Court Opinion

ID: 4647485
Source: CourtListenerOpinion
Date Created: 2020-12-29 19:00:35.325726+00
Date Added: 2024-06-11T08:01:06.129842
License: Public Domain

FILED
                                                            United States Court of Appeals
                                   PUBLISH                          Tenth Circuit

                     UNITED STATES COURT OF APPEALS                December 29, 2020

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

MARTIN CROWSON,

      Plaintiff - Appellee,

v.                                                   No. 19-4118

WASHINGTON COUNTY STATE OF
UTAH; CORY PULSIPHER, acting
Sheriff of Washington County; MICHAEL
JOHNSON,

      Defendants - Appellants,

and

JUDD LAROWE; JON WORLTON,

      Defendants.

–––––––––––––––––––––––––––––––––––

MARTIN CROWSON,

      Plaintiff - Appellee,

v.                                                   No. 19-4120

JUDD LAROWE,

      Defendant - Appellant,

and

WASHINGTON COUNTY STATE OF
UTAH; CORY PULSIPHER, acting
Sheriff of Washington County; MICHAEL
 JOHNSON; JON WORLTON,

      Defendants.
                       _________________________________

                    Appeal from the United States District Court
                              for the District of Utah
                           (D.C. No. 2:15-CV-00880-TC)
                      _________________________________

Frank D. Mylar (Andrew R. Hopkins with him on the briefs), Mylar Law, P.C., Salt
Lake City, Utah, for Defendants - Appellants Michael Johnson, Washington County,
and Sheriff Cory Pulsipher.

Gary T. Wight (Shawn McGarry and Jurhee A. Rice with him on the briefs), Kipp and
Christian, P.C., Salt Lake City, Utah, for Defendant - Appellant Judd LaRowe, M.D.

Devi Rao, Roderick & Solange MacArthur Justice Center, Washington, D.C. (Megha
Ram, Roderick & Solange MacArthur Justice Center, Washington, D.C.; Ryan J.
Schriever, The Schriever Law Firm, Spanish Fork, Utah; David M. Shapiro, Roderick &
Solange, MacArthur Justice Center, Northwestern Pritzker School of Law, Chicago,
Illinois, on the briefs) for Plaintiff - Appellee Martin Crowson.
                           _________________________________

Before MATHESON, BACHARACH, and McHUGH, Circuit Judges.
                  _________________________________

McHUGH, Circuit Judge.
                    _________________________________

      Martin Crowson was an inmate at the Washington County Purgatory

Correctional Facility (the “Jail”) when he began suffering from symptoms of toxic

metabolic encephalopathy. Nurse Michael Johnson and Dr. Judd LaRowe, two of the

medical staff members responsible for Mr. Crowson’s care, wrongly concluded

Mr. Crowson was experiencing drug or alcohol withdrawal. On the seventh day of

medical observation, Mr. Crowson’s condition deteriorated and he was transported to

                                          2
the hospital, where he was accurately diagnosed. After Mr. Crowson recovered, he

sued Nurse Johnson, Dr. LaRowe, and Washington County1 under 42 U.S.C. § 1983,

alleging violations of the Eighth and Fourteenth Amendments.

      The district court denied motions for summary judgment on the issue of

qualified immunity by Nurse Johnson and Dr. LaRowe, concluding a reasonable jury

could find both were deliberately indifferent to Mr. Crowson’s serious medical needs,

and that it was clearly established their conduct amounted to a constitutional

violation. The district court also denied the County’s motion for summary judgment,

concluding a reasonable jury could find the treatment failures were an obvious

consequence of the County’s reliance on Dr. LaRowe’s infrequent visits to the Jail

and the County’s lack of written protocols for monitoring, diagnosing, and treating

inmates.

      Nurse Johnson, Dr. LaRowe, and the County filed these consolidated

interlocutory appeals, which raise threshold questions of jurisdiction. Nurse Johnson

and Dr. LaRowe challenge the district court’s denial of qualified immunity, while the

      1
         Mr. Crowson also sued Cory Pulsipher, the acting Sheriff of Washington
County, in his official capacity. But official-capacity suits “generally represent only
another way of pleading an action against an entity of which an officer is an agent.”
Kentucky v. Graham, 473 U.S. 159, 165 (1985) (quoting Monell v. New York City
Dept. of Soc. Servs., 436 U.S. 658, 690 n.55 (1978)). “As long as the government
entity receives notice and an opportunity to respond, an official-capacity suit is, in all
respects other than name, to be treated as a suit against the entity.” Id. at 166. The
district court and the parties have treated Mr. Crowson’s Monell claims against
Sheriff Pulsipher accordingly. See, e.g., App., Vol. I at 209 n.1; Appellee Br. at 7 n.2.
We therefore refer only to Washington County.
                                            3
County contends we should exercise pendent appellate jurisdiction to review the

district court’s denial of its summary judgment motion.2

      For the reasons explained below, we exercise limited jurisdiction over

Nurse Johnson’s and Dr. LaRowe’s appeals pursuant to the exception to 28 U.S.C.

§ 1291 carved out for purely legal issues of qualified immunity through the collateral

order doctrine. See Mitchell v. Forsyth, 472 U.S. 511, 524–30 (1985). We hold

Nurse Johnson’s conduct did not violate Mr. Crowson’s rights and, assuming without

deciding that Dr. LaRowe’s conduct did, we conclude Dr. LaRowe’s conduct did not

violate any clearly established rights.

      Our holding on Nurse Johnson’s appeal is inextricably intertwined with the

County’s liability on a failure-to-train theory, so we exercise pendent appellate

jurisdiction to the extent Mr. Crowson’s claims against the County rest on that

theory. See Moore v. City of Wynnewood, 57 F.3d 924, 930 (10th Cir. 1995).

However, under our binding precedent, our holdings on the individual defendants’

appeals are not inextricably intertwined with Mr. Crowson’s claims against the

County to the extent he advances a systemic failure theory. See id. We therefore

reverse the district court’s denial of summary judgment to Nurse Johnson and

      2
         Nurse Johnson and the County’s Opening Brief is cited herein as “County
Br.,” and their Reply Brief is cited as “County Reply.” Dr. LaRowe’s Opening Brief
is cited as “LaRowe Br.,” and his Reply brief is cited as “LaRowe Reply.”
Mr. Crowson’s Brief is cited as “Appellee Br.”

                                           4
Dr. LaRowe, as well as to the County on the failure-to-train theory, and we dismiss

the remainder of the County’s appeal for lack of jurisdiction.

                                 I.     BACKGROUND

                                      A. Factual History3

       On June 11, 2014, Mr. Crowson was booked into the Washington County

Purgatory Correctional Facility for a parole violation. On June 17, due to a disciplinary

violation, Mr. Crowson was placed in solitary confinement, known as the “A Block.”

       “On the morning of June 25, while still in solitary confinement, Jail Deputy Brett

Lyman noticed that Mr. Crowson was acting slow and lethargic.” App., Vol. I at 205.

Deputy Lyman asked Nurse Johnson to check Mr. Crowson. “As a registered nurse,

Nurse Johnson could not formally diagnose and treat Mr. Crowson.” App., Vol. I at 205.

Rather, Nurse Johnson assessed inmates and communicated with medical staff. The

medical staff available to diagnose were Jon Worlton, a physician assistant (“PA”),4 and

Dr. LaRowe, the Jail’s physician.

       3
         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. See Mitchell v. Forsyth, 472 U.S. 511, 524–30 (1985).
       4
         There is some ambiguity concerning whether Jon Worlton was, in fact, a PA.
The district court found he was a PA. At oral argument, the County asserted that
Mr. Worlton was a nurse practitioner, not a PA, but suggested that accorded him
similar or greater medical training. In describing his education, Mr. Worlton stated,
“I’m a social worker. I have a master’s degree in social work. I also have a clinical
license, licensed clinical social worker.” App., Vol. II at 478. At oral argument
before this court, however, counsel for Mr. Crowson answered affirmatively when
asked whether Mr. Worlton was a PA and whether he could diagnose inmates. Where
neither party has challenged the district court’s finding that Mr. Worlton was a PA,
                                              5
       At all relevant times, PA Worlton was the Jail’s health services administrator and

also handled mental health care for the inmates. PA Worlton spent half to three quarters

of his time in clinical practice at the Jail, primarily in booking. Dr. LaRowe was

responsible for diagnosing and treating inmates, but he visited the Jail only one or two

days a week, for two to three hours at a time. Dr. LaRowe relied heavily on the Jail’s

deputies and nurses. Jail deputies checked on inmates who were in medical observation

cells at least once every thirty minutes, and the deputies would notify a Jail nurse when

an inmate was “not acting right” or “having problems.” App., Vol. I at 219 (quoting

App., Vol. II at 504). “Jail nurses—who, by law, could not diagnose inmates—generally

spent five to ten minutes with” inmates in medical observation cells once every twelve-

hour shift, “to take the inmate’s vital signs and conduct follow-up checks.” App., Vol. I at

219. If an inmate exhibited symptoms of a cognitive problem, the nurse would inform

Dr. LaRowe and PA Worlton. There are no written policies or procedures regarding

inmate medical care in the record.

       When Nurse Johnson evaluated Mr. Crowson on June 25, he noted Mr. Crowson

had normal vital signs and some memory loss. Specifically, “Mr. Crowson was ‘dazed

and confused,’ and ‘unable to remember what kind of work he did prior to being

arrested.’” App., Vol. I at 213 (quoting App., Vol. II at 374). Nurse Johnson “admitted in

his declaration that, despite recording normal vital signs, he ‘was concerned

[Mr. Crowson] may be suffering from some medical problem.’” App., Vol. I at 213

and Mr. Crowson’s counsel affirmed that professional status at oral argument, we
presume it is true for purposes of our analysis.
                                             6
(alteration in original) (quoting App., Vol. II at 317). Nurse Johnson ordered

Mr. Crowson moved to a medical observation cell following the examination. He also

“entered a request in the medical recordkeeping system for PA Worlton to conduct a

psychological evaluation.” App., Vol. I at 205.

       When Jail Deputy Fred Keil moved Mr. Crowson to a medical observation cell, he

noticed that Mr. Crowson appeared “unusually confused.” App., Vol I at 205. After

conducting a visual body cavity search of Mr. Crowson, Deputy Keil ordered

Mr. Crowson to re-dress. Mr. Crowson put on his pants and then put his underwear on

over his pants.

       Nurse Johnson checked Mr. Crowson again that afternoon. “Mr. Crowson’s pupils

were dilated but reactive to light” and “Mr. Crowson appeared alert and oriented.” App.,

Vol. I at 206. Nurse Johnson left the Jail at the end of his shift on June 25 without

conducting further assessments of Mr. Crowson or contacting Dr. LaRowe. PA Worlton

never received Nurse Johnson’s file notation requesting a psychological examination of

Mr. Crowson.

       Nurse Johnson did not work at the Jail on June 26 and 27. There is no

documentation in the Jail’s medical recordkeeping system for these days to show that

medical personnel checked on Mr. Crowson.

       On June 28, Nurse Johnson returned to work and visited Mr. Crowson in the early

afternoon. “Mr. Crowson seemed confused and disoriented and had elevated blood

pressure. He gave one-word answers to Nurse Johnson’s questions, and understood, but

could not follow, an instruction to take a deep breath.” App., Vol. I at 206. At this point,

                                              7
“Mr. Crowson’s symptoms had persisted beyond the expected timeframe for substance

withdrawal.” App., Vol. I at 213.

       Following the June 28 examination, Nurse Johnson called Dr. LaRowe and

informed him of some of his observations. But Nurse Johnson did not tell Dr. LaRowe

that Mr. Crowson had been in a medical observation cell for three days and had been in

solitary confinement for nine days before that. Dr. LaRowe ordered a chest x-ray and a

blood test. “The blood test, known as a complete blood count, could have detected an

acid-base imbalance in Mr. Crowson’s blood, a symptom of encephalopathy.” App., Vol.

I at 206.

       Nurse Johnson attempted to draw Mr. Crowson’s blood, but he was unsuccessful

due to scarring on Mr. Crowson’s veins and Mr. Crowson’s unwillingness to hold still.

Nurse Johnson reported this unsuccessful blood-draw attempt to Dr. LaRowe. Ultimately,

the chest x-ray and blood test were never completed. Dr. LaRowe made no further

attempts to diagnose Mr. Crowson at that time.

       On the morning of June 29, Nurse Johnson took Mr. Crowson’s vital signs and

noted an elevated heart rate. “Mr. Crowson was still acting dazed and confused, and was

experiencing delirium tremens, a symptom of alcohol withdrawal.” App., Vol. I at 206–

07. Nurse Johnson reported his observations to Dr. LaRowe, who prescribed Librium and

Ativan to treat substance withdrawal. Dr. LaRowe directed Nurse Johnson to administer a

dose of Ativan.5

       5
       Mr. Crowson’s circumstances prior to his incarceration suggest these
medications may have been harmful to him beyond worsening his encephalopathy.
                                           8
        “An hour later, Nurse Johnson checked on Mr. Crowson, who was sleeping, and

noted that his vital signs had returned to normal.” App., Vol. I at 207. He next checked on

Mr. Crowson later that afternoon. “He noted that Mr. Crowson was better able to

verbalize his thoughts and that his vital signs remained stable.” App., Vol. I at 207. But

Mr. Crowson continued to report memory loss, telling Nurse Johnson that he could not

remember the last five days. Nurse Johnson, believing Mr. Crowson was experiencing

substance withdrawal, told Mr. Crowson that he was in a medical observation cell, and he

was being given medication for his condition.

        The following day (June 30), Nurse Ryan Borrowman was assigned to the medical

holding area. Nurse Borrowman did not see Mr. Crowson until July 1, when he noted that

Mr. Crowson’s “physical movements were delayed and that he struggled to focus and

would lose his train of thought.” App., Vol. I at 207. “[D]ue to the severity of [Mr.

Crowson’s] symptoms and the length of time he had been in a medical holding cell,

[Nurse Borrowman] immediately called Dr. LaRowe for further medical care.” App.,

Vol. II at 313. Upon Dr. LaRowe’s order, Mr. Crowson was transported to the Dixie

Regional Medical Center, where he was diagnosed with metabolic encephalopathy.

Dr. LaRowe never visited the Jail while Mr. Crowson was in the medical observation

cell.

He was hospitalized at Dixie Regional Medical Center “a few weeks before being
arrested and detained” at the Jail. App., Vol. I at 207. The amended complaint
indicates medical records from this hospitalization “‘would have revealed to Facility
staff that [he] should not have been given any drug categorized as a benzodiazepine’
(such as Librium).” App., Vol. 1 at 207–08. That prior hospitalization appears to
have been the result of a heroin overdose.
                                             9
       “According to the amended complaint, Mr. Crowson remained in the hospital until

July 7, 2014, and continued to suffer from ‘residual effects of encephalopathy, liver

disease, and other problems.’” App., Vol. I at 208 (quoting App., Vol. I at 39).

Mr. Crowson spent two months recovering at his mother’s house, experiencing severe

memory and focus problems, before returning to the Jail on September 7, 2014.

                                 B. Procedural History

       Mr. Crowson filed a Complaint on December 15, 2015, which he amended on

March 14, 2016. The Amended Complaint brings, inter alia, § 1983 claims against Nurse

Johnson and Dr. LaRowe alleging they were deliberately indifferent to Mr. Crowson’s

serious medical needs in violation of Mr. Crowson’s Eighth and Fourteenth Amendment

rights. The Amended Complaint also includes § 1983 claims against Washington County

pursuant to Monell v. New York City Department of Social Services, 436 U.S. 658

(1978).6

       In 2018, Nurse Johnson, Dr. LaRowe, and Washington County moved for

summary judgment. Nurse Johnson and Dr. LaRowe argued they were entitled to

qualified immunity. The County argued that none of its employees committed a

constitutional violation and that there is no evidence of a County policy or custom

that caused the alleged constitutional violation. On July 19, 2019, the district court

denied the motions in relevant part. The district court concluded a reasonable jury

could find Nurse Johnson and Dr. LaRowe were deliberately indifferent to

       6
       These are the only surviving claims and defendants. Other parties and claims
have been dismissed by various court orders and party stipulations.
                                            10
Mr. Crowson’s medical needs, and that it was clearly established their conduct

amounted to a constitutional violation. The district court also concluded a reasonable

jury could find the treatment failures were an obvious consequence of the County’s

reliance on Dr. LaRowe’s infrequent visits to the Jail and the County’s lack of

written protocols for monitoring, diagnosing, and treating inmates. Nurse Johnson,

Dr. LaRowe, and Washington County filed these consolidated interlocutory appeals.

                                II.   DISCUSSION

      We begin our analysis by examining the individual defendants before turning

to the County. Mr. Crowson challenges our jurisdiction over this appeal, so each

discussion begins with the question of jurisdiction.

                               A. Individual Defendants

1. Jurisdiction

      When examining the denial of summary judgment on the issue of qualified

immunity, “this court has jurisdiction to review (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.”

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

marks omitted). Generally, we lack jurisdiction to review factual disputes in this

interlocutory posture. Lynch v. Barrett, 703 F.3d 1153, 1159 (10th Cir. 2013) (“[I]f a

district court concludes 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—

                                           11
and do so even if our own de novo review of the record might suggest otherwise as a

matter of law.” (quotation marks omitted)).

       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.’” Lewis v. Tripp, 604 F.3d 1221, 1225–26 (10th Cir.

2010) (quoting Scott v. Harris, 550 U.S. 372, 380 (2007)). In such circumstance, we

assess the facts de novo. Id. “A mere claim that the record ‘blatantly’ contradicts the

district court’s factual recitation . . . does not require us to look beyond the facts

found and inferences drawn by the district court. Rather, the court’s findings must

constitute ‘visible fiction.’” Lynch, 703 F.3d at 1160 n.2 (quoting Scott, 550 U.S. at

380–81). “The standard is a very difficult one to satisfy.” Cordero v. Froats, 613 F.

App’x 768, 769 (10th Cir. 2015) (unpublished).

       Nurse Johnson and Dr. LaRowe argue this case is the unusual one where we

may review the facts de novo. Because we find reversal is warranted taking the

district court’s facts as true, we need not analyze whether we would be permitted to

consider the facts de novo.

2. Merits Analysis

       “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.’” Mullenix v. Luna, 577 U.S.

7, 11 (2015) (quoting Pearson v. Callahan, 555 U.S. 223, 231 (2009)). When a

§ 1983 defendant asserts qualified immunity, this affirmative defense “creates a

                                            12
presumption that [the defendant is] immune from suit.” Perea v. Baca, 817 F.3d

1198, 1202 (10th Cir. 2016). “To overcome this presumption,” the plaintiff “must

show that (1) the officers’ alleged conduct violated a constitutional right, and (2) it

was clearly established at the time of the violation, such that ‘every reasonable

official would have understood,’ that such conduct constituted a violation of that

right.” Id. (quoting Mullenix, 577 U.S. at 11).

      Mr. Crowson alleges Nurse Johnson and Dr. LaRowe violated his Eighth and

Fourteenth Amendment rights. “The Fourteenth Amendment prohibits deliberate

indifference to a pretrial detainee’s serious medical needs.” Strain v. Regalado, 977

F.3d 984, 987 (10th Cir. 2020). “[W]e apply the two-part Eighth Amendment inquiry

when a pretrial detainee alleges deliberate indifference to serious medical needs.”

Quintana v. Santa Fe Cnty. Bd. of Comm’rs, 973 F.3d 1022, 1028 (10th Cir. 2020).

“This exercise requires both an objective and a subjective inquiry.” Id.7 “The

objective component is met if the deprivation is ‘sufficiently serious.’ . . . The

subjective component is met if a prison official ‘knows of and disregards an

excessive risk to inmate health or safety.’” Sealock v. Colorado, 218 F.3d 1205, 1209

(10th Cir. 2000) (quoting Farmer v. Brennan, 511 U.S. 825, 834, 837 (1970)).

      7
         Mr. Crowson argues the standard should be purely objective under Kingsley
v. Hendrickson, 576 U.S. 389 (2015). But during the pendency of this appeal, a panel
of this court held, in a published opinion, “deliberate indifference to a pretrial
detainee’s serious medical needs includes both an objective and a subjective
component, even after Kingsley.” Strain v. Regalado, 977 F.3d 984, 989 (10th Cir.
2020). We are bound by the holding in Strain. See Scalia v. Paragon Contractors
Corp., 957 F.3d 1156, 1162 (10th Cir. 2020).
                                           13
       As for the requirement it be clearly established that the conduct constituted a

violation, “‘the salient question . . . is whether the state of the law’ at the time of an

incident provided ‘fair warning’ to the defendants ‘that their alleged [conduct] was

unconstitutional.’” Tolan v. Cotton, 572 U.S. 650, 656 (2014) (alterations in original)

(quoting Hope v. Pelzer, 536 U.S. 730, 741 (2002)). “[F]or the law to be clearly

established, there must be a Supreme Court or Tenth Circuit decision on point, or the

clearly established weight of authority from other courts must have found the law to

be as the plaintiff maintains.” Halley v. Huckaby, 902 F.3d 1136, 1149 (10th Cir.

2018) (quotation marks omitted). We may not “define clearly established law at a

high level of generality.” Mullenix, 577 U.S. at 12 (quoting Ashcroft v. al-Kidd, 563

U.S. 731, 742 (2011)). “Nevertheless, our analysis is not a scavenger hunt for prior

cases with precisely the same facts, and a prior case need not be exactly parallel to

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

Reavis ex rel. Estate of Coale v. Frost, 967 F.3d 978, 992 (10th Cir. 2020) (quotation

marks omitted).

       a.     Nurse Johnson

       We assume without deciding that the harm suffered by Mr. Crowson meets the

objective component of the Eighth Amendment inquiry. Nurse Johnson argues he was

not deliberately indifferent under the subjective component. We agree.

       “Our cases recognize two types of conduct constituting deliberate indifference.

First, a medical professional may fail to treat a serious medical condition properly”;

second, a prison official may “prevent an inmate from receiving treatment or deny

                                            14
him access to medical personnel capable of evaluating the need for treatment.”

Sealock, 218 F.3d at 1211. Although medical personnel often face liability for failure

to treat under the first type of deliberate indifference, if “the medical professional

knows that his role . . . is solely to serve as a gatekeeper for other medical personnel

capable of treating the condition, . . . he also may be liable for deliberate indifference

from denying access to medical care.” Id. Mr. Crowson argues Nurse Johnson’s

conduct falls within this second type of deliberate indifference.

      The district court agreed, finding Nurse Johnson was deliberately indifferent

on June 25 when he “placed Mr. Crowson in an observation cell and left his shift

without ensuring that Mr. Crowson would receive further care,” and on June 28 when

he “failed to tell Dr. LaRowe that Mr. Crowson had already been in a medical

observation cell for three days and in solitary confinement for nine days before that.”

App., Vol. I at 213. On appeal, Nurse Johnson argues the district court erred in

“infer[ring his] knowledge of an excessive risk of inmate harm” and claims that by

referring Mr. Crowson to PA Worlton, he “fulfilled any possible gatekeeper role.”

County Br. at 25, 28. Regarding his June 28 visit to see Mr. Crowson, Nurse Johnson

argues “he fully fulfilled his ‘gatekeeper’ role by simply communicating with

Dr. LaRowe” and that “the failure to pass on some information is in the form of

negligence and not ‘deliberate indifference.’” County Br. at 27, 29.

      In response, Mr. Crowson claims Nurse Johnson’s June 25 attempted referral

to PA Worlton for a psychological evaluation, without also referring him to

Dr. LaRowe for a physical evaluation, “prevent[ed Mr. Crowson’s] physical

                                           15
symptoms from being evaluated and treated.” Appellee Br. at 24. Mr. Crowson also

contends Nurse Johnson’s admitted concern that Mr. Crowson might be suffering

from a medical problem “indicate[s] that the risk of harm was obvious and that

[Nurse] Johnson was aware of the risk on June 25.” Id. at 25. Regarding the June 28

conduct, Mr. Crowson argues Nurse Johnson failed to pass on “critical information”

that Dr. LaRowe could have used to rule out withdrawal as a possible diagnosis. Id.

       We address each instance of deliberately indifferent conduct found by the

district court.

              i. The referral to PA Worlton for psychological evaluation

       We agree with the district court that the evidence would allow a jury to

conclude Nurse Johnson was aware Mr. Crowson required medical attention. See

App., Vol. I at 213 (“Nurse Johnson himself noted that Mr. Crowson was ‘dazed and

confused,’ and ‘unable to remember what kind of work he did prior to being

arrested.’ He admitted in his declaration that, despite recording normal vital signs, he

‘was concerned [Mr. Crowson] may be suffering from some medical problem.’”

(alteration in original) (first quoting App., Vol. II at 374; then quoting App., Vol. II

at 317)). Nurse Johnson therefore knew Mr. Crowson had potentially alarming

symptoms and suspected there was a medical issue. That knowledge was sufficient to

trigger Nurse Johnson’s duty as a gatekeeper to provide Mr. Crowson access to

medical personnel who could provide care.

       On June 25, Nurse Johnson assessed Mr. Crowson and “entered a request in

the medical recordkeeping system for PA Worlton to conduct a psychological

                                           16
evaluation.” App. I at 205. Nurse Johnson then left the Jail, without also contacting

Dr. LaRowe. Upon Nurse Johnson’s return on June 28, he did contact Dr. LaRowe

about Mr. Crowson’s symptoms.

       Although the initial referral to PA Worlton was for a psychological

examination, rather than a physiological one, that was consistent with Nurse

Johnson’s belief Mr. Crowson was suffering from psychological issues caused by the

ingestion of illicit drugs or alcohol. Further, nothing in the record or the district

court’s opinion suggests PA Worlton—if presented with clear signs of medical

distress—would have limited the examination of Mr. Crowson to psychological

issues. Indeed, as the health services administrator for the Jail, PA Worlton could

refer Mr. Crowson to Dr. LaRowe as necessary. And, unlike Dr. LaRowe, PA

Worlton spent much of his time at the Jail.

       In his gatekeeping role, Nurse Johnson was required to inform medical staff

who could diagnose and treat a pretrial detainee exhibiting concerning symptoms. He

attempted to do so by requesting a psychological evaluation of Mr. Crowson, making

notations in Mr. Crowson’s file, and having discussions with PA Worlton about

Mr. Crowson’s condition.8

       8
        The district court’s statement that PA Worlton “never received Nurse
Johnson’s request for a psychological examination,” App., Vol. I at 206, does not
take into account PA Worlton’s deposition testimony that Nurse Johnson told
PA Worlton he was “concerned that [Mr. Crowson] had gotten involved in some
drugs or homemade alcohol on the block or something and he asked me to take a look
at him,” App., Vol. II at 482. On appeal, Mr. Crowson does not ask us to ignore that
testimony, but rather argues it is irrelevant because it related to Mr. Crowson’s
mental health rather than physical health, an argument we reject supra. However, the
                                            17
      It is true that Nurse Johnson could have done more. He could have ensured

that the referral reached PA Worlton, communicated the severity of Mr. Crowson’s

condition, or contacted Dr. LaRowe immediately. But Nurse Johnson did not “deny

[Mr. Crowson] access to medical personnel capable of evaluating the need for

treatment.” Sealock, 218 F.3d at 1211. He left a notation in Mr. Crowson’s file

regarding the referral to PA Worlton, who, as the health services administrator, was

not bound by Nurse Johnson’s presumption that the examination should focus on

psychological issues.

      Because Nurse Johnson did not “completely refuse[] to fulfill [his] duty as

gatekeeper,” and instead, referred the “prisoner to a physician assistant for medical

treatment,” Mata v. Saiz, 427 F.3d 745, 758 (10th Cir. 2005), he was not deliberately

indifferent to his gatekeeper role. Id. Nurse Johnson’s attempted method of referral

may have been negligent, but it was not deliberately indifferent. See Farmer, 511

U.S. at 835 (“[D]eliberate indifference describes a state of mind more blameworthy

than negligence.”).

             ii. June 28 referral to Dr. LaRowe

      Mr. Crowson next claims he had been in custody too long still to be suffering

from withdrawal related to pre-incarceration drug use, and Nurse Johnson’s failure to

inform Dr. LaRowe on June 28 of how long Mr. Crowson had been in custody thus

electronic referral sufficed to fulfill Nurse Johnson’s duty, even if negligently made;
accordingly, we need not determine whether the district court’s findings of fact were
blatantly contradicted by the record.
                                          18
constitutes deliberate indifference. Based on our decision in Sealock, we disagree.

There, the plaintiff was incarcerated and experiencing numerous medical symptoms.

Sealock, 218 F.3d at 1208. After repeated requests, he was moved to the infirmary

where he told the nurse “he had chest pain and couldn’t breathe.” Id. The nurse

informed the plaintiff “that he had the flu and that there was nothing she could do for

him until the physician’s assistant arrived at 8:00 a.m.” Id. Whether the nurse

informed the PA that the plaintiff was experiencing chest pains was a disputed fact—

the nurse testified she had, the PA testified she had not. Id. at 1212. According to the

PA, had he been informed of the chest pains, he would have called an ambulance to

take the plaintiff to the emergency room. Id. at 1208. Instead the PA prescribed

medication and the plaintiff was not treated for his actual condition—a heart attack—

until the next day. Id. We affirmed the district court’s grant of summary judgment to

the nurse, reasoning, “[a]t worst,” the nurse “misdiagnosed” the inmate and failed to

pass on information to the PA about the inmate’s chest pain. Id. at 1211. Although

the nurse omitted this critical symptom, we concluded it did not demonstrate that she

behaved with deliberate indifference. See id.

      The same is true here. On June 28, Nurse Johnson did “alert Dr. LaRowe to

Mr. Crowson’s condition.” App., Vol. I at 213. Via that telephone call, Nurse

Johnson fulfilled his gatekeeping role “by communicating the inmate’s symptoms to

a higher-up.” Burke v. Regalado, 935 F.3d 960, 993 (10th Cir. 2019). To be sure,

Nurse Johnson could have volunteered information about the length of Mr.

Crowson’s detention that might have assisted Dr. LaRowe in reaching a diagnosis. As

                                           19
in Sealock, however, Nurse Johnson did not act with deliberate indifference by

failing to do so. At worst, Nurse Johnson incorrectly concluded Mr. Crowson was

suffering withdrawal, based on an assumption that Mr. Crowson had obtained an

illicit substance while incarcerated, and Nurse Johnson then negligently failed to pass

along information concerning the length of Mr. Crowson’s incarceration.

                                         ***

      In summary, Nurse Johnson did not violate Mr. Crowson’s Fourteenth

Amendment rights on June 25 or June 28. The referral to PA Worlton fulfilled Nurse

Johnson’s gatekeeping function by passing Mr. Crowson to the health services

administrator who was capable of making a further referral. Likewise, Nurse Johnson

was not deliberately indifferent to Mr. Crowson’s medical needs on June 28, despite

his failure to notify Dr. LaRowe of the length of Mr. Crowson’s detention. We

therefore reverse the district court’s denial of qualified immunity to Nurse Johnson.

      b.     Dr. LaRowe

      Mr. Crowson contends that, by failing to obtain a blood test, Dr. LaRowe

exhibited deliberate indifference to Mr. Crowson’s serious medical condition. For

purposes of this analysis, we assume without deciding that Mr. Crowson has satisfied

the first requirement to overcome a claim of qualified immunity: violation of Mr.

Crowson’s constitutional right. We therefore proceed directly to the second prong of

the qualified immunity analysis: whether the violation was clearly established.9 See

      9
         Mr. Crowson asserts that Dr. LaRowe is a private contractor who is not
entitled to assert a defense of qualified immunity under Richardson v. McKnight, 521
                                          20
Pearson, 555 U.S at 236 (holding courts are “permitted to exercise their sound

discretion in deciding which of the two prongs of the qualified immunity analysis

should be addressed first in light of the circumstances in the particular case at

hand.”).

      The district court relied on our decision in Mata to conclude it was clearly

established that Dr. LaRowe’s failure to complete the blood test violated

Mr. Crowson’s constitutional rights. In doing so, the district court stated that

“Dr. LaRowe ‘did not simply misdiagnose’ Mr. Crowson, he ‘refused to assess or

diagnose [his] condition at all’ and simply assumed he was experiencing substance

withdrawals.” App., Vol. I at 216–17 (alteration in original) (quoting Mata, 427 F.3d

at 758). Dr. LaRowe argues he “is entitled to qualified immunity because no law

U.S. 399 (1997). Although Mr. Crowson concedes he did not raise this argument
before the district court, he requests we consider it as an argument for affirmance on
alternate grounds. Not only did Mr. Crowson fail to raise this argument before the
district court, his briefing on appeal treats it only perfunctorily. The entirety of his
legal argument relies on Richardson and consists of one sentence: “[T]he Supreme
Court has concluded that similarly-situated ‘private prison guards, unlike those who
work directly for the government, do not enjoy immunity from suit in a § 1983
case.’” Appellee Br. at 38 (quoting Richardson, 521 U.S. at 412). Mr. Crowson’s
one-sentence argument not only overlooks the limited nature of the Supreme Court’s
holding in Richardson, but also does not address the rule outlined in Richardson and
reiterated in Filarsky v. Delia, 566 U.S. 377 (2012), for determining when a private
party may assert a qualified immunity defense. Mr. Crowson also does not
acknowledge that other circuits are split on whether private health care providers
hired by the state may assert a qualified immunity defense. If we were to consider
this argument, the result would be deepening a circuit split without the benefit of
adequate adversarial briefing on the issue. We therefore decline to reach this
argument. See Elkins v. Comfort, 392 F.3d 1159, 1162 (10th Cir. 2004).
                                           21
characterized misdiagnosis of an inmate’s substance withdrawal as a constitutional

violation at the time he treated [Mr.] Crowson.” LaRowe Reply at 19.

      In the district court’s view, Dr. LaRowe failed to assess or diagnose

Mr. Crowson because Dr. LaRowe did not ensure complete diagnostic testing before

prescribing medication for withdrawal. The district court reasoned that Dr. LaRowe

“did not misdiagnose Mr. Crowson, but rather failed to conduct diagnostic tests that

would have informed him of Mr. Crowson’s medical needs” because, “despite vague

and nonspecific symptoms, he prescribed medication based on his unverified

suspicion that Mr. Crowson was suffering from withdrawals.” App., Vol. I at 215–

216. We do not reconsider the facts found by the district court, but we are not bound

by the district court’s conclusion that those facts amounted to a failure to diagnose

rather than a misdiagnosis as a matter of law.

      Although Dr. LaRowe failed to obtain complete diagnostic testing, he

ultimately prescribed medication to treat withdrawal. Thus, Dr. LaRowe apparently

determined Mr. Crowson’s symptoms were caused by withdrawal, and prescribed

medication to treat that condition. Although Dr. LaRowe’s diagnosis would have

been better informed by the blood test, we cannot conclude that Dr. LaRowe failed to

make a diagnosis at all.

      The question presented, then, is whether it was clearly established that

reaching a diagnosis without blood test results violated the plaintiff’s rights where

the plaintiff’s symptoms were consistent with either withdrawal or encephalopathy.

For law to be clearly established, “[t]he precedent must be clear enough that every

                                           22
reasonable official would interpret it to establish the particular rule the plaintiff seeks

to apply.” Brown v. Flowers, 974 F.3d 1178, 1184 (10th Cir. 2020) (alteration in

original) (quoting District of Columbia v. Wesby, 138 S. Ct. 577, 590 (2018)). “But

even when such a precedent exists, subsequent [controlling] cases may conflict with

or clarify the earlier precedent, rendering the law unclear.” Apodaca v. Raemisch,

864 F.3d 1071, 1076 (10th Cir. 2017). When “the question is within the realm of

reasonable debate,” the law is not clearly established. Id. at 1078.

       The facts of this case fall between two lines of precedent. On the one hand, “[a]

medical decision not to order an X-ray, or like measures, does not represent cruel and

unusual punishment[;] [a]t most it is medical malpractice.” Estelle v. Gamble, 429

U.S. 97, 107 (1976). If he had never ordered it, then, Dr. LaRowe’s failure to obtain a

blood test would be at most medical malpractice. See id. Similarly, if Dr. LaRowe

had treated Mr. Crowson for withdrawal based on vague, nonspecific symptoms, that

alone would not be enough to prove deliberate indifference. See Self v. Crum, 439

F.3d 1227, 1234 (10th Cir. 2006) (“Where a doctor faces symptoms that could

suggest either indigestion or stomach cancer, and the doctor mistakenly treats

indigestion, the doctor’s culpable state of mind [i.e., deliberate indifference] is not

established even if the doctor’s medical judgment may have been objectively

unreasonable.”).

       On the other hand, in Mata we concluded that a nurse who did a physical exam

and performed an EKG that produced normal results before sending an inmate away

was not deliberately indifferent because she “made a good faith effort to diagnose

                                            23
and treat” the inmate. Mata, 427 F.3d at 760–61. Mata establishes that a medical

professional faced with symptoms of a serious medical condition must make some

effort to assess and treat the patient. See Quintana, 973 F.3d at 1033 (“[I]t [is] clearly

established that when a detainee has obvious and serious medical needs, ignoring

those needs necessarily violates the detainee’s constitutional rights.”). But Mata does

not require a medical professional to perform any diagnostic testing, let alone any

specific diagnostic testing, to avoid liability.

       Here, Dr. LaRowe ordered diagnostic testing, was informed the testing could

not be completed, and did not make further attempts to test. Instead, he began

treatment for what he deemed the likely cause of Mr. Crowson’s symptoms. Even

where the blood test would have provided information that could have better

informed the diagnosis, the parties do not cite, and we have not found, any decision

from the Supreme Court or this court that would have put Dr. LaRowe on notice that

his conduct violated Mr. Crowson’s Fourteenth Amendment rights.

       Mr. Crowson points to our decision in Mata and asserts that an official can be

liable if he “declined to confirm inferences of risk that he strongly suspected to

exist.” Mata, 427 F.3d at 752 (quoting Farmer, 511 U.S. at 843 n.8). But there is

nothing that suggests Dr. LaRowe strongly suspected Mr. Crowson was suffering

from encephalopathy. To the contrary, Dr. LaRowe suspected Mr. Crowson was

suffering from withdrawal, as is indicated by the medication he prescribed. And, like

the inmate in Estelle, Mr. Crowson’s symptoms were consistent with either diagnosis.

                                            24
      To conclude Mata put all reasonable doctors on notice that failing to obtain a

test result violates an inmate’s rights would place the notice at too high a level of

generality. As discussed, Mata does not require testing and, consequently,

Dr. LaRowe’s conduct falls into a grey area created by the holdings of Estelle and

Self on the one hand and Mata on the other. We therefore cannot conclude that every

reasonable official would have known it was a violation of Mr. Crowson’s

constitutional rights to proceed with a diagnosis in the absence of blood test results.

Rather, it fell within the realm of reasonable debate. See Apodaca, 864 F.3d at 1078.

                                           ***

      For purposes of our analysis, we assume Dr. LaRowe violated Mr. Crowson’s

Fourteenth Amendment rights by treating him for withdrawal without first obtaining

the results from a previously ordered blood test. Because we have found no decisions

from the Supreme Court or this court that clearly establish the unconstitutionality of

such conduct, we conclude Dr. LaRowe is entitled to qualified immunity, and we

reverse the district court’s denial of summary judgment.

                              B. Institutional Defendant

      Mr. Crowson also claims the County is liable because it “failed to enact

adequate policies and properly train its nurses despite relying on the nurses to

provide the bulk of medical care.” Appellee Br. at 49. To state a claim against a

municipal entity in this context, “plaintiffs must allege facts showing: (1) an official

policy or custom, (2) causation, and (3) deliberate indifference.” Quintana, 973 F.3d

at 1034. Under our precedent, any of the following constitute an official policy:

                                           25
       (1) a formal regulation or policy statement; (2) an informal custom
       amounting to a widespread practice that, although not authorized by written
       law or express municipal policy, is so permanent and well settled as to
       constitute a custom or usage with the force of law; (3) the decisions of
       employees with final policymaking authority; (4) the ratification by such
       final policymakers of the decisions—and the basis for them—of
       subordinates to whom authority was delegated subject to these
       policymakers’ review and approval; or (5) the failure to adequately train or
       supervise employees, so long as that failure results from deliberate
       indifference to the injuries that may be caused.
Waller v. City & County of Denver, 932 F.3d 1277, 1283 (10th Cir. 2019) (quotation

marks omitted).

       Mr. Crowson argued to the district court that the County was “deliberately

indifferent to the risk of having nurses who were not trained and did not have policies

to follow.” App., Vol. I at 137. The district court treated this issue as encompassing

both a failure-to-train claim and a systemic-failure claim: “Mr. Crowson alleges that

Washington County is liable for its failure to train Jail nurses—specifically, for its

failure to promulgate written policies for Jail nurses to follow,” and cited the proper

standard for failure to train. App., Vol. I at 218. The district court found that the

“County’s healthcare policies at the time of Mr. Crowson’s incarceration seem

severely lacking.” App., Vol. I at 218. It further noted that there were “no written

policies in the record,” and that the Jail’s general practices for providing medical care

to inmates had to be pieced together from the deposition testimony of various

medical personnel. App., Vol. I at 218–19. The district court also considered Jail

policy that required Dr. LaRowe to rely heavily on the Jail’s deputies and nurses

because although he “was responsible for diagnosing and treating inmates, [he] only

                                            26
visited the Jail one or two day[s] a week.” App., Vol. I at 219. These deficiencies

were compounded by the practices at the Jail. The district court observed:

       When an inmate was placed in a medical observation cell, Jail deputies
       observed inmates at least once every thirty minutes, and would notify a Jail
       nurse when “this guy is not acting right or this guy is having problems.”
       (Dep. of Michael Johnson at 32:4–10 (ECF No. 76-7).) Jail nurses—who,
       by law, could not diagnose inmates—generally spent five to ten minutes
       with the inmate once every twelve-hour shift, to take the inmate’s vital
       signs and conduct follow-up checks. If an inmate exhibited symptoms of a
       cognitive problem (as did Mr. Crowson), the nurse would inform
       Dr. LaRowe and PA Worlton, who, in addition to his role as the Jail’s
       health services administrator, handles mental health care.
App., Vol. I at 219.

       The district court found that the Jail’s practices left the nurses “largely to their

own devices.” App., Vol. I at 219. This was particularly true as to brain injuries because

the “Jail has no guidelines or written policies” for assessing them. App., Vol. I at 219.

While Dr. LaRowe did provide training for alcohol withdrawal, Nurse Johnson “could

not remember a protocol or standards for assessing withdrawal symptoms,” and PA

Worlton testified the Jail did not have a written policy governing placement of inmates in

observation cells for detox or evaluation of the inmate thereafter. App., Vol. I at 219. The

district court also found it significant that Dr. LaRowe was unaware of any Jail policy for

nurses to follow in determining when an inmate should be transported to the hospital.

App., Vol. I at 219. From this evidence, the district court found: “Remarkably, it appears

from the record that Washington County failed to promulgate written policies pertaining

to the Jail’s core healthcare functions.” App., Vol. I at 220. And it further concluded that

a reasonable jury could find that Mr. Crowson’s injuries were “an obvious consequence

                                              27
of the County’s reliance on a largely absentee physician, and an attendant failure to

promulgate written protocols for monitoring, diagnosing, and treating inmates.” App.,

Vol. I at 220. The district court, therefore, considered the problems created both by the

failure to train and by the failure to adopt written policies.

       Before we reach the merits of Mr. Crowson’s claims against the County, we

must determine whether we have jurisdiction to consider those claims in this

interlocutory appeal. We have discretion to exercise pendent appellate jurisdiction

over the County’s appeal to the extent the issues it raises are “inextricably

intertwined” with the district court’s denial of qualified immunity to the individual

defendants. See Moore, 57 F.3d at 930 (quoting Swint v. Chambers Cnty. Comm’n,

514 U.S. 35, 51 (1995)). If resolution of the collateral qualified immunity appeal

“necessarily resolves” the County’s issues on appeal, then those otherwise

nonappealable issues are “inextricably intertwined” with the appealable decision. Id.

But “if our ruling on the merits of the collateral qualified immunity appeal [would]

not resolve all of the remaining issues presented by the [County],” then we lack

jurisdiction to consider the County’s appeal. Id.

       To place the analysis of our jurisdiction over the claims against the County in

context, we pause to set forth the relevant legal background.

       1. Legal Background

       Mr. Crowson asserts two related claims against the County: (1) failure to train

its nurses; and (2) reliance on policies and procedures that were deliberately

                                              28
indifferent to prisoners’ medical needs. Only the first of these claims is inextricably

intertwined with the claims of the individual defendants, as we shall now explain.

       In Garcia v. Salt Lake County, 768 F.2d 303 (10th Cir. 1985), we addressed a

claim for deliberate indifference against a municipality under circumstances like the

present. There, the family of a pretrial detainee who died while housed in the Salt

Lake County Jail sued various officials and the county. Id. at 305. According to the

plaintiffs, the detainee’s death was the result of official policies and practices of the

county that were deliberately indifferent to the serious medical needs of persons

confined in the Salt Lake County Jail. Id. A panel of this court allowed the jury

verdict against the county to stand despite the absence of individual liability as to any

county employee. Id. The panel concluded that where the county’s policy, or lack of

policies, evinces deliberate indifference, the county can be liable even in the absence

of individual liability by any county actor. See id. at 306–07. We explained:

“Deliberate indifference to serious medical needs may be shown by proving there are

such gross deficiencies in staffing, facilities, equipment, or procedures that the

inmate is effectively denied access to adequate medical care.” Id. at 308. And even

where “the acts or omissions of no one employee may violate an individual’s

constitutional rights, the combined acts or omissions of several employees acting

under a governmental policy or custom may violate an individual’s constitutional

rights.” Id. at 310.

       There is some tension in our subsequent caselaw with respect to this

conclusion in Garcia. In multiple cases we have made statements that suggest a claim

                                            29
against a municipality may never lie where none of the municipality’s individual

officers are liable under § 1983. When examined more carefully, however, most of

these decisions can be harmonized with the Supreme Court’s and our prior decisions.

Demarcating the precise dividing line in our precedent, moreover, demonstrates why

our jurisdiction in this posture extends to only one of Mr. Crowson’s theories of

municipal liability.

      To frame our prior decisions, it is important to begin with the Supreme Court’s

direction in Collins v. City of Harker Heights that “proper analysis requires us to

separate two different issues when a § 1983 claim is asserted against a municipality:

(1) whether plaintiff’s harm was caused by a constitutional violation, and (2) if so,

whether the city is responsible for that violation.” 503 U.S. 115, 120 (1992). The

absence of an affirmative answer to either of these questions is fatal to a claim

against the municipality.

      With respect to the first question, a claim under § 1983 against either an

individual actor or a municipality cannot survive a determination that there has been

no constitutional violation. Id. at 130 (affirming dismissal of action where none of

plaintiff’s allegations set forth a constitutional violation). In Washington v. Unified

Government of Wyandotte County, for example, we acknowledged that “a

municipality may be liable under § 1983 where the plaintiff identifies an

unconstitutional policy that caused the claimed injury.” 847 F.3d 1192, 1197 (10th

Cir. 2017). However, once we concluded the plaintiff had failed to show any

constitutional violation, we affirmed the district court’s decision rejecting the claims

                                           30
against all defendants, including the county. Id. at 1197–1203; see also Lindsey v.

Hyler, 918 F.3d 1109, 1116–17 (10th Cir. 2019) (rejecting plaintiffs’ failure-to-train

claim against municipality upon concluding there was no constitutional violation);

Jennings v. City of Stillwater, 383 F.3d 1199, 1205 n.1 (10th Cir. 2004) (rejecting

claims against city after affirming summary judgment for individual actors due to the

lack of any constitutional violation); Livsey v. Salt Lake County, 275 F.3d 952, 958

(10th Cir. 2001) (rejecting claims against county because the individual officer had

not violated constitutional right to privacy or substantive due process of surviving

wife and children); Trigalet v. City of Tulsa, 239 F.3d 1150, 1152, 1154–55 (10th

Cir. 2001) (rejecting claims against county for failure to train and failure to adopt

appropriate policies where individual officers had not violated the constitutional

rights of driver killed by suspect fleeing police).

      We turn next to the second question identified in Collins: whether the

municipality is responsible for the constitutional violation. Sometimes the

municipality’s failures are the driving force behind a constitutional violation by a

specific municipal employee. A failure-to-train claim is an example of these types of

§ 1983 claims against municipalities.

      In Williams v. City & County of Denver, we “emphasize[d] the distinction

between cases in which a plaintiff seeks to hold a municipality liable for failing to

train an employee who as a result acts unconstitutionally, and cases in which the

city’s failure is itself an unconstitutional denial of substantive due process.” 99 F.3d

1009, 1019 (10th Cir. 1996), reh’g en banc granted on other grounds, opinion

                                            31
vacated, 140 F.3d 855 (10th Cir. 1997), reh’g en banc sub nom. Williams v. Denver,

153 F.3d 730 (10th Cir. 1998) (unpublished).10 We explained that a city may not be

held liable for failure to train “when there has been no underlying constitutional

violation by one of its employees.” 99 F.3d at 1018. By contrast, where the claim is

premised upon a formally promulgated policy, well-settled custom or practice, or

final decision by a policymaker, we held “the inquiry is whether the policy or custom

itself is unconstitutional so as to impose liability on the city for its own

unconstitutional conduct in implementing an unconstitutional policy.” Id.

       Although Williams has a complex subsequent history, nothing in that history

casts doubt on the determination that a failure-to-train claim may not be maintained

without a showing of a constitutional violation by the allegedly un-, under-, or

improperly-trained officer. See 99 F.3d at 1018; see also Myers v. Okla. Cnty. Bd. of

Cnty. Comm’rs, 151 F.3d 1313, 1317 (10th Cir. 1998) (stating that “failure[-]to[-

]train claims . . . require[] a predicate showing that the officers did in fact” violate

       10
          Although the opinion in Williams was vacated, it was not reversed by the en
banc court. See 153 F.3d 730 (10th Cir. 1998) (unpublished). Thus, its expressions on
the merits may have at least persuasive value. See Los Angeles County v. Davis, 440
U.S. 625, 646 n.10 (1979) (Powell, J., dissenting) (explaining, in regard to a Ninth
Circuit judgment vacated by the Supreme Court, that “the expressions of the court
below on the merits, if not reversed, will continue to have precedential weight and,
until contrary authority is decided, are likely to be viewed as persuasive authority if
not the governing law of the Ninth Circuit”); cf. Rio Grande Silvery Minnow v.
Bureau of Reclamation, 601 F.3d 1096, 1133 (10th Cir. 2010) (explaining that “since
the district court’s opinion[s] will remain ‘on the books’ even if vacated, albeit
without any preclusive effect, future courts [and litigants] will be able to consult
[their] reasoning” (alterations in original) (quoting Nat’l Black Police Ass’n v.
District of Columbia, 108 F.3d 346, 354 (D.C. Cir. 1997))).
                                            32
the decedent’s rights). Thus, under Williams, our conclusion that the claim against

Nurse Johnson fails on summary judgment necessarily also defeats the failure-to-

train claim against the County, which is premised only upon the County’s failure to

train its nurses.

       Where the claim against the municipality is not dependent upon the liability of

any individual actor, however, our precedent is less clear. Recall that in Garcia, we

held: “Deliberate indifference to serious medical needs may be shown by proving

there are such gross deficiencies in staffing, facilities, equipment, or procedures that

the inmate is effectively denied access to adequate medical care.” 768 F.2d at 308.

More recently, however, we reached a contrary conclusion. See Martinez v. Beggs,

563 F.3d 1082 (10th Cir. 2009).

       In Martinez, an estate brought § 1983 claims against individual jailers and

against the Sheriff acting in his official capacity for the county after a man died in

police custody. Id. at 1084. The decedent’s estate alleged the individual defendants

were deliberately indifferent to the decedent’s serious medical needs, resulting in a

violation of his constitutional rights. Id. We affirmed the district court’s summary

judgment in favor of the individual defendants because there was no evidence they

had subjective knowledge of the decedent’s serious medical condition. Id. at 1090–

91. And therefore, we held the Sheriff acting in his official capacity could not be

“liable for the actions of the officers he trained and supervised” in the absence of a

constitutional violation by any of his officers. Id. at 1091.

                                            33
      So far, then, Martinez tracks our precedent. But next, the panel considered the

estate’s claim that even “if no single individual county employee is found liable, the

county may still be liable for a ‘systemic injury’ caused by ‘the interactive behavior

of several government officials, each of whom may be acting in good faith.’” Id. at

1092. We rejected that claim, stating, “[t]o the extent this argument suggests that the

county can be liable, even if no individual government actor is liable, it is precluded

by our prior precedent.” Id.

      In support, we cited Olsen v. Layton Hills Mall, 312 F.3d 1304 (10th Cir.

2002). Although Olsen did acknowledge that municipalities could not be held liable

absent an underlying violation by their officers, id. at 1317–18, the claim asserted in

that case was for failure to train rather than for a systemic lack of policies and

procedures. Compare Garcia, 768 F.2d at 310. And in Olsen, we ultimately reversed

the grant of summary judgment for the officer while affirming the grant of summary

judgment for the city on a wholly different ground—that the plaintiff had not

produced evidence of deliberate indifference on the city’s part. 312 F.3d at 1312–13,

1317–19.

      In Martinez, however, we went beyond Olsen in holding that a § 1983

deliberate indifference claim against a municipality based on systemic failures cannot

survive in the absence of a constitutional violation by at least one individual

defendant. 563 F.3d at 1092. That holding does not turn on whether the injury was

caused by a constitutional violation for which the municipality was responsible, as

                                           34
mandated by Collins. See 503 U.S. at 120. Instead, it directs that no claim against the

municipality can prevail in the absence of a liable individual.

       We are unable to reconcile the holdings in Martinez and Garcia. However,

Garcia is the earlier published decision, and “when faced with an intra-circuit

conflict, a panel should follow earlier, settled precedent over a subsequent deviation

therefrom.” Haynes v. Williams, 88 F.3d 898, 900 n.4 (10th Cir. 1996). This rule does

not hold if our earlier precedent has been reconsidered. See id. But we have not

overruled Garcia; to the contrary, we have relied on it recently. See Quintana, 973

F.3d at 1033–34 (marshaling Garcia to reject the district court’s conclusion that a

§ 1983 claim premised on deficient medical intake protocol could not lie absent “a

viable claim against an individual defendant,” because it “does not square with

circuit precedent holding that municipal liability under Monell may exist without

individual liability”). Furthermore, we are not the only circuit to cite Garcia recently

in the context of this theory of municipal liability. See Griffith v. Franklin County,

975 F.3d 554, 581–82 (6th Cir. 2020) (expressing willingness to entertain Garcia’s

theory of municipal liability, but declining to decide the issue because plaintiff failed

to establish a constitutional violation); Barnett v. MacArthur, 956 F.3d 1291, 1301–

02 (11th Cir. 2020) (allowing § 1983 claim against county to proceed despite a jury

finding that the individual officer did not violate the plaintiff’s constitutional rights,

while determining Garcia’s theory of municipal liability to be “not a controversial

concept”), petition for cert. filed sub nom Lemma v. Barnett, No. 20-595; Horton by

Horton v. City of Santa Maria, 915 F.3d 592, 604 & n.11 (9th Cir. 2019) (holding

                                            35
that city could be liable for deliberate indifference to safety of pretrial detainee even

where no individual officer had violated a clearly established constitutional right).

      We are also unconvinced that subsequent pronouncements from the Supreme

Court permit us to depart from our published decision in Garcia. See Haynes, 88 F.3d

at 900 n.4. We decided Garcia in 1985. The following year, the Supreme Court held

that “[i]f a person has suffered no constitutional injury at the hands of the individual

police officer, the fact that the departmental regulations might have authorized the

use of constitutionally excessive force is quite beside the point.” City of Los Angeles

v. Heller, 475 U.S. 796, 799 (1986). But in City of Los Angeles v. Heller, the issue

was whether damages could be awarded “against a municipal corporation based on

the actions of one of its officers when in fact the jury has concluded that the officer

inflicted no constitutional harm.” Id.

      The subsequent development of our municipal liability caselaw confirms that

Heller did not undermine Garcia. In Apodaca v. Rio Arriba County Sheriff’s

Department, we cited Heller in holding, “[w]hen there is no underlying constitutional

violation by a county officer, there cannot be an action for failing to train or

supervise the officer.” 905 F.2d 1445, 1447 (10th Cir. 1990) (emphasis added). Three

years later, we stated this rule more broadly: “A municipality may not be held liable

where there was no underlying constitutional violation by any of its officers.” Hinton

v. City of Elwood, 997 F.2d 774, 782 (10th Cir. 1993) (citing Heller, 475 U.S. at

799). But again, we made this statement in the context of the city’s failure to train

“regarding, or to adopt any written policies regulating, the use of force.” Id. at 777.

                                           36
Relying on Heller, we explained that “where a municipality is ‘sued only because [it

was] thought legally responsible’ for the actions of its officers, it is ‘inconceivable’

to hold the municipality liable if its officers inflict no constitutional harm, regardless

of whether the municipality’s policies might have ‘authorized’ such harm.” Id. at 782

(alteration in original) (quoting Heller, 475 U.S. at 799). “As in Heller, Hinton’s

excessive force claim against the City of Elwood seeks to hold the city liable solely

because of the actions of its individual officers.” Id.

       As previously discussed, in Collins the Supreme Court recognized a type of

§ 1983 claim against a municipality that may survive even in the absence of a

constitutional violation by a municipal employee. See 503 U.S. 115. There, the

widow of a municipal employee who died after entering a manhole to service a sewer

line, sued the city, claiming the decedent “had a constitutional right to be free from

unreasonable risks of harm to his body, mind and emotions and a constitutional right

to be protected from the city of Harker Heights’ custom and policy of deliberate

indifference toward the safety of its employees.” Id. at 117. The widow’s

constitutional claim was based on “the substantive component of the [Due Process]

Clause that protects individual liberty against ‘certain government actions regardless

of the fairness of the procedures used to implement them.’” Id. at 125 (quoting

Daniels v. Williams, 474 U.S. 327, 331 (1986)). The Court noted this claim fairly

advanced two theories: “that the Federal Constitution imposes a duty on the city to

provide its employees with minimal levels of safety and security in the workplace, or

that the city’s ‘deliberate indifference’ to [the decedent’s] safety was arbitrary

                                            37
government action that must ‘shock the conscience’ of federal judges.” Id. at 126.

After rejecting the first theory as inconsistent with substantive due process precedent,

the Court rejected the widow’s second theory because her claim was “analogous to a

fairly typical state-law tort claim,” id. at 126–128. As such, it did not meet the

requirement of arbitrary government action that shocks the conscience. Id.

Importantly, the analysis in Collins was not driven by the absence of a finding of

liability with respect to any individual city employee.

       We dissected the meaning of Collins for § 1983 municipal liability in

Williams. See 99 F.3d 1009. There, an estate sued the City and County of Denver for

the death of a motorist as a result of a collision with a police officer who sped

through an intersection against the light and without using a siren. Id. at 1012. The

estate brought a failure-to-train claim, as well as a substantive due process claim

based solely on the city’s own actions. Id. at 1018. “In light of Collins,” a panel of

this court held a municipality “may be liable for its own unconstitutional policy even

if [the individual defendant] is ultimately exonerated,” by drawing a “distinction

between cases in which a plaintiff seeks to hold a municipality liable for failing to

train an employee who as a result acts unconstitutionally, and cases in which the

city’s failure is itself an unconstitutional denial of substantive due process.” Id. at

1019. We further held the standard for a substantive due process violation is whether

the conduct was conscience-shocking; mere recklessness is insufficient. Id. at 1015.

       The en banc court granted the municipal defendants’ petition for rehearing to

address: (1) the proper standard for determining whether the conduct of the officer

                                            38
violated the decedent’s constitutional rights, (2) whether under that standard the

constitutional determination should be made by a judge or a jury, and (3) whether the

municipality could be found liable “by its own conduct or policies in hiring and/or

failing to train [the officer], even if the officer’s conduct did not violate the

constitutional rights of decedent.” Williams v. City & County of Denver, 140 F.3d

855, 855 (10th Cir. 1997).

       The rehearing in Williams was subsequently abated pending the Supreme

Court’s decision in County of Sacramento v. Lewis, 523 U.S. 833 (1998), which

directly considered whether the substantive due process analysis in Williams was

correct. Id. at 839–840 (citing Williams as part of the circuit split the case was

accepted on certiorari to resolve). In Lewis, the Court explained it had “always been

reluctant to expand the concept of substantive due process.” Id. at 842 (quoting

Collins, 503 U.S. at 125). Thus, “[w]here a particular Amendment provides an

explicit textual source of constitutional protection against a particular sort of

government behavior, that Amendment, not the more generalized notion of

substantive due process, must be the guide for analyzing these claims.” Id. (alteration

in original) (quoting Albright v. Oliver, 510 U.S. 266, 273 (1994) (plurality

opinion)). Where such explicit protection is not provided by another amendment,

however, “the substantive component of the Due Process Clause is violated by

executive action only when it ‘can properly be characterized as arbitrary, or

conscience shocking, in a constitutional sense.’” Id. at 847 (quoting Collins, 503 U.S.

at 128). Thus, the Court’s decision in Lewis is consistent with the substantive due

                                            39
process standard we applied in Williams. Id. at 839–40 (reversing a decision on the

other side of a circuit split from Williams).

      While the Williams rehearing was pending, the Supreme Court also decided

Board of County Commissioners of Bryan County v. Brown, 520 U.S. 397 (1997).

There, the Court ruled that to hold a municipality liable under § 1983, “a plaintiff

must show that the municipal action was taken with the requisite degree of

culpability and must demonstrate a direct causal link between the municipal action

and the deprivation of federal rights.” Id. at 404. In response to these intervening

Supreme Court decisions, we vacated the district court’s judgment in Williams and

remanded for the district court to consider their effect. Williams v. Denver, 153 F.3d

730, 1998 WL 380518, at *1 (10th Cir. June 26, 1998) (unpublished).

      We returned to the relevant question in Trigalet v. City of Tulsa. See 239 F.3d

1150. There, “we consider[ed] whether a municipality can be held liable for the

actions of its employees if those actions do not constitute a violation of a plaintiff’s

constitutional rights.” Id. at 1154. We held “even if it could be said that Tulsa’s

policies, training, and supervision were unconstitutional, the City cannot be held

liable where, as here, the officers did not commit a constitutional violation.” Id. at

1155–56.

      Under Trigalet, there is no question that where the actions of a municipality’s

officers do not rise to the level of a constitutional violation and the claim against the

municipality is based on it serving as the driving force behind those actions, liability

cannot lie. But the question here, and in Garcia, is different: whether, even where no

                                           40
individual action by a single officer rises to a constitutional violation, a municipality

may be held liable where the sum of actions nonetheless violates the plaintiff’s

constitutional rights. Garcia answers that question in the affirmative. And the

Supreme Court’s subsequent decision in Heller does not cast doubt on Garcia; in

Heller the theory of municipality liability was predicated on the actions of one officer

who was determined not to have violated the plaintiff’s constitutional rights.

       Because Garcia is not undermined by a subsequent Supreme Court decision,

and it also predates Martinez, Garcia is controlling here. See Haynes, 88 F.3d at 900

n.4.

       Moreover, assuming the expansion of the Collins analysis outside the

substantive due process context is appropriate, the reasoning of Garcia remains

sound. A core principle of Monell liability is that municipal entities are liable for

only their own actions and not vicariously liable for the actions of their employees.

See Schneider v. City of Grand Junction Police Dep’t, 717 F.3d 760, 770 (10th Cir.

2013). Because municipalities act through officers, ordinarily there will be a

municipal violation only where an individual officer commits a constitutional

violation. But, as in Garcia, sometimes the municipal policy devolves responsibility

across multiple officers. In those situations, the policies may be unconstitutional

precisely because they fail to ensure that any single officer is positioned to prevent

the constitutional violation. Where the sum of multiple officers’ actions taken

pursuant to municipal policy results in a constitutional violation, the municipality

                                           41
may be directly liable. That is, the municipality may not escape liability by acting

through twenty hands rather than two.

      The general rule in Trigalet is that there must be a constitutional violation, not

just an unconstitutional policy, for a municipality to be held liable. In most cases, this

makes the question of whether a municipality is liable dependent on whether a

specific municipal officer violated an individual’s constitutional rights. But Garcia

remains as a limited exception where the alleged violation occurred as a result of

multiple officials’ actions or inactions.

      With this legal background in place, we now proceed to the question of

whether our resolution of the claims against the individual defendants forecloses the

County’s liability. We conclude that it does with respect to the failure-to-train claim,

but not as to the theory based on a systemic failure of medical policies and

procedures. Accordingly, we reverse the district court’s denial of summary judgment

to the County on the failure-to-train claim, but we lack jurisdiction over the claim

against the County based on its allegedly deficient policies and procedures.

2.    Dr. LaRowe

      Recall that we did not decide whether Dr. LaRowe violated Mr. Crowson’s

constitutional rights, instead concluding that even if we assume a violation, the right

was not clearly established. Leaving the question of a constitutional violation by

Dr. LaRowe unresolved does not impact our jurisdiction over the claims against the

County on interlocutory appeal because Mr. Crowson’s failure-to-train claim respects

only the nurses employed at the Jail. Mr. Crowson does not allege the County failed

                                            42
to train Dr. LaRowe. And to the extent Mr. Crowson argues the County’s policies

constituted deliberate indifference to his rights, that claim does not depend upon an

individual employee (or contractor, in Dr. LaRowe’s case) having independently

violated his rights. Accordingly, neither of the two claims against the County are

inextricably intertwined with the claim against Dr. LaRowe.

3.    Nurse Johnson

      We have concluded Nurse Johnson did not violate Mr. Crowson’s

constitutional rights. As a result, we have pendent appellate jurisdiction only if we

also conclude Mr. Crowson’s claims against the County are dependent upon

Nurse Johnson violating his constitutional rights.11 Id. Put another way, if

Mr. Crowson’s claims against the County can succeed despite our holding that

Nurse Johnson did not violate his rights, we lack jurisdiction over those claims. See

id.

      The County contends that to succeed on his municipal liability claims,

Mr. Crowson must “show an underlying constitutional violation by at least one

Washington County employee and that the underlying constitutional violation was

directly caused by a county policy.” County Br. at 48. But as previously explained,

we agree with Mr. Crowson that even if we conclude Nurse Johnson and Dr. LaRowe

“did not violate the Constitution individually, . . . their combined acts may be

      11
          We lack jurisdiction to consider the County’s attacks on the other elements
of either Monell claim. See Moore v. City of Wynnewood, 57 F.3d 924, 930 (10th Cir.
1995).
                                           43
sufficient for Monell liability” such that Mr. Crowson still has a claim for municipal

liability irrespective of whether Nurse Johnson violated his rights. Appellee Br. at 48.

In a similar vein, Mr. Crowson argues the claims against the County “depend[] on the

actions of policymakers” and their alleged “systemic failures” which are distinct

“from the claims against the individual defendants.” Appellee Br. at 48–49.

      Mr. Crowson does assert a failure-to-train claim that, for the reasons discussed

above, is dependent upon a predicate violation by Nurse Johnson. This claim is

therefore inextricably intertwined with our decision that Nurse Johnson did not

violate Mr. Crowson’s rights. Accordingly, we exercise jurisdiction over the failure-

to-train claim and reverse. But Mr. Crowson also asserts a claim arising out of the

County’s systemic failure. For the reasons explained above, we lack jurisdiction over

this claim.

                                          ***

      Our conclusion that Nurse Johnson did not violate Mr. Crowson’s

constitutional rights does not completely resolve Mr. Crowson’s claims against the

County. The absence of a constitutional violation by Nurse Johnson forecloses

Mr. Crowson’s failure-to-train claim. However, it does not resolve the broader claim

that the County’s policy of failing to properly train nurses and guards, combined with

its policy of relying on a largely absentee physician, evidenced deliberate

indifference to Mr. Crowson’s serious medical condition. Because this claim is not

inextricably intertwined with the claim against any individual defendant, we lack

jurisdiction over it in this interlocutory appeal. We therefore dismiss the County’s

                                          44
appeal with respect to the systemic failure claim, and we remand for proceedings

consistent with this opinion. In doing so, we express no view as to the merits of this

claim. We simply decide we lack jurisdiction to consider it.

                               III.   CONCLUSION

      For the foregoing reasons, we REVERSE the district court’s denial of

summary judgment to Nurse Johnson and Dr. LaRowe. We REVERSE the district

court’s denial of summary judgment to the County on the failure-to-train theory of

liability, DISMISS the County’s appeal for lack of appellate jurisdiction as to the

systemic failure theory, and REMAND for further proceedings consistent with this

opinion.

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