Fourteenth

Amendment. Farmer v. Brennan, 511 U.S. 825, 828 (1994);

Frost, 152 F.3d at 1128. To set forth a constitutional claim

under the Eighth Amendment predicated upon the failure to

provide medical treatment,

3Because here, the Conns prevail under the Eighth Amendment deliberate indifference standard, we need not further explicate in this case the

more lenient but more amorphous test under the Fourteenth Amendment

that has been suggested by our case law. See, e.g., City of Revere v. Mass.

Gen. Hospital, 463 U.S. 239, 244 (1983); Youngberg v. Romeo, 457 U.S.

307, 321-22 (1982); Gibson v. County of Washoe, 290 F.3d 1175, 1188 n.9

(9th Cir. 2002); Mink, 322 F.3d at 1120, 1121 n.11; Jones v. Blanas, 393

F.3d 918, 934 (9th Cir. 2004). 

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[f]irst, the plaintiff must show a “serious medical

need” by demonstrating that “failure to treat a prisoner’s condition could result in further significant

injury or the ‘unnecessary and wanton infliction of

pain.’ ” Second, the plaintiff must show the defendant’s response to the need was deliberately indifferent.

Jett v. Penner, 439 F.3d 1091, 1096 (9th Cir 2006) (internal

citations omitted). The second prong requires both “(a) a purposeful act or failure to respond to a prisoner’s pain or possible medical need and (b) harm caused by the indifference.” Id.

Deliberate indifference thus requires an objective risk of harm

and a subjective awareness of that harm. Farmer, 511 U.S. at

837. We address these requirements — serious medical need,

indifference to that need, and harm caused by that indifference — each in turn.

1. “Serious medical need”

[3] We recognize that a prisoner has a “serious” medical

need if the failure to treat the condition could result in further

significant injury or the “unnecessary and wanton infliction of

pain.” Doty, 37 F.3d at 546 (citing McGuckin, 974 F.2d at

1059). A heightened suicide risk or an attempted suicide is a

serious medical need. See id. (citing Torraco v. Maloney, 923

F.2d 231, 235 & n.4 (1st Cir. 1991)); see also Colburn v.

Upper Darby Twp., 946 F.2d 1017, 1023 (3d Cir. 1991) (“A

‘particular vulnerability to suicide’ represents a ‘serious medical need.’ ”). 

The district court did not decide whether summary judgment would be appropriate on the issue of serious medical

need, although it commented that the evidence suggested that

“Clustka’s medical needs . . . were not objectively serious

enough to find a 14th Amendment violation.” We disagree.

The Conns presented sufficient evidence of their mother’s

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objective, serious medical need for a reasonable jury to find

in their favor. 

[4] First, the significance of Clustka’s medical evaluations

around the time of the choking incident and suicide threat is

disputed and presents a question for the jury. It is true that

Clustka underwent several medical evaluations in the days

before and after she tried to choke herself in the paddy wagon,

and that only one of these evaluations found her to be at serious risk of harm. The defendants argue that, for this reason,

the evaluations establish that Clustka did not present a serious

health risk. Their interpretation, however, is not conclusive;

rather, the conflict in the evaluations in itself raises a genuine

issue of fact for the jury to resolve. Moreover, due to the

police officers’ failure to report the choking incident and suicide threat, Clustka’s evaluators were unaware of those events

when they assessed Clustka’s mental health, and their conclusions were drawn in the absence of significant information

that would have supported the Conns’ position. 

[5] Second, Clustka’s long and undisputed history of mental health problems, alcohol and substance abuse, and suicide

threats and attempts — including suicidal ideation the day

before the incident in the paddy wagon — supports the conclusion that the threat to Clustka’s health was objectively serious, and that if untreated, she was likely to suffer further

significant injury. 

[6] Third, the choking incident, accompanied by Clustka’s

threat to kill herself, constituted adequate objective evidence

of a serious medical need. Although Ashton conceded that

Clustka was not joking when she wrapped the seatbelt around

her neck, the defendants attempt to minimize the seriousness

of Clustka’s situation by characterizing her threats as “manipulative” — as an attempt to catch the officers’ attention and

to avoid going to jail. The members of the jury, however, are

entrusted with the responsibility to weigh the officers’ interpretation of the events against other reasonable inferences

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more favorable to the plaintiffs. The events may appear differently to the jury than they purportedly did, in hindsight, to

Ashton and Robertson. To the jury, that Clustka attempted to

choke herself with a seatbelt and screamed at the defendants

that they should kill her or she would kill herself may, by

itself, be sufficient to establish her serious medical need. This

is particularly so since the Conns presented evidence that suicide threats by detainees must always be taken seriously. 

The defendants contend that, even if Clustka truly intended

to harm herself, there was no genuine possibility that she

would have succeeded in killing herself in the paddy wagon.

The defendants argue, rather callously, that the seatbelt would

have slackened if and when she passed out, and that Clustka

was therefore at no real risk of dying. This, of course, is

beside the point. Whether Clustka’s life was in danger en

route to the jail does not affect the more important question

whether Clustka was at a heightened risk of killing herself in

the near future, as she ultimately did — a heightened risk that

itself presents a serious medical need. It is not necessary,

moreover, that a serious medical need imminently result in

death — an attempted suicide is sufficient. See Doty, 37 F.3d

at 546 (citing Torraco, 923 F.2d at 235 & n.4). 

[7] An objective juror could certainly conclude that in light

of all the circumstances Clustka’s actions evidenced a serious

medical need. The defendants’ attempts to cast doubt on the

gravity of Clustka’s words and actions merely create a fact

question for the jury to resolve. We conclude, therefore, that

the Conns have raised a genuine issue of material fact as to

the question of serious medical need.

2. “[D]efendant’s response to the need was deliberately indifferent”

To demonstrate the second prong — deliberate indifference

— plaintiffs must show that the officers were (a) subjectively

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aware of the serious medical need and (b) failed to adequately

respond. Farmer, 511 U.S. at 828.

a. Subjective awareness

[8] To be liable under the Eighth Amendment for denial of

medical treatment to a detainee, an official must “know[ ] of

and disregard[ ] an excessive risk to inmate health or safety;

the official must both be aware of facts from which the inference could be drawn that a substantial risk of serious harm

exists, and he must also draw the inference.” Farmer, 511

U.S. at 834, 837. In other words, the official must demonstrate a subjective awareness of the risk of harm.

Ashton and Robertson do not dispute that they witnessed

Clustka wrapping a seatbelt around her neck and yelling that

she wanted to die. Rather, they assert that they did not believe

Clustka’s actions to be a “serious” threat or attempt of suicide. Put in Farmer’s terms, they contend that they did not

“draw the inference,” id., that Clustka was genuinely at risk

despite being “aware of facts from which the inference could

be drawn,” id. According to the officers, Clustka’s actions

seemed to them an attempt at manipulation. Once she realized

that she was being transported to jail, Clustka tapped repeatedly on the surveillance camera to get the officers’ attention

but received no response. By wrapping the seatbelt around her

neck, they explain, she was merely resorting to more dramatic

measures to get the officers’ attention, stop the paddy wagon,

and avoid going to jail. The officers, moreover, recall discounting the seriousness of her actions on account of her state

of intoxication. They also argue that Clustka could not have

succeeded in killing herself because the seatbelt would have

slackened around her neck once she passed out, thus her

threat of suicide could not have been serious. 

[9] We may not affirm the district court’s grant of the

defendants’ motion for summary judgment, however, simply

on the basis of the defendants’ assertions as to their own state

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of mind. Proof of “subjective awareness” is not limited to the

purported recollections of the individuals involved. “Whether

[an] official had the requisite knowledge of a substantial risk

is a question of fact subject to demonstration in the usual

ways, including inference from circumstantial evidence.” Farmer, 511 U.S. at 842. Indeed, in certain circumstances, “a factfinder may conclude that [an] official knew of a substantial

risk from the very fact that the risk was obvious.” Id. (internal

quotations omitted). Here, there is sufficient circumstantial

evidence to create a genuine issue of fact regarding defendants’ subjective awareness of Clustka’s serious medical

need. 

[10] First, the Conns have presented evidence from which

the jury could conclude that Clustka’s medical need was so

obvious that Ashton and Robertson must have been subjectively aware of it, despite their later denial of that awareness.

Clustka attempted to choke herself with a seat belt and

screamed something to the effect of “kill me or I’ll kill

myself”; these are warning signs that are difficult for any

observer to miss. The officers, moreover, admittedly knew

that Clustka was mentally unstable and that she was undergoing a particularly stressful time. Clustka’s detail report —

which the officers requested and reviewed — cautioned: “violent tendencies, known to abuse substances, alcoholic, and

other mental health problems.” The report also indicated that

Clustka’s mother had obtained a restraining order against her.

A reasonable jury could conclude that the officers’ knowledge

of Clustka’s mental and emotional instability, coupled with

their observation of her dangerous behavior, in fact produced

a subjective awareness that Clustka was at acute risk of harm

and suffered a serious medical need. 

[11] Second, the Conns offer circumstantial evidence to

explain why the officers might have failed to report the incident even if they were subjectively aware of Clustka’s medical need. Both officers believed that failing to handcuff

Clustka while transporting her, and failing to fasten her into

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her seat belt once she unbuckled it, were violations of policy.4

Had they reported the incident, they would have had to report

their own misconduct. A jury could reasonably conclude that

the officers had a motive for remaining silent. 

[12] Finally, Ashton’s comments both during and after the

incident in the paddy wagon establish a genuine question of

fact regarding his subjective awareness of the seriousness of

Clustka’s condition — as well as his discomfort with the way

in which he and Robertson handled the situation. Ashton

recalls telling Robertson at the time of the incident that

Clustka “was trying to choke herself.” The next day — the

day before Clustka committed suicide — Ashton approached

a senior officer expressing his discomfort with what had transpired. Later, when Ashton found out about Clustka’s suicide,

he told one deputy that Clustka had “attempted to choke herself” in the paddy wagon. A second deputy reported the following conversation:

[Ashton] stated that “she looked out the back window and once she realized she was coming to Parr

[the prison] she tried to hang herself in the wagon.”

He stated that he was “new” and therefore asked his

(unidentified) partner and senior officer if they

needed to write a report regarding the suicide

attempt. He stated that his partner declined the idea

of documenting this occurrence, therefore he did not.

(emphasis supplied). Ashton went on to say that he would

write a report and that his “sergeant will be pissed.” These

statements — both contemporaneous and after-the-fact —

could support a reasonable jury’s conclusion that Ashton, at

least, was subjectively aware of Clustka’s serious medical

4

It appears that this belief was not well-founded, and that the defendants

may not have violated policy after all. That, however, is irrelevant; what

matters is that the officers believed their actions violated policy and that

they may have feared that the policy violation would be discovered. 

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need. That he brought his concerns to Robertson’s attention

is a factor to consider with respect to whether Robertson was

also subjectively aware of the problem.

[13] We hold that, cumulatively, the above evidence is sufficient to create a material issue of fact on the question of the

subjective awareness of both officers. This is particularly so

because “questions involving a person’s state of mind are

generally factual issues inappropriate for resolution by summary judgment.” Mendocino Envtl. Ctr. v. Mendocino

County, 192 F.3d 1283, 1302 (9th Cir. 1999) (quotation and

internal alterations omitted). We, of course, “may not make

credibility determinations or weigh conflicting evidence.”

Bator v. Hawaii, 39 F.3d 1021, 1026 (9th Cir. 1994). We

must leave the question of subjective awareness to the jury.

b. “Failure to respond”

[14] The officers did not take Clustka to the Medical Center, nor did they report her behavior to jail personnel or to

their supervising sergeant; they did not even write an incident

report on the day that Clustka tried to choke herself. The

defendants do not argue that, if we find that the officers were

subjectively aware of Clustka’s serious medical need, they

nonetheless responded appropriately. The defendants are not,

therefore, entitled to summary judgment on the ground that

the officers responded adequately to the situation presented.

3. “[H]arm caused by the indifference”

The question of causation is closer. We are satisfied, nonetheless, that the Conns presented sufficient evidence of actual

and proximate causation to defeat summary judgment and

give rise to a jury question whether the officers’ omissions

caused Clustka’s eventual suicide.

a. Cause in fact

[15] The officers’ failure to report the choking incident and

suicide threat “is the actual cause of [the] injury only if the

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injury would not have occurred ‘but for’ that conduct.” White

v. Roper, 901 F.2d 1501, 1505 (9th Cir. 1990) (citing W.

Prosser & W. Keeton, The Law of Torts [hereinafter “Prosser

& Keeton”] § 41, at 266 (5th ed. 1984)). “The requisite causal

connection can be established not only by some kind of direct

personal participation in the deprivation, but also by setting in

motion a series of acts by others which the actor knows or

reasonably should know would cause others to inflict the constitutional injury.” Johnson v. Duffy, 588 F.2d 740, 743-44

(9th Cir. 1978). The Conns contend that had the officers

responded appropriately to her attempted choking and suicide

threat, Clustka would not have committed suicide at the time

she did and that the officers’ failure to respond set in motion

a sequence of events in which Clustka did not receive the

medical treatment she urgently needed. We agree that the

Conns have presented sufficient material evidence on cause in

fact such that a jury could reasonably find in their favor. 

The Conns argue that, had the officers properly responded

to the choking incident and threat of suicide in either of two

ways, they would have prevented her suicide less than 48

hours later. In support of this assertion, they presented expert

testimony to establish the appropriate procedures for handling

detainees who threaten suicide — procedures that were not

followed here. Based on this testimony, the Conns assert that

first, the officers could have properly taken Clustka directly

to the hospital under a Legal 2000 procedure and reported the

incident to hospital staff. Second, the officers could have continued on to the jail and reported the incident to jail personnel

upon their arrival. At that point, jail personnel would have

either (1) rejected Clustka at the door and sent her to the hospital, since the jail cannot provide medical treatment during

civil protective custody; or (2) admitted her and placed her

under suicide watch until she was detoxified, then evaluated

her and sent her to the hospital under a Legal 2000. According

to the plaintiffs, under either of these procedures Clustka

would have received timely suicide intervention services by

trained medical personnel who had full information about her

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most recent suicide attempt. At this point, she would have

been kept in the hospital for up to 72 hours or would have, in

some other way, received appropriate services in response to

her acute risk of suicide. 

Defendants counter that the outcome of either of these procedures “amount[s] to mere speculation.” They point to the

fact that on two occasions, including on April 26, Clustka was

evaluated at the emergency room and released soon thereafter

without being transferred to a psychiatric facility. On three

occasions between 2001 and 2005 when Clustka was transferred to NMHI, she did not stay there longer than a day.

Defendants note that each time a patient is seen at the emergency room, the medical evaluation is based solely on the

patient’s psychological state at that moment. Because Clustka

did not physically harm herself while in CPC on April 26,

there is reason to think that she was no longer suicidal at the

moment she was released. Consequently, had she been evaluated by medical staff at the prison or hospital at that time,

even had the medical staff been fully informed of the choking

incident and suicide threat, she may well have been released

from the jail or from the emergency room without further

intervention. Finally, defendants argue that even if the officers

had notified jail or hospital personnel of Clustka’s actions and

she had been flagged as a suicide risk, if she had been

released on April 26 (from either CPC or the emergency

room), the information about the choking incident and suicide

threat would not have been passed along to the jail intake personnel when Clustka was detained the next day on the misdemeanor charge; therefore, she would not have been put on

suicide watch or treated any differently than she was.5 The jail

keeps minimal documentation regarding CPC detainees —

5The jail already was aware that a month earlier, Clustka had been put

on suicide watch at the prison and that she had a history of mental health

problems. For that reason she was placed in the mental health unit. Nonetheless, without the information about her most recent suicide

attempt/threat, she was not placed on suicide watch on April 27, 2005. 

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apparently for privacy reasons — since these detainees have

not been charged with a crime and are merely in custody for

their own protection. As a result, there is an information gap

between CPC and the criminal detention facilities at the jail,

and mental health information about CPC detainees will generally be inaccessible if those individuals are later detained on

a criminal charge. When, after being released on April 26,

Clustka was picked up the next day on a misdemeanor charge,

unless the same intake nurse was on duty as on the day

before, it is likely that no one at the jail would have known

that she had been flagged as a suicide risk in CPC the previous day, and her treatment would have been no different.

When presented to the jury, the defendants’ argument may

well succeed. It is not, however, sufficient to warrant judicial

determination of causation as a matter of law. The defendants’

argument rests on the questionable assumption that knowledge of Clustka’s second suicide threat in two days, if

reported upon her arrival at the jail or at a hospital, would not

have raised an alarm for medical personnel such that Clustka

would have received more precautionary treatment than she

otherwise did. It presupposes, moreover, that any such treatment would have been ineffective and that, regardless, the

subsequent events would have occurred when they did. It

makes little sense, however, to argue that the failure to provide access to suicide prevention services has no causal effect

on a suicide that transpires less than 48 hours later. If suicide

intervention is expected to have no impact on whether someone attempts suicide, why would the City ever bother with the

Legal 2000 procedure? Suicide prevention services are

designed to assess the patient and release her only after a

determination that she is no longer at risk. In Clustka’s case,

this determination was never made by someone who had all

the requisite information about her psychological instability

at the time. A jury could reasonably find that the defendants’

failure to report critical information rendered the subsequent

medical evaluations ineffectual. Clustka’s suicide might well

have been prevented by effective medical intervention —

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such as holding her on a Legal 2000 for up to 72 hours — but

that intervention would likely have occurred only if the crucial information about the choking incident and suicide threat

were known by the persons making the necessary determinations. 

[16] We cannot affirm the grant of a motion for summary

judgment where, as here, each side has garnered substantial

evidence in support of its position, and important facts,

including the proper intake procedures for an intoxicated, suicidal detainee, remain in dispute. The Conns have presented

evidence that knowledge of Clustka’s suicide attempt and

threat of future suicide would have made a difference in her

medical evaluation, treatment and supervision. We construe

that evidence in the light most favorable to the Conns.

McDonald, 548 F.3d at 778. There need only be “evidence in

the record to support the inference that if medical staff had

evaluated [Clustka], prevented [her] from entering the jail,

and directed [her] to a mental hospital [Clustka] almost certainly would have received the care [s]he needed, rather than

face conditions that worsened [her] outlook.” Gibson, 290

F.3d at 1190. As the Conns have met their burden, we will

leave the jury to its proper function of assessing the weight

and credibility of that evidence as well as that presented by

the defendants. See Bator, 39 F.3d at 1026. 

b. Proximate cause

[17] “Once it is established that the defendant’s conduct

has in fact been one of the causes of the plaintiff ’s injury,

there remains the question whether the defendant should be

legally responsible for the injury.” White, 901 F.2d at 1506

(citing Prosser & Keaton, § 42 at 272-73). The officers’ conduct “is not the proximate cause of [Clustka’s] alleged injuries if another cause intervenes and supersedes [their] liability

for the subsequent events.” Id. (quoting Restatement (Second)

of Torts §§ 440-53 (1965)). However, “foreseeable intervening causes . . . will not supersede the defendant’s responsibiliCONN v. CITY OF RENO 667

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ty.” Id. (citing Prosser & Keeton, § 44 at 303-04) (emphasis

added). If “reasonable persons could differ” over the question

of foreseeability, “summary judgment is inappropriate and the

question should be left to the jury.” Id. 

Where defendant’s actions are a “moving force” behind a

series of events that ultimately lead to a foreseeable harm,

defendant is not relieved of liability on account of the intervening acts. See id; see also Duffy, 588 F.2d at 743; Cabrales

v. County of Los Angeles, 864 F.2d 1454 (9th Cir. 1988),

vacated, 490 U.S. 1087 (1989), reinstated, 886 F.2d 235 (9th

Cir. 1989). In White, defendant prison guards tried to force

the plaintiff into a violent inmate’s cell; the plaintiff resisted,

attempted to run, and subsequently suffered injury from the

guards. 901 F.2d at 1503. We held that the defendants’

actions were a “moving force” behind the plaintiff ’s attempt

to run and that, because it was foreseeable that the plaintiff

would resist entering the cell, his attempt to run was not an

intervening cause. Id. at 1505-06. In Cabrales, which involves

municipal rather than individual liability, an inmate made a

suicidal gesture while in isolation, after which prison officials

released him to the general jail population. Cabrales, 864

F.2d at 1457. Subsequently, he got into a fight and was subjected to ten days in isolation, during which time he committed suicide. Id. We held that the County’s inadequate

provision of psychiatric care was a “moving force” behind the

suicide. Id. at 1461. Similarly, a jury could reasonably find

that the officers’ failure to respond to Clustka’s suicidal

actions was a “moving force” behind her suicide. 

[18] Defendants argue that two principal intervening causes

of Clustka’s suicide supersede whatever responsibility they

might otherwise have had for causing her death. First, they

argue that because Clustka was medically evaluated three

times after the choking incident and suicide threat and each

time determined not to be at risk of suicide, her suicide could

not have been caused by the officers’ failure to report it. We

disagree. At none of the three examinations, two of which

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were cursory jail admission screenings, was potential suicide

a cause for or the subject of the review. When medical examiners have insufficient information about the patient they are

diagnosing, they are likely to give an inaccurate diagnosis. By

failing to report Clustka’s choking and threat of suicide, the

officers rendered these reviews of little value. More important, by doing so, they foreseeably undermined her access to

effective medical evaluations and adequate mental health

care. A jury could reasonably conclude that notwithstanding

the subsequent uninformed medical reviews, the failure to

take action following the incident in the paddy wagon was a

moving force and proximate cause of Clustka’s suicide. 

[19] Second, defendants argue that Clustka’s subsequent

arrest and detention on a misdemeanor charge was an intervening stressor that directly caused the suicide, breaking the

chain of causation. Again, however, plaintiffs have presented

sufficient material evidence to raise a jury question on the

issue of foreseeability. Even if she had not been detained

again, it was clear from the officers’ direct observations of

Clustka and from her detail report that she was mentally

unstable, that she suffered from alcohol and substance abuse,

and that she was having family troubles that exacerbated these

problems. In these circumstances, an incident that would further destabilize her — whether detention or some other similar intervening force — was entirely foreseeable.

[20] Construing all the evidence in the light most favorable

to the Conns, McDonald, 548 F.3d at 778, we conclude that

they have presented sufficient evidence of foreseeability that

the question of proximate cause must be decided by a jury.

B. Qualified immunity

[21] We next assess whether summary judgment is warranted because the defendants are entitled to qualified immunity. We apply a two-part inquiry: First, did the defendants’

actions violate the Constitution? Second, if so, was the right

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violated clearly established? Saucier v. Katz, 533 U.S. 194,

201 (2001); Pearson v. Callahan, 129 S. Ct. 808, 818 (2009)

(holding the “sequence set forth [in Saucier] is often appropriate” but not mandatory). Having determined that there is a

question for the jury on the first prong, we consider whether

we should nonetheless affirm the grant of summary judgment

at this stage because the constitutional rights at issue have not

been clearly established. This second inquiry “must be

undertaken in light of the specific context of the case, not as

a broad general proposition . . . .” Saucier, 533 U.S. at 201.

“The relevant, dispositive inquiry in determining whether a

right is clearly established is whether it would be clear to a

reasonable officer that his conduct was unlawful in the situation he confronted.” Id. at 202. Officers are entitled to qualified immunity if they reasonably misapprehend how the law

would govern in their particular situation. Id at 205.

[22] Qualified immunity is not warranted here. It is clearly

established that the Eighth Amendment protects against deliberate indifference to a detainee’s serious risk of suicide. See

Cabrales, 864 F.2d 1454; Cavalieri v. Shepard, 321 F.3d 616,

621 (7th Cir. 2003); Colburn, 946 F.2d at 1023. When a

detainee attempts or threatens suicide en route to jail, it is

obvious that the transporting officers must report the incident

to those who will next be responsible for her custody and

safety. Thus, the constitutional right at issue here has been

clearly established. Nevertheless, for the same reason that we

cannot determine at summary judgment whether a constitutional violation occurred, a grant of summary judgment to

either party with regard to qualified immunity would be inappropriate.

C. Municipal liability

Under Monell, a municipality is a legal “person” subject to

liability under § 1983 for injuries it inflicts through deliberate

indifference. Monell v. Dep’t of Social Servs. of City of N.Y.,

436 U.S. 658, 690-91 (1978). Municipal liability may be

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established on account of the city’s deliberate acts or omissions; liability under the theory of respondeat superior, however, is insufficient to support a § 1983 violation. Id. at 691;

Gibson, 290 F.3d at 1185-86. Municipal liability for a failure

to act requires a showing “(1) that a [municipal] employee

violated the plaintiff ’s constitutional rights; (2) that the

[municipality] has customs or policies that amount to deliberate indifference; and (3) that these customs or policies were

the moving force behind the employee’s violation of constitutional rights.” Long v. County of L.A., 442 F.3d 1178, 1186

(9th Cir. 2006) (citing Gibson, 290 F.3d at 1193-94). Because

we have denied the defendants’ motion for summary judgment on the constitutional claims against Robertson and Ashton, the first prong has been met for the purposes of summary

judgment here as well. 

The Conns seek to establish municipal liability on account

of four separate omissions: (1) failure to train; (2) failure to

adopt and implement policies; (3) failure to address Officer

Robertson’s deficient performance; and (4) failure to discipline. We consider each of these claims in turn.

1. Failure to Train

[23] “Only where a failure to train reflects a ‘deliberate’ or

‘conscious’ choice by a municipality . . . can a city be liable

for such a failure under § 1983.” City of Canton v. Harris,

489 U.S. 378, 389 (1989). Deliberate indifference by the

municipality may be established where “a violation of federal

rights may be a highly predictable consequence of a failure to

equip law enforcement officers with specific tools to handle

recurring situations.” Long, 442 F.3d at 1186 (quoting Bd. of

County Comm’rs v. Brown, 520 U.S. 397, 409 (1997)). 

Under this standard, the Conns have established a genuine

issue of fact for the jury on the question of the City of Reno’s

failure to train. First, they have provided substantial evidence

in the form of deposition testimony that before Clustka’s suiCONN v. CITY OF RENO 671

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cide the City did, in fact, fail to train its officers in suicide

prevention and the identification of suicide risks. The City of

Reno has not provided any evidence to the contrary.

Second, plaintiffs have provided evidence that officers predictably face situations where they must assess and react to

suicide risks in order to prevent grave harm to people under

their protection. Suicide is a leading cause of death in American prisons, Shevon L. Scarafile, “Deliberate Indifference”

or Not, 51 Vill. L. Rev. 1133, 1133-34 & n.4 (2006), and

Clustka’s suicide was one of six in less than two years at the

Washoe County Jail. While police officers are not prison

guards, they are the first law enforcement officials to deal

with detainees — and they do so in highly stressful situations.

Robertson testified that over the course of his career, he has

encountered between 500 and 1,000 people threatening to kill

themselves. Police officers frequently take mentally ill detainees to the hospital on Legal 2000s. The failure to train officers

on how to identify and when to report suicide risks produces

a “highly predictable consequence”: that police officers will

fail to respond to serious risks of suicide and that constitutional violations will ensue.

Finally, plaintiffs have made an adequate showing that, had

the City trained its officers, the violation of Clustka’s constitutional rights could have been avoided. For a policy to be a

moving force behind the violation of a constitutional right, the

failure of the policy or omission must be “closely related to

the ultimate injury.” Gibson, 290 F.3d at 1196 (quoting Canton, 489 U.S. at 391). Here, Robertson and Ashton believed

that they had the discretion not to report the choking incident

and suicide threat in the paddy wagon. Had they been trained

in suicide prevention, there is a reasonable probability that

they would have responded differently and reported to the jail

that Clustka was at risk of suicide, or taken her directly to the

hospital. 

[24] For these reasons, plaintiffs have presented sufficient

evidence to establish a genuine issue of fact with respect to

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municipal liability for failure to train. Because the City failed

to train its police officers in suicide prevention, a reasonable

jury could find that the City’s “customs or policies . . .

amount to deliberate indifference;” and because Ashton and

Robertson, who never received such training, failed to

respond appropriately by reporting the incident in the paddy

wagon, there is sufficient evidence for a reasonable jury to

find “that these customs or policies were the moving force

behind the employee[s’] violation of constitutional rights.”

Long, 442 F.3d at 1186. “[W]hether a local government has

displayed a policy of deliberate indifference to the constitutional rights of its citizens is generally a jury question.” Gibson, 290 F.3d at 1194-95. We are compelled to deny the

motion for summary judgment on municipal liability for failure to train. 

2. Failure to Adopt and Implement Policies

Plaintiffs also challenge the lack of an official, written policy on suicide prevention. “This Court consistently has found

that a county’s lack of affirmative policies or procedures to

guide employees can amount to deliberate indifference, even

when the county had other general policies in place.” Long

442 F.3d at 1189. 

The Conns assert — and appear to be correct — that there

was no written policy on reporting suicide threats at the time

of Clustka’s suicide,6 although there were written policies

regarding the Legal 2000 procedure. The absence of any written policy is supported by the fact that neither Robertson nor

Ashton was disciplined for failing to report Clustka’s suicide

threat, although each received negative comments about the

incident in their annual evaluation. Post-event evidence, such

as this, is admissible to prove the absence of a municipal

6Deputy Chief Johns was “not sure” if there was a written policy requiring officers to report suicide threats. 

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defendant’s policy or practice. Henry v. County of Shasta, 132

F.3d 512, 520 (9th Cir. 1997). 

Shortly after Clustka’s suicide, moreover, the City implemented a new suicide prevention policy. At intake in the jail,

the arresting officer must now fill out a form answering a

series of questions concerning the detainee’s mental health,

including questions about suicide risk. This is further evidence that as of April 26, 2006 no such policy had been

adopted and implemented.7

[25] As the Conns have presented sufficient evidence of a

failure to adopt and implement suicide-prevention policies so

as to give rise to a jury question, the rest of our analysis mirrors that which we described above regarding the failure to

train. Given the predictability of suicide risk among detainees,

and the likelihood of constitutional violations if suicide

threats go unreported, the plaintiffs have presented a genuine

issue for the jury on whether the failure to adopt and implement policies on suicide prevention was deliberately indifferent, and whether that deliberate indifference was a “moving

force” behind the violation of Clustka’s constitutional rights.

3. Failure to address the deficient performance of

Officer Robertson

[26] Whatever Robertson’s on-the-job weaknesses may

have been, there is no evidence in the record that the municipality should have known — or did know — that Robertson

would be likely to show deliberate indifference in circumstances such as these. Moreover, the causal link between the

City’s failure to address his deficient performance in other

aspects of his job and his failure to respond appropriately here

is tenuous at best. Accordingly, we affirm the grant of summary judgment on this issue.

7The evidence of the new policy is admissible solely as evidence of the

absence of an earlier policy and not for the purpose of proving negligence

or culpable conduct of any kind. See Fed. R. Evid. 407. 

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4. Failure to discipline

Robertson and Ashton were not disciplined in any way for

their misconduct in failing to report the choking incident and

suicide threat. They each received some negative comments

about their handling of the situation in their annual reports,

written by their supervising sergeant. 

[27] A failure to discipline is not a separate ground for

establishing municipal liability. Rather, it is evidence that

tends to establish the absence of or failure to enforce a policy

on suicide prevention. We will therefore affirm the district

court’s grant of summary judgment on this issue as well,

without commenting on the admissibility of the particular evidence regarding the two officers for the purpose described

above.

IV. CONCLUSION

Clustka’s surviving children have presented sufficient evidence to survive summary judgment on the large majority of

the claims brought under § 1983. On the basis of the evidence

presented by the Conns, the jury could reasonably find that

Clustka demonstrated a serious medical need when she

attempted to choke herself with a seatbelt in the paddy wagon

and threatened to kill herself; that Ashton and Robertson were

deliberately indifferent to that medical need; and that their

indifference was a factual and proximate cause of Clustka’s

death. On the basis of the Conns’ evidence, a jury could also

reasonably determine that the City of Reno’s failure to train

its law enforcement officials and implement written policies

on suicide prevention constituted deliberate indifference and

were, independently, a moving force behind Ashton and Robertson’s violation of Clustka’s constitutional rights. 

We therefore reverse the district court’s grant of the defendants’ motion for summary judgment with respect to individual and municipal liability, with the exception that we affirm

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the grant of summary judgment with respect to the City’s failure to address Robertson’s deficient performance and its failure to discipline the individual officers. The case is remanded

to the district court for further proceedings consistent with

this opinion.

REVERSED and REMANDED.

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