Court Opinion

ID: 4548428
Source: CourtListenerOpinion
Date Created: 2020-07-15 20:00:22.566506+00
Date Added: 2024-06-11T12:56:42.665228
License: Public Domain

In the

    United States Court of Appeals
                 For the Seventh Circuit
                    ____________________
No. 19-2291
ZACHARY PULERA,
                                               Plaintiﬀ-Appellant,
                                v.

VICTORIA SARZANT, et al.,
                                            Defendants-Appellees.
                    ____________________

        Appeal from the United States District Court for the
                    Eastern District of Wisconsin.
       No. 2:15-cv-00461-WCG — William C. Griesbach, Judge.
                    ____________________

       ARGUED JUNE 10, 2020 — DECIDED JULY 15, 2020
                 ____________________

   Before FLAUM, BARRETT, and ST. EVE, Circuit Judges.
    ST. EVE, Circuit Judge. Police arrested Zachary Pulera on
suspicion of bail jumping and brought him to the Kenosha
County Pre-Trial Facility. Just under forty-eight hours later,
Pulera attempted to hang himself in his cell. Fortunately, cor-
rectional oﬃcers noticed, swiftly cut him down, and called for
an ambulance that saved his life.
2                                                   No. 19-2291

    Over his two days at the facility, Pulera never told any of-
ﬁcial that he was contemplating suicide. This appeal asks
whether a long list of oﬃcials nevertheless unreasonably re-
sponded to other possible signs that Pulera was in distress, so
that they may face liability for his injuries under 42 U.S.C.
§ 1983. The district court concluded there was no genuine dis-
pute that all oﬃcials responded reasonably to the information
each had, so it granted the defendants’ motions for summary
judgment. We aﬃrm the judgment.
                        I. Background
A. Intake
    In the early morning of Saturday, April 21, 2012, police
stopped Edward Burke for a suspected hit-and-run. Pulera,
Burke’s cousin, was in the car’s passenger seat, drunk. Oﬃc-
ers arrested both men: Burke for the hit-and-run and Pulera
for drinking in violation of a condition of his bond pending
trial on state battery charges. According to the arresting of-
ﬁcer’s report (the accuracy of which Pulera does not dispute),
Pulera appeared drunk but exhibited no suicidal behavior
while in transit. When Pulera arrived at the facility, the intake
oﬃcer on duty, Victoria Sarzant, and her supervisor, Dennis
Zawilla, reviewed the arresting oﬃcer’s report and placed
Pulera and Burke in temporary holding cells across from each
other.
    Burke testiﬁed that he could just barely see and hear Pul-
era through their respective cell doors and the distance of the
hall, but what he witnessed alarmed him. Though the solid
door muﬄed the sounds and the small cell windows con-
strained his view, Burke saw that Pulera was “dragging his
No. 19-2291                                                  3

thumb across his neck as if he was going to harm himself” and
muttering “I’ll just take myself out” because he was “done,”
all of which Burke understood by reading Pulera's lips. This
went on for a while, and Burke testiﬁed that unidentiﬁed of-
ﬁcers “in the vicinity” should have seen and heard Pulera,
too. After about an hour, though, an oﬃcer took Burke out of
his holding cell and booked him into the facility proper. Burke
told the oﬃcer who transferred him, as well as one or two oth-
ers, that he was concerned about Pulera hurting himself. Each
brushed Burke oﬀ and, a few hours later, he left the facility.
    Meanwhile, Pulera stayed in his holding cell. Although
Sarzant had reported that Pulera was cooperative, if intoxi-
cated, at 2 AM, he started to become more disruptive. By
5 AM, he was standing on a bench, pounding the door, and
shouting. Based on this behavior—which Pulera explained
was because he was cold and wanted a jacket—Sarzant held
oﬀ on booking him and, near the end of her shift, prepared a
report explaining why. Sarzant wrote that she saw no evi-
dence Pulera was suicidal, just combative and possibly still
intoxicated. Zawilla reviewed this report, too, and Pulera
does not dispute the accuracy of its contents either.
    After the shift change, Shane Gerber began the booking
process. He screened Pulera using a standard form with med-
ical and mental health questions and wrote down that Pul-
era’s mother had died a month ago (but not that she had com-
mitted suicide) and that Pulera was prescribed medications.
Pulera testiﬁed that he may have told Gerber of his mother’s
cause of death and that his brother had also committed sui-
cide about a year before. The rest of the form Pulera thought
4                                                   No. 19-2291

accurate. It reﬂects that Gerber saw no behavior suggesting a
risk of suicide, and that Pulera answered “no” when asked
whether he had ever contemplated or was presently contem-
plating suicide and to a battery of questions reﬂecting possi-
ble suicide risk factors.
    Gerber also checked the facility's database for a “mental
health special instruction” connected to Pulera but found
none. This procedure resulted from a 2011 policy change to
reduce the risk of inmate suicides after a string of attempts at
the facility. The facility’s database includes an instruction in
the ﬁle of any arrestee who its oﬃcials had previously placed
on “level one” suicide watch (the more restrictive and protec-
tive of the two levels the facility recognized). If a booking of-
ﬁcer saw the instruction, he had to alert a supervisor, who
would then perform a second, more thorough mental health
risk assessment. During a prior stint at the facility in 2011, a
crisis worker had placed Pulera on suicide watch after he told
a nurse that he felt “really depressed” and his “mind was
mess[ed] up” after his brother’s suicide. The parties agree that
the worker ordered only the less restrictive level two watch,
however, so Pulera’s ﬁle did not contain a special instruction
in 2012. Without the instruction, the facility’s policy required
Gerber to order the additional risk assessment only if Pulera
showed signs of contemplating suicide or had three risk fac-
tors. The death of a family member was one such factor, but
Gerber found no others, so he placed Pulera in general popu-
lation without requesting a second look.
No. 19-2291                                                     5

B. Medical Requests
    Over the course of his day and a half in general popula-
tion, Pulera submitted three inmate medical requests relating
to his prescription medications—clonazepam and tramadol.
Clonazepam is a benzodiazepine that Pulera was apparently
prescribed for anti-anxiety purposes. Tramadol is an opioid
pain-reliever that he used to treat chronic pain from a back
injury.
   Pulera submitted his ﬁrst request a few hours after book-
ing, around noon on Saturday. Cleaned of spelling errors, it
said “I need my clonazepam and tramadol. My family is
dropping them oﬀ. For my pain, anxiety, and depression.” At
around 4:30, Nurse Erica Rea responded, telling Pulera that
he was under the care of the jail doctor and that she would
notify the doctor after his family dropped oﬀ the medications.
   As it turns out, Pulera’s brother, William, had brought the
prescriptions earlier that afternoon, and Rea reviewed them
minutes after responding to the request. She saw that Pulera
had reﬁlled his prescription the day before, so he should have
used just a couple of doses. Instead, the bottles contained only
34 out of the expected 60 clonazepam tablets, and 81 out of
120 tramadol tablets. She never asked, and no one ever dis-
covered, where the missing pills went.
    A half hour later, Rea called Dr. Karen Butler, the facility’s
medical director, who worked remotely except on Tuesdays.
Rea reported the missing pills and asked whether she should
distribute Pulera’s prescriptions while he was in the jail.
Dr. Butler declined to set up a regimen at that time and Rea
noted that order in Pulera’s chart. Testifying at her deposition,
Dr. Butler explained that she made this decision based on the
6                                                   No. 19-2291

missing pills, which she believed might be a sign of abuse and
could have made further dosages dangerous. Neither Dr. But-
ler nor Rea recorded these thoughts in the medical record.
Nevertheless, the jail’s written policy supported her decision;
it states, as a default rule, that non-compliant medications
would not be continued while in custody.
   That evening, at around 8 PM, Pulera sent his second re-
quest. Clariﬁed, it read “My heart hurts. I can’t breathe. I need
my meds or I can die. My heart is pounding. They are here, I
need you to please bring me my meds ASAP. Thank you.”
    Rea’s shift had ended, so Nurse Denise Gilanyi received
this request instead. She called a correctional oﬃcer to check
on Pulera around 9 PM, and the oﬃcer said that Pulera was
in no distress: he just wanted his medications. Gilanyi knew
that Dr. Butler had decided not to set up the medications just
hours before, and that neither prescription was “lifesaving,”
so she did nothing further. Near the end of her shift, at 5:55
AM, she wrote back to Pulera that the doctor had not set up
any medications.
    Pulera sent the third and ﬁnal request on Sunday after-
noon. This one—again cleaned up—said, “I can’t eat, sleep. I
am throwing up and I am dizzy. I can’t breathe. I need my
blood pressure taken. Please see me. My brother and mother
just died. I need my clonazepam. I am sick.” Within minutes,
the nurse on duty, Markella Reed, responded, telling Pulera
someone would check his blood pressure. Reed testiﬁed that
she based this immediate response on her guess that Dr. But-
ler would order a blood pressure check, once they talked.
   Reed further testiﬁed that between receiving the request
and responding, she, like Gilanyi, had called a correctional
No. 19-2291                                                    7

oﬃcer. This oﬃcer reported that Pulera was complaining he
had a cold, walking around, making phone calls, and asking
for a TV remote. Unlike Gilanyi, though, Reed did not add
this conversation to the chart when it happened. Instead, she
wrote it in a late entry the next day, after Pulera’s suicide at-
tempt.
    When Reed called Dr. Butler, a few hours later, her predic-
tion proved accurate. Dr. Butler ordered a vitals check, both
to conﬁrm Pulera’s health and to get him face-to-face with a
nurse. She asked that the nurse call her if anything abnormal
came up. Reed added the doctor’s new order to the chart.
    At 6 PM, Reed left, and Nurse Sylvia Summers-Sgroi
started her night shift. On reviewing the chart, Summers-
Sgroi saw the order to take Pulera's vitals and to call Dr. But-
ler if anything was wrong. Around 8 PM, she met Pulera in a
small room outside his cell block. She tested and recorded his
blood pressure, pulse, respiration rate, blood oxygen level,
and temperature. His results were not abnormal, indeed, they
were excellent, and she saw nothing else concerning, so she
did not call Dr. Butler. Although they disagree on the length
of their meeting (Pulera said it lasted only a minute), both Pul-
era and Summers-Sgroi agree that he did not mention any
concerns he had, let alone suicidal thoughts.
C. Suicide Attempt
    Sometime around 1:45 AM on Monday, April 23, Pulera
attempted to hang himself with his bed sheets.
    That night, Oﬃcer Bruce Clemens checked the cells every
thirty minutes. He passed through Pulera’s block at 1:35 AM
and noticed nothing amiss. Ten minutes later, Clemens and
another correctional oﬃcer, Duane Corso were talking in a
8                                                  No. 19-2291

hallway next to the block when they heard an inmate yell
“someone’s hanging.”
    Upon hearing the yell, Corso immediately started toward
Pulera’s cell door. Clemens meanwhile ran to the guard sta-
tion, which contained the controls for the cell and hall doors.
He sent out a radio alert, and Corporal Darron Newton re-
sponded in about thirty seconds. Clemens handed Newton an
emergency knife and opened the hall door, so Newton could
join Corso, who was awaiting back-up outside Pulera’s cell,
as he was trained not to enter cells alone.
   Once Newton made it to Pulera’s cell with the knife in
hand, Clemens opened the cell door for the two of them.
Corso held Pulera up while Newton cut the bedsheet down.
After Pulera was on the ground, someone called for an ambu-
lance at around 1:50 AM.
     Summers-Sgroi was still on duty, so she was the ﬁrst med-
ical responder. She recalled hearing the radio alert at 1:47 and
arrived around 1:50, after Pulera was on the ground. Once she
arrived at the cell, she began treating him with an oxygen
mask. His vitals improved, but he remained unresponsive,
and his eyes unfocused, so she continued to apply oxygen un-
til the ambulance arrived at 1:57. By the time the sheriﬀ’s de-
partment got to the facility at 2:04, Pulera was already on his
way to the hospital.
    Pulera suspects that he decided to attempt to kill himself
sometime after the last medication delivery of the night, when
he realized that they were still not giving him his prescrip-
tions. He testiﬁed that he was stressed, felt like he was going
No. 19-2291                                                  9

to die because his heart was pounding, and kept envisioning
his deceased mother and brother. He thinks he may have had
withdrawal from “benzos.” Other than through the medical
requests, he did not recall passing any of this information on
to facility oﬃcials or to his family.
    William testiﬁed diﬀerently. He said that starting after he
dropped oﬀ the medicine, Pulera frequently called saying that
he had not received his prescriptions and was going to hurt
or kill himself. Throughout the entire weekend, William ex-
plained, he called the facility repeatedly, trying to pass this
information on. Though William had no idea when he called
the facility or with whom he spoke, Summers-Sgroi admitted
she had received one of his calls. Well after Pulera’s suicide
attempt, she wrote in a late entry that William had called de-
manding that Pulera get his clonazepam, but she transferred
the call to a correctional oﬃcer when William started yelling.
D. Procedural Background
    Pulera eventually brought this suit under 42 U.S.C. § 1983
and state law against all the above-named oﬃcials, as well as
the private company that employed the nurses, Visiting
Nurses Community Care, Inc. (VNCC), and Kenosha County.
The county’s federal liability was premised on Monell v. De-
partment of Social Services, 436 U.S. 658 (1978). Under circuit
precedent, so was VNCC’s. See Iskander v. Vill. of Forest Park,
690 F.2d 126, 128 (7th Cir. 1982). (Pulera named even more
defendants in the district court but has abandoned those
claims on appeal.)
   Pulera’s expert on medical issues was Dr. Thomas White,
Ph.D. Dr. White opined that the nurses’ and Dr. Butler’s
10                                                No. 19-2291

indiﬀerence to Pulera caused his suicide attempt. As a clinical
psychologist, Dr. White had no expertise on medication and
lacked the authority even to prescribe drugs. He, therefore,
admitted he could not support a theory that, had Pulera re-
ceived his prescriptions, he would not have attempted sui-
cide. Instead, Dr. White contended that the lack of a face-to-
face interview with a nurse or mental health worker was a
possible factor in Pulera's attempt, although Pulera could
have also decided to hang himself minutes before he tried. Dr.
White also denied any link between withdrawal and suicide
and, although lacking expertise in the area, he did not think
there was evidence that Pulera had suﬀered withdrawal any-
way.
    The district court ultimately entered summary judgment
for all defendants over the course of two orders. As an initial
matter, the court concluded that Pulera was in the facility as
an arrestee because he had not yet had a probable cause hear-
ing on his suspected bail jumping. (A magistrate conﬁrmed
probable cause existed for Pulera’s arrest only the morning
after his attempt.) Accordingly, it applied a Fourth Amend-
ment objective reasonableness standard to the defendant’s ac-
tions, and not an Eighth or Fourteenth Amendment standard
as would apply to convicted criminals or those detained after
a probable cause hearing, respectively.
   The court ﬁrst granted Dr. Butler’s motion. She had unsuc-
cessfully argued for an Eighth Amendment standard, but the
court concluded that even under the Fourth Amendment,
there was no genuine dispute that her actions were objectively
reasonable. Given the possible risk of overdose, the court de-
termined that Dr. Butler had rationally withheld the
No. 19-2291                                                   11

medications and awaited speciﬁc reports of symptoms before
deciding whether to treat Pulera for withdrawal.
    The court subsequently entered summary judgment for
the remaining defendants. The non-medical defendants con-
tended that a Fourteenth Amendment due process standard
applied, but the district court stuck with its Fourth Amend-
ment reasoning. It determined there was no evidence to show
Sarzant heard Pulera’s comments to Burke, Gerber over-
looked present signs of Pulera’s intent to harm himself, the
county’s booking policies were constitutionally deﬁcient, or
Zawilla did anything other than supervise. The court further
concluded that Rea properly deferred to Dr. Butler, Gilanyi
and Reed permissibly relied on oﬃcers’ reports to assess Pul-
era’s complaints of physical discomfort, and Summers-Sgroi
rationally discounted William’s phone call, as Pulera never re-
ported suicidal thoughts to anyone at the facility. Because no
nurse’s actions were unreasonable in violation of the Fourth
Amendment, the court recognized that VNCC and the
county’s policies could not have caused a constitutional vio-
lation for Monell purposes. Finally, the court ruled that the re-
sponse defendants reasonably awaited back-up, which ar-
rived within a minute or two, before they entered Pulera’s cell
and cut him down.
   The court relinquished supplemental jurisdiction over the
remaining state-law claims, and Pulera appealed.
                        II. Discussion
   We review the entry of summary judgment de novo. Yeatts
v. Zimmer Biomet Holdings, Inc., 940 F.3d 354, 358 (7th Cir.
2019). At summary judgment, the nonmovant plaintiﬀ must
provide evidence that, when viewed in the light most
12                                                               No. 19-2291

favorable to him, suﬃces to prove every element of his claim
for which he bears the burden of proof. Id. If the plaintiﬀ fails
to show at least a triable issue on each element, summary
judgment is properly entered for the defendants. Burton v.
Kohn Law Firm, S.C., 934 F.3d 572, 579 (7th Cir. 2019).
   As an initial matter, the parties diﬀer on the proper stand-
ard that governs Pulera’s claims—the Fourth or the Four-
teenth Amendment. For those suspected of crimes, we have
drawn the line between the two standards at the probable
cause hearing mandated by Gerstein v. Pugh, 420 U.S. 103
(1975), and ordinarily held within 48 hours of a warrantless
arrest, Cty. of Riverside v. McLaughlin, 500 U.S. 44 (1991). See
Lopez v. City of Chicago, 464 F.3d 711, 719 (7th Cir. 2006). Before
a ﬁnding of probable cause, the Fourth Amendment protects
an arrestee; after such a ﬁnding, the Fourteenth Amendment
protects a pretrial detainee. Currie v. Chhabra, 728 F.3d 626,
629–30 (7th Cir. 2013). 1
    Pulera maintains that he was an arrestee subject to the
Fourth Amendment. In the non-medical defendants’ contrary
view, Pulera was properly classiﬁed as a pretrial detainee.
Although a judge conducted a Gerstein hearing for Pulera’s
bail jumping charge the day after his suicide attempt, they ar-
gue that another judge found probable cause to arrest him for

     1 We have recognized that our distinction between pre- and post-hear-

ing detention may need to be revisited after the Supreme Court, in Manuel
v. City of Joliet, 137 S. Ct. 911 (2017), rejected our similar distinction in the
malicious-prosecution context. See Otis v. Demarasse, 886 F.3d 639, 645 n.27
(7th Cir. 2018). Like in Otis, though, no party asks us to reconsider the
issue, so we leave it for another day.
No. 19-2291                                                   13

battery in 2011 and that this qualiﬁes him as a pretrial de-
tainee.
    At oral argument, though, the parties all agreed that the
standards are now eﬀectively the same for judging the ade-
quacy of custodial medical care under either Amendment.
Under the Fourth Amendment, an arrestee must demonstrate
that an oﬃcial’s actions were “objectively unreasonable under
the circumstances.” Estate of Perry v. Wenzel, 872 F.3d 439, 453
(7th Cir. 2017). This objective rule is easier for a plaintiﬀ to
meet than the subjective deliberate-indiﬀerence standard
used under the Eighth Amendment. Id. For years, we also
used the more onerous subjective approach for Fourteenth
Amendment claims relating to conditions of pretrial deten-
tion. See, e.g., Pittman ex rel. Hamilton v. Cty. of Madison, 746
F.3d 766, 775 (7th Cir. 2014). In 2018, however, we clariﬁed
that pretrial detainees’ medical-care claims are now governed
by an “objective unreasonableness inquiry.” Miranda v. Cty. of
Lake, 900 F.3d 335, 352 (7th Cir. 2018). Both standards, then,
are objective, and the non-medical defendants identify no
practical diﬀerence between them.
   Accepting that concession, and without deciding whether
the standards are identical in all respects, we see no reason to
resolve whether Pulera was properly classiﬁed as an arrestee
or a detainee. Either way, it was Pulera's burden to provide
evidence that the defendants’ actions were “objectively unrea-
sonable” and caused his injuries. Id. at 347, 352 (Fourteenth
Amendment); Ortiz v. City of Chicago, 656 F.3d 523, 530 (7th
Cir. 2011) (Fourth Amendment). Reasonableness, in turn,
must be determined in light of the totality of the circum-
stances. See McCann v. Ogle Cty., 909 F.3d 881, 886 (7th Cir.
14                                                   No. 19-2291

2018) (Fourteenth Amendment); Florek v. Vill. of Mundelein,
649 F.3d 594, 600 (7th Cir. 2011) (Fourth Amendment).
    For VNCC and the county, Pulera also must demonstrate
the elements of a Monell claim. This means he must have evi-
dence of “(1) an action pursuant to a municipal policy, (2) cul-
pability, meaning that policymakers were deliberately indif-
ferent to a known risk that the policy would lead to constitu-
tional violations, and (3) causation, meaning the municipal ac-
tion was the ‘moving force’ behind the constitutional injury.”
Hall v. City of Chicago, 953 F.3d 945, 950 (7th Cir. 2020) (citing
Bd. of Comm’rs of Bryan Cty. v. Brown, 520 U.S. 397, 404–07
(1997)).
A. Intake Defendants
    Pulera ﬁrst contends that Burke’s testimony created a dis-
pute whether Sarzant was aware of his suicidal thoughts. If
Sarzant saw what Burke did, that might be true, but she testi-
ﬁed she did not, and no competent evidence contradicts her
testimony. All she saw was Pulera standing on a bench and
yelling (which even he says was because he was cold, not be-
cause he was suicidal) and that was some time later. Critically,
Burke did not identify Sarzant as one of the oﬃcials “in the
vicinity” or whom he told of Pulera’s distressed statements
and gestures, and no other evidence places her near Pulera’s
cell at that time. All we have is an invitation to speculate that
because Burke could (barely) see and hear Pulera, so could
Sarzant. Speculation of this sort is not enough for a plaintiﬀ
to escape summary judgment. See, e.g., King v. Hendricks Cty.
Comm'rs, 954 F.3d 981, 985 (7th Cir. 2020).
    Next, Pulera argues that Gerber violated the county’s pol-
icy by failing to review his history at the facility, recognize
No. 19-2291                                                   15

that a crisis worker previously had him on suicide watch, and
order a second mental health risk assessment. The county
knew that Gerber and other booking oﬃcers ignored its spe-
cial instruction policy, Pulera asserts, yet it allowed this non-
compliance to persist.
    One obvious ﬂaw with these arguments is that Gerber fol-
lowed the county’s policy (which went beyond just the special
instruction that we focus on here). The policy required him to
obtain an extra risk assessment at booking if an arrestee had
a special instruction reﬂecting that he previously had been on
level one suicide watch. Gerber checked the database, but it is
undisputed that Pulera’s history included only a level two
watch, so he did not have a special instruction. Even if Gerber
had ignored the policy, though, a violation of a jail policy is
not a constitutional violation enforceable under 42 U.S.C.
§ 1983. See, e.g., Thompson v. City of Chicago, 472 F.3d 444, 454
(7th Cir. 2006). The only question that matters for our pur-
poses is whether Gerber or the county violated the Fourth
Amendment.
    Pulera has failed to show a genuine dispute on that issue.
He argues that, given his answers at booking, Gerber should
have known he was at a risk of suicide. Taking Pulera’s ver-
sion of the facts, as we must, he told Gerber that his mother
and brother had both recently committed suicide and that his
doctor had prescribed him clonazepam for depression. These
scant comments do not raise an issue of fact. “[N]ot every
prisoner who shows signs of depression … can or should be
put on suicide watch.” Matos ex rel. Matos v. O'Sullivan, 335
F.3d 553, 558 (7th Cir. 2003). The same goes for every arrestee
who also has had recent family deaths. Id. Given Pulera’s ex-
press statement that he was not considering suicide and the
16                                                      No. 19-2291

absence of more or more signiﬁcant indirect signs, no rational
jury could ﬁnd that Gerber unreasonably placed Pulera in
general population.
    Pulera’s theory against the county rests on his belief that
Gerber did not follow the special instruction policy and that
“ignoring a policy is the same as having no policy,” Woodward
v. Corr. Med. Servs. of Ill., Inc., 368 F.3d 917, 929 (7th Cir. 2004).
The county, however, had a policy aimed at preventing sui-
cide that Gerber did not ignore; one part of the policy simply
did not apply to Pulera. So, to succeed on his Monell claim, he
had to show that the county was deliberately indiﬀerent to the
risk that its polices (or a gap in them) would cause a constitu-
tional violation. Lapre v. City of Chicago, 911 F.3d 424, 430–31
(7th Cir. 2018). He has not developed this argument by, for
example, showing that county oﬃcials knew that formerly
level-two arrestees were attempting suicide at heightened
rates, and oﬃcials nevertheless made a “conscious decision
not to act.” Walker v. Wexford Health Sources, Inc., 940 F.3d 954,
966 (7th Cir. 2019). Certainly, the county could have expanded
its policy to require second screenings of more arrestees, but
the mere “existence or possibility of other better policies …
does not necessarily mean that the defendant was being de-
liberately indiﬀerent.” Lapre, 911 F.3d at 431 (quoting Frake v.
City of Chicago, 210 F.3d 779, 782 (7th Cir. 2000)).
    The district court also properly entered summary judg-
ment for Zawilla. He is not liable under § 1983 merely as a
supervisor, even assuming his subordinates had erred. See,
e.g., Doe v. Purdue Univ., 928 F.3d 652, 664 (7th Cir. 2019).
Zawilla did not have any personal contact with Pulera and
merely reviewed reports that did not record any indications
of suicide risk. Pulera presents no contrary argument.
No. 19-2291                                                   17

B. Dr. Butler
    Next, Pulera argues that it was unreasonable for Dr. Butler
to deny him his prescription medications without taking
some alternative step. If she really believed he had abused his
medications, he suggests, she should have implemented the
facility’s detoxiﬁcation or withdrawal protocols.
    Pulera, however, falls short with the medical and causa-
tion evidence. The record contains no evidence from which a
factﬁnder could infer that, had Pulera received his medica-
tions, he would not have attempted suicide. His own expert
denied such a theory. Dr. Butler’s expert—Dr. Keith Ness,
M.D.—declared in his aﬃdavit that cutting a patient oﬀ either
clonazepam or tramadol, even “cold turkey,” was not known
to make that patient suicidal, whereas giving either drug to
someone who had consumed them in excess within the past
few days could have been dangerous. Pulera oﬀered nothing
to rebut this medical opinion.
    Dr. Butler made a reasonable decision on imperfect infor-
mation. She knew only that many of Pulera’s pills were miss-
ing. Putting aside the facility’s policy directing her not to set
up his medications in this situation, there was at least some
chance that he had taken those pills and giving him more
could have been harmful, even deadly. Between the option
with some risk of death and the option with no apparent risk
(according to the only medical evidence in the record), Dr.
Butler chose the latter. That choice was objectively reasonable
as a matter of law, regardless of whether Pulera had, in fact,
abused his medications.
    A jury could not infer that depriving Pulera of his medica-
tions might be deadly from the mere fact that a physician had
18                                                  No. 19-2291

prescribed them to him. Pulera insists a prescription is evi-
dence of a “serious medical need.” See Gutierrez v. Peters, 111
F.3d 1364, 1373 (7th Cir. 1997) (deﬁning term to include a need
“that has been diagnosed by a physician as mandating treat-
ment”). Whether a medical need is serious, though, is just a
threshold requirement before the state has a duty under the
Eighth Amendment to provide medical care to a prisoner. Id.
at 1369, 1372. We have held that there is no such threshold
under the Fourth Amendment, as the “reasonableness analy-
sis operates on a sliding scale, balancing the seriousness of the
medical need with the third factor—the scope of the re-
quested treatment.” Williams v. Rodriguez, 509 F.3d 392, 403
(7th Cir. 2007).
    From what Dr. Butler and the nurses knew, Pulera’s need
for his medications was not serious relative to the risks of his
receiving them. Pulera likens his situation to that of a diabetic
deprived of insulin. Egebergh v. Nicholson, 272 F.3d 925, 928
(7th Cir. 2001). But a diabetic needs insulin to live. No evi-
dence suggest that Pulera depended on his medications to
stay alive; he needed them only to treat his pain and anxiety.
    Undoubtedly, a jury could infer that the defendants knew
Pulera might become anxious or suﬀer chronic pain without
his medications, but he points to nothing that would inform
them that this anxiety or pain might lead him to attempt sui-
cide or otherwise cause harm comparable to a risk of over-
dose. His reliance on Gil v. Reed, 381 F.3d 649 (7th Cir. 2004),
is misplaced. We held in Gil that a jury could infer a prison
doctor’s deliberate indiﬀerence when a specialist prescribed
certain medications noting the risks of alternative treatments,
No. 19-2291                                                  19

the doctor ignored that warning, and the prisoner suﬀered as
predicted. Id. at 662–64. If Pulera’s primary care physician
prescribed him clonazepam and tramadol because he was
known to be suicidal without them, that fact is missing from
the record. Based on the evidence that is in the record and of
which she was made aware, Dr. Butler reasonably concluded
the only foreseeable risk of depriving Pulera of his prescrip-
tions was a few days’ discomfort—a small price to pay com-
pared to even a low chance of overdose. All four nurses were
entitled to defer to Dr. Butler’s medical judgment weighing
the costs and beneﬁts of these two choices. See McCann, 909
F.3d at 887 (aﬃrming summary judgment for nurse who de-
ferred to doctor’s prescription that led to overdose).
    Pulera makes much of the fact that Dr. Butler never imple-
mented a withdrawal or detoxiﬁcation protocol, despite her
asserted belief that he was abusing his medications. But, as
Pulera himself emphasizes, Dr. Butler knew only that it was
possible that Pulera had abused his medications. We agree
with the district court that Dr. Butler could reasonably have
awaited a nurse or correctional oﬃcer’s report of concrete
symptoms before making further treatment decisions. When
Nurse Reed did report symptoms, on Sunday evening, Dr.
Butler asked that someone check Pulera’s vitals and call her if
any abnormalities arose. She heard nothing back, so it was
reasonable for her to infer (correctly) that all objective signs
showed Pulera was ﬁne and not suﬀering withdrawal. She
never had the opportunity to take this new information into
account and reassess Pulera’s medication regimen because of
his attempt a few hours later.
20                                                 No. 19-2291

C. The Nurse Defendants
    Moving on to the individual nurses’ actions, we agree with
the district court that Nurse Rea reasonably responded to Pul-
era’s ﬁrst medical request, which did not give her notice of
any serious problems, let alone a risk of suicide. Pulera simply
asked that she deliver his medications “for [his] pain, anxiety,
and depression.” He did not even mention symptoms. In-
deed, contrary to Pulera’s argument, he did not say he was
depressed, only that the pills were for depression. Any rational
factﬁnder would see this message the way Rea did: as a sim-
ple request for medicine. She reasonably responded to that re-
quest by telling Pulera he would receive his medications, if
Dr. Butler approved them. She then gave Dr. Butler all the in-
formation necessary to decide not to approve them.
    The request that Pulera sent to Nurse Gilanyi did include
symptoms—physical symptoms. Pulera complained that his
heart was pounding and hurt, that he could not breathe, and
that he needed his medications or he could die. That Pulera
was concerned about dying, or even that he might have been
having an anxiety attack, did not put Gilanyi on notice that he
might be contemplating suicide. The request signaled that he
feared dying not from self-harm, but from a heart attack or
lack of oxygen. A correctional oﬃcer was qualiﬁed to conﬁrm
that Pulera was, in fact, breathing and not apparently in car-
diac arrest, so it was reasonable for Gilanyi to ask one to do
so and rely on his assessment. Like in Florek, 649 F.3d at 600,
summary judgment was proper because Pulera’s “outward
appearance did not put oﬃcers on notice” of his condition de-
spite his complaints of serious symptoms. (And unlike Florek,
who did suﬀer a heart attack, there is no evidence those
No. 19-2291                                                      21

serious symptoms ever manifested.) With the oﬃcer’s conﬁr-
mation that Pulera was ﬁne and just wanted his medications,
Gilanyi appropriately responded that the doctor had not pre-
scribed them. The Fourth Amendment requires that arrestees
receive reasonable care, not speciﬁc care, no matter how many
times they ask. Id. at 600–01 (citing Jackson v. Kotter, 541 F.3d
688, 697 (7th Cir. 2008)); see also Williams v. Ortiz, 937 F.3d 936,
944 (7th Cir. 2019) (same under Fourteenth Amendment).
    Pulera resists the comparison to Florek and instead bases
his argument on Belbachir v. Cty. of McHenry, 726 F.3d 975 (7th
Cir. 2013). We recognized in Belbachir that “[a] severely de-
pressed person who has hallucinations, acute anxiety, and
feelings of hopelessness and helplessness and who cries con-
tinually, talks incessantly of death, and is diagnosed as sui-
cidal, is in obvious danger.” Id. at 982. Pulera’s request,
though, did not put Gilanyi on notice of any of these facts or
anything similar. At most, one might be able to infer she had
notice that Pulera was suﬀering “acute anxiety,” but we af-
ﬁrmed summary judgment for the nurse who knew only of
Belbachir’s anxiety and panic attacks and not her other issues.
Just like that nurse, Gilanyi was not even negligently respon-
sible for a suicide risk that Pulera never told her about. Id.
   Regarding Nurse Reed, Pulera argues that her calling a
correctional oﬃcer to check on him was an unreasonable re-
sponse to his third medical request. Just like the second,
though, Pulera’s most pressing assertion was that he could
not breathe. A call to a correctional oﬃcer to physically check
22                                                           No. 19-2291

on him was one reasonable way for Reed to conﬁrm that Pul-
era was not in immediate danger. 2
    Pulera’s third request admittedly went further than his
second and mentioned other symptoms—he was vomiting,
dizzy, and just generally sick—but Nurse Reed, too, went fur-
ther than relying on the correctional oﬃcers’ report. She in-
formed Pulera that someone would check his blood pressure
and called Dr. Butler, who expanded it to a full vitals check.
This was a reasonable response to Pulera’s remaining com-
plaints, which while certainly worthy of investigation, were
not an apparent emergency. Cf. Gayton v. McCoy, 593 F.3d 610,
621 (7th Cir. 2010) (noting that “[v]omiting, in and of itself, is
not an uncommon result of being mildly ill, and, absent other
circumstances … does not amount to an objectively serious
medical condition” under the Eighth Amendment). At the vi-
tals check, Pulera would be face-to-face with a nurse who
could see his symptoms and hear anything he had to say.
    When Nurse Summers-Sgroi performed the check, she
saw nothing wrong and Pulera admits he never said a thing
about other symptoms or suicidal thoughts. Pulera bases his
claim against her on his brother William’s phone call. Sum-
mers-Sgroi contends that this call did not give her notice of a
risk of suicide because all she heard was yelling about
clonazepam before she transferred the call. William, though,

     2 Although the timeline surrounding this call to the correctional oﬃcer

is jumbled, Pulera does not develop an argument that Reed did not in fact
call the oﬃcer. Even if he disputed whether she had, though, Pulera would
still have a problem with causation. A delayed response to Pulera’s re-
ported symptoms might be concerning, but there is no evidence that Pul-
era’s injuries resulted from those symptoms.
No. 19-2291                                                    23

disputed this story; he says he told whoever he spoke with
that Pulera was suicidal and never admitted yelling. That this
call came from an outside source does not “refute the receipt
of notice.” Ortiz, 656 F.3d at 533.
    Still, even under Pulera’s version of the facts, it was not
objectively unreasonable for Summers-Sgroi to discount the
call. Though no one knows whether she received the call be-
fore or after the vitals check (or even Pulera’s attempt), at best
she had either just seen Pulera or was just about to see him.
When confronted with a healthy patient who mentioned no
problems and an outside caller saying the patient was dis-
traught, a reasonable nurse could believe her own observa-
tions over the phone call. Indeed, that is precisely what we
suggested the defendant who answered the phones in Ortiz
should have done, given a jail’s understandable hesitance to
accept medical requests from outside sources. Id. at 529. Sum-
mers-Sgroi saw Pulera and observed no reason whatsoever to
believe Pulera was suicidal—Pulera admits he did not tell her
he was suicidal and does not contest her determination that
his vitals were “excellent.” Under these circumstances, it was
not unreasonable for her to take no special precautions
against his attempted suicide.
    Because Pulera’s individual claims against the nurses fail,
so too must his Monell claims against VNCC and the county.
Although individual liability is not always a prerequisite for
municipal liability, see Glisson v. Ind. Dep't of Corr., 849 F.3d
372, 378 (7th Cir. 2017) (en banc), Pulera argues only that the
facility inadequately trained its nurses and had a de facto pol-
icy permitting them to delegate all their duties to correctional
oﬃcers. Even assuming Pulera could prove the training inad-
equate or the lax policy unconstitutional, he cannot show
24                                                     No. 19-2291

causation. See id. at 379 (“The central question is always
whether an oﬃcial policy, however expressed … caused the
constitutional deprivation.”). The nurses acted appropriately
under the circumstances, both generally and to the extent they
relied on correctional oﬃcers, so their alleged lack of training
and overreliance on oﬃcers could not have caused Pulera’s
injuries. See City of Los Angeles v. Heller, 475 U.S. 796, 799 (1986)
(per curiam) (“If a person has suﬀered no constitutional injury
… the fact that the departmental regulations might have au-
thorized the use of constitutionally excessive force is quite be-
side the point.”).
D. Response Defendants
    Finally, Pulera contends that the district court erred in en-
tering summary judgment for oﬃcers Clemens, Corso, and
Newton. In his view, the oﬃcers violated his rights when they
wasted seconds waiting for back-up before entering his cell,
cutting him down, and calling an ambulance.
    No rational jury could agree with Pulera's hindsight-laden
assessment of the oﬃcers’ actions. “The Fourth Amendment
requires reasonableness, not immediacy.” Sallenger v. City of
Springﬁeld, 630 F.3d 499, 504 (7th Cir. 2010). Even with the de-
lays Pulera criticizes, it is undisputed that the oﬃcers sprang
into action, had the pressure oﬀ his neck in less than two
minutes, and summoned an ambulance in less than ﬁve, by
which time Summers-Sgroi was already providing emer-
gency treatment. Perhaps the oﬃcers could have acted faster,
but the Constitution does not demand perfection. See id.; see
also Florek, 649 F.3d at 600 (“[T]he Fourth Amendment reason-
ableness inquiry necessarily takes into account the suﬃciency
of the steps that oﬃcers did take”). Nor does it demand that
a correctional oﬃcer enter a potentially dangerous situation
No. 19-2291                                                  25

before back-up can arrive. Giles v. Tobeck, 895 F.3d 510, 514
(7th Cir. 2018) (per curiam). Under the totality of the chaotic
circumstances, the oﬃcers’ swift actions were indisputably
reasonable and preclude a ﬁnding that they violated Pulera’s
constitutional rights.
                       III. Conclusion
    It is unfortunate that Pulera attempted to kill himself and
fortunate that he did not succeed. That a tragedy almost hap-
pened under the watch of jail oﬃcers, though, does not mean
the oﬃcers are responsible. All that one can expect—and all
the Constitution demands—is that oﬃcials respond reasona-
bly to the situation presented. Because there is no genuine dis-
pute that all the defendants here did so, we AFFIRM the judg-
ment of the district court.v