Court Opinion

ID: 6343803
Source: CourtListenerOpinion
Date Created: 2022-05-25 16:00:41.253367+00
Date Added: 2024-06-11T08:43:44.540842
License: Public Domain

Appellate Case: 21-1010     Document: 010110688637     Date Filed: 05/25/2022    Page: 1
                                                                                 FILED
                                                                     United States Court of Appeals
                                      PUBLISH                                Tenth Circuit

                       UNITED STATES COURT OF APPEALS                       May 25, 2022

                                                                        Christopher M. Wolpert
                              FOR THE TENTH CIRCUIT                         Clerk of Court
                          _________________________________

  ESTATE OF TOMAS BEAUFORD;
  TIFFANY MARSH, personally and as
  representative of the estate of Tomas
  Beauford,

        Plaintiffs - Appellants,

  v.                                                        No. 21-1010

  MESA COUNTY, COLORADO;
  CORRECT CARE SOLUTIONS, LLC;
  CORRECTIONAL HEALTHCARE
  COMPANIES, INC.; CORRECTIONAL
  HEALTHCARE PHYSICIANS, P.C.;
  CORRECTIONAL HEALTHCARE
  MANAGEMENT, INC.; SHERIFF MATT
  LEWIS, in his official capacity; DEPUTY
  PETER M. DALRYMPLE; DEPUTY
  RICHARD D. PERKINSON; NURSE
  RENEE WORKMAN; NURSE VELDA
  HAVENS; NURSE AUDRA KEENAN;
  NURSE JEANNE ANNMARIE SCHANS;
  MICHAEL LEFEBRE, in his official and
  individual capacities; DR. KURT
  HOLMES, in his official and individual
  capacities,

        Defendants - Appellees.
                       _________________________________

                      Appeal from the United States District Court
                              for the District of Colorado
                         (D.C. No. 1:16-CV-00851-DDD-GPG)
                        _________________________________
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 David A. Lane (Darold W. Killmer, Michael Fairhurst, and Andy McNulty with him on
 the briefs), Killmer, Lane & Newman, LLP, Denver Colorado, for Plaintiffs – Appellants

 Jacob Z. Goldstein (Eric P. Schoonveld, Theodore C. Hosna, and Casey Kannenberg with
 him on the brief), Hall Prangle & Schoonveld, LLC, Chicago, Illinois, for CHC
 Defendants – Appellees

 Andrew B. Clauss (Chris W. Brophy with him on the brief), Dinsmore & Shohl LLP,
 Denver, Colorado, for Mesa County Defendants – Appellees
                        _________________________________

 Before McHUGH, MURPHY, and ROSSMAN, Circuit Judges.
                  ________________________________

 ROSSMAN, Circuit Judge.
                     _________________________________

       After midnight on April 16, 2014, Tomas Beauford suffered a fatal epileptic

 seizure in his cell while in pretrial custody at the Mesa County Detention Facility

 (“MCDF”). The administrator of Mr. Beauford’s estate sued various Mesa County

 and medical defendants1 in federal district court in Colorado under 42 U.S.C. § 1983

 alleging they were deliberately indifferent to Mr. Beauford’s serious medical needs in

 violation of the Fourteenth Amendment. The district court granted summary

 judgment to all defendants. Exercising jurisdiction under 28 U.S.C. § 1291, we

 reverse the district court’s grant of summary judgment to Deputy Dalrymple, and

       1
          Mr. Beauford’s Estate sued Mesa County, Colorado; Sheriff Matt Lewis, in
 his official capacity; and Deputies Richard D. Perkinson and Peter M. Dalrymple
 (collectively “Mesa County Defendants”). The Estate also sued the private healthcare
 companies that contracted with MCDF to provide medical services to inmates,
 including Correct Care Solutions, LLC; Correctional Healthcare Companies, Inc.;
 Correctional Healthcare Physicians, P.C.; and Correctional Healthcare Management,
 Inc. (“CHC,” and collectively, “Entity Medical Defendants”), as well as the nursing
 staff, physician, and mental health supervisor who oversaw Mr. Beauford’s care
 (“Individual Medical Defendants”).

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 accordingly, we also reverse the grant of summary judgment to the Mesa County

 Defendants on the Estate’s entity liability claim under Monell v. Department of

 Social Services of New York, 436 U.S. 658 (1978). The district court’s order is

 otherwise affirmed.

                                      I. Background

 A.   Factual Background2

        Mr. Beauford was a 24-year-old Black male who suffered from epilepsy. He

 also had a severe intellectual disability and several mental health disorders, including

 bipolar disorder, paranoid schizophrenia, attention hyperactivity disorder, and

 oppositional defiant disorder. Mr. Beauford’s IQ was 52, and he functioned at the

 level of a five- or six-year-old child.

        Mr. Beauford was prescribed many medications, including anti-seizure

 medicine, which he had a history of refusing. Mr. Beauford also had an implanted

 Vagus Nerve Stimulator (“VNS”) to control his epilepsy. A VNS is a “bodily implant

 that interferes with a seizure by sending a shock through the nervous system.” Aplt.

 App. vol. 12 at 3292. The device “has a microprocessor that automatically stimulates

        2
          These facts derive from our de novo review of the appellate record. The
 Estate filed a 30-volume appendix. But it appears volumes 14-30 are complete copies
 of witness depositions, which were never submitted in their entirety to the district
 court. Thus, we limit our review of the record to the materials in volumes 1-13,
 which include those portions of deposition testimony presented to the district court.
 See Birch v. Polaris Indus., Inc., 812 F.3d 1238, 1251 (10th Cir. 2015) (“Although
 our review of the record is de novo, we conduct that review from the perspective of
 the district court at the time it made its ruling, ordinarily limiting our review to the
 materials adequately brought to the attention of the district court by the parties.”)
 (quoting Fye v. Okla. Corp. Comm’n, 516 F.3d 1217, 1223 (10th Cir. 2008)).

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 the vagus nerve every few minutes,” and it also can be activated by a magnetic

 bracelet. Id. It is undisputed that, at the time he was arrested, Mr. Beauford had a

 VNS bracelet, but it was not with him when he died.

    1.       Mr. Beauford’s 2014 Detention at MCDF

         On March 1, 2014, Mr. Beauford was arrested on charges of assault and

 unlawful sexual contact and booked into MCDF. He was housed alone in a single

 cell, located either in the booking area or in an administrative segregation area called

 Cedar Pod.

         Mesa County contracted with a private company—defendant CHC—to provide

 medical services to inmates at MCDF. Defendant Dr. Kurt Holmes oversaw CHC’s

 medical care services and defendant Michael LeFebre was the mental health

 supervisor at MCDF. CHC also employed defendant nurses Velda Havens, Audra

 Keenan, Jeanne Schans, and Renee Workman. Each of these defendants cared for

 Mr. Beauford in some capacity while he was detained at MCDF.3

         During his detention, Mr. Beauford refused medications about fifty percent of

 the time. The defendant nurses encouraged him to take his medicine by offering his

 favorite snacks, such as Taco Bell burritos and Sprite. Dr. Holmes and Mr. LeFebre

 knew Mr. Beauford at times refused medication, including his anti-seizure medicine.

 But they took no action other than to advise the nurses they should continue to offer

 medication and to entice Mr. Beauford to take it.

         3
         Mr. Beauford had previously been detained at MCDF for about a month in
 late 2013, but that detention is not the subject of this appeal.

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         Mr. Beauford’s physical and mental condition deteriorated at MCDF. On

 March 20, Mr. LeFebre visited Mr. Beauford and marked his clinical status as

 “poor.” Aplt. App. vol. 6 at 1718-19. The nursing staff logs reported Mr. Beauford

 had developed a sore from spending so much time lying in bed in the same position.

 He sometimes refused to eat. Mr. Beauford struggled to get dressed, sit up, stand, or

 use the restroom on his own. He was sometimes found to be wet with urine. The jail

 guards frequently called for the nurses to change Mr. Beauford’s clothes and bring

 him a new adult diaper. The nurses often observed Mr. Beauford struggle—or

 outright refuse—to verbalize his wants and needs. During his approximately

 six-week detention, Mr. Beauford suffered documented seizures on March 1, 3,

 and 18 and April 15. See Aplt. App. vol. 10 at 2778.

    2.       The Night of April 15-164

         By the evening of April 15, Mr. Beauford had been refusing all medications,

 including his anti-seizure medicine, for the past three days. That evening and through

 the early morning of April 16, defendant Deputies Dalrymple and Perkinson were on

         4
         A written summary of MCDF’s video surveillance footage recorded on the
 night of April 15 and the early morning hours of April 16 is part of the appellate
 record, but the video itself is not. The video summary provides precise timestamps of
 the events at issue in this appeal. See Aplt. App. vol. 8 at 2383. The video summary
 appears to be consistent with the other record evidence, but there is a slight
 difference—about a two-minute discrepancy—between some of the times
 documented in the video-summary timestamps and the time of events described by
 the deputies in their interviews and depositions. Any discrepancy in the times
 reported and documented is minor, so it does not impact our analysis of the merits.
 Unless otherwise noted, we rely on the times reported by the deputies, as the district
 court did, and look to the video summary to fill in any gaps.

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 duty in Cedar Pod, along with Nurse Workman. Officers on the night shift conducted

 inmate security checks every half hour as required by MCDF policy. The exact time

 of each security check was recorded in the jail’s computer system. While one officer

 performed the security check, the other officer staffed the pod station. Officers also

 assisted the on-duty nurse with medication rounds and took inmate head counts.

       Deputies Dalrymple and Perkinson each conducted security checks from

 6:00 p.m. to 7:20 p.m. on April 15 and observed no issue with any inmate. Aplt. App.

 vol. 8 at 2282-83. During a security check at 7:50 p.m., Deputy Perkinson stepped

 into Mr. Beauford’s cell to pick up a dinner tray. He observed Mr. Beauford grunting

 underneath his blanket. Deputy Perkinson thought Mr. Beauford was probably

 masturbating and otherwise “seemed normal,” so he did not talk to him. Id. at 2283.

 “[A]ll seemed okay” with Mr. Beauford during the next security check at 8:20 p.m.

 Id.

       Around 8:40 p.m., Deputy Perkinson and Nurse Workman were on medication

 rounds when they came to Mr. Beauford’s cell and observed him “on the bed, and

 completely covered by a blanket.” Id. Deputy Perkinson first thought Mr. Beauford

 might be masturbating again. But “due to how he was shaking” and knowing that Mr.

 Beauford was an epileptic, Deputy Perkinson “had a second thought that

 Mr. Beauford may be seizing.” Id. Deputy Perkinson and Nurse Workman entered

 Mr. Beauford’s cell and discovered he was having a seizure. Nurse Workman turned

 Mr. Beauford on his side and sat with him through the duration of the seizure, which

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 lasted five more minutes. Deputy Perkinson and Nurse Workman then left Mr.

 Beauford’s cell at 8:49 p.m. to finish medication rounds. Id. at 2383.

       At 9:01 p.m., Deputy Dalrymple performed another security check. Id. He

 looked into Mr. Beauford’s cell and saw him lying on his bed shaking with his eyes

 open. Deputy Dalrymple said nothing to Mr. Beauford and continued on to complete

 his check of other inmates. When interviewed by an MCDF officer a few hours after

 Mr. Beauford died, Deputy Dalrymple said he reported the shaking to Deputy

 Perkinson, who had assured him that, according to Nurse Workman, Mr. Beauford

 would be “fine.” Id. at 2282. At his deposition, Deputy Dalrymple likewise testified

 he had reported the shaking to someone but was uncertain whether he told Deputy

 Perkinson or Nurse Workman. Id. at 2311.

       Deputy Perkinson and Nurse Workman returned to Mr. Beauford’s cell at 9:21

 p.m. Id. at 2284, 2383. Mr. Beauford refused to let Nurse Workman take his vitals

 and asked them to leave. Nurse Workman assured Deputy Perkinson that Mr.

 Beauford would be fine and she did not instruct the deputies to conduct extra

 monitoring of Mr. Beauford.

       The deputies completed more security checks about every half-hour over the

 next several hours, and each time, observed Mr. Beauford laying on his bed, reading

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 or sleeping. After doing a security round at 10:15 p.m., Deputy Perkinson moved off

 Cedar Pod to other duties, leaving Deputy Dalrymple as the only officer on the pod.5

       During his security check at 11:55 p.m., Deputy Dalrymple saw Mr. Beauford

 laying on the floor of his cell, facedown, with his head under his desk. Id. at 2281,

 2310. Deputy Dalrymple used his flashlight to illuminate Mr. Beauford and watched

 him for a few moments. He knew Mr. Beauford often slept in unusual positions in his

 cell and believed Mr. Beauford was breathing because he saw Mr. Beauford’s covers

 rising and falling. Id. at 2282. Deputy Dalrymple then finished his security check and

 returned to the pod officer station.

       On his next security round at around 12:15 a.m.,6 Deputy Dalrymple observed

 Mr. Beauford lying motionless in the same position on the floor of his cell. This time,

 however, Deputy Dalrymple “could not tell for sure” if Mr. Beauford was breathing.

 Id. at 2282-83. After completing his security check, Deputy Dalrymple alerted

 medical personnel he had observed Mr. Beauford lying on the floor of his cell.

 “About ten minutes passed between Deputy Dalrymple’s observation and his call to

       5
         Deputy Dalrymple took a lunch break around this time, so two other
 deputies—including one deputy trainee—oversaw Cedar Pod and did the security
 checks at 11:00 p.m. and 11:30 p.m. They did not note any concerns about
 Mr. Beauford or any other inmate; neither officer is named as a defendant in this
 case.
       6
        The parties rely on Deputy Dalrymple’s recollection that the time was
 “about” 12:15 a.m., but the video summary documents this event at 12:17 a.m.
 Compare Aplt. App. vol. 8 at 2282 with 2383.

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 the [MCDF] medical staff.” Aplt. App. vol. 12 at 3293. Around 12:25 a.m.,7 Deputy

 Dalrymple and Nurse Workman entered Mr. Beauford’s cell and found him

 unresponsive.

       Nurse Workman retrieved a medical kit while Deputy Dalrymple started CPR

 and other staff called 911. Deputies moved Mr. Beauford into the “dayroom area

 outside the cell door in order to have room for resuscitation.” Aplt. App. vol. 6

 at 1548. Nurse Workman used a portable defibrillator and deputies performed chest

 compressions until paramedics arrived. These rescue efforts were unavailing.

 Mr. Beauford was pronounced dead at approximately 2:45 a.m. on April 16, 2014.

 Aplt. App. vol. 7 at 1924. An autopsy concluded Mr. Beauford suffered “[s]udden

 unexpected death in epilepsy.” Id. at 1926; see also id. at 1923. Toxicology tests

 showed low blood concentrations of four anti-seizure medications.

 B.   Procedural History

       In 2016, the Estate filed the underlying lawsuit alleging8 (1) § 1983 claims

 against all defendants for violations of Mr. Beauford’s Fourteenth Amendment right

 to adequate medical care; (2) a § 1983 claim against all defendants for violation of

 Mr. Beauford’s Fourteenth Amendment right to life without due process of law

       7
        Again, the parties rely on Deputy Dalrymple’s estimate that this happened
 around 12:25 a.m. but the video summary shows it occurred at 12:28 a.m. Compare
 Aplt. App. vol. 8 at 2282 with 2383.
       8
           The operative complaint is the Estate’s third amended complaint.

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  against all defendants;9 (3) a claim against Mesa County for violation of the

  Americans with Disabilities Act (“ADA”), 42 U.S.C. § 12132; (4) a wrongful death

  claim against the Medical Defendants premised on medical negligence; and (5) a

  state-law survival claim against all defendants.

        The Mesa County Defendants moved for summary judgment on all claims

  asserted against them. The Medical Defendants moved for summary judgment on the

  § 1983 medical-care claims, and Nurse Havens also moved for summary judgment on

  the medical negligence claim asserted against her.

        The district court granted the Mesa County Defendants’ summary judgment

  motion in its entirety. The court concluded Deputies Perkinson and Dalrymple were

  entitled to qualified immunity on the Estate’s deliberate indifference claim because

  (1) the Estate failed to show the deputies violated Mr. Beauford’s Fourteenth

  Amendment rights, and (2) no clearly established law put the deputies on notice that

  they could not rely on Nurse Workman’s medical advice or that Deputy Dalrymple

  “needed to immediately call for help after seeing Mr. Beauford on the floor of his

  cell.” Aplt. App. vol. 12 at 3306-07 (district court’s emphasis). The district court also

  granted summary judgment to the County on the Estate’s ADA and Monell claims.

        9
          The Estate advances no appellate challenge to the district court’s summary
  judgment ruling on the claim of deprivation of life without due process of law.
  Accordingly, we consider it waived. See State Farm Fire & Cas. Co. v. Mhoon,
  31 F.3d 979, 984 n.7 (10th Cir. 1994) (explaining appellant’s failure to raise issue in
  opening brief waives the point).

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        The district court granted in part the Medical Defendants’ motion.10 Finding

  the Medical Defendants ineligible for qualified immunity, the district court then

  determined there was insufficient evidence to show the Individual Medical

  Defendants were deliberately indifferent to Mr. Beauford’s serious medical needs.

  And because none of the Individual Medical Defendants committed a constitutional

  violation, the district court further found the Entity Medical Defendants could not be

  liable under Monell.

        The district court certified its interlocutory order for immediate review under

  Federal Rule of Civil Procedure 54(b), rendering the order final and appealable. See

  HCG Platinum, LLC v. Preferred Prod. Placement Corp., 873 F.3d 1191, 1199 n.7

  (10th Cir. 2017) (noting the district court’s judgment ripened into a final and

  appealable order when the district court subsequently certified the judgment as final

  under Rule 54(b)). This appeal followed.

                                     II.   Discussion

  A.   Standard of Review

        We review the grant of summary judgment de novo, and apply the same legal

  standard used by the district court under Federal Rule of Civil Procedure 56(c). Allen

  v. Muskogee, 119 F.3d 837, 839 (10th Cir. 1997). Summary judgment is appropriate

        10
           The district court denied Nurse Havens’s motion for summary judgment on
  the Estate’s medical negligence claim against her. The court also granted summary
  judgment in favor of the Mesa County Defendants on the Estate’s state-law survival
  claim, holding that “‘survival’ isn’t a separate cause of action under Colorado law,”
  and that in any event, the Estate had made no argument regarding that claim.
  Aplt. App. vol. 12 at 3329 n.12. The Estate does not challenge this ruling on appeal.

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  if “the movant shows that there is no genuine dispute as to any material fact and that

  the movant is entitled to judgment as a matter of law.” Estate of Booker v. Gomez,

  745 F.3d 405, 411 (10th Cir. 2014) (quoting Fed. R. Civ. P. 56(a)). A disputed fact is

  “material” if it might affect the outcome of the suit under the governing law, and the

  dispute is “genuine” if the evidence is such that a reasonable jury could return a

  verdict for the nonmoving party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248

  (1986). The summary judgment standard requires us to construe the facts in the light

  most favorable to the nonmovant and to draw all reasonable inferences in its favor.11

  See Lance v. Morris, 985 F.3d 787, 793 (10th Cir. 2021). We do not have to accept

  versions of the facts contradicted by objective evidence, such as video surveillance

  footage. See Scott v. Harris, 550 U.S. 372, 380 (2007). “To defeat a motion for

  summary judgment, evidence, including testimony, must be based on more than mere

  speculation, conjecture, or surmise.” Self v. Crum, 439 F.3d 1227, 1230 (10th Cir.

  2006) (citation omitted). “Unsubstantiated allegations carry no probative weight in

  summary judgment proceedings.” Id. (citation omitted).

        11
           The Estate seems to suggest reversal is warranted solely because the district
  court misapplied the summary judgment standard. This contention is articulated only
  in a conclusory manner in argument headings and otherwise not meaningfully
  advanced in the Estate’s appellate briefing. Accordingly, we do not consider it. See
  Murrell v. Shalala, 43 F.3d 1388, 1389 n.2 (10th Cir. 1994) (“[P]erfunctory
  [allegations of error that] fail to frame and develop an issue [are] [in]sufficient to
  invoke appellate review.”). Even if the Estate had appropriately framed and
  developed this argument, we would reject it. Though we conclude the district court
  erred in granting summary judgment to Deputy Dalrymple based on qualified
  immunity, we otherwise discern no error in the district court’s application of the
  summary judgment standard.

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        We review summary judgment orders deciding qualified immunity questions

  differently from other summary judgment decisions. See Nelson v. McMullen,

  207 F.3d 1202, 1205-06 (10th Cir. 2000) (“This difference arises from the unique

  nature of qualified immunity, which is designed to protect public officials from

  spending inordinate time and money defending erroneous suits at trial.”). The

  doctrine of qualified immunity shields government officials from liability where

  “their conduct does not violate clearly established statutory or constitutional rights of

  which a reasonable person would have known.” Pearson v. Callahan, 555 U.S. 223,

  231 (2009) (quoting Harlow v. Fitzgerald, 457 U.S. 800, 818 (1982)). When a

  defendant asserts qualified immunity at summary judgment, the burden shifts to the

  plaintiff, who must demonstrate on the facts alleged that (1) the defendant’s actions

  violated his or her constitutional or statutory rights, and (2) the right was clearly

  established at the time of the alleged misconduct. See Riggins v. Goodman, 572 F.3d

  1101, 1107 (10th Cir. 2009). “If, and only if, the plaintiff meets this two-part test

  does a defendant then bear the traditional burden of the movant for summary

  judgment—showing ‘that there are no genuine issues of material fact and that he or

  she is entitled to judgment as a matter of law.’” Gutteridge v. Oklahoma, 878 F.3d

  1233, 1239 (10th Cir. 2018) (quoting Nelson, 207 F.3d at 1206).

        In the final analysis, even when qualified immunity is at issue, “the defendant

  still bears the normal summary judgment burden of showing that no material facts

  remain in dispute that would defeat the qualified immunity defense.” Olsen v. Layton

  Hills Mall, 312 F.3d 1304, 1312 (10th Cir. 2002). “When the record shows an

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  unresolved dispute of historical fact relevant to this immunity analysis, a motion for

  summary judgment based on qualified immunity should be ‘properly denied.’” Id.

  at 1312 (quoting Salmon v. Schwarz, 948 F.2d 1131, 1136 (10th Cir. 1991)).

  B.   Constitutional Right to Adequate Medical Care for Pretrial Detainees

        The right to custodial medical care is well settled. See generally Estelle v.

  Gamble, 429 U.S. 97 (1976). “The Fourteenth Amendment’s Due Process Clause

  entitles pretrial detainees to the same standard of medical care that the Eighth

  Amendment requires for convicted inmates.” Lance, 985 F.3d at 793; see also Clark

  v. Colbert, 895 F.3d 1258, 1267 (10th Cir. 2018) (explaining the Eighth Amendment

  includes “an entitlement to a certain minimum standard of medical care while

  incarcerated”). “Although pretrial detainees are protected under the Due Process

  Clause rather than the Eighth Amendment, this Court applies an analysis identical to

  that applied in Eighth Amendment cases brought pursuant to § 1983.” Olsen, 312

  F.3d at 1315.

        Prison officials violate the Constitution when they act with “deliberate

  indifference to an inmate’s serious medical needs.” Mata v. Saiz, 427 F.3d 745, 751

  (10th Cir. 2005). “The deliberate indifference standard lies ‘somewhere between the

  poles of negligence at one end and purpose or knowledge at the other.’” Id. at 752

  (quoting Farmer v. Brennan, 511 U.S. 825, 836 (1994)). The contours of

  constitutional liability under the deliberate-indifference standard are familiar: there is

  both an objective and a subjective component. See Farmer, 511 U.S. at 834. “[T]he

  focus of the objective component is the seriousness of the plaintiff’s alleged harm,

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  while the focus of the subjective component is the mental state of the defendant with

  respect to the risk of that harm.” Prince v. Sheriff of Carter Cnty., 28 F.4th 1033,

  1044 (10th Cir. 2022).

        To satisfy the objective component, the plaintiff must produce evidence that

  the prisoner’s medical need was “sufficiently serious.” Farmer, 511 U.S. at 834

  (citation omitted). “A medical need is sufficiently serious if it is one that has been

  diagnosed by a physician as mandating treatment or one that is so obvious that even a

  lay person would easily recognize the necessity for a doctor’s attention.” Sealock v.

  Colorado, 218 F.3d 1205, 1209 (10th Cir. 2000) (internal quotation marks omitted).

  A delay in medical care can also be sufficiently serious if “the delay resulted in

  substantial harm.” Mata, 427 F.3d at 751. “The substantial harm requirement may be

  satisfied by lifelong handicap, permanent loss, or considerable pain.” Id. (internal

  quotation marks omitted).

        The subjective prong requires a plaintiff to establish that a prison official had

  “a sufficiently culpable state of mind.” Farmer, 511 U.S. at 834 (internal quotation

  marks omitted). “In prison-conditions cases that state of mind is one of deliberate

  indifference to inmate health or safety.” Id. (internal quotation marks omitted).

  Deliberate indifference means “the official knows of and disregards an excessive risk

  to inmate health or safety; the official must both be aware of facts from which the

  inference could be drawn that a substantial risk of serious harm exists, and he must

  also draw the inference.” Id. at 837.

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        “Whether a prison official had the requisite knowledge of a substantial risk is a

  question of fact subject to demonstration in the usual ways, including inference from

  circumstantial evidence, and a factfinder may conclude that a prison official knew of

  a substantial risk from the very fact that the risk was obvious.” Mata, 427 F.3d at 752

  (citation omitted). “This is so because if a risk is obvious so that a reasonable man

  would realize it, we might well infer that the defendant did in fact realize it.” Id.

  (brackets and internal quotation marks omitted). But “prison officials who actually

  knew of a substantial risk to inmate health or safety may be found free from liability

  if they responded reasonably to the risk, even if the harm ultimately was not averted.”

  Farmer, 511 U.S. at 844.

  C.   Analysis

        The district court concluded Mr. Beauford’s epilepsy was a sufficiently serious

  medical condition that satisfied the objective component of the

  deliberate-indifference inquiry. The parties do not dispute this determination on

  appeal. Our analysis thus focuses on the Estate’s contentions of error surrounding the

  subjective prong of the deliberate-indifference standard. We consider first the

  Estate’s argument that the district court erred by concluding Deputies Perkinson and

  Dalrymple—the individual defendants who asserted a qualified immunity defense—

  did not violate Mr. Beauford’s Fourteenth Amendment rights on the night of his

  death. We then consider the Estate’s arguments about the subjective prong as it

  applies to the challenged conduct of the Individual Medical Defendants, who are

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  ineligible for qualified immunity. See Tanner v. McMurray, 989 F.3d 860, 874

  (10th Cir. 2021).12

     1.        Deputy Perkinson is entitled to qualified immunity, but the district court
               erred in granting summary judgment to Deputy Dalrymple.

       Deputies Perkinson and Dalrymple were both on duty at MCDF the night

  Mr. Beauford died. We affirm the district court’s ruling granting summary judgment

  to Deputy Perkinson, but we cannot reach the same conclusion with respect to

  Deputy Dalrymple.

       a.       Deputy Perkinson

          The district court ruled that Deputy Perkinson was entitled to qualified

  immunity because the Estate’s deliberate indifference claim against him was not

  supported by sufficient evidence. Deputy Perkinson sought the assistance of Nurse

  Workman, the district court explained, and reasonably relied on her medical expertise

  to treat and assess Mr. Beauford’s condition. On appeal, the Estate argues reversal is

  required because Deputy Perkinson failed to summon medical attention when it was

  obvious Mr. Beauford needed emergency care. We are not persuaded.

          12
            The district court, relying on Richardson v. McKnight, 521 U.S. 399 (1997),
  rejected the assertion of qualified immunity by the Individual Medical Defendants.
  Aplt. App. vol. 12 at 3308-10. While acknowledging our court had not yet reached
  the question, the district court found it compelling that “every other circuit to address
  the issue has determined that McKnight precludes the application of qualified
  immunity to private medical professionals hired to work in a prison.” Id. at 3310. The
  parties have not challenged this ruling on appeal and for good reason. Six months
  after the district court entered its amended summary judgment order, we decided
  Tanner v. McMurray, 989 F.3d 860, 874 (10th Cir. 2021), and like our sister circuits,
  held qualified immunity is not available to private medical professionals employed
  full-time in a detention facility.

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        The Estate’s contentions of error regarding Deputy Perkinson involve three

  specific incidents on the night of Mr. Beauford’s death. First, the Estate argues

  Deputy Perkinson was deliberately indifferent for “fail[ing] to check on or even ask

  [Mr.] Beauford what was happening during the 7:50 p.m. [security] check” when he

  observed Mr. Beauford grunting under his blanket. Aplt. Opening Br. at 50.

        To satisfy the subjective inquiry, the Supreme Court requires actual

  knowledge: “the official must both be aware of facts from which the inference could

  be drawn that a substantial risk of serious harm exists, and he must also draw the

  inference.” Farmer, 511 U.S. at 837 (emphases added). A “factfinder may conclude

  that a prison official knew of a substantial risk from the very fact that the risk was

  obvious.” Id. at 842. But this exception requires that such risks present themselves as

  obvious to the so-called “reasonable man.” See Mata, 427 F.3d at 752 (citing Garrett

  v. Stratman, 254 F.3d 946, 950 (10th Cir. 2001)). Viewing the evidence in the light

  most favorable to the Estate, it would not have been “obvious” to Deputy Perkinson

  at 7:50 p.m. that Mr. Beauford was having a seizure and required emergency medical

  care such that a reasonable jury could infer deliberate indifference. See id.

        Hours after Mr. Beauford died, Deputy Perkinson was interviewed and said

  only that Mr. Beauford was “under his blanket and grunting.” Aplt. App. vol. 8

  at 2283. The Estate contends that, according to Deputy Perkinson’s observation, Mr.

  Beauford was obviously experiencing a seizure. While it is possible Deputy

  Perkinson witnessed a seizure at 7:50 p.m., the Estate has pointed to no evidence

  showing Deputy Perkinson believed Mr. Beauford was seizing or otherwise drew the

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  inference Mr. Beauford faced a substantial risk of serious harm to his health or

  safety. See Farmer, 511 U.S. at 837; cf. Martinez v. Beggs, 563 F.3d 1082, 1088

  (10th Cir. 2009) (“The Supreme Court [has] cautioned that ‘an inadvertent failure to

  provide adequate medical care’ does not rise to a constitutional violation.” (quoting

  Estelle, 429 U.S. at 105-06)). Thus, the Estate has not carried its burden to show that

  Deputy Perkinson’s failure to check on Mr. Beauford during the 7:50 p.m. rounds

  amounted to deliberate indifference.

        Deputy Perkinson recognized more troubling physical signs one hour later

  while on medication rounds with Nurse Workman. At that time, Mr. Beauford was in

  his cell and still “on the bed, and completely covered by a blanket.” Aplt. App. vol. 8

  at 2283. Deputy Perkinson’s “first thought was Mr. Beauford was again

  masturbating, however due to how he was shaking [Deputy] Perkinson had a second

  thought that Mr. Beauford may be seizing.” Id. (emphasis added). Deputy Perkinson

  and Nurse Workman entered Mr. Beauford’s cell and discovered he was having a

  seizure. They stayed with Mr. Beauford until his seizure ended. And they both

  returned to check on him about thirty minutes later.

        The Estate argues that despite observing Mr. Beauford suffer “an over-five-

  minute seizure, combined with an unusually long postictal [or, recovery] state,”

  Deputy Perkinson was deliberately indifferent because he “did not transport [Mr.]

  Beauford for emergent medical treatment at a hospital.” Aplt. Opening Br. at 50. The

  Estate also maintains Deputy Perkinson “unreasonably rel[ied] on [Nurse]

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  Workman’s obviously deficient advice for the care of [Mr.] Beauford when it was

  clear [he] needed emergency medical attention.” Id.

         The district court rejected this deliberate indifference claim, reasoning that

  Deputy Perkinson “recognized a potential risk, asked the medical health professional

  what to do about it, and followed her advice. Whether [he] might have done more

  doesn’t alter the fact that what [he] did do is not a constitutional violation.” Aplt.

  App. vol. 12 at 3304. We agree.

         Prison officials generally may rely on the advice and course of treatment

  prescribed by medical personnel. See McRaven v. Sanders, 577 F.3d 974, 981

  (8th Cir. 2009) (“[A] prison official may rely on a medical professional’s opinion if

  such reliance is reasonable.”); Johnson v. Doughty, 433 F.3d 1001, 1010 (7th Cir.

  2006) (“Except in the unusual case where it would be evident to a layperson that a

  prisoner is receiving inadequate or inappropriate treatment, prison officials may

  reasonably rely on the judgment of medical professionals.”) (citation omitted). Here,

  the evidence, viewed in the light most favorable to the Estate, shows Nurse Workman

  took the lead in providing medical care to Mr. Beauford, while Deputy Perkinson

  helped securely hold him on the bed and “calm him down.” Aplt. App. vol. 5 at 1390.

  They stayed with Mr. Beauford “until the seizure was over. And then when [Nurse

  Workman] decided it was okay to leave, [they] exited the cell.” Id. at 1390. When

  Deputy Perkinson returned later with Nurse Workman to check on Mr. Beauford,

  they found him uncooperative. Mr. Beauford said, “something to the effect [of] ‘no,

  leave me alone, let me go back to sleep.’” Aplt. App. vol. 8 at 2284. Deputy

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  Perkinson performed two more security checks before rotating off Cedar Pod; both

  times Mr. Beauford was lying on his bed with the light off in his cell and did not

  appear to be “in any type of medical distress.” Id.

        As the district court correctly determined, this series of events does not evince

  deliberate indifference by Deputy Perkinson to Mr. Beauford’s serious medical needs

  sufficient to satisfy the subjective component of the Eighth Amendment inquiry.

  Sealock, 218 F.3d at 1209. Deputy Perkinson alerted Nurse Workman to Mr.

  Beauford’s “shaking” out of concern that Mr. Beauford may be seizing. Aplt. App.

  vol. 8 at 2283. As a result, Mr. Beauford actually received medical care during a

  critical time. That his condition worsened hours later does not mean Deputy

  Perkinson acted with deliberate indifference at 8:40 p.m.

        Finally, the Estate contends Deputy Perkinson acted with deliberate

  indifference by failing to relay to medical personnel that, as Deputy Dalrymple

  reported, Mr. Beauford was shaking at 9:00 p.m. Again, we disagree. The video

  surveillance footage shows Nurse Workman checking on Mr. Beauford after Deputy

  Dalrymple’s security round. Aplt. App. vol. 8 at 2383. Even if Deputy Perkinson

  failed to relay the report as the Estate contends, this was immaterial under the

  circumstances.

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         The district court correctly determined the Estate failed to establish a

  constitutional violation. Thus, we affirm the grant of summary judgment to Deputy

  Perkinson under the first prong of the qualified immunity analysis.13

       b.     Deputy Dalrymple

         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.

        i.    Constitutional Violation

         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).

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        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

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  “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.

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        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

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  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.”).

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         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.

       ii.   Clearly Established Law

         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

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  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

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  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

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  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.

       iii. Summary Judgment Ruling

        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

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  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.”).

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  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)).

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  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 *5 (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

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  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:

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  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.

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  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

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  (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.

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  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.

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        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

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  (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

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  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).

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  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

       1.        The Estate’s ADA Claim

            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).

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        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

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  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).

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  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 *3 (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.

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  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

                                        III.   Conclusion

        We affirm the grant of summary judgment to Deputy Perkinson and the

  Individual and Entity Medical Defendants on the Estate’s § 1983 claims. We also

  affirm the grant of summary judgment to Mesa County on the Estate’s ADA claim.

        We reverse the district court’s grant of summary judgment to Deputy

  Dalrymple and to the Mesa County Defendants on the Estate’s municipal liability

  claim. The case is remanded for further proceedings consistent with this opinion.

        24
           The Mesa County Defendants also argue the Estate’s attempt to substitute
  the new Sheriff under Federal Rule of Civil Procedure 25(d) was improper. We need
  not decide this issue because the Estate sued the Mesa County Sheriff in his official
  capacity.

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