In the 

United States Court of Appeals 

For the Seventh Circuit ____________________ 

No. 17-1603 

ALFREDO MIRANDA, Administrator of Estate of Lyvita Gomes, 

Plaintiff-Appellant, 

v.

COUNTY OF LAKE, et al., 

Defendants-Appellees. 

____________________ 

Appeal from the United States District Court for the 

Northern District of Illinois, Eastern Division. 

No. 12 C 4439 — Sharon Johnson Coleman, Judge. 

____________________ 

ARGUED DECEMBER 6, 2017 — DECIDED AUGUST 10, 2018 

____________________ 

Before WOOD, Chief Judge, and EASTERBROOK and 

HAMILTON, Circuit Judges. 

WOOD, Chief Judge. In the fall of 2011, Lyvita Gomes failed 

to show up for jury duty. This minor infraction triggered a 

series of events that led to her untimely death in the early days 

of 2012. She wound up in the county jail, where she refused 

to eat and drink. The medical providers who worked at the 

Jail did little other than monitoring as she wasted away in her 
2 No. 17-1603 

cell. By the time she was sent to the hospital, it was too late to 

save her. 

Alfredo Miranda, the administrator of Gomes’s estate, 

brought an action under 42 U.S.C. § 1983 and assorted statelaw theories against Lake County, the Jail officials (the 

“County defendants”), and Correct Care Solutions (CCS, the 

Jail’s contract medical provider) and its employees (the “medical defendants”). The district court dismissed the County defendants at summary judgment. The medical defendants proceeded to trial, but halfway through the proceeding the court 

granted judgment as a matter of law under Federal Rule of 

Civil Procedure 50(a) for them on some claims. The Estate prevailed to a modest degree on another claim, and part of the 

case resulted in a mistrial. Our principal ruling in response to 

the Estate’s appeal is that the Rule 50(a) judgment was premature, and so further proceedings are necessary. 

I 

A 

On October 12, 2011, an officer arrested Gomes, a 52-yearold Indian national, for failing to appear for jury duty. (In 

hindsight, this was the County’s first misstep: as a non-citizen, Gomes was categorically ineligible to serve as a juror. 

705 ILCS 305/2(a)(4).) Gomes pulled away from the officer as 

he attempted to arrest her. That action earned her a second 

charge of resisting arrest. The officers took Gomes to 

Lake County Jail, where she made statements that landed her 

on suicide watch the next day. But she did not stay at the Jail 

long. On October 14, Gomes was transferred to the custody of 

the federal Immigration and Customs Enforcement (ICE) service, which released her within a few days. 
No. 17-1603 3

Roughly two months later, on December 14, after failing 

to appear in court on the resisting-arrest charge, Gomes found 

herself back in the Lake County Jail. Though officials initially 

placed her in the general population, it quickly became apparent that her physical and mental health were deteriorating, 

and so she was moved. 

On December 16, CCS’s Director of Mental Health, 

Jennifer Bibbiano (a social worker), performed a mental 

health evaluation on Gomes. Bibbiano documented that 

Gomes had ingested no food or water since arriving at the Jail 

two days earlier. As a result, Gomes was transferred the next 

day to the Jail’s medical pod for closer monitoring. On 

December 18, staff placed Gomes on suicide watch and the 

hunger strike protocol. At that point, after she had gone four 

days without food or water, staff weighed her for the first time 

and recorded a weight of 146 pounds. Over the next ten days, 

this number plummeted; by December 28, Gomes weighed 

only 128 pounds. 

During this period, social workers and physicians continued to assess Gomes daily. Defendant Dr. Rozel Elazegui, an 

internist, saw Gomes on December 22 and 27. In several progress notes, the CCS staff reported various symptoms of dehydration, such as skin tenting. Gomes’s refusal to eat or 

drink and her unresponsiveness often prevented the medical 

staff from recording her vital signs and collecting any blood 

or urine samples. For most of this time, Gomes lay in bed and 

refused to speak. 

As Gomes’s physical condition worsened, concerns about 

her mental state grew. When Gomes appeared in court on December 20, the judge ordered a mental fitness examination. 

On December 22, Gomes was identified as needing an urgent 
4 No. 17-1603 

psychiatric visit. That prompted a visit two days later from 

psychiatrist Hargurmukh Singh, who first met Gomes then 

and diagnosed her with a “psychotic disorder not otherwise 

specified.” He prescribed no medication. After seeing Gomes 

again on December 27, Dr. Singh concluded that her psychosis rendered her unable to understand the risks of not eating 

and unable to participate in her treatment plan. But his only 

advice to Dr. Elazegui, who wanted to perform an involuntary blood draw for monitoring purposes, was that Elazegui 

could do so if push came to shove. 

Around this time the officials in charge of Lake County Jail 

entered the picture. On December 26, Wayne Hunter, the Jail’s 

acting chief, was first notified by email that Gomes was in the 

Jail and was refusing medical treatment and tests. Hunter received assurances that CCS staff were monitoring Gomes’s 

condition and that they would provide him with any updates. 

Two days later, Hunter personally went down to Gomes’s cell 

in a futile attempt to persuade her to eat. On December 27, 

Scott Fitch, the liaison between the correctional and medical 

staff, learned about Gomes. He too asked for updates. Fitch 

called Gomes’s public defender, entreating her to visit and encourage her client to eat. Sheriff Mark Curran did not hear 

about Gomes until December 29, the day she left the Jail. That 

same day, Jail officials went to court to get Gomes formally 

released from custody. 

Also on December 29, Dr. Young Kim, another CCS internist, returned to work from a vacation. Dr. Kim was surprised 

to learn that Gomes had remained in the Jail while continuing 

to refuse all food and drink. (A few stray comments in 

Gomes’s medical records suggest that she may have rubbed 

water on her body and perhaps taken a few sips of water from 
No. 17-1603 5

her sink. But the record as a whole implies little to no water 

intake.) Dr. Kim immediately called an ambulance to take 

Gomes to the hospital for evaluation and treatment of her dehydration and psychosis. Unfortunately, this intervention 

came too late. On January 3, 2012, five days after arriving at 

the hospital, Gomes died. The autopsy opined that she died 

of “Complications of Starvation and Dehydration.” The manner of death was suicide. 

B 

The Estate filed this action against Lake County, 

Sheriff Curran, Hunter, Fitch, CCS, Dr. Elazegui, Dr. Singh, 

Bibbiano, and two more social workers, Ruth Muuru and 

Edith Jones. It raised due process claims under 42 U.S.C. 

§ 1983, state statutory and common law tort claims, violations 

of international treaty obligations, and claims under the 

Americans with Disabilities Act, 42 U.S.C. § 12101 et seq. Only 

the claims against the medical defendants went to trial. 

But the jury never had the opportunity to resolve some of 

those claims. At the close of the Estate’s presentation of evidence, the court entered judgment as a matter of law under 

Rule 50(a) for social workers Muuru and Jones on all claims 

against them. The court also concluded that the Estate had 

failed to present enough evidence to reach the jury on the 

question whether the medical defendants caused Gomes’s 

death; it therefore granted them judgment as a matter of law 

on that part of the case. The only question remaining for the 

jury was the Estate’s due process claim for inadequate medical care, limited to the pain and suffering Gomes experienced 

while in the Jail. The jury failed to reach a unanimous verdict 

regarding the conduct of Dr. Elazegui and Dr. Singh but it 

held social worker Bibbiano liable. It awarded the Estate 
6 No. 17-1603 

$119,000 in compensatory damages, which Bibbiano has paid 

in full. 

The Estate does not challenge the jury verdict, but it takes 

issue with four aspects of the proceedings below: first, the district court’s dismissal of the County defendants; second, the 

judgment as a matter of law on causation of death; third, the 

court’s ruling barring the Estate from pursuing one of its theories of recovery under the Due Process Clause; and fourth, 

the court’s instruction on the applicable legal standard. While 

we find no merit in its first point, we conclude on the latter 

three that the Estate is entitled to the opportunity to try its full 

case against the medical defendants before a jury. 

II 

A 

We start with the Estate’s attempt to revive some of the 

claims against the County defendants. It first challenges the 

district court’s conclusion that the Jail’s chief, Hunter, and liaison, Fitch, were not deliberately indifferent to Gomes’s inadequate medical care in violation of her due process rights. 

We need not delve into the nuances of the standard for such a 

claim, because the Estate faces an insurmountable hurdle independent of that standard. We have long recognized the fact 

that correctional institutions (like most entities in a modern 

economy) engage in the division of labor. See Greeno v. Daley, 

414 F.3d 645, 656 (7th Cir. 2005) (citation omitted). When detainees are under the care of medical experts, non-medical jail 

staff may generally trust the professionals to provide appropriate medical attention. E.g., Rice ex rel. Rice v. Corr. Med. 

Servs., 675 F.3d 650, 676, 678–79 (7th Cir. 2012); see also Rasho 
No. 17-1603 7

v. Elyea, 856 F.3d 469, 478–79 (7th Cir. 2017) (holding that medical professionals were not liable when sued in their capacity 

as “prison administrators and policymakers, not treaters”). 

We will not find a jail official to have acted with deliberate 

indifference if she reasonably relied on the judgment of medical personnel. E.g., Greeno, 414 F.3d at 655–56; Estate of Perry 

v. Wenzel, 872 F.3d 439, 458–59 (7th Cir. 2017). On the other 

hand, if jail officials had reason to know that their medical 

staff were failing to treat or inadequately treating an inmate, 

liability is possible. King v. Kramer, 680 F.3d 1013, 1018 (7th 

Cir. 2012); Rice, 675 F.3d at 676. 

Nothing in this record justifies a finding of personal liability against the County defendants. Hunter and Fitch received 

assurances that CCS staff were regularly monitoring Gomes. 

They requested periodic updates on her condition. The medical providers informed Hunter and Fitch that Gomes was stable and promised to send her to the hospital if necessary. 

Knowing that the CCS employees were on the case, Hunter 

and Fitch were entitled to rely on their professional judgments. See Arnett v. Webster, 658 F.3d 742, 756 (7th Cir. 2011) 

(“This is not a case where [the plaintiff] was being completely 

ignored by medical staff.”). The fact that they expressed concern about Gomes’s condition and tried directly and indirectly to get her to eat does not make them culpable. 

Because we find that Fitch and Hunter’s reasonable reliance on their medical providers shields them from liability 

under section 1983, we need not consider the County defendants’ alternative arguments for dismissal. 
8 No. 17-1603 

B 

While the Estate has apparently abandoned its claim that 

Sheriff Curran is individually liable for Gomes’s inadequate 

medical care, it is still trying to pursue an official-capacity 

claim about the Jail’s allegedly deficient hunger-strike policy. 

As an Illinois sheriff, Curran has final policymaking authority 

over jail operations. DeGenova v. Sheriff of DuPage Cnty., 

209 F.3d 973, 976 (7th Cir. 2000). He is thus a proper party for 

a claim under Monell v. Department of Social Services of 

New York, 436 U.S. 658, 690–91 (1978), targeted at policies and 

customs that deprive inmates of their federal rights. Id. Monell

liability is possible even if no individual official is found deliberately indifferent. Glisson v. Ind. Dep’t of Corr., 849 F.3d 372, 

379 (7th Cir. 2017) (en banc). 

The focus of the Estate’s Monell claim is Lake County Jail’s 

hunger-strike policy. That policy required four things: (1) the 

immediate notification of medical staff when an inmate begins a hunger strike; (2) documentation of meal refusals and 

immediate notification of a command officer after an inmate’s 

third consecutive meal refusal; (3) the command’s investigation and communication with medical staff as needed; and 

(4) a conference including the health services administrator 

and the chief or deputy chief of corrections about the best 

course of action. The Estate finds the policy lacking in some 

respects, including the timing of notification and consultation, follow-up procedures if the hunger strike continues, 

methods to review past suicidality, and guidance on what to 

look for and how to document an inmate’s condition on suicide watch. 

The Estate’s concerns may be valid, but it has not shown 

that the Sheriff was deliberately indifferent in enacting this 
No. 17-1603 9

policy. Though hunger strikes may be common in jails, as 

amici suggest, Gomes went longer without food and water 

than anyone else in the Jail’s experience. This does not give 

the Sheriff a free pass, since a single incident can be enough 

for liability where a constitutional violation was highly foreseeable. Woodward v. Corr. Med. Serv. of Ill., Inc., 368 F.3d 917, 

929 (7th Cir. 2004) (rejecting the notion of a “‘one free suicide’ 

pass”). But this is not a case in which the Jail knew that hunger 

strikes were a risk yet did nothing. It had a system in place, 

and that system included a series of reasonable measures. 

The Estate presented no evidence that would allow a trier 

of fact to conclude that some feature in the Jail’s policy caused 

Gomes’s death. Once Jail staff learned about her refusal to eat 

or drink, they stayed in regular communication with CCS’s 

medical personnel. See Belbachir v. Cnty. of McHenry, 726 F.3d 

975, 983 (7th Cir. 2013). It is unclear whether anyone connected the dots between Gomes’s suicidal statements in October and her condition in December, but that is irrelevant because staff identified Gomes as actively suicidal almost from 

the start of her second detention. There is no reason to think 

that additional guidance in the hunger-strike policy would 

have made a difference in Gomes’s deterioration. Summary 

judgment was appropriate on this Monell claim. 

C 

We can be brief with the Estate’s complaint that the 

County defendants failed to comply with their international 

treaty obligations. Article 36 of the Vienna Convention guarantees a foreign national the right to have her home country’s 

consular office notified when she is detained. Vienna Convention on Consular Relations, art. 36, Apr. 24, 1963, 21 U.S.T. 77; 

Sandoval v. United States, 574 F.3d 847, 850 (7th Cir. 2009).
10 No. 17-1603 

When Gomes, an Indian national, was detained in October, 

ICE officials informed her of her Article 36 rights. No one repeated this advice when Gomes was taken back into custody 

in December. Still, we think summary judgment is appropriate, though for reasons different from those mentioned by the 

district court. 

The district court was concerned that the Estate failed to 

mention section 1983 when raising this claim, see Jogi v. Voges, 

480 F.3d 822, 825 (7th Cir. 2007) (Jogi II), but “complaints need 

not plead legal theories,” and so that alone does not support 

dismissal, see id. at 826. Another strike against the Estate, according to the district court, was the lack of evidence connecting Gomes’s death with the failure to notify. Indeed, when 

given the opportunity to speak with the Indian consulate in 

October, Gomes chose not to do so. Nonetheless, we have yet 

to explore the question whether a plaintiff is required to show 

actual harm in order to recover for an Article 36 violation, or 

if this is more in the nature of a failure to receive required Miranda warnings. 

We need not wrestle with that issue now, however, because our case is easily resolved on the more straightforward 

ground of qualified immunity. The County officials are immune from suit if it was not clearly established in 2011 that 

their conduct violated the Vienna Convention. See Pearson v. 

Callahan, 555 U.S. 223, 245 (2009). Article 36 charges “competent authorities” with notifying foreign nationals. The term 

“competent authorities” includes booking officers. Mordi v. 

Zeigler, 770 F.3d 1161, 1166–1167 (7th Cir. 2014). Consistent 

with this precedent, the Jail’s written policy places the notification obligation exclusively with booking officers. But the 

Estate did not sue the officer who booked Gomes. And, as we 
No. 17-1603 11

acknowledged in 2014, the boundaries of who else might 

qualify as a competent authority have “yet to be fixed.” Mordi, 

770 F.3d at 1167. Because it was not clearly established who, 

beyond the booking officer, had a duty to inform Gomes of 

her consular rights, the County defendants are entitled to 

qualified immunity. 

D 

The Estate also seeks to reinstate a Monell claim based on 

the County’s alleged failure to train Jail staff to notify detainees of their consular rights. A failure-to-train claim is actionable only if the failure amounted to deliberate indifference to 

the rights of others. City of Canton v. Harris, 489 U.S. 378, 388 

(1989). Deliberate indifference exists where the defendant 

(1) failed “to provide adequate training in light of foreseeable 

consequences”; or (2) failed “to act in response to repeated 

complaints of constitutional violations by its officers.” Sornberger v. City of Knoxville, 434 F.3d 1006, 1029–30 (7th Cir. 

2006). In essence, the defendant must have actual or constructive notice of a problem. See Robles v. City of Fort Wayne, 113 

F.3d 732, 735 (7th Cir. 1997). 

Here, Sheriff Curran had neither. The Estate points to no 

evidence indicating that detainees repeatedly complained 

about the absence of consular notification. The parties try to 

paint the problem as rampant or nonexistent, but the record 

does not support either extreme. 

Sheriff Curran did not fail to act in the face of foreseeable 

violations. Lake County Jail has had a policy about consular 

notification since at least October 2005. In addition to requiring booking officers to inform detainees, the policy specified 

that all officers who work at the booking desk “shall receive 
12 No. 17-1603 

appropriate training,” including a video, handouts, and a 

training session. Sheriff Curran testified that he knew about 

this policy and was never notified that it was not being followed. Thus, at most, Sheriff Curran was negligent in failing 

to ensure that the Jail’s training protocol was being implemented. This is not enough to establish that he was deliberately indifferent to detainees’ rights. See Rice, 675 F.3d at 675 

(requiring that “the failure to train reflect[] a conscious choice 

among alternatives”). The Sheriff did not display deliberate 

indifference, and so we need not consider the County defendants’ alternative arguments. 

III 

We turn now to the Estate’s claims against Drs. Elazegui 

and Singh, which the district court partially blocked on the 

ground that there was not enough evidence of causation to 

reach the jury. Though the Estate assigns error to the court’s 

ruling on a motion in limine and its jury instruction, we need 

reach these decisions only if we reverse on causation. This is 

because neither ruling prejudiced the Estate on the claim that 

did go to the jury. Under the single recovery rule, defendants 

are jointly and severally liable for the full amount of compensatory damages that result from an indivisible harm; a plaintiff can recover only once for those damages. Janusz v. City of 

Chi., 832 F.3d 770, 774, 777 (7th Cir. 2016); Minix v. Canarecci, 

597 F.3d 824, 829–30 (7th Cir. 2010). The Estate has already 

been fully compensated for Gomes’s suffering at the Jail, since 

Bibbiano paid the assessed $119,000. It has not, however, received any compensation for Gomes’s death. We thus turn to 

the question whether that issue too should have gone to the 

jury. 
No. 17-1603 13

A 

The court granted judgment as a matter of law on the Estate’s constitutional and state-law wrongful death claims 

against Drs. Elazegui and Singh because it thought that no rational jury could conclude that their actions caused Gomes’s 

death. It identified two evidentiary gaps: first, the lack of expert testimony explaining what the notation of “Complications of Starvation and Dehydration” in the autopsy report 

meant and how those complications related to Gomes’s death; 

and second, the lack of expert testimony about what took 

place during the five days between Gomes’s transfer to the 

hospital and her death. We consider this decision de novo. 

Holder v. Ill. Dep’t of Corr., 751 F.3d 486, 490 (7th Cir. 2014). 

We start with the Estate’s claim under the Fourteenth 

Amendment’s Due Process clause for inadequate medical 

care.1 Although Dr. Elazegui and Dr. Singh were employed by 

a private company that contracted with Lake County to provide detainees’ medical care, they are considered state actors 

amenable to suit under section 1983. West v. Atkins, 487 U.S. 

42, 54–56 (1988). They are not, however, entitled to qualified 

immunity. Petties v. Carter, 836 F.3d 722, 734 (7th Cir. 2016) 

(en banc). Moreover, they concede both that Gomes’s medical 

condition was objectively serious and that the evidence would 

have permitted the jury to conclude the doctors acted with 

 1 We do so because this was the claim that supports the district court’s 

subject-matter jurisdiction under 28 U.S.C. §§ 1331 and 1343; the Estate 

relied on the court’s supplemental jurisdiction, 28 U.S.C. § 1367, for its 

state-law theories. It is possible that the alienage branch of diversity jurisdiction may also have existed, see 28 U.S.C. § 1332(a)(2), but this was not 

explored. 
14 No. 17-1603 

deliberate indifference. Our focus is thus exclusively on causation. 

To recover on its due process claim, the Estate had to present “‘verifying medical evidence’ that the delay” in medical 

care “caused some degree of harm.” Williams v. Liefer, 491 F.3d 

710, 715 (7th Cir. 2007) (citation omitted). It did not, however, 

bear the burden of proving that but for the medical defendants’ inaction, Gomes would definitely have lived. It would 

have been enough for the Estate to show that the resulting 

harm was a diminished chance of survival. See Murrey v. 

United States, 73 F.3d 1448, 1453–54 (7th Cir. 1996); Holton v. 

Mem’l Hosp., 176 Ill. 2d 95, 119 (1997) (recognizing the lost 

chance doctrine in Illinois). While expert testimony could be 

used as “verifying medical evidence,” medical records alone 

could suffice. Grieveson v. Anderson, 538 F.3d 763, 779 (7th Cir. 

2008); Williams, 491 F.3d at 715. 

The record contains ample evidence from which a jury 

could infer that Drs. Elazegui and Singh’s inaction diminished Gomes’s chances of survival. First, it shows that she 

died from starvation and dehydration. Under Illinois law, autopsy reports are prima facie evidence of their findings and 

conclusions, including cause of death. 725 ILCS 5/115-5.1. The 

report here did not mince words about Gomes’s cause of 

death—“Complications of Starvation and Dehydration”—or 

her manner of death—“suicide.” The coroner implicitly ruled 

out the possibility that Gomes died from any hospital-based 

illnesses or other causes. The report is clear: not eating or 

drinking caused her death. (Hospital records underscore this 

conclusion. On the day she arrived at the hospital, Gomes was 

already experiencing acute liver and renal failure. For present 

purposes, however, we disregard these records, because they 
No. 17-1603 15

were excluded from trial at the request of the medical defendants, and the Estate has not challenged that exclusion on appeal.) 

Moreover, the Estate’s expert witnesses testified that the 

doctors’ failure to transfer Gomes to the hospital sooner allowed her deterioration to reach a dangerous point. Psychiatry expert Dr. James Gilligan repeatedly testified that 

Dr. Singh contributed to Gomes’s death by failing to initiate 

her transfer from the Jail to the hospital. Furthermore, 

Dr. Singh (a psychiatrist, recall) knew that Gomes was clinically incompetent, but he took no steps to treat her even 

though she was endangering her life. Dr. Gilligan concluded 

that Dr. Singh’s “failure to act ... contributed to [Gomes’s] 

death.” Internal medicine expert Dr. Jack Raba testified that 

Gomes’s pulse on December 25 was an “ominous sign,” raising the possibility of cardiovascular problems, electrolyte or 

metabolic imbalances, or renal failure. He added that Gomes’s 

blood pressure clearly indicated dehydration. Dr. Raba said it 

was “impossible” not to consider that Gomes was starting to 

show signs of organ failure. These “absolute signs” signaled 

that Gomes urgently needed to be admitted to a hospital for 

bloodwork and possibly forced feeding and medication. 

Dr. Raba concluded that Dr. Elazegui’s failure to intervene 

“contributed to [Gomes’s] ultimate demise and death.” 

The prison doctors’ testimony lent support to Dr. Raba’s 

expert opinion on causation. When Dr. Elazegui spoke with 

Gomes on December 22, he informed her that starvation 

risked organ failure and death. He asked to be informed when 

her weight loss hit 18%, since that number indicates an increased risk of organ failure. Dr. Kim’s testimony was also rel-
16 No. 17-1603 

evant to the causation question. When he returned from vacation, he was concerned that Gomes could go into respiratory 

failure or cardiac arrest at any minute (and unlike the others, 

he promptly acted on this concern). 

Taken together, this evidence was enough to support an 

inference on the jury’s part that the delay in sending Gomes 

to the hospital resulted in her death, or at least lessened her 

chance of survival. 

Our analysis applies with equal force to the Estate’s state 

malpractice claims. See 740 ILCS 180/1. Under this theory, the 

Estate had to show that the physicians’ negligent failure to 

comply with the standard of care proximately caused 

Gomes’s injury. See Sullivan v. Edward Hosp., 209 Ill. 2d 100, 

112 (2004). In Illinois, proximate cause “must be established 

by expert testimony to a reasonable degree of medical certainty.” Morisch v. United States, 653 F.3d 522, 531 (7th Cir. 

2011) (citation omitted). An expert’s opinion on the connection between a delay in treatment and injury must be factually 

supported in order to be submitted to the jury. Wiedenbeck v. 

Searle, 385 Ill. App. 3d 289, 293–94 (2008). 

The proximate-cause inquiry encompasses both cause-infact and legal cause. Palay v. United States, 349 F.3d 418, 432 

(7th Cir. 2003). For there to be legal cause, a reasonable person 

must have been able to foresee that the plaintiff’s injury 

would result from his conduct. Id. For cause-in-fact, the plaintiff must show that but for the defendant’s conduct, the injury 

would not have occurred. Id. Again, the injury can be the decedent’s lost chance at survival. Holton, 176 Ill. 2d at 119.

A jury would have been permitted to find legal cause here. 

By their own admission, Drs. Elazegui and Singh knew that if 
No. 17-1603 17

Gomes continued to refuse food and fluids, she could die. 

They warned her as much. The record also contained support 

for cause-in-fact. The experts opined that the medical defendants’ inaction contributed to Gomes’s death. This was not impermissibly conclusory for an expert opinion. See FED. R.

EVID. 705; see also Wilson v. Clark, 84 Ill. 2d 186, 196 (1981) 

(adopting Federal Rule of Evidence 705 for Illinois). The medical defendants are right that an expert’s testimony in a malpractice case cannot be based on “sheer, unsubstantiated 

speculation.” Wiedenbeck, 385 Ill. App. 3d at 293. But the opinions here suffered from no such flaw, and the defendants 

were free to cross-examine the experts about what led them 

to draw their conclusions. Wilson, 84 Ill. 2d at 194. Based on 

Drs. Raba and Gilligan’s expert testimony, a jury could have 

found that the defendants’ inaction more likely than not contributed to Gomes’s decreased chance of survival and her ultimate death. The Estate is entitled to a new trial in which it 

can present these arguments to a jury. 

B 

Since the Estate is entitled to a new trial against the medical defendants, we will also say a few words about its challenge to the district court’s decision to bar all reference to the 

theory that the medical defendants violated the Due Process 

Clause by failing to protect Gomes from harming herself. Our 

review is for abuse of discretion. Perry v. City of Chi., 733 F.3d 

248, 252 (7th Cir. 2013).2

 2 Once again, it is worth recalling that a person may recover only once 

for a given set of injuries. At this stage, however, no one has had any occasion to consider whether state law and federal law overlap so much that 

the elements supporting each theory are the same, or that full relief could 
18 No. 17-1603 

The Supreme Court has declared that “competent persons” have a due-process “right to refuse lifesaving hydration 

and nutrition.” Washington v. Glucksberg, 521 U.S. 702, 723 

(1997) (quoting Cruzan v. Dir., Mo. Dep’t of Health, 497 U.S. 261, 

279 (1990)). But this right does not extend to incarcerated persons who have been deemed incompetent. Freeman v. Berge, 

441 F.3d 543, 546 (7th Cir. 2006). For these detainees, jails have 

a duty “to prevent the prisoner from giving way” to the “unusual psychological strain” caused by incarceration. Id. at 547. 

We repeatedly have recognized a jail or prison official’s 

failure to protect an inmate from self-harm as one way of establishing deliberate indifference to a serious medical need. 

E.g., Estate of Miller, ex rel. Bertram v. Tobiasz, 680 F.3d 984, 989–

90 (7th Cir. 2012); Collins v. Seeman, 462 F.3d 757, 760–61 (7th 

Cir. 2006). The obligation to intervene covers self-destructive 

behaviors up to and including suicide. Rice, 675 F.3d at 665; 

Cavalieri v. Shepard, 321 F.3d 616, 620–22 (7th Cir. 2003). The 

duty applies “when suicide takes the form of starving oneself 

to death.” Freeman, 441 F.3d at 547; accord Rodriguez v. Briley, 

403 F.3d 952, 953 (7th Cir. 2005). 

In barring this theory, the court reasoned that the Estate 

had not presented evidence that Gomes’s suicidal ideation 

and mental illness were “so acute” that the defendants should 

have known about them and protected her from herself. See 

Seventh Circuit Pattern Civil Jury Instruction 7.19 (rev. 2017) 

(an element of a failure-to-protect-from-self-harm claim is 

that the defendant was aware or strongly suspected a strong 

likelihood of serious self-harm). The court attached particular 

 

be recovered under either. Reconciliation of those theories is something 

better done by the district court on remand. 
No. 17-1603 19

weight to testimony from Gomes’s family members and the 

administrator that she was a devout Catholic who had no history of mental illness and would not have committed suicide. 

In the past, we have taken into account jail officials’ 

knowledge of a decedent’s mental health history or warnings 

from family members, as that information pertains to the defendants’ subjective awareness of a problem. E.g., Payne for 

Hicks v. Churchich, 161 F.3d 1030, 1042 (7th Cir. 1998). But that 

is not the use to which the court put the testimony of Gomes’s 

family. It jumped from the fact that Gomes was a Catholic to 

an assumption that the defendants were aware of her religious affiliation, but there is no evidence that they knew any 

such thing. Furthermore, mental illness and suicide regrettably afflict devout members of all religious groups. While a 

jury could consider testimony from Gomes’s family when assessing this theory of recovery, it was not the court’s role to 

accept the family opinion as an undisputed fact. 

And in any event, the trial record was filled with evidence 

supporting a finding that the medical defendants knew that 

Gomes was at great risk of death by starvation and dehydration, and that she was unable to think rationally. On December 27, Dr. Singh deemed her not competent and concluded 

that she did not understand the risks of refusing to eat. Before 

then, CCS staff documented Gomes’s suicidal ideation and 

placed her on suicide watch. Dr. Elazegui had warned Gomes 

that if she continued to refuse nutrition, she could die. The 

defendants’ records reveal that they were aware that Gomes 

was at serious risk of causing her own death. The district court 

abused its discretion by prohibiting the Estate from pursuing 

this line of argument. At the next trial, the Estate must be allowed to argue this theory of recovery to the jury. 
20 No. 17-1603 

C 

Finally, we consider whether the district court properly instructed the jury on intent. We evaluate the jury instructions 

anew when deciding if they accurately state the law. Sanchez 

v. City of Chi., 880 F.3d 349, 355 (7th Cir. 2018). 

The Supreme Court first recognized an incarcerated person’s right to receive adequate medical treatment in Estelle v. 

Gamble, 429 U.S. 97 (1976), which concerned a convicted prisoner. In that case, the Court concluded that deliberate indifference to a prisoner’s serious medical need violates the 

Eighth Amendment’s protection against cruel and unusual 

punishment. Id. at 104–05. The “deliberate indifference” 

standard requires a showing that the defendant had a “sufficiently culpable state of mind” and asks whether the official 

actually believed there was a significant risk of harm. Pittman 

ex rel. Hamilton v. Cnty. of Madison, 746 F.3d 766, 775–76 (7th 

Cir. 2014). 

This subjective standard is closely linked to the language 

of the Eighth Amendment, which prohibits the infliction of 

“cruel and unusual punishments.” The Supreme Court has interpreted this to ban only the “unnecessary and wanton infliction of pain.” Farmer v. Brennan, 511 U.S. 825, 834 (1994). The 

Court has applied the deliberate-indifference standard not 

just to medical-care problems, but also to other types of 

claims. See Farmer, 511 U.S. at 837 (failure-to-protect); Wilson 

v. Seiter, 501 U.S. 294, 303 (1991) (conditions of confinement). 

Pretrial detainees stand in a different position: they have 

not been convicted of anything, and they are still entitled to 

the constitutional presumption of innocence. Thus, the pun-
No. 17-1603 21

ishment model is inappropriate for them. Kingsley v. Hendrickson, 135 S. Ct. 2466, 2475 (2015) (“[P]retrial detainees (unlike 

convicted prisoners) cannot be punished at all, much less ‘maliciously and sadistically.’” (citations omitted)); Bell v. Wolfish, 

441 U.S. 520, 535 (1979) (“For under the Due Process Clause, 

a detainee may not be punished prior to an adjudication of 

guilt in accordance with due process of law.”). Yet they also 

are protected from certain abusive conditions. The difference 

is that the claims of state detainees being held on probable 

cause arise under the Fourteenth Amendment’s Due Process 

Clause. Collins v. Al-Shami, 851 F.3d 727, 731 (7th Cir. 2017).

That said, we have typically assessed pretrial detainees’ 

medical care (and other) claims under the Eighth Amendment’s standards, reasoning that pretrial detainees are entitled to at least that much protection. E.g., Minix, 597 F.3d at 

831; Board v. Farnham, 394 F.3d 469, 477–78 (7th Cir. 2005). In 

conducting this borrowing exercise, we have grafted the 

Eighth Amendment’s deliberate indifference requirement 

onto the pretrial detainee situation. Cavalieri, 321 F.3d at 620. 

Missing from this picture has been any attention to the difference that exists between the Eighth and the Fourteenth 

Amendment standards. 

The Supreme Court recently disapproved the uncritical 

extension of Eighth Amendment jurisprudence to the pretrial 

setting in Kingsley v. Hendrickson, 135 S. Ct. 2466 (2015). There 

the Court held that a pretrial detainee bringing an excessiveforce claim did not need to prove that the defendant was subjectively aware that the amount of force being used was unreasonable. Id. at 2472–73. Rather, the plaintiff needed only to 

show that the defendant’s conduct was objectively unreasonable. Id. Kingsley, it is worth emphasizing, was a Fourteenth 
22 No. 17-1603 

Amendment Due Process case. Indeed, the Court took pains 

to reiterate the basic principles that apply to pretrial detainees: 

Several considerations have led us to conclude that the 

appropriate standard for a pretrial detainee’s excessive 

force claim is solely an objective one. For one thing, it 

is consistent with our precedent. We have said 

that “the Due Process Clause protects a pretrial detainee from the use of excessive force that amounts to 

punishment.” Graham [v. Connor, 490 U.S. 386,] 395, 

n. 10 [1989]. And in Bell [v. Wolfish, 441 U.S. 520 

(1979)], we explained that such “punishment” can consist of actions taken with an “expressed intent to punish.” 441 U.S., at 538. But the Bell Court went on to explain that, in the absence of an expressed intent to punish, a pretrial detainee can nevertheless prevail by showing 

that the actions are not “rationally related to a legitimate 

nonpunitive governmental purpose” or that the actions 

“appear excessive in relation to that purpose.” Id., at 

561. 

135 S. Ct. at 2473 (emphasis added). 

Though Kingsley’s direct holding spoke only of excessiveforce claims, two of our sister circuits have held that its logic 

is not so constrained. The Ninth Circuit first extended Kingsley’s objective inquiry to detainees’ Fourteenth-Amendment 

failure-to-protect claims. Castro v. Cnty. of L.A., 833 F.3d 1060, 

1070–71 (9th Cir. 2016) (en banc), cert. denied, 137 S. Ct. 831 

(2017). Since then, that court has applied the Kingsley holding 

more broadly to a medical-need claim brought by a pretrial 

detainee. Gordon v. Cnty. of Orange, 888 F.3d 1118, 1120, 1122–

25 (9th Cir. 2018). The Second Circuit followed suit, applying 
No. 17-1603 23

the objective standard to detainees’ Fourteenth-Amendment 

complaints about their conditions of confinement; in the process it overruled a decision applying a subjective test to a 

medical-care claim. Darnell v. Pineiro, 849 F.3d 17, 34–35 

(2d Cir. 2017) (overruling Caiozzo v. Koreman, 581 F.3d 63 

(2d Cir. 2009)); see Wilson, 501 U.S. at 303 (medical care is a 

condition of confinement). Later, the Second Circuit expressly 

applied an objective standard to a claim of deliberate indifference to a serious medical condition. Bruno v. City of Schenectady, No. 16-1131, 2018 WL 1357377, at *2–*3 (2d Cir. Mar. 16, 

2018) (unpublished) (asking “whether a ‘reasonable person’ 

would appreciate the risk to which the detainee was subjected”). Other courts of appeals have contemplated the same 

reading of Kingsley. Richmond v. Huq, 885 F.3d 928, 938 n.3 

(6th Cir. 2018) (not applying Kingsley, which neither party 

raised, but recognizing the “shift in Fourteenth Amendment 

deliberate indifference jurisprudence [that] calls into serious 

doubt whether [the plaintiff] need even show that the individual defendant-officials were subjectively aware of her serious 

medical conditions and nonetheless wantonly disregarded 

them”).

The Eighth, Eleventh, and Fifth Circuits have chosen to 

confine Kingsley to its facts—that is, to Fourteenth-Amendment claims based on excessive-force allegations in a pretrial 

setting. E.g., Whitney v. City of St. Louis, 887 F.3d 857, 860 n.4 

(8th Cir. 2018); Dang by & through Dang v. Sheriff, Seminole 

Cnty., 871 F.3d 1272, 1279 n.2 (11th Cir. 2017); Alderson v. Concordia Parish Corr. Facility, 848 F.3d 415, 419 n.4 (5th Cir. 2017) 

(following circuit precedent and concluding that the issue 

was not directly raised). It is worth noting, however, that a 

concurring judge in Alderson advocated reconsideration of the 
24 No. 17-1603 

subjective standard to detainees’ other claims in light of 

Kingsley. Id. at 424–25 (Graves, J., specially concurring in part). 

Some circuits have continued to analyze inadequate medical treatment claims under the deliberate indifference standard without grappling with the potential implications of 

Kingsley. E.g., Duff v. Potter, 665 F. App’x 242, 244–45 (4th Cir. 

2016) (applying the objective reasonableness standard to a detainee’s excessive-force claim but not his medical-need claim, 

which it affirmed on forfeiture grounds). 

We have not yet expressly weighed in on the debate. Since 

Kingsley, we have continued to duplicate the Eighth Amendment inquiry for claims of deficient medical treatment. E.g., 

Phillips v. Sheriff of Cook Cnty., 828 F.3d 541, 554 n.31 (7th Cir. 

2016). But we have acknowledged that Kingsley has “called 

into question” our case law treating the “protections afforded 

by” the Eighth and Fourteenth Amendments as “‘functionally 

indistinguishable’ in the context of a claim about inadequate 

medical care.” Smego v. Jumper, 707 F. App’x 411, 412 (7th Cir. 

2017); accord Collins, 851 F.3d at 731. 

Because the answer may make a difference in the retrial of 

Gomes’s claims, we think it appropriate to address the proper 

standard at this time. We begin with the fact that the Supreme 

Court has been signaling that courts must pay careful attention to the different status of pretrial detainees. In this respect, 

Kingsley does not stand alone. See, e.g., Manuel v. City of Joliet, 

137 S. Ct. 911 (2017) (allowing Fourth Amendment challenges 

to pretrial detention even beyond the start of legal process). 

The Court has cautioned that the Eighth Amendment and 

Due Process analyses are not coextensive. See Kingsley, 

135 S. Ct. at 2475 (“The language of the two Clauses differs, 

and the nature of the claims often differs.”); Currie v. Chhabra, 
No. 17-1603 25

728 F.3d 626, 630 (7th Cir. 2013) (“[D]ifferent constitutional 

provisions, and thus different standards, govern depending 

on the relationship between the state and the person in the 

state’s custody.”). We see nothing in the logic the Supreme 

Court used in Kingsley that would support this kind of dissection of the different types of claims that arise under the Fourteenth Amendment’s Due Process Clause. To the contrary, the 

Court said that “[t]he language of the [Eighth and Fourteenth 

Amendments] differs, and the nature of the claims often differs. And, most importantly, pretrial detainees (unlike convicted prisoners) cannot be punished at all, much less ‘maliciously and sadistically.’” 135 S. Ct. at 2475 (citations omitted). 

We thus conclude, along with the Ninth and Second Circuits, 

that medical-care claims brought by pretrial detainees under 

the Fourteenth Amendment are subject only to the objective 

unreasonableness inquiry identified in Kingsley. 

Although the defendants failed to mention Parratt v. Taylor, 451 U.S. 527 (1981), overruled in part on other grounds by 

Daniels v. Williams, 474 U.S. 327, 330–31 (1986), and thus have 

forfeited any argument based on that case, we see nothing in 

Parratt that points in the opposite direction. There the Supreme Court held that plaintiffs may not bring claims under 

the Due Process Clause where state law provides an adequate 

remedy. 451 U.S. at 543–44. Though the Estate has brought 

state malpractice claims in addition to its due-process claim, 

the availability of parallel and even overlapping forms of recovery does not doom its constitutional claim. See Zinermon 

v. Burch, 494 U.S. 113, 124 (1990); Armstrong v. Daily, 786 F.3d 

529, 539 (7th Cir. 2015). Parratt applies only to certain procedural-due-process claims. The violation of which the Estate 

complains derives from the substantive aspect of the Due Process Clause. See Youngberg v. Romeo, 457 U.S. 307, 315–16 
26 No. 17-1603 

(1982); see also City of Revere v. Mass. Gen. Hosp., 463 U.S. 239, 

244 (1983); Collignon v. Milwaukee Cnty., 163 F.3d 982, 988 

(7th Cir. 1998). In this situation, there is no amount of process 

that would justify a decision to sit by and leave serious medical needs unattended. Parratt is thus beside the point. 

We also see no conflict between this application of Kingsley 

and the Supreme Court’s later decision in Daniels v. Williams, 

474 U.S. 327 (1986). Daniels overruled part of Parratt and held 

(or underscored) that negligent conduct does not offend the 

Due Process Clause. Id. at 330–31. The defendants here worry 

that an objective-reasonableness standard will impermissibly 

constitutionalize medical malpractice claims, because it 

would allow mere negligence to suffice for liability. A careful 

look at Kingsley, however, shows that this is not the case; the 

state-of-mind requirement for constitutional cases remains 

higher. 

Here is what the Court had to say about this problem in 

Kingsley: 

We consider a legally requisite state of mind. In a case 

like this one, there are, in a sense, two separate stateof-mind questions. The first concerns the defendant’s 

state of mind with respect to his physical acts—i.e., his 

state of mind with respect to the bringing about of certain physical consequences in the world. The second 

question concerns the defendant’s state of mind with 

respect to whether his use of force was “excessive.” 

Here, as to the first question, there is no dispute. As to 

the second, whether to interpret the defendant’s physical acts in the world as involving force that was “excessive,” there is a dispute. We conclude with respect 

to that question that the relevant standard is objective 
No. 17-1603 27

not subjective. Thus, the defendant’s state of mind is 

not a matter that a plaintiff is required to prove. 

135 S. Ct. at 2472. As applicable here, the first of those inquiries asks whether the medical defendants acted purposefully, 

knowingly, or perhaps even recklessly when they considered 

the consequences of their handling of Gomes’s case. See id. at 

2472, 2474 (discussing purposeful or knowing conduct and 

leaving open the possibility that recklessness would also suffice). The courts of appeals that have applied Kingsley to detainees’ claims in contexts other than excessive force have 

taken that step, while continuing to recognize that it will not 

be enough to show negligence or gross negligence. Gordon, 

888 F.3d at 1125 (under Kingsley, a detainee must “prove more 

than negligence but less than subjective intent—something 

akin to reckless disregard” (quoting Castro, 833 F.3d at 1071)); 

accord Darnell, 849 F.3d at 36 & n.16. As Kingsley instructs, the 

second step is the objective one. 

The allegations here easily fit the mold of Gordon, Darnell, 

and Castro. A properly instructed jury could find that 

Drs. Elazegui and Singh made the decision to continue observing Gomes in the jail, rather than transporting her to the 

hospital, with purposeful, knowing, or reckless disregard of 

the consequences. (The jury could also reject such a conclusion.) It would be a different matter if, for example, the medical defendants had forgotten that Gomes was in the jail, or 

mixed up her chart with that of another detainee, or if 

Dr. Elazegui forgot to take over coverage for Dr. Kim when 

he went on vacation. Such negligence would be insufficient to 

support liability under the Fourteenth Amendment, even 

though it might support state-law liability. Here, there is evidence that Drs. Elazegui and Singh deliberately chose a “wait 
28 No. 17-1603 

and see” monitoring plan, knowing that Gomes was neither 

eating nor drinking nor competent to care for herself. See Glisson, 849 F.3d at 380, 382 (recognizing inaction as a choice). Because the Estate does not claim merely negligent conduct, a 

jury must decide whether the doctors’ deliberate failure to act 

was objectively reasonable. 

 IV 

Any death is a great loss, but one as preventable as 

Gomes’s is especially disturbing. On this record, a jury could 

have found that the intentional and knowing inaction of 

Drs. Elazegui and Singh caused Gomes’s death. We therefore 

REVERSE and REMAND for new trial of the Estate’s claim 

against them, as it relates to Gomes’s death. We AFFIRM the 

district court’s grant of summary judgment to the County defendants.