Court Opinion

ID: 7837953
Source: CourtListenerOpinion
Date Created: 2022-09-08 00:00:33.386807+00
Date Added: 2024-06-11T15:54:35.506823
License: Public Domain

Appellate Case: 21-4067     Document: 010110734963     Date Filed: 09/07/2022    Page: 1
                                                                                 FILED
                                                                     United States Court of Appeals
                                        PUBLISH                              Tenth Circuit

                       UNITED STATES COURT OF APPEALS                      September 7, 2022

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

  NOLEEN PAUGH and DONALD
  PAUGH, as heirs of Coby Lee Paugh,

        Plaintiffs,

  and

  TRISTEN CALDER, as personal
  representative of the estate of Coby Lee
  Paugh,

        Plaintiff - Appellee,

  v.                                                         No. 21-4067

  UINTAH COUNTY; KORI ANDERSON;
  DAN BUNNELL; KYLE FULLER;
  TYLER CONLEY; RICHARD GOWEN,

        Defendants - Appellants,

  and

  JUSTIN RIDDLE,

        Defendant.
                          _________________________________

                      Appeal from the United States District Court
                                for the District of Utah
                         (D.C. No. 2:17-CV-01249-JNP-CMR)
                        _________________________________

 Frank D. Mylar (Andrew R. Hopkins with him on the briefs), of Mylar Law, P.C., Salt
 Lake City, Utah, for Defendants-Appellants.
Appellate Case: 21-4067    Document: 010110734963         Date Filed: 09/07/2022     Page: 2

 C. Peter Sorensen (Robert B. Sykes and Christina D. Isom with him on the briefs), of
 Sykes McAllister Law Offices, Salt Lake City, Utah, for Plaintiffs-Appellees.
                        _________________________________

 Before HOLMES, BACHARACH, and PHILLIPS, Circuit Judges.
                   _________________________________

 PHILLIPS, Circuit Judge.
                      _________________________________

       Coby Lee Paugh died from complications related to alcohol withdrawal while

 being held in pretrial detention at Uintah County Jail in Vernal, Utah. His estate sued

 Uintah County and several of its jail officials under 42 U.S.C. § 1983, alleging

 violations of Paugh’s constitutional rights.

       The County and its jail officials—Kori Anderson, Dan Bunnell, Kyle Fuller,

 Tyler Conley, Richard Gowen, and Justin Riddle—moved for summary judgment,

 with the jail officials asserting qualified immunity. In a thorough order, the district

 court granted qualified immunity for Riddle,1 but it denied qualified immunity for

 Anderson, Bunnell, Fuller, Conley, and Gowen (collectively, “Individual

 Defendants”). It also denied the County’s motion for summary judgment.

       The Individual Defendants and the County have now filed this interlocutory

 appeal. The Individual Defendants challenge the district court’s denial of qualified

 immunity, and the County asks us to exercise pendent appellate jurisdiction and

 reverse the court’s denial of its motion for summary judgment.

       1
         The Estate does not dispute Riddle’s dismissal. See R. vol. 2 at 80
 (explaining that the Estate “concede[s] that there is insufficient evidence from which
 a jury could conclude that Riddle was deliberately indifferent to Paugh’s serious
 medical need” (citation omitted)).
                                             2
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        We hold that the Individual Defendants are not entitled to qualified immunity.

 We thus affirm the district court’s denial of the Individual Defendants’ motion for

 summary judgment. We do not consider the County’s appeal, because we lack

 jurisdiction to do so.

                                    BACKGROUND

 I.     Factual Background2

        A.     Paugh’s Arrest and Hospital Visit

        The underlying events of this case are tragic. For years, Paugh suffered from

 chronic alcoholism. In March 2015, Paugh pleaded guilty to an alcohol-related

 offense and was placed on supervised probation. One condition of Paugh’s probation

 barred him from consuming alcohol for six months.

        After going on a multiday drinking binge, Paugh realized that he needed help.

 So in the early morning of July 24, 2015, he turned himself over to the Vernal Police

 Department for his probation violation. At the time of his arrest, Paugh had a blood-

 alcohol concentration (“BAC”) of .324. This BAC veers “dangerously” close to

 “alcohol overdose levels.” R. vol. 2 at 9.

        Immediately after arresting him, Vernal police officers took Paugh to Ashley

 Regional Medical Center (“ARMC”), seeking medical clearance to admit him to

 Uintah County Jail. At about 1:30 a.m., Dr. Aaron Bradbury examined Paugh and

        2
          “Because our interlocutory review of an order denying qualified immunity is
 typically limited to issues of law, this factual history is drawn from the district
 court’s recitation of the facts.” Crowson v. Washington Cnty., 983 F.3d 1166, 1174
 n.3 (10th Cir. 2020).
                                              3
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 diagnosed him as suffering from chronic alcoholism and alcohol withdrawal. Though

 Dr. Bradbury did not give Paugh any medication at that time, he prescribed Paugh

 Chlordiazepoxide (commonly known as Librium) to help mitigate Paugh’s alcohol-

 withdrawal symptoms.

       Ultimately, Dr. Bradbury found Paugh “currently stable and safe for

 incarceration.” Id. at 10 (citation omitted). But he warned the Vernal police officers

 that if Paugh’s “alcohol withdrawal condition got any worse they’d have to bring him

 back to ARMC.” Id. (internal quotations and citation omitted). Indeed, according to

 the discharge instructions given to the Vernal police officers, jail officials were to

 administer Librium to Paugh “[a]s needed” and to bring him back to the hospital if

 his condition worsened.3 R. vol. 3 at 190.

       Around 2:10 a.m., Dr. Bradbury discharged Paugh from ARMC, and Paugh

 was taken to Uintah County Jail.

       B.     Paugh’s Arrival at the Jail and Night Shift on July 24, 2015 (2:20
              a.m. to 6:00 a.m.)

       At about 2:20 a.m., Paugh arrived at Uintah County Jail. Three Individual

 Defendants—Bunnell, Anderson, and Riddle—were working a 6:00 p.m. to 6:00 a.m.

 shift. Only Anderson and Bunnell interacted with Paugh during this shift. It was

       3
          Dr. Bradbury testified at his deposition that in discharging Paugh, he had
 expected the jail officials to “regularly observe and monitor Paugh for signs of
 gradually worsening alcohol withdrawal.” R. vol. 2 at 10 (internal quotations and
 citation omitted). These signs included “vomiting, becoming pale or sweaty,
 uncontrolled shaking or movement (tremors), having a seizure or a fever, becoming
 lightheaded or faint, or experiencing confusion, lack of coordination, or increased
 anxiety and restlessness.” Id. (internal quotations and citation omitted).
                                              4
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 Anderson’s first night as a shift supervisor. Bunnell was the designated medical

 official, making him responsible for administering medication to the inmates.4

       When the Vernal police officers turned Paugh over to Anderson and Bunnell,

 Paugh “was walking, talking[, and] [d]idn’t seem unsteady on his feet.” R. vol. 3

 at 135. In fact, Anderson described Paugh as seeming “just fine.”5 Id. at 85.

       The Vernal police officers apprised Anderson and Bunnell that Paugh had a

 BAC of .324 when he turned himself in, that they had immediately taken him to the

 hospital, and that Dr. Bradbury had prescribed him Librium. The officers then gave

 Dr. Bradbury’s written discharge instructions to Anderson and Bunnell, which the

 two placed into Paugh’s file. The Vernal police officers also repeated Dr. Bradbury’s

 instructions to Anderson. Thus, she understood that if Paugh manifested “red flags”

 of alcohol withdrawal, meaning that if his “condition worsened . . . in any way,” the

 staff needed to get Paugh to the hospital. R. vol. 2 at 11 (citation omitted).

       Bunnell placed Paugh in a detoxification cell to let him sleep. After that,

 Bunnell and Anderson did not check on or interact with Paugh for the rest of their

       4
          Bunnell knew about Paugh’s chronic alcoholism from his time as a patrol
 officer and because the two men lived near each other in Vernal, Utah.
       5
         The district court repeatedly found that Paugh’s condition worsened during
 his time at the jail. See, e.g., R. vol. 2 at 65 (“Anderson knew from the pass-along
 with Gowen that Paugh’s condition had worsened during the day on July 24.”).
 Accepting that as true, as we must on interlocutory appeal, we note Anderson and
 Bunnell’s description of Paugh when he first arrived at the jail. See Cox v. Glanz, 800
 F.3d 1231, 1242 (10th Cir. 2015) (“The district court’s factual findings and
 reasonable assumptions comprise the universe of facts upon which we base our legal
 review of whether defendants are entitled to qualified immunity.” (internal quotations
 and citation omitted)).
                                             5
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 shift, even though the jail maintains a “head count” policy requiring its officials to

 “at least once each hour, and whenever possible, every 30 minutes,” “individually

 observe inmates,” R. vol. 2 at 29 (citation omitted).

       C.     Day Shift on July 24, 2015 (6:00 a.m. to 6:00 p.m.)

       At 6:00 a.m., the other Individual Defendants—Gowen, Conley, and Fuller—

 began their twelve-hour shift at the jail. Gowen was the shift supervisor, and Fuller

 was the designated medical official. Jail policy requires officials from an earlier shift

 to brief their replacements about pertinent information when changing shifts. So

 during this “pass-along,” Anderson, Bunnell, and Riddle needed to inform Gowen,

 Conley, and Fuller about Paugh’s alcohol-withdrawal condition, Paugh’s unfilled

 Librium prescription, and Dr. Bradbury’s discharge instructions. Id. at 12 (citation

 omitted). But the night shift failed to pass this information along to the day shift.

 Still, Gowen, Conley, and Fuller later “reviewed at least part of Paugh’s medical file

 or otherwise learned that” Paugh was experiencing alcohol withdrawal. Id. at 13.

       At about 6:30 a.m., Conley served Paugh breakfast, but Paugh did not eat it.

 Despite not eating, according to Conley, Paugh “seemed normal and well.” Id. at 62

 (citation omitted). At 11:00 a.m., Fuller served Paugh lunch. When doing so, Fuller

 noticed the shakiness of Paugh’s hands, so he advised Paugh to “drink fluids and stay

 hydrated.” Id. at 13. Around the same time, Gowen also noticed that Paugh’s hands

                                             6
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 were shaking, and he knew that Paugh had already “retched, or dry-heaved” “two or

 three times” within the last “two or three hours.”6 Id. at 14 (citation omitted).

       At about 11:30 a.m., Fuller left the jail to fill Paugh’s Librium prescription

 after Conley realized that no one else had done so. After Fuller left, Conley started

 Paugh’s booking and screening processes. Gowen was present in the booking area as

 Paugh answered questions. While answering the jail’s screening questions, Paugh had

 to go back to his cell to vomit.

       After returning to the booking area, and in response to Conley’s medical-

 screening questions, Paugh told Conley that he was “currently going through

 withdrawals,” that he was in “lots of pain from three broken ribs,” that he had

 medical problems related to seizures, that he was feeling “restlessness/anxiety,” and

 that he suffered from alcoholism. Id. at 13 (citation omitted). Jail policy requires its

 officials to contact medical professionals if an inmate answers “yes” to “any medical

 screening question.” Id. at 173. Despite this policy and Paugh’s affirmative answers,

 neither Gowen nor Conley sought medical attention for him.

       Fuller then returned to the jail with Paugh’s Librium, which he says he gave to

 Paugh around 1:40 p.m. While giving Paugh his Librium, Fuller noticed that Paugh’s

 hands shook the entire time.

       After giving Paugh a dose of Librium, Fuller noticed a problem. The jail’s

 general policy was to distribute medication three times a day at 7:00 a.m., 12:00 p.m.,

       6
         The district court found a genuine dispute of material fact about how many
 times Paugh had vomited while at the jail.
                                             7
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 and 5:00 p.m. But Paugh’s Librium packaging specified that two Librium capsules

 needed to be given “every 2 hours as needed,” R. vol. 4 at 138, and Dr. Bradbury’s

 instructions called for Paugh to receive two capsules “as needed,” R. vol. 3 at 190.

       To resolve the discrepancy, Fuller called physician-assistant Logan Clark (“PA

 Clark”).7 PA Clark asked whether Fuller had seen “any symptoms of withdrawal,”

 including “any shaking, any issues like that.” R. vol. 2 at 75 (citation omitted). Fuller

 told PA Clark that he had seen no withdrawal symptoms, and he assured PA Clark

 that Paugh had been “walking around good,” “ha[d] been eating,” hadn’t been

 throwing up, and “seem[ed] to be doing good.” Id. (citation omitted). Fuller made

 these statements despite observing Paugh’s shaking hands and knowing that Paugh

 had vomited earlier.8

       Believing that Paugh was not suffering from alcohol-withdrawal symptoms,

 PA Clark instructed Fuller to lower Paugh’s Librium dosage to one capsule three

 times a day to conform with the jail’s standard protocol. PA Clark also told Fuller

 that he “expected to be notified if there was any change to Paugh’s symptoms.” Id.

 (cleaned up).

       7
         The jail had a contract with PA Clark to provide remote medical assistance to
 its inmates.
       8
          Fuller and PA Clark disagree “about the content of this phone conversation
 and the extent to which Fuller informed [PA] Clark about Paugh’s condition and the
 nature of his Librium prescription.” R. vol. 2 at 75. For our purposes, we recite the
 facts as the district court does. See Crowson, 983 F.3d at 1174 n.3.
                                             8
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       At about 4:00 p.m., Gowen served Paugh dinner. During this encounter, Paugh

 told Gowen that he was “feeling sick and nauseous” and that “he had not [yet] hit

 [the] peak” of his alcohol-withdrawal symptoms. Id. at 15 (citation omitted). While

 speaking to him, Gowen observed that Paugh’s hands and forearms were “visibly

 shaking.” Id. (citation omitted). Gowen even noted that Paugh seemed “really sick

 from detoxing,” given that he had vomited and “not eaten much throughout the day.”

 Id. at 15–16 (citation omitted).

       Around 5:00 p.m., Fuller began dispensing medication to the inmates. But

 before he reached Paugh, Fuller had to respond to an incident with another inmate.

 So Fuller had Conley take over the medication-distribution duties. For reasons still

 unclear, neither Conley nor anyone else on this shift gave Paugh his Librium. Nor did

 Fuller confirm with Conley that Paugh had properly received his Librium.

       At 5:30 p.m., when Conley retrieved Paugh’s dinner tray, he noticed that

 Paugh was “shaking pretty bad.” Id. at 15 (citation omitted). Paugh repeated to

 Conley what he had told Gowen—that his withdrawal “had not peaked yet.” Id. at 16

 (cleaned up).

       D.        Night Shift on July 24, 2015 to July 25, 2015 (6:00 p.m. to 6:00 a.m.)

       Anderson, Bunnell, Riddle, and Tony Alarid9 were on duty for the night shift.

 Once again, Anderson was the shift supervisor, and Bunnell was the designated

 medical official.

       9
           The Estate did not sue Alarid.
                                             9
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         Fuller testified that he had a “brief pass-along” to Alarid. Id. at 76 (citation

  omitted). But Fuller did not “fully inform Alarid about Paugh’s worsening

  condition.” Id. Nor did he tell anyone else that PA Clark expected to be updated “if

  there was any change to Paugh’s symptoms.” Id.

         Unlike Fuller, Gowen testified that he told Anderson about Paugh’s

  withdrawal symptoms. In fact, Gowen allegedly instructed Anderson to “get up” and

  check on Paugh “as often as she [could]” to make sure he was “breathing and in no

  distress.”10 Id. at 16 (citation omitted).11

         About an hour into this shift, Paugh told Bunnell and Anderson that he had not

  received any Librium during dinner. And because he was feeling sick from his

  withdrawal symptoms, he asked when he would be given his next round of

  medication. While speaking to Paugh, Anderson and Bunnell noticed that Paugh was

  shaking, looked pale, and didn’t appear to be well.

         Around 8:00 p.m., Bunnell allegedly gave Paugh a second dose of Librium.

  During this encounter, Paugh was still shaking and pale, and Paugh told Bunnell that

  “he was detoxing.” Id. at 17 (citation omitted).

         10
           Bunnell stated that no one updated him about Paugh’s condition during the
  pass-along. But he also admitted that he did not ask for an update.
         11
           Anderson does not recall Gowen communicating these expectations to her.
  She only remembers Gowen telling her that Paugh had started his Librium, that he
  had “slept a lot of the day,” that “he had thrown up once” or “had been throwing up,”
  and that he “had eaten some food.” R. vol. 2 at 16 (citation omitted).
                                                 10
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         Between 9:45 and 10:00 p.m., Bunnell went to speak with Paugh again, who

  was still shaking. But this time, Paugh also told Bunnell that “he was getting the

  chills then hot again.” Id. at 18 (citation omitted). Anderson then came over, and

  Paugh told her that he was nauseous. She observed that Paugh seemed “shaky,” had

  the chills, and looked sick. R. vol. 2 at 18 (citation omitted).

         At this time, Anderson and Bunnell decided to move Paugh to a different cell

  so that he could be in “a cell alone while he was sick.” Id. at 18 (citation omitted).

  Bunnell also gave Paugh another blanket.

         Sometime after moving Paugh, Anderson thought she heard Paugh vomit. And

  throughout that night, she heard him “coughing,” “sneezing,” and sounding like he

  was “trying to get phlegm out of his throat to spit.” Id. (cleaned up). Bunnell recalled

  hearing the same thing.

         At about 2:00 a.m., Bunnell felt ill and went home for the night. Before

  leaving, Bunnell peered into Paugh’s cell but did not otherwise check on Paugh.

  Riddle took over Bunnell’s duties. Neither Bunnell nor Anderson told Riddle that

  Paugh was withdrawing from alcohol. And Riddle didn’t review Paugh’s medical

  files. In fact, between 10:00 p.m. and 6:10 a.m., Anderson acknowledged that no jail

  officer “performed an actual physical check on Inmate Paugh.” Id. at 19.

         E.     Paugh’s Death: July 25, 2015

         At about 6:10 a.m., when Conley visited Paugh to administer his Librium, he

  found Paugh dead. Because Paugh’s lips were blue, Conley assumed that Paugh had

  probably been dead for a while.

                                              11
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         From Paugh’s autopsy, the medical examiner concluded that Paugh’s death

  had “resulted from chronic alcoholism, most likely a complication of withdrawal.”

  Id. at 20 (citation omitted). The examiner also found no Librium in Paugh’s blood.

  This was notable because Librium has an “extremely long half-life of . . . (24–48

  hours).” Id. at 23 (citation omitted). So the lack of Librium in Paugh’s blood raised

  the question of whether Paugh had ever received any Librium at the jail.12 One of

  Paugh’s experts opined that had Paugh been provided Librium, “he would have most

  likely not died” and that if he had been “returned to the hospital for life-saving

  measure[s] as his condition continued to worsen, he would have most likely not

  died.” Id. at 24 (citation omitted).

  II.    Procedural Background

         Under § 1983, the personal representative13 of Paugh’s estate sued Uintah

  County and the Individual Defendants.14 The Estate alleged that the Individual

  Defendants had violated Paugh’s constitutional rights by being deliberately

  indifferent to his serious medical needs. It also alleged that their conduct resulted

  from the County’s constitutionally deficient policies, customs, and training.

         12
           Paugh’s blood did show traces of Benadryl. This led one of Paugh’s experts
  to hypothesize that Paugh had “erroneously” received Benadryl, instead of Librium.
  R. vol. 2 at 23 (citation omitted).
         13
            Paugh’s brother Robert Harlow resigned as the personal representative of his
  estate, so his sister Tristen Calder assumed that role. Paugh’s parents also sued in
  their individual capacities, but the district court dismissed them for lack of standing.
         14
            The Estate also sued Dr. Bradbury, ARMC, and PA Clark. But the parties
  later stipulated to the dismissal of these Defendants.
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        The County and the Individual Defendants moved for summary judgment, with

  the Individual Defendants asserting qualified immunity. The district court denied

  both motions. This interlocutory appeal followed.

                                      DISCUSSION

  I.    Individual Defendants

        A.     Jurisdiction

        An order denying summary judgment is “generally not a final decision within

  the meaning of [28 U.S.C.] § 1291 and is thus generally not immediately appealable.”

  Plumhoff v. Rickard, 572 U.S. 765, 771 (2014). But under the collateral-order

  doctrine, “a circuit court may review certain orders as appealable final decisions

  within the meaning of [] § 1291 even though the district court has not entered a final

  judgment.” Henderson v. Glanz, 813 F.3d 938, 947 (10th Cir. 2015) (citing Cohen v.

  Beneficial Indus. Loan Corp., 337 U.S. 541, 546 (1949)).

        To establish jurisdiction under this doctrine, defendants must show that the

  district court’s order “(1) conclusively determined the disputed question, (2) resolved

  an important issue completely separate from the merits of the case, and (3) is

  effectively unreviewable on appeal from a final judgment.” Gray v. Baker, 399 F.3d

  1241, 1245 (10th Cir. 2005) (citing Midland Asphalt Corp. v. United States, 489 U.S.

  794, 799 (1989)). “The denial of a defendant’s motion for dismissal or summary

  judgment on the ground of qualified immunity easily meets these requirements.”

  Mitchell v. Forsyth, 472 U.S. 511, 527 (1985).

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        When reviewing a denial of summary judgment based on qualified immunity,

  we generally lack jurisdiction to review factual disputes.15 See Vette v. K-9 Unit

  Deputy Sanders, 989 F.3d 1154, 1162 (10th Cir. 2021). Instead, “we must accept any

  facts that the district court assumed in denying summary judgment.” Amundsen v.

  Jones, 533 F.3d 1192, 1196 (10th Cir. 2008).

        Thus, the focus of our review on interlocutory appeal concerns only “abstract

  issues of law relating to qualified immunity.” Behren v. Pelletier, 516 U.S. 299, 313

  (1996) (cleaned up). This means “we can consider only ‘(1) whether the facts that the

  district court ruled a reasonable jury could find would suffice to show a legal

  violation, or (2) whether that law was clearly established at the time of the alleged

  violation.’” Finch v. Rapp, 38 F.4th 1234, 1240–41 (10th Cir. 2022) (quoting

  Roosevelt-Hennix v. Prickett, 717 F.3d 751, 753 (10th Cir. 2013)).

        B.     Qualified Immunity Standard of Review

        “The doctrine of qualified immunity shields officials from civil liability so

  long as their conduct ‘does not violate clearly established statutory or constitutional

  rights of which a reasonable person would have known.’” Est. of Lockett v. Fallin,

  841 F.3d 1098, 1107 (10th Cir. 2016) (quoting Mullenix v. Luna, 577 U.S. 7, 11

  (2015)). In other words, it “protects all but the plainly incompetent or those who

        15
           “There is an exception to this jurisdictional limitation ‘when the version of
  events the district court holds a reasonable jury could credit is blatantly contradicted
  by the record.’” Crowson, 983 F.3d at 1177 (quoting Lewis v. Tripp, 604 F.3d 1221,
  1225–26 (10th Cir. 2010)).
                                             14
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  knowingly violate the law.” Mullenix, 577 U.S. at 12 (internal quotations omitted)

  (quoting Malley v. Briggs, 475 U.S. 335, 341 (1986)).

        “Because of the underlying purposes of qualified immunity, we review

  summary judgment orders deciding qualified immunity questions differently from

  other summary judgment decisions.” Medina v. Cram, 252 F.3d 1124, 1128 (10th Cir.

  2001). “When a defendant asserts the defense of qualified immunity, the burden

  shifts to the plaintiff to overcome the asserted immunity.” Ahmad v. Furlong, 435

  F.3d 1196, 1198 (10th Cir. 2006).

        To overcome the defense of qualified immunity, the plaintiff must raise a

  genuine issue of material fact that “(1) the defendant’s actions violated his or her

  constitutional or statutory rights, and (2) the right was clearly established at the time

  of the alleged misconduct.” Est. of Beauford v. Mesa Cnty., 35 F.4th 1248, 1261

  (10th Cir. 2022). Failure at either step requires us to grant qualified immunity.

  Grissom v. Roberts, 902 F.3d 1162, 1167 (10th Cir. 2018). We may address either

  step of the qualified-immunity analysis first. Id.

        “If, and only if, the plaintiff meets this two-part test does a defendant then bear

  the traditional burden of the movant for summary judgment—showing that there are

  no genuine issues of material fact and that he or she is entitled to judgment as a

  matter of law.” Estate of Beauford, 35 F.4th at 1261–62 (citation omitted). “When the

  record shows an unresolved dispute of historical fact relevant to this immunity

  analysis, a motion for summary judgment based on qualified immunity should be

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  ‘properly denied.’” Id. at 1262 (quoting Olsen v. Layton Hills Mall, 312 F.3d 1304,

  1312 (10th Cir. 2002)).

        C.     Deliberate Indifference

        “The right to custodial medical care is well settled.” Id. “A prison official’s

  deliberate indifference to an inmate’s serious medical needs violates the Eighth

  Amendment.” Sealock v. Colorado, 218 F.3d 1205, 1209 (10th Cir. 2000); see also

  Farmer v. Brennan, 511 U.S. 825, 828 (1994) (“A prison official’s ‘deliberate

  indifference’ to a substantial risk of serious harm to an inmate violates the Eighth

  Amendment.”). Those same constitutional protections apply to pretrial detainees,

  such as Paugh, through the Fourteenth Amendment’s Due Process Clause. See Burke

  v. Regalado, 935 F.3d 960, 992 (10th Cir. 2019) (“The constitutional protection

  against deliberate indifference to a pretrial detainee’s serious medical condition

  springs from the Fourteenth Amendment’s Due Process Clause.”).

        The Supreme Court has explained that “deliberate indifference entails

  something more than mere negligence.” Farmer, 511 U.S. at 835. But “it is satisfied

  by something less than acts or omissions for the very purpose of causing harm or

  with knowledge that harm will result.” Id. Thus, the Court has equated deliberate

  indifference to “recklessness,” in which “a person disregards a risk of harm of which

  he is aware.” Verdecia v. Adam, 327 F.3d 1171, 1175 (10th Cir. 2003) (quoting

  Farmer, 511 U.S. at 836–37).

        “Our cases recognize two types of conduct constituting deliberate

  indifference.” Sealock, 218 F.3d at 1211. The first applies when medical

                                            16
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  professionals “fail to treat a serious medical condition properly.” Id. This may occur,

  for example, when a medical professional “fails to treat a medical condition so

  obvious that even a layman would recognize the condition,” “completely denies care

  although presented with recognizable symptoms which potentially create a medical

  emergency,” or “responds to an obvious risk with treatment that is patently

  unreasonable.” Self v. Crum, 439 F.3d 1227, 1232 (10th Cir. 2006).

        But, at the same time, a medical professional has not acted with deliberate

  indifference if he or she merely negligently treats or diagnoses an inmate—even if

  that provided care would constitute medical malpractice. See Perkins v. Kan. Dep’t of

  Corr., 165 F.3d 803, 811 (10th Cir. 1999) (“A negligent failure to provide adequate

  medical care, even one constituting medical malpractice, does not give rise to a

  constitutional violation.”); see also Estelle v. Gamble, 429 U.S. 97, 106 (1976)

  (explaining that a physician’s negligence “in diagnosing or treating a medical

  condition does not state a valid claim of medical mistreatment under the Eighth

  Amendment” because “[m]edical malpractice does not become a constitutional

  violation merely because the victim is a prisoner”).

        But because none of the Individual Defendants were medical professionals, we

  instead focus on the second type of conduct—that of “gatekeepers.” “[W]hen prison

  officials prevent an inmate from receiving treatment or deny him access to medical

  personnel capable of evaluating the need for treatment,” they may be liable for

  deliberate indifference. Sealock, 218 F.3d at 1211. In other words, a jail official’s

  delay or refusal to obtain medical care for an inmate may constitute deliberate

                                             17
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  indifference. See id.; see also Estelle, 429 U.S. at 104–05 (explaining that deliberate

  indifference may be manifested “by prison guards in intentionally denying or

  delaying access to medical care”).

        Thus, using “the facts that the district court ruled a reasonable jury could

  find,” Crowson, 983 F.3d at 1177, we must determine whether the Estate has raised a

  genuine issue of material fact that the Individual Defendants failed to fulfill their

  “gatekeeper” roles, Sealock, 218 F.3d at 1211.

               a.         Constitutional Violation

        “The contours of constitutional liability under the deliberate-indifference

  standard are familiar: there is both an objective and a subjective component.” Estate

  of Beauford, 35 F.4th at 1262. The objective component focuses on the “seriousness

  of the plaintiff’s alleged harm,” and the subjective component focuses on “the mental

  state of the defendant with respect to the risk of that harm.” Prince v. Sherriff of

  Carter Cnty., 28 F.4th 1033, 1044 (10th Cir. 2022).

                     i.         Objective Component

        To satisfy the objective component, “the alleged deprivation must be

  ‘sufficiently serious’ to constitute a deprivation of constitutional dimension.” Self,

  439 F.3d at 1230 (quoting Farmer, 511 U.S. at 834). Generally, a medical need

  qualifies as “sufficiently serious” if it “has been diagnosed by a physician as

  mandating treatment” or if it is “so obvious that even a lay person would easily

  recognize the necessity for a doctor’s attention.” Sealock, 218 F.3d at 1209 (citation

  omitted).

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        But a plaintiff can also satisfy the objective component based on a “delay in

  medical care . . . if ‘the delay resulted in substantial harm.’” Estate of Beauford,

  35 F.4th at 1262 (quoting Mata v. Saiz, 427 F.3d 745, 751 (10th Cir. 2005)). “The

  substantial harm requirement may be satisfied by lifelong handicap, permanent loss,

  or considerable pain.” Id. (quoting Mata, 427 F.3d at 751). The “substantial harm”

  may be based on “an intermediate injury, such as the pain experienced while waiting

  for treatment and analgesics.” Al-Turki v. Robinson, 762 F.3d 1188, 1193 (10th Cir.

  2014) (citation omitted). Or it may be based on the inmate’s “ultimate harm.” Mata,

  427 F.3d at 754 (explaining that an inmate’s “ultimate harm, heart damage, would

  satisfy the objective component”).

        The plaintiff selects “what harm to claim.” Id. at 753. Sometimes a plaintiff

  “may be better off claiming some intermediate harm rather than the last untoward

  event to befall her.” Id. This is because the plaintiff “may not be able to prove that

  this last event was caused by any government actor or that the actor who caused the

  event acted with the requisite culpable state of mind.” Id.

        The Individual Defendants maintain that Paugh’s alcohol-withdrawal condition

  was not objectively serious enough to satisfy this standard. See Opening Br. at 37

  (“Plaintiff has not shown that alcohol withdrawal is an objectively serious medical

  need.”). But assuming that is correct,16 the Estate also argues that it has met the

  objective component with evidence that the Individual Defendants’ delay in

        16
           We do not decide whether alcohol withdrawal, on its own, is sufficiently
  serious to satisfy the objective component.
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  providing medical care caused Paugh’s death. See Response Br. at 31 (“A delay in

  treatment that causes death is, without a doubt, sufficiently serious to meet the

  objective component of the constitutional analysis.” (internal quotations and citation

  omitted)).

         We agree that the Estate has satisfied the objective component. It has

  presented expert evidence that the Individual Defendants’ failure to obtain medical

  care led to Paugh’s death. See R. vol. 2 at 24 (expert report stating: “If [Paugh] was

  returned to the hospital for life-saving measure[s] as his condition continued to

  worsen, he would have most likely not died”). And we’ve consistently held that death

  qualifies as a “substantial harm” that satisfies the objective component. Prince,

  28 F.4th at 1045 (“It is undisputed that [the prisoner’s] ultimate harm of death was

  sufficiently serious for purposes of the objective component of deliberate

  indifference.”); see also Burke, 935 F.3d at 994 (“An inmate’s death meets [the

  objective component] requirement without a doubt.” (internal quotations and citation

  omitted)); Martinez v. Beggs, 563 F.3d 1082, 1088–89 (10th Cir. 2009) (“We agree

  . . . that ‘the ultimate harm to [the inmate], that is, his heart attack and death, was,

  without doubt, sufficiently serious to meet the objective component’ necessary to

  implicate the Fourteenth Amendment.” (brackets omitted)); Est. of Booker v. Gomez,

  745 F.3d 405, 430–31 (10th Cir. 2014) (recognizing that death is sufficiently serious

  to meet the objective component); Stella v. Anderson, 844 F. App’x 53, 56 (10th Cir.

                                              20
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  2021) (“Thus, the objective component is satisfied if the claim is that the prisoner

  died as a result of the prison official’s conduct.”).17

                     ii.      Subjective Component

         The subjective component “requires the plaintiff to present evidence of the

  prison official’s culpable state of mind.” Mata, 427 F.3d at 751. That is, a plaintiff

  must present a triable issue of fact that a defendant “knows of and disregards an

  excessive risk to inmate health or safety.” Strain v. Regalado, 977 F.3d 984, 990

  (10th Cir. 2020). For this, the plaintiff must establish that a defendant was both

  “aware of facts from which the inference could be drawn that a substantial risk of

  serious harm exist[ed],” and that the defendant actually drew the inference. Id.

         A plaintiff “need not show that a prison official acted or failed to act believing

  that harm actually would befall an inmate.” Farmer, 511 U.S. at 842. Rather, it is

  enough that an official “merely refused to verify underlying facts that he strongly

  suspected to be true, or declined to confirm inferences of risk that he strongly

  suspected to exist.” Id. at 843 n.8. “Whether a prison official had the requisite

         17
            The Individual Defendants argue that the objective component cannot be met
  based on “the ultimate harm.” Opening Br. at 29. As support, they point out that in
  Quintana v. Santa Fe Cnty. Bd. of Comm’rs, 973 F.3d 1022 (10th Cir. 2020), where
  an inmate died, we did not conclude that death satisfied the objective component. See
  id. at 1029. Instead, we assumed, without deciding, that the “severe opioid
  withdrawal [the inmate] experienced does satisfy” the objective component. Id.
  (emphasis in original). But, as explained, the plaintiff selects “what harm to claim.”
  Mata, 427 F.3d at 753. Thus, the plaintiffs in Quintana were free to argue that heroin
  withdrawal, rather than death, satisfied the objective component.
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  knowledge of a substantial risk is a question of fact subject to demonstration in the

  usual ways, including inference from circumstantial evidence.” Id. at 842.

                             1. Obviousness of Paugh’s Medical Needs

        We have explained that a “factfinder may conclude that a prison official knew

  of a substantial risk from the very fact that the risk was obvious.” Quintana, 973 F.3d

  at 1029 (quoting Farmer, 511 U.S. at 842). But this requires “that such risks present

  themselves as ‘obvious’ to the so-called ‘reasonable man.’” Id. (citation omitted).

        In Quintana, we noted that, under our precedent, unconsciousness, “a

  gangrenous hand[,] or a serious laceration” qualify as “obvious” signs of medical

  distress. Id. (citing Garcia v. Salt Lake Ctny., 768 F.2d 303, 308 (10th Cir. 1985) and

  Self, 439 F.3d at 1232). But we explained that “characteristics common to many

  intoxicated individuals do not present an obvious risk.” Id. (cleaned up).

        With that in mind, we held that the symptom of “frequent vomiting alone does

  not present an obvious risk of severe and dangerous withdrawal.” Id. (citing

  Martinez, 563 F.3d at 1091). But a symptom like “bloody vomiting,” we reasoned,

  does present an obvious risk because it would reasonably imply “an actual internal

  injury” and make “the presence of a serious medical need more plausible and more

  obvious.” Id. at 1030.

        Relying on Quintana, the Individual Defendants argue that Paugh did not

  display obvious signs of a medical need, because his symptoms were “common to

  many intoxicated individuals.” Opening Br. at 29 (quoting Quintana, 973 F.3d

  at 1029). And because Paugh lacked obvious symptoms—like bloody vomit—the

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  Individual Defendants maintain that nothing could have alerted them that he was at

  an obvious risk of harm. See id.

         But this argument fails to account for one key fact—Dr. Bradbury’s discharge

  instructions. So we must decide whether Paugh’s observable symptoms—in light of

  those instructions—constituted such an obvious need for medical treatment that a

  reasonable jury could infer deliberate indifference in failing to follow those

  instructions.18

         Our decision in Spark v. Singh, 690 F. App’x 598 (10th Cir. 2017), is

  instructive. There, an inmate sued a physician assistant for failing to diagnose and

  treat his diabetes. Id. at 600. To support his claim, the inmate cited an infirmary note

  “which reported a questionable history of diabetes.” Id. at 606. The inmate argued

  that the physician assistant had been “deliberately indifferent in failing to treat him

  for diabetes despite having reviewed these records.” Id.

         In addressing the inmate’s claim, we considered whether the infirmary note

  “presented an obvious need for treatment.” Id. at 607. We held that the “infirmary

  note’s cursory reference to a questionable history of diabetes was” insufficient to

  “signal a need for treatment so obvious that even a layperson would recognize it.” Id.

         18
           We also note that in Quintana, we held that “frequent vomiting alone does
  not present an obvious risk of severe and dangerous withdrawal.” 973 F.3d at 1029
  (emphasis added). But here, there was more. The district court also found that “Paugh
  either reported or was observed experiencing tremors, paleness . . . , spitting up
  mucus, cold chills and other fever symptoms, loss of appetite, restlessness and
  anxiety, and significant shaking in his hands to the point that it extended through his
  forearms and the shaking could be seen from a distance.” R. vol. 2 at 58.
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  at 608. This was so, we explained, because the infirmary note was neither “a

  confirmed diagnosis requiring treatment,” nor “a clear directive for treatment.” Id.

        Likewise, in Clark v. Colbert, 895 F.3d 1258 (10th Cir. 2018), a plaintiff

  argued that a nurse practitioner had acted with deliberate indifference by failing to

  follow a hospital’s discharge instructions. Id. at 1269. We rejected this argument

  because the discharge instructions had merely directed the plaintiff to follow up with

  the surgeon who had previously operated on him. Id. “The instruction to follow up

  with the surgeon,” we explained, “[did] not amount to a diagnosis of a particular

  condition or a prescription of specific care.” Id. Thus, “the need for additional

  treatment” was not obvious. Id. (citation omitted).

        Here, unlike the instructions in Clark, Dr. Bradbury’s instructions did more

  than direct Paugh to schedule a follow-up appointment. In fact, they diagnosed more

  than one “particular condition”—alcohol withdrawal and alcoholism. Clark, 895 F.3d

  at 1269. Dr. Bradbury’s instructions also “manifest[ed] a clear directive for

  treatment,” Spark, 690 F. App’x at 608, and a “prescription of specific care,” Clark,

  895 F.3d at 1269—give Paugh Librium “as needed” and return him to the hospital if

  his symptoms worsened.19 In other words, Dr. Bradbury’s instructions were

        19
             Indeed, a pamphlet attached to Dr. Bradbury’s instructions even warned the
  Individual Defendants to look out for symptoms that would require “immediate
  medical care,” such as, among other things, a fever, uncontrolled vomiting, agitation,
  or confusion. R. vol. 3 at 193 (capitalization). These are the same symptoms that the
  district court concluded that a reasonable jury could find that Paugh had exhibited.
  See R. vol. 2 at 58, 58 n.17 (finding that Paugh had “vomited multiple times” while at
  the jail, that he was restless and anxious, and that he had “cold chills and other fever
  symptoms”).
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  everything the infirmary note in Spark and the follow-up instructions in Clark were

  not. Thus, Dr. Bradbury’s discharge instructions did indeed “signal a need for

  treatment so obvious that even a layperson would recognize it.” Spark, 690 F. App’x

  at 608.

           In sum, given Dr. Bradbury’s instructions, a reasonable jury could find that it

  would have been “obvious” to any reasonable jail official that Paugh needed medical

  assistance if the Individual Defendants saw Paugh’s condition worsening. See Gibson

  v. Cnty. of Washoe, 290 F.3d 1175, 1188 (9th Cir. 2002) (“[I]f a person is aware of a

  substantial risk of serious harm, a person may be liable for neglecting a prisoner’s

  serious medical needs on the basis of either his action or his inaction.”), overruled on

  other grounds by Castro v. Cnty. of Los Angeles, 833 F.3d 1060, 1076 (9th Cir.

  2016).

                               2. Knowledge of Paugh’s Worsening Condition and
                                  Disregard of Paugh’s Obvious Medical Need

           We now consider two questions. First, we ask whether a reasonable jury could

  find that the Individual Defendants saw Paugh’s condition worsen, signaling his

  obvious need for medical attention based on Dr. Bradbury’s discharge instructions.

  Second, we ask whether a reasonable jury could find that the Individual Defendants

  disregarded Paugh’s obvious medical needs. As we will explain below, the answer to

  both questions is yes.

           But before diving into the specific facts of this case, we review the type of

  evidence needed to show deliberate indifference in the face of a serious medical

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  need. In Mata, for example, an inmate sought medical attention for “severe chest

  pain.” 427 F.3d at 755. Despite the inmate’s pleas for medical attention, a nurse

  refused to administer first aid or summon medical assistance. Id. We held that the

  nurse had failed to fulfill her gatekeeping duties when she “completely refused to

  assess or diagnose [the inmate’s] medical condition at all.” Id. at 758.

        Likewise, in Burke, an inmate claimed to be paralyzed. 935 F.3d at 982. We

  held that a reasonable jury could find that two jail officials “were deliberately

  indifferent to the serious risk that [the inmate] was suffering from a medical issue

  that demanded attention.” Id. at 994. This was so, we explained, because the jail

  officials “made no attempt to determine the severity of [the inmate’s] medical need

  or the safety risk he might have posed,” and had “abdicated their gatekeeping roles

  by failing to relay the problem to medical staff.” Id.

        And in Quintana, an inmate died due to complications from heroin withdrawal.

  973 F.3d at 1027. His estate sued, and we held that the estate had adequately alleged

  a constitutional violation against one of the jail officials who “did not attempt to

  provide any . . . medical assistance” to the inmate. Id. We reasoned that because the

  inmate had told the jail official that he was “withdrawing from heroin and was

  throwing up blood,” the jail official’s inaction in the face of this “serious medical

  need” amounted to deliberate indifference. Id. at 1030 (internal quotations omitted).

        In contrast, we have affirmed the grant of qualified immunity to jail officials

  who had no reason to suspect that an inmate was in serious need of medical attention.

  In Boyett v. Cnty. of Washington, 282 F. App’x 667 (10th Cir. 2008), for example, an

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  inmate’s estate argued that jail officials had been deliberately indifferent by failing to

  prevent the inmate’s death. Id. at 678. We rejected this claim because the inmate had

  died of a coronary artery disease, and there was no evidence of “the disease on [the

  inmate’s] medical history paperwork, nor had he shown any symptoms of the disease

  before he died.” Id. Thus, we held that there was “no reason to believe any prison

  official should have been aware of this medical risk.” Id.; see also Garretson v. City

  of Madison Heights, 407 F.3d 789, 797–98 (6th Cir. 2005) (affirming grant of

  qualified immunity to jail officials who “had no prior notice of [an inmate’s] insulin

  dependence or of her deteriorating condition” but reversing grant of qualified

  immunity to jail officials who had known that the inmate “required insulin for her

  condition and that she was past due for her current dose”).

        In short, these cases illustrate that when a jail official knows, or “refuse[s] to

  verify underlying facts that he strongly suspected to be true, or decline[s] to confirm

  inferences of risk that he strongly suspected to exist” about an inmate’s serious

  medical need, the official’s failure to obtain medical assistance constitutes deliberate

  indifference. Farmer, 511 U.S. at 843 n.8; see Burke, 935 F.3d at 993 (“We have

  found deliberate indifference when jail officials confronted with serious symptoms

  took no action to treat them.”); see also Jones v. Minn. Dep’t of Corr., 512 F.3d 478,

  482 (8th Cir. 2008) (“If prison officials have actual knowledge of a serious medical

  need, and fail to take reasonable measures to address it, they may [be] held liable for

  deliberate indifference.”). We turn now to the specific facts of this case.

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                                    a. Anderson

        The district court found that the Estate had submitted sufficient evidence to

  allow a reasonable jury to conclude that Anderson had violated Paugh’s

  constitutional rights. R. vol. 2 at 66 (“[A] reasonable jury could find that Anderson

  ‘completely refused to assess or diagnose [Paugh’s] medical condition at all by’

  ignoring his serious medical problems[.]” (quoting Mata, 427 F.3d at 758)).

        We agree. First, a jury could find that Anderson had seen Paugh’s condition

  worsen. When Paugh first arrived at the jail, Anderson attested that he seemed “just

  fine.” R. vol. 3 at 85. Yet at her next shift, she learned about Paugh’s alcohol-

  withdrawal symptoms from Gowen, including that he had vomited “throughout the

  day,” that he was “feeling sick and nauseous,” and that he seemed “really sick from

  detoxing.” R. vol. 2 at 15–16 (citation omitted). A regression from “just fine” to

  exhibiting these symptoms qualifies as worsening of Paugh’s condition.

        Anderson also personally observed Paugh’s symptoms throughout the

  remainder of her shift. Between 7:00 and 8:00 p.m., Anderson saw Paugh shaking.

  Then, at 9:45 p.m., in addition to his shaking, Paugh told Anderson that he “was

  nauseous,” was feeling sick, and “had cold chills.” Id. at 66 (citation omitted). At

  minimum, these added symptoms—which Anderson had not previously seen—raise a

  triable issue of material fact about whether Anderson knew Paugh’s condition was

  worsening.

        Second, based on the worsening of Paugh’s condition, a reasonable jury could

  find that Paugh’s need for medical assistance was obvious. In Boyett, we held that

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  there was no evidence that the jail officials had acted with deliberate indifference in

  failing to prevent an inmate’s death. 282 F. App’x at 678. This was because the jail

  officials had been unaware that the inmate was suffering from coronary disease, there

  was no mention of the disease in his “medical history paperwork,” and the inmate

  displayed no “symptoms of the disease before he died.” Id. But here, Anderson knew

  about Paugh’s alcohol-withdrawal condition, Paugh’s file stated that he was suffering

  from alcohol withdrawal, and he displayed symptoms consistent with that condition.

        And given Dr. Bradbury’s discharge instructions, Paugh’s need for medical

  assistance was arguably more obvious than in Quintana. Recall, in Quintana, the

  obviousness of the inmate’s need for medical attention stemmed from a particular

  symptom—the presence of blood in his vomit, which would have likely signaled “an

  actual internal injury.” 973 F.3d at 1030. But here, the need for medical assistance

  was apparent from the face of Dr. Bradbury’s discharge instructions, which even

  warned Anderson of the symptoms to look for. And Paugh exhibited many of those

  symptoms, including agitation, fever-like symptoms, and anxiety. See R. vol. 2 at 58

  (finding that “Paugh either reported or was observed experiencing . . . cold chills and

  other fever symptoms, loss of appetite, restlessness and anxiety”); see also Williams

  v. City of Yazoo, 41 F.4th 416, 424 (5th Cir. 2022) (explaining that a plaintiff’s

  deliberate-indifference claim was “not a close case” given the inmate’s “diagnosis,

  symptoms, and requests for help”).

        Finally, a reasonable jury could find that Anderson abdicated her gatekeeping

  duties by failing to obtain medical assistance for Paugh. Anderson understood that if

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  Paugh exhibited “red flags” of alcohol withdrawal, meaning that if his “condition

  worsened . . . in any way,” she would have to return him to the hospital. R. vol. 2

  at 11 (emphasis added) (citation omitted). Thus, based on Paugh’s worsening

  condition and Dr. Bradbury’s discharge instructions, Anderson should have—at a

  minimum—contacted a medical professional about Paugh’s condition. Yet her

  inaction mirrors that of the jail officials in Burke who “made no attempt to determine

  the severity of [an inmate’s] medical need.” 935 F.3d at 994. As a result, Anderson,

  like those jail officials, “abdicated [her] gatekeeping role[] by failing to relay the

  problem to medical staff.” Id.

         In sum, we agree with the district court that a reasonable jury could find that

  Anderson: (1) was aware that Paugh was “in obvious need for medical attention,” and

  (2) abdicated her gatekeeping role by not “relay[ing] the problem to medical staff.”

  Id. at 995. So we agree with the district court that Anderson is not entitled to

  qualified immunity.

                                     b. Bunnell

         The district court ruled that the Estate had raised a triable issue of material fact

  that Bunnell knew of and disregarded a significant risk to Paugh’s health. R. vol. 2

  at 71 (“[A] reasonable jury could find that Bunnell’s conduct amounts to deliberate

  indifference because he was ‘confronted with serious symptoms’ . . . but ‘took no

  action to treat them.’”) (quoting Burke, 935 F.3d at 993)). We agree.

         Like Anderson, a reasonable jury could find that Bunnell saw Paugh’s

  condition worsen. For example, when Paugh first arrived at the jail on July 24, 2015,

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  Bunnell said that “[h]e was walking, talking,” and “[d]idn’t seem unsteady on his

  feet.” R. vol. 3 at 135. But an hour into his next shift on July 25, 2015, Bunnell saw

  Paugh shaking, looking “pale,” and seeming unwell. R. vol. 2 at 68 (citation

  omitted). In fact, Paugh confirmed to Bunnell that “he was feeling sick from

  withdrawal.” Id. Then, around 9:45 or 10:00 p.m., Paugh told Bunnell “he was

  getting the chills then hot again”—symptoms that Bunnell had not previously

  observed in Paugh. Id. at 69 (citation omitted). The Estate has thus raised a triable

  issue of fact that Bunnell had seen Paugh’s condition worsen.

        Based on Paugh’s worsening condition and Dr. Bradbury’s discharge

  instructions,20 a jury could reasonably infer that Paugh was in obvious need of

  medical attention. Cf. Boyett, 282 F. App’x at 678 (rejecting deliberate-indifference

  claim because there was “no reason to believe any prison official should have been

  aware of this medical risk”). Despite that obvious need, Bunnell did not return Paugh

  to the hospital, declined to monitor Paugh during his shift, and failed to even contact

  a medical professional about Paugh’s worsening condition. Indeed, Bunnell candidly

  admitted to disregarding Paugh’s health risk, stating: “of all the thousands of drunks

  that we deal with, they all have hangovers and they all get better.” R. vol. 2 at 70

  (citation omitted). In short, as the district court aptly put it, when “confronted with

        20
          The district court found that Bunnell understood “from the discharge
  paperwork that Paugh must be transported to the hospital if he experienced any
  worsening of his condition.” R. vol. 2 at 70 (cleaned up).
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  serious symptoms,” Bunnell “took no action to treat them.” See Burke, 935 F.3d

  at 993.

        Thus, the Estate has raised a triable issue of material fact that Bunnell acted

  with deliberate indifference towards Paugh’s serious medical needs. So the district

  court properly denied Bunnell qualified immunity.21

                                   c. Conley

        The district court also held that a reasonable jury could find that Conley was

  deliberately indifferent to Paugh’s serious medical needs. R. vol. 2 at 73 (“[A]

  reasonable jury could find that Conley was deliberately indifferent[.]”). Once again,

  we agree.

        Though Conley interacted with Paugh at different times than Anderson and

  Bunnell, there is still sufficient evidence that Conley observed Paugh’s deteriorating

  condition. On July 24, 2015, at 6:30 a.m., when Conley first saw Paugh, he thought

  Paugh “seemed well and normal.” Id. at 71 (citation omitted). But at 11:30 a.m.,

  Conley saw Paugh “run back” to his cell to vomit while answering the jail’s booking

  and screening questions. Id. Then by 5:30 p.m., Conley noticed that Paugh was

  “shaking pretty bad.” Id. at 72 (citation omitted). Indeed, at that time, Paugh even

  told Conley that his withdrawal “had not peaked yet,” indicating that his symptoms

        21
           The district court found “a fact dispute concerning whether Bunnell gave
  Paugh Librium.” R. vol. 2 at 70. We thus accept as true that Paugh did not receive
  any Librium from Bunnell. See Lewis, 604 F.3d at 1225 (explaining that on
  interlocutory appeal “if a district court concludes that a reasonable jury could find
  certain specified facts in favor of the plaintiff, the Supreme Court has indicated we
  usually must take them as true”).
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  would get worse. Id. (brackets and citation omitted). On these facts, the Estate has

  raised a material dispute about whether Conley had seen Paugh’s condition worsen

  from morning to night.

         Because Conley understood Dr. Bradbury’s discharge instructions22 and

  observed Paugh’s worsening condition, a reasonable jury could also conclude that

  Paugh’s need for medical attention was obvious. Cf. Boyett, 282 F. App’x at 678

  (rejecting deliberate-indifference claim because there was “no reason to believe any

  prison official should have been aware of this medical risk”). Yet Conley’s “absolute

  failure to . . . attempt to assist [Paugh] in any fashion” in the face of this obvious

  need, evinces Conley’s deliberate indifference. See Mata, 427 F.3d at 758. Indeed,

  Conley’s refusal to obtain medical assistance for Paugh despite seeing his withdrawal

  symptoms is similar to the jail official in Quintana who “did not attempt to provide

  any . . . medical assistance,” 973 F.3d at 1027, to the inmate he knew was

  withdrawing from heroin and was throwing up blood, id. at 1030.

         The district court also found that Conley’s failure to follow jail protocol and

  contact a medical professional following Paugh’s affirmative answers to the

  screening questionnaire was further evidence of deliberate indifference. R. vol. 2

  at 73 (“[A] reasonable jury could find that Conley was deliberately indifferent

  because of his ‘absolute failure’ to . . . [obtain] medical follow up on Paugh’s

         22
           The district court found that Conley understood from Dr. Bradbury’s
  instructions that Paugh “should come back to the hospital” if his condition worsened.
  R. vol. 2 at 72 (citation omitted).
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  affirmative answers to the screening questionnaire.” (quoting Mata, 427 F.3d

  at 758)).

         We agree. We acknowledge that “[f]ailing to comply with jail policy does not

  amount to a constitutional violation on its own.” George v. Beaver Cnty., 32 F.4th

  1246, 1254 (10th Cir. 2022). But, at the same time, it “certainly provide[s]

  circumstantial evidence that a . . . gatekeeper knew of a substantial risk of serious

  harm.” Prince, 28 F.4th at 1046 (citation omitted).

         In Phillips v. Roane Cnty., 534 F.3d 531 (6th Cir. 2008), for example, the

  Sixth Circuit held that a genuine issue of fact existed as to whether a jail’s

  correctional officers had acted with deliberate indifference in failing to render care to

  an inmate. Id. at 541. In coming to this conclusion, the Sixth Circuit found

  “persuasive” the officers’ “disregard of prison protocols,” which required the officers

  to transport the inmate to a hospital for diagnosis when she complained of chest

  pains. Id. The correctional officers’ failure to do so despite the inmate’s complaint of

  chest pains, the Sixth Circuit explained, was sufficient “to demonstrate the subjective

  component of deliberate indifference.” Id.; see also Mata, 427 F.3d 757 (recognizing

  that violations of internal prison procedures “certainly provide circumstantial

  evidence that a prison health care gatekeeper knew of a substantial risk of serious

  harm”).

         Here, in response to the booking and screening questions, Paugh told Conley

  that he was “currently going through withdrawals,” that he was in “lots of pain from

  three broken ribs,” that he had medical problems related to seizures, that he was

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  feeling “restlessness/anxiety,” and that he suffered from alcoholism. R. vol. 2 at 13.

  Jail policy required Conley to call a medical professional if an inmate answered

  affirmatively to any of these questions. Yet Conley failed to contact anyone.

  Conley’s failure is especially egregious in light of his knowledge of Paugh’s

  condition and Dr. Bradbury’s discharge instructions. So like the correctional officers’

  failure to follow protocol and transport the inmate to a hospital in Phillips, Conley’s

  failure to follow jail policy and contact medical professionals based on Paugh’s

  affirmative answers to screening questions is “persuasive” evidence of deliberate

  indifference. 534 F.3d at 541.

        Finally, the district court concluded that a reasonable jury could infer

  deliberate indifference from Conley’s failure to give Paugh his Librium. Recall,

  Fuller had instructed Conley to give Paugh his Librium when Fuller had to attend to

  another inmate. Despite this instruction, it’s undisputed that “Conley never gave

  Paugh his Librium during this shift.” R. vol. 2 at 72.

        “Failure to act in accordance with or intentional interference with prescribed

  medical treatment or instructions can give rise to an Eighth Amendment claim.” Ajaj

  v. United States, 293 F. App’x 575, 579 (10th Cir. 2008) (emphasis in original); see

  also Johnson v. Schwarzenegger, 366 F. App’x 767, 770 (9th Cir. 2010) (“Failure to

  provide medication to prevent a life-threatening condition may amount to deliberate

  indifference to a serious medical need.”). Thus, we agree with the district court that,

  on these facts, Conley’s failure to give Paugh his Librium—when he knew about

  Paugh’s need for it—raises a triable issue of fact about Conley’s deliberate

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  indifference. See Wakefield v. Thompson, 177 F.3d 1160, 1165 (9th Cir. 1999)

  (“[A]llegations that a prison official has ignored the instructions of a prisoner’s

  treating physician are sufficient to state a claim for deliberate indifference.”).

         In sum, we agree with the district court that “a reasonable jury could find that

  Conley was deliberately indifferent because of his ‘absolute failure’ to (a) ‘follow the

  required protocols’ concerning . . . medical follow up[s] on Paugh’s affirmative

  answers to the screening questionnaire; (b) ‘contact the appropriate medical

  personnel’ when he observed Paugh’s condition worsening from morning to night; or

  (c) ‘attempt to assist [Paugh] in any fashion’ during his shift.” R. vol. 2 at 73

  (quoting Mata, 427 F.3d at 758). Thus, the district court properly denied qualified

  immunity to Conley.

                                     d. Gowen

         Next, the district court held that a reasonable jury could also “find that Gowen

  had acted with deliberate indifference.” Id. at 79. Once again, we agree.

         Like the other Individual Defendants, there is evidence that Gowen saw

  Paugh’s condition worsen during his shift. For example, on July 24, 2015, by 12:00

  p.m., Gowen had already heard Paugh “retch[]” “two or three times” in the span of

  “two or three hours.” Id. at 78 (citation omitted). And when speaking to Paugh,

  Gowen could see that Paugh’s “hands and . . . forearms were shaking.” Id.

         Then around 4:00 p.m., when serving dinner, in addition to seeing Paugh

  “visibly shaking,” Paugh told Gowen that he was “feeling sick and nauseous” and

  that “he had not hit his peak yet” for his alcohol-withdrawal symptoms. Id. (citation

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  omitted). Indeed, Gowen even admitted that Paugh seemed “really sick from detoxing

  while at . . . the jail,” such that he felt the need to “instruct[] Anderson to monitor

  Paugh’s symptoms.” Id. (citation omitted). A jury could reasonably view Paugh’s

  condition as worsening, making Paugh’s need for medical attention obvious under

  Dr. Bradbury’s discharge instructions.23

         Gowen’s failure to obtain any medical assistance in the face of Paugh’s

  obvious need raises a material dispute about Gowen’s deliberate indifference. See

  Mata, 427 F.3d at 758 (holding that a nurse had failed to fulfill her gatekeeping

  duties when she “completely refused to assess or diagnose [the inmate’s] medical

  condition at all”); Burke 935 F.3d at 994 (concluding that two jail officials were

  deliberately indifferent because they had “abdicated their gatekeeping roles by failing

  to relay the problem to medical staff”); Quintana, 973 F.3d at 1027, 1030 (holding

  that a jail official who “did not attempt to provide any . . . medical assistance” to an

  inmate’s obvious medical needs amounted to a constitutional violation).

         We also note that Gowen was sitting near Conley when Paugh was answering

  his booking and screening questions. Thus, drawing inferences for the Estate, the

  district court found that Gowen “knew of Paugh’s affirmative answers to the medical

  screening questionnaire.” R. vol. 2 at 77–78. So like Conley, Gowen’s failure to

  follow jail protocol and contact a medical professional following Paugh’s affirmative

         23
           Gowen had “affirmed that he understood Dr. Bradbury’s discharge
  instructions to mean that Paugh needed to return to the hospital if there was
  ‘worsening of his condition.’” R. vol. 2 at 78 (citation omitted).
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  answers is further evidence of his deliberate indifference. See Prince, 28 F.4th

  at 1046 (noting that “violations of internal prison procedures ‘certainly provide

  circumstantial evidence that a prison health care gatekeeper knew of a substantial risk

  of serious harm’” (citation omitted)).

        In sum, the Estate has raised triable issues of material fact about Gowen’s

  deliberate indifference based on his failure to obtain medical assistance for Paugh. As

  a result, the court properly found that Gowen is not entitled to qualified immunity.

                                    e. Fuller

        The district court also ruled that a reasonable jury could find that Fuller was

  deliberately indifferent to Paugh’s serious medical needs. But unlike the other

  Individual Defendants, the court did not base its ruling on Fuller’s observations of

  Paugh’s worsening condition and Dr. Bradbury’s discharge instructions.24 Instead,

  the district court focused its analysis on Fuller’s failure to accurately report Paugh’s

  symptoms to PA Clark. See R. vol. 2 at 76 (“[A] reasonable jury could conclude that

  Fuller’s failure to fully or accurately inform [PA] Clark of Paugh’s condition and

  about his prescription was deliberately indifferent.”).

        24
           This may be because the record suggests that Fuller did not review Dr.
  Bradbury’s discharge instruction to return Paugh to the hospital if his condition
  worsened. See R. vol 3 at 176 (Fuller uncertainly stating that he doesn’t “believe [he]
  ever read through the discharge instructions”). But we do not review this factual
  dispute because we lack jurisdiction to do so. See Crowson, 983 F.3d at 1177
  (“Generally, we lack jurisdiction to review factual disputes in this interlocutory
  posture.”). Instead, we focus only on whether the district court’s analysis of Fuller’s
  actions amounts to a constitutional violation.
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         We agree that Fuller’s failure to accurately convey Paugh’s symptoms to PA

  Clark may be evidence of deliberate indifference. The Sixth Circuit’s decision in

  Winkler v. Madison Cnty., 893 F.3d 877 (6th Cir. 2018) is instructive here. There,

  after an inmate died while being held in jail, his estate’s representative sued the jail

  and its officials. Id. at 885. The plaintiff alleged that one of the jail officials had been

  deliberately indifferent by allegedly withholding information from the jail’s doctor

  during a call about the inmate. Id. at 895.

         The Sixth Circuit found no constitutional violation, highlighting that there was

  nothing “in the record to support a finding that [the jail official] withheld information

  from [the jail’s doctor].” Id. at 896. Instead, the Sixth Circuit determined that the jail

  official “responded immediately to [the inmate’s] complaints and took reasonable

  action” by “promptly” calling the jail’s doctor and reporting “what he knew about

  [the inmate’s] symptoms.” Id. at 895. This included telling the doctor that the inmate

  “was ‘sick to his stomach,’ ‘could not keep anything down,’ and was ‘dope sick.’” Id.

         The actions of Winkler’s jail official stand in stark contrast to those of Fuller’s.

  Unlike in Winkler, in which there was no evidence that the jail official withheld

  information from the jail’s doctor, there is evidence here that Fuller did exactly that

  when speaking with PA Clark. For example, PA Clark asked Fuller if he had seen

  Paugh exhibiting any withdrawal symptoms, including “any shaking, any issues like

  that.” R. vol. 2 at 75 (citation omitted). Despite knowing that Paugh had been

  shaking, nauseous, and “throwing up only a few hours earlier,” Fuller told PA Clark

  that Paugh was “walking around good,” had been eating, and had not “been throwing

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  up.” R. vol. 2 at 75 (citation omitted). The jail official in Winkler, on the other hand,

  reported “what he knew about [the inmate’s] symptoms,” including that the inmate

  “was ‘sick to his stomach,’ ‘could not keep anything down,’ and was ‘dope sick.’”

  893 F.3d at 895. In short, a reasonable jury could find that Fuller failed to fulfill his

  gatekeeping role by not “communicating [Paugh’s] symptoms to a higher-up.”25

  Burke, 935 F.3d at 993.

         Thus, we agree with the district court that Fuller is not entitled to qualified

  immunity.

                    iii.      Individual Defendants’ Counterarguments

         Still, the Individual Defendants argue that they could not have been

  deliberately indifferent for two reasons. First, they contend that Paugh exhibited only

  “mild” symptoms of withdrawal, so they were not indifferent to his serious medical

  needs. Second, the Individual Defendants insist that because they provided Paugh

  with some help, they could not have been deliberately indifferent under Strain. We

  address each argument in turn.

                              1. Paugh’s “Mild” Symptoms

         Relying on the informational pamphlet attached to Dr. Bradbury’s discharge

  instructions, the Individual Defendants argue that Paugh was suffering only “mild”

         25
            In addition, the district court found a material dispute “concerning whether
  Fuller gave Paugh Librium.” R. vol. 2 at 77. We thus assume that Fuller did not give
  Paugh any Librium. See Lewis, 604 F.3d at 1225 (explaining that on interlocutory
  appeal “if a district court concludes that a reasonable jury could find certain specified
  facts in favor of the plaintiff, the Supreme Court has indicated we usually must take
  them as true”).
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  withdrawal symptoms. See Opening Br. at 30. The pamphlet describes “mild”

  symptoms as “tremors in the hands”; “stomach upset”; “increases in heart rate,

  breathing, and temperature”; and “anxiety, panic attacks, and bad dreams.” R. vol. 3

  at 193. As the Individual Defendants see it, “Paugh only had occasional vomiting

  (upset stomach) and some hand tremors.” Opening Br. at 30. Thus, according to the

  Individual Defendants, because this pamphlet defined Paugh’s symptoms as only

  mild, they could not have been indifferent to his serious medical needs. See id. at 43.

        We disagree. First, the Individual Defendants misconstrue the evidence. Paugh

  did not “only” experience an upset stomach and hand tremors. Opening Br. at 30.

  Paugh had many other symptoms such as vomiting multiple times, uncontrollable

  shaking, anxiety, restlessness, and “cold chills and other fever symptoms.” See

  R. vol. 2 at 58. Second, if anything, the informational pamphlet on which the

  Individual Defendants rely cuts against them. That pamphlet states that individuals

  should seek “immediate medical care if” they experience symptoms such as a fever,

  uncontrolled vomiting, uncontrolled anxiety, or agitation and confusion—symptoms

  that Paugh was arguably exhibiting. R. vol. 3 at 193 (capitalization removed).

        In any event, the informational pamphlet was merely a document attached to

  Dr. Bradbury’s discharge instructions. And though this document lists at least one of

  Paugh’s symptoms—hand tremors—as a potentially “mild” indicator of withdrawal,

  id. at 193, this does not negate Dr. Bradbury’s actual instruction—to return Paugh to

  the hospital if there was “worsening of [Paugh’s] condition,” id. at 190. Dr.

  Bradbury’s instructions should have alerted the Individual Defendants to get Paugh

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  medical attention as soon as Paugh started turning for the worse—even if the start of

  his deteriorating condition began with a symptom that could be described as “mild”

  in less serious situations.

                                 2. Strain Does Not Support the Individual Defendants

         Next, the Individual Defendants argue that our decision in Strain bars a finding

  of deliberate indifference. Opening Br. at 32–33. In that case, an inmate “exhibited

  alcohol withdrawal symptoms while in county jail.” Strain, 977 F.3d at 987. Though

  the jail’s “[h]ealthcare providers diagnosed and treated [the inmate’s] symptoms,” the

  “treatment proved ineffective” and the inmate was left permanently disabled. Id.

  at 987–88.

         The inmate’s estate sued the jail and the medical professionals who had treated

  the inmate, alleging that they had been deliberately indifferent to his serious medical

  needs. Id. at 988. We held that the medical professionals were entitled to qualified

  immunity. Id. at 997. Likening this case to Strain, the Individual Defendants argue

  that they should also be entitled to qualified immunity because they “took similar

  actions to what the Strain defendants did.” Opening Br. at 40. This argument fails for

  two reasons.

         First, the defendants in Strain were all medical professionals, not lay officials

  like here. See 977 F.3d at 988 (describing the individual defendants as a nurse, a

  licensed professional counselor, and a doctor). And, as stated above, “[w]e

  distinguish a medical professional’s negligent failure to treat a serious medical

  condition properly, which does not constitute deliberate indifference, from ‘prison

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  officials who prevent an inmate from receiving treatment or deny him access to

  medical personnel capable of evaluating the need for treatment,’ which may

  constitute deliberate indifference.” Burke, 935 F.3d at 992 (brackets omitted)

  (quoting Sealock, 218 F.3d at 1211). Indeed, that is why Strain’s deliberate-

  indifference analysis focused on whether the defendants’ treatment of the inmate

  amounted to more than negligence, and not whether they delayed or refused to obtain

  medical assistance for the inmate. See 977 F.3d at 996–97 (“Although Plaintiff’s

  claims may smack of negligence, we conclude that they fail to rise to the high level

  of deliberate indifference against any Defendant.”). Thus, Strain is inapposite.

        Second, even if we disregarded that fact, the care that the Individual

  Defendants allegedly offered to Paugh—“monitoring Paugh and giving him

  medication”—falls far short of what was provided in Strain. Opening Br. at 40.

  There, we held that the inmate’s estate had not plausibly alleged deliberate

  indifference because the medical professionals tried to treat the inmate by “providing

  several physical and mental health assessments [], plac[ing] him on two forms of

  medication, and [keeping] him under routine observation.” 977 F.3d at 995.

        The Individual Defendants did none of those things for Paugh. At no point did

  they perform any physical assessment on Paugh. Nor did they keep him “under

  routine observation.” Id. Indeed, the district court found that the Individual

  Defendants repeatedly failed to observe or monitor Paugh.26 Finally, though the

        26
          See R. vol. 2 at 66 (pointing out that Anderson “failed to check on Paugh
  from about 9:45 p.m. to when she ended her shift at 6:00 a.m.”); id. at 69 (“Bunnell
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  Individual Defendants maintain that they gave Paugh Librium, even this material fact

  is in dispute, given that no Librium was found in his blood. As a result, Strain is

  inapplicable.

        At bottom, a reasonable jury could find that the Individual Defendants knew,

  based on Dr. Bradbury’s discharge instructions, that Paugh was at a serious risk of

  harm when they saw his condition worsen. And a reasonable jury could also find that

  the Individual Defendants disregarded that risk by failing to return Paugh to the

  hospital, as those instructions mandated, or at the very least contact a medical

  professional. The Estate has therefore raised a triable issue of material fact that the

  Individual Defendants violated Paugh’s constitutional rights, satisfying the first

  prong of the qualified-immunity analysis.

                  b.   Clearly Established Law

        Next, we must decide whether Paugh’s rights were clearly established at the

  time of the alleged constitutional violation. The law is clearly established when there

  is an “on point” Supreme Court or Tenth Circuit decision, “or the clearly established

  weight of authority from other courts have found the law to be as the plaintiff

  maintains.” Crowson, 983 F.3d at 1178 (quoting Halley v. Huckaby, 902 F.3d 1136,

  1149 (10th Cir. 2018)). We must be careful not to define clearly established law “at a

  again did not check on Paugh during the rest of his shift[.]”); id. at 72 (“Conley did
  not check on Paugh from when he finished the screening questionnaire to around
  5:30 p.m.” (brackets omitted)); id. at 76 (“Fuller did not check on Paugh in his cell
  from when he provided Paugh medication around 1:30 p.m. until the end of his
  shift.”); id. at 78 (“But Gowen did not speak to or monitor Paugh for the rest of his
  shift.”).
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  high level of generality.” Mullenix, 577 U.S. at 12 (quoting Ashcroft v. al-Kidd, 563

  U.S. 731, 742 (2011)). Instead, the “rule’s contours must be so well defined that it is

  ‘clear to a reasonable officer that his conduct was unlawful in the situation he

  confronted.’” City of Tahlequah v. Bond, 142 S. Ct. 9, 11 (2021) (quoting District of

  Columbia v. Wesby, 138 S. Ct. 577, 590 (2018)).

        At the same time, this inquiry does not require a “scavenger hunt for prior

  cases with precisely the same facts.” Est. of Smart v. City of Wichita, 951 F.3d 1161,

  1168 (10th Cir. 2020) (quoting Casey v. City of Federal Heights, 509 F.3d 1278,

  1284 (10th Cir. 2007)). Indeed, “a prior case need not be exactly parallel to the

  conduct here for the officials to have been on notice of clearly established law.” Id.

  (quoting Halley, 902 F.3d at 1149). The key question is whether the defendants had

  “fair warning” that their conduct was unconstitutional. Id. (quoting Tolan v. Cotton,

  572 U.S. 650, 656 (2014)).

                     i.      The Law is Clearly Established

        The district court held that the law was clearly established. Relying on our

  prior decisions in Sealock, Mata, and Al-Turki, the court ruled that “it is clearly

  established that the actions of prison officials who prevent an inmate from receiving

  treatment or deny him access to medical personnel capable of evaluating the need for

  treatment, constitute deliberate indifference.” 27 R. vol. 2 at 55–56 (cleaned up).

        27
            The district court also stated, in a footnote, that “other courts of appeals
  have also established that jailers who act with deliberate indifference to the health
  risks for an inmate undergoing alcohol withdrawal have violated the inmate’s
  constitutional rights.” R. vol. 2 at 56 n.16 (citing Harper v. Lawrence Cnty., 592 F.3d
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        We agree. “[T]here is little doubt that deliberate indifference to an inmate’s

  serious medical need is a clearly established constitutional right.” Mata, 427 F.3d

  at 749. And more specifically, we have said that it is “clearly established that when a

  detainee has obvious and serious medical needs, ignoring those needs necessarily

  violates the detainee’s constitutional rights.” Quintana, 973 F.3d at 1033.

        Other circuits have held the same. See Williams, 41 F.4th at 426 (“Officers and

  jailers have long had notice that they cannot ignore a detainee’s serious medical

  needs.”); Orlowski v. Milwaukee Cnty., 872 F.3d 417, 422 (7th Cir. 2017) (explaining

  that when “presented [with] obvious symptoms of a serious medical condition . . . ,

  any reasonable officer would know he had a duty to seek medical attention,” so if the

  officers “chose to do nothing despite this duty, they violated ‘clearly established’

  Eight[h] Amendment law”); Schaub v. VonWald, 638 F.3d 905, 918 n.6 (8th Cir.

  2011) (“This court holds that when personally confronted with the serious medical

  needs of a prisoner, prison officials cannot be deliberately indifferent to those needs

  by inaction, a well-established proposition.”); Phillips, 534 F.3d at 545 (“[W]here the

  circumstances are clearly sufficient to indicate the need of medical attention for

  injury or illness, the denial of such aid constitutes the deprivation of constitutional

  due process.” (citation omitted)).

  1227 (11th Cir. 2010) and Stefan v. Olson, 497 F. App’x 568 (6th Cir. 2012)). We
  need not consider whether these cases are sufficient to support clearly established law
  because, as we explain below, caselaw from our circuit gave the Individual
  Defendants “fair warning” that their actions were unconstitutional. Estate of Smart,
  951 F.3d at 1168 (citation omitted).
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        “We are mindful that we must not define clearly established law ‘at too high a

  level of generality,’ but we have seen cases like this before.” Williams, 41 F.4th

  at 426 (internal citation omitted). For example, in Sealock, a case from 2000, we held

  that, for purposes of summary judgment, a prison official’s refusal to obtain medical

  assistance for a prisoner who complained that he was having a heart attack and

  “displayed symptoms consistent with a heart attack” constituted deliberate

  indifference. 218 F.3d at 1210–11.

        Likewise, in Mata, a 2005 ruling, we reversed a grant of summary judgment to

  a nurse because the plaintiff had raised an issue of material fact as to the nurse’s

  deliberate indifference. 427 F.3d at 758. We explained that the nurse had refused to

  fulfill “her gatekeeping role in a potential . . . emergency by not seeking a medical

  evaluation” for an inmate, even though the inmate “was suffering from severe chest

  pains and required medical attention.” Id. at 756. We reasoned that the nurse’s

  “absolute failure” “to follow the required protocols, contact the appropriate medical

  personnel, and/or attempt to assist [the inmate] in any fashion” demonstrated

  deliberate indifference. Id. at 758.

        Then, in Al-Turki, a 2014 case, we affirmed the denial of qualified immunity

  to a prison nurse who refused to provide medical attention to an inmate complaining

  of severe abdominal pain. 762 F.3d at 1195. The plaintiff was “a diabetic inmate who

  had collapsed onto the floor, repeatedly vomited, and complained to different

  correctional officers of severe abdominal pain.” Id. at 1194. We held that “severe

  abdominal pain, particularly in someone with diabetes, may be a sign of any number

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  of serious, life-threatening conditions.” Id. Thus, the nurse’s decision to ignore the

  request for medical assistance amounted to a constitutional violation. Id. at 1195.

        Finally, in Quintana,28 we reversed the grant of qualified immunity to a jail

  official who failed to provide any medical assistance to an inmate who was suffering

  from heroin withdrawal and throwing up blood. 973 F.3d at 1035. We did so even

  though the inmate “did not request any further treatment,” id. at 1027, because the

  plaintiff had sufficiently alleged that the jail official had “consciously disregard[ed]

  [the inmate’s] obvious symptoms,” id. at 1033.

        These cases are sufficiently analogous to the facts here to have placed the

  Individual Defendants on notice that disregarding Paugh’s obvious and serious

  medical needs amounted to a constitutional violation. As noted in Prince, “[e]ach

  case involved the denial of medical attention to an individual in custody” who

  displayed a serious medical need. 28 F.4th at 1048. In addition, Al-Turki and

  Quintana involved a plaintiff with “pre-existing medical conditions,” like Paugh. Id.

  And most similar to Paugh’s situation, Quintana involved an inmate exhibiting

        28
            “This court has recognized that a case decided after the incident underlying
  a § 1983 action can state clearly established law when that case ruled that the
  relevant law was clearly established as of an earlier date preceding the events in the
  later § 1983 action.” Wilkins v. City of Tulsa, 33 F.4th 1265, 1276 n.8 (10th Cir.
  2022) (quoting Soza v. Demsich, 13 F.4th 1094, 1100 n.3 (10th Cir. 2021)). So even
  though Quintana was decided in 2020—after the July 2015 events of this case—it
  “recognized the law [to be] clearly established before that date,” id., because it relied
  on Mata and Sealock, which were decided before July 2015, 973 F.3d at 1033. See
  also Prince, 28 F.4th at 1047–48 n.10 (relying on McCowan v. Morales, 945 F.3d
  1276 (10th Cir. 2019)—a case decided in 2019—as clearly established law for events
  that transpired in 2016 because McCowan “surveyed the state of the law in 2015”).
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  withdrawal symptoms, and the jail official knew about the inmate’s condition.

  973 F.3d at 1027.

         At bottom, the district court correctly found that the law was clearly

  established that when “a detainee has obvious and serious medical needs, ignoring

  those needs necessarily violates the detainee’s constitutional rights.” Id. at 1033.

                      ii.     Counterarguments Against Clearly Established Law

         In response, the Individual Defendants argue that the law is not clearly

  established for three reasons. First, they contend that clearly established law requires

  pointing to “cases involving alcohol withdrawal in jails, or at least some sort of

  withdrawal in jails.” Opening Br. at 23. Second, the Individual Defendants argue that

  these cases are only “applicable to medical professionals and are not applicable to jail

  officers.” Id. at 23–24. Last, they argue that if these cases apply to non-medical

  professionals, “it only clearly establishes the law for prison officials who take no

  action whatsoever.” Id. at 24. And because the Individual Defendants “took some

  action and care” for Paugh, they argue that they cannot be liable for deliberate

  indifference. Id. We address each argument in turn.

                              1. Difference in Factual Contexts

         First, the Individual Defendants insist that a finding of clearly established law

  requires us to identify cases that involve “alcohol withdrawal in jails, or at least some

  sort of withdrawal in jails.” Id. at 23.

         But, as stated above, the relevant inquiry “in determining whether a right is

  clearly established is whether it would be clear to a reasonable officer that his

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  conduct was unlawful in the situation he confronted.” Quintana, 973 F.3d at 1033

  (citation omitted). Thus, there need not be “a case directly on point for a right to be

  clearly established.” McCowan, 945 F.3d at 1285 (quoting Kiesla v. Hughes, 138 S.

  Ct. 1148, 1152 (2018)); see also Baptiste v. J.C. Penney Co., 147 F.3d 1252, 1257

  n.9 (10th Cir. 1998) (“A plaintiff, however, need not cite a factually identical case to

  demonstrate the law was clearly established. Some level of generality is appropriate.”

  (internal citation omitted)).

         Indeed, we have previously relied on Sealock, Mata, and Al-Turki for clearly

  established law in factual contexts that differ from those cases. Most prominently, in

  Quintana—a case about heroin withdrawal—we held that Mata and Sealock clearly

  established “that when a detainee has obvious and serious medical needs, ignoring

  those needs necessarily violates the detainee’s constitutional rights.” 973 F.3d

  at 1033. Likewise, in Prince—a case about “severe acute psychosis causing an acute

  encephalopathy, or brain disease,” 28 F.4th at 1041—we held that Sealock and

  Al-Turki, among others, clearly established that “disregarding [an inmate’s] severe

  symptoms amount[s] to a constitutional violation,” id. at 1047–48.

         Thus, the lack of a case involving alcohol withdrawal does not preclude us

  from finding the law to be clearly established.

                              2. Applicability to Jail Officials

         Next, the Individual Defendants argue that Sealock and Mata are applicable

  only to medical professionals, not jail officials. We disagree.

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         First, in Sealock, we reversed a grant of summary judgment to a defendant jail

  official because he “refused to transport [the prisoner] immediately to a doctor or a

  hospital” despite complaints of chest pains. 218 F.3d at 1210–11. Thus, it is not true

  that Sealock involved only medical professionals.

         Second, as we explained in Lance v. Morris, 985 F.3d 787 (10th Cir. 2021),

  “lay officials (just like medical professionals) can incur liability for delays in

  providing medical treatment.” Id. at 800; see also Quintana, 973 F.3d at 1033

  (applying Sealock and Mata as clearly established law to a jail official, not a medical

  professional).

         So “it’s not fatal that some of the cited opinions involved medical

  professionals.”29 Lance, 985 F.3d at 799.

                              3. Whether the Law Applies Only to Those Who Took No
                                 Action Whatsoever

         Finally, the Individual Defendants argue that if Sealock applies to non-medical

  professionals, it applies only to “prison officials who take no action whatsoever.”

  Opening Br. at 24.

         Our decision in Estate of Jensen v. Clyde, 989 F.3d 848 (10th Cir. 2021)

  addressed this exact argument. There, a nurse argued, just as the Individual

  Defendants do here, that Mata, Sealock, and Quintana were inapplicable because

  “unlike the defendants in those cases,” she “did something to help” by providing an

  inmate with Gatorade. Estate of Jensen, 989 F.3d at 860.

         29
              The Individual Defendants’ briefing makes no mention of Al-Turki.
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         We rejected this argument. Id. We held that Sealock provided sufficient notice

  to the nurse that in light of the inmate’s serious symptoms, giving the inmate

  Gatorade instead of calling medical professionals violated the inmate’s right to

  medical care. Id. In reaching this conclusion, we pointed out that in Sealock, we held

  that a physician assistant could still be liable for deliberate indifference when he

  failed to summon an ambulance for an inmate complaining of chest pains—despite

  having given the inmate a shot of Phenergan. Id. (explaining Sealock). This was so,

  we explained, because “when an individual’s sole purpose is ‘to serve as a gatekeeper

  for other medical personnel,’ and that person delays or refuses to fulfill the

  gatekeeper role, he may be liable for deliberate indifference.” Id. (quoting Sealock,

  218 F.3d at 1211).

         So, as in Estate of Jensen, the law sufficiently notified the Individual

  Defendants that even with the little “help” they provided Paugh, their actions (and

  inactions) would still violate his constitutional rights.

         At bottom, since at least 2014, the law has clearly established that “when a

  detainee has obvious and serious medical needs, ignoring those needs necessarily

  violates the detainee’s constitutional rights.” Quintana, 973 F.3d at 1033. Thus, the

  Estate has satisfied the second prong of the qualified-immunity analysis.

         In sum, the Individual Defendants are not entitled to qualified immunity. So

  we affirm the district court’s denial of the Individual Defendants’ motion for

  summary judgment.

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  II.   The County

        Next, we consider the County’s appeal. The district court denied the County’s

  motion for summary judgment, ruling that the Estate had put forth sufficient

  evidence: (1) of customs and policies; (2) that caused Paugh’s constitutional

  violations; and (3) that the County maintained these customs and policies with

  deliberate indifference. Thus, it permitted the Estate’s claims against the County to

  proceed to trial. Now on appeal, the County argues that the Estate has neither shown

  any underlying constitutional violations, nor that “a county policy directly caused a

  constitutional violation.” Opening Br. at 51.

        We must first determine whether we have jurisdiction over the County’s

  interlocutory appeal. As explained, individual defendants asserting qualified

  immunity may immediately appeal a district court’s denial of that defense under the

  collateral-order doctrine. See Moore v. City of Wynnewood, 57 F.3d 924, 928–29

  (10th Cir. 1995). But municipalities are not entitled to qualified immunity. Id. at 929.

  So they “cannot invoke the collateral order doctrine to justify appeal of an otherwise

  nonappealable decision.” Id.

        But a municipality may still immediately appeal a district court’s denial of its

  summary-judgment motion by asking us to exercise pendent appellate jurisdiction. Id.

  Pendent appellate jurisdiction allows us to “exercise jurisdiction over an otherwise

  nonfinal and nonappealable lower court decision [if it] overlaps with an appealable

  decision.” Id. In other words, if a municipality’s appeal “overlaps” with an individual

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  defendant’s appeal challenging the denial of qualified immunity, we may exercise

  pendent appellate jurisdiction over the municipality’s appeal. Id.

         But “[p]endent appellate jurisdiction is a matter of discretion, not of right.”

  Walter v. Morton, 33 F.3d 1240, 1242 (10th Cir. 1994). And we must exercise this

  discretion sparingly. Cox, 800 F.3d at 1256; see also Est. of Ceballos v. Husk, 919

  F.3d 1204, 1221 (10th Cir. 2019) (explaining that “the exercise of pendent appellate

  jurisdiction is generally disfavored” (citation omitted)).

         Indeed, we may exercise pendent appellate jurisdiction to consider a

  municipality’s appeal only if the appeal raises issues that are “‘inextricably

  intertwined’ with the district court’s denial of qualified immunity to the individual

  defendants.” Crowson, 983 F.3d at 1185. A municipality’s appeal is “inextricably

  intertwined” with the qualified-immunity issues on collateral appeal if resolving

  qualified immunity would also “necessarily resolve[]” the municipality’s appeal. Id.

  (emphasis in original); see also Moore, 57 F.3d at 930 (explaining that a pendent-

  appellate claim is “inextricably intertwined” with a “properly reviewable claim on

  collateral appeal only if . . . the appellate resolution of the collateral appeal

  necessarily resolves the pendent claim as well” (emphasis in original)). Put simply, if

  our qualified-immunity ruling would not also resolve all the municipality’s issues,

  then we may not exercise pendent appellate jurisdiction. See Crowson, 983 F.3d

  at 1185.

         Here, the crux of the County’s appeal is that it cannot be liable because “there

  is no underlying constitutional violation by a county employee.” Opening Br. at 50.

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  But as we’ve explained, the Estate has shown that a reasonable jury could find the

  needed constitutional violations because the Individual Defendants are not entitled to

  qualified immunity. As a result, our ruling on qualified immunity would not resolve

  the claims against the County. So we lack jurisdiction to consider the County’s

  appeal.30 See Crowson, 983 F.3d at 1185.

                                       CONCLUSION

         For these reasons, we affirm the district court’s denial of the Individual

  Defendants’ motion for summary judgment. And we dismiss the County’s appeal for

  lack of jurisdiction.31

         30
            On appeal, the Individual Defendants and the County argue that the Estate’s
  suit should be dismissed for failure to state a claim, and that they may raise this issue
  at any time, including in their summary-judgment motion. Opening Br. at 51, 55. The
  district court disagreed, explaining that Individual Defendants had waived their
  ability to do so because they had answered “over two years before” moving for
  summary judgment. R. vol. 2 at 36 n.2. We agree with the district court that “the time
  for properly testing the sufficiency of the complaint [has] passed.” See SEC v.
  Wolfson, 539 F.3d 1249, 1265 (10th Cir. 2008) (holding that a defendant’s ability to
  challenge the sufficiency of a complaint had “passed” because he “never raised any
  objections to the complaint or otherwise sought a more particular statement of the
  allegations against him until two years after the complaint was filed and months after
  the parties had moved for summary judgment”).
         31
            The Individual Defendants and the County also ask us to dismiss any claims
  based on a violation of the Utah State Constitution, arguing that § 1983 only permits
  claims based on violations of federal law. But the district court already did so. See R.
  vol. 2 at 133 (“Thus, the court agrees that [the Estate’s] Section 1983 claims alleging
  violations of the . . . Utah Constitution . . . fail to state a claim for relief.”). We need
  not redo what the district court has already done.
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