Court Opinion

ID: 4527913
Source: CourtListenerOpinion
Date Created: 2020-04-23 00:00:23.065863+00
Date Added: 2024-06-11T12:17:25.886044
License: Public Domain

Case: 19-10222   Document: 00515392031     Page: 1   Date Filed: 04/22/2020

        IN THE UNITED STATES COURT OF APPEALS
                 FOR THE FIFTH CIRCUIT    United States Court of Appeals
                                                   Fifth Circuit

                                                                        FILED
                                                                     April 22, 2020
                                 No. 19-10222
                                                                     Lyle W. Cayce
                                                                          Clerk
NICHOLE SANCHEZ; CASY SIMPSON; EDWARD LAROY SIMPSON, II,
Individually and as the Representative of the Estate of Diana Lynn Simpson,

             Plaintiffs - Appellants

v.

YOUNG COUNTY, TEXAS; YOUNG COUNTY SHERIFF'S DEPARTMENT,

             Defendants - Appellees

                Appeal from the United States District Court
                     for the Northern District of Texas

Before CLEMENT, HIGGINSON, and ENGELHARDT, Circuit Judges.
EDITH BROWN CLEMENT, Circuit Judge:
      Diana Simpson died of a drug overdose while she was a pretrial detainee
at the Young County Jail. Her family (Plaintiffs) sued Young County for her
death under 42 U.S.C. § 1983. We previously affirmed summary judgment for
the County in part, dismissing Plaintiffs’ episodic-acts-or-omissions theory of
liability. Sanchez v. Young County (Sanchez I), 866 F.3d 274, 280 (5th Cir.
2017). But we remanded for the district court to evaluate Plaintiffs’ conditions-
of-confinement theory in the first instance. Id. at 279. The district court
granted summary judgment for the County on that theory, too. Plaintiffs
appeal. We reverse in part and remand.
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                                  No. 19-10222
                                        I.
      Simpson’s death was a suicide. This was not her first attempt. After her
previous attempt, she told her husband that, were she to try again, she would
get cash from an ATM and go to a motel so that he could not find her. Once
there, she would overdose on pills. So her husband was understandably
concerned when, a few weeks after Simpson said this, he noticed a cash
withdrawal from his bank account.
      He tried to contact Simpson, but she did not respond. He called the
hospital where she worked, but she was not there. When she did not report for
her shift the next evening, he called law enforcement and filed missing-person
and be-on-the-lookout reports. Eventually, someone saw her car on the side of
the road in a nearby city and called the police.
      Police officers found Simpson asleep in her vehicle. They woke her and
noticed that her “speech was slurred, that she was slow on her answers, and
that [she was] talking real[ly] quiet[ly].” She “had a hard time keeping her eyes
open to talk,” “kept leaning her head back against” the headrest, and “had a
hard time getting her [license] out of her wallet that was in her lap” and “trying
to get a cup of water to her mouth” for a drink. She denied being diabetic or
having any medical conditions. She initially denied taking any medications
and said that she had something to drink the previous night to help her sleep.
The officers called EMS to come evaluate her. EMS medics determined that
her vitals were “fine” and that her blood sugar was normal, but noted that her
blood pressure was high and her pulse was low.
      According to the officers, she “was unsteady on her feet and almost fell
down”; she “had to be assisted while walking and could not stand on her own.”
With Simpson’s permission, they searched her car and found beer cans—some
empty—and empty blister packs for twenty-four pills. These pills included
antihistamines, muscle relaxers, and antipsychotics. They asked her how
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                                  No. 19-10222
much she took. Her answer: “all of it.” She denied to officers that she was trying
to hurt herself and declined to go to the hospital. But she told one of the medics
that she was trying to kill herself.
      The officers determined that Simpson, if left alone, was a danger to
herself or to others, “due to her being on some type of medication,” so they
arrested her for public intoxication and took her to Young County Jail.
      When Simpson arrived, jailers started the book-in process. They never
finished. On the suicide-screening form, they completed only the detainee-
question portion; left undone was the portion for jailer observations.
Completing that form is mandatory, but because they thought that Simpson
was drunk, they put her in a holding cell at 6:30 p.m. to “sleep it off.” Several
jailers stated that this and other book-in forms, such as a computer-based
medical intake form, did not have to be completed at intake; they could be
completed later. Jailers also stated that they could review the state-mandated
Continuity of Care Query results later. See 37 TEX. ADMIN CODE § 273.5(b), (c).
The Query results show if a detainee has received state-provided mental-
health services.
      The Query results confirmed that Simpson had received such services,
but jailers did not review this information. Nor did they consider the be-on-the-
lookout report, the arrest report, the officers’ statements, or that officers
brought to the jail a bag of the empty pill packs—all of which suggested that
Simpson had taken medication and could be in danger. Instead, jailers relied
on Simpson’s responses to their questions and put on her screening form that
she was not on medication.
      Simpson’s husband called the jail three times to check on her. But jailers
apparently did not consider the information that he provided when
determining whether Simpson needed medical care. In his first call, before she
arrived at the jail, he told jailers that she had been missing for two days and
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was suicidal. In his second call, after she had arrived, he again said that she
was threatening suicide and asked that the jail get her help. That jailer did not
think these warnings were relevant because, according to him, the jail would
not contact mental-health services unless Simpson was sober and attempted
or admitted to attempting suicide at the jail. Her husband’s third call was after
she died.
      When a jailer returned to complete the book-in process at 2:55 a.m.,
Simpson was on the cell floor, unresponsive and naked from the waist down.
She had been lying there, half-naked, almost the entire night. Jailers took her
to the hospital where she was pronounced dead. Her cause of death was “mixed
drug intoxication.”
      While Simpson was in the cell, jailers performed periodic cell checks. The
only way to see Simpson in the cell during these checks was to slide open an
observation window on the cell door. These cell checks were logged using an
electronic wand system. According to the cell-check logs, jailers checked on
Simpson every 25 minutes between 6:52 p.m. and 2:54 a.m., and two jailers
swore that the logs were accurate. But a subsequent Texas Ranger
investigation revealed at least four discrepancies with the logs and video
recordings of Simpson’s cell. First, the jail somehow lost the recording for
7:52 p.m.–2:00   a.m.    The   investigating    Texas   Ranger   made     several
unsuccessful attempts to obtain this missing recording—the jail administrator
sent CDs supposedly containing the missing recording several times, but none
covered the missing six-hour window. The administrator’s explanations for
these mix-ups were that he downloaded the wrong day, then that the system
had been upgraded, and then that the video was inexplicably gone. The
company that performed the upgrade, however, stated that the upgrade would
not affect the recording. Second, the recordings that are available show that no
one checked on Simpson between 6:52 p.m. and 7:52 p.m., despite cell-check
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logs showing otherwise. Third, the recordings show a cell check at 2:45 a.m.,
but that check was not logged; and the log shows a cell check at 2:18 a.m., but
that check is not on the recording. Fourth, the recordings show that, contrary
to jailers’ statements, Simpson does not move at all after 2:00 a.m.
      The County did not conduct its own investigation of Simpson’s death,
and the County sheriff and jail administrator testified that there were no
issues with jail policies and that Simpson’s death was a suicide that no one
could have detected. No jailers were reprimanded or fired because of Simpson’s
death.
      In the five years before Simpson’s death, numerous Texas Commission
on Jail Standards reports noted that the County jail failed to document
observations of inmates, failed to conduct hourly face-to-face observations,
failed to conduct thirty-minute observations of detainees in holding or detox
cells, and failed to properly complete intake screening forms. After Simpson’s
death, Commission reports noted several more potential shortcomings at the
jail: failing to notify the magistrate or state mental-health services of inmates
who may have mental-health issues, exceeding thirty-minute observation
intervals of holding and detox cells, failing to provide “efficient and prompt
care to inmates for acute situations,” and using observation forms without
properly recording times.
      Plaintiffs sued the County for Simpson’s death under § 1983, alleging
Eighth and Fourteenth Amendment violations, and under the Texas Tort
Claims Act. After removing the case to federal court, the County moved for
summary judgment on all claims. The district court granted the motion.
Plaintiffs appealed the dismissal of only their § 1983 claim. We affirmed in
part, dismissing Plaintiffs’ § 1983 claim to the extent that it was based on an
episodic-acts-or-omissions liability theory. Sanchez I, 866 F.3d at 280. But we
held that the district court erred in failing to consider Plaintiffs’ alternative
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                                   No. 19-10222
conditions-of-confinement theory and, therefore, remanded for the district
court to consider whether a genuine dispute of material fact existed under that
theory. Id. at 280–81.
        On remand, Plaintiffs amended their complaint to allege twelve de facto
policies that caused Simpson to be denied her constitutional right to medical
care:
        a. Defendant Young County had no actual procedure for an
           assessment or determination of the suicide risk of pretrial
           detainees, despite the existence of a form, as the de facto policy
           of Young County officials was not to complete forms. Indeed, the
           policymaker undertook no efforts to ensure that forms were
           properly used or filled out thereby providing a de facto policy of
           not requiring adherence to proper suicide assessment.
        b. Defendant Young County systematically ignored the written
           policies for observation of pretrial detainees posing a suicide
           risk.
        c. Defendant Young County, while having a written policy, did
           not, in practice, place pretrial detainees deemed a suicide risk
           in the cells that would allow for maximum visual observation at
           all times of the safety and welfare of those detainees[.]
        d. Defendant Young County’s systematic failure to complete the
           required intake screening instrument resulted in the
           misclassification and misplacement of highly[ ]intoxicated
           pretrial detainees in cells that lacked maximum visual
           observation at all times by Young County Jail staff.
        e. Defendant Young County had no enforced policy for the proper
           monitoring of highly[ ]intoxicated pretrial detainees.
        f. Defendant Young County had a longstanding policy, custom,
           and practice of detaining highly[ ]intoxicated detainees without
           constitutionally adequate visual surveillance or audio
           monitoring, which did not allow for maximum visual
           observation at all times by Young County Jail staff.
        g. Defendant Young County chose a policy to only conduct “cell
           checks” on pretrial detainees every twenty-five minutes. But its
           policy and custom was to house highly[ ]intoxicated pretrial

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                                  No. 19-10222
         detainees in cells that lacked adequate audio and visual
         surveillance while only checking those cells once every twenty-
         five minutes and not actually entering the cells to closely
         monitor the detainees’ health and safety. Instead, the jail staff
         was allowed to use a wand system whereby they could record a
         “cell check” without ever actually entering the cell.
      h. Defendant Young County had no enforced policy to comply with
         [Commission] requirements related to the [Query] system,
         including its required training, use and required follow-up.
      i. Defendant Young County, by policy, allowed untrained
         personnel without proper jailer certificates and training to
         monitor inmates with documented mental and medical issues.
      j. Defendant Young County did not adequately train staff on how
         to properly recognize inmates at risk for overdose, suicide, or to
         monitor and keep [inmates safe] from overdose or suicide, in
         violation of [Texas law].
      k. Defendant Young County had no alcohol or detox policy for
         persons with documented coherency issues, documented drug
         ingestion and documented suicide tendencies such as Mrs.
         Simpson.
      l. Despite a written policy, Defendant Young County failed to
         have an established procedure for visual, face-to-face
         observation of all inmates by jailers, in violation of [Texas law].
      The County again moved for summary judgment, and the district court
again granted the motion. It found that Plaintiffs alleged three types of de facto
policies: failure to train, failure to observe detainees, and failure to complete
forms and identify suicidal tendencies upon intake. It held that Plaintiffs failed
to create a fact issue over whether the alleged training and observation policies
were pervasive. The court did find a fact issue over whether the third policy is
pervasive, but held that, even if it is, it did not cause Simpson’s death.
Plaintiffs again appeal.

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                                  No. 19-10222
                                        II.
      We review 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 (1986). A court must resolve all reasonable
doubts and draw all reasonable inferences in the light most favorable to the
nonmovant. See Walker v. Sears, Roebuck & Co., 853 F.2d 355, 358 (5th Cir.
1988). A court should enter summary judgment against a party when it has
the burden of proof at trial yet fails to establish an element of its case. Celotex
Corp. v. Catrett, 477 U.S. 317, 322 (1986). If “reasonable minds could differ” on
“the import of the evidence,” a court must deny the motion. Anderson, 477 U.S.
at 250.
                                       III.
      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, 690 (1978).
For pretrial detainees, such rights include the right to medical care, Sanchez I,
866 F.3d at 279, and the right to be protected from known suicidal tendencies,
Flores v. County of Hardeman, 124 F.3d 736, 738 (5th Cir. 1997). These
procedural and substantive due-process rights stem from the Fourteenth
Amendment. Hare v. City of Corinth, 74 F.3d 633, 639 (5th Cir. 1996) (en banc)
(citing Bell v. Wolfish, 441 U.S. 520 (1979)). This circuit characterizes such
§ 1983 violations of a pretrial detainee’s rights as either episodic-acts-or-
omissions claims or conditions-of-confinement claims. Id. at 644. For both
claims, a plaintiff has two burdens: to show (1) that a constitutional violation
occurred and (2) that a municipal policy was the moving force behind the
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                                   No. 19-10222
violation. See Monell, 436 U.S. at 694. We previously affirmed summary
judgment on Plaintiffs’ episodic-acts-or-omissions claim in Sanchez I,
remanding with instructions that the district court analyze whether a genuine
dispute of material fact precluded summary judgment on their conditions-of-
confinement claim. Sanchez I, 866 F.3d at 281. Such claims are challenges to
the    “general   conditions,   practices,    rules,    or   restrictions   of   pretrial
confinement.” Hare, 74 F.3d at 644. The issue is whether the conditions
“amount to punishment.” Bell, 441 U.S. at 535.
       To prevail on a conditions-of-confinement claim, a plaintiff must show a
condition—a “rule,” a “restriction,” an “identifiable intended condition or
practice,” or “sufficiently extended or pervasive” “acts or omissions” of jail
officials—that is not reasonably related to a legitimate government objective
and that caused the constitutional violation. Duvall v. Dallas County, 631 F.3d
203, 207 (5th Cir. 2011) (quoting Hare, 74 F.3d at 645)).
       Plaintiffs argue that the County has numerous de facto policies that
systematically deny medical care to highly intoxicated detainees—e.g., policies
of placing highly intoxicated detainees into holding or detox cells to “sleep it
off” without proper medical or risk-of-suicide assessment or treatment, of
ignoring outside information when assessing a detainee’s medical needs, and
of failing to train jailers to evaluate detainees’ mental-health and medical
needs. We find that these policies are best framed as covering three categories:
failure to assess, failure to monitor, and failure to train. Plaintiffs argue that
the district court erred in finding no genuine disputes of material fact about
whether the County had these alleged de facto policies or whether they caused
a violation of Simpson’s constitutional rights.
                                         A.
       Plaintiffs claim that the County denied Simpson adequate medical care
by failing to train its jail employees. The district court examined this failure-
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                                    No. 19-10222
to-train theory as a conditions-of-confinement claim. Sanchez v. Young County
(Sanchez II), No. 7:15-CV-00012-O, 2019 WL 280092, at *5 n.3 (N.D. Tex. Jan.
22, 2019). It should have examined this theory as an episodic-act-or-omissions
claim. See Flores, 124 F.3d at 738 (treating the plaintiff’s training- and
staffing-based allegations as an episodic-acts-or-omissions claim even though
the plaintiff attempted to plead them as a conditions-of-confinement claim).
Failure-to-train claims are not conditions-of-confinement claims, so dismissing
Plaintiffs’ claim as such was error. 1
      Nevertheless, we agree that this claim should be dismissed. As the
County correctly argues, the claim is barred. We affirmed the dismissal of
Plaintiffs’ episodic-acts-or-omissions claim in Sanchez I. 866 F.3d at 281. The
law-of-the-case doctrine therefore prohibits us from reexamining this legal
issue. See United States v. Teel, 691 F.3d 578, 582 (5th Cir. 2012). And
Plaintiffs do not argue that any exceptions to this doctrine apply here. Thus,
we affirm the district court’s dismissal of Plaintiffs’ failure-to-train claim.
                                          B.
      The district court dismissed Plaintiffs’ claims based on a failure to
monitor because it held that Plaintiffs failed to raise a fact issue over whether
the County had an “unofficial custom or practice—much less pervasive acts—
of failing to monitor detainees.” The court held that the evidence “plainly
contradicts Plaintiffs’ characterizations” of the County’s practices because
Plaintiffs did not offer evidence of other detainees who jailers failed to monitor;
the County’s use of an electronic wand system did not prove a failure to
complete cell checks, and any discrepancies in these checks do not show a de
facto policy; and several jailers attested to the existence of written monitoring

      1 The district court, for its part, correctly noted that we treat failure-to-train
claims as episodic-acts-or-omissions claims. Sanchez II, 2019 WL 280092, at *5 n.3.
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                                  No. 19-10222
policies. It therefore concluded that Plaintiffs’ allegations show that the
failures were individual ones, not generalized failures that evidenced a de facto
policy. This conclusion was error, however, because the court failed to consider
all of Plaintiffs’ evidence and arguments or to view them in the light most
favorable to Plaintiffs.
      First, the district court incorrectly faulted Plaintiffs for not “provid[ing]
evidence of other detainees [who] jailers failed to observe.” Plaintiffs did
provide such evidence: the Texas Commission on Jail Standards reports about
inadequate detainee monitoring from before and after Simpson’s death. Those
reports are evidence that jailers failed to monitor other detainees. The district
court erred in discounting these reports.
      Second, the district court did not even consider evidence that the county
policymaker effectively ratified the prior misconduct. In municipal-liability
cases, the issue is whether the complained-of “act[] may fairly be said to
represent official policy.” Monell, 436 U.S. at 694. Practices that are
“sufficiently extended or pervasive, or otherwise typical of extended or
pervasive misconduct,” can represent official policy. Hare, 74 F.3d at 645. This
is because pervasive practices can be evidence that the official policymaker
knew of and acquiesced to the misconduct, making the municipality culpable.
See Piotrowski v. City of Houston, 237 F.3d 567, 578 (5th Cir. 2001).
      Showing a pervasive pattern is a heavy burden. See Shepherd v. Dallas
County, 591 F.3d 445, 452 (5th Cir. 2009). But here, no one disputes that the
County sheriff is the relevant policymaker or that he knew about the
Commission reports and about the details of Simpson’s death. And Plaintiffs
argue that even after her death, the sheriff neither punished any jailers
involved nor took any action to correct the jail’s alleged deficiencies. When the
official policymaker knows about misconduct yet allegedly fails to take
remedial action, this inaction arguably shows acquiescence to the misconduct
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                                  No. 19-10222
such that a jury could conclude that it represents official policy. See Duvall,
631 F.3d at 208–09 (upholding jury finding that a county jail maintained an
unconstitutional condition where there was evidence that the county
policymaker knew of unconstitutional conditions yet failed to revise its
policies); Grandstaff v. City of Borger, 767 F.2d 161, 171 (5th Cir. 1985)
(holding that, because the city policymaker failed to change policies or to
discipline or reprimand officials, the jury was entitled to conclude that the
complained-of practices were “accepted as the way things are done and have
been done in” that city); see also Piotrowski, 237 F.3d at 578 n.18 (explaining
that Grandstaff affirmed municipal liability because a policymaker’s post-
incident actions can ratify the prior misconduct). Plaintiffs’ evidence therefore
creates a fact issue about whether the sheriff acquiesced to the allegedly
inadequate monitoring practices.
      Third, the district court misunderstood the relevance of evidence about
the County’s electronic wand system. The court did not consider how
discrepancies between cell-check logs and video recordings of Simpson’s cell—
or the inexplicably missing six hours of these recordings—might affect the
jailers’ credibility. This evidence might suggest to a jury that jailers were
dishonest about how they monitored Simpson and that they tried to cover up
their failure to monitor. A jury might then reasonably conclude that, in light
of multiple reports that the jail inadequately monitored detainees, such
dishonesty and an apparent cover-up is “typical of extended or pervasive
misconduct.” Hare, 74 F.3d at 645; see Kennett-Murray Corp. v. Bone, 622 F.2d
887, 895 (5th Cir. 1980) (holding that inconsistent testimony “present[s]
questions of credibility which require jury resolution”). This creates a fact issue
over whether jailers habitually failed to properly monitor detainees.
      Fourth, the existence of written monitoring policies does not, as a matter
of law, negate Plaintiffs’ above-mentioned evidence that the allegedly
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inadequate monitoring practices were pervasive. Indeed, Plaintiffs allege that
the jail had a practice of ignoring its written policies. A jury might conclude
that such written policies undercut Plaintiffs’ failure-to-monitor theory, but
the written policies do not compel that conclusion. Plaintiffs’ evidence, when
viewed in the light most favorable to them, creates several disputes of material
fact about whether the jail has a de facto policy of inadequately monitoring
detainees. Thus, the district court’s contrary holding was error.
                                         C.
      The district court categorized Plaintiffs’ failure-to-assess allegations as
making two claims: that the County had a pervasive practice of (1)
“misclassifying and misplacing highly intoxicated pretrial detainees in cells
that lacked maximum visual observation at all times,” and (2) “not ensuring
intake assessment forms were properly used or filled out.” For the first claim,
the court held that Plaintiffs did not provide evidence that the alleged practice
of placing intoxicated detainees in holding cells before completing the book-in
process is pervasive. For the second claim, though the court found that
Plaintiffs created a fact issue over whether jailers “pervasively failed to timely
complete suicide screenings and medical intake forms when intoxicated
detainees first arrived” at the jail, it held that Plaintiffs failed to create a fact
issue over whether this alleged practice caused a violation of Simpson’s
constitutional rights.
      For the first claim, the district court’s holding was error. Our holding in
an uncannily similar case, Montano v. Orange County, 842 F.3d 865 (5th Cir.
2016), makes this clear. One way a plaintiff can prove the existence of a de
facto policy is through the “consistent testimony of jail employees.” Id. at 875.
At least three jailers here testified that the jail’s protocol with highly
intoxicated detainees is to place them in holding cells to “sleep off” their
apparent intoxication before completing book-in. For example, (1) the jail
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                                  No. 19-10222
administrator testified that intoxicated detainees are put in holding cells
before completing medical and other intake forms; (2) another jailer stated that
the “protocol for alcohol or drug detox” is to place detainees “in the holding cell
after their initial book-in,” allowing “very very drunk” inmates to “sleep for a
while”; and (3) the jailer who spoke to Simpson’s husband when he called the
jail stated that Simpson would have to “sleep it off” before she could receive
help or treatment. Indeed, the district court noted this practice, stating that
several jailers “testified that medical forms were generally completed later
during the book-in process than the suicide screening—after a detainee had
time to regain sobriety.” This seemingly consistent testimony creates a fact
issue over whether the County has a policy of placing highly intoxicated
detainees in holding cells to “sleep off” their apparent intoxication without
completing book-in procedures like medical and suicide screening. And as we
held in Montano—a case we affirmed after a full trial—a de facto policy can be
established through consistent testimony that a jail has a practice of leaving
intoxicated detainees in a cell until they become coherent. Id. Thus, given the
similarities between these cases, Montano controls our holding: consistent
jailer testimony about a de facto policy creates a factual dispute that precludes
summary judgment.
      To the extent the County disputes that this is the jail’s detox protocol or
that jailer testimony is consistent, resolving those disputes is the province of
the jury. Who the jury believes depends on who it finds credible. And credibility
determinations are the “purest of jury issues.” Hindman v. City of Paris, 746
F.2d 1063, 1068 (5th Cir. 1984). The County might show that this alleged “sleep
it off” policy is not pervasive, but whether it succeeds is for the jury to decide.
      For the second claim, we agree with the district court that the jailers’
testimony on whether they “pervasively failed to timely complete suicide
screenings and medical intake forms when intoxicated detainees first arrived”
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at the jail “was strikingly consistent.” We therefore also agree that Plaintiffs
raised a fact issue over whether this practice showed a de facto policy. But we
disagree that Plaintiffs failed to create a fact issue about causation.
      The district court concluded that the failure to complete the bottom of
the suicide-screening form was not itself a but-for cause of Simpson being
denied needed medical care. That might be so, but the court erred in viewing
the failure to complete this form in isolation. We do not require a plaintiff to
show that a “policy or practice [was] the exclusive cause of the constitutional
deprivation.” M.D. ex rel. Stukenberg v. Abbott, 907 F.3d 237, 254 (5th Cir.
2018). Courts “may . . . consider how individual policies or practices interact
with one another within the larger system.” Id. at 255. This is because
confinement conditions may be constitutionally inadequate if, when viewed in
combination, they have a “mutually enforcing effect that produces the
deprivation of a single, identifiable human need.” Wilson v. Seiter, 501 U.S.
294, 304 (1991).
      Plaintiffs allege numerous de facto policies affecting highly intoxicated
detainees. For example, policies where jailers are not required to complete
suicide- or medical-screening forms, review Query results, or complete the
book-in process; a policy of not contacting mental-health services unless the
detainee is sober and attempts suicide or indicates on the suicide-screening
form that she is suicidal; a policy of accepting detainees arrested for public
intoxication without a known blood-alcohol content or further medical
clearance so long as they are responsive and not falling down at intake; and a
“sleep it off” detox policy that does not include further medical assessments or
adequate monitoring. Plaintiffs also allege a policy of disregarding outside
information when assessing a detainee’s medical needs. The district court did
not address these alleged policies, much less consider how they might interact.

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                                 No. 19-10222
      Reasonable minds might disagree about whether these alleged policies
interacted to violate Simpson’s constitutional rights. But a jury is “free to
choose among reasonable constructions of the evidence.” E.E.O.C. v. Boh Bros.
Constr. Co., 731 F.3d 444, 452 (5th Cir. 2013) (en banc) (quoting United States
v. Ramos-Cardenas, 524 F.3d 600, 605 (5th Cir. 2008)). A jury could reasonably
conclude that policies where jailers are not required to review Query results or
to complete medical forms during the book-in process for highly intoxicated
detainees—coupled with a policy of ignoring outside information when
assessing medical needs—were a substantial factor in causing Simpson to be
denied medical care. One jailer testified that outside information such as
missing-person and be-on-the-lookout reports are not considered when
assessing an inmate at book-in. Another jailer testified that, when determining
whether to contact mental-health services, jail policy is to consider only the
Query information, the suicide-screening form, and jailers’ own observations,
but not outside information from family members or the arresting officer. And
even though reviewing the Query results here might have led to Simpson
receiving medical care—one jailer admitted that, had she reviewed the Query
results, she would have known that Simpson’s responses at intake were not
true—the alleged practice is to not review those results until completing book-
in. That might happen hours later, because the jail’s alleged policy is to place
highly intoxicated detainees like Simpson into a holding cell to “sleep it off”
before completing book-in.
      Indeed, viewing the evidence in the light most favorable to Plaintiffs,
how jailers could ever detect and treat a suicidal detainee who took a fatal
overdose of drugs is unclear. The County’s alleged policies are to place
seemingly intoxicated detainees in a cell to sober up before they receive further
medical screening. In situations like the one here, where a detainee is arrested
for public intoxication but her blood-alcohol content is unknown, jailers do
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                                  No. 19-10222
nothing to confirm their suspicion that the detainee is merely intoxicated or to
confirm that the detainee is not too intoxicated to safely sleep it off. Cf.
Montano, 842 F.3d at 879 (faulting the defendant for not addressing why,
under its policies, “detainees were expected to heal themselves, particularly
when the assumed drug influence was never established”). Unless the detainee
decides to abandon her suicide effort, she will sit in a cell to sober up before
she can receive further medical screening. But someone who has ingested a
lethal dose of drugs, like Simpson did, will never sober up, so she will never get
further medical screening.
      The County has no apparent process or policy for preventing such an
overdosee from successfully killing herself. The jail has no medical staff, jailers
do not consider outside information that contradicts what a detainee states at
intake, and after intake, jailers do not conduct follow-up assessments. The only
follow-up they do is periodic monitoring. And Plaintiffs claim that this
monitoring is pervasively inadequate.
      Given the different, compounding ways that these alleged policies might
interact, a jury could reasonably conclude that they had a “mutually enforcing
effect” that deprived Simpson of needed medical care. Wilson, 501 U.S. at 304.
The district court therefore erred as a matter of law in finding no genuine
dispute of material fact about causation.
      The County argues, however, that we already decided this causation
issue in its favor in Sanchez I. That is incorrect. Although we stated that
Plaintiffs did not offer proof that failing to complete intake forms caused
Simpson’s death, we did so when evaluating Plaintiffs’ episodic-acts-or-
omissions claim. Sanchez I, 866 F.3d at 280. We explicitly remanded for the
district court to consider Plaintiffs’ conditions-of-confinement claim “in the
first instance” and, therefore, could not have decided the causation issue for
that claim. Id. at 281. Moreover, our previous holding addressed whether an
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                                No. 19-10222
episodic act or omission, in isolation, caused Simpson harm. But as the
Supreme Court has held and as our court has confirmed, conditions-of-
confinement claims can be based on multiple interacting policies. Wilson, 501
U.S. at 304; Stukenberg, 907 F.3d at 254. And in any event, Plaintiffs produced
additional causation evidence on remand that we did not review in Sanchez I.
Because a fact issue exists over whether multiple policies interacted to cause
constitutionally inadequate confinement conditions, the district court erred in
granting summary judgment for the County.
                                     IV.
      Plaintiffs raised several material factual disputes that precluded
summary judgment. They offered sufficient evidence to create fact issues over
whether the County has de facto policies of failing to monitor and failing to
assess pretrial detainees’ medical needs, and whether these policies caused
Simpson to be denied needed medical care. Plaintiffs’ failure-to-train claim,
however, was barred. We therefore reverse in part and affirm in part the
district court’s grant of summary judgment and remand for further
proceedings consistent with this opinion.

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