Court Opinion

ID: 4531499
Source: CourtListenerOpinion
Date Created: 2020-05-04 20:00:30.168749+00
Date Added: 2024-06-11T09:27:06.457418
License: Public Domain

RECOMMENDED FOR PUBLICATION
                               Pursuant to Sixth Circuit I.O.P. 32.1(b)
                                      File Name: 20a0135p.06

                   UNITED STATES COURT OF APPEALS
                                  FOR THE SIXTH CIRCUIT

JACOB ANDREWS, Personal Representative of the               ┐
Estate of Angela White, Deceased,                           │
                                  Plaintiff-Appellant,      │
                                                            │         No. 19-1992
                                                             >
       v.                                                   │
                                                            │
                                                            │
WAYNE COUNTY, MICHIGAN,                                     │
                                 Defendant-Appellee.        │
                                                            ┘

                         Appeal from the United States District Court
                        for the Eastern District of Michigan at Detroit.
                     No. 2:17-cv-11684—Paul D. Borman, District Judge.

                               Decided and Filed: May 4, 2020

              Before: SUHRHEINRICH, BUSH, and MURPHY, Circuit Judges.

                                     _________________

                                           COUNSEL

ON BRIEF: John C. Kaplansky, LAW OFFICE OF JOHN C. KAPLANSKY, P.C., Bingham
Farms, Michigan, Robert M. Sosin, ALSPECTOR, SOSIN & NOVECK, Bingham Farms,
Michigan, for Appellant. Sue Hammoud, WAYNE COUNTY CORPORATION COUNSEL,
Detroit, Michigan, for Appellee.
 No. 19-1992                     Andrews v. Wayne Cty., Mich.                             Page 2

                                      _________________

                                           OPINION
                                      _________________

SUHRHEINRICH, Circuit Judge.

                                     I. INTRODUCTION

       In Gray v. City of Detroit, we observed that “[s]uicide is a difficult event to predict and
prevent and often occurs without warning.” 399 F.3d 612, 616 (6th Cir. 2005). That is the sad
reality in this case. Angela White overdosed on blood pressure medication while a pretrial
detainee at Defendant-Appellee Wayne County’s Jail (“County” or “Jail”) and died. White had
been permitted to keep 45 pills on her person pursuant to Wayne County Jail’s “Keep on Person”
(“KOP”) program, which allows inmates to keep with them certain drugs for self-administration.
In this § 1983 action White’s former fiancé, Jacob Andrews, alleges that the Jail’s KOP policy
and inmate intake policy violate the constitutional rights of inmates and pretrial detainees like
White who are emotionally unstable and potentially suicidal. The district court granted summary
judgment to the County, holding that the facts did not establish municipal liability or deliberate
indifference toward White. This appeal follows.

                                     II. BACKGROUND

                                            A. Facts

       On June 5, 2014, at 4:45 a.m., the City of Canton Police Department received a 911
phone call from Andrews. Andrews left the line open, allowing police to hear “loud arguing
between a male and female,” and the female’s reference to “slitting your throat.” Andrews told
the police dispatched to the scene that he and White were engaged, had been together over three
years, and had a child together. Andrews relayed that he had been drinking tequila at his
brother’s house nearby and fell asleep there. He got a phone call from a “highly agitated” White
and went home. Andrews stated that White physically attacked him after he got into bed and
poked him in the chest with a kitchen knife. That’s when he called 911. The Canton police
determined that White was the aggressor and arrested her.
 No. 19-1992                    Andrews v. Wayne Cty., Mich.                            Page 3

       Later that morning White called Andrews, apologized, and asked him to bring her
medications to the Canton Police Department. Andrews dropped off five or six bottles. He did
not speak to White.
       Just after 8:00 p.m. that evening White was taken to Oakwood Hospital after complaining
of a headache and chest and back pain. She was released at 2:15 a.m. on June 6 and returned to
the Canton Jail.
       Later the same day White was arraigned in the 35th District Court on a charge of felony
assault with a dangerous weapon. Bail was set at $3,000 with a 10 percent cash/surety bond and
a preliminary hearing was scheduled for June 20, 2014. Andrews did not post White’s bond.
She was transferred to the Jail about 7:00 p.m. that evening. Along with White were her six
medications: (1) Klonopin, (2) oxygen, (3) Sumatriptan, (4) Verapamil, (5) Toradol, and
(6) Lexapro.
       The Jail’s “Receiving Screening - Intake” policy requires all incoming inmates to be
screened within four hours of arrival booking. The express purpose of the policy is “to identify
and appropriately direct inmates who have health and/or safety issues that require timely
intervention.” White was seen at 8:39 p.m. by Medical Assistant Dawn Benette, who worked in
the intake unit. Benette asked White a series of questions about her medical and mental history,
using the intake screening questionnaire. Key questions and responses included:

       Was the inmate taken to the hospital prior to arrival at intake:
                Yes
                Explain: [Blank]
       …
       Is the inmate taking medications?
                No
       …
       Have you ever attempted to harm yourself or commit suicide?
                Yes
                Explain: In the past
       Are you thinking of harming yourself or are suicide thoughts a problem now?
                No
                Explain: [Blank]
       Do you have a history of psychiatric illness or treatment?
                No
                Explain: [Blank]
 No. 19-1992                            Andrews v. Wayne Cty., Mich.                                         Page 4

Benette also made her own observations in response to certain questions. She recorded that
White was not acting or talking in a strange manner, did not show signs of depression, was not
overly anxious, and was not shy or ashamed. Benette cleared White for housing in the general
prison population and referred her for a medical and a mental evaluation.

         Because Benette had flagged White for further evaluation, R.N. Raymond Carnill
evaluated her about 10:15 p.m., in a session that lasted nearly two hours. Carnill did not review
Benette’s intake form. He conducted his own history and assessment of White,1 using a separate
questionnaire. Carnill noted that White had bad cluster headaches and was taking medications
for anxiety. Carnill reported White’s chief complaints were “anxiety and depression.” Carnill
noted that White denied being suicidal or homicidal. He described her behavior as “soft,” her
speech as “cooperative,” her mood as “anxious.”

         Carnill contacted a pharmacy to verify White’s prescriptions and obtained orders to
continue them. Carnill also filled out a “PSY Referral” form directing that White be seen by the
“psychiatric social worker” and that the “on call psychiatrist” be contacted. On that form he
listed that White’s “chief complaint” was “anxiety and depression,” that she was taking Lexapro
and Klonopin, and that she “[d]eines [sic] being suicidal or homicidal.” Carnill testified that he
did not execute the KOP policy because his shift ended. The briefing does not make clear who
actually allowed White to keep her Verapamil.

         In his deposition testimony Carnill reiterated that during the two hours he spent with her,
White did not exhibit any psychotic behavior, suicidal ideation, or psychiatric distress. For these
reasons, he did not admit her to the mental health unit. He placed her in a special housing unit,
the infirmary, which is adjacent to the medical clinic, so she could access her oxygen tank as
needed.

         Carnill further testified that had he perceived that White might harm herself, he “would
have called the psychiatrist . . . [and] I would have had her admitted to the mental health floor
under suicide interventions.” Knowledge of a prior suicide attempt would not have been a game

         1
           Carnill also explained that the purpose of the intake form is “to get an initial overview of what’s going on
with the inmate and to [see] whether they need further services.”
 No. 19-1992                      Andrews v. Wayne Cty., Mich.                           Page 5

changer because Carnill “base[d] [his] evaluation upon the here and now rather than what’s
occurred in the past.”

       The next day, June 7, White made twelve outside phone calls on the Jail payphone
system, half to Andrews. Andrews did not answer them and White became visibly upset. White
was returned to her cell at 3:23 p.m.        A moment later, Wayne County Sheriff’s Deputy
Christopher Paulsen conducted a security round of the unit. He noted that “all appears secure.”
At 4:25 p.m., however, Paulsen heard knocking and went to White’s cell. She was sitting on the
floor with traces of vomit on her face. White told Paulsen that she did not feel well. He
immediately contacted medical personnel. Nurse Rhonda Harris came to White’s cell, evaluated
her, and “stated [that] she needed to contact the doctor.”

       Paulsen left to serve dinner to the infirmary unit. On his next security round about ten
minutes later, he asked White if she wanted her meal tray. White responded repeatedly that she
“took to [sic] many pills.” Paulsen dashed to the clinic and told Nurse Harris. While en route,
he had his shift command notified of the incident. Nurse Harris contacted Nurse DeAngela
Guest. Guest ran to the Infirmary. White was on the floor but still talking. Guest took her vital
signs, which were very low, 60/33.        The nurses tried to keep her alert.   White remained
conscious.

       EMS arrived at 5:00 p.m. and took over White’s care. EMS transported her to Detroit
Receiving Hospital at 5:30 p.m. Just after 2:30 p.m. the next day, June 8, White was found to be
bradycardic. After sixty minutes of CPR, she was pronounced dead. An autopsy deemed the
cause of death as Verapamil toxicity and the manner of death as suicide.

                                 B. White’s Psychiatric History

       Unbeknownst to the Canton Police Department or the Jail staff, White had recently
visited several other area hospitals. On May 14, 2014, she spent two days at the Henry Ford
Hospital Kingswood Facility (“Kingswood”) after being diagnosed with major depressive order
(moderate), chronic headaches, insomnia, and anxiety. While a patient there, she was put on
suicide precautions, although she “denied overt suicidal ideations.” White was discharged on
May 16, 2014.
 No. 19-1992                    Andrews v. Wayne Cty., Mich.                              Page 6

       From May 22 through May 26, 2014, White had been admitted to Sinai Grace Hospital in
Detroit, presenting with an altered mental state. White reported that she had been “seen in the
past for depression and suicide attempt by Seroquel overdose by Psych consult service.” There
is no indication when the attempt occurred.

       White was also seen on May 7, May 21, and May 28, 2014, by the University of
Michigan Neurology Headache Clinic for an evaluation and follow-up care for chronic left-sided
headache. She received treatment for cellulitis at the University of Michigan Hospital on May
31, 2014.

       White did not report any of these hospital visits to the Canton Police or the Jail. Neither
did Andrews.

                                      C. The KOP Policy

       The Jail’s KOP Policy has been in effect, subject to revisions, since 1998. The Jail
adopted the standards formulated by the National Commission of Correctional Healthcare. As
revised in 2012, it provided:

       It is the policy of Wayne County Jail Health Services (WCJHS) that
       R.N.’s/L.P.N.’s [sic] shall distribute non restricted medications for the Self
       Medication Program to patient/inmates in the general population and medical
       special housing so that they can store and administer their own medications. All
       psychotropic medications for patients/inmates will be nurse dispensed regardless
       of the location of the inmate. Inmate/patients who reside on the mental health
       unit will be excepted from the Self Medication Program and as such all
       medications to Mental Health Unit patients will be Nurse administered. WCJHS
       reserves the right to restrict self administration privileges to any inmate if
       necessary, to assure the safety and security of the patient, other inmates or the
       institution. A current drug list will be posted in all medication books and clinical
       areas at all times.

(Emphasis added.) Thus, as of 2012, only patients housed on the mental health unit are excluded
from participating in the KOP program.

       Five categories of medications were on the “Nurse Administered Medications” list.
These included: (1) tuberculosis medications, (2) miscellaneous drugs—including Catapres but
not Verapamil, (3) psychotropic antidepressant medications, (4) psychotropic antipsychotic
 No. 19-1992                               Andrews v. Wayne Cty., Mich.                                    Page 7

medications, and (5) antiretroviral medications. The Jail had identified these drugs as having “an
abuse potential” or “warrant[ing] close monitoring for patient/inmate compliance.” The drugs on
the list were “restricted to individual dose administration.”

         Medical Director Thomas Clafton, M.D.,2 explained that medicines “known to be abused
by inmates” made it to the list. The blood pressure medication Catapres was listed under the
“miscellaneous” category “because it’s sedating, it’s a sleeper. The inmates know that they can
take a bunch of that and it will make them go to sleep.” Dr. Keith Dlugokinski, Ph.D., the
Director of Jail Health Services, also knew that Catapres had “some value on the trade market in
the jail” because it has “sedating components” and “sleep is . . . a valuable commodity in the
jail.” Verapamil, although also “an anti-hypertensive,” was not on the list because it would not
have the same effect.

         Prior to the 2012 version, the KOP precluded any inmate on psychotropic medication
from participating in the self-administration program.3 Thus, had White arrived at the Jail in
2009 instead of 2014, she would not have been permitted to keep any drugs with her, because
she was taking two psychotropic medications, Klonopin and Lexapro. Under the 2012 KOP
Policy, White was allowed to participate in the program because she had not been placed on the
mental health unit.

         Not long after White’s death, the KOP Policy was amended to add Verapamil to the
“miscellaneous” drug category.

         2
             Dr. Clafton no longer works for the Jail.
         3
             The 2009 KOP Policy stated:
         It is the policy of the Wayne County Jail Health Services (WCJHS) that R.N.’s/L.P.N.’s [sic] will distribute
non restricted medications for the Self Medication Program to responsible patients/inmates in the general population
only to carry and administer their own medications. The self medication program is restricted to patients/inmates
who do not receive any psychotropic medications inclusive of the present restricted drug list. All psychotic [sic]
medications for patients/inmates will be nurse dispensed regardless of his/her location. A current drug list will be
posted in all medication books and clinical areas at all times. (Emphasis added)
 No. 19-1992                      Andrews v. Wayne Cty., Mich.                              Page 8

                                     D. Procedural History

       Andrews sued the County under 42 U.S.C. § 1983, alleging that its KOP Policy as well as
its failure to train its personnel in suicide assessment policies were deliberately indifferent to
White’s serious medical needs. The district court granted Wayne County’s motion for summary
judgment. It held that the KOP Policy did not violate White’s constitutional right to medical
treatment because it (1) did not interfere with Carnill’s follow-up interview of Benette’s initial
screening of White, (2) did not prevent Carnill from placing White on the mental health unit if
she appeared mentally unstable, and (3) gave the Jail staff discretion to restrict inmates’ access to
medications and participation in the KOP program when they were not on the mental health unit
if they were mentally ill or likely to abuse medication. The district court rejected the failure-to-
train claim because a detainee does not have a right to receive suicide screening unless the
detainee demonstrates a strong likelihood of committing suicide and White did not.

       Andrews appeals.

                                III. STANDARD OF REVIEW

       A district court’s grant of summary judgment is reviewed de novo. Jackson v. City of
Cleveland, 925 F.3d 793, 806 (6th Cir. 2019), cert. denied, 140 S. Ct. 855 (2020). Summary
judgment is proper “if there is no genuine dispute as to any material fact” and the moving party
“is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a).

                                         IV. ANALYSIS

       Pretrial detainees have a right to receive adequate medical attention under the Due
Process Clause of the Fourteenth Amendment. Gray, 399 F.3d at 616 (citing City of Revere v.
Mass. Gen. Hosp., 463 U.S. 239, 244 (1983)). This includes psychological needs, ‘“especially
when they result in suicidal tendencies.’” Comstock v. McCrary, 273 F.3d 693, 703 (6th Cir.
2001) (quoting Horn v. Madison Cty. Fiscal Court, 22 F.3d 653, 660 (6th Cir. 1994)).
“The ‘right’ that is truly at issue . . . is . . . the right to have steps taken that would have
prevented suicide.” Danese v. Asman, 875 F.2d 1239, 1244 (6th Cir. 1989). A pretrial detainee
does not have a general constitutional right to receive a suicide screening or to be placed on
 No. 19-1992                         Andrews v. Wayne Cty., Mich.                                    Page 9

suicide watch unless she manifests “a strong likelihood of committing suicide.” Gray, 399 F.3d
at 616; see also Barber v. City of Salem, 953 F.2d 232, 239–40 (6th Cir. 1992); Danese, 875 F.2d
at 1244.

        “[A] municipality can be liable under § 1983 only where its policies are the ‘moving
force [behind] the constitutional violation.’” City of Canton v. Harris, 489 U.S. 378, 389 (1989)
(quoting Monell v. New York City Dep’t of Soc. Serv., 436 U.S. 658, 694 (1978)).
A municipality cannot be held liable simply because one of its employees has committed a
constitutional violation. Monell, 436 U.S. at 694. In other words, a municipality is liable “only
if the injury is caused by [the implementation of] a municipal custom or policy, or if the city’s
failure to train employees amounts to deliberate indifference to constitutional rights.” Arrington-
Bey v. City of Bedford Heights, 858 F.3d 988, 994 (6th Cir. 2017); Morgan v. Fairfield Cty.,
903 F.3d 553, 565 (6th Cir. 2018) (same). “There are important differences between these types
of claims,” Arrington-Bey, 903 F.3d at 994, so they must be analyzed differently, Morgan, 903
F.3d at 566.4

                                            A. Official Policy

        “[W]hen an injury is caused by the straightforward carrying out of a municipal policy or
custom, the determination of causation is easy.” Morgan, 903 F.3d at 566 (citing Garner v.
Memphis Police Dep’t, 8 F.3d 358, 364–65 (6th Cir. 1993)). The plaintiff must “identify the
policy, connect the policy to the [municipality] itself and show that the particular injury was
incurred because of the execution of that policy.” Garner, 8 F.3d at 364 (quoting Coogan v. City
of Wixom, 820 F.2d 170, 176 (6th Cir. 1987)); Morgan, 903 F.3d at 566 (same).

        Andrews offers several arguments for why the 2012 KOP Policy was “clearly
constitutionally defective and just as plainly caused [White’s] death.”

        4
          The County’s argument that the deliberate indifference standard applies to official policy claims is
untenable, as Arrington-Bey and Morgan make clear.
 No. 19-1992                            Andrews v. Wayne Cty., Mich.                       Page 10

                                           1. Defective on its Face5

       Andrews argues that the KOP Policy is defective on its face for three reasons. First, it is
based on where the inmate is housed and not upon the inmate’s condition. Second, the KOP
Policy does not require a suicide risk assessment prior to participation in the program. Third, the
policy does not contain an automatic exclusion for individuals with a mental health history or
who have previously attempted suicide.

       Andrews’ first assertion is flawed because, as the district court observed, it glosses over
the fact that the KOP Policy does not dictate where an inmate is housed; the Jail staff make that
decision, based upon an individualized assessment of the inmate.           And, even if a patient
otherwise qualifies for the program because she is housed in the general population, the Policy
allows the Jail personnel “to restrict self administration privileges to any inmate if necessary, to
assure the safety and security of the patient.” Dr. Clafton also attested to this discretion. Carnill
said the same—that the KOP did not restrict him from deeming White ineligible for the KOP if
he perceived that White might be a danger to herself. The district court correctly rejected this
argument.

       Andrews’ second argument fails because, as noted, a pretrial detainee does not have an
automatic right to a suicide screening. See Gray, 399 F.3d at 616. As for the third argument,
Andrews offers no explanation why a past suicide attempt makes a current one “clearly
foreseeable” such that an automatic exclusion was required.6 In fact, this court has held that a
prison official’s duty to recognize an inmate’s risk of committing suicide has a temporal
component. See Linden v. Washtenaw Cty., 167 F. App’x 410, 421 (6th Cir. 2006) (holding that
to be held liable, “a prison official must be cognizant of the significant likelihood that an inmate
may imminently seek to take his own life”) (quoting Estate of Novack ex rel. Turbin v. Cty. of
Wood, 226 F.3d 525, 529 (7th Cir. 2000)). In short, the KOP Policy is not defective on its face.

       5
           We have reordered Andrews’ arguments somewhat.
       6
           The Jail did not have White’s mental health history.
 No. 19-1992                      Andrews v. Wayne Cty., Mich.                           Page 11

                                        2. Policy Change

       Andrews contends that the County deliberately changed its KOP policy in 2012 without
justification or basis to allow individuals taking psychotropic drugs to participate. Under the
2009 version, White would have been automatically excluded from the KOP program because
she was taking two psychotropic medications, Klonopin and Lexapro. Andrews points out that
Dr. Clafton, the Jail’s Medical Director, thought that the policy change was probably to clarify a
“poorly worded” policy which according to Andrews is a poor reason to implement a policy that
allows vulnerable persons to retain dangerous medications.

       But Dr. Dlugokinski, who also signed off on the 2012 policy change along with Dr.
Clafton, explained that the revision was a conscious, collective decision by the policy team, who
wanted to “include the mental health patients and provide them with a greater opportunity to
participate in their own treatment, . . . [and] be responsible and accountable as they do now on
the outside to take their own medication if they were not ill such that they needed housing on the
mental health unit.” Dr. Clafton also confirmed that the intake staff have discretion to exclude
persons from the KOP program. This was Carnill’s understanding as well. Furthermore, the
explicit exclusion for safety purposes in the 2012 KOP Policy adds an important safeguard.
Thus, although the 2012 version of the KOP Policy is more inclusive than the 2009 version, it
cannot be said that the revision was constitutionally irresponsible.

       Thus, as the district court held, the County provided an adequate reason for changing the
KOP policy.

                3. Allowing Participation Before a Mental Health Evaluation

       Andrews contends that the KOP Policy is deficient because it allows inmates in need of a
psychological evaluation like White to participate prior to the psychiatrist’s assessment of proper
housing. Only a psychiatrist can place an inmate on the mental health unit.

       But Carnill testified that he referred White for further mental health evaluation with a
social worker because “she was on medication for depression and anxiety,” not because she
reported or exhibited any psychiatric distress.      Carnill could have restricted access to all
 No. 19-1992                     Andrews v. Wayne Cty., Mich.                           Page 12

medications under the KOP Policy but exercised his discretion not to. Again, White did not have
an automatic right to a suicide screening. The absence of a blanket exclusion for “unsettled”
inmates does not render the KOP Policy constitutionally defective.

                                4. Failure to Act as a Backstop

       Andrews maintains that the KOP Policy is constitutionally defective because it did not
catch mistakes in the intake process. He points out that had Carnill reviewed the intake form, he
would have learned that White had attempted suicide in the past. Furthermore, the answers
recorded on White’s intake form were incomplete or inconsistent.

       This argument fails to persuade because it is essentially a repurposing of Andrews’
arguments that the KOP Policy should require suicide risk assessments as a matter of course and
should automatically exclude persons with any sort of mental health history. What Andrews is
really complaining about is the adequacy of the intake screening process. This allegation is
better characterized as a failure to train claim against the County, and to that extent will be
addressed infra.

                                    5. Restricted Drug List

       Andrews argues that the 2012 KOP policy ignored the serious medical needs of inmates
because it restricted Catapres but not Verapamil.

       Dr. Dlugokinski testified that Catapres was on the list because it was a hot commodity in
the prison due to its sedative effects. Both Dr. Dlugokinski and Dr. Clafton testified that
Verapamil, while also a blood pressure medication, did not share the same side effect, so it was
not considered subject to abuse by inmates. Andrews did not offer any evidence to the contrary.
Thus, its absence from the restricted drug list cannot be characterized as a constitutional
violation.

       In sum, none of the foregoing factors, individually or collectively, create a genuine issue
of fact regarding the constitutionality of the KOP policy and its application to White. The
district court did not err in granting summary judgment to the County on Andrews’ official
policy claim.
 No. 19-1992                              Andrews v. Wayne Cty., Mich.                                       Page 13

                                                 B. Failure to Train

         Andrews argues that the Jail’s policy of failing to train its employees in suicide risk
assessment shows deliberate indifference. “A municipality may be liable under § 1983 where
the risks from its decision not to train its officers were ‘so obvious’ as to constitute deliberate
indifference to the rights of its citizens.” Gray, 399 F.3d at 618. To establish liability on this
basis,

         the claimant must show not only that an employee’s act caused a constitutional
         tort, but also that the city’s failure to train its employees caused the employee’s
         violation and that the city culpably declined to train “its employees to handle
         recurring situations presenting an obvious potential for such a violation.”

Arrington-Bey, 858 F.3d at 995 (quoting Bd. of Cty. Comm’rs of Bryan Cty. v. Brown, 520 U.S.
397, 409 (1997)). “As applied to suicide claims, the case law imposes a duty on the part of
municipalities to recognize, or at least not to ignore, obvious risks of suicide that are
foreseeable.” Gray, 399 F.3d at 618. And “[w]here such a risk is clear, the municipality has a
duty to take reasonable steps to prevent the suicide.” Id.

         As the district court recognized, Andrews cannot prevail on a failure-to-train theory of
liability against the County because no constitutional tort was committed. No constitutional tort
was committed here because White did not demonstrate a strong likelihood of committing
suicide. Like the pretrial detainee who committed suicide in Gray, White “never made any
statements that could reasonably be interpreted as threatening to harm [her]self.” Id. at 619.
During the intake process, White appeared mentally stable during two separate intake interviews
and the Jail had no other information to suggest that she was threatening harm.7 She expressly
denied suicidal ideation or thoughts of harm when asked (twice). Even her former fiancé failed
to flag the issue—because he did not think White was suicidal.8 Furthermore, Carnill testified
that had White presented as mentally unstable, he would have taken appropriate precautions,
including housing her on the mental health unit and contacting the on-call psychiatrist. Thus,

         7
             Contrary to Andrews’ assertion, the Jail did not have White’s other mental health records at intake.
         8
         Andrews testified that the only time White expressed suicidal thoughts was when she admitted herself to
Kingswood, where she “[f]ound out it was a particular medication that was pushing suicide thoughts.” White also
told Andrews that she had stopped taking the medication.
 No. 19-1992                      Andrews v. Wayne Cty., Mich.                           Page 14

any purported lack of specific suicide risk assessment training did not cause White to commit
suicide. Finally, like the defendant city jail in Gray, the County has no history of suicides
relative to the KOP program. Thus, as in Gray, any purported failure to train its employees in
suicide risk assessment did not cause White’s death.

       Other factors, such as White’s use of depression and anxiety medication, did not change
the calculus. As Andrews’ own expert, Dr. A. E. Daniel, M.D., admitted, “just because a person
has depression, [that] doesn’t mean [she is] suicidal,” and “not all persons with depression or
anxiety are suicidal.” Indeed, the fact that White had already taken steps to treat her anxiety and
depression suggest that any potential suicidal tendencies were under control, and Carnill
followed up by asking White if she had any suicidal thoughts or ideations, which she denied. He
also referred her to a social worker for evaluation.        In short, Carnill, a trained medical
professional in the County’s employ and entrusted by it to assess White’s mental and physical
condition, did not display deliberate indifference towards White.

       Which brings us back to the only defendant in this case, Carnill’s employer, the County.
This court has “continuously held that under § 1983, a county can only be held liable if there is a
showing of an underlying constitutional violation by the county’s officials.” Burkey v. Hunter,
790 F. App’x 40, 41 (6th Cir. 2020) (listing cases). Axiomatically, “[t]here can be no Monell
municipal liability under § 1983 unless there is an underlying unconstitutional act.” Wilson v.
Morgan, 477 F.3d 326, 340 (6th Cir. 2007) (citing City of Los Angeles v. Heller, 475 U.S. 796,
799 (1986)). For this reason, the district court properly held that the County was entitled to
summary judgment on the failure to train claim.

                                       V. CONCLUSION

       For these reasons, as well as those articulated in its detailed opinion, we AFFIRM the
judgment of the district court.