Court Opinion

ID: 3065384
Source: CourtListenerOpinion
Date Created: 2015-10-14 22:31:08.640746+00
Date Added: 2024-06-11T11:41:24.839454
License: Public Domain

FOR PUBLICATION
  UNITED STATES COURT OF APPEALS
       FOR THE NINTH CIRCUIT

GREGORY CLOUTHIER; ANN                      
CLOUTHIER, individually and on
behalf of the Estate of Robert
John Clouthier,
               Plaintiffs-Appellants,
                 v.                               No. 07-16703
COUNTY OF CONTRA COSTA;                            D.C. No.
                                                CV-06-03893-MMC
WARREN RUPF; MATT FOLEY,
Sheriff’s Deputy; ERIK STEELE;                      OPINION
MARGARET BLUSH, sued in their
individual capacities and as
employees of Contra Costa
County,
              Defendants-Appellees.
                                            
        Appeal from the United States District Court
           for the Northern District of California
        Maxine M. Chesney, District Judge, Presiding

                   Argued and Submitted
          March 10, 2009—San Francisco, California

                      Filed January 14, 2010

Before: M. Margaret McKeown and Sandra S. Ikuta, Circuit
       Judges, and Frederic Block,* District Judge.

                  Opinion by Judge Ikuta;
  Partial Concurrence and Partial Dissent by Judge Block

   *The Honorable Frederic Block, Senior United States District Judge for
the Eastern District of New York, sitting by designation.

                                 1117
            CLOUTHIER v. COUNTY OF CONTRA COSTA         1121

                        COUNSEL

Stan Casper and Thomas A. Seaton, Casper, Meadows, Sch-
wartz & Cook, Walnut Creek, California, attorneys for the
appellant.

Janet L. Holmes, Office of County Counsel, Martinez, Cali-
fornia, attorney for the appellees.

                         OPINION

IKUTA, Circuit Judge:

   The plaintiffs in this appeal brought an action under 42
U.S.C. § 1983 alleging that a mental health specialist, two
sheriff’s deputies, and the County of Contra Costa violated
the Fourteenth Amendment due process rights of their son,
Robert Clouthier, by failing to prevent his suicide while he
was in pretrial detention. The district court granted summary
judgment in favor of the defendants. We have jurisdiction
1122         CLOUTHIER v. COUNTY OF CONTRA COSTA
under 28 U.S.C. § 1291, and we affirm the district court’s
grant of summary judgment as to the two deputies and the
County, but we reverse as to the mental health specialist
because there are genuine issues of material fact as to whether
she was deliberately indifferent to a substantial risk of serious
harm to Clouthier.

                                I

   On the evening of July 26, 2005, after an argument with his
father at the Clouthiers’ home, Clouthier became violent,
destroyed a china cabinet, and jumped through a plate glass
window, resulting in lacerations and severe bleeding. His
family called the police; the sheriff’s office responded along
with ambulance and fire personnel. After Clouthier’s father
signed a citizen’s arrest for battery, the sheriff’s office placed
Clouthier into custody for both misdemeanor battery and fel-
ony vandalism. Clouthier was extremely upset about being
taken into custody. As he was taken into the ambulance, he
hit his head against the side of the ambulance several times.
Once at the hospital, he refused to have his wounds stitched.
The next morning, July 27, Clouthier was booked into the
Martinez Detention Facility (“MDF”).

   At MDF, new detainees fill out a mental health question-
naire during the intake process. If an inmate answers “yes” to
certain questions, he is interviewed by a member of Contra
Costa County Mental Health Services. The Mental Health
Services department, run by administrative director Miles
Kramer, works in conjunction with the Sheriff’s Department
by virtue of a contractual agreement. Mental Health Services
provides on-site evaluation, counseling, therapy, suicide pre-
vention, medication management, crisis intervention, and sub-
stance abuse counseling, while the Sheriff’s Department
custodial deputies maintain security and safety in the jail’s
housing units.

  After filling out a mental health questionnaire, Clouthier
was evaluated by Sharlene Hanaway, a Contra Costa County
            CLOUTHIER v. COUNTY OF CONTRA COSTA            1123
Mental Health Specialist. Clouthier told Hanaway several
times that he was suicidal, and that he wanted to be “uncon-
scious for the rest of his life.” Hanaway described Clouthier
as “despondent, hopeless, suicidal” and “one of the most sui-
cidal inmates she had ever seen.” Hanaway’s notes state that
Clouthier had made numerous past suicide attempts, including
one incident two months earlier that required hospitalization
after he cut his wrists. Hanaway’s notes reflect that Clouthier
had taken medication for several years, but that he had ceased
doing so two and a half years ago.

   Hanaway placed Clouthier in a “safety cell” in the intake
area of the jail. She had him wear a suicide smock, a stiff gar-
ment that cannot be fashioned into a noose. She restrained his
ankles and began noting his status every fifteen minutes in an
Observation Log. She also approached the mental health
workers, including Margaret Blush, and the deputies in the
intake area, and advised them that Clouthier was “truly suici-
dal” and “the real deal.”

   Hanaway spoke with Clouthier periodically throughout the
morning of July 27, “talking to him and making sure he was
okay and [asking] what his state of mind was.” By that after-
noon, Clouthier informed Hanaway that he was not feeling
suicidal anymore. Hanaway did not trust him, however, not-
ing “he had multiple suicide attempts before, and given his
history and his despondency, his hopelessness, you just don’t
recover that quickly.” Hanaway convinced Clouthier to con-
sider medication, and she called for an emergency consulta-
tion with Dr. Douglas Hanlin, a psychiatrist. Hanlin
prescribed Effexor XR for Clouthier’s depression and Trazo-
done to help him sleep. Hanlin also recommended that Clou-
thier be placed in M-Module, a housing section for unstable
inmates, and that he subsequently be reevaluated to determine
whether a short-term involuntary hospitalization would be
necessary.

   Around 2 p.m., Hanaway transferred Clouthier to Observa-
tion Room 7, one of the rooms in M-Module equipped with
1124          CLOUTHIER v. COUNTY OF CONTRA COSTA
large windows through which the Sheriff’s deputies can moni-
tor the occupant. Hanaway spoke to Matt Foley, the deputy on
duty in M-Module at the time, and asked Foley whether there
was room for Clouthier in the M-Module. She told Foley that
Clouthier was suicidal, had been suicidal all day long, “had
numerous prior attempts,” and needed to be on 15-minute
checks. As documented in the Observation Log, Foley
checked on Clouthier every fifteen minutes for the next five
hours, until Clouthier was taken off the Observation Log.

   Before she left her shift, Hanaway gave a copy of her notes
to Blush and told her that Clouthier “had been very suicidal
throughout the day and that [Hanaway] felt that he needed to
be in the observation room and that he needed to be observed
and [Blush] needed to look in on him.” Hanaway left MDF
around 6:30 p.m. on July 27.1

   Around 7 p.m. the same evening, Blush went up to M-
Module and spoke with Clouthier for “[l]ess than five min-
utes.” She informed Foley that Clouthier could be given regu-
lar prison clothes and a blanket but that he was not to be given
any utensils or personal hygiene items. She also told Foley
that Clouthier could be removed from the fifteen minute
Observation Log, and she made an entry to that effect in the
log. Blush testified that she took Clouthier off the Observation
Log because in her view, the risk of suicide had decreased,
although she was uncertain whether it had disappeared. She
explained that her “clinical judgment was that Robert was
improving, would benefit from having normal jail clothes and
bedding and could be further evaluated by mental health staff
the following day.” However, Blush also agreed that Clou-
thier was not “out of the woods” yet.

   Blush claims she told Foley to keep Clouthier in the Obser-
vation Room, and Foley indicated he understood and
responded “I’m sitting right here.” Foley disputes this. He tes-
  1
   Hanaway did not return to work until after Clouthier’s suicide.
             CLOUTHIER v. COUNTY OF CONTRA COSTA            1125
tified that Blush did not instruct him to keep Clouthier in the
Observation Room. Later, he testified that he could not
remember if Blush directed him to keep Clouthier in the
Observation Room, but that if she had so directed him it
would have been something to which he would have paid
attention. Foley did not write down Blush’s alleged instruc-
tion to keep Clouthier in the Observation Room in the “Red
Book,” a log the deputies kept to inform one another of
important events, or otherwise communicate an instruction to
the next deputy on duty.

   Regardless of whether Blush instructed Foley to keep Clou-
thier in the Observation Room, Foley did not move Clouthier
from the room, and he remained there when Foley left work
on July 27. Foley returned on July 28 to find Clouthier was
still in the Observation Room. Per M-Module standard prac-
tice, Foley continued to check on Clouthier every thirty min-
utes. Foley ended his duty at 9:30 pm on the evening of July
28 with Clouthier still in the Observation Room. Foley did not
return to work until August 1st, when Clouthier had already
been moved into the M-Module general population.

   The next day, on July 29, Victoria Brown, another mental
health specialist, observed Clouthier in Observation Room 7
during dinner hour for three to five minutes. She “understood
that he was suicidal,” and asked him some questions to evalu-
ate his mental state. She observed that “while he appeared
calm . . . he still appeared acute to me, his affect or what I
could see on his face suggested that he was still . . . not feel-
ing well.” Therefore, she did not think that “trying to have a
lengthy conversation would be appropriate at that time.” She
further testified that she was not “overly concerned with
[Clouthier’s] situation, given the background information I
had on him. He was calm and looked emotionally drained. He
looked like he needed rest more than anything.” Based on her
“over 37 years of working with potentially suicidal mental
health patients,” Brown’s clinical evaluation “was that he was
not actively suicidal at the time.” Although she “did not feel
1126         CLOUTHIER v. COUNTY OF CONTRA COSTA
the need to put him back on the observation log,” she did
“feel he would benefit from additional time in the observation
room.” She did not make any notes on Clouthier’s medical
chart, “as the situation was status quo.” She did not confer
with any deputies or Mental Health staff regarding her obser-
vations.

   That evening, Deputy Eric Steele began his shift on M-
Module. The other deputies told him that earlier in the week
Clouthier had been placed in Observation Room 7 “for being
a danger to himself,” and since then had been “taken off the
Observation Log but had not yet been moved” from the
Observation Room. Steele reviewed the Red Book, but he did
not see any information about why Clouthier was in the
Observation Room. Nor did Steele see any of Clouthier’s
medical records kept by Mental Health. Clouthier remained in
the Observation Room from July 29 through July 31.

   On July 31, the Red Book stated that Clouthier had refused
free time at 10:21 a.m., refused lunch at 11:36 a.m., and
refused dinner at 5:11 p.m. Steele testified that the Red Book
notation about Clouthier skipping his free time did not raise
a “red flag” because it was not unusual for inmates not to
come out in the morning because they want to sleep. Steele
testified that when an inmate skips meals he would “keep a
closer eye on him,” and stated:

    [A]fter speaking with [Clouthier] all weekend he
    explained his reasons to me . . . . He told me he
    wasn’t hungry. He told me he was trying — he just
    wanted to catch up on his sleep, and he was okay. So
    after talking with him the whole weekend, it wasn’t
    the general red flag. If he refused to talk to me or
    something like that, that might — that would make
    me think differently than I was about him.

Steele testified further that:
            CLOUTHIER v. COUNTY OF CONTRA COSTA             1127
    I’d been talking to Mr. Clouthier throughout the
    weekend, seeing how he’s doing, where his head was
    at, talked to him about what he was going to do once
    he got out of the observation room and what could
    help him progress. And after that, I was just looking
    for inmates that would be able to help him through
    that.

    ...

    [H]e was off an observation log, so to me that tells
    me that he’s not a danger to himself. He had been
    talking to me during the week. He expressed wanting
    to come out for recreation with the other inmates,
    which he had opportunity to come out. Yeah, he had
    a positive outlook on wanting to come out, waiting
    to just get out of the room and get more mobile and
    get more interaction, yes.

   Captain David Pascoe, the Deputy Supervisor, testified
that, based on the Sheriff’s Department’s training, he would
expect a deputy to ask Mental Health to evaluate an inmate
that was skipping meals and free time. Steele did not inform
Mental Health of the Red Book entries.

   Sometime between 12:00 a.m. and 6:30 a.m. on August 1,
Steele received a call from Sergeant Yates, who stated that he
needed Observation Room 7. Steele called Mental Health Ser-
vices to ask whether Clouthier should be moved, but no one
answered because Mental Health staff do not work the grave-
yard shift. Steele testified that he had been looking for an
appropriate roommate for Clouthier before the phone call and
that, because Clouthier “was off an observation log . . . he’s
not a danger to himself.” Steele then moved Clouthier into the
M-Module general population and placed him in a cell with
inmate Marc Watkins.

   Foley reported back for duty the afternoon of August 1. He
testified that he had no reason to question Clouthier’s transfer
1128         CLOUTHIER v. COUNTY OF CONTRA COSTA
from Observation Room 7 into the general population.
According to Watkins, after dinner that evening, Clouthier sat
on his bunk and tied his sheet into a knot on one end. At 7:15
p.m., Foley went to Clouthier’s cell to let Watkins out for rec-
reational time. Foley told Clouthier that he could not come
out right then, but that Foley would return to take him out.
Watkins testified that, “when [Watkins] left the room [he] saw
the sheet, still knotted, sitting on the edge of the bed, hanging
over slightly. Dep[uty] Foley didn’t say anything about the
sheet, but he sure should have been able to see it.” Foley testi-
fied that he did not see the knotted sheet, but rather that he
saw Clouthier “lying on his bunk, with the sheets pulled
around him. This is the way many if not most inmates spend
a great deal of their time in the cells on M-Module.”

  Roughly thirty minutes later, at 7:42 p.m., Foley and a
nurse went to Clouthier’s cell. They discovered him hanging
by the neck from the knotted sheet. Foley administered CPR,
and Clouthier was taken to the County Hospital. After being
removed from life support ten days later, Clouthier died.

   Clouthier’s parents filed suit under 42 U.S.C. § 1983
against Blush, Steele, Foley, and the County. The Clouthiers
alleged that the individual defendants violated Clouthier’s
constitutional right to due process under the Fourteenth
Amendment due to the officials’ deliberate indifference to
Clouthier’s serious medical needs. They also alleged that
Clouthier’s death was caused by the County’s established pol-
icies, its failure to train employees, and its ratification of the
officials’ illegal actions. After discovery, the defendants
moved for summary judgment, which the district court
granted on the merits as to each defendant. This timely appeal
followed.

                                II

  Summary judgment is reviewed de novo. Olsen v. Idaho
State Bd. of Med., 363 F.3d 916, 922 (9th Cir. 2004). We
             CLOUTHIER v. COUNTY OF CONTRA COSTA             1129
must determine whether there are any genuine issues of mate-
rial fact and whether the district court correctly applied the
relevant substantive law. Id.

   “Although the district court did not reach the issue of quali-
fied immunity we may do so where it is clear from the record
before us.” Humphries v. County of Los Angeles, 554 F.3d
1170, 1201 (9th Cir. 2009). “The doctrine of qualified immu-
nity protects government officials from liability for civil dam-
ages insofar as their conduct does not violate clearly
established statutory or constitutional rights of which a rea-
sonable person would have known.” Pearson v. Callahan,
129 S. Ct. 808, 815 (2009) (quoting Harlow v. Fitzgerald, 457
U.S. 800, 818 (1982) (internal quotation marks omitted)). In
considering a claim of qualified immunity, the court must
determine “whether the facts that a plaintiff has alleged . . .
make out a violation of a constitutional right,” and “whether
the right at issue was ‘clearly established’ at the time of
defendant’s alleged misconduct.” Id. at 816. Whether a right
is clearly established turns on the “objective legal reasonable-
ness of the action, assessed in light of the legal rules that were
clearly established at the time it was taken.” Id. at 822 (quot-
ing Wilson v. Layne, 526 U.S. 603, 614 (1999)).

   On appeal, the Clouthiers raise three arguments. First, they
claim that the district court made a legal error by applying the
“deliberate indifference” test articulated by the Supreme
Court in Farmer v. Brennan, 511 U.S. 825 (1994). Second,
they argue that even if the deliberate indifference test is appli-
cable here, there was a genuine issue of material fact as to
whether the individual defendants were liable under that test.
Further, the Clouthiers argue that Robert Clouthier’s rights in
this context were clearly established, so the individual defen-
dants were not entitled to summary judgment on the ground
of qualified immunity. Finally, they argue that the district
court erred in concluding that the Clouthiers had not estab-
lished a genuine issue of material fact as to the County’s lia-
1130        CLOUTHIER v. COUNTY OF CONTRA COSTA
bility on account of its deficient polices. We consider these
issues in turn.

                              III

  We first consider the Clouthiers’ argument that the district
court erred in holding that liability could be imposed on the
individual defendants only if they had a “ ‘deliberate indiffer-
ence’ to inmate health or safety.” Farmer, 511 U.S. at 834
(quoting Wilson, 501 U.S. at 302-03).

   [1] We have long analyzed claims that correction facility
officials violated pretrial detainees’ constitutional rights by
failing to address their medical needs (including suicide pre-
vention) under a “deliberate indifference” standard. See, e.g.,
Lolli v. County of Orange, 351 F.3d 410, 418-19 (9th Cir.
2003) (applying the “deliberate indifference” standard to a
diabetic pretrial detainee’s claims of failure to provide care
for serious medical needs); Gibson v. County of Washoe, 290
F.3d 1175, 1188 & n.9 (9th Cir. 2002) (applying the “deliber-
ate indifference” standard to the claims of a mentally ill pre-
trial detainee who died in custody); Cabrales v. County of Los
Angeles, 864 F.2d 1454, 1461 & n. 2 (9th Cir. 1988) (apply-
ing the “deliberate indifference” standard to a § 1983 claim by
the mother of a pretrial detainee who committed suicide in
detention, and explaining that “the fourteenth amendment due
process rights of pretrial detainees are analogized to those of
prisoners under the eighth amendment”), vacated on other
grounds, 490 U.S. 1087 (1989), opinion reinstated, 886 F.2d
235 (9th Cir. 1989).

   [2] This approach is grounded in Supreme Court precedent.
In Bell v. Wolfish, the Supreme Court held that pretrial detain-
ees had a due process right not to be punished. 441 U.S. 520,
535 & n.16 (1979). The Court explained that, “what is at issue
when an aspect of pretrial detention that is not alleged to vio-
late any express guarantee of the Constitution is challenged,
is the detainee’s right to be free from punishment . . . .” Id.
             CLOUTHIER v. COUNTY OF CONTRA COSTA              1131
at 534 (emphasis in original); see id. at 535 (“In evaluating
the constitutionality of conditions or restrictions of pretrial
detention that implicate only the protection against depriva-
tion of liberty without due process of law, we think that the
proper inquiry is whether those conditions amount to punish-
ment of the detainee.”). The key question “in determining
whether particular restrictions and conditions accompanying
pretrial detention amount to punishment in the constitutional
sense of that word,” is whether the restrictions evince a puni-
tive purpose or intent. Id. at 538-39.

   The Supreme Court has explained the meaning of “punitive
intent” in the context of its Eighth Amendment jurisprudence.
For a prisoner to establish “cruel and unusual punishment,” he
must show both an objective component, addressing whether
a deprivation was sufficiently serious to be “cruel and unusu-
al,” and a subjective component, addressing whether correc-
tion facility officials acted with “a sufficiently culpable state
of mind,” so that the condition of confinement may be
deemed to be “punishment.” Wilson v. Seiter, 501 U.S. 294,
298 (1991). With respect to the second component, the Court
explained, “[i]f the pain inflicted is not formally meted out as
punishment by the statute or the sentencing judge, some men-
tal element must be attributed to the inflicting officer before
it can qualify” as punitive. Id. at 300 (emphasis in original).

   In cases claiming an Eighth Amendment violation “based
on a failure to prevent harm,” the first, objective component
is met if the inmate shows that “he is incarcerated under con-
ditions posing a substantial risk of serious harm.” Farmer,
511 U.S. at 834. The second component, punitive intent, is
met if the claimant shows that the detention facility official’s
“state of mind is one of ‘deliberate indifference’ to inmate
health or safety.” Id. This is a subjective test in that “the offi-
cial must both be aware of facts from which the inference
could be drawn that a substantial risk of serious harm exists,
and he must also draw the inference.” Id. at 837. “[A]n offi-
cial’s failure to alleviate a significant risk that he should have
1132         CLOUTHIER v. COUNTY OF CONTRA COSTA
perceived but did not, while no cause for commendation, can-
not under our cases be condemned as the infliction of punish-
ment.” Id. at 838; see also Gibson, 290 F.3d at 1188 (“If a
person should have been aware of the risk, but was not, then
the person has not violated the Eighth Amendment, no matter
how severe the risk.” (citing Jeffers v. Gomez, 267 F.3d 895,
914 (9th Cir. 2001))).

   [3] In light of the Supreme Court’s rulings that conditions
of confinement violate pretrial detainees’ Fourteenth Amend-
ment rights if the conditions amount to punishment, Bell, 441
U.S. at 535, and that failure to prevent harm amounts to pun-
ishment where detention officials are deliberately indifferent,
Farmer, 511 U.S. at 834, we have concluded that the “deliber-
ate indifference” standard applies to claims that correction
facility officials failed to address the medical needs of pretrial
detainees. See, e.g., Lolli, 351 F.3d at 418-19; Gibson, 290
F.3d at 1188 n.9; Cabrales, 864 F.2d at 1461 & n.2. Although
we have noted that the Eighth Amendment may provide “a
minimum standard of care” for determining the rights of pre-
trial detainees, Or. Advocacy Ctr. v. Mink, 322 F.3d 1101,
1120 (9th Cir. 2003), neither we nor the Supreme Court have
departed from the standard set forth in Bell and Farmer for
considering pretrial detainees’ claims that government offi-
cials violated their Fourteenth Amendment rights by failing to
prevent harm. See, e.g., Frost v. Agnos, 152 F.3d 1124, 1128
(9th Cir. 1998) (“Because pretrial detainees’ rights under the
Fourteenth Amendment are comparable to prisoners’ rights
under the Eighth Amendment . . . we apply the same stan-
dards.”).

   [4] In this case, Clouthier was a pretrial detainee confined
at MDF in connection with battery and vandalism charges.
Accordingly, under Bell and our cases, we must consider
whether Clouthier was subjected to punishment. This requires
us to inquire into the subjective component of punishment,
that is, whether Foley, Steele, or Blush acted with deliberate
indifference as defined in Farmer and our cases.
             CLOUTHIER v. COUNTY OF CONTRA COSTA             1133
   The Clouthiers argue, however, that the deliberate indiffer-
ence standard is not applicable here. Relying on Mink and
Jones v. Blanas, 393 F.3d 918 (9th Cir. 2004), the Clouthiers
contend that mentally ill pretrial detainees are entitled to
greater protection under the Fourteenth Amendment. The
Clouthiers invite us to adapt the standard suggested by Young-
berg v. Romeo, 457 U.S. 307 (1982), and hold that mentally
ill detainees have a constitutional right to mental health care
that does not substantially depart from accepted professional
judgment, practice, or standards. Under such a standard, the
Clouthiers could prosecute their § 1983 action without carry-
ing the burden of showing that the individual defendants sub-
jectively acted with deliberate indifference to a substantial
risk of serious harm to Clouthier.

   [5] We must decline this invitation. The cases cited by the
Clouthiers considered the substantive due process rights of
individuals detained by the state for the purpose of addressing
issues associated with their mental incapacity; they do not
address the liberty interests of pretrial detainees who are con-
fined to ensure their presence at trial, as in Bell. In Young-
berg, the Court held that a profoundly mentally retarded man
who had been civilly committed to a state mental institution
had a liberty interest in “reasonable conditions of safety and
freedom from unreasonable restraints.” 457 U.S. at 321. Bal-
ancing such liberty interests against the state’s legitimate
interests in managing the institution, the Court held that the
patient’s interests would be adequately protected if the state
addressed them in a reasonable manner as determined by a
professional decision maker. Id. at 322-23. The Court did not
suggest that such rights were applicable to pretrial detainees.
Rather, it cited Bell with approval, noting it had similarly bal-
anced a pretrial detainee’s liberty interest against the state’s
interest and the Court there had “upheld those restrictions on
liberty that were reasonably related to legitimate government
objectives and not tantamount to punishment.” Id. at 320.

   Nor are subsequent Ninth Circuit cases weighing the liberty
interests of mentally incapacitated plaintiffs against the legiti-
1134         CLOUTHIER v. COUNTY OF CONTRA COSTA
mate interests of the state applicable in this context. See Mink,
322 F.3d 1101, Jones, 393 F.3d 918. In Mink, for example, a
state law required criminal defendants who were declared
mentally incapacitated and unable to stand trial to be commit-
ted to a state mental hospital for the purposes of evaluation,
treatment, and restoration. Id. at 1106. We held that the state
mental hospital violated those defendants’ constitutional
rights by not accepting their transfer from county jails on a
timely basis. Id. at 1121. We determined that there was no
“legitimate state interest in keeping mentally incapacitated
criminal defendants locked up in county jails for weeks or
months,” and in fact the state hospital’s delay “undermine[d]
the state’s fundamental interest in bringing the accused to
trial.” Id. In Jones, we held that an individual detained await-
ing civil commitment proceedings was, at a minimum, enti-
tled to the rights of a civilly committed mentally retarded
person in Youngberg and a pretrial detainee in Bell. Jones,
393 F.3d at 932. Accordingly, we ruled that holding a civil
detainee under conditions similar to or more restrictive than
the conditions imposed on a criminal detainee constituted
“punishment,” and therefore violated the civil detainees’
Fourteenth Amendment rights. Id.

   In sum, the cases cited by the Clouthiers involve plaintiffs
who were differently situated and who enjoyed different
rights from the plaintiffs considered in Bell. Moreover, these
cases involved distinct state interests. Because none of these
cases signal a departure from Bell, we do not consider them
persuasive here. Accordingly, we must evaluate the Clou-
thiers’ claim that Blush, Steele, and Foley violated Clouthier’s
due process rights under the deliberate indifference standard
articulated in Farmer and applied by our cases in the context
of pretrial detainees.

                               IV

   Even under the deliberate indifference standard, however,
the Clouthiers argue that Blush, Steele, and Foley are not enti-
             CLOUTHIER v. COUNTY OF CONTRA COSTA            1135
tled to summary judgment. To defeat a motion for summary
judgment by the individual defendants, the Clouthiers must
show a genuine issue of material fact as to both prongs of the
deliberate indifference test: (1) whether Clouthier was con-
fined under conditions posing a “substantial risk of serious
harm” and (2) whether the officers were deliberately indiffer-
ent to that risk. Lolli, 351 F.3d at 420. Here, defendants do not
contest that the conditions of Clouthier’s confinement posed
“a substantial risk of serious harm.” Id. at 420. Rather, they
dispute whether the Clouthiers presented “evidence from
which a reasonable jury could conclude that any of the indi-
vidual officers knew of and were deliberately indifferent to
this substantial risk of serious harm.” Id. at 420. We examine,
in turn, the Clouthiers’ claims against Blush, Steele, and
Foley. We view the evidence in the light most favorable to the
non-moving party. See Olsen, 363 F.3d at 922. In order to
ensure that our examination of Clouthier’s claims against each
defendant rests on a resolution of the facts most favorable to
the Clouthiers, the analysis below must occasionally resolve
factual disputes regarding the same incident in different ways.

                               A

   [6] Viewing the evidence in the light most favorable to the
Clouthiers, a rational jury could conclude that Blush was “on
notice” of Clouthier’s suicidal condition and that she actually
“inferred from this information that [Clouthier] was at serious
risk of harm if he did not receive” proper care. Lolli, 351 F.3d
at 420. Blush was given a copy of Hanaway’s notes, which
reflected that Clouthier had told Hanaway he was suicidal and
that he had previously attempted suicide. The notes also stated
that Clouthier was put in a suicide smock, was to be “con-
stantly monitored throughout the day to ensure his safety,”
and that Mental Health would gather more of his history.
Hanaway also personally informed Blush that she thought
Clouthier was truly suicidal, that he was going to try to kill
himself, and that he was the “real deal.” Hanaway emphasized
that Clouthier “had been very suicidal throughout the day and
1136          CLOUTHIER v. COUNTY OF CONTRA COSTA
that [Hanaway] felt that he needed to be in the observation
room and that he needed to be observed and [Blush] needed
to look in on him.”

    [7] In addition to Hanaway’s notes and personal warnings,
which give rise to the inference that Clouthier faced a sub-
stantial risk of serious harm, the Clouthiers adduced evidence
that Blush actually inferred that Clouthier was suicidal. After
meeting with Clouthier for “[l]ess than five minutes,” Blush
told Foley that Clouthier should not have access to utensils or
other objects because she “felt it was best that some limita-
tions be placed on his access to anything.” Blush also agreed
that Clouthier was not “out of the woods” yet and that his
condition could “go either way.” She testified she was “uncer-
tain” whether his suicidality had disappeared. Yet, Blush
removed Clouthier from the Observation Log, told the depu-
ties he could be given regular clothes and regular bedding,
failed to instruct Foley to keep Clouthier in the Observation
Room,2 and neglected to determine if additional care was
needed. From this circumstantial evidence, a jury could rea-
sonably infer that Blush knew of Clouthier’s depressive, sui-
cidal condition and need for mental health treatment, and
“also knew of the risk of harm that he faced if denied medical
attention.” Lolli, 351 F.3d at 421; see also Farmer, 511 U.S.
at 843 n.8 (“While the obviousness of a risk is not conclusive
and a prison official may show that the obvious escaped him,
. . . he would not escape liability if the evidence showed that
he 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 . . . .”). Accordingly,
resolving factual disputes in favor of the Clouthiers, “the cir-
cumstances suggest that [Blush] had been exposed to informa-
tion concerning the risk and thus ‘must have known’ about it
. . . .” Farmer, 511 U.S. at 842. Therefore, there exists a genu-
  2
    Blush claims she did instruct Foley to keep Clouthier in the Observa-
tion Room.
               CLOUTHIER v. COUNTY OF CONTRA COSTA                     1137
ine issue of material fact as to whether Blush was deliberately
indifferent to a substantial risk of harm to Clouthier.3

   In light of this conclusion, we must consider whether Blush
is entitled to qualified immunity. This inquiry involves the
question whether “the law governing [Blush’s] conduct was
clearly established” and whether “a reasonable state official
[could] have believed [Blush’s] conduct was lawful.” Estate
of Ford v. Ramirez-Palmer, 301 F.3d 1043, 1050 (9th Cir.
2002). Blush argues that Clouthier’s constitutional rights in
this context were not clearly established at the time of Blush’s
alleged misconduct. According to Blush, although it was clear
in 2005 that pre-trial detainees had a right to mental health
care, the contours of that right were vague at that time, and
she was not on notice that her conduct was unlawful.

   [8] We disagree. In 1988, we affirmed a jury verdict impos-
ing § 1983 liability on a municipality and its official policy-
maker for deliberate indifference to a pretrial detainee’s
mental health needs that resulted in the detainee’s suicide. See
Cabrales, 864 F.2d at 1461 & n.2; see also Gibson, 290 F.3d
at 1196, 1187 (evaluating individual deputies’ liability under
the deliberate indifference standard where pretrial detainee
alleged insufficient medical care). Blush, a mental health spe-
cialist, was tasked with caring for a pretrial detainee who had
recently expressed suicidal intent and whose suicidality had
been described to her by a fellow mental health professional
as “the real deal.” In light of her understanding that Clouthier
was not “out of the woods” yet, and in light of the clearly
established law at the time, a reasonable mental health profes-
sional could not have thought it was lawful to remove key sui-
  3
    The district court did not reach the issue of causation, and neither of
the parties briefed the issue. See White v. Roper, 901 F.2d 1501, 1505 (9th
Cir. 1990) (to prevail on a § 1983 claim under a deliberate indifference
theory, plaintiff must prove that the official’s actions were both the actual
and proximate cause of plaintiff’s injuries). Accordingly, we do not reach
this issue here.
1138         CLOUTHIER v. COUNTY OF CONTRA COSTA
cide prevention measures put in place by a prior Mental
Health staff member. Accordingly, taking the evidence in the
light most favorable to the Clouthiers, Blush is not entitled to
qualified immunity.

                               B

   [9] As to Steele, we conclude that the Clouthiers’ evidence
is insufficient to allow a reasonable jury to conclude that
Steele knew Clouthier was subject to a substantial risk of seri-
ous harm when he moved him to the general population. The
Clouthiers argue that a jury could find that Steele must have
known of the risk to Clouthier “from the very fact that the risk
was obvious.” They point out that, on July 31, Steele knew
that Clouthier had recently refused to eat both lunch and din-
ner, and had refused to partake in free time. Further, the Clou-
thiers note that Steele had been trained to recognize the signs
of at-risk detainees by looking for individuals illustrating sub-
tle signs of self-destructive intent, such as loss of appetite or
withdrawal.

   [10] The Clouthiers’ argument is unavailing. Here, the evi-
dence, comprised of the Red Book entries and Steele’s prior
training, does not create an inference that the substantial risk
of serious harm to Clouthier was so obvious that Steele “must
have known” of it. Unlike Blush, who was personally
informed of Clouthier’s suicidal proclivities, Steele knew only
that the Red Book entries noted Clouthier’s missed meals and
free time. Steele testified that when he reported to work on
July 28, “[t]hey explained to me that earlier in the week
[Clouthier] was placed in there for being a danger to himself,
and since then was taken off the observation log and had . . .
yet to be moved out of there.” As to the Red Book entries,
Steele noted that, when an inmate skips meals, he would
“need to keep a closer eye on him,” and indeed Steele fol-
lowed up with Clouthier, “speaking with him all weekend.”
After inquiring multiple times into Clouthier’s status, Steele
noted that Clouthier “had a positive outlook on wanting to
               CLOUTHIER v. COUNTY OF CONTRA COSTA                    1139
come out, waiting to just get out of the room.” Moreover,
Brown, the mental health specialist who evaluated Clouthier
hours before Steele first came on duty, testified that while
Clouthier looked “acute,” “fatigued, somewhat shell-
shocked,” he also appeared to be “calm” and “emotionally
drained,” as if he “needed rest more than anything,” and her
clinical evaluation was that “he was not actively suicidal at
the time,” although he “would benefit from additional time in
the observation room.” There is no evidence that Brown com-
municated her observations to Steele, or that he saw any notes
indicating Clouthier was acting strangely. Moreover, given
Brown’s evaluation, there is no basis for concluding that it
was obvious that Clouthier was suicidal. Instead, on July 31,
neither Steele nor another deputy “had a firm understanding
of why” Clouthier was still in the Observation Room. Accord-
ingly, the circumstantial evidence is too limited for a reason-
able factfinder to “conclude that [Steele] knew of a substantial
risk from the very fact that the risk was obvious.”4 Farmer,
511 U.S. at 842.

  [11] In the absence of a risk so “obvious” that Steele must
have drawn an impermissible inference, the Clouthiers were
required to adduce evidence that raised a genuine issue of
   4
     In Conn v. City of Reno, 572 F.3d 1047 (9th Cir. 2009), we reversed
a district court’s grant of summary judgment in favor of two officers,
because there was “sufficient circumstantial evidence to create a genuine
issue of fact regarding defendants’ subjective awareness” of a serious
medical need. Id. at 1057. In that case, the two officers were transporting
a detainee when they observed the detainee wrap a seatbelt around her
neck and scream that she would kill herself. The officers neglected to
report the incident, because they interpreted it as a “belligerent” and “un-
cooperative” attempt “to manipulate the situation.” Id. at 1052. We held
that a “reasonable jury could conclude that the officers’ knowledge of [the
detainee’s] mental and emotional instability, coupled with their observa-
tion of her dangerous behavior, in fact produced a subjective awareness.”
Id. at 1057. Here, in contrast, the Clouthiers adduced no evidence showing
Steele observed suicidal actions, heard statements of a suicidal nature, or
witnessed other evidence of Clouthier’s suicidal intent of the obvious kind
exhibited in Conn.
1140         CLOUTHIER v. COUNTY OF CONTRA COSTA
material fact demonstrating Steele was subjectively aware of
the risk to Clouthier. Because the Clouthiers did not do so, the
evidence was insufficient to allow a jury to conclude “that
[Steele’s] conduct violated a constitutional right,” Estate of
Ford, 301 F.3d at 1050, and summary judgment in Steele’s
favor was therefore proper.

                               C

   [12] As to Foley, the evidence adduced by the Clouthiers
is insufficient to allow a jury to conclude that Foley knew
Clouthier was suicidal and deliberately ignored that risk. The
Clouthiers argue that Foley knew of the risk facing Clouthier
because he had initially been informed by Hanaway of Clou-
thier’s suicidality and had been told by Blush to continue cer-
tain restrictions on Clouthier. Moreover, the Clouthiers claim
that Foley saw the knotted sheet in Clouthier’s cell. Given
Foley’s knowledge that Clouthier was suicidal, the Clouthiers
argue that Foley deliberately failed to take steps to address the
risk.

   We again must disagree. The record does not include suffi-
cient direct or circumstantial evidence to create a genuine
issue of material fact as to whether Foley was subjectively
aware of a substantial risk of harm to Clouthier and that he
deliberately ignored that risk.

   [13] Foley had two different encounters with Clouthier.
The first occurred during the period from July 27, when
Hanaway transferred Clouthier to the M-Module, until July
28, when Foley’s shift ended. There is no evidence that Foley
was subjectively aware that Clouthier was actively suicidal at
the time Foley left his shift. Foley’s information about Clou-
thier’s condition was limited. At the time Hanaway trans-
ferred Clouthier, she told Foley that Clouthier was suicidal,
had “numerous prior attempts” at suicide, and needed to be on
15-minute checks. But Foley had no other information regard-
ing Clouthier’s mental state; Foley did not have access to
               CLOUTHIER v. COUNTY OF CONTRA COSTA                      1141
Hanaway’s notes or to Clouthier’s medical chart, and he had
not seen Clouthier’s health questionnaire detailing his mental
health history. When Blush took Clouthier off the Observa-
tion Log, she told Foley to give Clouthier his regular clothes
and bedding but not utensils or personal hygiene items, and
instructed Foley to keep Clouthier in the Observation Room.5
There is no evidence that Blush shared her perceptions of
Clouthier’s mental state with Foley. To Foley, Clouthier’s
removal from the Observation Log meant he could be moved
out of an Observation Room and into M-Module’s general
population. In Foley’s experience, inmates having extremely
serious mental health issues would be transferred to the Coun-
ty’s Psychiatric Emergency Services.

   Nor does the evidence indicate that Foley’s understanding
of Clouthier’s situation was willful ignorance of the obvious:
Blush testified that she took Clouthier off the Observation
Log because she believed the risk that Clouthier would com-
mit suicide had decreased, although she was uncertain
whether it had disappeared. On July 29, Brown visited Clou-
thier in the Observation Room and determined, based on her
37 years of clinical experience, that Clouthier was not actively
suicidal.

   [14] Although Foley did not note Blush’s instructions to
keep Clouthier in the Observation Room in the Red Book or
communicate these instructions to other deputies, Foley’s
behavior towards Clouthier was not otherwise indicative of
deliberate indifference. Foley followed Hanaway’s instruc-
tions to check on Clouthier every 15 minutes until Blush
released Clouthier from the Observation Log. Moreover,
Foley complied with Blush’s instructions to keep Clouthier in
the Observation Room; indeed, Clouthier did not leave that
room until four days after Foley’s shift ended.
  5
   As noted earlier, Foley testified that he did not receive this instruction.
1142           CLOUTHIER v. COUNTY OF CONTRA COSTA
   [15] Under these facts, there is insufficient evidence to
establish that Foley was subjectively aware that his failure to
communicate Blush’s instructions to other deputies consti-
tuted a substantial risk of serious harm to Clouthier, and
deliberately ignored that risk. See Farmer, 511 U.S. at 844
(“Because . . . prison officials who lacked knowledge of a risk
cannot be said to have inflicted punishment, it remains open
to the officials to prove that they were unaware even of an
obvious risk to inmate health or safety . . . . Prison officials
charged with deliberate indifference might show, for example,
that they did not know of the underlying facts indicating a
sufficiently substantial danger and that they were therefore
unaware of a danger, or that they knew the underlying facts
but believed (albeit unsoundly) that the risk to which the facts
gave rise was insubstantial or nonexistent.”).6 Although
Foley’s failure to communicate Blush’s instructions may have
been negligent, in the absence of evidence that Foley knew
Clouthier was in substantial danger, it cannot be said that
Foley acted with deliberate indifference. Id. at 835
(“[D]eliberate indifference describes a state of mind more
blameworthy than negligence.”).7
  6
     The dissent argues that whether Foley deliberately ignored a substan-
tial risk of harm to Clouthier is a question that should be decided by a jury.
Dissent at 1154. We disagree. Even if a jury could reasonably conclude
that Blush’s instruction “communicated to Foley that Clouthier still posed
a substantial risk of serious harm to himself,” Dissent at 1154, it does not
follow that a jury also could conclude that Foley showed deliberate indif-
ference to this risk. Rather, Foley acted reasonably under the circum-
stances by following Blush’s instructions and keeping Clouthier in the
Observation Room (where he remained for three more days). See Farmer,
511 U.S. at 844 (“[P]rison officials who actually knew of a substantial risk
to inmate health or safety may be found free from liability if they
responded reasonably to the risk, even if the harm ultimately was not
averted. A prison official’s duty . . . is to ensure ‘reasonable safety’ ”
(quotation marks omitted)).
   7
     The dissent “fail[s] to understand why we should rule as a matter of
law that Foley’s failure to pass that information on to subsequent shifts
was mere negligence.” Dissent at 1155. The answer lies in Farmer’s pro-
nouncement that “an official’s failure to alleviate a significant risk that he
               CLOUTHIER v. COUNTY OF CONTRA COSTA                     1143
   When Foley returned on August 1, Clouthier had been
moved into M-Module’s general population. On this second
shift, Foley “noted nothing unusual” and “saw nothing in
[Clouthier’s] behavior or in his record that [would] lead
[Foley] to believe that [Clouthier] was at risk for suicide.”
The Clouthiers adduced testimony from Clouthier’s cell mate,
Watkins, that when Foley took Watkins out for free time on
August 1, Foley “sure should have been able” to see the knot-
ted sheet hanging over the edge of Clouthier’s bed. But Wat-
kins did not allege that Foley had in fact seen the knotted
sheet, and the Clouthiers adduced no evidence to that effect.8
Foley’s testimony that he did not see the knotted sheet is
therefore undisputed. Again, there is insufficient circumstan-
tial evidence that Foley was subjectively aware of a substan-
tial risk of harm to Clouthier and deliberately ignored it. See
Gibson, 290 F.3d at 1188. Because “the record taken as a
whole could not lead a rational trier of fact to find for” the
Clouthiers, Ricci v. DeStefano, 129 S. Ct. 2658, 2677 (2009)
(quoting Matsushita Elec. Indus. Co. v. Zenith Radio Corp.,
475 U.S. 574, 587 (1986)), summary judgment in favor of
Foley was proper.

                                     V

   We next turn to the Clouthiers’ argument that the district
court erred in granting summary judgment in favor of the
County. Although the Clouthiers frame their argument in dif-
ferent ways, their claim amounts to the assertion that the

should have perceived but did not, while no cause for commendation, can-
not under our cases be condemned as the infliction of punishment.” 511
U.S. at 838. Here the record provided no evidence of Foley’s subjective
awareness that failure to pass on Blush’s instruction created a substantial
risk of harm. Even if Foley should have perceived this risk, his failure to
do so does not rise to “the infliction of punishment.” Id.
   8
     Nor was this a situation like that which took place in Conn, where there
were “warning signs that [would be] difficult for any observer to miss.”
Conn, 572 F.3d at 1057.
1144         CLOUTHIER v. COUNTY OF CONTRA COSTA
County’s procedures for dealing with mentally ill detainees
were deficient, that the County knew of these deficiencies,
and that the County’s deliberate indifference to these deficien-
cies resulted in their son’s death.

   We first examine the legal framework for this claim. The
Clouthiers may recover from the County under § 1983 for
failure to prevent harm to Clouthier under one of three theo-
ries of municipal liability. First, a local government may be
held liable “when implementation of its official policies or
established customs inflicts the constitutional injury.” Monell
v. New York City Dep’t of Soc. Servs., 436 U.S. 658, 708
(1978) (Powell, J. concurring); see also Price v. Sery, 513
F.3d 962, 966 (9th Cir. 2008) (stating that plaintiffs may “es-
tablish municipal liability by demonstrating that . . . the con-
stitutional tort was the result of a longstanding practice or
custom which constitutes the standard operating procedure of
the local government entity” (internal quotation marks omit-
ted)). We have referred to these sorts of local government
conduct as acts of “commission.” Cabrales, 864 F.2d at 1461.

   Second, under certain circumstances, a local government
may be held liable under § 1983 for acts of “omission,” when
such omissions amount to the local government’s own official
policy. Id. (“[A]cts of omission, as well as commission, may
constitute the predicate for a finding of liability under section
1983.”). To impose liability on a local government for failure
to adequately train its employees, the government’s omission
must amount to “deliberate indifference” to a constitutional
right. This standard is met when “the need for more or differ-
ent training is so obvious, and the inadequacy so likely to
result in the violation of constitutional rights, that the policy-
makers of the city can reasonably be said to have been delib-
erately indifferent to the need.” City of Canton v. Harris, 489
U.S. 378, 390 (1989). For example, if police activities in
arresting fleeing felons “so often violate constitutional rights
that the need for further training must have been plainly obvi-
               CLOUTHIER v. COUNTY OF CONTRA COSTA                    1145
ous to the city policymakers,” then the city’s failure to train
may constitute “deliberate indifference.” Id. at 390 n.10.9

   “Only where a failure to train reflects a ‘deliberate’ or ‘con-
scious’ choice by a municipality—a ‘policy’ as defined by our
prior cases—can a city be liable for such a failure under
§ 1983.” Id. at 389. And only under such circumstances does
the failure to train constitute “a policy for which the city is
responsible, and for which the city may be held liable if it
actually causes injury.” Id. at 390. Although this is a high
standard, the Supreme Court warned against diluting the
requirement that a local government can be held liable only
for an action or inaction that amounts to an official policy:

      In virtually every instance where a person has had
      his or her constitutional rights violated by a city
      employee, a § 1983 plaintiff will be able to point to
      something the city “could have done” to prevent the
      unfortunate incident. Thus, permitting cases against
      cities for their “failure to train” employees to go for-
      ward under § 1983 on a lesser standard of fault
      would result in de facto respondeat superior liability
      on municipalities—a result we rejected in Monell. It
      would also engage the federal courts in an endless
      exercise of second-guessing municipal employee-
      training programs. This is an exercise we believe the
      federal courts are ill suited to undertake, as well as
      one that would implicate serious questions of feder-
      alism.
  9
    The “deliberate indifference” standard for municipal liability set forth
in Canton is different from the subjective “deliberate indifference” stan-
dard set forth in Farmer. As explained in Farmer, the “Canton under-
standing of deliberate indifference, permitting liability to be premised on
obviousness or constructive notice,” is an objective standard; however,
such an objective standard “is not an appropriate test for determining the
liability of prison officials.” Farmer, 511 U.S. at 841.
1146         CLOUTHIER v. COUNTY OF CONTRA COSTA
Canton, 489 U.S. at 392 (internal citations omitted).

   [16] Third, a local government may be held liable under
§ 1983 when “the individual who committed the constitu-
tional tort was an official with final policy-making authority”
or such an official “ratified a subordinate’s unconstitutional
decision or action and the basis for it.” Gillette v. Delmore,
979 F.2d 1342, 1346-47 (9th Cir. 1992) (internal quotation
marks and citations omitted); see also City of St. Louis v. Pra-
protnik, 485 U.S. 112, 123-24, 127 (1988); Pembaur v. City
of Cincinnati, 475 U.S. 469, 480-81 (1986). “If the authorized
policymakers approve a subordinate’s decision and the basis
for it, their ratification would be chargeable to the municipal-
ity because their decision is final.” Praprotnik, 485 U.S. at
127 (1988). “There must, however, be evidence of a con-
scious, affirmative choice” on the part of the authorized poli-
cymaker. Gillette, 979 F.2d at 1347. A local government can
be held liable under § 1983 “only where ‘a deliberate choice
to follow a course of action is made from among various
alternatives by the official or officials responsible for estab-
lishing final policy with respect to the subject matter in ques-
tion.’ ” Id. (quoting Pembaur, 475 U.S. at 483-84 (plurality
opinion)).

   The Clouthiers identify two principal deficiencies in the
County’s procedures. First, they allege that the custodial staff
did not comply with the County’s written policy requiring
mental health staff approval for moving a detainee into the
general population. Compounding this problem, the Clou-
thiers allege, was an inadequate system of communication
between mental health staff and custodial staff regarding
when a detainee could be moved from an observation cell.
Second, the Clouthiers allege that the County’s jail was
understaffed, resulting in mental health staff failing to observe
mentally ill detainees with sufficient frequency to ensure their
safety. The Clouthiers make the additional argument that the
County ratified the constitutional violations of its employees.
            CLOUTHIER v. COUNTY OF CONTRA COSTA               1147
                               A

   [17] To evaluate the claim that County employees did not
rigorously implement the policy governing movement of an
inmate out of an observation cell into the general population,
we must begin with the policy itself. The County’s written
policy, Sheriff’s Policy 13.10(II)(B) states, in pertinent part:

    2) If the inmate is not referred to the In-Patient Psy-
    chiatric Unit by medical staff, one of three alterna-
    tive actions will be employed . . . .

    a. Open observation

    ...

    If Mental Health staff determines the inmate can be
    housed with other inmates, the inmate may be
    housed at MDF or WCDF and shall be based on
    Mental Health staff’s recommendation.

    ...

    Deputies will report any changes in behavior to
    Medical/Mental Health staff.

While this language does not expressly preclude deputies
from moving inmates into the general population without
mental health staff approval, the language suggests that depu-
ties would ordinarily obtain a recommendation from mental
health staff before making such a move.

  Other evidence in the record indicates that an inmate is
moved into general population through a consultation
between mental health staff and custodial staff. Captain Pas-
coe testified that “movement of inmates on M Module is a
consultation between health services staff who’s [sic]
assigned there and the deputy . . . . If an officer had an indi-
1148         CLOUTHIER v. COUNTY OF CONTRA COSTA
vidual in one regular housing cell and wanted to move them
to another, they can facilitate that unless they have some indi-
cation that there would be a problem in doing so.” Similarly,
Kramer, the head of Detention Health Services, testified that,
when deputies are concerned about the directions they receive
from mental health staff, they must “get another opinion,”
“ask again the next day,” or otherwise follow “whatever is
within their procedures” in order to move the inmate. The
record indicates that Steele, the deputy who moved Clouthier
into the general population, believed that mental health staff
had approved the move. Viewing the evidence in the light
most favorable to the Clouthiers, this misapprehension was
caused by Foley’s failure to document Blush’s instructions,
Steele’s misunderstanding of the significance of removing an
inmate from the Observation Log in this case, and the
unavailability of mental health staff on the late shift.

   [18] Drawing all inferences in favor of the Clouthiers, a
reasonable jury could conclude that the custodial and mental
health staff were deficient in their implementation of the
County’s written policy, because the custodial staff failed to
ensure they had the approval of mental health staff before
moving Clouthier. However, that does not create a triable
issue of fact on the question whether the County itself is liable
for this deficiency. There is no evidence that the County had
a longstanding custom or practice of moving detainees from
an observation cell into general population without consulta-
tion with mental health staff or contrary to their recommenda-
tions. Nor is there evidence of a longstanding custom or
practice of miscommunication between mental health staff
and custodial staff. There is no evidence that the County was
on actual or constructive notice that deficiencies in the imple-
mentation of its policy would likely result in a constitutional
violation.

   Moreover, nothing in the record indicates that improper
transfers of suicidal inmates happened so frequently that the
need for corrective measures “must have been plainly obvious
              CLOUTHIER v. COUNTY OF CONTRA COSTA                  1149
to the city policymakers.” Canton, 489 U.S. at 390 n.10. In
fact, the evidence in the record indicates that between 2001
and 2006, out of more than 175,000 inmates processed at the
County’s Martinez Detention Facility, 158 suicide attempts
were discovered and only six inmates succeeded in commit-
ting suicide.10 The County’s expert testified that this suicide
rate is “far lower than the statewide average, and far lower
than the rate in jails in most counties with similar population
sizes.” Not only did the Clouthiers fail to adduce evidence of
a pattern of repeated tortious conduct by County staff, but
they also failed to adduce evidence of even a single other sui-
cide resulting from the improper transfer of an inmate from an
observation cell into the general population.

   [19] The Clouthiers point to the affidavit of an expert, who
opined, based on a review of the incident, that the mental
health staff and custodial staff did not share their records and
“did not work together as a team.” The expert also stated there
was a “disconnect” between the mental health staff and the
custodial staff and noted “an inadequacy in training which
appears to be purposely indifferent to the mental health needs
of pre-trial detainees.” But such conclusory assertions are
insufficient to avoid summary judgment. Soremekun v. Thrifty
Payless, Inc., 509 F.3d 978, 984 (9th Cir. 2007) (“Conclusory,
speculative testimony in affidavits and moving papers is
insufficient to raise genuine issues of fact and defeat summary
judgment.”). Moreover, the factual basis for the expert’s dec-
laration is limited to the “sequence of events and the state-
ments of the participants” surrounding Clouthier’s transfer
into the general population. The expert’s report does not
address the key question whether the alleged “disconnect”
was so obvious and “the inadequacy so likely to result in the
violation of constitutional rights, that the policymakers of the
[local government] can reasonably be said to have been delib-
erately indifferent” to the problem. Canton, 489 U.S. at 390.
  10
   The suicide rate in the prison system at issue in Conn was six in only
two years. 572 F.3d at 1053.
1150         CLOUTHIER v. COUNTY OF CONTRA COSTA
In sum, there is no material evidence on the issue of the
County’s knowledge or the obviousness of the problem.

   The Clouthiers also failed to dispute the County’s evidence
that it was not deliberately indifferent to the needs of mentally
ill pretrial detainees. The County had reasonable and well-
established written policies for handling detainee mental
health needs, which the Clouthiers concede “pass constitu-
tional muster.” In addition, the record indicates the County
invested considerable resources in developing its policies and
training its employees, including requiring all new deputies to
complete an eight-week training course and an annual
refresher course concerning people with mental disorders. The
County’s mental health staff are licensed mental health practi-
tioners with graduate degrees, and they receive both on-the-
job training and training in new developments in their areas
of expertise.

   [20] There is little doubt the Clouthiers identified a series
of missteps and miscommunications that led to Clouthier’s
transfer to the general population while he was suicidal. Yet,
the Clouthiers have pointed to no evidence that would allow
a reasonable jury to conclude the County had caused the
improper transfer through deliberate omissions or the imple-
mentation of longstanding practices or customs. Accordingly,
the Clouthiers have not adduced evidence creating a triable
issue of material fact on the crucial issues for County liability.

                                B

   To support their second argument, that the County’s prac-
tices were deficient because the County lacked adequate men-
tal health staffing, the Clouthiers point to Kramer’s testimony:
“We don’t stipulate how often people are to be seen. We don’t
have the staff to put in those sorts of guidelines.” Drawing all
inferences in favor of the Clouthiers, this testimony indicates
that the County did not require mental health staff to observe
mentally ill detainees on a set schedule, which was inconsis-
             CLOUTHIER v. COUNTY OF CONTRA COSTA            1151
tent with its written policy. See Sheriff’s Policy
10.22(III)(E)(3)(a)(iii) (“Special supervision will be given to
any inmate housed in an Observation Room as directed in
writing by Medical/Mental Health staff . . . . Medical/Mental
Health staff will . . . [r]eview the status of the inmate and
update the Housing Unit Deputy every 10 hours so long as the
special supervision is required.”).

   [21] However, the Clouthiers failed to adduce evidence that
the County was on actual or constructive notice of a problem
with mental health understaffing that would amount to a con-
stitutional tort. Further, there was no evidence that this
alleged understaffing problem led to repeated violations of
inmates’ constitutional rights or that the County was aware of
and acquiesced in a pattern of constitutional violations. See
Canton, 489 U.S. at 398 (O’Connor, J., concurring in part and
dissenting in part) (stating plaintiff failed to show a triable
issue where no evidence indicated “that there had been past
incidents of ‘deliberate indifference’ to the medical needs of
emotionally disturbed detainees or that any other circum-
stance had put the city on actual or constructive notice”). The
Clouthiers’ claim thus amounts to the argument that “an
injury or accident could have been avoided” if mental health
staffers had made more frequent observations of Clouthier.
Canton, 489 U.S. at 391. This is precisely the argument
against which the Supreme Court cautioned in Canton. Id. at
392

                               C

   [22] Finally, the Clouthiers argue the County is liable for
the constitutional torts of its employees because it ratified the
employees’ unconstitutional acts. The Clouthiers have not
developed their argument on this point, but merely state that
the County ratified their employees’ conduct by failing to dis-
cipline the employees who violated Clouthier’s constitutional
rights. The Clouthiers adduced evidence that, although
Kramer had “the power to impose any discipline on any of the
1152          CLOUTHIER v. COUNTY OF CONTRA COSTA
mental health specialists,” he did not do so in response to
Blush’s actions.11 This bare allegation is insufficient to create
a triable issue of fact. The Clouthiers have not adduced evi-
dence that Kramer was a final policymaker or, even if he
were, that he made a conscious, affirmative choice to approve
Blush’s actions and adopt them as official policy. As we
stated in Gillette, “[t]o hold cities liable under section 1983
whenever policymakers fail to overrule the unconstitutional
discretionary acts of subordinates would simply smuggle
respondeat superior liability into section 1983 law [creating
an] end run around Monell.” 979 F.2d at 1348.

   Taking all evidentiary inferences in favor of the Clouthiers,
they have at most shown that the County could have better
implemented its policies. But as the Supreme Court has indi-
cated, “[i]n virtually every instance where a person has had
his or her constitutional rights violated by a city employee, a
§ 1983 plaintiff will be able to point to something the city
‘could have done’ to prevent the unfortunate incident.” Can-
ton, 489 U.S. at 392. The Clouthiers have not produced suffi-
cient evidence to create a triable issue as to the question
whether Clouthier’s death was due to a long-standing custom
or practice of the County, an omission that amounted to delib-
erate indifference, or actions the County adopted as policy
when it failed to discipline Blush. Holding the County liable
for the missteps of its employees in this case would therefore
amount to “de facto respondeat superior liability,” an avenue
rejected in Monell. Id.

                                  VI

   We hold that the district court did not err in holding that the
individual defendants in this case could not be held liable for
failing to prevent Robert Clouthier’s suicide unless the defen-
dants had a punitive intent, which in the context of failing to
prevent harm requires a determination whether the defendants
  11
    Victoria Brown was disciplined by the County for her actions.
              CLOUTHIER v. COUNTY OF CONTRA COSTA         1153
were deliberately indifferent to a serous risk of harm. See
Bell, 441 U.S. at 535; Farmer, 511 U.S. at 834. Here, the
Clouthiers adduced sufficient evidence to create a genuine
issue of material fact as to whether Blush was deliberately
indifferent to a substantial risk of serious harm to Robert
Clouthier, and therefore the district court erred in granting
Blush’s motion for summary judgment. Because a reasonable
official would have known such conduct amounted to a con-
stitutional violation, Blush is not entitled to qualified immu-
nity. The district court did not err in granting summary
judgment in favor of Foley and Steele, because the Clouthiers
failed to adduce sufficient evidence to create a genuine issue
of material fact as to whether Foley and Steele were deliber-
ately indifferent to a substantial risk of serious harm. With
regard to their claim against the County, the Clouthiers failed
to adduce sufficient evidence to create a genuine issue of
material fact as to whether Clouthier’s death was due to a
long-standing custom or practice, an act of omission that
amounted to deliberate indifference, or actions the County
adopted as policy when it failed to discipline its employees.
Therefore, the district court properly granted the County’s
motion for summary judgment.12

 AFFIRMED in part, REVERSED in part, and
REMANDED.

BLOCK, Senior District Judge, concurring in part and dis-
senting in part:

  I concur in the majority opinion in all respects save one: I
cannot agree that Deputy Foley is entitled to summary judg-
ment.
  12
    Each party bears its own costs on appeal.
1154         CLOUTHIER v. COUNTY OF CONTRA COSTA
   The crux of the plaintiffs’ claim against Foley is that he
was instructed by Mental Health Specialist Blush not to move
Clouthier out of the Observation Room and failed to commu-
nicate that instruction to subsequent shifts, either orally or by
noting it in the Red Book. With respect to that claim, we must
take as true Blush’s testimony that she gave such an instruc-
tion. Although the majority does so, it concludes that “there
is insufficient evidence to establish that Foley was subjec-
tively aware that his failure to communicate Blush’s instruc-
tion[ ] to other deputies constituted a substantial risk of
serious harm to Clouthier, and deliberately ignored that risk.”
Thus, if a jury were to determine that Blush was not deliber-
ately indifferent because she instructed Foley not to move
Clouthier from the Observation Room, the majority has con-
cluded as a matter of law that it could not then consider
whether Foley deliberately ignored a substantial risk of harm
to Clouthier.

   The majority’s conclusion with respect to Foley resolves
issues that, in my view, should be decided by a jury. As for
the “substantial risk” issue, although I appreciate that Foley’s
training suggested to him that Blush’s decision to remove
Clouthier from the Observation Log meant that he was no lon-
ger a suicide risk, there must have been some reason why
Blush also instructed him not to move Clouthier out of the
Observation Room (assuming that the jury finds that such an
instruction was given); the most obvious candidate is that she
still believed him to be suicidal. Thus, a jury could reasonably
conclude that Blush’s instruction communicated to Foley that
Clouthier still posed a substantial risk of serious harm to him-
self. See Farmer v. Brennan, 511 U.S. 825, 842 (1994)
(“Whether a prison official had the requisite knowledge of a
substantial risk is a question of fact subject to demonstration
in the usual ways, including inference from circumstantial
evidence.”).

  I am also satisfied that a jury could reasonably find that
Foley’s failure to communicate Blush’s instruction crossed
             CLOUTHIER v. COUNTY OF CONTRA COSTA               1155
the line between negligence and deliberate indifference.
According to Captain Pascoe, deputies were expected to use
the Red Book to pass important information to future shifts.
A factfinder could surely determine that Blush’s instruction
was a key suicide prevention measure; indeed, the failure to
implement it arguably paved the way for Clothier’s suicide.
Thus, if a jury were to find that Blush told Foley that Clothier
was not to be taken out of the Observation Room, I fail to
understand why we should rule as a matter of law that Foley’s
failure to pass that information on to subsequent shifts was
mere negligence. See Farmer, 511 U.S. at 847 (official is
deliberately indifferent if “he knows that inmates face a sub-
stantial risk of serious harm and disregards that risk by failing
to take reasonable measures to abate it”).

   Finally, if a jury were to determine that Foley was a trained
deputy charged with the responsibility of implementing a key
suicide prevention measure (i.e., passing on instructions given
by a mental health professional that a detainee at risk of sui-
cide was to remain in the Observation Room), qualified
immunity would not attach because such an officer could not
reasonably have thought it was lawful to do nothing in
response to such an instruction. See Conn v. City of Reno, 572
F.3d 1047, 1062 (9th Cir. 2009) (“When a detainee attempts
or threatens suicide en route to jail, it is obvious that the trans-
porting officers must report the incident to those who will
next be responsible for her custody and safety. Thus, the con-
stitutional right at issue here has been clearly established.”).