[DO NOT PUBLISH]

In the

United States Court of Appeals

For the Eleventh Circuit

____________________

No. 21-12622

Non-Argument Calendar

____________________

CHRISTOPHER SANDERS, 

Plaintiff-Appellant,

versus

BRIAN STARLING, 

In his individual capacity, 

SEAN FOGARTY, 

In his individual capacity, 

LIEUTENANT WOODS, 

In his or her individual capacity, 

CRYSTAL WAITE,

BRYAN ALLEN, 

In his individual capacity, et al.,

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2 Opinion of the Court 21-12622

Defendants-Appellees,

CARRIE REED, et al.,

Defendants.

____________________

Appeal from the United States District Court

for the Middle District of Florida

D.C. Docket No. 3:19-cv-00430-MMH-JBT

____________________

Before GRANT, LUCK, and LAGOA, Circuit Judges.

PER CURIAM:

Christopher Sanders, a Florida prisoner proceeding pro se, 

appeals the district court’s dismissal of his complaint against two 

prison nurses, Crystal Waite and Sharron Braziel-Marshall. He 

alleges that both nurses violated the Eighth Amendment by 

subjecting him to cruel and unusual punishment, and that Waite 

retaliated against him for exercising his First Amendment rights. 

Because Sanders did not plead sufficient factual allegations to 

support his claims, we affirm.

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21-12622 Opinion of the Court 3

I. 

Sanders alleges that on January 27, 2017, while he was 

housed in the close management unit of the Florida State Prison, 

he witnessed the cell extraction team beat another inmate and 

signaled to a handheld camera that he had seen the beating.1 

Waite, who he says “used the cell extraction team” to abuse the 

inmate, told Sanders that because he “wanted to be a witness they 

had something for [him].” The next day, a prison officer came to 

Sanders’s cell and told him that he was being placed on property 

restriction because he had his window covered with a sheet. When 

Sanders stated that he did not have anything covering his window, 

the officer responded that he was refusing, and another officer put 

a chain on his cell door to restrict how far it could open. Waite 

then came to his cell and asked if he would come out. 

In response, Sanders told Waite that he was having a mental 

health emergency and swallowed a handful of Tegretol, an 

anti- seizure medication, in front of her. Waite stated that the pills 

were “just Ibuprofen” and walked away while Sanders remained in 

his cell. One of the officers then told Sanders that he was refusing 

a strip search while a second officer sprayed him with an 

unidentified chemical agent. Yet another officer grabbed Sanders’s

1 We “accept the allegations in the complaint as true and construe them in the 

light most favorable to the plaintiff,” and we liberally construe pro se 

pleadings. Cox v. Nobles, 15 F.4th 1350, 1357 (11th Cir. 2021); Henley v. 

Payne, 945 F.3d 1320, 1327 (11th Cir. 2019).

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4 Opinion of the Court 21-12622

arm while another slammed the cell door on it repeatedly, all while 

a different officer sprayed Sanders in his throat. Sanders exited his 

cell, and he fell to the ground because his knee had been slammed 

in the door and gave out. The cell extraction team picked him up 

and carried him to the shower, where they ran his head into the 

shower wall. After Sanders took a shower, the cell extraction team 

escorted him to the emergency medical area with handcuffs and 

shackles on.

Once Sanders was in the medical area, Waite told him that 

she would not place him on self-harm observation status. Sanders 

alleges that Waite “had the cell extraction team block the window 

so the camera couldn’t see what they were doing” and “had the cell 

extraction team” choke him, poke him in the eyes, punch him in 

the face, head, and ribs, and bend his fingers and his wrist, even 

though he was not resisting. After pumping his stomach, Waite 

refused to place him in a cell in the medical area on self-harm 

observation status, which Sanders claims violated protocol.

Sanders alleges that Waite and two officers had him placed 

in a cell without sheets, a mat, or a blanket, and with no clothes 

except boxer shorts. He claims that they chose that cell because

“they knew the window was broken and did not close, and it was 

extremely cold outside.” In Sanders’s telling, they left him there 

for three days in freezing temperatures, and he slept in a footlocker 

for warmth. He attempted to report “staff abuse” several times, 

but Waite refused to file an incident report. Sanders also says that 

the day after he was placed in the cold cell, he declared a medical 

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21-12622 Opinion of the Court 5

emergency and was treated for an injured shoulder and a cut on his 

head. He does not allege that he complained of the temperature.

In the several months that followed, Sanders swallowed 

more pills in successive attempted overdoses, had his stomach 

pumped multiple times, and tried to hang himself in the shower. 

He was treated by other nurses during that time.

On August 3, 2017, officers came to Sanders’s cell and again 

told him that they were placing him on property restriction for 

covering his window, which Sanders insisted he did not have 

covered. After an officer told him to submit to a strip search, 

Sanders again “swallowed a bunch of pills” and was taken to the 

medical area. Braziel-Marshall “jammed” ammonia up his nose 

until his nose bled. She and another nurse pumped his stomach 

until he started throwing up blood, and they refused to place him 

on self-harm observation status. Sanders was taken out of the 

medical area to the shower, where prison staff “sprayed” him 

(presumably with chemical agents) when he tried to hang himself. 

He was taken back to the medical area, and Braziel-Marshall gave 

him an emergency treatment order shot. Sanders attempted to 

walk out, but an officer stopped him by stepping on his shackles 

and making him fall. Braziel-Marshall then “jammed” ammonia 

into his nose again, and Sanders kicked her in the leg trying to get 

away. Officers punched him and poked him in the eyes, and then 

carried him into a dark room where they continued to beat him, 

resulting in a “busted” mouth, lip, and right eye. The eye injury 

led to a scar.

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Sanders filed a pro se complaint under 42 U.S.C. § 1983

against 19 staff members at the Florida State Prison, including the 

warden, a captain, several sergeants, and other officers. His 

complaint also included claims against four nurses. The district 

court dismissed the claims against six officers and each of the four

nurses, and Sanders filed a notice of appeal of the dismissal order 

relating to his claims against nurses Waite and Braziel-Marshall. 

Sanders then reached a settlement with the remaining defendants. 

The district court entered a final judgment dismissing the case with 

prejudice after the settling parties stipulated to a voluntary 

dismissal. We now address Sanders’s appeal of the dismissal of his 

claims against Waite and Braziel-Marshall. 

II. 

We review the district court’s dismissal of a complaint for 

failure to state a claim under Federal Rule of Civil Procedure 

12(b)(6) de novo. Cox v. Nobles, 15 F.4th 1350, 1356 (11th Cir. 

2021). “To survive a motion to dismiss, a complaint must contain 

sufficient factual matter, accepted as true, to state a claim to relief 

that is plausible on its face.” Ashcroft v. Iqbal, 556 U.S. 662, 678 

(2009) (quotation omitted). Facial plausibility exists “when the 

plaintiff pleads factual content that allows the court to draw the 

reasonable inference that the defendant is liable for the misconduct 

alleged.” Id. A plaintiff cannot rely on mere “labels and 

conclusions,” “a formulaic recitation of the elements of a cause of 

action,” or “naked assertions devoid of further factual 

enhancement.” Id. (quotations and brackets omitted).

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III. 

We first address Sanders’s claims against both nurses related 

to the medical treatment that they provided him. Sanders alleges 

that both Waite and Braziel-Marshall violated the Eighth 

Amendment by refusing to place him on self-harm observation 

status after he overdosed (Counts 11 and 13); observing him harm 

himself but not having him taken immediately to the medical area 

(Count 12); refusing to document his injuries (Count 16); and not 

treating his injuries (Count 17). He also claims that 

Braziel-Marshall violated the Eighth Amendment by pumping his 

stomach until he started throwing up blood (Counts 14 and 21).

The Eighth Amendment “prohibits deliberate indifference 

to serious medical needs of prisoners.” Hoffer v. Sec’y, Florida 

Dep’t of Corr., 973 F.3d 1263, 1270 (11th Cir. 2020) (quotation 

omitted). To show deliberate indifference, the inmate must prove 

that prison officials “(1) had subjective knowledge of a risk of 

serious harm; (2) disregarded that risk; and (3) acted with more 

than gross negligence.” Id. (quotation omitted); see also id. at 1270 

n.2 (explaining that “no matter how serious the negligence,

conduct that can’t fairly be characterized as reckless” is not 

sufficient to show deliberate indifference).

Deliberate indifference is “far more onerous than normal 

tort-based standards of conduct sounding in negligence.” Swain v. 

Junior, 961 F.3d 1276, 1288 (11th Cir. 2020) (quotation omitted). 

Medical care violates the Eighth Amendment “only when it is so 

grossly incompetent, inadequate, or excessive as to shock the 

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8 Opinion of the Court 21-12622

conscience or to be intolerable to fundamental fairness.” Harris v. 

Thigpen, 941 F.2d 1495, 1505 (11th Cir. 1991) (quotation omitted). 

The Constitution does not require that the medical care provided 

to prisoners be “perfect, the best obtainable, or even very good.” 

Id. at 1510 (quotation omitted). And “a simple difference in 

medical opinion between the prison’s medical staff and the inmate 

as to the latter’s diagnosis or course of treatment” does not support 

a claim of cruel and unusual punishment. Id. at 1505.

Sanders’s factual allegations about his course of treatment 

do not support a conclusion that the nurses acted with deliberate 

indifference to his serious medical needs. Instead, Sanders relates 

that the nurses provided him with medical care upon his arrival in 

the medical area after his overdoses, with no suggestion that they 

are responsible for his transport to the medical area. He claims that 

Braziel-Marshall pumped his stomach until he vomited blood, but 

he does not provide facts to support his claim that she performed 

that treatment in a reckless manner. 

As for the nurses’ decision not to put him on self-harm 

observation status, Sanders claims that Waite instead chose to put 

him in a different cell where he was able to declare medical 

emergencies, and he was placed on self-harm observation status 

after he was stopped from hanging himself in the shower following 

his treatment by Braziel-Marshall. At most, these claims amount 

to an assertion of negligence or disagreement with the nurses’ 

choice of treatment, so they fall short of deliberate indifference. 

See Hoffer, 973 F.3d at 1271; Harris, 941 F.2d at 1505.

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21-12622 Opinion of the Court 9

Sanders alleges no facts that are relevant to his claims that 

the nurses failed to document his injuries. In any event, 

shortcomings in the nurses’ documentation or their adherence to 

protocol amount to a claim that they violated prison regulations, 

not the Eighth Amendment. A “failure to follow procedures does 

not, by itself, rise to the level of deliberate indifference because 

doing so is at most a form of negligence.” Taylor v. Adams, 221 

F.3d 1254, 1259 (11th Cir. 2000). The district court correctly 

dismissed these Eighth Amendment claims.

IV. 

 In a second set of claims, Sanders asserts that Waite and 

Braziel-Marshall are liable for the abuse that prison officers 

inflicted. He alleges that both nurses refused to file an incident 

report and alert the administration to the abuse (Count 15), that 

Braziel-Marshall (Count 18) and both nurses (Count 16) together 

with other staff covered up the abuse, and that they conspired with 

other defendants to cause him physical and emotional harm in 

violation of the Eighth Amendment (Count 7).2

A prison official violates the Eighth Amendment by failing 

to prevent harm “only when a substantial risk of serious harm, of 

which the official is subjectively aware, exists and the official does 

not respond reasonably to the risk.” Bowen v. Warden Baldwin 

State Prison, 826 F.3d 1312, 1320 (11th Cir. 2016) (quotation 

2 Sanders alleges some staff violated his rights by failing to intervene and stop 

the acts of others, but those claims do not involve Waite or Braziel-Marshall. 

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omitted). An inmate must show that “(1) a substantial risk of 

serious harm existed; (2) the defendants were deliberately 

indifferent to that risk, i.e., they both subjectively knew of the risk 

and also disregarded it by failing to respond in an objectively 

reasonable manner; and (3) there was a causal connection between 

the defendants’ conduct and the Eighth Amendment violation.” Id. 

To prove a conspiracy under § 1983, “a plaintiff must show that the 

parties reached an understanding to deny the plaintiff his or her 

rights and prove an actionable wrong to support the conspiracy.” 

Bailey v. Bd. of Cnty. Comm’rs of Alachua Cnty., 956 F.2d 1112, 

1122 (11th Cir. 1992) (quotations and brackets omitted). The 

“linchpin for conspiracy is agreement, which presupposes 

communication.” Id.

Sanders alleges that prison officers unnecessarily abused him 

in the nurses’ presence while he was receiving medical care. So we 

cannot agree with the district court that Sanders failed to suggest 

that the nurses “witnessed abusive events that warranted the filing 

of incident reports.” But the failure to file an incident report, even 

if prison regulations require doing so, does not by itself amount to 

a constitutional violation. See Taylor, 221 F.3d at 1259. Sanders 

does not allege sufficient facts to support the conclusion that the 

nurses were “subjectively aware that he faced a substantial risk of 

serious harm,” or that their failure to file incident reports based on 

the abuse they witnessed was causally connected with any 

subsequent injury. Marbury v. Warden, 936 F.3d 1227, 1238 (11th 

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21-12622 Opinion of the Court 11

Cir. 2019); see also Valdes v. Crosby, 450 F.3d 1231, 1236–37 (11th 

Cir. 2006). 

Our case law does not indicate that medical personnel act 

with deliberate indifference when they fail to report instances of 

abuse by prison officers, especially absent any allegation of 

supervisory authority. See, e.g., Valdes, 450 F.3d at 1236–37. 

Sanders does not allege any facts to support his claims that the 

nurses concealed the abuse he experienced by refusing to 

document his injuries or by falsifying documents, so the district 

court did not err by dismissing those claims.

And we agree that Sanders did not adequately support his 

claim that an agreement existed between the nurses and the prison 

officers to engage in abusive conduct. Although he once states that 

Waite and a prison officer “had the cell extraction team” block the 

window and abuse him in the medical area, he does not provide 

any facts suggesting that Waite had the authority to direct their 

actions. Because Sanders’s factual allegations are not “enough to 

raise a right to relief above the speculative level,” the district court 

correctly dismissed the conspiracy claim. Bell Atl. Corp. v. 

Twombly, 550 U.S. 544, 555 (2007). 

V. 

We next address the claims that Sanders asserts against 

Waite in particular. First, Sanders alleges that Waite knowingly 

placed him in a cell with extremely cold temperatures without 

clothes, sheets, or blankets (Count 4). We assess challenges to 

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12 Opinion of the Court 21-12622

conditions of confinement under the Eighth Amendment using a 

two-part analysis. Chandler v. Crosby, 379 F.3d 1278, 1289 (11th 

Cir. 2004). Under the first (objective) prong, an inmate must prove 

that the condition is “sufficiently serious to violate the Eighth 

Amendment” by showing, at the very least, that the condition 

“poses an unreasonable risk of serious damage to his future health

or safety.” Id. (quotation and brackets omitted). 

And under the second (subjective) prong, the inmate must 

show that the prison official acted with deliberate indifference. Id. 

Again, negligence alone is not enough. The prison official can only 

be found liable for denying humane conditions of confinement if 

(1) the official “knows of and disregards an excessive risk to inmate 

health or safety”; (2) the official is “aware of facts from which the 

inference could be drawn that a substantial risk of serious harm 

exists”; and (3) the official draws that inference. Id. at 1289–90 

(quotation omitted).

The district court reasoned that even if Sanders satisfied the 

first prong of the analysis by showing an objectively extreme 

condition, he failed to satisfy the subjective prong. We agree. 

Sanders did not provide facts supporting an inference that Waite 

knew of, but disregarded, a substantial risk of harm. His complaint 

rests largely on Waite’s decision not to place him in a cell in the 

medical unit on self-harm observation status. To the extent he 

alleges that Waite had authority over cell assignment beyond that 

decision, he does not allege that Waite was responsible for 

monitoring his cell conditions or provide facts to support his claim 

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that she knew about the cell’s cold temperature. He also does not 

allege that he alerted her to his discomfort due to the cold 

temperature—even though he did seek medical attention for a 

shoulder injury and a cut on his head the day after he was placed in 

the cell.

Second, Sanders claims that Waite retaliated against him for 

exercising his First Amendment rights after he indicated to a 

camera that he witnessed the cell extraction team beat another 

inmate (Counts 5 and 8).3 To prevail on a First Amendment 

retaliation claim, an inmate must establish that (1) “his speech was 

constitutionally protected”; (2) “the inmate suffered adverse action 

such that the official’s allegedly retaliatory conduct would likely 

deter a person of ordinary firmness from engaging in such speech”; 

and (3) “there is a causal relationship between the retaliatory 

action” and “the protected speech.” O’Bryant v. Finch, 637 F.3d 

1207, 1212 (11th Cir. 2011) (quotation and brackets omitted); Smith 

v. Mosley, 532 F.3d 1270, 1276 (11th Cir. 2008). A plaintiff must 

establish that “the protected conduct was a motivating factor 

behind the harm” before the burden shifts to the defendant to show 

that she “would have taken the same action in the absence of the 

protected activity.” Smith v. Florida Dep’t of Corr., 713 F.3d 1059, 

1063 (11th Cir. 2013).

3 Sanders’s complaint characterized these counts as Eighth Amendment 

violations, but the district court reframed them as First Amendment claims. 

Sanders did not challenge this recharacterization on appeal. 

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14 Opinion of the Court 21-12622

Although Sanders alleges retaliatory actions by prison 

officers—who he says unjustly put him on property restriction, 

sprayed him with chemical agents, and used excessive force during 

his Tegretol incident—Waite was not plausibly responsible for any 

of those acts. She was not even present for any except the first, 

when a captain issued the property restriction order in her 

presence. Consequently, these acts cannot form the basis of a 

§ 1983 claim against her. See Zatler v. Wainwright, 802 F.2d 397, 

401 (11th Cir. 1986). What Sanders plausibly alleges is that she 

knew he should have been on observation status because of the 

Tegretol, but nevertheless declined to place him on that status

(even though she ultimately provided treatment). Assuming that

Sanders’s speech was constitutionally protected and to the extent 

that any mistreatment occurred, Sanders does not plausibly allege 

that Waite’s actions were taken in response to or were motivated 

by his speech.

Third, Sanders claims that Waite unlawfully sprayed him 

with chemical agents (Count 9). No factual allegation supports that 

claim: Sanders alleges that other defendants sprayed him, but not 

Waite. As the district court correctly concluded, Sanders “provides 

no facts suggesting” that Waite “had the authority to direct the 

extraction team to physically abuse Sanders.” We agree that 

Sanders did not state a plausible claim against Waite.

* * *

We AFFIRM the dismissal of Sanders’s complaint against 

Waite and Braziel-Marshall.

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