Circuit Judge Evans died on August 10, 2011, and did not 

participate in the decision of this case, which is being

resolved by a quorum of the panel under 28 U.S.C. § 46(d).

In the

United States Court of Appeals

For the Seventh Circuit

Nos. 09-2804 & 10-2389

ESTATE OF NICHOLAS D. RICE, 

deceased, by: RICK D. RICE and

DIANE J. WALDROP, co-personal

representatives,

Plaintiff-Appellant,

v.

CORRECTIONAL MEDICAL

SERVICES, a Missouri corporation, et al.,

Defendants-Appellees.

Appeals from the United States District Court

for the Northern District of Indiana, South Bend Division.

Nos. 06 C 697 and 09 C 319—Robert L. Miller, Jr.,

and Rudy Lozano, Judges.

ARGUED DECEMBER 3, 2010—DECIDED MARCH 20, 2012

Before FLAUM, ROVNER, and EVANS , Circuit Judges.


2 Nos. 09-2804 & 10-2389

ROVNER, Circuit Judge. Nicholas D. Rice died in the

Elkhart County Jail in December 2004, nearly fifteen

months after he was booked at the jail pending trial on a

charge of attempted bank robbery. Rice was known to

suffer from schizophrenia, and shortly before his death

a judge had found him incompetent to stand trial. Although he was seen by mental health professionals

while he was being detained, Rice frequently refused to

take his prescribed medications, cooperate with medical

personnel at the jail, eat his meals, or bathe himself. He

was briefly hospitalized at psychiatric and other medical

facilities on several occasions during the period of his

confinement, and at the time of his death he was awaiting

placement at a state psychiatric facility pursuant to the

judge’s finding of incompetence. Rice died as a result of

psychogenic polydipsia (excessive water drinking), which

is a disorder known to manifest in a minority of persons

with schizophrenia. Following Rice’s death, his parents,

representing his estate (the “Estate”), filed suit in federal

court pursuant to 42 U.S.C. § 1983, alleging among other

things that jail officials and medical personnel had deprived Rice of due process by exhibiting deliberate indifference to his declining mental and physical condition.

The district court entered summary judgment against the

Estate on its section 1983 claims, finding in part that

correctional and medical personnel had not consciously

disregarded Rice’s medical needs and that the ultimate

cause of his death was not reasonably foreseeable to

them. Estate of Rice ex rel. Rice v. Correctional Med. Servs.,

No. 06 C 697, Opinion & Order, 2009 WL 1748059 (N.D.

Ind. June 17, 2009) (Miller, J.). The Estate then filed a
Nos. 09-2804 & 10-2389 3

second federal suit, invoking the court’s diversity jurisdiction, in which it reasserted the state wrongful death

claims that the judge in the first suit had dismissed

without prejudice after disposing of the federal claims.

The judge in the second suit dismissed that case on

the basis of collateral estoppel, reasoning that his colleague’s finding as to the foreseeability of the cause of

Rice’s death precluded recovery on any of the state

claims. Estate of Rice ex rel. Rice v. Correctional Med. Servs.,

No. 09 C 319, Order (N.D. Ind. May 17, 2010) (Lozano, J.)

(unpublished). The Estate appeals both judgments. On

review of the record, we conclude that a material dispute

of fact precludes summary judgment on one of the

Estate’s section 1983 claims: that his conditions of confinement were inhumane. We also conclude that the

district court erred in dismissing his state claims. We

therefore affirm in part and reverse in part.

I.

On March 5, 2003, Rice, then twenty years old, walked

into the KeyBank in Nappanee, Indiana, and announced

to a teller that he had a bomb that he would detonate if

he was not given money. Then, without explanation and

without having taken any money, Rice walked out of

the bank. He made his way back to his hometown of

Stevensville, Michigan, in a car he had stolen that morning

from a neighbor. As he drove back into Stevensville,

the owner of the car spotted Rice and summoned the

police. Rice was jailed in Berrien County, Michigan, on

a charge of auto theft.
4 Nos. 09-2804 & 10-2389

It soon became apparent to the Michigan authorities

that Rice had mental difficulties. Rice had begun to

exhibit mental problems while he was in high school,

and he was eventually diagnosed as suffering from undifferentiated schizophrenia. Schizophrenia is a chronic

mental illness which interferes with a person’s ability

to accurately perceive what is going on around him, to

distinguish fact from fantasy, and to regulate his emotions. Although Rice was prescribed medications for his

illness, he did not take them consistently and stopped

taking them altogether once he was no longer covered

by his parents’ health insurance. Not long after he was

jailed in Michigan, various physical and mental problems—including weight loss, unresponsiveness, and lack

of hygiene—resulted in Rice’s hospitalization, a finding

that he was not competent to stand trial, and eventually

his commitment to the Kalamazoo Psychiatric Hospital

for a period of nearly two months. The therapy and

medication that Rice received during his commitment

resulted in a marked improvement in his condition.

His mother would later testify that Rice was in the best

condition he had been in for quite some time. By the time

Rice was discharged from the psychiatric hospital in

late August 2003, Indiana authorities had identified him

as the suspect in the KeyBank robbery, and a bench

warrant was issued for his arrest. After the Michigan

charges against him were resolved, Rice was transferred

to the Elkhart County Jail in Indiana, where he was

booked on a charge of attempted robbery on September 8,

2003. His bail was set at $20,000.
Nos. 09-2804 & 10-2389 5

The Elkhart County Jail had an ongoing contract

with Correctional Medical Services (“CMS”) to provide

comprehensive health care services to inmates of the jail.

To serve the general medical needs of the jail’s inmate

population, CMS provided the jail with a staff which, in

2004, included the equivalent of approximately six fulltime licensed practical nurses, one full-time registered

nurse, one half-time social worker, and a physician who

served as the jail’s medical director. CMS in turn contracted with Oaklawn Psychiatric Center in Goshen,

Indiana, to provide psychiatric services to jail inmates

as needed. Pursuant to that contract, mental health treatment decisions were reserved to Oaklawn and one of

its physicians, Dr. Bryce B. Rohrer. Rohrer is boardcertified in family medicine rather than psychiatry, but

he has practiced family psychiatry for many years (his

specialty is drug and alcohol addiction), and by the time

of Rice’s detention he had been providing psychiatric

services to the jail for the previous ten years. Rohrer

generally spent one-half day per week at the jail.

The CMS medical personnel who performed a screening

upon Rice’s arrival at the jail had access to his medical

records and were aware of his psychiatric history and

the psychotropic medications he had been prescribed

for his schizophrenia. Dr. Rohrer met with Rice two

days after he was booked into the jail and wrote him a

prescription for Seroquel, an anti-psychotic medication

that he had been taking prior to his transfer from Michigan. When Rohrer examined Rice several weeks later, Rice

had been placed in the jail’s “tank” because he was not

communicating. Rohrer’s notes indicate that Rice was not

taking his prescribed medication but was practicing self-
6 Nos. 09-2804 & 10-2389

Subsequently, in December 2003, Ceniceros was asked to 1

evaluate Rice’s competency to stand trial. He concluded that

Rice was competent.

care. Rohrer was not sure if he was eating. Rohrer concluded that Rice’s behavior was likely explained by

psychosis, a traumatic event, or malingering (i.e., feigning

illness for secondary gain) and noted his intent to hospitalize Rice at Oaklawn if further observation revealed

that Rice was not eating or was outwardly psychotic.

In late October, Rohrer petitioned an Indiana state

court to involuntarily commit Rice to a mental facility

for a period of seventy-two hours, explaining that Rice

was “refusing psychotropic medication and refusing to

eat, refusing to communicate most of [the] time, diagnosed

as schizophrenic.” R. 198-70 at 3. The court granted the

petition, and Rice was admitted to Oaklawn. He was

given an intramuscular injection of Haldol, a psychotropic medication, upon his arrival at Oaklawn, but his

treating physician there, Dr. Salvador Ceniceros, who is

board-certified in both psychiatry and neurology, concluded in short order that there was no probable cause

to believe that Rice met the criteria for involuntary commitment or forced medication. Ceniceros would later

testify that Rice showed no signs of psychosis, answered

his questions plainly and coherently, interacted with

others appropriately, was eating and drinking, and accepted medication voluntarily. At Ceniceros’ instruction,

Rice was discharged back to the jail less than twenty-four

hours after he was admitted.1
Nos. 09-2804 & 10-2389 7

In the following months, Rice continued to exhibit the

sort of behavior at the jail which had led Rohrer to seek

his involuntary commitment to Oaklawn in October.

Rohrer’s notes from November 2003 and January 2004

indicated that although at times Rice was communicative

and appeared to be doing better, at other times he

was refusing to take his medication and uncommunicative and that his psychotic disorder appeared to be worsening. 

On November 16, 2003, Rice struck his cellmate in the

eye, causing the cellmate to seek medical attention.

When Rice subsequently refused an instruction by the

correctional staff to step out of the cell, Officer Jennifer

Shelton directed her colleague, Jason Koontz, to spray

Rice’s face with pepper foam, and Rice was then placed

in a restraint chair. Nurses Cindy Lambright and Joy

Bell were present when Rice was pepper-sprayed, and

they helped rinse his face and eyes. Rice later refused

multiple invitations to leave the restraint chair and remained there for a period of over eighteen hours. Ultimately he was dragged from the chair and into a cell

by jail staff.

In mid-November, Rohrer ordered the nursing staff to

administer an intramuscular injection of Haldol to Rice

every four weeks provided that he did not object. One

such shot was given to Rice, in early December. Rice

subsequently asked Rohrer to put him back on Seroquel

instead, and Rohrer acceded. But in January 2004, Rohrer

noted that Rice was again uncommunicative and sometimes refused to take his medication. Rohrer increased
8 Nos. 09-2804 & 10-2389

Rice’s prescribed dosage of Seroquel and directed that

he be returned to Haldol injections if he refused to take

the Seroquel.

Rohrer did not see Rice from February 10—when

Rice was again refusing his medication, and Rohrer had

to visit Rice in his cell because Rice otherwise refused to

see Rohrer—until May 11, 2004. During that time, the

nursing staff saw him regularly and observed more of

the same behavior that Rohrer himself had documented

previously. Nurse Lambright noted in February that

Rice refused to take his medications or to wear clothing.

His continuing refusal to take medications became

a frequent refrain in the subsequent notations of the

jail’s medical staff.

By April, jail officials, in apparent recognition of the

particular challenges that Rice presented, were requesting that his condition and behavior be thoroughly

documented. That month, Captain Brad Rogers, the jail’s

commander, asked that he be updated on Rice’s status

at the jail. In response to that request, Nurse Rebecca

Hess, a regional manager for CMS who supervised

nurses at both the Elkhart County Jail and other facilities,

wrote a one-page memorandum to Rogers and Lieutenant

Fred Call, the jail’s warden, concisely summarizing

Rice’s history at the jail. Hess noted that efforts had

been made to monitor Rice’s weight beginning in December 2003 due to his periodic refusal to eat. She added

that there had been no significant changes in Rice’s

weight since that time, although he frequently refused

to be weighed. Rice also continued to refuse his medica-
Nos. 09-2804 & 10-2389 9

tions and often refused to see Rohrer. In addition, he

refused to leave his cell for visits with family or with

his attorney. On April 15, Call emailed a memorandum

to the jail’s supervisory staff directing that all out-of-the

ordinary occurrences involving Rice be videotaped and

or reported, both to document Rice’s behavior on these

occasions and to assist his attorney in taking appropriate action. “I’m attempting to work with the public defender office to show this person m[a]y need . . . help. . . .

So I would appreciate your reports. The sooner we

can get this individual help the better off for all of us.”

R. 198-80 at 20. As a result of that directive, the record

includes video recordings of several instances in the

ensuing months in which jail staff forcibly removed

Rice from his cell and showered him.

By the end of April, Rice’s condition appears to have

deteriorated further. In an April 30 note, Lambright

reported that officers had to physically remove Rice

from his cell during a “shake down” when he refused to

leave the cell on his own. Lambright noted that Rice

was unable to stand, that his entire body was jaundiced,

that he had a large, three-inch area of dark skin over

his coccyx, and that when officers picked him up, dead

skin cells sloughed off his body in large numbers. He

refused to speak. Rice repeatedly refused to see his

parents when they came to the jail.

Dr. Paul J. Yoder, a psychologist at Oaklawn, evaluated

Rice on April 28, 2004, at the request of Rice’s attorney.

Based on Rice’s catatonic and unresponsive behavior,

Rice’s counsel was concerned that he was not able to
10 Nos. 09-2804 & 10-2389

assist in his defense, notwithstanding the prior findings

by two psychiatrists (including Ceniceros) that Rice was

competent to stand trial. Rice was largely unresponsive

when Yoder interviewed him. It was clear to Yoder

that Rice suffered from schizophrenia, and that Rice’s

functioning improved when he took his medications

and worsened when he did not. In his report of May 4,

2004, Yoder considered whether the catatonia Rice displayed might be due to malingering rather than to his

mental illness. There were reports from the jail suggesting that Rice altered his behavior depending on

whether or not he was being observed. Rice might be

feigning catatonia in the hope that he could avoid trial or

be found not guilty by reason of insanity, Yoder posited. “However, given Nicholas’ documented history

of poor functioning and poor insight when not being

treated, this seems very unlikely as a motivating factor

for his current behavior.” R. 198-127 at 7-8. Yoder considered other potential motives for Rice to pretend he was

more ill than he was, but ultimately was skeptical of

the notion that Rice was intentionally and genuinely

malingering. He pointed out that the overt symptoms

of schizophrenia can wax and wane even when one is

not being treated. “Regardless [of] [Rice’s] actual motive

and whether or not he is aware of it, it does not appear

that he is engaged in this type of malingering behavior

when his illness is being effectively treated. As a result,

it is my opinion that the malingering is itself the product

of his mental illness.” R. 198-127 at 8. Yoder therefore

concluded that Rice was not competent to assist his attorney with his defense. “The record is clear that Nicholas
Nos. 09-2804 & 10-2389 11

is severely mentally ill.” R. 198-127 at 8. Yoder recommended that the court consider ordering Rice’s compliance with psychiatric treatment (i.e., that he be

forcibly medicated), and noted that given how well

Rice responded to involuntary treatment in Michigan,

it was likely that Rice’s symptoms would remit within

four to six weeks. “At that point it should be possible

to more clearly distinguish between symptoms of schizophrenia and ongoing malingering.” R. 198-127 at 8.

On May 11, Rohrer concluded that Rice should again

be committed to a psychiatric facility for observation

and evaluation for the possibility of involuntary medication. Rohrer’s notes indicate that Rice was refusing to see

him, refusing his medications, did not communicate,

did not practice self-care, ate only junk food in lieu of

regular meals, and appeared to be developing bedsores.

In his petition to the court for an order of involuntary

commitment and forced medication, Rohrer noted that

Rice was “psychotic” and “unable to perform self-care.”

R. 192-9 at 47. The court granted the petition.

Rice was transferred to Oaklawn that same day.

On arrival at the facility, he was catatonic and had to be

lifted out of the transport van. However, once again

his behavior appears to have changed dramatically following his arrival at the hospital. Ceniceros noted that

Rice was cooperating, showering, eating, drinking and

agreeing to take his prescribed medication. Ceniceros

surmised that Rice was malingering in order to get out

of jail, and he again concluded that there was “no probable cause to believe that [Rice] meets the criteria for
12 Nos. 09-2804 & 10-2389

involuntary commitment.” R. 192-9 at 50. He diagnosed Rice with undifferentiated schizophrenia and/or

malingering, and for the second time discharged Rice

back to the jail less than twenty-four hours after he

was committed. His discharge notes concluded with the

following observations: “This morning [Rice] is alert,

cooperative, and oriented x 3. He denies any current

suicidal or homicidal ideation. Thoughts are linear and

goal directed. . . . He also denies hallucination in all

five senses. There is no looseness of association or flight

of ideas noted. Intelligence appears to be average based

on fund of knowledge and vocabulary; judgment and

insight appear [to be] intact. . . .” R. 198-145 at 16.

Shortly after his return to the jail, Rice was placed in

the administrative segregation unit, known as Ward

One, where he could be observed more closely. Previously

Rice had been housed in the medical ward as well as

other areas of the jail, but according to Rogers, medical

personnel at the jail had asked that Rice not be returned

to the medical ward given his poor hygiene and conduct. In Ward One, he was assigned to cell number 5A,

which we are told was the cell most easily viewed from

the first-floor control room across from Ward One.

Because the cells in Ward One were single-occupancy

units, Rice had no cellmate. He was allowed out of the

cell one hour per day. Rice remained in the administrative segregation unit until his death seven months later.

In June 2004, an Indiana circuit court judge found that

Rice was competent to stand trial on the bank robbery

charge. At the invitation of and with the agreement of
Nos. 09-2804 & 10-2389 13

the parties, the judge made that finding without a

hearing and based solely on his review of the written

reports of the three professionals (including Ceniceros

and Yoder) who had evaluated Rice.

After examining all reports the Court finds the Defendant to be competent to assist his counsel and

further notes that the Defendant was able to converse with the presiding judge in open court and

express himself and answer questions appropriately.

The Court further notes that Paul J. Yoder’s written

report indicates there is some reasonable belief

that this Defendant may be faking his catatonic state

since he was reported to sleep on a top bunk and

the officers did not put him there. Additionally, he

has been seen out of his cell on a number [of] occasions

and as soon as he spots an officer he freezes and

becomes unresponsive. The Court notes that he was

responsive in open court and appeared to be welloriented on the date of hearing herein (June 10, 2004).

R. 198-51 at 2-3. The court set Rice’s case for trial on

December 6, 2004.

Despite the competency finding, Rice continued to

exhibit abnormal behavior at the jail:

– Captain Rogers would later testify that by June,

“I think we were all concerned about his mental

capacity . . . .” R. 198-20 at 18, Rogers Dep. 109.

– On June 25, 2004, another inmate assaulted Rice in

his cell by poking him in the groin with a broomstick

through the bars of his cell door. Rather than move
14 Nos. 09-2804 & 10-2389

in order to avoid the broomstick, Rice simply stood

in place, catatonic, while he was assaulted. The attack

left visible welts on his back, buttocks, and side.

– On August 2, 2004, Rice cut his neck with a disposable razor from which he had bent or broken off the

plastic guard in order to expose a portion of the

blade. Lambright, on being summoned to Rice’s cell,

found him holding a towel over the wound. The oneinch laceration, although located over his carotid

artery, was superficial. Rice later told Nurse

Sharrone Jones, who became the jail’s charge nurse

in 2004, “I just hurt myself,” R. 198-37 at 26, and

when asked why by Nurse Lambright, he remarked

“I just felt like it,” R. 198-14 at 11. He was taken to

Goshen General Hospital for treatment and the

wound was sutured. Rice denied any effort to

commit suicide, and the physician who treated him

in the hospital’s emergency room, Dr. David E. Van

Ryn, agreed that he was not genuinely suicidal.

Upon being returned to the jail, Rice was placed in

a restraint chair for a period of eighteen hours, evidently to ensure that he would not harm himself

again. When Rohrer met with Rice the following

day, Rice told him, “I won’t talk to you. I’m not psycho.” R. 198-37 at 27. Rohrer indicated in his notes

that he thought Rice might be malingering. After

investigating the incident, Nurse Hess concluded

that Rice had not attempted to kill himself. Given

that conclusion, neither CMS nor the jail followed

their suicide prevention policies by placing Rice

under heightened observation. 
Nos. 09-2804 & 10-2389 15

– Shortly after this incident, Rice experienced a dizzy

spell and hit his head on his cell door, resulting in

a one-inch laceration between his eyes. CMS personnel treated the wound, but other than lab work,

no additional action was taken.

– Rice’s abysmal lack of hygiene continued. On

August 18, 2004, Lieutenant Call emailed several jail

staff members indicating that “[i]t’s time for Mr. Rice

to get another shower and have his room cleaned.” R.

198-122 at 2. When correctional officer Stephanie

Snyder emailed later that day to report that “[i]t

was a very dirty job but we accomplished it,” R. 198-

122 at 2, Captain Rogers replied to thank the

officers involved. “A person has to feel some

empathy toward someone like Nick Rice, who has to

be in such a pathetic state of mind to allow himself

to get into such a dirty physical state and to behave

as he does.” R. 198-122 at 2.

During this time period, Rice was not eating regular

meals. In July 2004, Rogers emailed a memorandum to

the jail’s supervisory officers instructing them to be

more proactive in ensuring that food was made available to inmates like Rice (whom he cited by name) who

exhibited a reluctance to eat. He admonished staff not

to construe an inmate’s silence at meal distribution

times as a refusal to eat. He also directed that food be

left inside rather than outside of an inmate’s cell, noting

that “[i]f the meal is left inside, Rice will typically eat

it.” R. 98-118 at 2.

By the Fall of 2004, however, Rice’s weight had

dropped significantly. A video of him being showered
16 Nos. 09-2804 & 10-2389

on September 30 reveals him to have been quite thin, if not

gaunt. As of the beginning of October, Rice, who was six

feet, two inches tall, weighed just 132 pounds, some fifty

pounds less than he did at the time of his admission in

2003. A nurse noted the presence of a sore or sores on

his hips. On October 5, Rohrer noted that Rice had lost

a significant amount of weight, was still refusing to eat

or to take medication, appeared to be exhibiting the

early onset of bedsores, and required medical attention.

For the third and final time, Rohrer sought Rice’s involuntary commitment to an inpatient psychiatric

facility for additional care. In support of the petition,

Rohrer wrote that “[Rice] is seriously medically [and]

psychiatr[ically] ill and needs intensive medical care

as well as [the] availability of psychiatric care.” R. 192-9

at 56. “Oaklawn Hosp[ital] would not be able to provide the intensive medical care,” he added. R. 192-9 at

56. Rohrer explained that in addition to having

serious psychiatric difficulties, Rice was “dying from

malnourishment.” R. 192-9 at 54. The court granted another seventy-two hour commitment. The order identified four hospitals at which Rice could be placed, in

the discretion of the Sheriff: Oaklawn, Goshen General Hospital, Bowen Center, and Elkhart General

Hospital for Behavioral Medicine (“Elkhart General”).

R. 192-9 at 57.

Rohrer had requested that Rice be committed to a

hospital where psychiatric care was available, and it

was Rohrer’s intent that he be taken to Elkhart General,

which had an inpatient psychiatric unit. However, that
Nos. 09-2804 & 10-2389 17

hospital refused Rice’s admission in the mistaken

belief that it did not have a contract with the jail.

Instead, Rice was taken to Goshen General Hospital,

which unlike Elkhart General had no psychiatric

unit. He was admitted and observed by Dr. Allison P.

Mathew, who found him to be suffering from symptoms of dehydration and mild malnutrition. After rehydrating Rice and encouraging him to eat, Dr. Mathew

concluded that he had been medically stabilized. She

assumed that upon discharge, he would be “sent back to

Oaklawn for further psychiatric evaluation and management.” R. 198-45 at 27. But when she consulted by telephone the following morning with Dr. Ceniceros at

Oaklawn, he opined in light of what Dr. Mathew told

him that Rice did not pose an imminent danger to

himself or others. According to Mathew, Ceniceros

added that he would not accept Rice for admission

to Oaklawn in view of his previous conclusion that

Rice was malingering, although Ceniceros denies that

he said this. Dr. Mathew discharged Rice back to the

jail on October 6 with instructions that he be encouraged

to eat, given high protein shakes if he would take them,

continue on his current medications, and follow up

with the Oaklawn psychiatrist (presumably Rohrer)

within a week.

Upon Rice’s return to the jail, CMS staff made various

efforts to improve Rice’s nutrition and more generally to

convince him to eat more food. Nurse Jones instructed

the jail’s food service to provide Rice with high-protein

Resource Health Shakes twice daily, along with two ®

milks at all meals and extra juice for breakfast. When
18 Nos. 09-2804 & 10-2389

the jail’s medical director, Dr. Alan Bierlein, assessed

Rice on October 25, he issued a second order that Rice be

provided with extra food. It appears that there was

some delay in obtaining high-protein shakes and that

Rice initially was provided with Carnation Instant ®

Breakfast drinks in lieu of the prescribed protein shakes,

but otherwise he was provided with extra food by the

jail’s food service as instructed. In addition, there is

evidence that CMS nurses saw Rice several times daily

following his return from the hospital. As they had

since his weight loss was first noted, the nurses

brought him extra snacks, encouraged him to eat, and

urged him to take his medications. These efforts met

with mixed results. Rice continued to refuse many of

his meals. On the other hand, he frequently did eat his

breakfast, and the record indicates that Rice did not lose

additional weight following his return to the jail. And

in marked contrast to his typically reclusive and unresponsive behavior, Rice just three days before his death

walked out of his cell and showered himself when

invited to do so.

Other problems persisted, however. Rice regularly

refused to take his medication. He was often uncommunicative. He typically did not bathe himself or otherwise attend to his own hygiene. Joshua Shaw, an inmate

who was housed in the cell next to Rice, indicated that

Rice was “always naked, he had unbelievable odor due

to his total lack of hygiene, feces on his body, urine

through out his cell, also rotting, uneaten food strewn

through out his cell.” According to Shaw, Rice rarely

spoke, other than to mumble “go away, go away, go

away, go away.” R. 277-105 at 3.
Nos. 09-2804 & 10-2389 19

When Rohrer saw Rice on November 9, 2004, he wrote:

“Refuses to communicate and closes his eyes. Is observed

at times getting up [and] eating [and] can run through

[the] unit (did this recently), but refuses all help [and]

has to practically be carried to get shower by staff.

Uncompt. caked feces, refusing all meds. ” R. 198-37 at

34. Rohrer ordered the nurses to discontinue Rice’s antipsychotic medications (which he was not taking) and to

ask him weekly whether he would resume taking

them. Rohrer planned to see him again in a month.

On December 6, 2004, the judge presiding over Rice’s

criminal case reversed his earlier competency assessment

and found Rice incompetent to stand trial. The judge

committed Rice to the custody of the Indiana Division

of Mental Health and ordered Sheriff Michael E. Books

to deliver Rice to a facility designated by the Division.

The Division in turn designated the Logansport State

Hospital, a psychiatric facility, which accepted Rice for

admission. However, because there was no bed available

at that time, Rice remained at the jail until space

opened up. Unfortunately, Rice died before that happened.

Late in the evening of December 17, 2004, inmate

Shaw heard Rice gulping water and vomiting in his cell.

In the ensuing hours, Shaw and other inmates in the

administrative segregation unit “mule-kicked” their cell

doors in an effort to get someone’s attention, but

according to Shaw’s account, no one ever responded.

Jail policy required the guards to conduct hourly checks

of all inmates in the administrative segregation unit,

but crediting Shaw’s account, one may infer that neither
20 Nos. 09-2804 & 10-2389

a guard nor anyone else on duty in the overnight hours

ever checked on Rice.

At approximately 4:30 a.m. on December 18. Rice was

found dead in his cell. A frothy pink discharge was

noted near his mouth. Autopsies would later reveal

that Rice died of acute cardiac arrhythmia triggered by

a lethal decline in the sodium level in his blood, which

was in turn caused by his excessive consumption of

water in the hours prior to his death.

Psychogenic polydipsia, a disorder characterized by

excessive thirst and compulsive water drinking, is a

poorly understood phenomenon that occurs in between

six and twenty percent of patients with psychiatric disorders, and most commonly is seen in patients with

schizophrenia. Brian Dundas, M.D., Melissa Harris, B.S.,

and Meera Narasimhan, M.D., Psychogenic Polydipsia

Review: Etiology, Differential, and Treatment, 9 CURRENT

PSYCHIATRY REPORTS 236, 236 (2007). It is undisputed

in this case that the disorder can occur both in individuals who are taking medication for their schizophrenia

and those who are not, and that unless an individual

has previously experienced a bout of psychogenic

polydipsia, there are no known warning signs that

enable medical professionals to predict whether or when

he or she will ever suffer from this disorder. How great

the risk is that a schizophrenic individual suffering

from psychogenic polydipsia will in turn experience

hyponatremia, sometimes described colloquially as

“water toxicity,” is a matter of dispute on the record in

this case. Dr. John Pless, a forensic pathologist who
Nos. 09-2804 & 10-2389 21

offered evidence on behalf of the defense, wrote in his

report that inappropriate hormone secretion, which

causes a compulsive water drinker to retain water and

excrete electrolytes, thus causing one’s blood sodium

level to drop, is “commonly seen” in people with schizophrenia. R. 169-5 at 2. Although he tried to withdraw

that statement in a subsequent affidavit (in which he

asserted that the phenomenon is “exceedingly rare,”

R. 281-10 at 3 ¶ 20, and that the odds of death due

to excessive water intake were one in a million, R. 281-10

at 3 ¶ 21), the district court excluded the retraction

from evidence. Our research indicates that of all those

individuals who do experience psychogenic polydipsia,

only ten to twenty percent experience hyponatremia as

a result of their compulsive water drinking. Psychogenic

Polydipsia Review, 9 CURRENT PSYCHIATRY REPORTS at 236. 

The autopsies also support the conclusion that Rice

was to some degree underweight and malnourished (the

parties’ experts differ as to the degree) at the time of his

death. Defense expert Dr. Daniel Scherb indicated that

Rice’s recorded weight at death was seventy-five to

eighty percent of what would be ideal. Although at least

one expert for the Estate opined that malnutrition

played a role in Rice’s death, others found no evidence

that this was true, and based on the arguments that

the parties made on summary judgment, the district court

found there to be no dispute that Rice died as a result

of compulsive water drinking rather than malnutrition.

2009 WL 1748059, at *5 & n.5. The Estate does not

quarrel with this finding on appeal.
22 Nos. 09-2804 & 10-2389

The Estate brought this suit under 42 U.S.C. § 1983

against jail officials (in both their official and individual

capacities), jail guards, CMS and Oaklawn, CMS nurses

who worked at the Elkhart County jail, and Drs. Rohrer

and Ceniceros, among others. The Estate contended that

jail officials and staff had subjected Rice to inhumane

conditions of confinement, used excessive force against

him, failed to protect him from harm inflicted by other

inmates, employed policies and customs that reflected

institutional indifference to the constitutional right of

a mentally ill inmate to adequate medical (including

psychiatric) care and protection from self-inflicted harm,

and individually displayed deliberate indifference to

his well-being. The Estate alleged that CMS and Oaklawn also followed policies and customs that reflected

deliberate indifference to the plight of mentally ill

inmates who lack the ability to care for themselves.

The nurses employed by CMS to care for inmates at the

jail were alleged to have manifested deliberate indifference to Rice’s declining health and self-destructive

tendencies. The Estate charged Drs. Rohrer and Ceniceros

with deliberate indifference to Rice’s need for more

intensive and proactive psychiatric treatment than he

could obtain at the jail. In addition to the federal claims,

the Estate asserted wrongful death claims under

Indiana law against all defendants.

Following two years of extensive discovery, the defendants moved for summary judgment. Judge Miller

granted their motions as to each of the section 1983

claims. We shall discuss the particular allegations underlying these claims, and the grounds on which the court
Nos. 09-2804 & 10-2389 23

entered summary judgment, as we address each claim

in turn below. As we have noted, the court also relinquished jurisdiction over the wrongful death claims

premised on state law. When the Estate subsequently refiled the wrongful death claims—now limited to the

CMS defendants alone—in federal court, Judge Lozano

dismissed them on the basis of Judge Miller’s determination that the particular cause of Rice’s death was not

reasonably foreseeable to the defendants.

II.

A. CONDITIONS OF CONFINEMENT

The Estate contends that owing to the deliberate indifference of jail officials and staff, from Sheriff Books on

down to the guards, Rice’s conditions of confinement

were inhumane. In particular, the Estate alleges that his

cell was often filthy and unsanitary, that uneaten food

was left to rot there, that his skin was sometimes caked

with his own feces, that he had an extremely foul body

odor owing to the long periods of time during which

he went unbathed, and that he either developed or

was on the verge of developing bedsores on multiple

occasions (although apparently these were healing at the

time of his death). Although there may be unresolved

questions as to how often and for how long these conditions occurred, there is no genuine dispute that they did

in fact occur. They are documented not only in the declaration from inmate Joshua Shaw, who was housed in

the administrative segregation unit in the cell next to

Rice’s, but also in various notations and memoranda
24 Nos. 09-2804 & 10-2389

written by Dr. Rohrer, the nursing staff, and jail

officials, and to some extent in the video recordings of

the instances in 2004 in which Rice was removed from

his cell and showered by jail staff. Nor is there any

mystery as to why these conditions occurred: Rice

typically refused to shower or perform any sort of selfcare whatsoever, left much of the food delivered to his

cell untouched, and lay naked and unmoving on his bunk

for most of the time. The record (including the videos)

reveals that the jail did intervene on occasion to clean

both Rice and his cell (there is some evidence that Rice

was eventually showered on a weekly basis, although

neither the jail’s shower log nor the videos confirm

this), but the gist of the Estate’s claim is that there were

significant periods of time during which the jail’s staff

members simply turned their back on the condition of

Rice’s person and cell, knowing that he was living in

his own filth.

Incarcerated persons are entitled to confinement under

humane conditions which provide for their “basic human

needs.” Rhodes v. Chapman, 452 U.S. 337, 347, 101 S. Ct.

2392, 2399 (1981); see also Farmer v. Brennan, 511 U.S. 825,

832, 114 S. Ct. 1970, 1976 (1994); Helling v. McKinney, 509

U.S. 25, 33, 113 S. Ct. 2475, 2480-81 (1993); Gillis v. Litscher,

468 F.3d 488, 493 (7th Cir. 2006) (prison has duty to provide, inter alia, adequate sanitation and hygienic materials); Board v. Farnham, 394 F.3d 469, 482-83 (7th Cir. 2005)

(personal hygiene items). Because Rice was a pretrial

detainee, it is the due process clause of the Fourteenth

Amendment rather than the Eighth Amendment’s proscription against cruel and unusual punishment which
Nos. 09-2804 & 10-2389 25

is the source of this right. See Bell v. Wolfish, 441 U.S.

520, 535-37, 99 S. Ct. 1861, 1872-73 (1979). However, courts still look to Eighth Amendment case law

in addressing the claims of pretrial detainees, given that

the protections of the Fourteenth Amendment’s due

process clause are at least as broad as those that the

Eighth Amendment affords to convicted prisoners, City

of Revere v. Mass. Gen. Hosp., 463 U.S. 239, 244, 103 S. Ct.

2979, 2983 (1983); Brown v. Budz, 398 F.3d 904, 910 (7th

Cir. 2005); Collignon v. Milwaukee County, 163 F.3d 982, 988

(7th Cir. 1998), and the Supreme Court has not yet determined just how much additional protection the Fourteenth Amendment gives to pretrial detainees. Woloszyn

v. County of Lawrence, 396 F.3d 314, 319 n.5 (3d Cir.

2005); Estate of Cole by Pardue v. Fromm, 94 F.3d 254, 259

n.1 (7th Cir. 1996); see also Weiss v. Cooley, 230 F.3d 1027,

1032 (7th Cir. 2000) (“there is little practical difference

between the two standards”). A claim that the conditions of an inmate’s confinement were constitutionally

inadequate proceeds through a two-step inquiry. We

consider first whether the adverse conditions complained of were “sufficiently serious,” such that the

acts or omissions of prison officials giving rise to these

conditions deprived the prisoner of a “minimal civilized

measure of life’s necessities.” Farmer, 511 U.S. at 834, 114

S. Ct. at 1977; Chapman, 452 U.S. at 347, 101 S. Ct. at 2399.

If the answer to that question is yes, we consider

whether prison officials were deliberately indifferent to

the adverse conditions. Farmer, 511 U.S. at 834, 114 S.

Ct. at 1977; Wilson v. Seiter, 501 U.S. 294, 302-04, 111 S. Ct.

2321, 2326-27 (1991). An official is deliberately indif-
26 Nos. 09-2804 & 10-2389

ferent when he is subjectively aware of the condition or

danger complained of, but consciously disregards it.

Farmer, 511 U.S. at 837, 114 S. Ct. at 1979; Minix v. Canarecci,

597 F.3d 824, 831 (7th Cir. 2010); Sanville v. McCaughtry,

266 F.3d 724, 734 (7th Cir. 2001); see also Connick v. Thompson, 131 S. Ct. 1350, 1360 (2011).

The district court disposed of this claim largely on

the ground that Rice himself created the unsanitary

conditions. The jail did not prevent Rice from showering

or keeping his cell clean and, on occasion, showered

him and cleaned out his cell for him. In the court’s

view, this is what distinguished the instant case from

Vinning-El v. Long, 482 F.3d 923, 924 (7th Cir. 2007) (per

curiam), in which we held that assigning an inmate to a

cell in which, inter alia, feces and blood covered the

wall, presented a triable issue of fact as to whether he

was deliberately deprived of his Eighth Amendment

right to incarceration in humane conditions. Here, by

contrast, “[t]he conditions Mr. Rice endured were selfinflicted and don’t give rise to a claim of deliberate indifference.” 2009 WL 1748059, at *11 (citing Isby v. Clark,

100 F.3d 502, 505-06 (7th Cir. 1996) (noting that if the

inmate is the cause of the conditions of which he complains, his Eighth Amendment claim is tenuous)). The

court did acknowledge that “Mr. Rice’s behavior was

driven by his mental illness,” but chose to account for

that factor in considering his need for mental health

treatment rather than whether jail officials were deliberately indifferent to the conditions of his confinement. Id.

The court also added, somewhat more cryptically, that

“[u]nder the circumstances of this case, Mr. Rice’s unsani-
Nos. 09-2804 & 10-2389 27

tary condition wasn’t sufficiently serious to constitute

a constitutional violation. Prison conditions may be

harsh and uncomfortable without violating the Eighth

Amendment’s prohibition against cruel and unusual

punishment.” Id.

We conclude, contrary to the district court, that whether

jail officials were deliberately indifferent to Rice’s conditions of confinement presents a material dispute of fact

that the factfinder must resolve at trial. That Rice

himself created the unsanitary conditions of which his

Estate complains certainly is a fact relevant to this claim,

as our decision in Isby makes clear. 100 F.3d at 505-06.

But given Rice’s mental condition, it by no means forecloses the claim, as the district court appears to have

assumed. As we noted in Freeman v. Berge, 441 F.3d 543,

546 (7th Cir. 2006), and Hall v. Ryan, 957 F.2d 402, 406

(7th Cir. 1992), prison officials have an obligation to

intervene when they know a prisoner suffers from selfdestructive tendencies. There is evidence that Rice

may have been malingering, and it is possible that a

factfinder might conclude that Rice’s failure of self-care

was knowing, voluntary, and deliberate rather than the

product of his mental illness. But there is also a wealth

of evidence in the record that would support a contrary

finding that Rice truly became incapable of caring

for himself as a result of his schizophrenia and that jail

officials were well aware of this. In light of that evidence,

a factfinder reasonably could conclude that Rice was

not responsible for the conditions of his cell and his

person, and that prison officials, who were aware of

these conditions and of Rice’s illness, were responsible
28 Nos. 09-2804 & 10-2389

for them in the sense that they did not make more conscientious efforts to bathe Rice and to clean his cell. No

doubt Rice’s behavior placed the jail in a difficult position; and a factfinder might conclude that even if jail

officials could have done more, they were not deliberately indifferent to the cleanliness of Rice’s person

and cell. For example, the record does confirm that jail

staff did shower Rice and clean out his cell on multiple

occasions. However, in view of evidence suggesting

that uneaten food was allowed to accumulate in Rice’s

cell, that he went for long periods without being

showered, and that the stench of his cell and his person

were overwhelming, this claim cannot be resolved on

summary judgment.

For the same reasons, we cannot sustain the district

court’s alternative conclusion that the conditions of

Rice’s confinement were not sufficiently serious to support his Fourteenth Amendment claim. Perhaps a factfinder could reach that conclusion. As the district court

noted, prison conditions may be uncomfortable, even

harsh, without being inhumane. See Farmer, 511 U.S. at

832, 114 S. Ct. at 1976. But on this record, granting

the Estate the benefit of all inferences to which it is

entitled on summary judgment, a factfinder reasonably

could conclude that the conditions of Rice’s confinement

exceeded mere discomfort and were constitutionally

unacceptable. See, e.g., Gillis, 468 F.3d at 493-94 (evidence

that prisoner was stripped naked and placed in cell

without, inter alia, adequate sanitation sufficient to survive summary judgment); Vinning-El v. Long, supra, 482

F.3d at 924 (holding defendants were not entitled to

qualified immunity on Eighth Amendment claim that
Nos. 09-2804 & 10-2389 29

inmate was subjected to unsanitary and otherwise inhumane confinement for period of three to six days) (coll.

cases).

B. ADMINISTRATIVE SEGREGATION

The Estate has a separate conditions-of-confinement

claim relating to Rice’s prolonged assignment to Ward

One, the administrative segregation unit of the jail. The

record indicates that Rice was housed in that unit

for approximately seven months, from mid-May, 2004,

until his death the following December. Ostensibly, he was

assigned to that unit so that he could be more readily

monitored and because his behavior made his assignment elsewhere in the jail problematic. (None of the

briefs in this case, unfortunately, discuss with any particularity the nature of this jail’s administrative segregation unit and what types of inmates were housed

there.) One of the Estate’s experts, Dr. Joe Goldenson,

opined that Rice should have been in placed in the jail’s

medical ward, where he had been placed on previous

occasions, instead of administrative segregation, because “[i]t is a well established fact that individuals

with psychiatric problems decompensate when they are

in extreme isolation.” R. 157-2 at 18 ¶ 7.

We may make short work of this claim because, as the

district court noted, the Estate has provided “little support” for it. 2009 WL 1748059, at *12. Dr. Goldenson’s

analysis certainly suggests that a prolonged placement

in segregation might have adverse effects on someone
30 Nos. 09-2804 & 10-2389

in Rice’s condition; and our own decision in Walker v.

Shansky, 28 F.3d 666, 673 (7th Cir. 1994), recognizes

that prolonged confinement in administrative segregation may constitute a violation of the Eighth Amendment (and therefore the Fourteenth), depending on the

duration and nature of the segregation and whether

there were feasible alternatives to that confinement. (We

note, however, that the claim in Walker also included

allegations that the inmate had been denied water for

periods of up to one week, had been given inadequate

time to exercise, and had been subject to physical

abuse.) But the Estate has not discussed in any detail

what alternative placements were available to the jail

nor, more importantly, has it documented the differences those placements would have made in terms of

Rice’s social isolation. We take it as a given that the

Estate does not believe he should have been placed in

the general population of the jail, as its other claims

are premised on the notion that Rice should have been

monitored more rather than less closely than he

was—and it is undisputed that he was placed in administrative segregation for that very purpose. Rice had been

placed in the medical ward on prior occasions, and presumably had he been assigned to that ward rather than

to administrative segregation he would have received

as much if not more medical attention than he did in

segregation. But the record suggests that Rice was not

returned to the medical ward at the request of the

jail’s medical staff. It also indicates that Rice had

daily contact with medical personnel in administrative

segregation. More to the point, the Estate does not ex-
Nos. 09-2804 & 10-2389 31

plain why placement in the medical ward or any other

unit of the jail would have reduced the likelihood of

decompensation due to isolation. All we know is that

Rice had one hour each day to mingle with other

prisoners while he was housed in administrative segregation (which the record indicates he often declined);

we do not know what additional opportunities for

social interaction he would have had in other feasible

placements within the jail. It is not too much to expect

the Estate’s lawyers, when complaining about the debilitating effects of the jail’s housing decisions, to identify

feasible alternatives and to tender evidence supporting

the contention that Rice likely would have fared better

in one of those alternative placements. This they have

not done.

C. EXCESSIVE FORCE

As we noted in our factual summary, on November 16,

2003, Rice struck his cellmate in the eye. When correctional officers ordered him out of the cell, he did not

comply and remained standing in his cell. Officer Koontz,

at the direction of Officer Shelton, sprayed pepper foam

into Rice’s face in an effort to secure Rice’s compliance

with their orders. Rice was then placed in a restraint

chair. Nursing staff helped rinse the pepper foam

from Rice’s eyes. After some period of time, jail staff

attempted to release Rice from the restraint chair, but

Rice was unwilling to leave the chair and ultimately

remained there for a total of eighteen hours. The Estate

contends that the use of the pepper foam, along with
32 Nos. 09-2804 & 10-2389

Rice was also placed in a restraint chair and left there for a 2

similarly prolonged period of time on August 2, 2004, after he

cut his neck with a razor and received treatment at Goshen

General Hospital for the injury. But the Estate does not cite

this incident in connection with its excessive force claim.

his prolonged confinement in the restraint chair,

amounted to excessive force.2

The use of force qualifies as excessive for the purpose

of Eighth Amendment and due process jurisprudence

when it entails the “ ‘unnecessary and wanton infliction

of pain.’ ” Whitley v. Albers, 475 U.S. 312, 319, 106 S. Ct.

1078, 1084 (1986) (quoting Ingraham v. Wright, 430 U.S.

651, 670, 97 S. Ct. 1401, 1412 (1977)). That the degree

of force used appears in retrospect to have been unreasonable is not sufficient to establish a constitutional

violation. Id. at 319, 106 S. Ct. at 1084. Where, as here,

force is employed in the course of resolving a disturbance, the pertinent inquiry is “ ‘whether force was applied in a good faith effort to maintain or restore discipline or maliciously and sadistically for the very purpose of causing harm.’ ” Id. at 320-21, 106 S. Ct. at 1085

(quoting Johnson v. Glick, 481 F.2d 1028, 1033 (2d Cir. 1973)

(Friendly, J.)). Factors relevant to that inquiry include

whether jail officials perceived a threat to their safety

and the safety of other inmates, whether there was a

genuine need for the application of force, whether the

force used was commensurate with the need for force,

the extent of any injury inflicted, and whatever efforts

the officers made to temper the severity of the force
Nos. 09-2804 & 10-2389 33

they used. Id. at 321, 106 S. Ct. at 1085. See also Forrest v.

Prine, 620 F.3d 739, 744-75 (7th Cir. 2010); Lewis v.

Downey, 581 F.3d 467, 475-77 (7th Cir. 2009). 

The district court characterized the force employed by

jail officials on this occasion not as excessive, but as

“justified and restrained,” applied in good faith, and resulting in no significant injury to Rice, 2009 WL 1748059,

at *13, and the Estate’s cursory treatment of this claim

on appeal has not convinced us that the court erred

in its analysis. Although the Estate contends that Rice

posed no threat to anyone, it does not dispute either

that Rice had been fighting with his cellmate or that

he failed to comply with the directive that he step out

of his cell. A fight among two inmates certainly poses

a danger to the inmates involved as well as the jail

officials who must intervene to stop it. Rice’s mental

illness may explain why he stood unmoving when

ordered out of the cell, as the Estate suggests, but the

Estate cites no evidence showing that the officer who

sprayed Rice’s face with pepper foam appreciated that

he was unable, as opposed to unwilling, to comply with

the order and employed the pepper spray maliciously

rather than in a good faith effort to restore order. The

same is true as to the decision to place Rice in a restraint

chair. The Estate contends in passing that jail officials

violated multiple internal rules in deploying pepper

spray, treating Rice for the effects of that spray, and

then leaving him in the restraint chair for hours on end,

but fails to discuss the relevant rules and how specifically

they were violated. That Rice was left in the chair for

eighteen hours does give one pause. Yet, it is undisputed
34 Nos. 09-2804 & 10-2389

that Rice himself refused to leave the chair when invited

to do so. This too may have been due to Rice’s mental

illness, and to the extent jail officials and/or CMS nurses

recognized this possibility, they may have had some

obligation not to leave him in the chair. But removing

Rice from the chair against his will itself required the

use of force (recall that Rice ultimately had to be dragged

from the chair), so the nurses along with the guards

were in a damned-if-you-do, damned-if-you-don’t situation. The Estate does not identify what alternative steps

jail officials should have taken, let alone discuss why

their actions would enable a jury to find that they acted

maliciously and sadistically as opposed to negligently

or reasonably. The district court appropriately entered

summary judgment against the Estate on this claim.

D. FAILURE TO PROTECT

The Estate next argues that the district court erred in

granting summary judgment as to its claim that the jail

failed to protect Rice from assaults by other inmates. The

claim is based on two incidents: (1) the just-discussed

November 16, 2003, incident in which Rice fought with

his cellmate, and (2) the incident on June 25, 2004, in

which inmate Montie George poked a broomstick through

the bars of Rice’s cell and repeatedly struck Rice in

the groin area, resulting in visible welts on his body. The

district court in its ruling discussed only the second

of these two incidents, concluding that summary judgment was warranted because there was no evidence

that either the jail or for that matter Rice expected the
Nos. 09-2804 & 10-2389 35

attack, which the court described as a “random” one. 2009

WL 1748059, at *14.

Jail officials have a duty to protect inmates from

violent assaults by other inmates. Farmer v. Brennan, supra,

511 U.S. at 833, 114 S. Ct. at 1976-77. They incur liability

for the breach of that duty when they were “aware of

a substantial risk of serious injury to [an inmate] but

nevertheless failed to take appropriate steps to protect

him from a known danger.” Guzman v. Sheahan, 495 F.3d

852, 857 (7th Cir. 2007) (quoting Butera v. Cottey, 285 F.3d

601, 605 (7th Cir.2002)); see also Santiago v. Walls, 599 F.3d

749, 758-59 (7th Cir. 2010).

The evidence in this case would not support a finding

that jail officials were aware of but did not appropriately

respond to a substantial risk that Rice might be assaulted. We know little about the first incident in 2003

other than that Rice struck his cellmate. The defendants

represent that Rice actually instigated that fight; but

even if he did not, the Estate points to no evidence suggesting that the jail was on notice of the possibility

that Rice was at substantial risk of an assault from another inmate and that jail officials knew of this risk. Nor

has the Estate identified any connection between this

incident and the second one—they occurred in different

units of the jail and involved different inmates—which

might suggest that the later incident was foreseeable

in light of the former. 

The Estate submitted an affidavit from inmate George,

who assaulted Rice with the broomstick, explaining that

he attacked Rice because he had become fed up with
36 Nos. 09-2804 & 10-2389

Collectively, the affidavits and declaration from these in- 3

mates reiterated Shaw’s account of what happened the night

that Rice died—i.e., that they heard Rice’s distress and attempted without success to gain the attention of the guards—

and also asserted that Rice’s health was in an obvious state

of decline during the final months of his life, that Rice did not

always receive his meals, that his cell was frequently littered

with uneaten food, and that his hygiene was noticeably poor.

the smell emanating from Rice’s cell. But the district

court excluded from evidence George’s affidavit, along

with another affidavit and a declaration from two

other inmates who were housed in the administrative

segregation unit with Rice, because the Estate had not 3

disclosed these three inmates as prospective witnesses

as required by Federal Rule of Civil Procedure 26(a) and

(e), and the court surely did not abuse its discretion in

so ruling. Although the Estate had obtained the names

of these individuals from the defendants during discovery, the Estate did not disclose them as witnesses

until responding to the defendants’ motions for summary judgment, and by that time, discovery had closed

and the defendants could not depose them. The omission

was neither substantially justified nor harmless, such

that it might be overlooked pursuant to Rule 37(c)(1).

As the district court rightly observed, “The defendants

aren’t required to guess which of the many individuals

identified during discovery the Estate intends to use to

support its claims—that is the sort of indirection

the disclosure rules are designed to avoid.” 2009 WL

1748059, at *8.
Nos. 09-2804 & 10-2389 37

Without George’s affidavit, the second attack on Rice

indeed appears to have been random, just as the district

court characterized it. But even with the explanation

provided by George’s affidavit, there would be no basis

on which to conclude that the jail was aware of a substantial risk of injury to Rice. Jail personnel certainly

were aware that Rice had a hygiene problem, but so far

as the record reveals, they had no notice that he was at

risk of assault because of that problem, particularly

within the more secure confines of the administrative

segregation unit.

E. IS CENICEROS A STATE ACTOR?

The Estate’s claim against Dr. Ceniceros is primarily

focused on his refusal to admit Rice to Oaklawn in

October 2004. Recall that Dr. Rohrer, concerned that

Rice was in peril of dying, had obtained a court order

authorizing Rice’s involuntary commitment to one of

four inpatient facilities, and Rohrer had attempted to

have Rice admitted to Elkhart General Hospital. But

after Elkhart General refused to admit Rice in the

mistaken belief that it had no contract with the jail, Rice

was instead taken to Goshen, where he was seen by

Dr. Mathew. Although Rice was determined to be medically stable, Dr. Mathew consulted by telephone with

Dr. Ceniceros as to whether Rice might need inpatient

psychiatric care, which Goshen was not equipped to

provide. But Ceniceros allegedly told Mathew that he

did not believe Rice met the criteria for involuntary

admission and, based on his prior observations of Rice,
38 Nos. 09-2804 & 10-2389

that he was likely malingering. The Estate contends that

Ceniceros’ refusal to admit Rice sight unseen, despite

familiarity with Rice’s schizophrenia, his troubled

history at the jail, as well as his colleague Rohrer’s conclusion that Rice was in urgent need of inpatient care,

amounted to deliberate indifference to Rice’s condition.

Ceniceros’ employer, Oaklawn, had contractually undertaken to provide inpatient psychiatric services to jail

inmates who needed it, and so, in the Estate’s view,

Ceniceros was a state actor vis-à-vis the psychiatric care

that he provided to (or withheld from) inmates. In the

Estate’s view, then, if Ceniceros was deliberately indifferent to Rice’s psychiatric condition as alleged, he could

be liable as a state actor for his indifference just as CMS’s

nurses could be and, for that matter in the same way

that Ceniceros’ colleague, Dr. Rohrer—himself an Oaklawn physician—could be.

The district court disposed of the claim against

Ceniceros on the ground that he was not a state actor,

contrary to the Estate’s contention. The court focused

on Rice’s prior commitments to Oaklawn in October

2003 and May 2004, rather than Ceniceros’ refusal to

admit Rice in October 2004. The record, as the court

understood it, indicated that Ceniceros had accepted

Rice for treatment at Oaklawn on the two prior occasions not by virtue of Oaklawn’s contract with CMS,

but rather pursuant to the court orders which committed Rice involuntarily to Oaklawn for observation

and treatment. 2009 WL 1748059, at *16. Presumably,

although the court did not address the events of October 2004, the court likewise would have emphasized
Nos. 09-2804 & 10-2389 39

that Rice’s commitment to Oaklawn was being sought

on that occasion not pursuant to Oaklawn’s contract

with the jail but pursuant to the court’s order

authorizing Rice’s involuntary commitment to one of

four facilities, including Oaklawn. The court acknowledged that the Supreme Court’s decision in West v.

Atkins, 487 U.S. 42, 51, 108 S. Ct. 2250, 2256 (1988), recognizes that private physicians may be deemed state

actors when they provide medical care to prisoners at

the prison. But the court concluded that West’s rationale

does not extend to a private psychiatrist who accepts

an inmate into his care pursuant to an emergency commitment order. 2009 WL 1748059, at *16. Providing psychiatric care to an individual who has been involuntarily committed for such care is not a function traditionally reserved to the state, the court reasoned. Id. Because, in the court’s view, Dr. Ceniceros did not serve

a public function in caring for Rice, his role was not that

of a state actor.

We have our doubts as to whether the district court

was correct in categorizing Ceniceros as a private rather

than a state actor. Rice was treated by Ceniceros in fulfillment of the jail’s obligation to provide medical care,

including necessary psychiatric care, to Rice as an

inmate of the jail. The orders committing Rice to a

private facility simply reflect a judicial determination, solicited by Rohrer as the jail’s mental health care

provider, that Rice required more intensive psychiatric

treatment than could be provided to him at the jail, and

treatment that had to be provided without his consent.

And the record suggests that it was not happenstance
40 Nos. 09-2804 & 10-2389

We note that when Rohrer sought Rice’s admission to Elkhart 4

General in October 2004, that hospital refused to accept Rice

in the erroneous belief that it had no contractual arrangement

with the jail. This suggests that neither Elkhart nor any of the

other three facilities designated in the court’s commitment

order were obligated to accept Rice in the absence of a contractual relationship with the jail.

or judicial fiat that resulted in Oaklawn’s selection as

the facility to which Rice would be committed on the

first two occasions in October 2003 and May 2004 (and

as one of the four facilities to which he could have been

committed in October 2004). Rather, the facts support

the inference that Rice was committed to Oaklawn

because of Oaklawn’s voluntary, contractual undertaking

to provide psychiatric services to the jail’s inmates.4

The commitment orders did not alter Rice’s status as

a pretrial detainee. Because he was incarcerated, the jail

had an obligation to address Rice’s serious medical needs.

Estelle v. Gamble, 429 U.S. 97, 103, 97 S. Ct. 285, 290 (1976).

That obligation included a duty to provide psychiatric

care to Rice as needed. Sanville v. McCaughtry, supra, 266

F.3d at 734; Wellman v. Faulkner, 715 F.2d 269, 272 (7th

Cir. 1983).

If Rice had been committed to the state’s own facility

for treatment by state-employed physicians, there would

be no question that those physicians would qualify as

state actors who could be liable for any deliberate indifference to his psychiatric needs: “ ‘Institutional physicians assume an obligation to the mission that the
Nos. 09-2804 & 10-2389 41

State, through the institution, attempts to achieve.’ ” West,

487 U.S. at 51, 108 S. Ct. at 2256 (quoting Polk County

v. Dodson, 454 U.S. 312, 320, 102 S. Ct. 445, 451 (1981)).

This would be true whether Rice were committed to a

psychiatric unit within the jail, cf. Washington v. Harper,

494 U.S. 210, 110 S. Ct. 1028 (1990) (prisoner medicated

against his will at prison medical facility), or instead

transferred to a state-owned facility outside of the jail,

cf. Youngberg v. Romeo, 457 U.S. 307, 102 S. Ct. 2452

(1982) (recognizing that state facility for mentally

disabled has duty to provide, among other things, safe

conditions of confinement to mentally disabled adult

who was involuntarily committed to that facility); see

also Collignon v. Milwaukee County, supra, 163 F.3d at 987

(“When a state actor such as Milwaukee County deprives

a person of his ability to care for himself by incarcerating

him, detaining him, or involuntarily committing him,

it assumes an obligation to provide some minimal level

of well-being and safety.”) (coll. cases).

That Rice was instead committed to the care of a

private psychiatrist—or, in the third instance, was

refused care by that psychiatrist—whose employer

had contracted to provide psychiatric care to the jail’s

inmates, arguably does not alter the analysis materially.

The Supreme Court has not yet addressed whether

medical care provided to a prisoner in a private facility

outside of the prison walls constitutes state action. However, in West, the Court held that medical care provided

on the grounds of the prison by a private physician under

contract with the state does constitute state action: “Respondent, as a physician employed by North Carolina to
42 Nos. 09-2804 & 10-2389

provide medical services to state prison inmates, acted

under color of state law for purposes of § 1983 when

undertaking his duties in treating petitioner’s injury. Such

conduct is fairly attributable to the State.” 487 U.S. at 54,

108 S. Ct. at 2258. Although the court cited the location

of the treatment as one factor supporting its conclusion,

id. at 56 n.15, 108 S. Ct. at 2259 n.15, nothing in its analysis

suggests that the result necessarily would have been

different had the care been provided at a private facility.

See Rodriguez v. Plymouth Ambulance Serv., 577 F.3d 816,

827 (7th Cir. 2009) (“The state clearly does not relieve

itself of its responsibility to provide medical care solely

on account of the venue where those services are rendered.”) (citing Conner v. Donnelly, 42 F.3d 220, 225-26 (4th

Cir. 1994) (deeming private physician who treated prisoner’s injury in physician’s office outside prison to be

state actor). Instead, central to the court’s analysis was

that the care was provided under contract with the

prison in fulfillment of the prison’s obligation to provide for the inmate’s medical needs.

That is arguably just as true here as it was in West.

One might infer that on each of the three occasions

when the court ordered Rice’s involuntary commitment,

Ceniceros and Oaklawn became involved not because

the court chose Oaklawn for its own reasons, or because

Oaklawn was otherwise obliged to provide psychiatric

care to all who sought it, as an emergency room might

be, cf. Rodriguez, 577 F.3d at 827-28, but rather because

Oaklawn had voluntarily agreed to provide inpatient

psychiatric care to the jail’s inmates when needed. As

we observed in Rodriguez:
Nos. 09-2804 & 10-2389 43

When a party enters into a contractual relationship

with the state’s penal institution to provide specific

medical services to inmates, it is undertaking freely,

and for consideration, responsibility for a specific

portion of the state’s overall obligation to provide

medical care for incarcerated persons. In such a circumstance, the provider has assumed freely the

same liability as the state. Similarly, when a person

accepts employment with a private entity that contracts with the state, he understands that he is a

accepting the responsibility to perform his duties

in conformity with the constitution.

Id. at 827. Had it been possible for Rice to receive

inpatient care from Ceniceros on the premises of the jail,

there would be no question that Ceniceros would qualify

as a state actor under both West and Rodriguez. And the

district court’s focus on the court-ordered nature of

Rice’s commitments implicitly presumes that had Rice

been accepted for admission at Oaklawn in the absence

of such an order, the same might be true. Cf. Rodriguez,

577 F.3d at 830 (assuming that claim against private

ambulance service for alleged deliberate indifference

during inmate’s transport from prison to hospital would

be viable if, inter alia, transportation was provided pursuant to contract with prison system); id. at 831-32

(private hospital that accepted inmate for care pursuant

to contract could be liable as state actor).

The court viewed the judicial commitment orders as

superseding Oaklawn’s voluntary assumption of the

jail’s duty to provide psychiatric care to its inmates. But
44 Nos. 09-2804 & 10-2389

the record suggests that the orders had much more to

do with overruling Rice’s will than with Oaklawn’s

willingness to treat Rice on its premises. Rohrer sought

the court orders because Rice, among other things, was

refusing to take his anti-psychotic medications. As we

discuss below, provided he did not pose a danger to

himself or others, Rice had that right. He was committed

involuntarily for inpatient treatment so that, in part,

he could be forcibly medicated. One could infer that

Oaklawn’s status did not change as a result of the

court orders—it was still providing exactly the sort of

inpatient psychiatric care that it had contractually

agreed to provide. Indeed, Oaklawn and Ceniceros remained free to reject Rice’s admission, as evidenced

by Ceniceros’ outright refusal to admit Rice in October

2004. Elkhart General itself refused Rice’s admission

in October 2004 in the mistaken belief that it had no

contract to provide inpatient care to the jail’s inmates. On

these facts, a factfinder might conclude that Oaklawn

and Ceniceros were not dragooned into treating Rice

as a result of the court’s commitment orders, but

rather had voluntarily assumed that role by virtue of

Oaklawn’s contract with the jail. Cf. Rodriguez, 577

F.3d at 831 (hospital which declined to provide nonemergency care to prisoner because it lacked contract

with prison system, and instead provided only such

emergency care as it would have provided to any member of general public, did not constitute state actor).

We need not ultimately resolve Ceniceros’ status,

however, because as we discuss later in this opinion, we

conclude that the facts do not support a finding of delib-
Nos. 09-2804 & 10-2389 45

erate indifference on Ceniceros’ part. We have voiced

our doubts about the district court’s conclusion that

Ceniceros was not a state actor because that is the

sole basis on which the district court resolved the

Estate’s claim against Ceniceros and because, given

the widespread practice of outsourcing jail and prison

medical services to private contractors, it is certain

that this issue will recur. We do not consider what we

have said here to be binding, but we do wish any

future court’s exploration of this issue to take into consideration the circumstances we have highlighted as

relevant to the state-actor determination.

F. OFFICIAL POLICY OR CUSTOM CLAIMS

The Estate has sued Sheriff Books, the keeper of the

jail, and two other officials of the jail (Captain Rogers,

jail commander, and Lieutenant Call, warden) in their

official capacities, along with CMS and Oaklawn, seeking

to hold them liable for customs or policies—including

the failure to train their respective staffs to deal appropriately with mental illness—which the Estate believes

contributed to Rice’s death. The Estate cites Books and

the jail for a laundry list of omissions and failures which

it contends evinces the jail’s indifference to mentally

ill inmates with self-destructive tendencies. In particular,

it criticizes Books for (1) inadequate training and supervision of the jail staff generally; (2) not adequately

training Rogers and Call and the rest of the jail staff in

the appropriate treatment of mentally ill inmates; (3) not

having adequate policies in place to deal with severe
46 Nos. 09-2804 & 10-2389

mental illness; (4) not educating Rogers as to the jail’s

suicide prevention policy and not ensuring that this policy

was followed after Rice cut his neck; (5) having a policy

conditioning the transfer of an inmate to a psychiatric

facility on Oaklawn’s approval (which Ceniceros repeatedly refused to give), and, knowing of Rice’s condition,

not exercising his own purported authority to transfer

Rice to such a facility; (6) not ensuring compliance with

the jail policy requiring hourly checks on inmates in

administrative segregation, which the Estate alleges

were not made on the night of Rice’s death; and (7) inadequate training of jail staff as to the use of force on

mentally ill inmates, and/or faulty policies as to the use

of force on such inmates. As to CMS, which was responsible for the general medical care of the jail’s inmates, the

Estate’s theory is that inaction on the part of CMS’s

nursing staff at a minimum reflects a failure to adequately

train its staff to properly care for mentally ill inmates like

Rice, if not a policy and practice of ignoring the medical

needs of such inmates. The Estate reasons that Rice’s

mental illness was known from the outset of his incarceration, and by the close of 2003 his overall decline was

apparent in his refusal to take his medication, weight

loss, repeated state of undress, and recorded observations

that he was psychotic. Yet, according to the Estate, the

nurses took no meaningful steps to correct Rice’s downward spiral. They remained passive in the ensuing

months even as Rice’s physical and mental states continued to decline. By way of example, the Estate notes the

lack of any affirmative evidence in the jail’s shower log

that Rice was showered between November 2003 and
Nos. 09-2804 & 10-2389 47

August 2004, along with the nurses’ purported failure to

take appropriate steps after Rice cut his neck with the

razor. Finally, the Estate contends that Oaklawn too

is responsible for Rice’s demise through the actions

of Ceniceros, whom it characterizes as Oaklawn’s

decisionmaker by virtue of his unfettered discretion vis-àvis the admission of inmates to Oaklawn’s facility. The

Estate alleges that Ceniceros recklessly wrote Rice off as

a malingerer and refused his admission to Oaklawn

in October 2004 despite his colleague Rohrer’s conclusion that Rice was in danger of dying from malnourishment and Dr. Mathew’s consultation with him as to

the possibility of psychiatric intervention.

The district court found that the evidence did

not support the imposition of municipal or corporate

liability against any of these defendants. The court found

that because the Sheriff was entitled generally to defer

to medical professionals as to the appropriate treatment

of mentally ill prisoners, there was nothing deliberately indifferent about the jail’s practice of leaving to

Oaklawn the decision whether or not to transfer a particular inmate to a facility outside of the jail for treatment.

2009 WL 1748059, at *18. And the Estate had cited no

authority for its contention that Sheriff Books could

have ordered such a transfer on his own. Id. As to the

adequacy of the training and supervision that the Sheriff

had provided to Rogers and Call and the rest of the

jail’s staff, the Estate had not shown any causal link

between the purported deficiencies and any shortcomings in the medical and psychological care provided
48 Nos. 09-2804 & 10-2389

to Rice. Id., at *19. Books had in no way impeded

or interfered with Rice’s treatment by the medical professionals and was entitled to rely on them to provide

adequate care to Rice. Id. Finally, assuming that personnel had failed to follow the jail’s suicide prevention

policy after Rice cut his neck, and assuming that this

failure was reflective of a policy or practice rather

than being a one-time omission, there was no proof

that this had anything to do with Rice’s eventual death:

Rice did not, after all, commit suicide. Id. With respect

to CMS, the court saw no evidence of a custom or

policy reflecting indifference to the needs of mentally ill

inmates like Rice. Id., at *20-*21. CMS nurses had

generally seen Rice three times every day and had made

efforts to care for him. Id., at *20. Decisions as to Rice’s

psychiatric care were reserved to Rohrer and Oaklawn

pursuant to the contract between CMS and Oaklawn,

and the record indicated that CMS personnel relied

upon and carried out Rohrer’s instructions and communicated with him regularly to keep him apprised

of Rice’s condition. Id. Finally, to the extent that the

nurses were responsible for the decision not to put Rice

on suicide watch following the razor incident, there was

no evidence that they exhibited deliberate indifference

in making that decision. Id. Last, as to Oaklawn, the

court found the Estate’s claim deficient in that it was

based solely on the individual actions of Rohrer and

Ceniceros rather than any custom or policy of Oaklawn

itself. Id., at *21.

Private corporations acting under color of state law

may, like municipalities, be held liable for injuries
Nos. 09-2804 & 10-2389 49

resulting from their policies and practices. Monell v. Dep’t

of Social Servs. of City of New York, 436 U.S. 658, 690-91,

98 S. Ct. 2018, 2035-36 (1978); Rodriguez v. Plymouth Ambulance Serv., supra, 577 F.3d at 822 (Monell framework

applies to private corporation acting under color of state

law) (citing Johnson v. Dossey, 515 F.3d 778, 782 (7th Cir.

2008)). In order to recover against a municipal or

corporate defendant under section 1983, it is not

enough for the plaintiff to show that an employee of

the municipality or corporation violated his constitutional rights; he must show that his injury was the result

of the municipality’s or corporation’s official policy or

custom. See Pembaur v. City of Cincinnati, 475 U.S. 469, 479-

80, 106 S. Ct. 1292, 1298 (1986) (plurality); City of

Oklahoma City v. Tuttle, 471 U.S. 808, 817, 105 S. Ct. 2427,

2432-33 (1985); Monell, 436 U.S. at 690-91, 98 S. Ct. at 2035-

36. “[M]unicipal liability under § 1983 attaches where—

and only where—a deliberate choice to follow a course

of action is made from among various alternatives”

by municipal policymakers. City of Canton, Ohio v. Harris,

489 U.S. 378, 389, 109 S. Ct. 1197, 1205 (1989) (quoting

Pembaur, 475 U.S. at 483-84, 106 S. Ct. at 1300-01) (plurality)). An official policy or custom may be established

by means of an express policy, a widespread practice

which, although unwritten, is so entrenched and wellknown as to carry the force of policy, or through the

actions of an individual who possesses the authority to

make final policy decisions on behalf of the municipality

or corporation. E.g., Milestone v. City of Monroe, Wis.,

665 F.3d 774, 780 (7th Cir. 2011); Waters v. City of Chicago,

580 F.3d 575, 581 (7th Cir. 2009). The plaintiff must also
50 Nos. 09-2804 & 10-2389

show a direct causal connection between the policy or

practice and his injury, in other words that the policy

or custom was the “ ‘moving force [behind] the constitutional violation.’ ” Harris, 489 U.S. at 389, 109 S. Ct. at 1205

(quoting Monell, 436 U.S. at 694, 98 S. Ct. at 2038, and

Polk County v. Dodson, supra, 454 U.S. at 326, 102 S. Ct. at

454). The failure to provide adequate training to its employees may be a basis for imposing liability on a municipality or private corporation, but as with any other

policy or practice for which the plaintiff seeks to hold

the municipal or corporate defendant liable, the plaintiff

must show that the failure to train reflects a conscious

choice among alternatives that evinces a deliberate indifference to the rights of the individuals with whom

those employees will interact. Ibid.

We affirm the district court’s judgment as to these

claims. The Estate has not identified evidence sufficient for the factfinder to conclude that any of the

three sets of defendants maintained a policy or custom

evincing deliberate indifference to the needs of mentally

ill prisoners that resulted in harm to Rice.

Beginning with Sheriff Books and the jail supervisors,

we note that most of the errors and omissions cited by

the Estate have to do with how Rice’s mental illness

and the manifestations of that illness were handled by

the jail staff. The jail certainly has an obligation to

provide for the psychiatric care of its inmates pursuant

to its constitutional obligation to address their serious

medical needs. See Sanville v. McCaughtry, supra, 266 F.3d

at 734; Wellman v. Faulkner, supra, 715 F.2d at 272. But the
Nos. 09-2804 & 10-2389 51

Estate makes no allegation that the jail had any sort

of policy or practice that deprived inmates of reasonable

access to medical and psychiatric professionals or interfered in some way with the treatment prescribed by

those professionals. The closest to such an allegation

is the Estate’s charge that the jail would not transfer an

inmate to a psychiatric facility without Oaklawn’s

approval and that Sheriff Books failed to exercise his

own purported authority to transfer Rice without such

approval. The Estate’s expert, Ken Katsaris, former

sheriff of Leon County, Florida (Tallahassee), opined

that Books had this authority and should have exercised

it in Rice’s case. But as the district court noted, jail

officials ordinarily are entitled to defer to the judgment

of medical professionals. Arnett v. Webster, 658 F.3d 742,

755 (7th Cir. 2011); Johnson v. Doughty, 433 F.3d 1001, 1010

(7th Cir. 2006); Brownell v. Figel, 950 F.2d 1285, 1291-92

(7th Cir. 1991). Certainly jail officials may not turn a

blind eye to an inmate in distress or to obvious incompetence on the part of the physicians and nurses treating

its inmates. See Arnett, 658 F.3d at 755-56. However,

although it cannot be denied that Rice fared poorly

within the confines of the jail, no evidence cited to us

would permit a factfinder to conclude that Books,

Rogers, or Call should have second-guessed the judgment of Drs. Rohrer or Ceniceros or any other medical

professional as to how Rice should be treated and sought

care for him elsewhere. The Estate, in broad strokes,

criticizes the training of jail staff generally and

their training in the handling of mentally ill prisoners

in particular, but has not explained how any particular
52 Nos. 09-2804 & 10-2389

omission in their training harmed Rice. Its only specific

contention is that personnel did not follow the jail’s

suicide prevention policy after Rice cut his neck with

a razor. But there are multiple and obvious flaws with

this theory: (1) the Estate does not come to grips with

the fact that a CMS nurse, Hess, concluded after looking

into the incident that it was not, in fact, a suicide attempt—a view shared by the physician who saw Rice

at Goshen General Hospital; (2) even assuming it was

a suicide attempt, no showing has been made that the

failure to follow the suicide prevention policy was something other than an aberration; (3) Rice’s subsequent

death, as the district court rightly emphasized, was

not the result of suicide but rather as the result of his

psychogenic polydipsia; and (4) assuming, as the Estate

evidently does, that placing Rice on suicide watch would

have made it more likely that his compulsive water

drinking and its lethal effects would have been

discovered by jail personnel in time to save his life,

the Estate does not explain why the jail should be held

liable for the failure to follow a policy that is aimed at

a danger altogether distinct from the one that actually

killed Rice. The staff’s alleged failure to conduct

the requisite hourly checks of the administrative segregation unit on the night Rice died arguably has a

more direct and foreseeable connection to his death,

assuming that such checks are designed to detect the

very sort of sudden and unexpected occurrence that

killed Rice. But as with the failure to observe the dictates

of the suicide prevention policy, the Estate has made

no attempt to argue that the failure to conduct the
Nos. 09-2804 & 10-2389 53

hourly checks on the night of Rice’s death was a common

and known practice at the jail rather than an isolated

occurrence. Cf. Woodward v. Correctional Med. Servs of Ill.,

Inc., 368 F.3d 917, 929 (7th Cir. 2004) (evidence that

CMS knew of and condoned violations of its written

policies supported imposition of corporate liability).

Finally, although the Estate complains that staff

members were not given adequate instruction as to the

proper use of force against mentally ill prisoners, it

offers no detail as to what specifically was lacking in

their training and how better training would have

altered their conduct when Rice fought with his cellmate

or when he refused to remove himself from a restraint

chair, for example. We said earlier that the Estate’s

custom or practice allegations against Books and the

jail amounted to a laundry list, and we reiterate that

point here: The Estate has made a series of conclusory

allegations without in most instances making even a

rudimentary attempt to identify a policy or practice

which was the moving force between a constitutional

harm that Rice suffered.

The case against CMS fares little better. CMS’s nurses

were arguably best situated to observe Rice’s decline not

only because they saw him on a daily basis, knew of his

diagnosis, and witnessed firsthand his frequent refusals

to be medicated, to communicate, and to eat, but also

because as medical professionals they likely would have

appreciated the connection between those behaviors

and Rice’s schizophrenia as well as the potential ramifications of his seclusion, lack of self-care, and weight loss.

The record does not suggest, as the Estate at points does,
54 Nos. 09-2804 & 10-2389

that the nurses simply threw up their hands while

Rice’s health declined. They did make regular efforts to

convince him to eat and to take his prescribed medications; and so far as the record reveals, they faithfully

reported his condition to the physicians who were

charged with overseeing his care. The Estate may have

a point when they assert that the nurses could have

done more to ensure that Rice was cleaned up more

regularly than the record indicates that he was. But even

if we assume that the nursing staff failed Rice in this

or other respects, the Estate, beyond criticizing the sufficiency of their training, has once again made no effort

to identify a policy or practice that would support a

finding that CMS itself was deliberately indifferent to

the plight of mentally ill prisoners like Rice. Insofar as the

nurses, too, are criticized for the response to the razor

incident, we repeat the point that there is no evidence

linking this one incident to some broader policy or

practice of CMS.

As for Oaklawn, the district court rightly pointed out

that the Estate’s claim rests entirely on the acts of

Rohrer and Ceniceros as opposed to some policy or

custom attributable to the hospital. The acts of an individual with policymaking authority can be attributed

to the corporation that employs him, Pembaur, 475 U.S.

at 480, 106 S. Ct. at 1298-99, and this is the theory that

the Estate presses on appeal. Ceniceros, it argues, had

final say on whether an inmate like Rice could be

admitted to Oaklawn, and thus he was a policymaker in

that respect. This is the extent of its abbreviated argument. The district court did not address this theory in its
Nos. 09-2804 & 10-2389 55

thorough decision, and for good reason: It was not argued

below. We have reviewed the written memorandum that

the Estate submitted in opposition to the defendants’

motions for summary judgment, R. 276, and also the

transcript of the oral argument that the district court

held on those motions, R. 349, and nowhere did we find

any argument, let alone a developed one, making a case

that Ceniceros should be treated as a policymaker for

Oaklawn. Even in this court, the argument is so summarily made that Oaklawn has neither noticed nor responded to it. We therefore deem the argument forfeited,

and because this is not the extraordinary case that might

warrant overlooking the forfeiture, see Shlahtichman v. 1-800

Contacts, Inc., 615 F.3d 794, 803 (7th Cir. 2010), we will

not address it.

G. DELIBERATE INDIFFERENCE OF JAIL OFFICIALS

The Estate asserts that two groups of jail personnel are

liable for Rice’s death. These include four of the guards

who were on duty the night that Rice died (officers

Shelton, Scott Eisenhour, Kimberly Baxter, and Samantha

Werth) as well as Books, Rogers, and Call, this time in

their individual capacities. The Estate’s theory is that

the entire staff of the jail, from supervisors to guards,

was aware that Rice was severely mentally ill. Even if

jail personnel were unaware of the possibility that he

might die from water toxicity brought on by compulsive

water drinking, the Estate reasons, there were fifteen

months of warning signs prior to his death that

Rice could not care for himself and suffered from self-
56 Nos. 09-2804 & 10-2389

destructive tendencies, and a jury could find that

staff members were subjectively aware of the substantial

risk that Rice might harm himself fatally in some way.

That knowledge, the Estate argues, compelled the jail

defendants to keep Rice under close watch in order to

prevent him from hurting himself. Certainly once Rice

had cut his throat with the razor in August 2004, he

should have been treated as a suicide risk, the Estate

reasons: “Had Defendants followed their own suicide

prevention policies, the likelihood of Nicholas’s death

would have been greatly diminished or prevented.” Estate

Br. 45. Instead, they ignored the risk, and thus increased

the odds that Rice might injure himself to the point

of death before anyone could intervene. And the guards

on duty the night Rice died allegedly did not comply

with the jail’s standing rule that inmates housed in the

administrative segregation unit be checked upon hourly

and did not respond to the door-kicking of inmates

who heard Rice’s distress.

The district court rejected the deliberate indifference

claims against these defendants on the ground that jail

staff, even if they did appreciate the gravity of Rice’s

mental illness, had no warning that Rice might

experience the psychogenic polydipsia that caused his

death. With respect to the guards, the court assumed,

consistent with inmate Shaw’s affidavit, that they had

not made hourly checks of the administrative segregation

unit on the night Rice died. 2009 WL 1748059, at *5, *22.

Still, the court believed that the guards could not be

characterized as deliberately indifferent to Rice’s plight

because there was no evidence that those guards in par-
Nos. 09-2804 & 10-2389 57

ticular knew of his serious medical condition and, even

if they did, they could not have foreseen his death from

water intoxication. Id., at *22. And assuming that other

inmates in the unit with Rice had indeed kicked their

doors when they heard Rice in distress, the evidence

did not suggest that their entreaties included any

warning that Rice was in extremis and needed medical

attention. Id. In short, the guards were not alerted to the

need to regularly monitor Rice to prevent an occurrence

of the kind that resulted in his death. Id. As for Books,

Rogers, and Call, the court agreed that they were aware

of Rice’s medical condition. Id., at *23. But they were

entitled to rely on the expertise of medical personnel as

to the appropriate care of Rice, and they granted Rice

access to medical treatment, did not interfere with

said treatment, and did not withhold relevant information from the medical professionals. Id. There was no

evidence that jail managers should have questioned

the judgment of those professionals, especially where

medical personnel had access to medical records that

jail officials themselves were forbidden under federal

law from seeing. Id.

Although we do not concur with the district court’s

reasoning in all respects, we nonetheless conclude that the

district court correctly granted summary judgment to

these defendants. A factfinder might conclude that the

guards exhibited a generalized recklessness with respect

to the safety of the inmates housed on Ward One by

failing to conduct hourly checks of the administrative

segregation unit. But there is no evidence that the

guards were subjectively aware of the possibility that
58 Nos. 09-2804 & 10-2389

Rice might engage in a behavior such as compulsive

water drinking that would cause him to die within a

matter of hours and that they consciously disregarded

that risk. Nor is there evidence that the jail’s supervisors were aware of such a possibility. On this record,

a factfinder could not reasonably conclude that any of

the jail personnel were deliberately indifferent to this

sort of risk.

A reading of the record favorable to the Estate certainly would support a finding that the guards failed to

conduct hourly checks of the administrative segregation

unit on the night of Rice’s death. Inmate Shaw, who

was housed in the cell next to Rice’s, averred in his affidavit that over the course of multiple hours during

which Rice could be heard vomiting, no guard came

to check on inmates in the unit, even after Shaw and

other inmates began mule-kicking their doors in an unsuccessful effort to gain the guards’ attention. Although

the named guards and the jail insist that hourly checks

on the unit were made, and that nothing out of the ordinary was apparent, Shaw’s affidavit is enough to create

a factual dispute on this point, as the guards’ counsel

rightly concedes. Payne v. Pauley, 337 F.3d 767, 772-73

(7th Cir. 2003). If no checks were made, a factfinder

certainly could conclude that the guards who were required to make those checks were indifferent to the

concerns underlying the rule mandating those checks.

Surprisingly, not only do the briefs fail to discuss

the purpose and nature of the jail’s administrative segregation unit and the types of inmates who are placed
Nos. 09-2804 & 10-2389 59

in that unit, they also omit any discussion of the reasons

for the hourly check rule. Administrative segregation

is often used to isolate from the general population of

the prison inmates who either pose a danger to other

inmates or who may be especially vulnerable to assaults

by other inmates. But we do not know whether the administrative segregation unit in Elkhart’s county jail

was regularly used (and was known by the guards to be

used) as a place to house prisoners who required

frequent observation because they were medically fragile

or likely to harm themselves. Proof along those lines

might support a finding that the guards appreciated

the risk they were taking by not conscientiously making

their rounds. Cf. Arnett v. Webster, supra, 658 F.3d at 755

(“Non-medical defendants simply cannot ignore an inmate’s plight.”); Sanville v. McCaughtry, supra, 266 F.3d at

739 (“If the [guards] were aware of the alleged risk [of

suicide], failing to determine what was going on in [the

inmate’s] cell could easily be conduct egregious to rise

to the level of deliberate indifference.”). But no such

evidence is cited to us. Rice’s mental illness appears

to have been common knowledge at the jail, and so we

may assume for the sake of argument that each of

the guards on duty knew of his illness. Yet there is no

evidence that any of them, even if they were aware of

his full history at the jail (including his weight loss,

inability to care for himself, and frequent catatonia)

knew that he might engage in behavior like compulsive

water drinking that could quickly result in his death

absent intervention by the jail staff.
60 Nos. 09-2804 & 10-2389

The Estate’s reliance on the razor incident as sufficient

to place jail staff on notice of the risk to Rice is understandable, as that is the only prior incident that might

fall into the category of self-destructive behavior necessitating immediate intervention. But the incident was

investigated by nurse Hess and deemed not to be a

suicide attempt. As we have noted, her view was shared

by the physician at Goshen Hospital who treated Rice

for his wound. And, again, Rice ultimately did not commit suicide. Rather than deliberately harming himself, he suffered a compulsion to drink excessive water

which resulted in a drop in his blood sodium levels and

a heart attack. Categorizing both incidents as manifestations of Rice’s self-destructive tendencies, and insisting

that the incident with the razor blade was enough to

make the jail staff aware that Rice might harm himself

involuntarily and inadvertently, ignores the substantial

differences between the two incidents and the lack of any

warning whatsoever that Rice might die as a result of

a phenomenon like psychogenic polydipsia. So even if

the guards recklessly failed to conduct hourly checks

as they were required to do, no reasonable factfinder

could find that they knew of, and were deliberately

indifferent to, a risk that Rice might come to medical

harm like cardiac arrhythmia brought on by water

toxicity were he not checked on regularly. See State Bank

of St. Charles v. Camic, 712 F.2d 1140, 1146 (7th Cir. 1983)

(even if defendant police officers disregarded established procedures, such as conducting hourly checks of

detainees, deliberate indifference not shown in absence

of evidence that defendants were actually aware that
Nos. 09-2804 & 10-2389 61

detainee who killed himself was a suicide risk, and reasonable precautions against suicide had otherwise

been taken); see also Cagle v. Sutherland, 334 F.3d 980, 987-88

(11th Cir. 2003) (per curiam) (failure to conduct hourly

checks of detainees as required by prior consent decree

insufficient by itself to establish deliberate indifference

to detainee who committed suicide, absent evidence that

defendants had actual knowledge of risk that a detainee

was likely to commit suicide); Hott v. Hennepin County,

Minn., 260 F.3d 901, 907-08 (8th Cir. 2001) (deputy’s

alleged failure to conduct requisite hourly checks of

special needs section of detention center insufficient to

show deliberate indifference to needs of inmate who

killed himself, where evidence did not show deputy’s

awareness of substantial risk that an inmate might

commit suicide); Timson v. Juvenile & Jail Facility Mgmt.

Servs., Inc., 355 F. App’x 283, 286 (11th Cir. 2009) (per

curiam) (non-precedential decision) (deliberate indifference not shown despite failure of guards to check jail

inmates every thirty minutes as required by their

corporate employer’s policy, where evidence did not

show guards had reason to be suspicious that inmate

had suicidal tendencies).

Accepting the Estate’s version of the facts as true, the

possibility that the guards did not respond to the

kicking and shouting of other inmates is particularly

disturbing. We do not agree that simply because the

inmates did not somehow expressly signal that there

was a medical emergency, the guards were not placed

on notice that an inmate was in medical distress. Presumably that information would have been conveyed had
62 Nos. 09-2804 & 10-2389

any guard heard the commotion and responded;

and medical distress would be one possibility that the

inmates’ urgent kicking would convey. The whole point

of the door-kicking, one may infer, was to alert the

guards that something was amiss and convince them

to come into the unit so that they could be told just

what that was. Either none of the named guards heard

the kicking and shouting, or one or more of them did

hear it and simply did not bother to investigate.

Nonetheless there are at least two problems with this

claim that foreclose relief to the Estate. First, there is no

discussion in the Estate’s brief as to which of the four

named guards, if any, would have been in a position to

hear the door-kicking of the inmates on Ward One. We

know very little about how the jail, and the administrative segregation unit in particular, was monitored in the

overnight hours; nor do we know where any of the four

named guards was stationed in the jail on the night of

Rice’s death. Was the jail so small that vigorous doorkicking in Ward One would have been heard anywhere

on the premises? Even if not, would the assigned

rounds of all four of the named guards—apart from

conducting hourly checks of Ward One itself—have at

least brought them within hearing range of the administrative segregation unit at some point during the

hours immediately prior to Rice’s death, such that

they would have heard the kicking? Such questions

are left unaddressed by the briefs. Second, the Sheriff’s

counsel, at oral argument both before the district court

and this court, and without contradiction by the

Estate, noted that the guard (Bruno Martinsky) who was
Nos. 09-2804 & 10-2389 63

stationed in the control room just across the hall from

the administrative segregation unit on the night of

Rice’s death—and was thus in a position to have heard

any commotion on Ward One—had been dismissed

from the litigation by the Estate. See R. 349 at 50.

Our discussion as to the jail supervisors (Books, Call,

Rogers) may be much more brief. The Estate does not

contend that any of these three defendants was responsible (in his individual capacity) for the failure to check

on Rice the night he died. Its theory instead is that

these defendants were all aware of Rice’s severe

mental illness and his increasingly pitiful condition and

should have, at the least, taken steps to monitor his

condition more closely, as by putting him on suicide

watch, so that his compulsive water drinking on the

night of his death would not have gone unnoticed.

We have already disposed of the notion that the jail

should have put Rice on suicide watch. It appears that

Rice was put in the administrative segregation unit at

least in part to monitor him more closely, and we are

told that his assigned cell (5A) was the cell most

easily seen from the control room across the hall. It

also appears that as Rice’s condition deteriorated, jail

administrators made more of an effort to keep track of

his weight, showering, and so forth. We may assume

that jail officials, short of treating Rice as a suicide

risk, could have done more to watch Rice. (We have

already observed that a jury could find jail personnel

liable for deliberate indifference to his conditions of

confinement.) But what precludes the Estate from recovering against these officials for Rice’s death is the
64 Nos. 09-2804 & 10-2389

lack of any evidence that they were on notice of the type

of risk that materialized when Rice unexpectedly began

to consume excessive amounts of water. Jail officials

had no forewarning of that type of event, or of the risk

that he might die suddenly when it occurred.

H. DELIBERATE INDIFFERENCE OF CMS NURSES

The Estate’s claims against the individual nurses who

cared for Rice at the jail fall into three categories: (1) a

claim based on the failure to note Rice’s distress on the

night Rice died; (2) a claim based on the incident in

which Rice was pepper-sprayed by a guard and then

left for a prolonged period in the restraint chair; and

(3) a claim based on the adequacy of the care Rice

received from the nurses over the period of his incarceration at the jail. The claim as to the night of Rice’s

death is focused on Lambright. Because Lambright was

on duty at the jail on the night that Rice died, and

because she was aware of his condition and history at

the jail, the Estate appears to suggest that Lambright

should have been checking on Rice herself over the

course of the evening. Relatedly, the Estate contends

that Lambright, being aware of the razor incident,

should have seen to it that Rice was placed on suicide

watch, so that he would have been monitored more

closely and so that the distress associated with his psychogenic polydipsia would have been noticed. Lambright

is also cited for the response to the pepper-spray incident, along with Bell. The Estate’s contention is that the

two nurses displayed deliberate indifference by not
Nos. 09-2804 & 10-2389 65

doing more to prevent and/or remediate the guards’ use

of pepper spray and by leaving Rice shackled in a

restraint chair for eighteen hours. As to the totality of

Rice’s care at the jail, Hess, Lambright, Bell, and Jones

are named along with Nurse Florence Makousky and

social worker Margaret Miller. The Estate reasons that

their deliberate indifference may be inferred from their

alleged failure to heed multiple warning signs that

Rice’s mental illness was severe and to pursue more

proactive intervention rather than blindly deferring to

the physicians whose own conduct was, in the Estate’s

view, far too passive. See Berry v. Peterman, 604 F.3d 435,

443 (7th Cir. 2010) (a nurse’s deference to physician

“may not be blind or unthinking, particularly if it is

apparent that the physician’s order will harm the patient”).

The district court gave primary emphasis to two

points in rejecting the Estate’s claim against CMS’s

nurses. First, it stressed that the nurses were entitled to

defer to the medical judgment of Oaklawn, Ceniceros,

and Rohrer as to the appropriate treatment of Rice. 2009

WL 1748059, at *24. Second, the court noted that the

nursing staff visited Rice multiple times daily, monitored

his weight, regularly made efforts to get him to eat

more, and also encouraged him to take the medications

prescribed by Dr. Rohrer. Id., at *24, *26. Although the

court agreed that more could have been done to

monitor Rice’s condition and to treat his illness, it

found the evidence insufficient to support an inference

that the nurses were deliberately indifferent to Rice’s

serious medical needs. Id., at *26.
66 Nos. 09-2804 & 10-2389

We agree with the district court that the record does

not support a finding that any of the CMS nurses

ignored a known medical risk in caring for Rice. To

begin with a point we have made already, Rice died not

as a result of any volitional self-destructive tendencies

that were known to the nursing staff but rather due to

a compulsion to drink large amounts of water that,

so far as anyone knew, Rice had never experienced

before. Moreover, as the district judge pointed out, decisions as to Rice’s treatment—including a decision to

medicate him against his will, which might have

reduced the likelihood of psychogenic polydipsia—

belonged to Rice’s physicians rather than his nurses.

Nurse Lambright was on duty the night Rice died, and

the Estate appears to fault her for not ensuring that he

was checked on regularly and/or for failing to check on

Rice herself. But the Estate points us to no evidence

that Lambright was under an obligation to check on

Rice and the other inmates in the administrative segregation unit hourly, for example, nor does it cite any

evidence that Lambright was within hearing range of

the unit such that she would have heard the kicking of

the other inmates in that unit. Insofar as it might have

been within Lambright’s province to admonish the

guards to make their own hourly checks of Ward One,

the notion that she should have exercised that authority

is premised on Lambright’s knowledge of the incident

in which Rice had cut his neck with the razor. Again,

however, we reject the Estate’s contention that an

incident that could have been understood as a suicide

attempt (although CMS did not construe it as such) was
Nos. 09-2804 & 10-2389 67

As the district court noted, the Estate did not effectively 5

dispute this fact in response to the defendants’ statement

of material facts below. 2009 WL 1748059, at *5 n.4.

sufficient to make Lambright or any other nurse aware

that Rice was at risk for an entirely distinct harm such

as compulsive water drinking.

It is true that a nurse may not unthinkingly defer

to physicians and ignore obvious risks to an inmate’s

health, Berry, 604 F.3d at 443; but with one possible exception we mention below (and which the Estate does

not pursue), there is no evidence that any nurse consciously disregarded Rice’s schizophrenia or its manifestations. Jones’ testimony indicates that she and her

colleagues saw Rice three or more times daily (when

they distributed pills and made their rounds of the segregation unit), monitored his condition and reported it 5

to his physicians, attempted to convince him to take his

medications, and tried to get him to eat more. They

redoubled their efforts in the latter regard after Rice

returned to the jail following his brief hospitalization

at Goshen General Hospital, with the result that Rice’s

weight loss ceased.

We have considered whether a factfinder could

conclude that the nurses were indifferent to the state of

Rice’s nutrition, given his weight loss and the mild to

moderate malnutrition detected postmortem. Contrary

to the defendants, we believe that Rice’s malnutrition

would be actionable regardless of whether it contributed

to his death. See Farmer v. Brennan, supra, 511 U.S. at 832,
68 Nos. 09-2804 & 10-2389

114 S. Ct. at 1976 (citing provision of “adequate food” as

among prison officials’ duties); Wilson v. Seiter, supra, 501

U.S. at 303, 111 S. Ct. at 2326-27 (citing food as a condition of confinement); Reed v. McBride, 178 F.3d 849, 852,

853-54 (7th Cir. 1999) (alleged deprivation of food states

Eighth Amendment claim depending on amount and

duration of deprivation); Freeman v. Berge, supra, 441

F.3d at 546 (prison has duty to force-feed mentally

ill prisoner if necessary to prevent starvation to degree

which might seriously impair his health). Perhaps a

factfinder could find some negligence on the part of

the nurses in this regard, given the extent of Rice’s

weight loss before his hospitalization and their evident

ability to help stop his weight loss after he was hospitalized without resorting to extraordinary measures like

forced feeding. But we see no evidence that the nurses

ever ignored the risks to Rice’s health posed by his

failure to eat. They were trying to get Rice to eat well

before he was hospitalized; and if their efforts were

more effective after the hospitalization, it was not, so far

as the record reveals, because they were deliberately

indifferent to the problem earlier.

The individual incidents that the Estate cites as

examples of indifference by the nurses do not alter our

conclusion that the nurses were not deliberately indifferent to Rice’s condition. For example, it faults Nurses

Lambright and Bell for standing by while Officer Shelton

ordered that Rice be pepper-sprayed following the altercation with his cellmate and then leaving Rice in

the restraint chair for eighteen hours. This is an echo of

the Estate’s excessive force claim, and it does not call
Nos. 09-2804 & 10-2389 69

into question the nurses’ response to Rice’s medical needs

(recall that the nurses helped cleanse Rice’s face of the

pepper spray, and that Rice refused to leave the restraint

chair when invited to do so). The razor incident is mentioned once again, but we have already addressed

that. Finally, Nurse Bell, as evidenced by her own notes,

once told Rice (in response to his refusal to eat, take

his medications, and communicate) that “acting like

this won’t get [you] out of jail like before.” R. 198-37 at 5.

Bell evidently thought that Rice was malingering, but

she was not alone in that perception, and even if she

was mistaken, the remark does not support the conclusion that she was deliberately indifferent to Rice’s

mental health or that she deliberately or recklessly withheld medical care that Rice needed.

There arguably might be one respect in which a

factfinder might conclude that the nurses were deliberately indifferent, and that has to do with the state of

Rice’s hygiene and self-care. We noted earlier with

respect to the conditions of confinement claim against

the jail officials and guards that there is evidence that

Rice went unshowered for long enough periods of time

and that his body was visibly filthy and so malodorous

that other inmates complained about the smell. There

was also the one incident in which dead skin sloughed

off of Rice’s person as guards lifted him off his bunk.

Bedsores, or the beginnings of such sores, were also noted

on his body at times. As we have noted, jail personnel,

including doctors and nurses, have an obligation to

protect an inmate from his own self-destructive tendencies, in this case Rice’s failure to clean himself. A
70 Nos. 09-2804 & 10-2389

factfinder possibly could conclude that Rice’s failure of

self-care was a result of his schizophrenia and that the

nurses, who saw Rice on a daily basis when he was in the

administrative segregation unit, appreciated as much.

Certainly there is evidence that the nurses made some

efforts to address the problem: For example, Jones, the

charge nurse, volunteered to come into the jail on her

own time to shower Rice. Nonetheless, given the

evidence that Rice went unbathed for significant periods

of time, was developing bedsores, and had skin

sloughing off his body when lifted up off of his bed, it is

conceivable that a jury would find that the nursing staff

had consciously disregarded the consequences of Rice’s

failure to care for himself and thus deprived him (or

helped to deprive him) of humane conditions of confinement. Depriving Rice of sanitary conditions of confinement would be actionable regardless of whether

the deprivation played a role in his death. Cf. Vinning-El

v. Long, supra, 482 F.3d at 924 (sustaining viability of

claim that inmate was subjected to unsanitary and otherwise inhumane confinement for period of three to six

days) (coll. cases).

The Estate does not make such an argument as to

the nurses, however. We therefore pursue the issue

no further.

I. DELIBERATE INDIFFERENCE OF DR. ROHRER 

The Estate contends that Dr. Rohrer knew that Rice

required inpatient psychiatric care and was deliberately

indifferent to Rice’s need for such care in failing to
Nos. 09-2804 & 10-2389 71

obtain it for him. Rohrer knew that Rice’s condition

was declining: His notes reflect his knowledge of Rice’s

weight loss, Rice’s refusal to take his medications, his

unwillingness to communicate, and his otherwise psychotic behavior. On three separate occasions he petitioned for Rice’s involuntary commitment to a psychiatric

facility, observing on the third occasion in October 2004

that Rice was in peril of dying. Yet, after Dr. Ceniceros

at Oaklawn returned Rice to the jail within twenty-four

hours in the first two instances, concluding that Rice

did not meet the criteria for involuntary commitment

and likely was malingering, Rohrer simply acceded to

Ceniceros’ assessment and took no further action. In the

third instance, Rohrer sought Rice’s admission to a different facility (Elkhart General), which refused the admission in the mistaken belief that it did not have a

contract with the jail to treat inmates. Rice was

then taken to Goshen Hospital, where he was declared

medically stable and returned to the jail after Ceniceros

refused his admission to Oaklawn. When, two months

later, Rice was found incompetent to stand trial, he was

designated for admission to Logansport State Hospital,

which put him on a waiting list. In the view of one

of the defense experts, Dr. Daniel Scherb, there was a

meritorious argument that Rohrer should have considered securing a court order authorizing Rice to be

forcibly medicated and fed by means of a feeding tube.

Although Scherb did not believe that Rice’s refusal to

eat and take medication factored into his death, he acknowledged the possibility that had Rice been medicated, he might not have experienced the psychogenic
72 Nos. 09-2804 & 10-2389

polydipsia that ultimately resulted in his death. Estate

experts opined more affirmatively that had Rice been

involuntarily medicated, he would not have died. Thus,

in the Estate’s view, Rohrer may be found liable for

failing to prescribe an effective course of treatment—

including involuntary admission to a psychiatric facility

and/or forced medication—to prevent Rice’s death.

As with the Estate’s claims against the CMS nurses

and the jail’s staff, the district court rejected this claim

for want of proof that Rohrer was deliberately indifferent to Rice’s condition. Again, the court emphasized

that Rice’s medical needs had not been ignored. 2009 WL

1748059, at *26. Rohrer, like the other medical defendants,

was aware of Rice’s schizophrenia and took steps to

treat it: He visited Rice regularly, monitored his condition between visits, prescribed psychotropic medication subject to Rice’s willingness to take it, and petitioned for his commitment to inpatient facilities on three

separate occasions. Id., at *25. Although Rohrer saw

Rice only once in late 2004 following Rice’s return to

the jail from Goshen Hospital, he did instruct the nurses

to ask Rice weekly whether he would resume his medications; he knew that Rice was eating some food; and

the Estate presented no evidence that any particular

psychiatric care, other than forced medication, would

have improved his medical condition. Id. Second, the

court pointed out that Rice enjoyed both a right under

Indiana statutory law to refuse medical treatment as

well as a significant liberty interest recognized by the

Supreme Court in Washington v. Harper, supra, 494 U.S.

210, 110 S. Ct. 1028, in avoiding unwanted anti-psychotic
Nos. 09-2804 & 10-2389 73

drugs. Id. Rice could not be forcibly medicated without

affording him procedural protections, which among

other things entailed a proof of an overriding justification for involuntary medication along with a finding

that the drugs were medically appropriate. Id. Where,

as in this case, a doctor’s obligation to address his

patient’s serious medical needs conflicts with the

patient’s right to refuse treatment, the proper resolution

of the conflict implicates the physician’s medical judgment. Id., at *25-*26. Third, because Rice had not experienced compulsive water drinking prior to the night he

died, his death as a result of psychogenic polydipsia,

hyponatremia, and cardiac arrhythmia was not reasonably foreseeable to Rohrer. Id., at *26. Finally,

assuming, consistent with the criticisms of Rice’s care

expressed by the Estate’s experts, that Rohrer could

have done more to treat Rice’s schizophrenia, a jury

still lacked any basis on which to find that Rohrer

was guilty of deliberate indifference to Rice’s serious

medical needs. Id.

We view it as a somewhat closer question than others

whether Rohrer was entitled to summary judgment. In

resolving the claims against the jail staff, we have

stressed that they could justifiably rely on the judgment

of the medical professionals, and we have similarly

observed that the nurses were entitled to rely on the

judgment of the physicians. Rohrer was the medical

professional who was responsible for making decisions

as to how Rice’s schizophrenia should be treated. To the

extent that Rice’s condition demanded inpatient care,

forced medication, or forced nutrition, Rohrer was the
74 Nos. 09-2804 & 10-2389

physician in a position to pursue such care on Rice’s

behalf. In fact, Rohrer did seek Rice’s involuntary admission to Oaklawn for seventy-two hours for forced

medication as well as observation on two occasions, only

to have Ceniceros conclude that Rice was malingering

and order him returned to the jail within twenty-four

hours. Yet, it is undisputed that Rohrer had the ability

to have Rice admitted to another facility, which is what

he tried to do in October 2004, only to run into Elkhart

General’s mistaken belief that it had no contract with

the jail and Ceniceros’ refusal to admit him at Oaklawn

when Dr. Mathew explored that possibility with him.

The Estate contends that had Rohrer sought Rice’s admission to another facility sooner than he did, or alternatively sought authority to medicate Rice involuntarily

at the jail (assuming that was possible), then the odds

of Rice engaging in compulsive water drinking, and experiencing the fatal complications of that polydipsia,

might have been reduced, as Dr. Scherb theorized. Granting it the benefit of those inferences, the Estate has

shown a plausible nexus between Rohrer’s treatment

decisions and Rice’s death.

But ultimately we agree with the district court that the

Estate has made at most a case for negligence on the

part of Dr. Rohrer. On this record, no reasonable factfinder could characterize Rohrer’s treatment decisions

as being deliberately indifferent to Rice’s serious

medical needs, or, put another way, that his decisions

represented “ ‘such a substantial departure from accepted professional judgment, practice, or standards

as to demonstrate that [he] actually did not base the
Nos. 09-2804 & 10-2389 75

decision[s] on such a judgment.’ ” Collignon v. Milwaukee

County, supra, 163 F.3d at 989 (quoting Youngberg v. Romeo,

supra, 457 U.S. at 323, 102 S. Ct. at 2462); see also id. at 988-89

(discussing professional judgment standard as a variant

of Eighth Amendment deliberate indifference standard

and noting there is little difference between the two).

As the district court rightly noted, Rice had a statutory

and a constitutional right, provided he did not pose a

danger to himself or others, to refuse the very medications that might have mitigated the symptoms of his

schizophrenia and lessened the odds of him experiencing psychogenic polydipsia. See Harper, 494 U.S. at 221-

22, 110 S. Ct. at 1036-37 (1990); Ind. Stat. 12-27-5-1, 12-27-5-

2 (formerly Ind. Stat. 16-14-1.6-7); In re Mental Commitment of M.P., 510 N.E.2d 645, 647-48 (Ind. 1987); see also

Sanville v. McCaughtry, supra, 266 F.3d at 736. Rohrer

was aware that Rice’s unwillingness to take his prescribed

anti-psychotic medications was adversely affecting his

mental and physical health, and for that very reason he

did try, on three separate occasions, to have Rice involuntarily committed for treatment. But as it turned out,

Rohrer’s colleague, Ceniceros, concluded that Rice was

not psychotic and likely malingering and had him

returned to the jail on the first two occasions and

refused his admission outright in the third instance

after Elkhart General turned Rice away and Goshen’s

Dr. Mathew spoke to him about the possibility of his

admission to Oaklawn. Ceniceros, unlike Rohrer, was

board-certified in psychiatry. Even if we assume that it

was imprudent for Rohrer to accept Ceniceros’ assessment, no evidence supports an inference that Rohrer
76 Nos. 09-2804 & 10-2389

was consciously disregarding a risk to Rice’s well-being.

Rohrer believed that involuntary, inpatient treatment

was warranted, but his colleague found no need for it.

By October 2004, when Rohrer concluded that Rice’s

life was in danger, it was obviously clear to Rohrer that

medical intervention was required notwithstanding

what Ceniceros may have thought—thus Rohrer’s decision to seek Rice’s admission to a facility other than

Oaklawn. Despite the failure of that effort, Rice was

declared medically stable by the physicians at Goshen

Hospital and returned to the jail with a directive that

his diet be supplemented. After that, his weight loss,

which was one of the major reasons Rohrer had sought

his hospitalization, ceased. And once Rice was declared

incompetent to stand trial in December, he was on

a waiting list for admission to Logansport. Given the

stabilization of Rice’s weight, there is nothing in the

record suggesting that Rohrer was aware of a serious risk

to Rice’s life, and certainly there was no warning that

Rice might experience the psychogenic polydipsia that

led to his death. We assume, as the district court did, that

Rohrer and the other medical professionals at the jail

could have done more generally to monitor Rice’s condition and could have tried sooner and more forcefully

to have his schizophrenia treated involuntarily. Perhaps

a factfinder could find that Rohrer breached the duty of

care he owed to Rice by failing to do more than he did

to monitor and treat Rice’s mental illness. Some of the

gaps in time between Rohrer’s visits to Rice, and in particular the fact that Rohrer only saw Rice once following his return to the jail in October 2004, are troubling
Nos. 09-2804 & 10-2389 77

given Rohrer’s own concern that Rice’s condition was

declining. But the Estate has not shown how any such

omissions harmed Rice, and we cannot characterize

any omission on his part as deliberate indifference to

Rice’s medical needs.

Earlier in this opinion, we expressed our doubts as to

the district court’s conclusion that Ceniceros did not

qualify as a state actor. The district court never proceeded beyond that threshold question, but assuming

that Ceniceros was a state actor, we believe that he

would still be entitled to summary judgment on

grounds similar to those we have just articulated as to

Rohrer. Ceniceros was obviously much more removed

from Rice’s day-to-day condition than Rohrer was. Indeed, on the occasions that Ceniceros observed Rice firsthand, Rice behaved far differently than he did at the

jail, which was what led Ceniceros to conclude that

Rice was not in need of inpatient treatment and/or

forced medication. But even if Ceniceros is charged with

Rohrer’s knowledge, the claim against Ceniceros is not

strong enough to survive summary judgment. The best

argument that can be made against Ceniceros is that,

knowing of the concerns that twice led Rohrer to seek

Rice’s commitment to Oaklawn, he should not so

hastily have discharged Rice from Oaklawn on the two

occasions Rice was sent there, and he should not have

refused Rice’s admission in October 2004 when Dr.

Mathew at Goshen consulted with him on the need for

inpatient psychiatric care. Although we view this question too as closer than others in this case, given the nonpsychotic behavior that Rice had displayed at Oaklawn,
78 Nos. 09-2804 & 10-2389

we do not believe that a reasonable factfinder could

conclude that Ceniceros was deliberately indifferent as

opposed to negligent (at worst) in discounting the possibility that Rice was so seriously mentally ill as to need

inpatient care and forcible medication. There is evidence

that the malingering Ceniceros perceived itself could

have been due to Rice’s schizophrenia (Dr. Yoder, the

Oaklawn psychologist who evaluated Rice’s competency

in April 2004, so opined), but there is no real dispute

that Rice did exhibit signs of manipulative behavior,

and whether this behavior was due to Rice’s illness or

simply to his desire to get out of jail was a matter on

which reasonable professionals could (and did) disagree.

That point aside, Ceniceros, like Rohrer, had no warning

that Rice might experience compulsive water drinking,

and therefore did not consciously disregard the circumstances that led to Rice’s death.

J. STATE CLAIMS

As we noted earlier in our factual summary, after

granting summary judgment in favor of the defendants

on all of the federal claims, Judge Miller relinquished

jurisdiction over the Estate’s state-law claims for

wrongful death (which included claims of negligence,

gross negligence, and wilful and wanton misconduct)

once he determined that the Estate had not properly

alleged the existence of diversity jurisdiction over those

claims (and concluding that diversity appeared to be

lacking). 2009 WL 1748059, at *27. The Estate then narrowed the list of defendants named in its state-law claims
Nos. 09-2804 & 10-2389 79

to citizens of states other than Michigan (of which the

Estate is a citizen) and re-filed these claims against

the CMS defendants alone in federal court, expressly

invoking the court’s diversity jurisdiction. The new suit

was assigned to Judge Lozano, who dismissed the

claims on the basis of collateral estoppel.

The linchpin of the collateral estoppel ruling was

Judge Miller’s finding, in disposing of the deliberate

indifference claims, that “ ‘it wasn’t reasonably foreseeable that Mr. Rice would suffer from cardiac

arrhythmia due to hyponatremia arising from Mr. Rice’s

ingestion of excessive amounts of water over a short

period of time.’ ” Estate of Rice ex rel. Rice v. Correctional

Med. Servs., No. 09 C 319, Order at 2-3 (N.D. Ind. May 17,

2010) (quoting 2009 WL 1748059, at *26). Judge Lozano

noted that in order to recover for wrongful death under

Indiana law, the Estate would have to prove, inter alia,

that a defendant breached a duty that he or she owed

to Rice, and that the breach proximately caused an injury

to Rice. Id. at 6. The foreseeability of an injury is a fundamental test of proximate cause. Id. at 6. But Judge Miller

had already determined, in his summary judgment

ruling on the federal claims, that Rice’s death as a result

of compulsive water drinking was not reasonably foreseeable. Although the legal theory underlying the

federal claims (deliberate indifference) differed from

that underlying the state claims (negligence), the specific

issue of foreseeability did not differ. Id. at 7-9. In order

to prevail on its state claims, the Estate would inevitably

have to prove that death as a result of psychogenic

polydipsia was a foreseeable risk to Rice that the CMS
80 Nos. 09-2804 & 10-2389

defendants had a duty to guard against. Id. at 9-10.

Judge Miller unequivocally determined that Rice’s death

by water ingestion was not reasonably foreseeable. Id. at

10. Given that the parties had spent three years

litigating the case, including the foreseeability of Rice’s

death, in the litigation before Judge Miller, the Estate

had enjoyed a full and fair opportunity to litigate that

issue. Id. at 10-11. Judge Miller’s finding on this point

was thus entitled to collateral estoppel effect, barring

the Estate from relitigating the question in the context

of its state claims.

The Estate contends that it is inequitable to give

Judge Miller’s finding as to the foreseeability of Rice’s

death preclusive effect as to the state claims. Because

the federal claims of deliberate indifference are governed

by a distinct standard, and because Judge Miller in recognition of the difference expressly abstained from addressing the possibility that any of the defendants, including the CMS defendants, were negligent, it would

be unfair to dispose of the state claims on the basis of

his foreseeability finding.

We agree that Judge Miller’s finding as to foreseeability

should not be given preclusive effect, because it was

unnecessary for him to resolve the issue of foreseeability

in order to dispose of the Estate’s deliberate indifference

claims. Because Judge Miller’s decision was a federal

judgment, we look to federal common law for the criteria

governing preclusion. Taylor v. Sturgell, 553 U.S. 880,

891, 128 S. Ct. 2161, 2171 (2008); Firishchak v. Holder, 636

F.3d 305, 308 (7th Cir. 2011), cert. denied, 2012 WL 538406
Nos. 09-2804 & 10-2389 81

(U.S. Feb. 21, 2012). For a federal court’s ruling on a

particular issue to be given preclusive effect, that issue

must have been both actually and necessarily decided in

the prior action. Id.; see also RESTATEMENT (SECOND) OF

JUDGMENTS § 27 & comment h (1982) (prior determination

of issue must have been, inter alia, “essential to the judgment”). No one disputes that Judge Miller actually

decided that Rice’s death due to psychogenic polydipsia

was not reasonably foreseeable to the CMS defendants

(among others), but the pertinent question is whether it

was necessary for him to decide that question. The

Estate is on the right track when it emphasizes the

material differences between the federal claims of deliberate indifference and the state claims of negligence. Such

differences do not, in and of themselves, prevent an

invocation of collateral estoppel, as Judge Lozano quite

rightly pointed out. E.g., Taylor, 553 U.S. at 892, 128 S. Ct.

at 2171 (citing New Hampshire v. Maine, 532 U.S. 742, 748-

49, 121 S. Ct. 1808, 1814 (2001)). But such distinctions

do shed light on whether it was necessary for the court

in prior litigation to reach a particular issue. In order

for the Estate to succeed on its claim that the medical defendants were deliberately indifferent to Rice’s

serious medical needs, it was necessary to show that

the defendants consciously disregarded a known risk, not

merely a reasonably foreseeable risk, to Rice’s safety and

well-being. See Knight v. Wiseman, 590 F.3d 458, 463

(7th Cir. 2009), and Matos ex rel. Matos v. O’Sullivan, 335

F.3d 553, 557 (7th Cir. 2003), both citing Proffitt v.

Ridgway, 279 F.3d 503, 506 (7th Cir. 2002). Although the

parties before Judge Miller spent a fair amount of time
82 Nos. 09-2804 & 10-2389

talking about whether it was foreseeable to the medical

defendants that Rice might suffer a bout of psychogenic

polydipsia, the relevant question was whether they

knew Rice was at risk for polydipsia yet consciously

disregarded the risk (the subjective inquiry called for

by the deliberate indifference standard) rather than

whether the risk was reasonably foreseeable to them

(which is the objective inquiry that typifies negligence

cases). See Knight, 590 F.3d at 463. Thus, when

Judge Miller concluded that none of the medical defendants were deliberately indifferent to the possibility that

Rice might experience psychogenic polydipsia, he was

necessarily finding that they were not subjectively

aware of this risk and in turn did not consciously

disregard it. And that was all that he needed to find.

His broader observation that Rice’s compulsive water

drinking, and in turn the possibility that he might die

from it, were not reasonably foreseeable to these defendants was unnecessary to his ruling on the deliberate

indifference claims. In the words of the Restatement, his

finding as to foreseeability was “not essential to the

judgment.” RESTATEMENT (SECOND) OF JUDGMENTS § 27

& comment h. See, e.g., George E. Hoffman & Sons, Inc. v.

Int’l Brotherhood of Teamsters, 617 F.2d 1234, 1246 n.31

(7th Cir. 1980); Gen. Conference Corp. of Seventh-Day Adventists v. McGill, 617 F.3d 402, 413-14 (6th Cir. 2010), cert.

denied, 131 S. Ct. 2097 (2011); Ass’n of Bituminous Contractors, Inc. v. Andrus, 581 F.2d 853, 860 (D.C. Cir. 1978).

There are, at the same time, unmistakable hints elsewhere in Judge Miller’s opinion that he did not intend
Nos. 09-2804 & 10-2389 83

to make any ruling that would preclude the Estate’s statelaw claims. In particular, the judge expressly stated that

he was not speaking to the possibility that the medical

defendants (including, of course, the CMS defendants)

may have been negligent. 2009 WL 1748059, at *24 (“the

Estate’s state law malpractice claims remain, so no discussion is appropriate as to whether the medical care

provided by the defendants fell below the applicable

standard of care under Indiana law”); id., at *23 (“Deliberate indifference is not medical malpractice . . . .”)

(internal quotation marks and citations omitted). We

are confident that had he been asked whether

he meant to render a finding on the foreseeability of

psychogenic polydipsia that would be preclusive as to

the Estate’s state-law claims, the judge would have answered that he did not. See id., at *27.

We therefore conclude that Judge Miller’s finding as to

the foreseeability of Rice’s polydipsia should not be

accorded preclusive effect as to the state-law claims. No

other basis for affirming the dismissal of those claims

has been argued to us. Consequently, those claims

will be remanded to the district court for further proceedings. It may make sense to consolidate the litigation over those claims with what remains of the federal

suit before Judge Miller. As the substance of the state

claims has not yet been addressed by the district court

and has not been argued in this court, nothing we

have said in this opinion should be construed as

speaking to the merits of those claims. 
84 Nos. 09-2804 & 10-2389

III.

For the foregoing reasons, in No. 09-2804, we affirm

in part and reverse in part the district court’s entry

of summary judgment in favor of the defendants,

and in No. 10-2389, we reverse the district court’s decision to dismiss on the basis of collateral estoppel.

We remand both cases to the district court for further

proceedings consistent with this opinion.

3-20-12