In the

United States Court of Appeals

For the Seventh Circuit ____________________

No. 19-2291

ZACHARY PULERA,

Plaintiff-Appellant,

v.

VICTORIA SARZANT, et al.,

Defendants-Appellees.

____________________

Appeal from the United States District Court for the

Eastern District of Wisconsin.

No. 2:15-cv-00461-WCG — William C. Griesbach, Judge.

____________________

ARGUED JUNE 10, 2020 — DECIDED JULY 15, 2020

____________________

Before FLAUM, BARRETT, and ST. EVE, Circuit Judges.

ST. EVE, Circuit Judge. Police arrested Zachary Pulera on 

suspicion of bail jumping and brought him to the Kenosha 

County Pre-Trial Facility. Just under forty-eight hours later, 

Pulera attempted to hang himself in his cell. Fortunately, correctional officers noticed, swiftly cut him down, and called for 

an ambulance that saved his life.
2 No. 19-2291

Over his two days at the facility, Pulera never told any official that he was contemplating suicide. This appeal asks 

whether a long list of officials nevertheless unreasonably responded to other possible signs that Pulera was in distress, so 

that they may face liability for his injuries under 42 U.S.C. 

§ 1983. The district court concluded there was no genuine dispute that all officials responded reasonably to the information 

each had, so it granted the defendants’ motions for summary 

judgment. We affirm the judgment.

I. Background

A. Intake

In the early morning of Saturday, April 21, 2012, police 

stopped Edward Burke for a suspected hit-and-run. Pulera, 

Burke’s cousin, was in the car’s passenger seat, drunk. Officers arrested both men: Burke for the hit-and-run and Pulera 

for drinking in violation of a condition of his bond pending 

trial on state battery charges. According to the arresting officer’s report (the accuracy of which Pulera does not dispute),

Pulera appeared drunk but exhibited no suicidal behavior

while in transit. When Pulera arrived at the facility, the intake 

officer on duty, Victoria Sarzant, and her supervisor, Dennis 

Zawilla, reviewed the arresting officer’s report and placed

Pulera and Burke in temporary holding cells across from each 

other. 

Burke testified that he could just barely see and hear Pulera through their respective cell doors and the distance of the 

hall, but what he witnessed alarmed him. Though the solid 

door muffled the sounds and the small cell windows constrained his view, Burke saw that Pulera was “dragging his 
No. 19-2291 3

thumb across his neck as if he was going to harm himself” and 

muttering “I’ll just take myself out” because he was “done,”

all of which Burke understood by reading Pulera's lips. This 

went on for a while, and Burke testified that unidentified officers “in the vicinity” should have seen and heard Pulera, 

too. After about an hour, though, an officer took Burke out of 

his holding cell and booked him into the facility proper. Burke 

told the officer who transferred him, as well as one or two others, that he was concerned about Pulera hurting himself. Each

brushed Burke off and, a few hours later, he left the facility.

Meanwhile, Pulera stayed in his holding cell. Although 

Sarzant had reported that Pulera was cooperative, if intoxicated, at 2 AM, he started to become more disruptive. By 

5 AM, he was standing on a bench, pounding the door, and 

shouting. Based on this behavior—which Pulera explained 

was because he was cold and wanted a jacket—Sarzant held 

off on booking him and, near the end of her shift, prepared a 

report explaining why. Sarzant wrote that she saw no evidence Pulera was suicidal, just combative and possibly still 

intoxicated. Zawilla reviewed this report, too, and Pulera 

does not dispute the accuracy of its contents either.

After the shift change, Shane Gerber began the booking

process. He screened Pulera using a standard form with medical and mental health questions and wrote down that Pulera’s mother had died a month ago (but not that she had committed suicide) and that Pulera was prescribed medications.

Pulera testified that he may have told Gerber of his mother’s 

cause of death and that his brother had also committed suicide about a year before. The rest of the form Pulera thought 
4 No. 19-2291

accurate. It reflects that Gerber saw no behavior suggesting a 

risk of suicide, and that Pulera answered “no” when asked 

whether he had ever contemplated or was presently contemplating suicide and to a battery of questions reflecting possible suicide risk factors.

Gerber also checked the facility's database for a “mental 

health special instruction” connected to Pulera but found 

none. This procedure resulted from a 2011 policy change to 

reduce the risk of inmate suicides after a string of attempts at 

the facility. The facility’s database includes an instruction in 

the file of any arrestee who its officials had previously placed

on “level one” suicide watch (the more restrictive and protective of the two levels the facility recognized). If a booking officer saw the instruction, he had to alert a supervisor, who 

would then perform a second, more thorough mental health

risk assessment. During a prior stint at the facility in 2011, a 

crisis worker had placed Pulera on suicide watch after he told 

a nurse that he felt “really depressed” and his “mind was 

mess[ed] up” after his brother’s suicide. The parties agree that 

the worker ordered only the less restrictive level two watch, 

however, so Pulera’s file did not contain a special instruction

in 2012. Without the instruction, the facility’s policy required 

Gerber to order the additional risk assessment only if Pulera 

showed signs of contemplating suicide or had three risk factors. The death of a family member was one such factor, but 

Gerber found no others, so he placed Pulera in general population without requesting a second look.
No. 19-2291 5

B. Medical Requests

Over the course of his day and a half in general population, Pulera submitted three inmate medical requests relating 

to his prescription medications—clonazepam and tramadol. 

Clonazepam is a benzodiazepine that Pulera was apparently 

prescribed for anti-anxiety purposes. Tramadol is an opioid

pain-reliever that he used to treat chronic pain from a back 

injury. 

Pulera submitted his first request a few hours after booking, around noon on Saturday. Cleaned of spelling errors, it 

said “I need my clonazepam and tramadol. My family is 

dropping them off. For my pain, anxiety, and depression.” At 

around 4:30, Nurse Erica Rea responded, telling Pulera that

he was under the care of the jail doctor and that she would 

notify the doctor after his family dropped off the medications.

As it turns out, Pulera’s brother, William, had brought the 

prescriptions earlier that afternoon, and Rea reviewed them 

minutes after responding to the request. She saw that Pulera

had refilled his prescription the day before, so he should have 

used just a couple of doses. Instead, the bottles contained only 

34 out of the expected 60 clonazepam tablets, and 81 out of 

120 tramadol tablets. She never asked, and no one ever discovered, where the missing pills went.

A half hour later, Rea called Dr. Karen Butler, the facility’s 

medical director, who worked remotely except on Tuesdays.

Rea reported the missing pills and asked whether she should 

distribute Pulera’s prescriptions while he was in the jail. 

Dr. Butler declined to set up a regimen at that time and Rea 

noted that order in Pulera’s chart. Testifying at her deposition, 

Dr. Butler explained that she made this decision based on the 
6 No. 19-2291

missing pills, which she believed might be a sign of abuse and 

could have made further dosages dangerous. Neither Dr. Butler nor Rea recorded these thoughts in the medical record.

Nevertheless, the jail’s written policy supported her decision;

it states, as a default rule, that non-compliant medications 

would not be continued while in custody.

That evening, at around 8 PM, Pulera sent his second request. Clarified, it read “My heart hurts. I can’t breathe. I need 

my meds or I can die. My heart is pounding. They are here, I 

need you to please bring me my meds ASAP. Thank you.”

Rea’s shift had ended, so Nurse Denise Gilanyi received 

this request instead. She called a correctional officer to check 

on Pulera around 9 PM, and the officer said that Pulera was 

in no distress: he just wanted his medications. Gilanyi knew 

that Dr. Butler had decided not to set up the medications just 

hours before, and that neither prescription was “lifesaving,” 

so she did nothing further. Near the end of her shift, at 5:55 

AM, she wrote back to Pulera that the doctor had not set up 

any medications.

Pulera sent the third and final request on Sunday afternoon. This one—again cleaned up—said, “I can’t eat, sleep. I 

am throwing up and I am dizzy. I can’t breathe. I need my 

blood pressure taken. Please see me. My brother and mother 

just died. I need my clonazepam. I am sick.” Within minutes, 

the nurse on duty, Markella Reed, responded, telling Pulera 

someone would check his blood pressure. Reed testified that 

she based this immediate response on her guess that Dr. Butler would order a blood pressure check, once they talked.

Reed further testified that between receiving the request 

and responding, she, like Gilanyi, had called a correctional 
No. 19-2291 7

officer. This officer reported that Pulera was complaining he 

had a cold, walking around, making phone calls, and asking 

for a TV remote. Unlike Gilanyi, though, Reed did not add 

this conversation to the chart when it happened. Instead, she 

wrote it in a late entry the next day, after Pulera’s suicide attempt.

When Reed called Dr. Butler, a few hours later, her prediction proved accurate. Dr. Butler ordered a vitals check, both 

to confirm Pulera’s health and to get him face-to-face with a 

nurse. She asked that the nurse call her if anything abnormal 

came up. Reed added the doctor’s new order to the chart.

At 6 PM, Reed left, and Nurse Sylvia Summers-Sgroi 

started her night shift. On reviewing the chart, SummersSgroi saw the order to take Pulera's vitals and to call Dr. Butler if anything was wrong. Around 8 PM, she met Pulera in a 

small room outside his cell block. She tested and recorded his 

blood pressure, pulse, respiration rate, blood oxygen level, 

and temperature. His results were not abnormal, indeed, they 

were excellent, and she saw nothing else concerning, so she 

did not call Dr. Butler. Although they disagree on the length 

of their meeting (Pulera said it lasted only a minute), both Pulera and Summers-Sgroi agree that he did not mention any 

concerns he had, let alone suicidal thoughts.

C. Suicide Attempt

Sometime around 1:45 AM on Monday, April 23, Pulera 

attempted to hang himself with his bed sheets.

That night, Officer Bruce Clemens checked the cells every 

thirty minutes. He passed through Pulera’s block at 1:35 AM 

and noticed nothing amiss. Ten minutes later, Clemens and 

another correctional officer, Duane Corso were talking in a 
8 No. 19-2291

hallway next to the block when they heard an inmate yell

“someone’s hanging.”

Upon hearing the yell, Corso immediately started toward 

Pulera’s cell door. Clemens meanwhile ran to the guard station, which contained the controls for the cell and hall doors. 

He sent out a radio alert, and Corporal Darron Newton responded in about thirty seconds. Clemens handed Newton an 

emergency knife and opened the hall door, so Newton could 

join Corso, who was awaiting back-up outside Pulera’s cell,

as he was trained not to enter cells alone.

Once Newton made it to Pulera’s cell with the knife in 

hand, Clemens opened the cell door for the two of them. 

Corso held Pulera up while Newton cut the bedsheet down.

After Pulera was on the ground, someone called for an ambulance at around 1:50 AM.

Summers-Sgroi was still on duty, so she was the first medical responder. She recalled hearing the radio alert at 1:47 and

arrived around 1:50, after Pulera was on the ground. Once she 

arrived at the cell, she began treating him with an oxygen 

mask. His vitals improved, but he remained unresponsive,

and his eyes unfocused, so she continued to apply oxygen until the ambulance arrived at 1:57. By the time the sheriff’s department got to the facility at 2:04, Pulera was already on his 

way to the hospital.

Pulera suspects that he decided to attempt to kill himself 

sometime after the last medication delivery of the night, when 

he realized that they were still not giving him his prescriptions. He testified that he was stressed, felt like he was going 
No. 19-2291 9

to die because his heart was pounding, and kept envisioning 

his deceased mother and brother. He thinks he may have had 

withdrawal from “benzos.” Other than through the medical 

requests, he did not recall passing any of this information on 

to facility officials or to his family.

William testified differently. He said that starting after he 

dropped off the medicine, Pulera frequently called saying that 

he had not received his prescriptions and was going to hurt

or kill himself. Throughout the entire weekend, William explained, he called the facility repeatedly, trying to pass this 

information on. Though William had no idea when he called

the facility or with whom he spoke, Summers-Sgroi admitted 

she had received one of his calls. Well after Pulera’s suicide

attempt, she wrote in a late entry that William had called demanding that Pulera get his clonazepam, but she transferred 

the call to a correctional officer when William started yelling. 

D. Procedural Background

Pulera eventually brought this suit under 42 U.S.C. § 1983 

and state law against all the above-named officials, as well as 

the private company that employed the nurses, Visiting 

Nurses Community Care, Inc. (VNCC), and Kenosha County.

The county’s federal liability was premised on Monell v. Department of Social Services, 436 U.S. 658 (1978). Under circuit 

precedent, so was VNCC’s. See Iskander v. Vill. of Forest Park, 

690 F.2d 126, 128 (7th Cir. 1982). (Pulera named even more 

defendants in the district court but has abandoned those 

claims on appeal.)

Pulera’s expert on medical issues was Dr. Thomas White, 

Ph.D. Dr. White opined that the nurses’ and Dr. Butler’s 
10 No. 19-2291

indifference to Pulera caused his suicide attempt. As a clinical 

psychologist, Dr. White had no expertise on medication and 

lacked the authority even to prescribe drugs. He, therefore,

admitted he could not support a theory that, had Pulera received his prescriptions, he would not have attempted suicide. Instead, Dr. White contended that the lack of a face-toface interview with a nurse or mental health worker was a 

possible factor in Pulera's attempt, although Pulera could 

have also decided to hang himself minutes before he tried. Dr. 

White also denied any link between withdrawal and suicide 

and, although lacking expertise in the area, he did not think

there was evidence that Pulera had suffered withdrawal anyway. 

The district court ultimately entered summary judgment 

for all defendants over the course of two orders. As an initial 

matter, the court concluded that Pulera was in the facility as 

an arrestee because he had not yet had a probable cause hearing on his suspected bail jumping. (A magistrate confirmed 

probable cause existed for Pulera’s arrest only the morning 

after his attempt.) Accordingly, it applied a Fourth Amendment objective reasonableness standard to the defendant’s actions, and not an Eighth or Fourteenth Amendment standard 

as would apply to convicted criminals or those detained after 

a probable cause hearing, respectively.

The court first granted Dr. Butler’s motion. She had unsuccessfully argued for an Eighth Amendment standard, but the 

court concluded that even under the Fourth Amendment,

there was no genuine dispute that her actions were objectively 

reasonable. Given the possible risk of overdose, the court determined that Dr. Butler had rationally withheld the 
No. 19-2291 11

medications and awaited specific reports of symptoms before 

deciding whether to treat Pulera for withdrawal.

The court subsequently entered summary judgment for 

the remaining defendants. The non-medical defendants contended that a Fourteenth Amendment due process standard 

applied, but the district court stuck with its Fourth Amendment reasoning. It determined there was no evidence to show 

Sarzant heard Pulera’s comments to Burke, Gerber overlooked present signs of Pulera’s intent to harm himself, the 

county’s booking policies were constitutionally deficient, or 

Zawilla did anything other than supervise. The court further 

concluded that Rea properly deferred to Dr. Butler, Gilanyi

and Reed permissibly relied on officers’ reports to assess Pulera’s complaints of physical discomfort, and Summers-Sgroi 

rationally discounted William’s phone call, as Pulera never reported suicidal thoughts to anyone at the facility. Because no 

nurse’s actions were unreasonable in violation of the Fourth 

Amendment, the court recognized that VNCC and the 

county’s policies could not have caused a constitutional violation for Monell purposes. Finally, the court ruled that the response defendants reasonably awaited back-up, which arrived within a minute or two, before they entered Pulera’s cell 

and cut him down.

The court relinquished supplemental jurisdiction over the 

remaining state-law claims, and Pulera appealed.

II. Discussion

We review the entry of summary judgment de novo. Yeatts 

v. Zimmer Biomet Holdings, Inc., 940 F.3d 354, 358 (7th Cir. 

2019). At summary judgment, the nonmovant plaintiff must

provide evidence that, when viewed in the light most 
12 No. 19-2291

favorable to him, suffices to prove every element of his claim 

for which he bears the burden of proof. Id. If the plaintiff fails 

to show at least a triable issue on each element, summary 

judgment is properly entered for the defendants. Burton v. 

Kohn Law Firm, S.C., 934 F.3d 572, 579 (7th Cir. 2019).

As an initial matter, the parties differ on the proper standard that governs Pulera’s claims—the Fourth or the Fourteenth Amendment. For those suspected of crimes, we have 

drawn the line between the two standards at the probable 

cause hearing mandated by Gerstein v. Pugh, 420 U.S. 103 

(1975), and ordinarily held within 48 hours of a warrantless 

arrest, Cty. of Riverside v. McLaughlin, 500 U.S. 44 (1991). See 

Lopez v. City of Chicago, 464 F.3d 711, 719 (7th Cir. 2006). Before 

a finding of probable cause, the Fourth Amendment protects 

an arrestee; after such a finding, the Fourteenth Amendment 

protects a pretrial detainee. Currie v. Chhabra, 728 F.3d 626, 

629–30 (7th Cir. 2013).1

Pulera maintains that he was an arrestee subject to the 

Fourth Amendment. In the non-medical defendants’ contrary 

view, Pulera was properly classified as a pretrial detainee.

Although a judge conducted a Gerstein hearing for Pulera’s 

bail jumping charge the day after his suicide attempt, they argue that another judge found probable cause to arrest him for 

1 We have recognized that our distinction between pre- and post-hearing detention may need to be revisited after the Supreme Court, in Manuel 

v. City of Joliet, 137 S. Ct. 911 (2017), rejected our similar distinction in the 

malicious-prosecution context. See Otis v. Demarasse, 886 F.3d 639, 645 n.27 

(7th Cir. 2018). Like in Otis, though, no party asks us to reconsider the 

issue, so we leave it for another day.
No. 19-2291 13

battery in 2011 and that this qualifies him as a pretrial detainee. 

At oral argument, though, the parties all agreed that the 

standards are now effectively the same for judging the adequacy of custodial medical care under either Amendment. 

Under the Fourth Amendment, an arrestee must demonstrate 

that an official’s actions were “objectively unreasonable under 

the circumstances.” Estate of Perry v. Wenzel, 872 F.3d 439, 453 

(7th Cir. 2017). This objective rule is easier for a plaintiff to 

meet than the subjective deliberate-indifference standard 

used under the Eighth Amendment. Id. For years, we also 

used the more onerous subjective approach for Fourteenth 

Amendment claims relating to conditions of pretrial detention. See, e.g., Pittman ex rel. Hamilton v. Cty. of Madison, 746 

F.3d 766, 775 (7th Cir. 2014). In 2018, however, we clarified 

that pretrial detainees’ medical-care claims are now governed 

by an “objective unreasonableness inquiry.” Miranda v. Cty. of 

Lake, 900 F.3d 335, 352 (7th Cir. 2018). Both standards, then, 

are objective, and the non-medical defendants identify no 

practical difference between them.

Accepting that concession, and without deciding whether 

the standards are identical in all respects, we see no reason to 

resolve whether Pulera was properly classified as an arrestee 

or a detainee. Either way, it was Pulera's burden to provide 

evidence that the defendants’ actions were “objectively unreasonable” and caused his injuries. Id. at 347, 352 (Fourteenth 

Amendment); Ortiz v. City of Chicago, 656 F.3d 523, 530 (7th 

Cir. 2011) (Fourth Amendment). Reasonableness, in turn,

must be determined in light of the totality of the circumstances. See McCann v. Ogle Cty., 909 F.3d 881, 886 (7th Cir. 
14 No. 19-2291

2018) (Fourteenth Amendment); Florek v. Vill. of Mundelein, 

649 F.3d 594, 600 (7th Cir. 2011) (Fourth Amendment).

For VNCC and the county, Pulera also must demonstrate 

the elements of a Monell claim. This means he must have evidence of “(1) an action pursuant to a municipal policy, (2) culpability, meaning that policymakers were deliberately indifferent to a known risk that the policy would lead to constitutional violations, and (3) causation, meaning the municipal action was the ‘moving force’ behind the constitutional injury.”

Hall v. City of Chicago, 953 F.3d 945, 950 (7th Cir. 2020) (citing 

Bd. of Comm’rs of Bryan Cty. v. Brown, 520 U.S. 397, 404–07 

(1997)).

A. Intake Defendants

Pulera first contends that Burke’s testimony created a dispute whether Sarzant was aware of his suicidal thoughts. If 

Sarzant saw what Burke did, that might be true, but she testified she did not, and no competent evidence contradicts her

testimony. All she saw was Pulera standing on a bench and

yelling (which even he says was because he was cold, not because he was suicidal) and that was some time later. Critically, 

Burke did not identify Sarzant as one of the officials “in the 

vicinity” or whom he told of Pulera’s distressed statements 

and gestures, and no other evidence places her near Pulera’s 

cell at that time. All we have is an invitation to speculate that 

because Burke could (barely) see and hear Pulera, so could 

Sarzant. Speculation of this sort is not enough for a plaintiff 

to escape summary judgment. See, e.g., King v. Hendricks Cty. 

Comm'rs, 954 F.3d 981, 985 (7th Cir. 2020).

Next, Pulera argues that Gerber violated the county’s policy by failing to review his history at the facility, recognize 
No. 19-2291 15

that a crisis worker previously had him on suicide watch, and

order a second mental health risk assessment. The county 

knew that Gerber and other booking officers ignored its special instruction policy, Pulera asserts, yet it allowed this noncompliance to persist.

One obvious flaw with these arguments is that Gerber followed the county’s policy (which went beyond just the special 

instruction that we focus on here). The policy required him to

obtain an extra risk assessment at booking if an arrestee had 

a special instruction reflecting that he previously had been on 

level one suicide watch. Gerber checked the database, but it is 

undisputed that Pulera’s history included only a level two 

watch, so he did not have a special instruction. Even if Gerber 

had ignored the policy, though, a violation of a jail policy is 

not a constitutional violation enforceable under 42 U.S.C. 

§ 1983. See, e.g., Thompson v. City of Chicago, 472 F.3d 444, 454 

(7th Cir. 2006). The only question that matters for our purposes is whether Gerber or the county violated the Fourth 

Amendment.

Pulera has failed to show a genuine dispute on that issue. 

He argues that, given his answers at booking, Gerber should

have known he was at a risk of suicide. Taking Pulera’s version of the facts, as we must, he told Gerber that his mother 

and brother had both recently committed suicide and that his 

doctor had prescribed him clonazepam for depression. These 

scant comments do not raise an issue of fact. “[N]ot every 

prisoner who shows signs of depression ... can or should be 

put on suicide watch.” Matos ex rel. Matos v. O'Sullivan, 335 

F.3d 553, 558 (7th Cir. 2003). The same goes for every arrestee 

who also has had recent family deaths. Id. Given Pulera’s express statement that he was not considering suicide and the 
16 No. 19-2291

absence of more or more significant indirect signs, no rational 

jury could find that Gerber unreasonably placed Pulera in 

general population.

Pulera’s theory against the county rests on his belief that 

Gerber did not follow the special instruction policy and that 

“ignoring a policy is the same as having no policy,” Woodward 

v. Corr. Med. Servs. of Ill., Inc., 368 F.3d 917, 929 (7th Cir. 2004). 

The county, however, had a policy aimed at preventing suicide that Gerber did not ignore; one part of the policy simply 

did not apply to Pulera. So, to succeed on his Monell claim, he

had to show that the county was deliberately indifferent to the 

risk that its polices (or a gap in them) would cause a constitutional violation. Lapre v. City of Chicago, 911 F.3d 424, 430–31

(7th Cir. 2018). He has not developed this argument by, for 

example, showing that county officials knew that formerly 

level-two arrestees were attempting suicide at heightened 

rates, and officials nevertheless made a “conscious decision 

not to act.” Walker v. Wexford Health Sources, Inc., 940 F.3d 954, 

966 (7th Cir. 2019). Certainly, the county could have expanded 

its policy to require second screenings of more arrestees, but 

the mere “existence or possibility of other better policies ... 

does not necessarily mean that the defendant was being deliberately indifferent.” Lapre, 911 F.3d at 431 (quoting Frake v. 

City of Chicago, 210 F.3d 779, 782 (7th Cir. 2000)).

The district court also properly entered summary judgment for Zawilla. He is not liable under § 1983 merely as a

supervisor, even assuming his subordinates had erred. See, 

e.g., Doe v. Purdue Univ., 928 F.3d 652, 664 (7th Cir. 2019). 

Zawilla did not have any personal contact with Pulera and 

merely reviewed reports that did not record any indications 

of suicide risk. Pulera presents no contrary argument.
No. 19-2291 17

B. Dr. Butler

Next, Pulera argues that it was unreasonable for Dr. Butler 

to deny him his prescription medications without taking 

some alternative step. If she really believed he had abused his 

medications, he suggests, she should have implemented the 

facility’s detoxification or withdrawal protocols. 

Pulera, however, falls short with the medical and causation evidence. The record contains no evidence from which a 

factfinder could infer that, had Pulera received his medications, he would not have attempted suicide. His own expert 

denied such a theory. Dr. Butler’s expert—Dr. Keith Ness, 

M.D.—declared in his affidavit that cutting a patient off either 

clonazepam or tramadol, even “cold turkey,” was not known 

to make that patient suicidal, whereas giving either drug to 

someone who had consumed them in excess within the past 

few days could have been dangerous. Pulera offered nothing 

to rebut this medical opinion.

Dr. Butler made a reasonable decision on imperfect information. She knew only that many of Pulera’s pills were missing. Putting aside the facility’s policy directing her not to set 

up his medications in this situation, there was at least some

chance that he had taken those pills and giving him more 

could have been harmful, even deadly. Between the option 

with some risk of death and the option with no apparent risk 

(according to the only medical evidence in the record), Dr.

Butler chose the latter. That choice was objectively reasonable 

as a matter of law, regardless of whether Pulera had, in fact,

abused his medications.

A jury could not infer that depriving Pulera of his medications might be deadly from the mere fact that a physician had 
18 No. 19-2291

prescribed them to him. Pulera insists a prescription is evidence of a “serious medical need.” See Gutierrez v. Peters, 111 

F.3d 1364, 1373 (7th Cir. 1997) (defining term to include a need 

“that has been diagnosed by a physician as mandating treatment”). Whether a medical need is serious, though, is just a 

threshold requirement before the state has a duty under the 

Eighth Amendment to provide medical care to a prisoner. Id.

at 1369, 1372. We have held that there is no such threshold 

under the Fourth Amendment, as the “reasonableness analysis operates on a sliding scale, balancing the seriousness of the 

medical need with the third factor—the scope of the requested treatment.” Williams v. Rodriguez, 509 F.3d 392, 403 

(7th Cir. 2007).

From what Dr. Butler and the nurses knew, Pulera’s need

for his medications was not serious relative to the risks of his 

receiving them. Pulera likens his situation to that of a diabetic 

deprived of insulin. Egebergh v. Nicholson, 272 F.3d 925, 928

(7th Cir. 2001). But a diabetic needs insulin to live. No evidence suggest that Pulera depended on his medications to 

stay alive; he needed them only to treat his pain and anxiety.

Undoubtedly, a jury could infer that the defendants knew 

Pulera might become anxious or suffer chronic pain without 

his medications, but he points to nothing that would inform

them that this anxiety or pain might lead him to attempt suicide or otherwise cause harm comparable to a risk of overdose. His reliance on Gil v. Reed, 381 F.3d 649 (7th Cir. 2004), 

is misplaced. We held in Gil that a jury could infer a prison 

doctor’s deliberate indifference when a specialist prescribed 

certain medications noting the risks of alternative treatments, 
No. 19-2291 19

the doctor ignored that warning, and the prisoner suffered as 

predicted. Id. at 662–64. If Pulera’s primary care physician 

prescribed him clonazepam and tramadol because he was 

known to be suicidal without them, that fact is missing from

the record. Based on the evidence that is in the record and of 

which she was made aware, Dr. Butler reasonably concluded

the only foreseeable risk of depriving Pulera of his prescriptions was a few days’ discomfort—a small price to pay compared to even a low chance of overdose. All four nurses were 

entitled to defer to Dr. Butler’s medical judgment weighing 

the costs and benefits of these two choices. See McCann, 909 

F.3d at 887 (affirming summary judgment for nurse who deferred to doctor’s prescription that led to overdose).

Pulera makes much of the fact that Dr. Butler never implemented a withdrawal or detoxification protocol, despite her 

asserted belief that he was abusing his medications. But, as 

Pulera himself emphasizes, Dr. Butler knew only that it was 

possible that Pulera had abused his medications. We agree 

with the district court that Dr. Butler could reasonably have 

awaited a nurse or correctional officer’s report of concrete 

symptoms before making further treatment decisions. When 

Nurse Reed did report symptoms, on Sunday evening, Dr. 

Butler asked that someone check Pulera’s vitals and call her if 

any abnormalities arose. She heard nothing back, so it was 

reasonable for her to infer (correctly) that all objective signs 

showed Pulera was fine and not suffering withdrawal. She 

never had the opportunity to take this new information into 

account and reassess Pulera’s medication regimen because of 

his attempt a few hours later.
20 No. 19-2291

C. The Nurse Defendants

Moving on to the individual nurses’ actions, we agree with 

the district court that Nurse Rea reasonably responded to Pulera’s first medical request, which did not give her notice of 

any serious problems, let alone a risk of suicide. Pulera simply 

asked that she deliver his medications “for [his] pain, anxiety, 

and depression.” He did not even mention symptoms. Indeed, contrary to Pulera’s argument, he did not say he was 

depressed, only that the pills were for depression. Any rational 

factfinder would see this message the way Rea did: as a simple request for medicine. She reasonably responded to that request by telling Pulera he would receive his medications, if 

Dr. Butler approved them. She then gave Dr. Butler all the information necessary to decide not to approve them. 

The request that Pulera sent to Nurse Gilanyi did include 

symptoms—physical symptoms. Pulera complained that his 

heart was pounding and hurt, that he could not breathe, and 

that he needed his medications or he could die. That Pulera 

was concerned about dying, or even that he might have been 

having an anxiety attack, did not put Gilanyi on notice that he

might be contemplating suicide. The request signaled that he 

feared dying not from self-harm, but from a heart attack or 

lack of oxygen. A correctional officer was qualified to confirm 

that Pulera was, in fact, breathing and not apparently in cardiac arrest, so it was reasonable for Gilanyi to ask one to do 

so and rely on his assessment. Like in Florek, 649 F.3d at 600, 

summary judgment was proper because Pulera’s “outward 

appearance did not put officers on notice” of his condition despite his complaints of serious symptoms. (And unlike Florek,

who did suffer a heart attack, there is no evidence those 
No. 19-2291 21

serious symptoms ever manifested.) With the officer’s confirmation that Pulera was fine and just wanted his medications, 

Gilanyi appropriately responded that the doctor had not prescribed them. The Fourth Amendment requires that arrestees 

receive reasonable care, not specific care, no matter how many 

times they ask. Id. at 600–01 (citing Jackson v. Kotter, 541 F.3d 

688, 697 (7th Cir. 2008)); see also Williams v. Ortiz, 937 F.3d 936, 

944 (7th Cir. 2019) (same under Fourteenth Amendment).

Pulera resists the comparison to Florek and instead bases 

his argument on Belbachir v. Cty. of McHenry, 726 F.3d 975 (7th 

Cir. 2013). We recognized in Belbachir that “[a] severely depressed person who has hallucinations, acute anxiety, and 

feelings of hopelessness and helplessness and who cries continually, talks incessantly of death, and is diagnosed as suicidal, is in obvious danger.” Id. at 982. Pulera’s request, 

though, did not put Gilanyi on notice of any of these facts or 

anything similar. At most, one might be able to infer she had 

notice that Pulera was suffering “acute anxiety,” but we affirmed summary judgment for the nurse who knew only of 

Belbachir’s anxiety and panic attacks and not her other issues.

Just like that nurse, Gilanyi was not even negligently responsible for a suicide risk that Pulera never told her about. Id.

Regarding Nurse Reed, Pulera argues that her calling a 

correctional officer to check on him was an unreasonable response to his third medical request. Just like the second,

though, Pulera’s most pressing assertion was that he could 

not breathe. A call to a correctional officer to physically check 
22 No. 19-2291

on him was one reasonable way for Reed to confirm that Pulera was not in immediate danger.2

Pulera’s third request admittedly went further than his 

second and mentioned other symptoms—he was vomiting, 

dizzy, and just generally sick—but Nurse Reed, too, went further than relying on the correctional officers’ report. She informed Pulera that someone would check his blood pressure

and called Dr. Butler, who expanded it to a full vitals check. 

This was a reasonable response to Pulera’s remaining complaints, which while certainly worthy of investigation, were 

not an apparent emergency. Cf. Gayton v. McCoy, 593 F.3d 610, 

621 (7th Cir. 2010) (noting that “[v]omiting, in and of itself, is 

not an uncommon result of being mildly ill, and, absent other 

circumstances ... does not amount to an objectively serious 

medical condition” under the Eighth Amendment). At the vitals check, Pulera would be face-to-face with a nurse who 

could see his symptoms and hear anything he had to say.

When Nurse Summers-Sgroi performed the check, she 

saw nothing wrong and Pulera admits he never said a thing 

about other symptoms or suicidal thoughts. Pulera bases his 

claim against her on his brother William’s phone call. Summers-Sgroi contends that this call did not give her notice of a 

risk of suicide because all she heard was yelling about 

clonazepam before she transferred the call. William, though, 

2 Although the timeline surrounding this call to the correctional officer 

is jumbled, Pulera does not develop an argument that Reed did not in fact 

call the officer. Even if he disputed whether she had, though, Pulera would 

still have a problem with causation. A delayed response to Pulera’s reported symptoms might be concerning, but there is no evidence that Pulera’s injuries resulted from those symptoms.
No. 19-2291 23

disputed this story; he says he told whoever he spoke with 

that Pulera was suicidal and never admitted yelling. That this 

call came from an outside source does not “refute the receipt 

of notice.” Ortiz, 656 F.3d at 533. 

Still, even under Pulera’s version of the facts, it was not

objectively unreasonable for Summers-Sgroi to discount the 

call. Though no one knows whether she received the call before or after the vitals check (or even Pulera’s attempt), at best 

she had either just seen Pulera or was just about to see him.

When confronted with a healthy patient who mentioned no 

problems and an outside caller saying the patient was distraught, a reasonable nurse could believe her own observations over the phone call. Indeed, that is precisely what we 

suggested the defendant who answered the phones in Ortiz

should have done, given a jail’s understandable hesitance to 

accept medical requests from outside sources. Id. at 529. Summers-Sgroi saw Pulera and observed no reason whatsoever to 

believe Pulera was suicidal—Pulera admits he did not tell her 

he was suicidal and does not contest her determination that 

his vitals were “excellent.” Under these circumstances, it was 

not unreasonable for her to take no special precautions 

against his attempted suicide.

Because Pulera’s individual claims against the nurses fail, 

so too must his Monell claims against VNCC and the county.

Although individual liability is not always a prerequisite for 

municipal liability, see Glisson v. Ind. Dep't of Corr., 849 F.3d 

372, 378 (7th Cir. 2017) (en banc), Pulera argues only that the 

facility inadequately trained its nurses and had a de facto policy permitting them to delegate all their duties to correctional 

officers. Even assuming Pulera could prove the training inadequate or the lax policy unconstitutional, he cannot show 
24 No. 19-2291

causation. See id. at 379 (“The central question is always 

whether an official policy, however expressed ... caused the 

constitutional deprivation.”). The nurses acted appropriately 

under the circumstances, both generally and to the extent they 

relied on correctional officers, so their alleged lack of training 

and overreliance on officers could not have caused Pulera’s 

injuries. See City of Los Angeles v. Heller, 475 U.S. 796, 799 (1986)

(per curiam) (“If a person has suffered no constitutional injury 

... the fact that the departmental regulations might have authorized the use of constitutionally excessive force is quite beside the point.”).

D. Response Defendants

Finally, Pulera contends that the district court erred in entering summary judgment for officers Clemens, Corso, and 

Newton. In his view, the officers violated his rights when they 

wasted seconds waiting for back-up before entering his cell, 

cutting him down, and calling an ambulance.

No rational jury could agree with Pulera's hindsight-laden 

assessment of the officers’ actions. “The Fourth Amendment 

requires reasonableness, not immediacy.” Sallenger v. City of 

Springfield, 630 F.3d 499, 504 (7th Cir. 2010). Even with the delays Pulera criticizes, it is undisputed that the officers sprang 

into action, had the pressure off his neck in less than two 

minutes, and summoned an ambulance in less than five, by 

which time Summers-Sgroi was already providing emergency treatment. Perhaps the officers could have acted faster, 

but the Constitution does not demand perfection. See id.; see 

also Florek, 649 F.3d at 600 (“[T]he Fourth Amendment reasonableness inquiry necessarily takes into account the sufficiency 

of the steps that officers did take”). Nor does it demand that 

a correctional officer enter a potentially dangerous situation 
No. 19-2291 25

before back-up can arrive. Giles v. Tobeck, 895 F.3d 510, 514

(7th Cir. 2018) (per curiam). Under the totality of the chaotic 

circumstances, the officers’ swift actions were indisputably 

reasonable and preclude a finding that they violated Pulera’s 

constitutional rights.

III. Conclusion

It is unfortunate that Pulera attempted to kill himself and 

fortunate that he did not succeed. That a tragedy almost happened under the watch of jail officers, though, does not mean

the officers are responsible. All that one can expect—and all 

the Constitution demands—is that officials respond reasonably to the situation presented. Because there is no genuine dispute that all the defendants here did so, we AFFIRM the judgment of the district court.v