RECOMMENDED FOR PUBLICATION

Pursuant to Sixth Circuit I.O.P. 32.1(b)

File Name: 23a0090p.06

UNITED STATES COURT OF APPEALS

FOR THE SIXTH CIRCUIT

KARLA HOWELL, as administratrix of the Estate of 

Cornelius Pierre Howell,

Plaintiff-Appellant,

v.

NAPHCARE, INC.; CHRISTINA JORDAN and PIERETTE 

ARTHUR, individually and in their official capacities; 

JIM NEIL, MATTHEW COLLINI, and DANIEL ERWIN, 

individually and in their official capacities in the 

Hamilton County Sheriff’s Department; JUSTIN HUNT,

Defendants-Appellees, 

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Nos. 21-4132/22-3306

Appeal from the United States District Court for the Southern District of Ohio at Cincinnati.

No. 1:19-cv-00373—Douglas Russell Cole, District Judge.

Argued: October 20, 2022

Decided and Filed: May 1, 2023

Before: SUTTON, Chief Judge; STRANCH, and DAVIS, Circuit Judges.

_________________

COUNSEL

ARGUED: Megha Ram, RODERICK & SOLANGE MACARTHUR JUSTICE CENTER, 

Washington, D.C., for Appellant. Robert W. Hojnoski, REMINGER CO., L.P.A., Cincinnati, 

Ohio, for the NaphCare Appellees. John B. Welch, ARNOLD TODARO WELCH & 

FOLIANO, Dayton, Ohio, for the Hamilton County Appellees. ON BRIEF: Megha Ram, 

Elizabeth Bixby, David F. Oyer, RODERICK & SOLANGE MACARTHUR JUSTICE 

CENTER, Washington, D.C., Rosalind Eileen Dillon, RODERICK & SOLANGE 

MACARTHUR JUSTICE CENTER, Chicago, Illinois, Konrad Kircher, RITTGERS & 

RITTGERS, Lebanon, Ohio, David M. Shapiro, RODERICK & SOLANGE MACARTHUR 

>
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 2

JUSTICE CENTER NORTHWESTERN PRITZKER SCHOOL OF LAW, Chicago, Illinois, for 

Appellant. Robert W. Hojnoski, Jennifer J. Jandes, Michael J. Caligaris, REMINGER CO., 

L.P.A., Cincinnati, Ohio, for the NaphCare, Appellees. John B. Welch, ARNOLD TODARO 

WELCH & FOLIANO, Dayton, Ohio, for the Hamilton County Appellees.

_________________

OPINION

_________________

JANE B. STRANCH, Circuit Judge. Cornelius Pierre Howell died of a sickle cell crisis 

while in pretrial custody at the Hamilton County Justice Center on December 9, 2018. Rather 

than transport a distressed Howell to a local hospital, nurses and jail personnel placed him in a 

restraint chair and put him in an observation room in the Jail’s mental health unit. Howell 

remained strapped to the chair with minimal observation until jail personnel found him dead 

approximately four hours later. His Estate sued the nurses, their employer, NaphCare, Inc., the 

jail personnel, and Hamilton County for, as relevant to this appeal, deliberate indifference to his 

serious medical needs, excessive force, and failure to train, all in violation of the Fourteenth 

Amendment. The district court found that none of the Defendants violated Howell’s 

constitutional rights and granted summary judgment. We AFFIRM IN PART, REVERSE IN 

PART, and REMAND for further proceedings. 

I. BACKGROUND

A. Factual Background

On December 2, 2018, Cornelius Pierre Howell was arrested and booked at Hamilton 

County Justice Center (the Jail). Over the course of the next week, Howell received two 

medical screenings from nurses employed by NaphCare, Inc., a private company that contracts 

with the Jail to provide medical services. The nurses placed him on the “chronic care list” 

because of his charted diagnosis of sickle cell disease, and Howell informed them that he 

typically took Oxycodone for his sickle cell pain, which he stated had worsened during his 

incarceration. 

Howell returned to the medical unit on December 9 after he started a fight with his 

cellmate. Video shows that two officers attempted to lead Howell down a hallway, but he 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 3

immediately fell to the ground, requiring the officers to pick him up. Again, the officers 

attempted to assist Howell to an elevator, but he continued to fall to the ground. After leaning 

him against a wall, the officers placed Howell in a wheelchair and took him to the medical 

sallyport. 

Nurse Christina Jordan first evaluated Howell’s cellmate. Meanwhile, Howell exclaimed 

that he was in pain and “yell[ed], moan[ed], and groan[ed]” in an adjacent room—loud enough 

that those inside the sallyport could hear his cries. He also stated that he could not feel his legs. 

Once inside the medical sallyport, Howell continued with more of the same: he yelled, 

complained of pain in his back and legs, and rated his pain at ten-out-of-ten. Again, he 

“yell[ed] that his legs wouldn’t work.” Video shows that Howell continued to slide out of the 

wheelchair and was eventually left rolling around on the floor. 

Jordan ultimately evaluated Howell in the medical sallyport with Officers Hunt and 

Erwin present. Although Howell refused to take a glucose tablet or provide a urine sample, the 

nurses did take Howell’s vitals. NaphCare’s medical director subsequently acknowledged that 

his respiratory rate of 22 was “abnormal.” Jordan reviewed Howell’s medical chart, seeing 

Howell’s sickle cell diagnosis and his medical history from previous incarcerations. Howell 

also told Jordan that he had sickle cell. On two prior occasions at the jail, at least one of which 

was memorialized in his medical chart, medical staff sent Howell to a local hospital due to 

sickle cell pain. 

In previous jobs and during her time at the jail, Jordan had treated sickle cell patients, and 

she had received training about sickle cell disease. She knew that “pain [is] the primary 

symptom of sickle cell” and a sickle cell crisis can manifest as numbness in the legs. Jordan 

concluded Howell was in pain. But ultimately, she determined that Howell was experiencing 

“a psych[iatric] issue more than a sickle cell [issue], because [with] sickle cell. . . you’re in too 

much pain to do anything,” like moving or yelling. Accordingly, Jordan suggested that Jail 

officers transport Howell to the psychiatric department for evaluation. 

Around 5:40 p.m., officers placed Howell in a restraint chair; at that time, Jordan 

recorded Howell’s blood pressure as 90/56. The Defendants dispute whether the NaphCare 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 4

Defendants or the Hamilton County Defendants ordered that Howell be placed in a restraint 

chair. But all Defendants concede that they did not object to that decision. Next, the officers 

transported Howell to the mental health unit, placed him in a cell that had a small window on 

its door, and attached the restraint chair to the wall.

Jail restraint-chair policy required jail officers to perform a “check” every ten minutes. 

Policy also required officers to consider removing the restrained detainee from the chair every 

hour, recommended at least ten minutes of limb rotations every two hours “to prevent blood 

clots,” and required access to the restroom and water. The medical staff relied on the officers to 

complete these checks and to report anything unusual with the restrained detainee. The officers 

had received some training at the officer academy and at orientation on how to perform 

observational checks on persons in restraint chairs. Alternatively, one sergeant explained that a 

“field training officer” conducted restraint-chair monitoring training after the academy. 

Additionally, the officers received “on-the-job” training, and the policy guidance was 

distributed with an encouragement to “read it” and “review it”. The frequency of checks 

performed by the medical staff depended on who ordered the detainee to the chair. If medical 

personnel ordered a restraint chair, medical staff were required to perform a check every fifteen 

minutes; if jail personnel ordered the chair, medical staff were required to perform a check 

every two hours. 

At approximately 6:06 p.m., Nurse Periette Arthur checked on Howell in the presence of 

Officers Collini and Erwin. Arthur stated that Howell was still yelling but decided that he did 

not need further medical treatment. After Arthur’s initial check, no NaphCare employee 

checked on Howell again. From 6:23 p.m. to 8:03 p.m., Officers Collini and Erwin did not 

perform checks on Howell every 10 minutes; instead, they checked approximately every 20 

minutes—six checks in total. Officer Collini performed one more check, approximately an hour 

later at 9:14 p.m. 

The observations of Howell by Collini and Erwin consisted of looking through the “small 

little window” on the locked door—a view that provided only a side profile of Howell. But the 

Officers did not enter the cell, and they could not see Howell’s eyes and could not tell if he was 

alive. The Officers thought that Howell was sleeping. In reality, Howell may have already 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 5

died. Collini and Erwin failed to consider Howell for removal every hour, rotate Howell’s 

limbs every two hours, or provide Howell with water or the opportunity to use the restroom. 

Instead, the Officers falsified entries on the restraint chair log to appear to comply with the 

policy requiring a check every ten minutes. At 9:45 p.m., approximately four hours after being 

placed in the mental health unit, Officers, including Hunt, went to remove Howell from the 

restraint chair. The Officers found Howell dead. 

Dr. Gretel Stephens, the Hamilton County Deputy Coroner, performed an autopsy the 

next day. She determined that Howell died from sickle cell crisis; “once the sickling began” 

Howell likely died within “minutes.” The Estate’s expert, Dr. Martin Steinberg, a sickle cell 

expert, determined that Howell died as a result of rhabdomyolysis, a common complication of 

sickle cell disease, onset by a “short period of intense exertion.”1 Dr. Steinberg opined that a 

transfer to a hospital “would more likely than not have prevented [] Howell’s death.” 

B. Procedural History 

Howell’s sister, as administratrix of his estate, sued the NaphCare Defendants—

NaphCare, Inc. and Nurses Arthur and Jordan—and the Hamilton County Defendants—Matthew 

Collini, Daniel Erwin, Justin Hunt, and Jim Neil—for injuries related to Howell’s death while he 

was in pretrial custody. Pursuant to 42 U.S.C. § 1983, the Estate claims all Defendants violated 

the Fourteenth Amendment through deliberate indifference to Howell’s serious medical need and 

excessive force. Defendant Sheriff Neil was sued only in his official capacity for failure to train, 

inadequate supervision, and ratification. The operative complaint also includes state law claims 

for negligence, wrongful death, and survivorship against various Defendants. 

The district court granted summary judgment for all Defendants on all federal claims and 

declined to retain jurisdiction over the remaining state law claims. The Estate appealed that 

decision2in November 2021 and in January 2022, moved for relief from judgment based on the 

district court’s failure to consider our September 2021 decision in Brawner v. Scott County, 

1The NaphCare Defendants’ expert opined that Howell died from a sudden cardiac arrest, resulting from a 

prior chest stab wound that had required open heart surgery a year earlier.

2The Estate brought its excessive force claim against all individual Defendants. On appeal, the Estate 

contests the district court’s judgment on its excessive force claims only as to Nurse Jordan. 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 6

14 F.4th 585 (6th Cir. 2021) cert. denied sub nom., Scott County v. Brawner, 143 S. Ct. 84 

(2022), which changed the standard for deliberate indifference claims under the Fourteenth 

Amendment. The court denied the motion for relief, finding that under Brawner, Defendants 

were still entitled to summary judgment on the deliberate indifference claim. The Estate again 

appealed, and we consolidated the appeals. 

II. ANALYSIS

We review the district court’s grant of summary judgment de novo. Briggs v. Univ. of 

Cincinnati, 11 F.4th 498, 507 (6th Cir. 2021). Summary judgment should be granted if, viewing 

the record in the light most favorable to the nonmoving party, there is no genuine issue as to any 

material fact such that the movant is entitled to judgment as a matter of law. Id. (citing Fed. R. 

Civ. P. 56(c)). In our review, we draw all justifiable inferences in the nonmoving party’s favor. 

Id. If there is sufficient evidence such that a jury could return a verdict for the nonmoving party, 

a genuine dispute of material fact exists, and summary judgment is improper. Id.

A. Deliberate Indifference Claim Against Individual Defendants

Both pretrial detainees, like Howell, and convicted prisoners have a constitutional right to 

be free from deliberate indifference to their serious medical needs. For a pretrial detainee, the 

right arises under the Fourteenth Amendment, while a prisoner’s right comes from the Eighth 

Amendment. Richmond v. Huq, 885 F.3d 928, 937 (6th Cir. 2018). Until our decision in 

Brawner, this was a distinction without a difference: both groups’ claims of deliberate 

indifference were analyzed under the test formulated by the Supreme Court in Farmer v. 

Brennan. 511 U.S. 825 (1994). Farmer requires a plaintiff to satisfy two components—one 

objective and one subjective. To satisfy the objective component, a plaintiff must show that the 

individual had an “objectively” serious medical need. Id. at 834. The subjective component 

requires a showing that “an official kn[ew] of and disregard[ed] an excessive risk to inmate 

health or safety; the official must both [have been] aware of facts from which the inference could 

be drawn that a substantial risk of harm exist[ed], and he must also [have] draw[n] the 

inference.” Id. at 837. Farmer’s formulation of the subjective component adopted a standard 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 7

akin to criminal-law recklessness and rejected a civil-law recklessness standard that would not 

require subjective knowledge. Id. at 836-37.

While Farmer’s criminal-law recklessness standard still governs a prisoner’s Eighth 

Amendment deliberate indifference claim, Brawner changed the standard for pretrial detainees 

under the Fourteenth Amendment, adopting a civil-law recklessness standard that “calls a person 

reckless who acts or . . . fails to act in the face of an unjustifiably high risk of harm that is either 

known or so obvious that it should be known.” Id. at 836. Brawner reasoned that this change 

was necessary in light of the Supreme Court’s decision in Kingsley v. Hendrickson, 576 U.S. 389 

(2015), which drew a distinction between claims brought by pretrial detainees and prisoners. 

Brawner, 14 F.4th at 596. In Kingsley, the Supreme Court held that for excessive force claims, a 

pretrial detainee need only show that the force used was objectively unreasonable, and it rejected 

a subjective unreasonableness inquiry. 576 U.S. at 392. Applying Kingsley’s reasoning, 

Brawner held that a pretrial detainee must make a showing (1) that he had an objectively serious 

medical need and (2) that each defendant “acted deliberately [and] also recklessly ‘in the face of 

an unjustifiably high risk of harm that is either known or so obvious that it should be known.’”3 

Brawner, 14 F.4th at 596 (quoting Farmer, 511 U.S. at 836). 

An objectively serious medical need includes conditions that have been “diagnosed by a 

physician as mandating treatment” or that are “so obvious that even a lay person would easily 

recognize the necessity for a doctor’s attention.” Harrison v. Ash, 539 F.3d 510, 518 (6th Cir. 

2008) (quoting Blackmore v. Kalamazoo County, 390 F.3d 890, 897 (6th Cir. 2004)). We have 

“routinely held that a condition resulting in death is ‘sufficiently serious’ to meet the objective 

component.” Burwell v. City of Lansing, 7 F.4th 456, 463 (6th Cir. 2021). In this case, Howell 

suffered a sickle cell crisis that, according to Dr. Stephens and Dr. Steinberg, caused his death. 

3After Brawner, a panel of this court held that a pretrial detainee must satisfy a third element: that “the 

prison official knew that his failure to respond [to an excessive risk of harm] would pose a serious risk to the pretrial 

detainee and ignored that risk.” Trozzi v. Lake County, 29 F.4th 745, 757-58 (6th Cir. 2022). But that language is 

nearly identical in substance to Farmer’s subjective requirement for convicted prisoners: that an “official kn[ew] of 

and disregard[ed] an excessive risk to inmate health or safety; the official must both [have been] aware of facts from 

which the inference could be drawn that a substantial risk of harm exist[ed], and he must also [have] draw[n] the 

inference.” 511 U.S. at 837. Brawner expressly departed from that standard. We agree with the panel in 

Helphenstine v. Lewis County that Trozzi’s “framing of the elements is irreconcilable with Brawner,” and “[b]ecause 

Brawner was decided before Trozzi, Brawner controls.” 60 F.4th 305, 316-17 (6th Cir. 2023). 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 8

After initially being taken from his cell, moreover, Howell continuously fell to the ground, 

seemingly unable to walk under his own power, complained about numbness and pain in his 

legs, complained about pain in his back, and rated his pain at ten-out-of-ten, evidencing an 

“obvious need for medical care.” Id. at 464 (quoting Blackmore, 390 F.3d at 900). Howell’s 

sickle cell crisis, pain, and death undoubtedly satisfy the objective prong. 

Moving to the second prong, the Estate must show that the individual Defendants 

recklessly acted or recklessly failed to act where a reasonable official in their position would 

have recognized that Howell’s serious medical need posed “an unjustifiably high risk of harm.” 

See Brawner, 14 F.4th at 596-97 (quoting Farmer, 511 U.S. at 836). It is sufficient that the risk 

is known by the defendant or “so obvious that it should be known.” Id. at 596 (quoting Farmer, 

511 U.S. at 836). And the Estate must prove “more than negligence but less than subjective 

intent—something akin to reckless disregard.” Id. at 598 (quoting Castro v. County of Los 

Angeles, 833 F.3d 1060, 1071 (9th Cir. 2016) (en banc)). We analyze each Defendant’s liability 

individually. Greene v. Crawford County, 22 F.4th 593, 607 (6th Cir. 2022). 

1. Individual NaphCare Defendants

The Estate claims a genuine dispute of material fact exists as to whether NaphCare 

Nurses Jordan and Arthur were deliberately indifferent to Howell’s serious medical need—

Jordan because she failed to send Howell to the emergency room after evaluation and Arthur 

because her monitoring of Howell in the mental health unit was inadequate. 

a. Defendant Nurse Christina Jordan

There is no dispute that Jordan knew Howell had sickle cell disease. She saw it in 

Howell’s chart, and he told her during her evaluation. Notably, Jordan had professional 

experience, “academic,” and on-the-job training in treating patients with sickle cell, and she 

acknowledged that sickle cell crises can manifest in extreme pain and numbness in the arms and 

legs. A reasonable inference can be drawn that based on her review of Howell’s history in his 

medical chart, Jordan knew that Howell had been hospitalized during previous incarcerations due 

to sickle cell complications.
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 9

Jordan heard Howell’s repeated complaints of leg and back pain, and it is reasonable to 

infer that she also heard Howell’s complaints about not being able to feel his legs or that his 

“legs wouldn’t work,” because Howell was “yelling” them and other Defendants present heard 

these complaints. She witnessed Howell fall out of a wheelchair and roll around on the floor. 

Jordan took Howell’s vitals, but there is a dispute of material fact regarding the irregularity of his 

respiratory rate and blood pressure. Most importantly, Jordan believed Howell was in pain; she 

did not think he was “faking” his anguish. 

To be sure, there were other facts for Jordan to consider. She knew the officers brought 

Howell for evaluation after he uncharacteristically started a fight with his cellmate, and when 

reviewing his medical chart, she noticed a previous incident of drug use while incarcerated. 

Further, Howell refused a glucose tablet and hydration and refused to provide a urine sample.

Based on all these facts, Jordan ordered Howell to be put in a restraint chair and 

transported to a locked observation cell in the mental health unit; she then failed to check on him. 

She did nothing to treat Howell for a sickle cell crisis or for his excruciating pain. The Estate’s 

expert opined that Howell’s symptoms were well-known complications of sickle cell disease and 

that a detainee with sickle cell experiencing bad pain represents a medical emergency: “A patient 

with sickle cell disease complaining of severe pain should never be ignored . . . .” The Estate’s 

experts concluded that Jordan “should have immediately” sent Howell to the emergency 

department and “even a layperson” would have recognized the risk. 

There is no dispute that Jordan subjectively believed Howell was experiencing a 

psychiatric episode. But after Brawner, subjective belief is not the end of the analysis. Brawner

is satisfied if a jury could find that Jordan acted recklessly by failing to treat Howell’s sickle cell 

disease when it was obvious that he faced an unjustifiably high risk of harm. A jury could make 

that finding here based on the following facts: (1) Jordan knew Howell had sickle cell; (2) she 

knew he had previously been transported to a local hospital for sickle cell complications while 

incarcerated; (3) she observed his inability to stand and saw him fall out of a wheelchair; (4) she 

heard his complaints about pain in his legs and back and numbness in his legs—common sicklecell symptoms; (5) she read Howell’s irregular vitals; and (6) as expert testimony established, a 

sickle cell patient complaining of severe pain represents a medical emergency that would have 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 10

made it apparent to a layperson that Howell needed to go to the emergency department. Yet 

Jordan never took further action to rule out a sickle cell crisis. Accordingly, the district court 

erred in granting summary judgment to Nurse Jordan. See Greene, 22 F.4th at 613 (denying 

summary judgment to jail official that did not seek additional medical assistance); see also 

LeMarbe v. Wisneski, 266 F.3d 429, 437 (6th Cir. 2001) (denying summary judgment where risk 

“was extreme and obvious” to medical professionals and “most lay people”); Sours v. Big Sandy 

Reg’l Jail Auth., 593 F. App’x 478, 481, 485 (6th Cir. 2014) (reversing grant of summary 

judgment in favor of nurse who believed detainee who died of diabetic ketoacidosis was 

“probably detoxing”). 

Jordan argues she is entitled to summary judgment because she reasonably diagnosed 

Howell as experiencing a psychiatric episode, and a reasonable misdiagnosis does not subject her

to liability. The district court granted summary judgment on that basis, holding that her 

misdiagnosis was not “clearly inconsistent” with Howell’s symptoms. The record below reveals 

disputes of fact over whether and to what degree Howell’s symptoms were inconsistent with a 

psychiatric episode and were instead consistent with a sickle cell crisis. 

Under our caselaw, the simple fact that a medical professional misdiagnosed a patient 

does not rise to the level of deliberate indifference, Griffith v. Franklin County, 975 F.3d 554, 

573 (6th Cir. 2020), and as a general matter, courts are “reluctant to second guess the medical 

judgment of prison medical officials,” Jones v. Muskegon County, 625 F.3d 935, 944 (6th Cir. 

2010). Medical officials, however, “may not entirely insulate themselves from liability under § 

1983 simply by providing some measure of treatment.” Id. (quoting McCarthy v. Place, 313 F. 

App’x 810, 814 (6th Cir. 2008)); LeMarbe, 266 F.3d at 439 (“A government doctor has a duty to 

do more than simply provide some treatment to a prisoner who has serious medical needs.”) 

Our cases clarify the operation of these principles. In Jones v. Muskegon County, we 

determined that a doctor who misdiagnosed a detainee’s cancer as constipation was not 

deliberately indifferent in part because some of the detainee’s symptoms were consistent with 

constipation. 625 F.3d at 945. We held that the doctor’s merely negligent misdiagnosis did not 

rise to the level of “grossly inadequate” care. Id. at 945-46. As noted, however, the doctor in 

Jones also “scheduled various exams to determine more precisely what was affecting [the 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 11

detainee] and transferred him to the hospital when it was apparent that his condition was 

worsening.” Id. at 945. In Rouster v. County of Saginaw, we held that a nurse who 

misdiagnosed a detainee’s perforated ulcer as alcohol withdrawal was not deliberately indifferent 

in part because “the majority of [the detainee’s] symptoms were entirely consistent” with alcohol 

withdrawal. 749 F.3d 437, 451-52 (6th Cir. 2014). That opinion reasoned that the medical 

personnel,

were ignorant of the single critical fact that might have caused them to interpret 

[the detainee’s] symptoms in a different light: At no point did [the detainee] tell 

any member of the medical staff about his previous treatment for a perforated 

duodenal ulcer. Had [the medical staff] received full information regarding [the 

detainee’s] medical history, we could easily conclude that [the medical staff 

defendants] were deliberately indifferent to [the detainee’s] needs. 

Id. at 453. In a recent unpublished opinion, Britt v. Hamilton County, a nurse misdiagnosed a 

detainee’s endocarditis as heroin withdrawal. 2022 WL 405847, at *1-2 (6th Cir. Feb. 10, 

2022). The Britt panel held that the nurse was not deliberately indifferent, noting that the 

detainee’s symptoms were undisputedly consistent with heroin withdrawal and the only facts 

before the nurse at the time of the misdiagnosis were a slightly elevated temperature and pulse 

rate that was “close to the typical range.” Id. at *3. Britt explained that the nurse was “far less 

negligent than other conduct we have held did not create a triable issue of fact on deliberate 

indifference.” Id.

The facts in Howell’s case are readily distinguishable from these cases. It is undisputed 

that, unlike the medical staff in Rouster, Jordan knew the critical facts that should have caused 

her to interpret Howell’s symptoms in a different light, 749 F.3d at 453; she knew Howell had 

sickle cell, heard him make repeated complaints synonymous with sickle cell illness, and the 

record provides a reasonable inference that Jordan knew about Howell’s recent hospitalizations 

related to sickle cell. Moreover, unlike the medical professionals in Jones and Britt, Jordan was 

faced with multiple symptoms that were unrelated to the misdiagnosis and consistent with the 

proper diagnosis, yet she failed to undertake any additional evaluation, care, or treatment during 

or after the misdiagnosis. 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 12

Jordan is “not entirely insulate[d] . . . from liability under § 1983 simply” because she 

made some diagnosis. Jones, 625 F.3d at 944 (quoting McCarthy v. Place, 313 F. App’x at 814). 

This record and our precedent do not support the conclusion that a diagnosis as generic as

“psychiatric episode,” which could cover almost any physiological symptom, can serve as 

blanket insulation from liability. In the light most favorable to the Estate, a jury could find that 

Jordan was reckless by failing to act in the face of an obvious, unjustifiably high risk of harm, 

amounting to deliberate indifference to Howell’s serious medical need. We reverse the district 

court’s grant of summary judgment to Nurse Jordan on the Estate’s deliberate indifference claim.

b. Defendant Nurse Pierette Arthur

Nurse Arthur’s exposure to Howell was far more limited than Nurse Jordan’s. Arthur 

only interacted with Howell on one occasion when she checked on him immediately after the 

Officers brought him to the mental health unit in the restraint chair. She did not observe 

Howell’s behavior in the medical sallyport, and the record does not support the inference that 

Arthur knew Howell had sickle cell disease. Based on Jordan’s diagnosis, Arthur believed that 

Howell was in the restraint chair for a mental health evaluation.

The Estate argues that, given Arthur’s knowledge of Howell’s low blood pressure, her 

failure to call a doctor or perform further checks raises a genuine dispute of material fact whether 

she was deliberately indifferent. In contrast to Jordan, however, Arthur did not know any of the 

“critical fact[s]” that would have led a reasonable official to recognize the unjustifiably high risk 

Howell faced. Rouster, 749 F.3d at 453. She did not see Howell’s demeanor in the medical 

sallyport or hear his complaints that would have tipped off a reasonable medical professional that 

he was experiencing a medical crisis. While the Estate is correct that policy dictated Arthur 

should have checked on Howell every fifteen minutes, and she only checked on him once in 

roughly 90 minutes, our caselaw states that a “‘failure to follow internal policies, without more,’ 

does not equal deliberate indifference.” Hyman v. Lewis, 27 F.4th 1233, 1238 (6th Cir. 2022) 

(quoting Winkler v. Madison County, 893 F.3d 877, 891 (6th Cir. 2018)). There is not something 

“more” in this record that pushes Arthur’s conduct beyond the level of negligence to deliberate 

indifference. Griffith, 975 F.3d at 570-71. The district court’s grant of summary judgment to 

Arthur on the Estate’s deliberate indifference claim is affirmed.
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 13

2. Individual Hamilton County Defendants

The Estate claims a genuine dispute of material fact exists whether Hamilton County 

Defendants Deputy Erwin, Deputy Collini, and Sergeant Hunt were deliberately indifferent to 

Howell’s serious medical need by failing to adequately monitor and observe Howell while he 

was restrained in a locked cell in the mental health unit. 

Our caselaw has recognized that generally “a non-medically trained officer does not act 

with deliberate indifference to an inmate’s medical needs when he ‘reasonably deferred to [a] 

medical professionals’ opinions.’” Greene, 22 F.4th at 608 (quoting McGaw v. Sevier County, 

715 F. App’x 495, 498 (6th Cir. 2017)). Such deference, however, may not be absolute or 

indefinite, particularly when officers are tasked with monitoring a detainee. See, e.g., Stojcevski 

v. Macomb County, 827 F. App’x 515, 522 (6th Cir. 2020) (summarizing the relevant law that an 

officer can rely on a medical opinion for a “reasonable period of time after it is issued, absent 

circumstances such as the onset of new and alarming symptoms”). Moreover, “[a]t a certain 

point, bare minimum observation ceases to be constitutionally adequate.” Greene, 22 F.4th at 

609.

a. Defendant Deputy Daniel Erwin

Erwin first saw Howell in the medical sallyport, where he observed Howell “slumped 

over in the chair,” then “sprawled out on the floor,” and heard him “making noises.” Other 

officers present heard Howell “moaning,” and yelling that “his legs wouldn’t work” and that he 

“could not feel his legs.” Erwin overheard medical staff and officers debating whether Howell 

needed to go to the hospital, then he and other officers were ordered to place Howell in a 

restraint chair and transport him to the mental health unit for “safety and for observation.” Erwin 

later stated that he thought Howell should have gone to the hospital. 

It is undisputed that medical staff made the decision to send Howell to the mental health 

unit instead of the hospital, and Erwin reasonably deferred to that medical determination. But 

importantly, that medical determination relied on the understanding that officers would complete 

observational checks every ten minutes as required by policy and would alert the medical staff if 

they saw anything unusual. It is undisputed that Erwin completed only four checks after his 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 14

initial check with Arthur at 6:06 p.m. and before Howell was found dead at 9:45 p.m. He did not 

complete a check after 8:03 p.m. Between Erwin and Collini, who was also responsible for 

observing Howell, only seven observational checks were performed during the approximately 

three-and-a-half-hour period. Policy specified that over 20 checks should have been performed. 

The Officers instead falsified entries to the restraint chair log, knowingly failing to comply with 

policy. 

The infrequency of the observational checks violated policy. In addition, the 

methodology of the checks raises concerns. Erwin would “look in the . . . small little window 

. . . and observe [Howell]” from the left side. Collini testified that on two occasions he could not 

see Howell’s eyes or tell if he was alive, which leads to the inference that Erwin could not either. 

Erwin never entered Howell’s cell, despite having the discretion to do so and despite an abrupt 

change in Howell’s demeanor. Nor did Erwin comply with the policy to offer Howell water and 

a chance to use the restroom. 

The infrequency and inadequacy of Erwin’s observational checks is compounded by the 

record evidence that he knew, or should have known, that Howell faced a high risk of harm. 

Erwin himself believed that Howell should have gone to the hospital after observing Howell’s 

condition in the sallyport. He knew the medical staff considered sending Howell to the hospital 

prior to deciding that Howell would be restrained for further observation. 

 Considering these facts, a jury could find that Erwin’s actions were the kind of “bare 

minimum observation” that “ceases to be constitutionally adequate.” Greene, 22 F.4th at 609. 

In Erwin’s case, there is “more” in the record beyond policy violations, Hyman, 27 F.4th at 1238, 

and a jury could determine that Erwin’s actions crossed the line from negligence to reckless 

disregard. See Speers v. County of Berrien, 196 F. App’x 390, 397-98 (6th Cir. 2006) (denying 

summary judgment where officer heard of detainee’s troubling symptoms but only observed the 

detainee through plexiglass and believed detainee was “sleeping”). The district court’s grant of 

summary judgment to Erwin on the Estate’s deliberate indifference claim is reversed.
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 15

b. Defendant Deputy Matthew Collini

Unlike Hunt and Erwin, Collini was not present during Howell’s evaluation in the 

medical sallyport; his first interaction with Howell was during Arthur’s check around 6:06 p.m., 

after Howell had been placed in the restraining chair and brought to the mental health unit. He 

checked on Howell three times, once at 7:24 p.m., once at 7:40 p.m., and finally at 9:14 p.m., and 

he violated the same internal policies as Erwin during the observation period.

While Collini knew of the general risks a detainee faced in the restraint chair, he did not 

have the same knowledge as Erwin, who saw Howell’s troubling symptoms in the sallyport and 

heard the medical staff’s hospitalization discussion and their orders. While Collini did not see 

Howell’s condition in the sallyport, he did see Howell’s condition worsen while he was in the 

restraining chair, and he did nothing to alert the medical staff. For example, during his third 

check, Collini testified that Howell’s head “was maybe a little more down . . . . More straight 

down, I guess.” As explained, the medical staff relied on the officers to observe and alert them 

of these changes. Nonetheless, on this record, a jury could not find that a reasonable officer in 

Collini’s position—without knowledge of what precipitated Howell’s arrival in the mental health 

unit—would have recognized an unjustifiably high risk of harm to Howell. See Brawner, 14 

F.4th at 597. Collini’s failure to act and policy violations did not rise above the level of 

negligence. See Hyman, 27 F.4th at 1238. The district court’s grant of summary judgment to 

Collini on the Estate’s deliberate indifference claim is affirmed.

c. Defendant Sergeant Justin Hunt

Hunt was present in the medical sallyport while Howell was evaluated. He saw Howell 

slide out of a chair onto the floor and heard him yell about pain and numbness in his legs and 

pain in his back. He heard the debate whether to send Howell to the hospital, heard the ultimate 

decision to keep Howell at the jail for “safety and for observation,” and saw officers place 

Howell in the restraint chair and transport him from the medical sallyport. Hunt did not see 

Howell again until he came to remove Howell from the restraint chair and found him dead, 

approximately four hours later. 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 16

Like Erwin, Hunt reasonably deferred to the medical staff’s judgment not to send Howell 

to the hospital. But unlike Erwin, Hunt was not responsible for performing the observational 

checks while Howell was restrained in the mental health unit. To be sure, approximately two 

hours into the observation period, Collini called Hunt to perform a limb rotation, which required 

a supervisor, and Hunt did not arrive until two hours later. The Estate faults Hunt for this failure 

to timely arrive and perform the limb rotation, but the jail’s policy did not require a limb 

rotation, it merely recommended it. At the most, a jury could find that Hunt was negligent given 

that he reasonably deferred to the medical staff’s judgment and was not personally responsible 

for observing Howell. Griffith, 975 F.3d at 570-71. The district court’s grant of summary 

judgment to Hunt on the Estate’s deliberate indifference claim is affirmed. 

3. Qualified Immunity 

In response to the deliberate indifference claim, the individual Hamilton County 

Defendants assert qualified immunity.4 Qualified immunity operates to shield government 

officials from liability for their actions unless the officials are on notice that those actions are 

unlawful. See Occupy Nashville v. Haslam, 769 F.3d 434, 441-42 (6th Cir. 2014). To overcome 

the Officers’ claims to qualified immunity, the Estate must show that (1) the Officers violated 

one of Howell’s constitutional rights and (2) that right was clearly established. Id. at 442. As 

explained above, the Estate fails to carry its burden of showing a constitutional violation on the 

part of Deputy Collini and Sergeant Hunt, so they are entitled to qualified immunity. But 

because a jury could find that Deputy Erwin violated Howell’s constitutional right to be free 

from deliberate indifference to his serious medical need, we analyze whether that right was 

clearly established in 2018. “For a right to be clearly established, the contours of the right must 

be sufficiently clear that a reasonable official would understand that what he is doing violates 

that right.” Burwell, 7 F.4th at 476 (cleaned up). The illegality of the conduct must be apparent 

considering “pre-existing law, but we need not find a case in which the very action in question 

has previously been held unlawful.” Id. at 476-77 (cleaned up).

4Nurses employed by a private medical provider, like NaphCare, are not entitled to assert qualified 

immunity. Harrison, 539 F.3d at 524. 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 17

“As early as 1972, we stated that ‘where the circumstances are clearly sufficient to 

indicate the need of medical attention for injury or illness, the denial of such aid constitutes the 

deprivation of constitutional due process.’” Id. at 477 (citing Est. of Carter v. City of Detroit, 

408 F.3d 305, 313 (6th Cir. 2005)). “Furthermore, we reiterated in 2013 that it is clearly 

established that a prisoner has a right not to have his known, serious medical needs disregarded 

by a medical provider or an officer.” Helphenstine, 60 F.4th at 327 (quoting Greene, 22 F.4th at 

615). Under comparable circumstances, in Phillips v. Roane County, we denied qualified 

immunity to officers who inadequately monitored an inmate exhibiting signs of a serious medical 

condition. 534 F.3d 531, 540-41, 545 (6th Cir. 2008). The officers were tasked with monitoring 

the inmate in an observation room, observed her concerning symptoms, and disregarded prison 

protocols, ultimately leading to a failure to pursue further medical intervention. Id. at 540-41. 

The same is true in this case; Erwin observed Howell’s condition, was tasked with monitoring 

him, and failed to follow policy in doing so, which a jury could find amounted to deliberate 

indifference. We hold that Erwin was sufficiently on notice that such conduct was unlawful and 

is not entitled to qualified immunity.

B. Monell Claims 

The Estate also brought claims against NaphCare, Inc., and Hamilton County pursuant to 

Monell v. Department of Social Services of the City of New York, 436 U.S. 658 (1978). The 

Estate argues that NaphCare had a custom of authorizing its nurses to order restraint chairs, 

which practice led to Howell’s inadequate medical care. As for the County, the Estate contends 

it was deliberately indifferent in failing to train its officers on proper restraint-chair monitoring. 

The district court granted summary judgment to both Defendant entities. 

1. Custom Claim Against NaphCare

A private corporation performing traditional state functions can be held directly liable 

under § 1983 if its customs, practices, or policies led to a constitutional deprivation. Winkler, 

893 F.3d at 904. A custom that has not been formally approved may still serve as a basis for 

liability if “the relevant practice is so widespread as to have the force of law.” Bd. of Cnty. 

Comm’rs of Bryan Cnty. v. Brown, 520 U.S. 397, 404 (1997). The Estate bears “a heavy burden 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 18

in proving municipal liability, and [it] cannot rely solely on a single instance to infer a policy of 

deliberate indifference.” Thomas v. City of Chattanooga, 398 F.3d 426, 433 (6th Cir. 2005).

The Estate argues that “there is evidence showing that nurses routinely ordered restraint 

chairs,” and that custom “caused the denial of adequate medical care” to Howell. If such a 

custom existed, it violated jail policy that the “application of any clinically ordered restraints 

must be ordered by an advanced clinical provider.” The Estate contends that this caused 

Howell’s injury because if Jordan had complied with policy, a doctor would have been contacted 

and that doctor likely would have ordered Howell to the emergency room. 

The Estate points to only one piece of deposition testimony that, according to a 

corrections officer, shows that it was “typical for nurses to be the ones who are authorizing the 

restraint chair.” Notably, this single piece of evidence does not make clear that it was “typical” 

for nurses to order restraint chairs without first receiving authorization from an advanced medical 

provider, which the policy permitted to be provided “in writing or via telephone consultation.” 

That testimony alone is insufficient to show a genuine dispute of material fact as to whether there 

was a custom of nurses ordering restraints in violation of policy that was “so widespread as to 

have the force of law.” Brown, 520 U.S. at 404.

The district court’s grant of summary judgment to NaphCare on the Estate’s Monell

claim is affirmed.

2. Failure to Train Claim Against Hamilton County

The Estate sued Sheriff Neil in his official capacity under a failure-to-train theory, a 

claim that amounts to suit against Hamilton County itself. Leach v. Shelby County, 891 F.2d 

1241, 1245-46 (6th Cir. 1989). A municipality may be liable under § 1983 for failure to train 

when it amounts to deliberate indifference. City of Canton v. Harris, 489 U.S. 378, 388-89 

(1989). To succeed on a failure-to-train claim, a plaintiff must show: “(1) the training or 

supervision was inadequate for the tasks performed; (2) the inadequacy was the result of the 

municipality’s deliberate indifference; and (3) the inadequacy was closely related to or actually 

caused the injury.” Ellis ex rel. Pendergrass v. Cleveland Mun. Sch. Dist., 455 F.3d 690, 700 

(6th Cir. 2006). Regarding the second prong, a plaintiff most commonly demonstrates a 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 19

municipality’s deliberate indifference by pointing to a failure to act “in response to repeated 

complaints of constitutional violations by its officers.” Ouza v. City of Dearborn Heights, 969 

F.3d 265, 287 (6th Cir. 2020) (quoting Cherrington v. Skeeter, 344 F.3d 631, 646 (6th Cir. 

2003)). But a plaintiff can rely on a single incident to establish liability in a narrow range of 

circumstances “if the risk of the constitutional violation is so obvious or foreseeable” that it 

amounts to deliberate indifference for the municipality to fail to prepare its officers for it. Id. 

The Estate relies on this latter route to show the County’s deliberate indifference.

The Estate initially argues that the County did not provide any training on restraint-chair 

monitoring, but ultimately argues that the County only provided limited on-the-job training that 

was inadequate. Three types of training regarding observation of inmates in restraint chairs 

were evinced by the record: training at correctional officer academy; training at orientation; and 

on-the-job training. One sergeant testified that training was offered by a “field training officer” 

after the academy. 

Collini stated that he received training at the academy and received ongoing on-the-job 

training; Erwin received the same and showed an awareness and familiarity with the restraint 

chair policies. Based on the record, it is difficult to ascertain the substance of these trainings—

formal or informal—and the Estate’s expert only provides in conclusory terms that the County 

“failed to properly train and supervise” officers on the “proper supervision and careful 

observation of inmates” in restraint chairs. 

To support its proposition that the County’s training was inadequate, the Estate primarily 

relies on Shadrick v. Hopkins County, which held that a jail medical provider inadequately 

trained its nurses by providing only “some limited on-the-job-training.” 805 F.3d 724, 740 (6th 

Cir. 2015). But Shadrick contained no indication that the nurses received “any type of ongoing 

training”; the only training provided appeared to be “some limited on-the-job training when 

beginning their employment, such as learning where supplies were kept.” Id. They also did not 

receive any feedback or evaluations based on their performance. Id. Finally, none of the 

nurses, including their supervisor, could identify any of the requirements of the written policies 

that governed their work. Id. The record in Shadrick reveals that the “limited on-the-job 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 20

training” offered at the beginning of the nurses’ employment on housekeeping issues amounted 

to no training at all. 

On this record, we cannot say the same is true regarding the County’s training on 

restraint-chair monitoring. The County offered initial training, and, while it did rely on on-thejob training, that training was ongoing. The Officers displayed knowledge of and familiarity 

with the relevant polices that governed restraint chairs, which the Estate’s expert agreed were 

reasonable and appropriate. Finally, “failure-to-train liability is concerned with the substance of 

the training, not the particular instructional format.” Connick v. Thompson, 563 U.S. 51, 68 

(2011). Contrary to the Estate’s argument, the County did not wholly fail to train its officers on 

restraint-chair monitoring. The Estate has failed to show a genuine dispute of fact regarding 

whether the training was deficient in substance. The Estate’s failure-to-train claim against the 

County fails at prong one, and the district court’s grant of summary judgment is affirmed. 

C. Excessive Force Claim Against Nurse Jordan

The Estate brought an excessive force claim against Jordan, claiming that her use of the 

restraint chair violated Howell’s Fourteenth Amendment rights. To succeed, the Estate must 

show “that the force purposely or knowingly used against [a pretrial detainee] was objectively 

unreasonable.” Kingsley, 576 U.S. at 396-97. The reasonableness of the force turns on the facts 

and circumstances of the particular case, and “[a] court must make this determination from the 

perspective of a reasonable [official] on the scene, including what the [official] knew at the time, 

not with the 20/20 vision of hindsight.” Id. at 397. Factors that may bear on the reasonableness 

analysis include:

[T]he relationship between the need for the use of force and the amount of force 

used; the extent of the plaintiff’s injury; any effort made by the officer to temper 

or to limit the amount of force; the severity of the security problem at issue; the 

threat reasonably perceived by the officer; and whether the plaintiff was actively 

resisting.

Id.

In the light most favorable to the Estate, Jordan ordered Howell into the restraint chair 

around 5:40 p.m., and it is undisputed that he remained in the chair for approximately four hours 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 21

without any further check by Jordan. There is no evidence any force more than necessary was 

used to place Howell in the chair. Regarding the propriety of ordering a restraint chair based on 

Howell’s symptoms, NaphCare’s Health Services Administrator opined that “[y]elling, [falling] 

on the floor, rolling around,” and “non-complian[ce] with medical care” would not be grounds to 

place a detainee in a restraint chair, but “it depends on the events that led up to this [behavior],” 

and on “what was going on at that time.” 

Neither party cites authority from this court analyzing the failure to remove a detainee 

from a restraining chair in the context of an excessive force claim. The Estate relies on 

Blackmon v. Sutton, 734 F.3d 1237 (10th Cir. 2013), a case authored by then-Judge Gorsuch. 

Blackmon recognized that “the government may have a legitimate interest in ensuring the safety 

and order of the facilities where it houses pretrial detainees” and restraints can aid that interest 

even if they cause discomfort but noted that very harsh conditions might not be reasonably 

related to “any purpose except punishment.” Id. at 1241 (quoting Bell v. Wolfish, 441 U.S. 520, 

539 n. 20, 540 (1979)). In Blackmon, the defendants were denied summary judgment because on 

some occasions they restrained the plaintiff to a chair “without any legitimate penological 

purpose.” Id. at 1242 (emphasis in original). This included occasions where the plaintiff had 

been restrained “for extensive periods after any threat of self-harm had dissipated.” Id. The 

Estate argues that Jordan’s initial order to place Howell in the restraint chair and the subsequent 

failures to check on Howell are analogous to the facts in Blackmon. It contends that, based on 

the record, a jury could find there was no legitimate purpose for putting Howell in the chair and 

Howell was left in the restraint chair long after “any threat . . . had dissipated.” 

Logic supports consideration of the Estate’s excessive force claim as distinct from the 

inadequate-medical-care claim. Excessive force raises the question of what harm Howell 

incurred based on Jordan’s decision to place him in the restraint chair, instead of a decision that 

did not involve the force inherent in restraints, such as returning him to his cell or leaving him 

unrestrained in an observation room. Regarding the harm caused to Howell, the Estate’s expert, 

Dr. Steinberg, concluded, “I don’t think it was the restraint chair itself. I think it was . . . the lack 

of observation during this time.” Indeed, the Estate did not contend that “the restraint chair 

killed Howell”; rather, that “Defendants killed Howell through their deliberate indifference to his 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 22

serious medical condition while left alone in the chair.” The record suggests that Howell’s injury 

was caused by the failures to send him to the hospital and to properly monitor him. Whether 

those failures violated Howell’s constitutional rights is properly analyzed in the Estate’s 

deliberate indifference claim. 

Given that Jordan determined Howell would not be sent to the hospital—again, a decision 

that is scrutinized in the inadequate-medical-care context—it was not objectively unreasonable to 

order Howell to a restraint chair for his safety and observation and for him to remain restrained 

for four hours. Cf. Grinter v. Knight, 532 F.3d 567, 573-74 (6th Cir. 2008) (holding that a 

convicted prisoner did not have a due process liberty interest in freedom from being restrained 

for four hours). Weighing the appropriate factors, the Estate has not shown a genuine dispute of 

material fact that Jordan used excessive force against Howell. See Kinglsey, 576 U.S. at 397. 

The district court’s grant of summary judgment to Jordan on the excessive force claim is 

affirmed.

D. State Law Claims

In addition to the federal claims analyzed in this opinion, the Estate brought state law 

claims against the Defendants. After granting summary judgment in favor of Defendants on the 

Estate’s § 1983 claims, the district court declined to retain supplemental jurisdiction over 

remaining state law claims. Because we reverse the district court’s grant of summary judgment 

regarding Nurse Jordan and Deputy Erwin, we also reverse the district court’s dismissal of the 

state law claims regarding those Defendants. See, e.g., Helphenstine, 60 F.4th at 327. On 

remand, the district court should reconsider its decision to decline supplemental jurisdiction 

over these state law claims against Jordan and Erwin. See id.

III. CONCLUSION

The district court erred in granting summary judgment to Nurse Jordan and Deputy Erwin 

on the Estate’s deliberate indifference claims, because, pursuant to Brawner, a reasonable jury 

could find that they recklessly failed to act to mitigate an unjustifiably high risk of harm to 

Howell that a reasonable official would have recognized. Erwin was not entitled to qualified 

immunity. Otherwise, the district court properly granted summary judgment on all other claims. 
Nos. 21-4132/22-3306 Howell v. NaphCare, Inc. Page 23

We therefore REVERSE IN PART and AFFIRM IN PART the district court’s grant of 

summary judgment, and REMAND for further proceedings consistent with this opinion.