Opinion ID: 6343803
Heading Depth: 3
Heading Rank: 2

Heading: Deputy Dalrymple

Text: The district court also granted summary judgment to Deputy Dalrymple, concluding he, too, was entitled to qualified immunity on the Estate’s deliberate indifference claim. We agree with the Estate that the district court erred. The Estate has carried its burden to meet the two-part qualified immunity test, see Gutteridge, 878 F.3d at 1238, and Deputy Dalrymple’s motion for summary judgment based on qualified immunity should have been denied.
As the district court acknowledged, there was a “ten-minute delay between when [Deputy Dalrymple] saw Mr. Beauford lying on the floor of his cell at 12:15 a.m. and when he alerted the nursing staff to this fact.” Aplt. App. vol. 12 at 3304. The district court excused Deputy Dalrymple’s delay in calling for medical help, however, reasoning “the mere fact that an officer observes a prisoner laying on the floor in the middle of the night is not, itself, enough to make it obvious to any lay person that immediate medical attention is required.” Id. The district court concluded the Estate had failed to show a constitutional violation. 13 Under these circumstances, we need not reach the Estate’s allegation of error concerning the second prong of qualified immunity as applied to the claim against Deputy Perkinson. See Pearson, 555 U.S. at 236 (courts may address either prong of the qualified immunity test first). 22 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 23 The Estate contends the district court erred in its deliberate-indifference analysis by focusing only on the “mere fact” that Deputy Dalrymple observed Mr. Beauford motionless on the floor of his cell. As the Estate points out, Deputy Dalrymple waited ten minutes to summon medical assistance even though, at approximately 12:15 a.m., he was unsure if Mr. Beauford was breathing. The district court’s failure to account for this fact and view it in the light most favorable to the nonmovant, the Estate argues, is reversible error. We agree. During the 11:55 p.m. security check, Deputy Dalrymple looked into Mr. Beauford’s cell and noticed the light was shut off. Deputy Dalrymple used his flashlight to illuminate Mr. Beauford and watched him for a few moments. He observed Mr. Beauford lying on the floor, facedown, with his head under his desk. In an interview statement given shortly after Mr. Beauford’s death, Deputy Dalrymple said he was not concerned at the time about Mr. Beauford’s sleeping position because “he ha[d] seen Mr. Beauford sleep in strange positions both on the floor and bed” so it was not “that unusual for him.” Aplt. App. vol. 8 at 2282. He also stated he “believe[d] he saw Mr. Beauford’s covers rising and falling indicating breathing.” Id. At about 12:15 a.m., Deputy Dalrymple conducted his next security round. He “only waited about 15 minutes”—instead of the usual 30 minutes—so he could “double check” on Mr. Beauford. Id. When interviewed on the night of Mr. Beauford’s death, Deputy Dalrymple stated that, around 12:15 a.m., he looked inside Mr. Beauford’s cell and “did not see any movement.” Id. He “knocked on the door trying to get a response, but did not get any.” Id. At this time, Deputy Dalrymple 23 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 24 “could not tell for sure if Mr. Beauford was breathing or not, so he returned to his officer station and got on the intercom trying to raise Mr. Beauford with negative results.” Id. at 2282-83. Deputy Dalrymple said he “then got on the radio and asked for the nurse and another deputy to respond to help his check on Mr. Beauford.” Id. Approximately ten minutes later, at 12:25 a.m.,14 Deputy Dalrymple returned with Nurse Workman, and together they entered Mr. Beauford’s cell. Deputy Dalrymple’s deposition testimony, however, suggests he may have thought Mr. Beauford was breathing at 12:15 a.m.: I decided to, at the time, you know, because of what happened earlier and with what Deputy Perkinson experienced with [Mr. Beauford] and previous briefings before, hearing that he had had medical events, I thought I would look into it a little bit more, which was why I did another security check starting at 12:15, you know, and walked around. And noticed that Mr. Beauford, as I came to his cell, he was in the same position. I used my flashlight, thought that, you know, he was—and it looked like his chest was rising and falling. He wasn’t uncontrollably shaking. So I even knocked on the door a couple times. “Mr. Beauford?” “Mr. Beauford?” Got no response. It’s not uncommon for inmates when they sleep, that they sleep hard and they don’t hear you initially. So I continued on to finish the security check. Which prompted me to contact the nursing staff. Because I was not there to observe him when he had his medical event with Deputy Perkinson, I contacted the medical staff and said, Okay, what’s normal? You know, is this normal, or is this not normal? So I deferred to Nurse [Workman]. ... 14 The video summary shows Deputy Dalrymple and Nurse Workman entered Mr. Beauford’s cell at 12:28 a.m. Aplt. App. vol. 8 at 2383. 24 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 25 I go back with Nurse [Workman]. We go back to the cell. She looks in, and automatically—and looked at me and says, Start—muttered, Oh, shit, start CPR compressions. Aplt. App. vol. 8 at 2310. The focus of the subjective component of the deliberate indifference inquiry is the mental state of the defendant regarding the risk of harm. See Prince, 28 F.4th at 1044. Whether Deputy Dalrymple “kn[ew] of and disregard[ed] an excessive risk to inmate health or safety,” Sealock, 218 F.3d at 1209 (quoting Farmer, 511 U.S. at 837), turns on his awareness, at approximately 12:15 a.m., that Mr. Beauford may not have been breathing, see Mata, 427 F.3d at 752 (whether a prison official knew of a substantial risk is a question of fact). According to his interview statement, Deputy Dalrymple was not sure whether Mr. Beauford was breathing at 12:15 a.m. Notwithstanding this uncertainty, Deputy Dalrymple waited ten minutes, completing his security check before seeking medical assistance for Mr. Beauford. But according to his deposition testimony, Deputy Dalrymple thought Mr. Beauford may have been breathing at 12:15 a.m. but was just nonresponsive. Any doubt about whether Mr. Beauford was in “obvious” medical distress is resolved by Nurse Workman’s reaction when she arrived at Mr. Beauford’s cell at around 12:25 a.m.: “She looks in [to Mr. Beauford’s cell], and automatically . . . muttered, Oh, shit, start CPR compressions.” Aplt. App. vol. 8 at 2310 (emphasis added). The standard of review requires us “to view the facts and draw reasonable inferences ‘in the light most favorable to the party opposing the [summary judgment] motion.’” Scott, 550 U.S. at 378 (alteration in original) (citation omitted). “In 25 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 26 qualified immunity cases, this usually means adopting . . . the plaintiff’s version of the facts,” id., unless it is “blatantly contradicted by the record, so that no reasonable jury could believe it,” id. at 380. When the facts in the summary judgment record, and all reasonable inferences to be drawn from those facts, are viewed in the Estate’s favor, a reasonable jury could believe Deputy Dalrymple acted with deliberate indifference by waiting ten minutes to call for medical help even though he knew Mr. Beauford might not be breathing. A delay in medical care “only constitutes an Eighth Amendment violation where the plaintiff can show the delay resulted in substantial harm.” Oxendine v. Kaplan, 241 F.3d 1272, 1276 (10th Cir. 2001) (citation omitted). The substantial harm requirement “may be satisfied by lifelong handicap, permanent loss, or considerable pain.” Garrett, 254 F.3d at 950. Here, Mr. Beauford died. But our conclusion that substantial harm can result from a ten-minute delay in securing medical attention for an inmate who may not be breathing does not depend on the benefit of hindsight. See Mata, 427 F.3d at 752 (deliberate indifference does not require a corrections officer to “believ[e] that harm actually would befall an inmate; it is enough that the official acted or failed to act despite his knowledge of a substantial risk of serious harm”) (citation and emphasis omitted); see also Gordon ex rel. Gordon v. Frank, 454 F.3d 858, 862 (8th Cir. 2006) (“Intentional delay in providing medical treatment shows deliberate disregard if a reasonable person would know that the inmate requires medical attention or the actions of the officers are so dangerous that a knowledge of the risk may be presumed.”). 26 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 27 Whether Deputy Dalrymple was aware Mr. Beauford may not have been breathing at 12:15 a.m. raises a material factual dispute directly relevant to the qualified immunity analysis that precludes summary judgment. While we take no position on the merits, this genuine dispute of material fact undermines the district court’s conclusion that the Estate has not satisfied its burden to show a constitutional violation at summary judgment. See Olsen, 312 F.3d at 1312 (“When the record shows an unresolved dispute of historical fact relevant to [the qualified] immunity analysis, a motion for summary judgment based on qualified immunity should be properly denied.”) (internal citation omitted)). Accordingly, on de novo review, we conclude the Estate has satisfied its burden on the first prong of qualified immunity, and the district court erred in concluding otherwise.
We now turn to the second prong of the qualified immunity analysis. “‘[T]he salient question . . . is whether the state of the law’ at the time of an incident provided ‘fair warning’ to the defendants ‘that their alleged [conduct] was unconstitutional.’” Tolan v. Cotton, 572 U.S. 650, 656 (2014) (alterations in original) (quoting Hope v. Pelzer, 536 U.S. 730, 741 (2002)). “[F]or the law to be clearly established, there must be a Supreme Court or Tenth Circuit decision on point, or the clearly established weight of authority from other courts must have found the law to be as the plaintiff maintains.” Halley v. Huckaby, 902 F.3d 1136, 1149 (10th Cir. 2018) (citation omitted). Clearly established law should not be defined “at a high 27 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 28 level of generality,” Mullenix v. Luna, 577 U.S. 7, 12 (2015) (quoting Ashcroft v. al-Kidd, 563 U.S. 731, 742 (2011)), and should be “particularized to the facts of the case,” White v. Pauly, 137 S. Ct. 548, 552 (2017) (internal quotation marks omitted). “It is not enough that a rule be suggested by then existing precedent; the ‘rule’s contours must be so well defined it is clear to a reasonable [official] that his conduct was unlawful in the situation he confronted.’” City of Tahlequah v. Bond, 142 S. Ct. 9, 11 (2021) (quoting District of Columbia v. Wesby, 138 S. Ct. 577, 590 (2018)). “[T]here is little doubt that deliberate indifference to an inmate’s serious medical need is a clearly established constitutional right.” Mata, 427 F.3d at 749; see, e.g., Sealock, 218 F.3d at 1210-11 (concluding shift commander’s inaction constituted deliberate indifference where inmate stated he might be having a heart attack and displayed symptoms consistent with a heart attack). But more specifically, “failing to provide . . . life-saving measures to an inmate in obvious need can provide the basis for liability under § 1983 for deliberate indifference.” Sandoval v. Cnty. of San Diego, 985 F.3d 657, 678-79 (9th Cir. 2021) (citation omitted) (alteration in original). This includes delay—even brief delay—in summoning medical assistance, resulting in either unnecessary pain or a worsening of the prisoner’s condition. Mata, 427 F.3d at 755; see also Bozeman v. Orum, 422 F.3d 1265, 1273 (11th Cir. 2005) (“A delay in care for known unconsciousness brought on by asphyxiation is especially time-sensitive and must ordinarily be measured not in hours, but in a few minutes.”), abrogated on other grounds by Kingsley v. Hendrickson, 576 U.S. 389 (2015); McRaven, 577 F.3d at 983 (seven-minute delay); Estate of Bradich v. City of 28 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 29 Chicago, 413 F.3d 688, 691-92 (7th Cir. 2005) (holding a ten-minute delay in summoning assistance for inmate who had hanged himself could support finding of deliberate indifference); Tlamka v. Serrell, 244 F.3d 628, 633-34 (8th Cir. 2001) (holding a ten-minute delay in providing CPR or any other form of assistance to unconscious inmate could support finding of deliberate indifference). The district court concluded the Estate failed to identify “a relevant case putting Deputy Dalrymple on notice that he needed to immediately call for help after seeing Mr. Beauford on the floor of his cell, which, as explained, was a common occurrence.” Aplt. App. vol. 12 at 3307 (district court’s emphasis). But, as we explained, the district court’s framing was factually incomplete and thus misdirected the clearly-established-law inquiry. The relevant case here is not one that would have required Deputy Dalrymple to summon assistance immediately because Mr. Beauford was lying on the floor of his cell. Rather, the question is whether Deputy Dalrymple should have been on notice that the Constitution does not permit a ten-minute delay in seeking medical help for an inmate who he knows may not be breathing. Here, the contours of the right are clearly established such that any reasonable officer in the situation Deputy Dalrymple confronted at 12:15 a.m. would know that delay could violate the Constitution. See Estate of Booker v. Gomez, 745 F.3d 405, 434 (10th Cir. 2014) (denying qualified immunity where officers delayed seeking medical care for three minutes after their use of force left inmate “limp and unconscious”); Estate of Owensby v. Cincinnati, 414 F.3d 596, 603 (6th Cir. 2005) (holding that arresting officers’ six-minute delay in seeking medical care for arrestee 29 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 30 who died of asphyxiation could evince deliberate indifference); McRaven, 577 F.3d at 983 (denying qualified immunity where officer “made no attempt to resuscitate” the prisoner “for seven minutes before paramedics arrive[d]”); Bozeman, 422 F.3d at 1273 (“We also conclude that the Officers, who knew [the prisoner] was unconscious and not breathing and who then failed for fourteen minutes to check [his] condition, call for medical assistance, administer CPR or do anything else to help, disregarded the risk facing [him] in a way that exceeded gross negligence.”); Tlamka, 244 F.3d at 633 (“Based on the obvious and serious nature of [the inmate’s] condition, the corrections officers’ alleged failure to even approach [the inmate] during the maximum 10-minute period would rise to a showing of deliberate indifference.”). For these reasons, we also conclude the Estate has satisfied its burden on the second prong of the qualified immunity test—to show Deputy Dalrymple violated a clearly established constitutional right.
Because Deputy Dalrymple asserted a qualified immunity defense at summary judgment, the burden shifted to the Estate to demonstrate on the facts alleged that (1) Deputy Dalrymple acted with deliberate indifference to Mr. Beauford’s serious medical needs in violation of the Fourteenth Amendment, and (2) that the right was clearly established at the time of the alleged misconduct. See Riggins, 572 F.3d at 1107. As we have explained, the Estate has carried its burden to meet this two-part test. See Gutteridge, 878 F.3d at 1238. Even when qualified immunity is at issue, the 30 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 31 defendant still must show that no material facts remain in dispute that would defeat the qualified immunity defense. Whether Deputy Dalrymple was aware that Mr. Beauford was not breathing is a material fact in genuine dispute. We cannot imagine a more material fact in the context of the Estate’s deliberate indifference claim than whether Deputy Dalrymple knew of the risk that Mr. Beauford was not breathing. The district court failed to account for this dispute, which a reasonable jury could resolve in favor of the Estate. Under these circumstances, we must reverse the district court’s grant of summary judgment to Deputy Dalrymple. 2. The district court did not err by granting summary judgment to the Individual Medical Defendants. a. The Estate’s Claims Against Dr. Holmes and Mr. LeFebre We turn now to the Estate’s contentions of error surrounding the district court’s grant of summary judgment in favor of the medical staff at MCDF,15 beginning with Dr. Holmes and Mr. LeFebre—the two defendants who oversaw the care Mr. Beauford received during his detention. The district court ruled the evidence 15 The Estate has taken a kitchen-sink approach to its appellate contentions concerning the grant of summary judgment to the medical staff at MCDF. For example, the Estate maintains the nurse defendants practiced beyond the scope of their abilities and failed to provide appropriate care for Mr. Beauford’s seizures or change his course of treatment. These arguments are presented in a conclusory manner without factual and legal development, so we decline to address them. See Stuart v. Erickson Living Mgmt., 822 F. App’x 682, 684 (10th Cir. 2020) (“We ‘will not consider such issues adverted to in a perfunctory manner, unaccompanied by some effort at developed argumentation.’”) (quoting United States v. Wooten, 377 F.3d 1134, 1145 (10th Cir. 2004)); United States v. Davis, 622 F. App’x 758, 759 (10th Cir. 2015) (“[I]t is not this court’s duty, after all, to make arguments for a litigant that he has not made for himself.”). 31 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 32 was insufficient to establish Dr. Holmes or Mr. LeFebre acted with deliberate indifference to Mr. Beauford’s serious medical needs. The Estate challenges this ruling on appeal, contending Dr. Holmes and Mr. LeFebre were deliberately indifferent by depriving Mr. Beauford of access to his VNS bracelet and failing to forcibly medicate him, transfer him to another facility, and ensure he received appropriate psychiatric care. Viewing the facts in the light most favorable to the Estate, we discern no error in the district court’s ruling. “[A]bsent an extraordinary degree of neglect,” the subjective component of the deliberate-indifference test is not satisfied “where a doctor merely exercises his considered medical judgment.” Self, 439 F.3d at 1232. “So long as a medical professional provides a level of care consistent with the symptoms presented by the inmate, absent evidence of actual knowledge or recklessness, the requisite state of mind cannot be met.” Id. at 1233. Applying de novo review, we disagree with the Estate that Dr. Holmes and Mr. LeFebre acted with deliberate indifference.16 Rather, the evidence supports the conclusion they exercised medical judgment. For example, the Estate insists 16 We take no position on whether any of the Individual Medical Defendants were medically negligent in providing (or failing to provide) care to Mr. Beauford. See, e.g., Estelle, 429 U.S. at 105-06 (The “inadvertent failure to provide adequate medical care” or “a complaint that a physician has been negligent in diagnosing or treating a medical condition does not state a valid claim of medical mistreatment under the Eighth Amendment.”); Self, 439 F.3d at 1233 (“[N]egligent failure to provide adequate medical care, even one constituting medical malpractice, does not give rise to a constitutional violation.”) (quoting Perkins v. Kan. Dep’t of Corr., 165 F.3d 803, 811 (10th Cir. 1999)). 32 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 33 Dr. Holmes and Mr. LeFebre should have pursued a forcible medication order because Mr. Beauford only took his anti-seizure medication half the time. But as the district court properly found, the evidence shows Mr. Beauford “had responded for the most part to less-intrusive methods of encouragement.” Aplt. App. vol. 12 at 3314. But see Estate of Wright v. Lake City, No. 2:13-CV-333 JVB, 2017 WL 3896270, at  (N.D. Ind. Sept. 6, 2017) (concluding doctors should have considered “more aggressive measures” where inmate was “repeatedly refus[ing] medication and treatment against his own interest,” but “the medical staff did little more than chart [the inmate’s] downward spiral”). And despite his refusals, Mr. Beauford continued to receive medical care. Likewise, as Defendant CHC correctly observes on appeal, Dr. Holmes and Mr. LeFebre considered—but ultimately decided against—transferring Mr. Beauford to another facility or referring him to a psychiatrist. Both defendants explained that inmates were considered for transfers or referrals when they exhibited certain behaviors that posed a risk to themselves or others. But in their view, Mr. Beauford never exhibited such behaviors. Aplt. App. vol. 6 at 1614, 1737. Given this explanation, a reasonable jury could not infer conscious disregard for Mr. Beauford’s serious medical needs. Self, 439 F.3d at 1232-34. And regarding access to the VNS bracelet, our de novo review of the record confirms the district court’s conclusion: Mr. LeFebre was the only medical defendant who definitively knew Mr. Beauford had a VNS bracelet when he came to the jail. And it is undisputed he believed Mr. Beauford was allowed to have access to the 33 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 34 bracelet but chose not to wear it. Aplt. App. vol. 6 at 1736. The Estate has shown no evidence to suggest Dr. Holmes was also aware the bracelet existed, let alone that he or Mr. LeFebre took particular steps to deprive Mr. Beauford of it. Although the Estate disagrees with Dr. Holmes and Mr. LeFebre, a “mere difference of opinion over matters of expert medical judgment or a course of medical treatment fails to rise to the level of a constitutional violation.” Strain v. Regalado, 977 F.3d 984, 996 (10th Cir. 2020) (quoting Johnson v. Leonard, 929 F.3d 569, 576 (8th Cir. 2019)). Nor will we “freely substitute [our] judgment” for that of Dr. Holmes or Mr. LeFebre or “otherwise second-guess [their] course of treatment with the benefit of hindsight.” Id. (alteration in original) (quoting Redmond v. Crowther, 882 F.3d 927, 938 (10th Cir. 2018)). The Estate makes two other appellate arguments, singling out Dr. Holmes and Mr. LeFebre for particular decisions they made (or failed to make) about Mr. Beauford’s care. Neither is availing. Regarding Dr. Holmes, the Estate contends he was deliberately indifferent by failing to draw and test Mr. Beauford’s blood to monitor for therapeutic levels of anti-seizure medication in his bloodstream. There is no dispute Mr. Beauford’s blood was never drawn—that clearly violates CHC policy. But a policy violation, without more, is not a constitutional violation. See Mata, 427 F.3d at 760. And the Estate has identified no evidence suggesting Dr. Holmes disregarded Mr. Beauford’s serious medical needs by failing to conduct these blood tests. This absence of evidence undermines an essential component of the Estate’s deliberate indifference claim: 34 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 35 Dr. Holmes’s subjective intent. Given these evidentiary shortcomings, and because the decision to conduct specific testing generally falls within the bounds of medical judgment, see Self, 439 F.3d at 1232, we discern no error in the grant of summary judgment to Dr. Holmes. Finally, the Estate asserts Mr. LeFebre violated Mr. Beauford’s constitutional rights by housing him in “solitary confinement.”17 Aplt. Opening Br. at 65-66. The district court rejected this argument, concluding there was insufficient evidence Mr. Beauford was housed in a single cell “out of indifference to the effects on him, rather than because [MCDF] believed the benefits outweighed the costs.” Aplt. App. vol. 12 at 3325. We agree with the district court. On appeal, the Estate advances conclusory assertions but points to no evidence from which a jury could reasonably infer Mr. LeFebre knew that a single-cell housing placement presented a substantial risk to Mr. Beauford’s health and safety.18 For instance, Mr. LeFebre explained MCDF considered Mr. Beauford “a vulnerable 17 To the extent the Estate asks us to hold that placing inmates with Mr. Beauford’s health conditions in solitary confinement or single cells is per se deliberate indifference, we decline to do so in this case. But see Crane v. Utah Dep’t of Corr., 15 F.4th 1296, 1306 (10th Cir. 2021) (discussing district court cases from before 2014 holding “that isolating mentally ill inmates in conditions that seriously and predictably exacerbate their mental illness is cruel and unusual when the official has subjective knowledge of both the mental illness and the impact of isolation”). 18 Citing its experts, the Estate maintains that, as a general matter, housing an individual with medical and mental health conditions in solitary confinement is inappropriate. Aplt. Opening Br. at 17 (citing Aplt. App. vol. 7 at 1921-22, 1958). A reasonable jury could not infer from such generalized assertions that Mr. LeFebre acted with deliberate indifference in this case. 35 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 36 inmate that would be taken advantage of by other inmates.” Aplt. App. vol. 6 at 1712. Placing Mr. Beauford in a single cell separated him from other inmates and ensured he was “housed in a safe environment.” Id. Our de novo review confirms Mr. LeFebre’s decision about Mr. Beauford’s housing placement was an exercise of professional medical judgment and thus does not satisfy the subjective component of the deliberate indifference test. See Self, 439 F.3d at 1232. Accordingly, we affirm the grant of summary judgment to Dr. Holmes and Mr. LeFebre. b. The Estate’s Claims Against the Nurses The Estate also challenges the district court’s ruling that defendant Nurses Workman, Havens, Keenan, and Schans were not deliberately indifferent to Mr. Beauford’s serious medical needs. According to the Estate, the evidence shows the nurses—together—evinced deliberate indifference to Mr. Beauford’s serious medical needs when they (1) failed to elevate concerns about Mr. Beauford’s seizures and medication refusals to Dr. Holmes, (2) practiced beyond the scope of their abilities, (3) failed to monitor Mr. Beauford’s medications through blood draws, (4) deprived Mr. Beauford of his VNS bracelet, and (5) failed to intervene to prevent Mr. Beauford from refusing his medications. We reject this challenge. It is the Estate’s burden under § 1983 to establish what each defendant actually did and how that act (or omission) violated Mr. Beauford’s constitutional rights. See Pahls v. Thomas, 718 F.3d 1210, 1225-26 36 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 37 (10th Cir. 2013). As the nurses correctly argue, the Estate fails at a fundamental level to explain who is alleged to have done what; instead, the Estate simply groups the nurses together without, as required, “identify[ing] specific actions taken by particular defendants.” Id. at 1226 (citation omitted). For example, the Estate contends the nurses generally knew Mr. Beauford “had an implanted VNS device with a bracelet that was required for its activation” but they deprived him of access to it. Aplt. Opening Br at 54. For support, the Estate cites deposition testimony from Nurses Schans and Keenan. But that testimony reflects only these two defendants knew Mr. Beauford had an implanted VNS device, not a bracelet to activate it. And it says nothing about what Nurses Workman and Havens knew nor does it suggest either nurse actually deprived Mr. Beauford of his bracelet. The Estate also asserts the nurses “knew about [Mr.] Beauford’s medication refusals” but “did nothing more than continu[e] to ineffectually offer [Mr.] Beauford his medications.” Aplt. Opening Br. at 57-58. This contention is general and vague, and it fails to account for the varying levels of involvement each nurse had in Mr. Beauford’s care. We discern no error in the district court’s grant of summary judgment to the nurses. The Estate also challenges the district court’s ruling regarding the subjective prong as it applies to Nurse Workman’s conduct on the night Mr. Beauford died in custody. The Estate contends Nurse Workman acted with deliberate indifference by repeatedly failing to provide or to refer Mr. Beauford for adequate medical care— emergency or otherwise. The Estate highlights three occasions on the evening of Mr. 37 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 38 Beauford’s death when Nurse Workman allegedly should have, but failed, to do more: (1) after Mr. Beauford suffered a five-minute seizure at 8:40 p.m.; (2) when Deputy Dalrymple observed Mr. Beauford shaking in his cell around 9:00 p.m. and Nurse Workman opined he would be fine without checking on him; and (3) at 12:25 a.m. when she waited for another deputy to respond before entering Mr. Beauford’s cell to discover he was dead. Viewing the record in the light most favorable to the Estate, we agree Nurse Workman should have notified Dr. Holmes about Mr. Beauford’s seizure at 8:40 p.m. An internal report documenting the incident states, “If [a] patient with a known seizure disorder has a seizure and it resolves without consequence call the provider” with a checkmark next to that statement, suggesting it was done. Aplt. App. vol. 7 at 1889. Yet the evidence is clear that Nurse Workman never notified Dr. Holmes. Rather, as we described, Nurse Workman and Deputy Perkinson entered Mr. Beauford’s cell and cared for him until his seizure ended. Nurse Workman “made sure he was safe [and] breathing. When the seizure stopped, [she] made sure he wasn’t injured.” Id. at 1831. She asked Mr. Beauford if he needed anything and tried to take his vitals, but he refused. She returned with Deputy Perkinson to check on Mr. Beauford thirty minutes later, but he “still refused to let [her] check his vital signs.” Aplt. App. vol. 6 at 1548; vol. 8 at 2284. She noted no “injuries” or “distress,” and believed “officers will notify medical if they note any problems.” Aplt. App. vol. 6 at 1548. 38 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 39 Although medical judgment and misdiagnosis can cross the line into a denial of care amounting to deliberate indifference, we conclude, under the circumstances here, that Nurse Workman’s treatment of Mr. Beauford did not go so far. Cf. Mata, 427 F.3d at 758 (holding where medical provider had knowledge inmate was suffering chest pain, it would be more than malpractice or negligence not to call an ambulance). Here, the Estate fails to show how Nurse Workman disregarded Mr. Beauford’s wellbeing, where the record shows she was with him during his seizure, remained with him immediately afterward, and returned thirty minutes later to check on him. And according to her observations of Mr. Beauford’s condition, she believed his seizure had resolved and he was no longer in medical distress. See Self, 439 F.3d at 1233 (“[O]ur subjective inquiry is limited to consideration of the doctor’s knowledge at the time [they] prescribed treatment for the symptoms presented, not to the ultimate treatment necessary.”). Yet the Estate insists “there is ample evidence from which a jury could conclude that promptly calling paramedics was the only medically acceptable option for [Nurse] Workman, yet she consciously chose not to” do so. Aplt. Opening Br. at 48-49 (internal quotation marks omitted). We are not persuaded. A conclusory assertion that ample evidence exists does not make it so. The Estate offers no record citations to support its argument nor have we discerned that any such evidence exists in our independent review. At most, the Estate’s argument reflects a difference of opinion over whether Mr. Beauford should have been sent to a hospital—a scenario that cannot support deliberate indifference. See Petties v. Carter, 836 F.3d 722, 729 39 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 40 (7th Cir. 2016) (“[E]vidence that some medical professionals would have chosen a different course of treatment is insufficient to make out a constitutional claim.”). The Estate’s other two arguments concerning Nurse Workman also fail. First, the evidence shows Nurse Workman checked on Mr. Beauford after Deputy Dalrymple reported seeing him shaking in his cell. Given Nurse Workman’s more recent visit to Mr. Beauford’s cell, we conclude she was not deliberately indifferent when opining his condition was “fine.” Aplt. App. vol. 8 at 2282. The Estate next contends that “[r]ather than responding emergently, [Nurse] Workman waited for another deputy to arrive before going into [Mr. Beauford’s] cell” at 12:25 a.m. Aplt. Opening Br. at 48. But a written summary of the video surveillance footage states otherwise: “At 0028 hrs. on 041614 Deputy Dalrymple and Nurse Workman return to [Mr. Beauford’s cell] and enter the cell, Deputy Dalrymple stays in the cell as Nurse Workman leaves for about a minute, then Nurse Workman returns carrying an item and many other deputies arrive to the scene at about 0030 hrs. on 041614.” Aplt. App. vol. 8 at 2283. The Estate’s arguments are contradicted by the record. We affirm the grant of summary judgment for the defendant nurses. D. The Estate’s Municipal Liability Claim under § 1983 A municipality cannot be liable under Monell v. Department of Social Services of New York, 436 U.S. 658, 691 (1978), “solely because it employs a tortfeasor—or, in other words, a municipality cannot be held liable under a respondeat superior theory.” Rather, to be held liable the municipality itself must have generated the “moving force” behind the alleged constitutional violation, either through official 40 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 41 policy or widespread and pervasive custom. See City of Canton v. Harris, 489 U.S. 378, 388-89 (1989). At its core, the Estate’s Monell claim against Mesa County and the Entity Medical Defendants is the alleged customs and practices at MCDF of providing an unconstitutional level of care to detainees. The district court granted summary judgment to the entity defendants because none of their agents committed an underlying constitutional violation. Because we reverse the district court’s ruling as to Deputy Dalrymple, we must reverse and remand the grant of summary judgment on the Estate’s Monell claim to allow the district court an opportunity to assess whether there is a viable claim for municipal liability against Mesa County. See Lowe v. Fairland, 143 F.3d 1378, 1381 (10th Cir. 1998). As for CHC, we agree with the district court that summary judgment was proper. This Court has extended Monell liability to private entities.19 See Dubbs v. Head Start, Inc., 336 F.3d 1194, 1216 (10th Cir. 2003). Because none of the Individual Medical Defendants committed a constitutional violation, the Entity 19 The Estate asks us to revisit Dubbs because federal district courts in this circuit and elsewhere have called into question Monell’s application to private entities sued under § 1983. We decline the invitation in this case. See Strain, 977 F.3d at 993 (explaining that generally one panel may not overrule the decision of a prior panel absent en banc consideration or an intervening Supreme Court decision). 41 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 42 Medical Defendants cannot be liable under Monell.20 See Graves v. Thomas, 450 F.3d 1215, 1218 (10th Cir. 2006). The Estate’s argument to the contrary is unavailing. E. Remaining Contentions
The district court granted summary judgment to Mesa County on the Estate’s ADA claims. We reject the Estate’s challenge to that ruling. Title II of the ADA provides that “no qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.” 42 U.S.C. § 12132. “This provision extends to discrimination against inmates detained in a county jail.” Robertson v. Las Animas Cnty. Sheriff’s Dep’t, 500 F.3d 1185, 1193 (10th Cir. 2007). 20 On appeal, the Estate contends the district court’s holding regarding Monell liability “was incorrect and in direct contravention of . . . well-established precedent.” Aplt. Opening Br. at 68. The Estate maintains that, even absent a constitutional violation by an individual employee, the district court should still have considered whether CHC was liable under Garcia and its progeny. See Garcia v. Salt Lake Cnty., 768 F.2d 303, 310 (10th Cir. 1985) (“Although the acts or omissions of no one employee may violate an individual’s constitutional rights, the combined acts or omissions of several employees acting under a governmental policy or custom may violate an individual’s constitutional rights.”); see also Crowson v. Washington Cnty., 983 F.3d 1166, 1191 (10th Cir. 2020) (“[T]he municipality may not escape liability by acting through twenty hands rather than two.”). But the Estate did not present this theory of liability to the district court. See Richison v. Ernest Grp., Inc., 634 F.3d 1123, 1131 (10th Cir. 2011) (applying waiver where legal arguments were raised for the first time on appeal and plaintiff further failed to argue for plain-error review). And regardless, the Estate’s custom-or-practice claims fail on the merits because it does not point to any evidence from which a jury could reasonably infer CHC acted with deliberate indifference by enacting the alleged customs or policies. See Barney v. Pulsipher, 143 F.3d 1299, 1307 (10th Cir. 1998). 42 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 43 To state a claim under Title II, the Estate must show: (1) Mr. Beauford is a “qualified individual with a disability”; (2) he was “excluded from participation in or denied the benefits of [MCDF’s] services, programs, or activities”; and (3) “such exclusion, denial of benefits, or discrimination was by reason of his disability.” Id. In granting summary judgment to Mesa County on the Estate’s ADA claim, the district court found the Estate “produced no evidence of any specific service [Mr. Beauford] wanted access to and was denied” and, consequently, the Estate was “ask[ing] the court to assume that [Mr. Beauford] was necessarily denied access to the Detention Facility’s services or programs because he was segregated” in single cell housing in Cedar Pod. Aplt. App. vol. 12 at 3327-28. The district court characterized the Estate’s arguments as “conclusory and insufficient” and rejected them. Id. at 3327. We do the same. On appeal, the Estate merely reprises the arguments it made in the district court, without persuasively explaining why the district court erred. The gist of the Estate’s argument is Mr. Beauford’s mere placement in administrative segregation was a de facto denial of access to all MCDF’s programs, services, and benefits available to detainees not in administrative segregation. But to show a violation under Title II, the Estate must identify evidence in the record of a specific service, program, or activity requested by, but denied to, Mr. Beauford. See Hockaday v. Colo. Dep’t of Corr., 766 F. App’x 572, 575 (10th Cir. 2005). The Estate has not 43 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 44 made this showing or explained why it is relieved of the burden imposed on it by applicable law to do so.21 Thus, the district court did not err in granting summary judgment to the County on the Estate’s ADA claims. 2. Mesa County’s Personal Jurisdiction Arguments The Mesa County Defendants raised a lack of personal jurisdiction defense in district court. The district court did not address the merits of this argument, however, concluding any challenge to personal jurisdiction was moot because all claims against the County had been dismissed on summary judgment. On appeal, the County again advances the lack of personal jurisdiction defense. The district court never obtained jurisdiction over Mesa County or the Mesa County Sheriff, the argument proceeds, because the Estate “failed to properly sue the board of county commissioners of Mesa County and sued the wrong sheriff.” Cnty. Answer Br. at 38.22 Because we reverse in part the grant of summary judgment to the Mesa County Defendants, the personal jurisdiction question is no longer moot, as the 21 In light of this conclusion, we need not reach the Estate’s remaining contention that any such exclusion, denial of benefits, or discrimination was by reason of Mr. Beauford’s disability. 22 To the extent the County’s arguments regarding Sheriff Lewis involve insufficient service of process rather than personal jurisdiction, they fail for similar reasons. Service, like personal jurisdiction, is a waivable defense if not timely asserted. See Fed. R. Civ. P. 12(h)(1). 44 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 45 district court assumed.23 We now consider the Mesa County Defendants’ lack of personal jurisdiction defense and reject it. “Until the court has established personal jurisdiction [over a party], any assertion of judicial power over the party violates due process.” Ins. Corp. of Ireland v. Compagnie des Bauxites de Guinee, 456 U.S. 694, 706 (1982). However, unlike subject-matter jurisdiction, the defenses of lack of personal jurisdiction and service are waived if not timely asserted. See Fed. R. Civ. P. 12(h)(1); Fed. Deposit Ins. Corp. v. Oaklawn Apartments, 959 F.2d 170, 174-75 (10th Cir. 1992). It is well settled that “jurisdiction over a party may be conferred upon a court . . . by voluntary appearance of a party.” Williams v. Life Sav. & Loan, 802 F.2d 1200, 1202 (10th Cir. 1986) (per curiam); see also Hunger U.S. Special Hydraulics Cylinders Corp. v. Hardie-Tynes Mfg. Co., No. 99-4042, 2000 WL 147392, at  (10th Cir. Feb. 4, 2000) (“After its lengthy participation in this litigation, efforts to seek affirmative relief, and settlement of claims, [Defendant] may not pull its personal jurisdiction defense out of the hat like a rabbit.”) (citation omitted)). Federal Rule of Civil Procedure 12 “not only contemplates the lodging of certain defenses at the earliest point in a lawsuit, it mandates a waiver of those defenses if not presented at the first 23 In the interest of judicial efficiency, we exercise our discretion to consider the merits of the personal jurisdiction issue instead of remanding the issue to the district court. The standard of review for questions of personal jurisdiction is de novo, see ClearOne Commc’ns, Inc. v. Bowers, 651 F.3d 1200, 1214 (10th Cir. 2011); there are no appellate preservation problems; the parties have had an opportunity to brief the issue; and the facts are undisputed. 45 Appellate Case: 21-1010 Document: 010110688637 Date Filed: 05/25/2022 Page: 46 available opportunity.” Travelers Cas. & Sur. Co. v. Unistar Fin. Serv. Corp., 35 F. App’x 787, 787 (10th Cir. 2002). By the time the County raised personal jurisdiction as a defense, it had been actively defending against the Estate’s lawsuit for years. Under the circumstances, we conclude the County and the Mesa County Sheriff waived any personal jurisdiction or service defenses.24