1

RECOMMENDED FOR FULL-TEXT PUBLICATION

Pursuant to Sixth Circuit Rule 206

ELECTRONIC CITATION: 2004 FED App. 0043P (6th Cir.)

File Name: 04a0043p.06

UNITED STATES COURT OF APPEALS

FOR THE SIXTH CIRCUIT

_________________

CAROLYN GRAHAM, as

Personal Representative of the

Estate of Terance Anthony

Graham, 

Plaintiff-Appellant,

v.

COUNTY OF WASHTENAW,

Defendant-Appellee.

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No. 02-1614

Appeal from the United States District Court

for the Eastern District of Michigan at Detroit.

No. 00-72195—Anna Diggs Taylor, District Judge.

Argued: October 23, 2003

Decided and Filed: February 10, 2004 

Before: KEITH, MARTIN, and SUTTON, Circuit Judges.

_________________

COUNSEL

ARGUED: Hugh M. Davis, Jr., CONSTITUTIONAL

LITIGATION ASSOCIATES, Detroit, Michigan, for

Appellant. Cynthia L. Reach, REACH, RANNEY &

2 Graham v. County of Washtenaw No. 02-1614

1

There is some discrepancy in the record and briefs as to the correct

spelling of Mr. Graham’s first name. According to the Notice of Appeal,

however, it is spelled “Terance.”

CARPENTER, Ann Arbor, Michigan, for Appellee.

ON BRIEF: Hugh M. Davis, Jr., CONSTITUTIONAL

LITIGATION ASSOCIATES, Detroit, Michigan, for

Appellant. Cynthia L. Reach, REACH, RANNEY &

CARPENTER, Ann Arbor, Michigan, for Appellee.

_________________

OPINION

_________________

BOYCE F. MARTIN, JR., Circuit Judge. This case arises

from the tragic death of Terance Anthony Graham.1 Mr.

Graham died in police custody shortly after secretly ingesting

large quantities of cocaine upon being arrested for an

unrelated marijuana offense. Carolyn Graham, the personal

representative of Mr. Graham’s estate, sued Washtenaw

County pursuant to 42 U.S.C. § 1983, claiming that the

County’s policy regarding the provision of medical care to

prisoners in the County jail contributed to Mr. Graham’s

death. The district court granted the County’s motion for

summary judgment. For the following reasons, we affirm. 

I. BACKGROUND

The facts giving rise to this case are, for the most part,

undisputed. On May 6, 2000, at approximately 8:39 in the

evening, Deputy Sinks arrested Mr. Graham for possession of

marijuana. A few minutes after the arrest, the deputy

permitted Mr. Graham to go behind a tree, allegedly to relieve

himself. It was later determined that while behind the tree

Mr. Graham had swallowed approximately an ounce of

cocaine, which is a felony under Michigan law. Mr. Graham

was escorted into the County jail at approximately 8:55.

Most of the events occurring inside the jail were captured on
No. 02-1614 Graham v. County of Washtenaw 3

2

In a written report, Deputy Sinks claimed that at this point Nurse

Lakatos told Mr. Graham that his heart was racing at around two hundred

beats per minute and asked him why his heart rate was so high. The

County denies that Nurse Lakatos observed or reported that Mr. Graham’s

heart rate was two hundred beats per minute and claims that the deputy’s

report is inadmissible hearsay. This disagreement does not, however,

constitute a genuine dispute of material fact that would preclude summary

judgment. 

videotape. Shortly after his arrival, jail personnel observed

Mr. Graham walking and acting erratically. At one point, he

pulled down his pants in full view of everyone in the booking

area. Jail personnel asked him several times, “What did you

take?” Instead of revealing that he had ingested cocaine, Mr.

Graham stated that he had smoked marijuana and drank

alcohol. After witnessing Mr. Graham’s erratic behavior, a

deputy requested that he be medically examined. 

At approximately 9:00, Tracy Lakatos, a licensed practical

nurse, responded and examined Mr. Graham. Nurse Lakatos

was an employee of SecureCare, Inc., a company that the

County had hired to provide medical care to prisoners in the

County jail. Mr. Graham told her that he had been drinking

and using marijuana that evening and that he had asthma.

Nurse Lakatos gave him two doses of albuterol, a medication

used to treat asthma that has a known side effect of causing an

accelerated heart rate. At 9:06, Nurse Lakatos and Deputy

Sinks took Mr. Graham to an interview room.

2

 After a blood

alcohol test indicated that Mr. Graham was not intoxicated,

Nurse Lakatos said that Deputy Sinks could interview Mr.

Graham and she left the room at 9:11.

After providing a statement about his marijuana purchase

– the event prompting his arrest – Mr. Graham was turned

over to another deputy and was scheduled to be booked and

then released. At this point, jail personnel observed him

sweating profusely and using his shirt, which he had removed

from his body, to wipe off the sweat. Jail personnel

determined that he was not well enough to go through the

4 Graham v. County of Washtenaw No. 02-1614

booking process, so they placed him in a general population

cell at 9:23.

While inside the cell, Mr. Graham admitted to a cellmate

that he had ingested cocaine, but insisted that he did not want

the jail personnel to find out. Statements from his cellmates

indicate that while in the cell Mr. Graham “could barely talk,”

“was staggering,” “looked sick,” and “was holding his

stomach and rubbing his throat.” At approximately 10:00, a

cellmate pounded on the plexiglass window and yelled “He’s

hurt!” Witnesses reported that Mr. Graham appeared to be

having a seizure and that he had “a blank look on his face and

his eyes were real glassy.”

Nurse Lakatos responded and asked what was wrong.

Again, instead of telling Nurse Lakatos the truth, Mr. Graham

only said that he had swallowed some pills. Nurse Lakatos

used a pulse oximeter to determine his heart rate. One

cellmate observed that the pulse oximeter indicated a high

heart rate, which Nurse Lakatos apparently explained was due

to the marijuana. Satisfied that Mr. Graham needed no

additional medical care, Nurse Lakatos left the cell at

approximately 10:05. 

At 10:16, Nurse Lakatos responded to another cry from a

cellmate that Mr. Graham had “passed out.” At this point, he

was taken to the medical room in the jail building, requiring

assistance from jail personnel to stay on his feet. At

approximately 10:40, he began to have multiple seizures, at

which point an ambulance was summoned. He was

transported to a hospital emergency room a few minutes later

and was pronounced dead at 11:31. 

On May 12, 2000, Carolyn Graham, the personal

representative of Mr. Graham’s estate, filed a complaint

against the County, its Sheriff and certain officers. She filed

an amended complaint four days later. The claims against the

Sheriff and officers were subsequently dismissed, leaving a

section 1983 municipal liability claim against the County,
No. 02-1614 Graham v. County of Washtenaw 5

which is the only claim at issue in this appeal. The essence of

the municipal liability claim is that the County’s contract with

SecureCare constituted a municipal “policy” that led to a

deprivation of Mr. Graham’s constitutional right to adequate

medical care while in police custody. Specifically, the

complaint alleges that: (1) the contract impermissibly creates

a policy of “automatic deference” by jail personnel to the

decisions of SecureCare staff concerning the medical

treatment of prisoners; and (2) the contract improperly

permits licensed practical nurses – like Nurse Lakatos – to

perform duties that exceed their competence under Michigan

law. 

On August 3, 2001, the County filed a motion for summary

judgment, which was supplemented on August 28. On

October 1, the district court denied the motion without

prejudice and allowed Graham additional time to conduct

further discovery and to amend her complaint. She made no

attempt to file an amended complaint during the allotted time.

On February 4, 2002, the County renewed its motion for

summary judgment and, on February 11, filed a motion for

sanctions pursuant to Federal Rule of Civil Procedure 11

based upon Graham’s failure to withdraw the case in light of

this Court’s decision in Watkins v. Battle Creek, 273 F.3d 682

(6th Cir. 2001). In Watkins, we affirmed an award of

summary judgment to individual and municipal defendants in

a section 1983 case arising out of the death of an individual

who, like Mr. Graham, died in police custody after secretly

ingesting cocaine upon his arrest. Id.

On February 19, without requesting leave of the district

court, Graham attempted to file an amended complaint that

purportedly “clarified” her claim against the County and

asserted additional section 1983 claims, as well as a “medical

negligence” claim against various new defendants, including

SecureCare. The district court sua sponte rejected the

attempted filing. On February 25, Graham filed a motion for

leave to file the newly amended complaint.

6 Graham v. County of Washtenaw No. 02-1614

On March 11, the district court held a hearing during which

the following ruling was made from the bench:

It appears to the Court that at this time it must grant the

defendant’s motion for summary judgment because there

is no showing of any unconstitutional custom or policy

on the part of the Washtenaw County Jail which required

the deliberate indifference which could have led to the

plaintiff’s death. Indeed any other ruling here would be

extremely detrimental to prisoners who are incarcerated

in Michigan jails because the presence of medical

personnel is essential to their safety and their health.

Unfortunately the plaintiff here, as Watkins, in his case,

was the only person who knew what he had ingested, and

he was asked on several occasions by the medical

personnel and others, apparently, at this jail what was

wrong, and he did not disclose what his medical need

was. So I have to grant the motion for summary

judgment in this case.

After granting the County’s motion for summary judgment,

the district court denied Graham’s motion to file the amended

complaint. Graham later filed a motion for reconsideration,

which was denied on April 12. She also filed a medical

malpractice action against SecureCare and other defendants

in Michigan state court, which apparently is still pending.

After the completion of appellate briefing in this case, this

Court decided Weaver v. Shadoan, 340 F.3d 398 (6th Cir.

2003), another case involving the death of an individual in

police custody after secretly ingesting cocaine. In Weaver,

we relied upon our recent decision in Watkins to reverse the

district court’s denial of summary judgment to individual

defendants on the plaintiff’s section 1983 claims. Id.

On appeal, Graham argues that the district court erred in

granting summary judgment in favor of the County, in

denying her motion to file an amended complaint and in
No. 02-1614 Graham v. County of Washtenaw 7

3

The parties agree that Mr. Graham had a constitutional right to

adequate medical care while in the custody of the County. Farmer v.

Brennan, 511 U.S. 825, 832 (1994); Estelle v. Gamble, 429 U.S. 97, 104

(1976). It is well established that “deliberate indifference to the serious

medical needs of prisoners” constitutes cruel and unusual punishment in

violation of the Eighth Amendment. Estelle, 429 U.S. at 104. While the

Eighth Amendment does not apply to pretrial detainees such as Graham,

the Fourteenth Amendment affords pretrial detainees a due process right

to adequate medical treatment that is analogous to the Eighth Amendment

rights of prisoners. City of Revere v. Mass. Gen. Hosp., 463 U.S. 239,

244 (1983). 

denying her motion for reconsideration. We find these

arguments to be without merit.

II. ANALYSIS

We review de novo the district court’s grant of summary

judgment in favor of the County. Dotson v. Wilkinson, 329

F.3d 463, 466 (6th Cir. 2003). Summary judgment should be

granted when “the pleadings, depositions, answers to

interrogatories, and admissions on file, together with the

affidavits, if any, show that there is no genuine issue as to any

material fact and that the moving party is entitled to a

judgment as a matter of law.” FED. R. CIV. P. 56(c). In

determining whether a genuine issue of material fact exists,

we must draw all reasonable inferences in favor of Graham,

as the nonmoving party. Bonds v. Cox, 20 F.3d 697, 701 (6th

Cir. 1994).

A. Section 1983 Claim

The essence of the section 1983 claim is that Mr. Graham

suffered a violation of his right to adequate medical care

while in custody and that the County’s policy regarding the

provision of medical care to its prisoners – as embodied in its

contract with SecureCare – led to that constitutional

violation.3 This claim implicates the familiar principles set

forth in Monell v. Department of Social Services, 436 U.S.

658, 694 (1978). In Monell, the Supreme Court explained

8 Graham v. County of Washtenaw No. 02-1614

4

Our decisions in Watkins and Weaver centered upon whether

individual defendants committed a constitutional violation by virtue of

their deliberate indifference to the serious medical needs of the respective

decedents. While one municipal liability claim was asserted in Watkins,

we did not discuss in much detail the merits of that claim, explaining

simply that “[i]f no constitutional violation by the individual defendants

is established, the municipal defendants cannot be held liable under

§ 1983.” Watkins, 273 F.3d at 687 (citing City of Los Angeles v. Heller,

475 U.S. 796, 799 (1986)). Thus, in light of our conclusion that none of

the individual defendants had committed a constitutional violation, we

held that summary judgment was properly granted on the municipal

liability claim as a matter of course. Id. This case is different from both

Watkins and Weaver in that there are no claims asserted against individual

defendants; the focus is solely upon the County’s liability. Therefore,

despite the factual similarities between this case and Watkins and Weaver,

our opinions in those cases do not automatically compel the outcome here.

that municipal liability under section 1983 may only attach

where the “execution of a government’s policy or custom,

whether made by its lawmakers or by those whose edicts or

acts may fairly be said to represent official policy, inflicts the

injury” complained of. Thus, Graham must prove two basic

elements: (1) that a constitutional violation occurred; and

(2) that the County “is responsible for that violation.” Doe v.

Claiborne Cty., 103 F.3d 495, 505-06 (6th Cir. 1996). Our

decisions in Watkins and Weaver, discussed above, would be

relevant to the first element – i.e., whether Mr. Graham

suffered a deprivation of his constitutional right to adequate

medical care.

4

 We need not decide that issue, however,

because we find that even assuming that a constitutional

violation occurred, the County cannot be held liable for it.

A plaintiff asserting a section 1983 claim on the basis of a

municipal custom or policy must “identify the policy, connect

the policy to the [County] itself and show that the particular

injury was incurred because of the execution of that policy.”

Garner v. Memphis Police Dep’t, 8 F.3d 358, 364 (6th Cir.),

cert. denied, 510 U.S. 826 (1994). Graham’s claim is based

upon the County’s contract with SecureCare, which gives

SecureCare responsibility over the provision of medical care
No. 02-1614 Graham v. County of Washtenaw 9

to prisoners in the County jail. The County concedes that this

contract constitutes a municipal “policy” within the meaning

of Monell.

The primary issue is whether Graham has alleged sufficient

facts to establish that the alleged constitutional violation

happened “because of the execution of [the County’s] policy.”

Id. (emphasis added). There must be “a direct causal link”

between the policy and the alleged constitutional violation

such that the County’s “deliberate conduct” can be deemed

the “moving force” behind the violation. Waters v. City of

Morristown, 242 F.3d 353, 362 (6th Cir. 2001) (citing Bd. of

Cty. Comm’rs v. Brown, 520 U.S. 397, 404 (1997)) (quotation

marks omitted); see also Searcy v. City of Dayton, 38 F.3d

282, 286 (6th Cir. 1994). These stringent standards are

“necessary to avoid de facto respondeat superior liability

explicitly prohibited by Monell.” Doe, 103 F.3d at 508.

Applying these standards, we conclude that Grahamhas failed

to establish the requisite causal link between the County’s

policy and the alleged constitutional violation.

As noted, Graham believes that two particular aspects of

the contract are most problematic. First, she argues that the

contract impermissibly creates a policy of “automatic

deference” by jail personnel to SecureCare medical staff with

respect to decisions concerning prisoners’ medical treatment.

According to Graham, that so-called automatic deference

policy is reflected in a provision stating that SecureCare “will

have the responsibility of determining whether emergency

services and/or hospitalization are necessary.” Additionally,

she relies upon a “Medical Autonomy” standard appearing in

the “SecureCare, Inc. Washtenaw County Sheriff Department

Policies and Procedures Manual,” which reads: “PURPOSE:

To insure that members of the medical, dental and mental

health staff have autonomy relative to professional judgement

in their respective profession.” 

Graham also challenges the contract on the ground that it

permits licensed practical nurses, like Nurse Lakatos, to make

10 Graham v. County of Washtenaw No. 02-1614

5

The County claims that Bailey’s affidavit, as well as the affidavits

of two other individuals, were deemed inadmissible by the district court

and, accordingly, should not be considered part of the record on appeal.

The record contains no written district court order declaring the affidavits

inadmissible, nor do the transcripts reveal a ruling from the bench to that

effect. The only pronouncement by the district court on this subject is a

passing statement during an oral argument in which the judge stated: 

That’s all right. The Court is not going to consider those

affidavits and I don’t think they’re helpful at any rate at this

stage of events. I’m going to deny this motion without prejudice

for summary judgment and give the plaintiff 60 days to attempt

to rectify the things that have not been done in this case.

However, while that statement indicates the court’s unwillingness to

consider the affidavits at that particular time, it does not represent a

definitive ruling as to the admissibility of the affidavits. Thus, it appears

that the affidavits are properly part of the record on appeal. 

some medical decisions that are beyond their competence

under Michigan law. This assertion is based primarily upon

an affidavit of a licensed practical nurse named Cynthia

Bailey,

5

 but no legal authority is cited.

Thus, the crux of Graham’s argument is that the County’s

policy was responsible for the alleged constitutional violation

in this case because “the booking deputies deferred to Nurse

Lakatos” – who was unqualified under Michigan law to make

certain decisions concerning Mr. Graham’s treatment that the

contract permitted her to make – “and retained [Mr. Graham]

in a general population cell without referring him for

emergency medical treatment/evaluation because of the

County’s policy of deference . . . .”

Contrary to Graham’s assertions, we find nothing in the

County’s policy that is actionable under section 1983.

Graham concedes that it is not unconstitutional for

municipalities to hire independent medical professionals to

provide on-site health care to prisoners in their jails. Nor is

it unconstitutional for municipalities and their employees “to

rely on medical judgments made by medical professionals
No. 02-1614 Graham v. County of Washtenaw 11

6

In fact, as this and other recent cases such as Watkins and Weaver

have confirmed, it is not unusual for individuals to ingest narcotics

surreptitiously in an attempt to hide them from the police, and then to

conceal that illegal activity while in custody – even when they become

dangerously ill – out of fear of prosecution. This dangerous practice

presents a significant problem for the law enforcement community. It

appears that, in general, more should be done in order to ensure that

arresting officers prevent, to the best of their ability, individuals from

ingesting narcotics in the first place, as well as to ensure that individuals

who show symptoms of a drug overdose while in custody obtain the

medical care that they so urgently need, despite their possible reluctance

to reveal the true nature of their condition.

responsible for prisoner care.” Ronayne v. Ficano, No. 98-

1135, 1998 WL 183479, at *3 (6th Cir. Mar. 15, 1999)

(unpublished opinion). In fact, most would find such a policy

laudable in many respects. Not only does such a policy – like

the one at issue in this case – allow prisoners to receive

prompt health care from on-site doctors or nurses, it also

ensures that an independent party, rather than a corrections

officer, makes the critical decisions about whether and at

what point a prisoner’s medical needs are sufficiently severe

that ambulatory care or hospitalization is warranted. 

Graham’s argument is essentially that the County’s policy

did not, in this particular case, adequately address Mr.

Graham’s specific medical needs. That may be so.6

However, “[t]he fact that alternative procedures might have

better addressed [a prisoner’s] particular needs does not show

that the [County was] deliberately indifferent to his medical

needs.” Id. Even if, as Graham contends, the policy required

jail personnel to defer to the medical decisions of SecureCare

employees, and even if it permitted licensed practical nurses

to make medical decisions that Michigan law does not permit

them to make, those alleged defects are insufficient to hold

the County liable for the alleged constitutional violation in

this case. It is possible that Mr. Graham received medical

care that fell below the applicable standard of care under

Michigan law. It is even possible that the medical care that he

received was so woefully inadequate as to rise to the level of

12 Graham v. County of Washtenaw No. 02-1614

a constitutional violation. But even assuming that Graham

did suffer a constitutional violation, that violation “resulted

from factors other than a faulty [County policy].” City of

Canton v. Harris, 489 U.S. 378, 390-91 (1989) (citations

omitted). 

There can be no municipal liability where “an otherwise

sound program has occasionally been negligently

administered.” Id. at 391. The fact that individual actors may

“occasionally make mistakes . . . says little about the . . . legal

basis for holding the [County] liable.” Id. Yet that is

precisely the essence of Graham’s claim in this case. The

allegations in her complaint focus primarily upon the

inadequacy of the medical treatment that was provided to Mr.

Graham by SecureCare and its staff. However, “[w]here a

prisoner has received some medical attention and the dispute

is over the adequacy of the treatment, federal courts are

generally reluctant to second guess medical judgments and to

constitutionalize claims that sound in state tort law.”

Westlake v. Lucas, 537 F.2d 857, 860, n.5 (6th Cir. 1976).

Perhaps in recognition of the fact that her complaint is more

properly remediable under state law, Graham has filed a

medical malpractice lawsuit in Michigan state court against

SecureCare and others arising from the same events that

underlie this lawsuit.

In sum, the County instituted its policy regarding the

provision of medical care to prisoners undoubtedly in an

effort to improve the quality of their medical care. Even if

Mr. Graham received constitutionally inadequate medical

care, there is simply no evidence that the policy was the

“moving force” behind that constitutional violation. Waters,

242 F.3d at 362. Under the circumstances presented in this

case, the section 1983 claim against the County was properly

dismissed. 
No. 02-1614 Graham v. County of Washtenaw 13

7

Presumably, after the district court denied her motion for leave to

file the amended complaint, Graham could have simply filed a separate

lawsuit alleging the new claims (other than, of course, the section 1983

claim against the County, which was dismissed with prejudice). It is

unclear why she chose not to pursue that option. 

B. Amended Complaint

Graham also challenges the district court’s denial of her

motion for leave to file a proposed amended complaint, which

purportedly “clarified” her municipal liability claim against

the County and asserted new claims against SecureCare and

Nurse Lakatos, along with Jeannette Figurel (a SecureCare

medical assistant) and corrections officers Dwight Settles and

Jay Klimowicz. Because her original complaint had already

been properly dismissed, however, there was no complaint

pending for Graham to amend. Under these circumstances,

we find that the district court did not abuse its discretion in

refusing to permit an amended complaint to be filed at that

point.7 

C. Motion for Reconsideration

Finally, Graham appeals the district court’s denial of her

motion for reconsideration. In its written order denying the

motion, the district court explained that under Eastern District

of Michigan Local Rule 7.1(g)(1)-(3), “[g]enerally, and

without restricting the court’s discretion, the court will not

grant motions for rehearing or reconsideration that merely

present the same issues ruled upon by the court, either

expressly or by reasonable implication. The movant must not

only demonstrate a palpable defect by which the court and the

parties have been misled but also show that correcting the

defect will result in a different disposition of the case.” In the

district court’s view, Graham’s motion for reconsideration

merely raised arguments that were already ruled upon; it

failed to show either a reason justifying relief from the

judgment or a palpable defect by which the court was misled.

14 Graham v. County of Washtenaw No. 02-1614

We agree with the district court’s characterization of the

motion and, thus, find no abuse of discretion. 

III. CONCLUSION

For the reasons discussed above, the district court’s

judgment is AFFIRMED.