In the

United States Court of Appeals

For the Seventh Circuit

No. 17-3024

VERTULIE LAPRE, Administrator of the

Estate of Okoi Ofem,

Plaintiff-Appellant,

v.

CITY OF CHICAGO,

Defendant-Appellee.

Appeal from the United States District Court for the 

Northern District of Illinois, Eastern Division.

No. 1:15-cv-03199 — Virginia M. Kendall, Judge.

ARGUED SEPTEMBER 12, 2018 — DECIDED DECEMBER 17, 2018

Before EASTERBROOK, ROVNER, and HAMILTON, Circuit

Judges.

ROVNER, Circuit Judge. Okoi Ofem committed suicide in a

jail cell at a City of Chicago lockup. His mother, Vertulie Lapre,

sued the City under 42 U.S.C. § 1983, for failing to prevent her

son’s death. Because Lapre lacks evidence that the City was
2 No. 17-3024

deliberately indifferent to the risk of suicide for detainees held

in City lockups and also cannot show that the City’s policies

and practices were the cause of Ofem’s death, we affirm the

district court’s grant of summary judgment in favor of the City.

I.

Chicago police officers arrested eighteen-year-old Okoi

Ofem on a misdemeanor assault charge on September 12, 2013,

and took him to the City’s 4th District Police Station. After

processing, Ofem arrived at the 4th District Lockup (“Lockup”)

at approximately 3:30 p.m., roughly two hours after his arrest.

A Chicago police officer and two detention aides were on duty

at the Lockup. Pursuant to City policy, detention aide William

Zaremba conducted a visual inspection of Ofem and asked him

a series of screening questions, marking his responses on a

processing report. From the visual inspection, Zaremba noted

on the report that Ofem displayed no signs of pain, injury, or

infection; he did not appear to be under the influence of drugs

or alcohol or showing signs of withdrawal; he did not seem to

be despondent or irrational, and was not carrying medication.

Zaremba recorded a “No” in response to every screening

question, including whether Ofem was taking any medication,

whether this was his first arrest, whether he had ever attempted suicide or serious harm, whether he had serious

medical or mental problems, whether he was receiving any

treatment, and whether he was “transgender/intersex/gender

non-conforming.” Ofem refused to list an emergency contact,

and appeared to be “miffed” or angry about the charge, but

did not appear depressed. Zaremba took Ofem’s shoelaces, belt

and keys and placed him in a one-person cell. Ofem declined

all offers of food that day.
No. 17-3024 3

The next morning, one of the assigned detention aides for

the Lockup did not show up to work. At 6 a.m., Officer James

Carrillo was assigned to take the place of the missing aide.

Carrillo’s regular assignment was that of paper review officer.

He had received no specific training as a lockup keeper but he

occasionally filled in when the need arose. Another assigned

aide, Dennis Graham, began the shift but left at approximately

8 a.m. to attend a meeting. Early that morning, Ofem was taken

to the criminal court. Ofem arrived back at the Lockup at 10

a.m., an unexpected and unusually early return. During the

ride back to the Lockup, Ofem did not inform the transport

officers that he was suicidal or contemplating self-harm.

Carrillo received Ofem back into the Lockup, and was the only

person on duty at that time. Ofem appeared surprised and

confused about what had happened at court, and asked

Carrillo what was happening. Carrillo replied that Ofem had

likely been sent to the wrong court—one that handled felony

charges—and that he would have to go instead to another

court that handled misdemeanor charges. Carrillo thought that

Ofem appeared tired and Ofem again declined all offers of

food. Ofem did not inform Carrillo or any other officer that he

was contemplating suicide or self-harm. He was again placed

in a one-person cell, and there were no other detainees in the

Lockup at that time.

Between his 10:00 a.m. return and 1:00 p.m., someone at the

jail visually inspected Ofem every fifteen minutes, sometimes

in person and sometimes via a poor-quality video monitor. The

District Station Supervisor also conducted a walk-through at

11:30 a.m. At 12:45 p.m., Carrillo and detention aide Graham

(who had apparently returned from his meeting) checked on
4 No. 17-3024

Ofem in person. At 1:00 p.m., Carrillo checked on Ofem

through the video monitor and did not notice anything amiss.

At 1:10 p.m., Carrillo glanced at the video monitor and saw

Ofem hanging from a horizontal bar in his cell. Carrillo and

Graham immediately went to the cell, which was approximately fifteen feet away on the other side of a door, and saw

that Ofem had used his jeans to hang himself. He had tied the

jeans to the cell in such a way that the officers had difficulty

opening the cell door. Graham used a pocket knife to cut

through the jeans and Carrillo forced the door open. At the

same time, Officer James Mangan ran to call for medical

assistance. Once they removed the pants from Ofem’s neck, he

let out a groan. Carrillo attempted to rouse Ofem by calling to

him, slapping him and shaking him. When Ofem did not

respond, Carrillo administered chest compressions. Paramedics arrived and took over from Carrillo. Ofem was transported

to a hospital where he died the following day. 

At the time of Ofem’s incarceration and death, City lockup

facilities operated under “Special Order S06-01-02,” a directive

from the Superintendent of Police outlining the responsibilities

of lockup personnel “to ensure arrestees are properly processed, booked, and safeguarded.” R. 120–25 (hereafter

“Special Order”). The Special Order specified, in relevant part,

that lockup personnel will:

7. prior to accepting any arrestee, conduct an initial

inspection of the subject following the Guidelines
No. 17-3024 5

for Arrestee Screening and Monitoring chart (CPD11.523).1

8. if screening process indicates that the arrestee is

perceived to be mentally/chemically impaired or

suicidal, the station supervisor will be notified

immediately.

9. not accept any arrestee into the lockup who has

injuries or illnesses that may require hospitalization

or the immediate attention of a healthcare professional.

1

 The Guidelines for Arrestee Screening and Monitoring is a color chart

that, under City policy, is to be posted in the arrestee processing area of

each facility, among other places. It contains four columns for evaluating

arrestees: “SICK/INJURED/EMOTIONAL RISK;” “INTOXICATED/

IMPAIRED/PREGNANT;” “INFECTION/COMMUNICABLE DISEASES;”

and “NO SIGNS OF DISTRESS.” Under the first column, a section titled, “Is

arrestee suicidal?” lists warning signs: “Express Desire or Intent to Harm

Self or Others;” “Actual Self Harm/Suicide Attempt;” “Hyperactive/Extremely Agitated;” and “Intense Guilt/Remorse.” Another section

of the same column advises officers to assess whether the arrestee is

irrational or delusional, cannot follow simple commands, is disoriented or

hallucinating, or is unaware of his or her surroundings. For all parts of the

first column, affirmative answers require notifying the District Station

Supervisor and sending the arrestee to the nearest approved hospital or

mental health intake facility. Although there are multiple references to this

chart in the record, the chart itself does not appear to be part of the record,

and so we provide this information for background purposes only. A

version last revised in May 2013 can be accessed through https://home.

chicagopolice.org/inside-the-cpd/department-directives-system/ (last visited

December 4, 2018). 
6 No. 17-3024

13. complete the intake screening questions process

following the Guidelines for Arrestee Screening and

Monitoring chart.

15. in those instances in which an arrestee responds

“yes” to the arrestee questions of “attempted

suicide/serious harm,” check the corresponding box

in the Additional Lockup Demographics/Cautionary

Descriptors field.

16. in those instances during the visual check of the

arrestee they determine/categorize the arrestee to be

despondent, check the corresponding box in the

Additional Lockup Demographic/Cautionary

Descriptors field.

18. in those instances in which the subject arrestee

has been identified as a present or prior danger to

themselves (i.e. attempt suicide, caused harm to self,

despondent), place the subject in a cell closest to the

lockup keeper and will place another arrestee in the

cell with the subject arrestee.

23. complete a visual check of each arrestee every 15

minutes following the Guidelines for Arrestee

Screening and Monitoring chart and record the time

of each inspection, a concise statement of conditions

found, notable occurrences, actions take[n], if any,

and the initials and employee identification number

on the Inspection Log.

R.120–25 (emphasis in original). The Special Order also

requires the Station Supervisor to inspect the lockup and the
No. 17-3024 7

arrestees at the start of his or her tour, and, at a minimum,

conduct at least four thorough inspections of the lockup and

the arrestees per tour. Station Supervisors are also charged

with immediately evaluating any arrestees who exhibit signs

of being mentally or chemically impaired or suicidal, and

taking appropriate action. R. 120–25. The State of Illinois also

enacted jail and lockup standards (“Illinois Lockup Standards”) that were in effect at the time of Ofem’s death, including requirements to personally inspect detainees at least every

thirty minutes. 

Vertulie Lapre, Ofem’s mother and the administrator of his

estate, sued the City and several individual officers and

detention aides pursuant to 42 U.S.C. § 1983, alleging that the

City and these individuals were responsible for Ofem’s death

in custody. The claims against the individuals were dismissed

with prejudice and the City sought summary judgment on the

only claim remaining, Count III of the First Amended Complaint. That count alleged that the City was liable for Ofem’s

death under Monell v. Dep’t of Social Servs. of City of New York,

436 U.S. 658 (1978), because the City’s policies, practices and

customs led to Ofem’s death. 

Lapre originally asserted twelve policies (we will use

“policies” as shorthand for “policies, practices and customs”)

or gaps in policies as leading to Ofem’s death, but at the

summary judgment stage, the parties and the district court

focused on five specific policies or gaps. The district court

granted summary judgment in favor of the City, largely

because Lapre failed to present evidence of constitutionally

inadequate City-wide policies and because she could not
8 No. 17-3024

demonstrate that the City’s policies caused a deprivation of

Ofem’s federal rights. Lapre appeals.

II.

On appeal, Lapre contends that the City’s policies regarding detainees were deliberately indifferent to the risk of suicide

and were the “moving force” behind Ofem’s suicide. She faults

the City for not implementing policy changes that the City

knew would prevent suicides, and would have prevented

Ofem’s suicide. She contends that the district court improperly

ignored disputed facts and inappropriately resolved certain

fact disputes in favor of the defendants, viewing the evidence

in a light most favorable to the City. We review the district

court’s grant of summary judgment de novo, examining the

record in the light most favorable to Lapre and construing all

reasonable inferences from the evidence in her favor. Anderson

v. Liberty Lobby, Inc., 477 U.S. 242, 255 (1986); Yahnke v. Kane

County, Ill., 823 F.3d 1066, 1070 (7th Cir. 2016). Summary

judgment is appropriate when there are no genuine disputes

of material fact and the movant is entitled to judgment as a

matter of law. Fed.R.Civ.P. 56(a); Anderson, 477 U.S. at 256;

Yahnke, 823 F.3d at 1070. We may affirm summary judgment on

any basis we find in the record. Nature Conservancy v. Wilder

Corp. of Delaware, 656 F.3d 646, 653 (7th Cir. 2011).

A plaintiff seeking to impose liability on a municipality

under section 1983 must identify a municipal policy or custom

that caused the plaintiff’s injury. Board of Cty. Comm’rs of Bryan

Cty., Okla. v. Brown, 520 U.S. 397, 403 (1997). 

Locating a “policy” ensures that a municipality

is held liable only for those deprivations result-
No. 17-3024 9

ing from the decisions of its duly constituted

legislative body or of those officials whose acts

may fairly be said to be those of the municipality. Similarly, an act performed pursuant to a

“custom” that has not been formally approved

by an appropriate decisionmaker may fairly

subject a municipality to liability on the theory

that the relevant practice is so widespread as to

have the force of law. 

Brown, 520 U.S. at 403–04 (citations omitted). The plaintiff must

not only identify conduct properly attributable to the municipality but must also demonstrate that, “through its deliberate

conduct, the municipality was the ‘moving force’ behind the

injury alleged. That is, a plaintiff must show that the municipal

action was taken with the requisite degree of culpability and

must demonstrate a direct causal link between the municipal

action and the deprivation of federal rights.” Brown, 520 U.S.

at 404. See also Estate of Novack ex rel. Turbin v. County of Wood,

226 F.3d 525, 531 (7th Cir. 2000) (where the municipal policy is

itself unconstitutional, the constitutional injury can be said to

have been directly caused by the municipality; indirect liability

may be proved by demonstrating a series of bad acts that allow

an inference that the policymaking level of government was

aware of the problem and, by failing to do anything to remedy

it, adopted the misconduct of subordinates). Finally:

a plaintiff seeking to establish municipal liability

on the theory that a facially lawful municipal

action has led an employee to violate a plaintiff's

rights must demonstrate that the municipal

action was taken with “deliberate indifference”
10 No. 17-3024

as to its known or obvious consequences. A

showing of simple or even heightened negligence will not suffice.

Brown, 520 U.S. at 407 (citation omitted).

In certain circumstances, municipal liability may also be

established by a policy gap, by a city’s failure to have procedures in place for addressing a known risk of serious harm.

Suicide is a known risk in the custody setting, and occurs at

higher rates than in non-custodial settings. Boncher ex rel.

Boncher v. Brown Cty., 272 F.3d 484, 486 (7th Cir. 2001). For that

reason, we have remarked that “[j]ail managers who decided

to take no precautions against the possibility of inmate

suicide—to have no policy, for example no suicide-watch

option—would be guilty of deliberate indifference in the

relevant sense; they would be ignoring a known and serious

risk of death of persons under their control for whose safety

they are responsible.” Boncher, 272 F.3d at 486 (citations

omitted). But when a policy is in place, the standards detailed

above apply.

On appeal, Lapre identifies five municipal policies that she

asserts evidenced the City’s deliberate indifference towards the

risks of suicide and that were the moving force behind Ofem’s

death: “1) the policy decision to not remove horizontal bars

from the 4th District; 2) the practice of not providing first aid

to hanging victims by not training lockup personnel and not

installing suicide kits; 3) the policy of not reassessing returnees;

4) the policy and custom of not personally inspecting detainees

and leaving them isolated; and 5) the failure to properly train

personnel on detecting mental health issues and potential
No. 17-3024 11

suicide subjects.” Plaintiff-Appellant’s Brief, at 18. For each of

these policies, she argues that the district court improperly

construed the facts in favor of the defendant or ignored

evidence that she presented. Because our review is de novo, we

need not address whether the district court erred on evidentiary matters. We will independently review the record

evidence on which Lapre relies.

A.

We begin with the presence of horizontal bars at the 4th

District Lockup. The City is, in fact, aware of the risk posed by

horizontal bars in lockup cells, and this very issue has been

litigated previously. See Frake v. City of Chicago, 210 F.3d 779,

781–82 (7th Cir. 2000). Like Ofem, Frake hanged himself from

the horizontal bars of his City lockup cell using an item of

clothing that he had been allowed to keep. Frake’s father sued

the City under section 1983 for deliberate indifference to the

risk of suicide posed by the horizontal bars. At the time of

Frake’s death, City policies were similar to those in place under

the Special Order that controlled at the time of Ofem’s death.

Lockup personnel were required to visually assess arriving

detainees for signs of pain, injury, drug or alcohol intoxication,

despondency and the need for medication. They also questioned detainees about medical and mental health issues and

whether the detainee had ever attempted suicide. As is

currently required, lockup personnel also confiscated belts,

shoelaces, ties and other items that a person could use for selfharm. At the time of Frake’s death, the jailers checked the cells

every fifteen minutes and the watch commander and desk

sergeant were required to inspect the lockup twice per tour of
12 No. 17-3024

duty. Training was provided to officers for suicide awareness.

210 F.3d at 781. 

We noted in Frake that a finding of deliberate indifference

required a showing that officials were aware of a substantial

risk of serious injury to detainees but nevertheless failed to

take appropriate steps to protect detainees from that known

danger. 210 F.3d at 782. Jailers are not required to guarantee

the safety of detainees, and the “existence or possibility of

other better policies which might have been used does not

necessarily mean that the defendant was being deliberately

indifferent.” Id. We rejected the plaintiff’s contention that the

number of suicides and attempts alone could demonstrate

deliberate indifference but we also declined to endorse the

City’s argument that the relatively low rate of suicides compared to the number of arrests proved it could not be held

liable. We declined to consider the risks of the horizontal bars

in isolation, instead weighing the additional precautions taken

to reduce the risk of suicide. In light of the City’s other safeguards, we found that continued use of cells with horizontal

bars did not meet the standard for deliberate indifference. 210

F.3d at 782. 

Lapre cites Frake as evidence that the City has been well

aware of the risks posed by horizontal bars for twenty years.

She contends that, since Frake, the City does not use horizontal

bars when building new lockup facilities. She notes anecdotal

evidence from personnel at the 4th District regarding the

prevalence of continued attempted and completed suicides.

She also cites statistical evidence of the rates of suicides per

detainee, asserting that the rate has actually increased substantially since Frake. All of this, she asserts, demonstrates that the
No. 17-3024 13

continued presence of horizontal bars exhibits deliberate

indifference.

Lapre’s proposed statistical evidence suffers serious flaws.

She co-mingles suicides and suicide attempts and appears to

have no reliable information supporting her contention that the

rate of suicides has increased in the last twenty years. Nor does

she provide the metric that we have held is the most relevant

when assessing government responsibility for suicide risk:

It is not the number of suicides that is a meaningful index of suicide risk and therefore of governmental responsibility, ... but the suicide rate; ...

and it is not even the rate by itself, but rather the

rate relative to the “background” suicide rate in

the relevant free population (the population of

the area from which the jail draws its inmates)

and to the rate in other jails.

Boncher, 272 F.3d at 486–87. There is no basis on this record to

conclude that there are more suicides in City lockups now than

there were at the time of Frake, or that these are disproportionate to the suicide rate in the relevant free population. See also

Pittman v. County of Madison, Ill., 746 F.3d 766, 780 (7th Cir.

2014) (the bare fact that other inmates attempted or committed

suicide does not demonstrate that a jail’s policies were inadequate, that officials were aware of any suicide risk posed by the

policies or that officials failed to take appropriate steps to

protect the inmate). She also provides no evidence regarding

the rate of suicides in lockups that still have horizontal bars

versus the rate in the new lockups that are constructed without

horizontal bars.
14 No. 17-3024

Nor does Lapre acknowledge the other precautionary

measures that the City took to prevent the known risk of

suicide in its facilities. As we noted above, at the time of

Ofem’s death, the City had in place policies that exceeded

those in effect at the time of Frake’s death. In addition, the

City’s efforts to replace old lockup facilities with new ones that

do not employ horizontal bars is not evidence of deliberate

indifference but of deliberate efforts to remedy the situation.

That the City might have proceeded more quickly does not

mean that it was deliberately indifferent to the risk. Pittman,

746 F.3d at 780 (possibility of better policies does not necessarily mean the defendant was deliberately indifferent); Frake, 210

F.3d at 782 (same). Finally we note that Lapre’s anecdotal

evidence of events in the 4th District is insufficient to demonstrate a City-wide “practice [that] is so widespread as to have

the force of law.” Brown, 520 U.S. at 403–04. Taken as a whole,

the measures in place and the changes being made by the City

do not demonstrate deliberate indifference under Frake for the

City’s continued use of cells with horizontal bars. See also Estate

of Novack, 226 F.3d at 531 (finding no liability for an inmate

suicide where the plaintiff failed to show a pattern of suicide

at the jail from which the finder of fact could draw an inference

that the county was aware that its policies for treating mentally

ill inmates at risk for suicide were inadequate and chose to do

nothing in the face of this knowledge).

B.

We turn to Lapre’s assertion that the City has a practice of

not providing first aid to hanging victims by not training

lockup personnel and not installing “suicide kits.” She contends that a jury must decide whether the failure to provide
No. 17-3024 15

proper first aid in the first few minutes after discovering Ofem

in distress was a proximate cause of his death. Although Lapre

does not specify the contents of the suicide kits, it is apparent

from her argument that such kits would at least include a

device for cutting down a person who is hanging, and a device

to enable lockup personnel to engage in mouth-to-mouth

resuscitation. Lapre asserts that the absence of a suicide kit

caused a delay in cutting Ofem down from the bar, and that

the aid delivered thereafter was disjointed and ineffective. 

The City did not provide first aid training to lockup

personnel prior to 2012, and the officers present on the day of

Ofem’s death were arguably not trained regarding when and

how to perform CPR. Graham testified that he cut Ofem down

in a matter of seconds using a pocket knife that he carries with

him. Carrillo called out to Ofem, slapped and shook him, and

then delivered chest compressions when Ofem did not

respond. At the same time, another officer called for emergency responders, who arrived and took over the chest

compressions from Carrillo. We need not decide whether

Lapre has presented sufficient evidence to demonstrate that

this care was inadequate or inappropriate because she has

presented no evidence that the absence of a suicide kit or a lack

of training for lockup personnel proximately caused Ofem’s

death.2

2

 The American Heart Association provides science-based CPR guidelines.

For healthcare providers and trained persons, the AHA recommends

conventional CPR, which consists of repeated cycles of thirty chest

compressions and two mouth-to-mouth breaths. For the general public or

bystanders, the AHA recommends hands-only CPR, which consists of chest

(continued...)
16 No. 17-3024

On appeal, Lapre concedes that she did not present

evidence related to causation on this claim, but asserts that the

City did not mention causation when it moved for summary

judgment. Because she was not on notice that causation would

be an issue, she argues that she did not have an opportunity to

present facts from the medical examiner and from her expert

regarding causation. But the City did in fact argue in its

opening brief on summary judgment that Lapre provided no

evidence that any of the alleged City policies caused a constitutional deprivation. R. 119, at 13–14. The City repeated the point

in its reply brief. R. 131, at 9–10. Lapre was therefore on notice

that causation was at issue. 

Moreover, to recover from a municipality under section

1983, a plaintiff must demonstrate that, “through its deliberate

2

 (...continued)

compressions only. See https://cpr.heart.org/AHAECC/CPRAnd

ECC/AboutCPRECC/WhatIsCPR/UCM_499896_What-is-CPR.jsp (last

visited Nov. 30, 2018). The Mayo Clinic additionally recommends that

before beginning CPR, if the person appears unconscious, the person

rendering aid should tap or shake his or her shoulder and ask loudly, “Are

you OK?” If the person does not respond, the person rendering aid should

call for emergency services and then begin chest compressions only. See

https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 (last

visited Nov. 30, 2018). Neither site mentions the use of a device to aid

mouth-to-mouth respiration. The American Red Cross sells such devices in

order to protect the person rendering aid from disease transmission. See

https://www.redcross.org/store/cpr-keychain-with-face-shield-and-glove

s/ARC-CPR-03.html?#start=2&cgid=cpr-keychains&viewratings=true (last

visited Nov. 30, 2018). Although it is not necessary for us to decide the issue

of whether the care provided to Ofem was appropriate, it appears to have

conformed largely to guidelines provided by reputable organizations.
No. 17-3024 17

conduct, the municipality was the ‘moving force’ behind the

injury alleged,” showing “a direct causal link between the

municipal action and the deprivation of federal rights.” Brown,

520 U.S. at 404. A plaintiff opposing summary judgment must

identify “admissible evidence that would permit the trier of

fact to make a finding in the non-movant's favor as to any issue

as to which it bears the burden of proof.” Packer v. Trustees of

Ind. Univ. Sch. of Medicine, 800 F.3d 843, 847 (7th Cir. 2015).

Because Lapre admittedly presented no evidence on causation,

the district court correctly rejected this claim.

C.

Lapre next contends that the City had a policy of not

reassessing detainees who were returning to the Lockup after

an absence. According to Lapre, the Special Order does not

require lockup personnel to reassess detainees via the mental

health questionnaire, Ofem was not reassessed when he

returned from court, Carrillo was not trained to reassess

detainees, and none of the deposed City personnel were aware

that reassessment was required. She argues that, if Carrillo had

reassessed Ofem, it is likely that the assessment would have

provided information that prompted further inquiry into

Ofem’s state of mind. As such, she asserts that the failure to

reassess was a cause in fact of Ofem’s death.

The Special Order is arguably ambiguous on the issue of

whether a detainee will be reassessed via the intake screening

questions on return to the lockup following an absence.

Construing the Special Order in Lapre’s favor, we will assume

that the Special Order requires personnel to employ the intake

questions only when a detainee first arrives at a lockup. The
18 No. 17-3024

Special Order does, however, require some assessment of a

detainee’s mental health every fifteen minutes during the

visual check. At that time, lockup personnel are directed to

follow the Guidelines for Arrestee Screening and Monitoring

chart. The warning signs listed on the chart include whether

the detainee expresses a desire to harm himself, engages in

actual self-harm, is hyperactive or extremely agitated, or is

feeling intense guilt or remorse. That said, it seems highly

unlikely that a visual check through a grainy video feed would

reveal whether an arrestee is suicidal under the standards

provided in the chart. 

But even if we assume that the City had a policy of assessing detainees only on initial entry to the lockup, Lapre’s

evidence falls short of demonstrating that the City’s facially

lawful policy was deliberately indifferent to a known or

obvious consequence of the policy. Brown, 520 U.S. at 407.

Lapre has presented no evidence that the policy itself led to

additional suicides or that suicides would have been prevented

by a different policy. Nor has she shown that the City was

aware that this policy was leading to an increase in detainee

suicides, for example, and yet persisted in continuing the

practice. See Brown, 520 U.S. at 406–07. See also Connick v.

Thompson, 563 U.S. 51, 61–62 (2011) (deliberate indifference is

a stringent standard of fault, requiring proof that a municipal

actor disregarded a known or obvious consequence of his

action). In Connick, the Court held that “when City

policymakers are on actual or constructive notice that a

particular omission in their training program causes City

employees to violate citizens’ constitutional rights, the City

may be deemed deliberately indifferent if the policymakers
No. 17-3024 19

choose to retain that program.” 563 U.S. at 61–62. Because

Lapre has presented no evidence that the City was on actual or

constructive notice that its policy to fully assess mental health

only on first admission to the lockup was leading to constitutional deprivations, we cannot say that the City acted with the

requisite level of fault for a finding of deliberate indifference.

Moreover, Lapre has presented little more than speculation in

support of causation on this claim, asserting without evidence

that a full reassessment would have led to further inquiry

which would have presumably led to an intervention that

saved Ofem. 

D.

Lapre next asserts that the City was deliberately indifferent

to the risk of detainee suicide through its policy of not personally inspecting detainees and leaving them isolated. Instead,

the City conducted at least some of the visual inspections

through a grainy video feed even though the Illinois Lockup

Standards require in-person checks at least every half hour.

Lapre asserts that failing to follow the Illinois standards is

evidence of deliberate indifference. She also contends that a

reasonable inference may be drawn from the record that Ofem

was left completely alone and isolated from his return to the

jail at 10 a.m. until his suicide a little more than three hours

later. Such isolation was the moving force behind Ofem’s

suicide, she argues. 

We begin with the only evidence in the record regarding inperson inspections and interactions. When Ofem returned

unexpectedly from court, he was the only person in the

Lockup. He spoke with Carrillo on his return at 10 a.m.
20 No. 17-3024

regarding the court mixup. Carrillo also asked Ofem if he

wanted something to eat, and Ofem declined. Ofem accepted

Carrillo’s offer of a phone call, and the call lasted a few

minutes. Although Ofem was placed in the cell closest to

Carrillo’s work station, only fifteen or twenty feet away, there

was a closed steel door separating them. Carrillo testified that

either he, an unnamed fellow officer, or the Station Supervisor

personally checked on Ofem every fifteen minutes from 10 a.m.

to 12:45 p.m. On two or three occasions, Carrillo asked Ofem

if he wanted something to eat, and Ofem declined each time.

On one occasion when the other officer checked on Ofem, that

officer asked Carrillo to come in to discuss the court mixup

again. At 11:30, the Station Supervisor checked the Lockup in

person. At 12:45, Carrillo and Graham jointly conducted an inperson check on Ofem. Carrillo noticed nothing unusual at any

of these inspections. When Carrillo was getting ready to check

Ofem at 1:00 p.m., he was busy responding to a request from

another officer, and so Carrillo checked on Ofem through the

video monitor instead of conducting an in-person check. At

1:10 p.m., Carrillo and Graham discovered Ofem hanging from

the bars of his cell, less than a half hour after the final in-person

check. 

Lapre faults the district court for crediting Carrillo’s

testimony that someone inspected Ofem in person every fifteen

minutes (except at 1:00 p.m., when Carrillo testified that he

viewed Ofem via the video feed), arguing that a jury could

disbelieve Carrillo’s testimony. But Lapre herself concedes,

consistent with Carrillo’s testimony, that Carrillo offered food

to Ofem multiple times between 10 a.m. and the time of his

death, and that Ofem refused to eat each time. So Lapre admits
No. 17-3024 21

that Carrillo made at least several in-person visits to Ofem’s

cell. Moreover, although the “movant has the burden of

showing that there is no genuine issue of fact, ... the plaintiff

is not thereby relieved of his own burden of producing in turn

evidence that would support a jury verdict.” Anderson, 477 U.S.

at 256. Lapre’s assertions that a jury could disbelieve Carrillo

are not sufficient to establish that Ofem was left alone for the

three hours preceding his death. “When the testimony of a

witness is not believed, the trier of fact may simply disregard

it. Normally the discredited testimony is not considered a

sufficient basis for drawing a contrary conclusion.” Bose Corp.

v. Consumers Union of U.S., Inc., 466 U.S. 485, 512 (1984). If we

disregard Carrillo’s testimony, the record still shows that

Carrillo spoke to Ofem approximately three times after he

returned from court and before his death less than three hours

later. No fair inference may be drawn that Ofem was completely isolated because Lapre concedes that Carrillo offered

Ofem food multiple times. We are left then with the City’s

policy of visually inspecting detainees every fifteen minutes,

a policy which does not expressly require an in-person check.

The City’s policy additionally requires the Station Supervisor

to conduct thorough inspections of the Lockup and the

detainees at the start of each tour and at least four times per

tour. And there is some evidence that Carrillo personally

checked Ofem several times during the last three hours of his

life. 

Lapre has offered no evidence of any particular widespread practice regarding the visual inspections, and so we do

not know whether detainees in general were left isolated for

extended periods of time, whether they were inspected in
22 No. 17-3024

person every fifteen minutes or whether there was a combination of in-person and video checks. Moreover, Lapre presents

no evidence that the City, as a matter of wide-spread custom

or practice, failed to follow the Illinois Lockup Standard of

conducting an in-person inspection every half hour. In any

case, a violation of a state law would not necessarily demonstrate a denial of due process, and compliance with state law

is not an automatic defense because state law might not

comport with constitutional standards. Boncher, 272 F.3d at 487.

See also Estate of Novack, 226 F.3d at 532–33 (section 1983

provides no remedy for failure to meet state law requirements). We have only anecdotal evidence regarding what

happened in the 4th District on the day of Ofem’s death. That

evidence does not support Lapre’s contention that Ofem was

isolated or that the City’s general practice was to isolate

detainees. 

Lapre also failed to offer evidence that in-person inspections of any particular frequency would affect the suicide risk

for detainees or that the City was aware that more frequent inperson visits would make a difference. Her evidence that the

City had contemplated installing computer card readers at the

back of each lockup so that the visits could be recorded

electronically adds nothing to the analysis because there is no

evidence regarding why the City was considering adopting

this procedure. Without evidence of either a wide-spread

practice, knowledge of a risk created by a practice, or causation, the claim was properly rejected.
No. 17-3024 23

E.

Lapre’s final claim regards the failure to properly train

personnel on detecting mental health issues and identifying

persons who are suicidal. Under City of Canton, Ohio v. Harris,

“the inadequacy of police training may serve as the basis for

§ 1983 liability only where the failure to train amounts to

deliberate indifference to the rights of persons with whom the

police come into contact.” 489 U.S. 378, 388 (1989).

In resolving the issue of a city's liability, the

focus must be on adequacy of the training program in relation to the tasks the particular officers must perform. That a particular officer may

be unsatisfactorily trained will not alone suffice

to fasten liability on the City, for the officer's

shortcomings may have resulted from factors

other than a faulty training program. It may be,

for example, that an otherwise sound program

has occasionally been negligently administered.

Neither will it suffice to prove that an injury or

accident could have been avoided if an officer

had had better or more training, sufficient to

equip him to avoid the particular injury-causing

conduct. Such a claim could be made about

almost any encounter resulting in injury, yet not

condemn the adequacy of the program to enable

officers to respond properly to the usual and

recurring situations with which they must deal.

And plainly, adequately trained officers occasionally make mistakes; the fact that they do says
24 No. 17-3024

little about the training program or the legal

basis for holding the City liable.

Moreover, for liability to attach in this circumstance the identified deficiency in a city's training program must be closely related to the ultimate injury. Thus in the case at hand, respondent

must still prove that the deficiency in training

actually caused the police officers' indifference to

her medical needs. Would the injury have been

avoided had the employee been trained under a

program that was not deficient in the identified

respect?

Harris, 489 U.S. at 390–91 (citations and footnote omitted).

As we noted above, the City’s Special Order and the

Guidelines for Arrestee Screening and Monitoring both

provided standards for determining whether a person is

suffering from mental illness or heightened suicide risk. The

City also provided extensive training records for each person

who interacted with Ofem on the day of his death, indicating

course titles and whether the employee passed or failed the

course. Lapre’s only evidence regarding City training policies

is anecdotal evidence of the training provided to the 4th

District personnel who monitored Ofem during his time in the

Lockup. Those officers did not recall specific training programs

or the dates of any training that they were given on identifying

mental health issues or suicide risk. Although Lapre asserts

both that the City failed entirely to train its officers and that the

training provided was inadequate, Lapre has presented no

evidence regarding City-wide policies or practices regarding
No. 17-3024 25

training. She does not point, for example, to evidence that the

City has no training program or that the program the City

employs has faults. Even if we disregard the City’s evidence,

Lapre has produced no evidence regarding the City’s training

practices from which we may infer deliberate indifference.

That there may have been lapses in training in the 4th District

is not sufficient to allow an inference of deliberate indifference

by the City as a matter of policy or wide-spread practice. 

Finally, Lapre also fails to show causation on her training

claim. She has provided no evidence that the City’s training

program led to Ofem’s death, or that the City’s program

ignored a recurring problem. She has provided nothing more

than speculation regarding whether better trained officers

would have responded differently, or that a different outcome

was possible based on better training. In the absence of this key

evidence, summary judgment in favor of the City was appropriate.

III.

The suicide of a teenager in a City lockup is an unmitigated

tragedy. The question is whether that death occurred as a

result of deliberate indifference by the City through its policies,

practices or customs. Lapre focused her discovery on the

narrow circumstances of Ofem’s death rather than on the

City’s official policies or unofficial but wide-spread practices

or customs. As a result, she was unable to provide evidence

that the City failed to adequately address the known consequences of its official or unofficial practices in the lockups. Nor

did she provide evidence that any policy or policy gap was the
26 No. 17-3024

moving force in Ofem’s death. The judgment in favor of the

City is therefore

AFFIRMED.