Court Opinion

ID: 4639739
Source: CourtListenerOpinion
Date Created: 2020-12-04 20:00:44.296443+00
Date Added: 2024-06-11T07:58:59.987221
License: Public Domain

Case: 19-41039     Document: 00515660480         Page: 1     Date Filed: 12/03/2020

           United States Court of Appeals
                for the Fifth Circuit                                 United States Court of Appeals
                                                                               Fifth Circuit

                                                                             FILED
                                                                      December 3, 2020
                                  No. 19-41039                          Lyle W. Cayce
                                                                             Clerk

   Estate of Rosa Bonilla, by and through her Authorized
   Representative Zoey Bonilla; Zoey Bonilla,
   Individually; J.B., Minor; A.B., Minor,

                                                           Plaintiffs—Appellants,

                                      versus

   Orange County, Texas; Tiffani Dickerson, LVN; Jenifer
   Schafer,

                                                         Defendants—Appellees.

                  Appeal from the United States District Court
                       For the Eastern District of Texas
                            USDC No. 1:18-CV-104

   Before Higginbotham, Jones, and Higginson, Circuit Judges.
   Edith H. Jones, Circuit Judge:
         Appellants, the family of a woman who committed suicide while in
   custody, appeal the district court’s grant of summary judgment to
   Defendants Orange County, LVN Tiffany Dickerson, and corrections officer
   Jenifer Shafer. Agreeing with the district court that decedent Rosa Bonilla’s
   constitutional rights were not violated, we AFFIRM.
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                                     No. 19-41039

                                 BACKGROUND
          On the morning of February 24, 2017, Rosa Bonilla and her boyfriend
   Kendrick Soloman were pulled over by law enforcement. A consent search
   turned up a plastic baggie with multiple Xanax pills, and Bonilla was arrested
   for the possession of Xanax. Bonilla arrived at the jail shortly before 11 a.m.
   and was evaluated by appellee Officer Jenifer Shafer in the booking area.
   Shafer is a corrections officer licensed by the Texas Commission on Law
   Enforcement who had completed required coursework on suicide detection
   and prevention before she met Bonilla. Shafer noted that Bonilla was
   “agitated” when she arrived at the jail, but she quickly became “calm” and
   “positive.” Shafer asked Bonilla a series of questions specified in the jail’s
   intake questionnaire and suicide screening form. Bonilla disclosed that she
   was bi-polar, suffered from ADHD, and was taking Wellbutrin, Trazodone,
   and Xanax for these conditions. Bonilla also disclosed that “she had taken
   Xanax and smoked a little bit of weed” that morning. Finally, Bonilla
   disclosed some sort of past head injury.
          In Shafer’s estimation, Bonilla did not appear intoxicated. In response
   to Bonilla’s disclosures, Shafer inquired further about her mental health and
   Xanax use. Bonilla admitted a history of abusing Xanax. She described
   herself as suffering from PTSD brought on by sexual abuse she suffered as a
   child. She also described herself as “depressed” by the death of a friend the
   previous year. Bonilla denied having ever attempted suicide or having
   thoughts of suicide since being arrested. She also denied feeling hopeless and
   explained to Shafer that she would “be leaving [the jail] tomorrow.” When
   asked if “she was going to get sick if she did not have the Xanax,” Bonilla
   responded, “No.”
          Because Bonilla denied past suicide attempts, having suicidal
   thoughts, or feeling hopeless, the guidance in the jail’s suicide screening form

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   did not require that she be placed on suicide watch. Shafer observed Bonilla
   throughout the interview and noted that she did not show signs of depression,
   erratic behavior, or self-harm such as cuts or ligature marks. Nonetheless,
   Shafer determined that Bonilla’s answers warranted discussion with her
   supervising officer, Sergeant Cynthia Jowers.         After Shafer had this
   discussion, the officers kept Bonilla in a waiting area for approximately an
   hour to observe her demeanor. They observed that Bonilla’s demeanor was
   generally “positive” and concluded she did not need immediate medical
   attention or suicide watch. Shafer then placed Bonilla alone in a holding cell,
   where she observed Bonilla sleeping in subsequent cell checks.
          Around 3:20 p.m., Shafer escorted Bonilla to the visiting room to meet
   with Kendrick Solomon. Shafer recalls Bonilla being “agitated” on her way
   to the visiting room, muttering under her breath something to the effect that
   Solomon had better bail her out.       Another corrections officer, Crystal
   Yocham, was present in the visiting room and reported that Bonilla told
   Solomon to go to Goodman Bail Bonds and bail her out either that day or first
   thing the next morning. After the visit, Shafer escorted Bonilla back to her
   cell and noted that her mood had again improved; she seemed “hopeful.”
   Shafer had no further direct interaction with Bonilla, but she continued to
   observe Bonilla in the holding cell at thirty-minute intervals until her shift
   ended at 6:00 p.m.
          Around 4 p.m., defendant Tiffany Dickerson, the Licensed Vocational
   Nurse (“LVN”) on duty, reviewed the intake screening form concerning
   Bonilla. An LVN is “the Texas equivalent of a licensed practical nurse,
   receives nine months’ training in a certificate program, and provides basic
   medical monitoring under the supervision of physicians or registered
   nurses.” Montano v. Orange County, 842 F.3d 865, 870 (5th Cir. 2016). After
   reviewing Shafer’s notes, LVN Dickerson did not believe that Bonilla was a
   suicide risk, but Bonilla’s mental health-related answers required Dickerson

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   to email an “Inmate Mental Condition Report” to the local magistrate judge
   and mental health services requesting further evaluation. She did so at 4:10
   p.m. Dickerson had also obtained a possible “continuum of care query”
   (CCQ) match for Bonilla, a search result indicating that Bonilla had
   previously sought mental health treatment at a state facility. In addition,
   Dickerson initiated the process of verifying that Bonilla had valid
   prescriptions. She did not complete the verification process before her shift
   ended at 6:00 p.m., but she states that she left a note directing the next nurse
   on duty to finish verifying Bonilla’s prescriptions. The LVN on the following
   shift, Phillip Thompson, was not aware of the verification request and had
   not verified Bonilla’s prescriptions prior to her suicide. Neither Dickerson
   nor Thompson met with or observed Bonilla. No one at the jail distributed
   any medications to Bonilla.
          At 6:00 p.m. Officer Madeline Lewis relieved Officer Shafer of duty.
   At the time, Bonilla remained the only inmate in the female holding cell.
   Shafer indicated to Lewis that she had not had problems with any inmate
   during her shift and that no one in her care was on suicide watch. Lewis first
   observed Bonilla during the shift change with Shafer and found her lying on
   a sleeping mat. She continued to check on Bonilla at least every thirty
   minutes thereafter. Around 6:40 p.m., Lewis delivered, and Bonilla ate, an
   evening meal. Lewis spoke with Bonilla during her rounds and recalls that
   Bonilla had asked to use the phone. According to Lewis, Bonilla never asked
   for medication or showed any signs of distress. At around 8:40 p.m., Lewis
   was escorting another inmate to the female holding cell. She looked into the
   holding cell before unlocking the door and saw Bonilla hanging from a phone
   conduit with a bedsheet wrapped around her neck. Lewis radioed her
   supervisors for assistance. Several officers and a nurse arrived at the holding
   cell and began performing life-saving measures. Bonilla was taken to the
   hospital and placed on a ventilator. She was declared brain dead two days

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   later on February 26, 2017.
          After Bonilla’s suicide, the Texas Commission on Jail Standards
   investigated Bonilla’s time at the jail. The Commission noted that although
   Bonilla’s answers at intake presented “numerous flags,” jail staff had
   responded appropriately by notifying the magistrate and mental health
   services. The Commission concluded that jail personnel had committed “no
   violation of minimum standards” in their treatment of Bonilla.
          A year later, Plaintiffs filed suit in state court against Orange County,
   Sheriff Keith Merritt, and numerous individual jail employees. After the case
   was removed to federal court, the district court dismissed several claims and
   defendants. Summary judgment was sought by the remaining defendants.
   Addressing the Plaintiffs’ § 1983 claims against the County, Officer Shafer,
   and LVN Dickerson, the district court concluded that Plaintiffs had failed to
   create a genuine issue of material fact, and that the Defendants were entitled
   to judgment as a matter of law. The Plaintiffs timely appealed.
                                  DISCUSSION
          This court reviews a district court’s grant of summary judgment de
   novo. Bridges v. Empire Scaffold, L.L.C., 875 F.3d 222, 225 (5th Cir. 2017).
   Summary judgment is appropriate when no genuine dispute of material fact
   exists and the movant is entitled to judgment as a matter of law. FED. R.
   CIV. P. 56(a). A genuine dispute of material fact exists “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; 106 S. Ct. 2505 (1986). A
   court must resolve all reasonable doubts and draw all reasonable inferences
   in the light most favorable to the nonmovant. Sanchez v. Young Cty., Texas,
   956 F.3d 785, 791 (5th Cir. 2020) (quoting Walker v. Sears, Roebuck & Co.,
   853 F.2d 355, 358 (5th Cir. 1988)).

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          Plaintiffs pursue two types of claims on appeal. As to the individual
   defendants, they assert liability based on unconstitutional “episodic acts or
   omissions,” and they indict Orange County for unconstitutional conditions
   of confinement. We address each type.
             CLAIMS AGAINST INDIVIDUAL DEFENDANTS
   I. The Episodic Acts or Omissions Claim
          An episodic acts or omissions claim arises where “the complained-of
   harm is a particular act or omission of one or more officials.” Flores v. Cty. of
   Hardeman, Tex., 124 F.3d 736, 738 (5th Cir. 1997). More specifically, the
   Fourteenth Amendment protects pretrial detainees’ right to medical care
   and to “protection from known suicidal tendencies.” Baldwin v. Dorsey,
   964 F.3d 320, 326 (5th Cir. 2020) (citing Garza v. City of Donna, 922 F.3d
   626, 632 (5th Cir. 2019)); Hare v. City of Corinth, 74 F.3d 633, 639 (5th Cir.
   1996) (en banc). A government official violates a Fourteenth Amendment
   right when the official acts with deliberate indifference to a detainee’s serious
   medical needs. Id. “Deliberate indifference is an extremely high standard to
   meet.” Domino v. Tex. Dep't of Crim. Justice, 239 F.3d 752, 756 (5th Cir.
   2001). To prove deliberate indifference, the Plaintiffs must show that the
   defendants were “aware of facts from which the inference could be drawn
   that a substantial risk of serious harm exists,” that the defendants actually
   “dr[e]w the inference,” and that the defendants “disregard[ed] that risk by
   failing to take reasonable measures to abate it.” Hyatt, 843 F.3d at 177 (5th
   Cir. 2016) (quoting Farmer v. Brennan, 511 U.S. 825, 837 (1994)); Id. at 179
   (quoting Gobert v. Caldwell, 463 F.3d 339, 346 (5th Cir. 2006)).
          The Plaintiffs claim that Officer Shafer and LVN Dickerson
   committed several allegedly culpable acts or omissions: “(1) inadequate
   screening for a risk of self-harm; (2) failure to provide medical care by failure
   to provide prescription medication; (3) failure to adequately monitor Rosa

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   Bonilla; and (4) failure to provide suicide prevention bedding.” Plaintiffs
   claim that there “is overwhelming evidence [Shafer and Dickerson]
   disregarded an obvious risk of self-harm for Bonilla.”
          Plaintiffs contend that Shafer knew that Bonilla was “coming down
   off of [] drugs.” This is an inaccurate representation of the deposition
   testimony.     The quoted language comes from counsel’s question, not
   Shafer’s answer. Shafer’s testimony indicates that she did not believe
   Bonilla was intoxicated. Here even if true, the fact of Bonilla’s intoxication
   would not indicate that Shafer inferred she was a suicide risk. “[E]vidence
   that an official was aware of a substantial risk to inmate safety does not alone
   establish deliberate indifference.” Hyatt, 843 F.3d at 177 (5th Cir. 2016).
   Plaintiffs also maintain that Dickerson “ignored the CCQ” search result
   indicating that Bonilla may have previously received state-provided mental
   health services.     This too is inaccurate; Dickerson notified both the
   magistrate and the mental health resources center of the possible CCQ match
   for Bonilla.
          Plaintiffs also argue that Shafer, Dickerson, and Jowers relied
   exclusively on “Bonilla’s inherently inaccurate oral responses, while
   ignoring all objective evidence,” in violation of the Facility Operating Plan.
   Shafer did not disregard the “red flags” in Bonilla’s answers; instead she
   asked further questions until she determined that there was no indication that
   Bonilla was at high risk of self-harm. Her assessment may have proven
   incorrect, but her response was not indifferent. Even if Plaintiffs’ view of the
   process could be accepted, evidence of inadequate screening or a violation of
   facility procedure would not raise an issue of deliberate indifference without
   additional evidence that the officers or nurses knew that Bonilla was in fact
   at risk for suicide. Hyatt, 843 F.3d at 178 (“[E]ven if an officer responds
   without the due care a reasonable person would use—such that the officer is
   only negligent—there will be no liability.”). Finally, the report of Plaintiffs’

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   expert Dr. Kiekbusch “does not support an inference that [Bonilla] was so
   obviously suicidal that [Defendants] must have known yet disregarded that
   risk.”    Domino, 239 F.3d at 756.          This is especially true given that
   Dr. Kiekbusch cannot point to evidence of Bonilla’s behaving in an erratic or
   alarming manner in custody nor to evidence that she had any established
   suicidal tendencies.
            This court has previously observed that “[s]uicide is inherently
   difficult for anyone to predict, particularly in the depressing prison setting.”
   Domino, 239 F.3d at 756.        In Flores v. County of Hardeman, the court
   determined that the sheriff did not act with deliberate indifference when he
   took off of suicide watch an inmate who later committed suicide, despite the
   fact that the deceased had just been arrested after a one-hour standoff with
   police and “was not acting like himself.” 124 F.3d at 738–39. Similarly, in
   Sibley v. Lemaire, the plaintiff offered evidence that jail personnel had
   “observed [Sibley] holding his Bible upside down while appearing to read
   from it, cleaning the walls of his cell with toilet paper, lying next to his toilet
   and staring into it. . . . [and] kicking the door to his cell. 184 F.3d 481, 484
   (5th Cir. 1999). Sibley was having a psychotic episode and eventually blinded
   himself by attempting to remove his own eyes. Nonetheless, the court
   concluded that “[a]lthough Sibley’s actions seem to have become
   increasingly erratic, nothing he did so clearly indicated an intent to harm
   himself that the deputies caring for him could have only concluded that he
   posed a serious risk of harm to himself.” Id. at 489.
            The common thread is a reluctance to hold that generalized evidence
   of an inmate’s mental illness invariably indicates a substantial risk of self-
   harm. Yet, that is essentially what Plaintiffs argue here. Apart from lacking
   support in the case law, the proposition lacks logical force, given the varied,
   individualized nature of mental illness. Bonilla presented with fewer warning
   signs than either Flores or Sibley. The circumstances of her arrest, booking

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   and detention did not raise questions concerning her mental stability or
   capacity for self-harm. She had no history of suicidal tendencies. The
   evidence indicates that Bonilla did not request medical help, and her behavior
   in detention was unremarkable prior to her suicide. This evidence did not
   give rise to reasonable inferences that the individual defendants were aware
   of Bonilla’s suicidal tendency, much less that they disregarded the risk. The
   district court correctly awarded summary judgment in the absence of
   evidence that Shafer or Dickerson “acted or failed to act with subjective
   deliberate indifference to the detainee’s rights.”
   II. Qualified Immunity
          Even if Plaintiffs had been able to thwart summary adjudication of an
   episodic acts or omissions claim, their claim would still fail because LVN
   Dickerson and Officer Shafer are entitled to qualified immunity.
          “Qualified immunity protects officers from suit unless their conduct
   violates a clearly established constitutional right.” Hyatt, 843 F.3d at 177
   (citing Mace v. City of Palestine, 333 F.3d 621, 623 (5th Cir. 2003)). “Once a
   defendant asserts the qualified immunity defense, ‘[t]he plaintiff bears the
   burden of negating qualified immunity.’” Id. (quoting Brown v. Callahan,
   623 F.3d 249, 253 (5th Cir. 2010)). To do so, Plaintiffs “must adduce facts
   to show that [Defendants] violated her constitutional rights, and she must
   show that the asserted “right was clearly established at the time of the alleged
   misconduct.” Baldwin, 964 F.3d at 325 (internal quotations omitted). A
   court may consider either condition first, and if either condition is not met,
   then the Defendants are immune. Id. (citing Morgan v. Swanson, 659 F.3d
   359, 385 (5th Cir. 2011) (en banc)). To be clearly established, a right must be
   “sufficiently clear that every reasonable official would have understood that
   what he is doing violates that right.” Ashcroft v. al-Kidd, 563 U.S. 731, 741;
   131 S. Ct. 2074, 2083 (2011). “When properly applied, [qualified immunity]

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   protects all but the plainly incompetent or those who knowingly violate the
   law.” Id. at 743.
          As an inmate, Bonilla had a clearly established right to be protected
   from her known suicidal tendencies. Garza, 922 F.3d at 632 (citing Flores,
   124 F.3d at 738). But Plaintiffs have failed to offer any evidence that Bonilla’s
   tendencies were known to anyone—let alone Defendants; even Bonilla’s
   mother denied that her daughter had ever attempted or expressed thoughts
   of suicide. Bonilla also had a clearly established right “‘not to have [her]
   serious medical needs met with deliberate indifference on the part of the
   confining officials.’” Dyer, 964 F.3d at 380 (quoting Thompson v. Upshur
   County, 245 F.3d 447, 457 (5th Cir. 2001)). But, as discussed above,
   Defendants did not treat Bonilla’s medical needs with indifference. After
   Bonilla disclosed her drug use and mental health issues, Shafer made further
   inquiries into Bonilla’s psychological wellbeing. Dickerson sent the required
   mental health referral and initiated verification of Bonilla’s claimed
   prescriptions. These actions do not evidence indifference. See Hyatt,
   843 F.3d at 180 (“Although these measures were ultimately, and tragically,
   insufficient, we cannot say that they constitute deliberate indifference.”).
          The more specific rights that Plaintiffs claim for Bonilla lack adequate
   support in the case law to be “clearly established.” For instance, Plaintiffs
   identify no cases establishing a clear constitutional right to adequate suicide
   screening or to screening only by medical professionals. In Taylor v. Barkes,
   a case involving a factually similar instance of suicide by a pretrial detainee,
   the Supreme Court observed: “No decision of this Court establishes a right
   to the proper implementation of adequate suicide prevention protocols. No
   decision of this Court even discusses suicide screening or prevention
   protocols.”    Taylor, 575 U.S. 822; 135 S. Ct. 2042, 2044 (2015). The
   Supreme Court has not revisited Taylor.            Further, since no “robust
   consensus of cases” has developed within this circuit on the issue of suicide

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   screening, there is no basis for asserting such a “right” is clearly established.
   Id.
          Similarly, Plaintiffs identify no cases establishing that adequate
   medical care requires the distribution of prescription narcotics to an inmate
   within hours of her intake. If Bonilla had exhibited signs of serious physical
   or psychological distress while detained, the staff’s failure to address those
   needs by providing her with necessary medication may have violated her
   established right to medical care. See, e.g., Shepherd, 591 F.3d 445, 449–50
   (5th Cir.) (upholding jury verdict in favor of detainee with chronic
   hypertension who was denied his prescription medication over several
   months despite multiple hypertensive emergencies that required medical
   attention). But Plaintiffs identify no such signs of distress, nor requests by
   Bonilla for medication.
          Plaintiffs rely heavily on Montano v. Orange County, but other than
   featuring the same jail, the case is not sufficiently analogous to clearly
   establish that Bonilla had a constitutional right to suicide screening or to
   faster verification of prescriptions.        The facts of Montano bear little
   resemblance to Plaintiffs’ case. Montano did not involve inmate suicide. In
   that case, jail staff had left a severely intoxicated detainee alone in a cell for
   over four days, with his own excrement and the food he refused to eat, while
   they expected he would eventually sober up. 842 F.3d at 870-72. He died of
   acute renal failure after his calls for assistance went unanswered. Id. at 872.
   Montano had arrived at the jail so intoxicated that he was unable to answer
   the officer’s intake questions, and the officers ignored obvious signs of his
   physical deterioration over a period of days. Id. at 870. Montano dealt with
   neither prescription verification nor suicide screening; Bonilla’s condition
   and behavior were entirely different; and the defendants’ conduct here bears
   no resemblance to that in Montano.

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          As the Supreme Court has warned, courts should not “define clearly
   established law at a high level of generality.” Mullenix v. Luna, 136 S. Ct.
   305, 308 (2015) (per curiam) (quotation omitted). Thus, the inadequacy of
   Orange County’s response to the distinguishable circumstances attending
   Montano’s death cannot establish the violation of Bonilla’s rights. She was
   checked every 30 minutes and was served and ate a meal. Plaintiffs have not
   identified a case that would have put Shafer or Dickerson on “‘fair notice’
   that [they were] acting unconstitutionally” when they failed to classify
   Bonilla as a suicide risk or failed to verify her prescriptions with sufficient
   dispatch. Cleveland, 938 F.3d at 677.
                   CLAIMS AGAINST ORANGE COUNTY
          Municipalities can be held liable for violating a person’s constitutional
   rights under § 1983. See Monell v. Dep’t of Soc. Servs., 436 U.S. 658; 98 S. Ct.
   2018 (1978). “[M]unicipal liability under section 1983 requires proof of three
   elements: a policymaker; an official policy; and a violation of constitutional
   rights whose ‘moving force’ is the policy or custom.” Piotrowski v. City of
   Houston, 237 F.3d 567, 578 (5th Cir. 2001) (citing Monell, 436 U.S. at 694.)
          Plaintiffs attempt to predicate liability for Bonilla’s suicide on two
   theories, one derived specifically from Monell, and one based on
   unconstitutional conditions of confinement. This is error. Elsewhere this
   court has observed that “[u]nder Monell, a plaintiff must show either an
   official policy or persistent and widespread customs. Under [conditions of
   confinement], . . . the plaintiff must show an intended condition or practice,
   or show that jail officials’ acts are ‘sufficiently extended or pervasive . . . to
   prove an intended condition or practice.’ We see no meaningful difference
   between these showings.” Duvall v. Dallas Cty., Tex., 631 F.3d 203, 208 (5th
   Cir. 2011) (quoting Hare, 74 F.3d at 645). Moreover, the standard of
   causation appears to be same: the policy or custom must have been “the

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   moving force behind the violation.” Sanchez, 956 F.3d at 791. Consequently,
   the failure of Plaintiffs’ conditions of confinement claims is fatal to their
   Monell claim.
          Plaintiffs assert that two unconstitutional conditions of confinement
   led to Bonilla’s death: “Orange County’s customs or de facto policies of oral,
   self-classification by a detainee of her risk of self-harm, and the effective
   denial of prescription medication, are extensive and pervasive.”
          “A ‘condition of confinement’ case is a constitutional attack on
   ‘general   conditions,    practices,   rules,    or   restrictions   of   pretrial
   confinement.’” Flores v. Cty. of Hardeman, Tex., 124 F.3d 736, 738 (5th Cir.
   1997). When a plaintiff challenges conditions of confinement, “the proper
   inquiry is whether those conditions amount to punishment of the detainee.”
   Garza, 922 F.3d at 632. Three elements must be established to prove an
   unconstitutional condition of confinement:
                  (1) “a rule or restriction or . . . the existence of an
          identifiable intended condition or practice . . . [or] that the jail
          official’s acts or omissions were sufficiently extended or
          pervasive”; (2) which was not reasonably related to a
          legitimate governmental objective; and (3) which caused the
          violation of [a detainee’s] constitutional rights. Montano,
          842 F.3d at 874 (quoting Estate of Henson v. Wichita County,
          795 F.3d 456, 468 (5th Cir. 2015)).
          “[A] detainee challenging jail conditions must demonstrate a
   pervasive pattern of serious deficiencies in providing for his basic human
   needs; any lesser showing cannot prove punishment in violation of the
   detainee’s Due Process rights.” Shepherd, 591 F.3d at 454. This court has
   written that proving “a pattern is a heavy burden, one that has rarely been
   met in our caselaw.” Id. at 452. And “isolated examples of illness, injury, or
   even death, standing alone, cannot prove that conditions of confinement are
   constitutionally inadequate.” Montano, 842 F.3d at 876. Further, a plaintiff

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   must show that the pattern or practice “was the moving force behind the
   violation.” Sanchez, 956 F.3d at 791. When that showing is made, the court
   “assume[s], by the municipality’s promulgation and maintenance of the
   complained of condition, that it intended to cause the alleged constitutional
   deprivation.” Flores, 124 F.3d at 738.
   I. Policy or Custom of Allowing Inmate Self-Classification
          Plaintiffs premise their self-classification theory on Shafer’s
   deposition testimony indicating that she evaluated suicide risk was based on
   Bonilla’s answers that she was not considering suicide and that she would be
   fine without Xanax. Plaintiffs’ expert, Dr. Kiekbusch, allegedly fortified
   their claim because he concluded that Defendants’ assessment of Bonilla was
   based “solely upon Bonilla’s assurances that she would be ok . . . and that she
   would be alright without her Xanax prescription.” Dr. Kiekbusch is a
   Professor of Criminology with “over 20 years experience in correctional
   administration.”
          On the contrary, the record does not support Plaintiffs’ theory that
   Orange County has a pervasive policy or custom of allowing detainees to self-
   classify their risk of self-harm. The evidence relating to Bonilla’s intake is
   not consistent with this theory, Plaintiffs offer no evidence of other detainees
   who were so classified, and Plaintiffs offer no consistent jailer testimony
   indicating such a policy.
          The suicide screening form directs the interviewing officer to consider
   factors that are not contingent on the detainee’s accurate self-reporting. For
   instance, the form first requires the officer to answer the threshold questions
   whether the inmate is able to participate in the interview, and whether the
   officer has received information from outside sources, such as the arresting
   officer, indicating that the inmate may be at risk of suicide.             The
   questionnaire directs the officer to observe whether the inmate shows signs

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   of depression, intoxication, disorientation, unusual behaviors, etc. Orange
   County requires corrections officers to complete training on how to
   recognize and interpret the signs of mental illness that an inmate may
   manifest during such an interview. Thus, the training provides officers with
   some objective framework for assessing whether the inmate they are
   interviewing presents a serious risk of self-harm. The jail personnel deposed
   in this case were virtually uniform in their testimony that staff assess an
   inmate’s potential mental health issues on a holistic basis, which, in addition
   to the inmate’s self-reported answers, includes an assessment of the inmate’s
   physical appearance, behavior, and affect.
          Plaintiffs fault Shafer for placing any weight at all on Bonilla’s self-
   assessment that she would not become ill without swift access to Xanax.
   Whether it was advisable for Shafer to give Bonilla’s answer any weight or
   not, Shafer’s testimony and her notes on Bonilla’s screening form make it
   plain that Shafer did not rely on these answers alone when she determined
   whether Bonilla posed a risk of self-harm or needed immediate medical
   attention. Shafer’s contemporaneous observations indicate that Bonilla was
   not visibly impaired, nor was her behavior unusual. These observations were
   enhanced by Shafer’s direct interaction with Bonilla for more than an hour in
   the waiting area. Further, Shafer consulted with her superior, Sergeant
   Jowers, concerning these observations before placing Bonilla in a cell.
          Dr. Kiekbusch’s report does not alter the fact that Orange County
   corrections officers generally, and Shafer specifically, consider more than an
   inmate’s subjective self-assessment in determining whether she is at
   imminent risk of self-harm. The expert’s report and supporting affidavit
   merely repeat Plaintiffs’ fundamental, but incorrect, assumption by
   concluding that “[i]n relying solely on Bonilla’s reassurances, Shafer
   disregarded well known suicide risk indicators.” (Emphasis added). These
   are conclusions the record does not support.

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                                        No. 19-41039

           Plaintiffs alternatively contend that Defendants’ decision not to
   classify Bonilla as a suicide risk violated the jail’s Facility Operations Plan,
   and in so doing demonstrates a policy or pervasive pattern of disregarding the
   Plan. The language Plaintiffs cite is found under the subheading “Training”
   and states in relevant part that “[u]pon initial employment and on an ongoing
   basis, staff shall be trained on the provisions for recognition of mental
   disability, mental illness and/or potentially suicidal tendencies.” Plaintiffs
   read this language to contend that the Operations Plan “classifies a detainee
   [] with ‘mental disabilities’ or ‘mental illness’ as the same level of risk [] as
   potentially suicidal tendencies.”          As a result, Bonilla’s mental health
   diagnoses required Defendants to treat her as a suicide risk, provide her with
   suicide-proof bedding, and observe her every fifteen minutes.
           This is a plain misreading of the Operations Plan, which uses the
   “and/or” conjunction to indicate that the listed mental health categories are
   related but distinct from one another. The provision says nothing specific
   about the risk classifications required for any of these categories, and it does
   not mandate a uniform response whenever an inmate presents with a
   condition covered by one of the listed categories. The Operations Plan did
   not require the Defendants to treat Bonilla as a suicide risk simply because
   she disclosed certain mental health diagnoses. Consequently, their failure to
   classify Bonilla as a suicide risk does not evidence any violation of the
   Operations Plan, much less such a pervasive custom of violating the Plan that
   would be required to impose liability on the County. 1
           Plaintiffs again rely heavily on this court’s 2016 decision in Montano
   v. Orange County to support their claim against the county. But apart from

           1
            County liability also fails because even if there were a custom of violating the
   Operations Plan, that custom would itself have to be shown unconstitutional. In the
   preceding section, however, we rejected such a claim.

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                                    No. 19-41039

   the fact that the Orange County jail facility was at issue in both cases,
   Montano bears little resemblance to Plaintiffs’ case.
          Nor is Sanchez v. Young County applicable here. 956 F.3d 785 (5th Cir.
   2020). In Sanchez, a female detainee’s husband called the jail three times and
   claimed to report that she was suicidal. Id. at 788. Further, the detainee had
   been discovered with an empty bag of pills, which should have led officials to
   at least suspect a suicide attempt, rather than simply wait for her to sober up
   before finishing the suicide screening form. Id. In Sanchez, therefore, the
   court held that there were issues of material fact as to whether the County
   had a de facto policy of failing to monitor and assess pretrial detainees’
   medical needs. Here, there are no such issues. In addition to a wealth of
   evidence cited above, Bonilla’s conversation with her boyfriend gave no
   indication that she was suicidal. Officer Shafer did conduct a CCQ inquiry
   and prepare a suicide risk form. Bonilla was able to give apparently complete,
   coherent answers to Shafer’s intake questions and showed no signs of
   intoxication.
   II. Policy or Custom of Unreasonably Delaying Prescriptions
          Plaintiffs base an alleged county policy of delaying inmate
   prescriptions theory primarily on two items: Sheriff Merritt’s testimony that
   “there is no time limit” within which the medical staff on duty must verify a
   detainee’s prescriptions; and Bonilla received no medication during her time
   in detention. The argument focuses almost exclusively on Bonilla’s Xanax
   prescription. However, Orange County’s official policy is to “NOT refuse
   ANY medications prescribed to an inmate by a physician.” Nevertheless,
   before giving an inmate a medication, nursing staff must confirm “the inmate
   is prescribed the medication in accordance with local, state, and federal
   regulation.” Bonilla stated during intake at the jail, and her mother would
   later testify, that Bonilla had a valid prescription for Xanax, despite the

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                                         No. 19-41039

   suspicious circumstances of her arrest. No prescription is in the record,
   however, and the jail never verified it.
           LVN Dickerson began the prescription verification process within a
   few hours of Bonilla’s arrival. Because the pharmacy apparently did not
   return her call, she left a note for the LVN on the next shift to finish the job.
   These facts show that the county had no de facto policy of denying or
   withholding prescriptions, and Plaintiffs offer nothing else.
           Further, Bonilla cannot meet the causation element for a conditions
   of confinement claim. There is no evidence that Bonilla ever asked the
   officers for Xanax, or any medication, despite having multiple conversations
   with both Shafer and Lewis. Plaintiffs allude to testimony by Bonilla’s
   mother that an unidentified inmate heard Bonilla “screaming” for her
   medication, but this is not competent evidence capable of creating an issue of
   fact.2 There is also no competent evidence that Bonilla suffered symptoms
   of withdrawal while in custody. Bonilla stated that she had already taken
   Xanax that morning before being arrested.                There is also no evidence
   indicating how often Bonilla needed to take Xanax or how long it would be
   before she began to experience withdrawal symptoms. In short, there are
   crucial gaps between the Defendants’ failure to provide Xanax and Bonilla’s
   decision to take her own life. A jury would have to resort to impermissible
   speculation to conclude that there was a “direct causal link” between the
   alleged constitutional violation—Defendants’ failure to distribute Xanax to
   Bonilla during her 10-hour stay—and her death. Fraire v. City of Arlington,
   957 F.2d 1268, 1281 (5th Cir. 1992) (citing City of Canton, 489 U.S. 378, 387;
   109 S. Ct. 1197, 1204–05 (1989)); Oklahoma City v. Tuttle, 471 U.S. 808, 823;

           2
            The deposition excerpts in question indicate that this testimony is double hearsay
   from an unidentified source that cannot properly create a genuine issue of fact at summary
   judgment. See Bellard v. Gautreaux, 675 F.3d 454, 461 (5th Cir. 2012).

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                                     No. 19-41039

   105 S. Ct. 2427, 2436 (1985)) ([A] “direct causal connection must exist
   between the policy and the alleged constitutional deprivation.            This
   connection must be more than a mere “but for” coupling between cause and
   effect.”).
                                  CONCLUSION
            There is no genuine issue of material fact and Defendants are entitled
   to judgment as a matter of law. We AFFIRM the judgment of the district
   court.

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