Court Opinion

ID: 9369855
Source: CourtListenerOpinion
Date Created: 2023-02-09 20:00:25.369718+00
Date Added: 2024-06-11T17:16:17.682910
License: Public Domain

RECOMMENDED FOR PUBLICATION
                               Pursuant to Sixth Circuit I.O.P. 32.1(b)
                                      File Name: 23a0024p.06

                   UNITED STATES COURT OF APPEALS
                                  FOR THE SIXTH CIRCUIT

                                                            ┐
 JULIE HELPHENSTINE, Administratrix of the Estate of
                                                            │
 Christopher Dale Helphenstine and Guardian of
                                                            │
 B.D.H., the minor son of Christopher Dale
                                                            │
 Helphenstine,
                                                            │         No. 22-5407
                                 Plaintiff-Appellant,        >
                                                            │
                                                            │
        v.                                                  │
                                                            │
 LEWIS COUNTY, KENTUCKY; JEFF LYKINS, ANTHONY               │
 RUARK, ANDY LUCAS, BEN CARVER, AMANDA                      │
 MCGINNIS, SANDY BLOOMFIELD, MARK RILEY,                    │
 MELINDA MONROE, JEFFERY THOROUGHMAN, TOMMY                 │
 VON LUHRTE, D.O., JOHNNY BIVENS, and JOHN                  │
 BYARD, individually,                                       │
                           Defendants-Appellees.            │
                                                            ┘

 Appeal from the United States District Court for the Eastern District of Kentucky at Ashland.
                 No. 0:18-cv-00093—Henry R. Wilhoit, Jr., District Judge.

                                  Argued: December 7, 2022

                             Decided and Filed: February 9, 2023

             Before: SUTTON, Chief Judge, COLE and GRIFFIN, Circuit Judges.
                                 _________________

                                           COUNSEL

ARGUED: Gregory A. Belzley, BELZLEY, BATHURST & BENTLEY, Prospect, Kentucky,
for Appellant. Jeffrey C. Mando, ADAMS, STEPNER, WOLTERMANN & DUSING, PLLC,
Covington, Kentucky, for Lewis County Appellees. Clayton L. Robinson, ROBINSON &
HAVENS, PSC, Lexington, Kentucky, for Appellee Tommy von Luhrte, D.O. ON BRIEF:
Gregory A. Belzley, BELZLEY, BATHURST & BENTLEY, Prospect, Kentucky, James L.
Thomerson, ROSE GRASCH CAMENISCH MAINS PLLC, Lexington, Kentucky, for
Appellant. Jeffrey C. Mando, ADAMS, STEPNER, WOLTERMANN & DUSING, PLLC,
Covington, Kentucky, for Lewis County Appellees. Clayton L. Robinson, Courtney L. Soltis,
ROBINSON & HAVENS, PSC, Lexington, Kentucky, for Appellee Tommy von Luhrte, D.O.
 No. 22-5407                     Helphenstine v. Lewis County, et al.                     Page 2

                                        _________________

                                            OPINION
                                        _________________

       GRIFFIN, Circuit Judge.

       Christopher Helphenstine was arrested and charged with drug crimes in Lewis County,
Kentucky.    While detained, he began to withdraw from alcohol or drugs.          Despite severe
vomiting and diarrhea, the only medical care he received was two doses of antiemetics,
prescribed via fax machine by a doctor who never saw him. He died five days after his arrest.
His estate sued several jail employees, the doctor contracted to provide medical care at the jail,
and Lewis County for deliberate indifference to his serious medical needs in violation of the
Fourteenth Amendment, and for negligence in violation of state law. The district court ruled that
no defendant violated Helphenstine’s constitutional rights, declined to exercise jurisdiction over
the state-law negligence claim, and granted summary judgment in favor of all defendants.
We affirm in part, reverse in part, and remand for further proceedings.

                                                I.

       Christopher Helphenstine was arrested and charged with drug offenses on April 14, 2017
and taken to the Lewis County Detention Center (the “jail”). He was detained there until he died
en route to the hospital on April 19.

       April 16, 2017. Around 8:30 p.m. on Sunday, April 16, Helphenstine “vomit[ed] all over
the floor” in general population, so defendant Deputy Jailer Mark Riley moved him to a single-
man “detox” cell. Helphenstine told Riley that he was “dope sick” and “wanted to be by hisself
[sic] so he can get over it.” Riley testified that he asked Helphenstine if he wanted to see a
doctor or go to the hospital, but Helphenstine responded that he did not.

       At the time of Helphenstine’s detention, no jail employee had medical training beyond
first aid and CPR. Instead, the jail contracted with local doctor Tommy von Luhrte, D.O., to
provide medical care to inmates. Dr. von Luhrte was contractually obligated to visit the jail at
least once a week, but he did not always do so if the jail did not report that any inmates were
 No. 22-5407                           Helphenstine v. Lewis County, et al.                   Page 3

sick. When he visited, he came on Tuesday nights. So when Helphenstine began feeling ill on
Sunday evening, the jailers knew he would not receive any medical care for at least two days
unless someone reached out to Dr. von Luhrte.

        Beginning at 9:20 p.m., the jailers took turns checking on Helphenstine about every
twenty minutes by opening a flap in the door to the isolation cell, looking into the cell, and
occasionally talking to him. They recorded their observations on a log sheet that hung on the
door of the cell. Helphenstine vomited again at 10:34 p.m.

        April 17, 2017. According to the log sheet, Helphenstine was observed vomiting at
12:17 a.m. and 2:44 a.m. by defendant Deputy Jailer Anthony Ruark, and again at 5:42 a.m. by
defendant Deputy Jailer Melinda Monroe.1 He was “sitting up” for a brief period between
10:23 a.m. and 11:30 a.m., “talking” at 9:23 p.m., and “moving” at 11:12 p.m., but the log sheet
otherwise notes him as “laying down” all day.

        By midnight, Helphenstine’s condition had deteriorated.               Defendant Deputy Jailer
Amanda McGinnis prepared a non-emergency but “urgent” medical request for Helphenstine,
stating that he was in withdrawal (though she did not know from what), vomiting and soiling
himself, refusing to eat or drink, and had not gotten out of bed for twenty-four hours. McGinnis
faxed this request to Dr. von Luhrte’s office, even though she knew the office was closed due to
the late hour.

        April 18, 2017. Between 6:00 a.m. and 7:00 a.m., Helphenstine was sweaty and smelled
of vomit and feces, so he showered for almost an hour while jail staff cleaned his cell.

        Helphenstine was scheduled to be arraigned that morning, so at about 9:15 a.m.,
defendant Deputy Sheriff John Byard escorted Helphenstine on the short walk from the jail to the
courthouse. Byard noticed that Helphenstine was lethargic and drooling. Before the arraignment
began, Byard approached the bench and told the judge that Helphenstine was “acting like he’s
just clear out of it,” had “[s]tuff coming out of his mouth,” and was “really not coherent.”

        1
            Apparently, Monroe has not been located, and thus not deposed.
 No. 22-5407                    Helphenstine v. Lewis County, et al.                       Page 4

The judge postponed the arraignment after speaking with deputies about his condition. Byard
walked Helphenstine back to the jail, apparently without incident.

       McGinnis’s overnight fax was brought to Dr. von Luhrte’s attention by mid-morning.
Dr. von Luhrte testified that he called the jail and directed that Helphenstine be taken to a
hospital to receive IV fluids, but he was told that Helphenstine refused to go to the hospital.
Dr. von Luhrte could not remember with whom he spoke, and he did not document the call.
There is no record of this call at the jail, and no defendant recalls taking a call from Dr. von
Luhrte. Further, no jailer recalls Helphenstine ever refusing treatment (with the exception of
Riley’s question on April 16, after Helphenstine first vomited).

       Regardless, Dr. von Luhrte testified that, because he believed Helphenstine had refused
to go to the hospital, he faxed a prescription to the jail for Reglan (an antiemetic), and he
encouraged Helphenstine to rest, sip liquids, and eat bland food. Dr. von Luhrte was concerned
Helphenstine “might be getting dehydrated,” but he did not instruct the jailers to monitor
Helphenstine’s food or fluid intake.

       Around 3:00 p.m., Helphenstine received a dose of Reglan. Dr. von Luhrte testified that
he received a call around that time from someone who identified themself only as “the jailer,”
whom Dr. von Luhrte thought might be defendant Jailer Jeff Lykins. Dr. von Luhrte testified
that he again informed the jailer that Helphenstine needed to go to the hospital, but was told that
Helphenstine refused again.     Dr. von Luhrte told the jailer to try again, but Helphenstine
purportedly refused a third time. As with the first call from Dr. von Luhrte, there is no record of
this call taking place, and Lykins specifically denies ever speaking with Dr. von Luhrte.
Dr. von Luhrte then prescribed Zofran, a stronger antiemetic, for Helphenstine.

       Although April 18 was a Tuesday (his normal night to visit the jail) and although he
knew of Helphenstine’s condition, Dr. von Luhrte did not visit the jail that evening. There is a
dispute over whether the jail sent a “Sick Call List” to Dr. von Luhrte’s office. The doctor
claims he did not receive one. But the jail produced a Sick Call List dated April 17, 2017, listing
three inmates that needed medical attention. Nonetheless, Dr. von Luhrte failed to go to the jail
to treat Helphenstine.
 No. 22-5407                    Helphenstine v. Lewis County, et al.                     Page 5

       At 9:00 p.m., Helphenstine received doses of both Reglan and Zofran. About that time,
defendant Deputy Jailer Andy Lucas checked on Helphenstine, who told Lucas “that he was not
going to drink any more whiskey again.” Lucas testified that Helphenstine was standing and
alert at that time. Around 11:00 p.m., Helphenstine asked for something cold to drink, so Lucas
brought him a Mountain Dew. Helphenstine drank some of the soda and then said, “I’m feeling
all right now.”

       April 19, 2017. At about midnight, Helphenstine laid face-down on his mat. For the next
few hours, he remained there, largely motionless. Video shows him occasionally twitching and
raising or shaking his feet.

       At 2:42 a.m., a deputy entered Helphenstine’s cell to check on him. McGinnis testified
that this was Ruark, but Ruark was unsure whether he did this.          The jailer twice offered
Helphenstine a drink, but he refused. At 2:50 a.m., McGinnis also entered Helphenstine’s cell.
While the first deputy lifted Helphenstine’s head, McGinnis put a straw to his mouth and
encouraged him to drink. At about 2:56 a.m., McGinnis helped Helphenstine drink a small
amount again. And at 3:13 a.m., McGinnis observed Helphenstine through the window and
noted that he had consumed some liquid. Defendant Deputy Jailer Sandy Bloomfield, the shift
supervisor, watched this entire interaction on video from the control room.

       Around 3:30 a.m., Ruark looked through the window into Helphenstine’s cell, where it
“appeared to [him] that something may be wrong[.]” Helphenstine did not respond to his name,
so Ruark asked another jailer to get Bloomfield from the control room and see if she could get
Helphenstine to respond. McGinnis also came to help; she could not locate Helphenstine’s
pulse. They observed Helphenstine as cold, blue, and unresponsive, and began CPR while
Bloomfield called 911. EMTs described Helphenstine as “warm and drenched in sweat” when
they arrived. They took over CPR and transported Helphenstine to the hospital. He was
pronounced dead en route.

       Plaintiff’s experts testified that Helphenstine died either from withdrawal or from severe
dehydration caused by withdrawal. But Helphenstine’s death certificate lists his cause of death
as “acute (fentanyl) and chronic drug abuse,” with the interval between onset and death listed as
 No. 22-5407                        Helphenstine v. Lewis County, et al.                               Page 6

minutes. The medical examiner who performed the autopsy, Dr. Meredith Frame, testified that
fentanyl was present in Helphenstine’s blood at a level of 1.8 ng/ml. This was within her
understanding of the therapeutic levels of fentanyl (1 to 3 ng/ml). However, there is no evidence
that Helphenstine took fentanyl at any time while at the jail.

          Plaintiff Julie Helphenstine, the decedent’s wife and administratrix of his estate,2 sued,
bringing a deliberate indifference claim under 42 U.S.C. § 1983 against all defendants and a
negligence claim under Kentucky law against the individual defendants.                         In addressing
defendants’ motion for summary judgment, the district court analyzed plaintiff’s § 1983 claim
against each defendant individually, concluded that none were deliberately indifferent, and
declined to exercise jurisdiction over the state-law negligence claim. Accordingly, the court
granted summary judgment in favor of all defendants. Plaintiff timely appealed.3

                                                      II.

          We review the district court’s summary judgment rulings de novo. Wilmington Tr. Co. v.
AEP Generating Co., 859 F.3d 365, 370 (6th Cir. 2017). “Summary judgment is proper when,
viewing the evidence in the light most favorable to the nonmoving party, there is no genuine
dispute as to any material fact and the moving party is entitled to judgment as a matter of law.”
Id. (citation omitted).      “Credibility determinations, the weighing of the evidence, and the
drawing of legitimate inferences from the facts are jury functions, not those of a judge,” when
ruling on a motion for summary judgment. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255
(1986).

          The parties quibble regarding our standard of review. Plaintiff argues that we must view
defendants’ “self-serving testimony” with “a heightened degree of skepticism.” The Lewis
County defendants respond that we need not do so because plaintiff forfeited this argument and
because she relies on nonbinding out-of-circuit precedent for this proposition.

          2
         Because the couple shares a surname, we refer to decedent Chris Helphenstine as Helphenstine, and Julie
Helphenstine as plaintiff.
          3
          Plaintiff has not appealed the district court’s grant of summary judgment in favor of defendant Johnny
Bivens, and on appeal, she has waived any opposition to the grant of summary judgment in favor of defendants Ben
Carver and Jeffrey Thoroughman.
 No. 22-5407                      Helphenstine v. Lewis County, et al.                      Page 7

       While plaintiff did not characterize the Lewis County defendants’ testimony as “self-
serving” before the district court, the thrust of her argument was the same:           because all
reasonable inferences must be drawn in her favor, we need not accept defendants’ statements or
arguments as true if there is conflicting evidence to the contrary. Thus, she has not forfeited this
argument. But the Lewis County defendants are correct when they note that, in our circuit, we
do not “disregard evidence merely because it serves the interests of the party introducing it.”
Harris v. J.B. Robinson Jewelers, 627 F.3d 235, 239 (6th Cir. 2010). True, we may disregard
self-serving statements when they are “blatantly contradicted by the record.” Scott v. Harris,
550 U.S. 372, 380 (2007). But we need not apply any special scrutiny to defendants’ statements
simply because they are self-serving. See, e.g., Bledsoe v. Tenn. Valley Auth. Bd. of Dirs.,
42 F.4th 568, 589 (6th Cir. 2022). Of course, the general rules—that we must take all reasonable
inferences in plaintiff’s favor and may not make any credibility determinations—still apply.
Liberty Lobby, 477 U.S. at 255.

                                                 A.

       Plaintiff claims that defendants were deliberately indifferent to a serious risk of harm to
Helphenstine, in violation of his constitutional rights.

                                                  1.

       Until recently, we analyzed both pretrial detainees’ and prisoners’ claims of deliberate
indifference “under the same rubric.” Brawner v. Scott Cnty., 14 F.4th 585, 591 (6th Cir. 2021)
(citation omitted). A prisoner’s deliberate indifference claim arises from the Eighth Amendment
and has objective and subjective components. See, e.g., Farmer v. Brennan, 511 U.S. 825, 834
(1994). The “objective component” addresses the conditions leading to the alleged violation: it
“requires a plaintiff to prove that the alleged deprivation of medical care was serious enough to
violate the Constitution.” Griffith v. Franklin Cnty., 975 F.3d 554, 567 (6th Cir. 2020) (citation
and brackets omitted). The “subjective” component, meanwhile, addresses the officials’ state of
mind and requires a plaintiff to show that a defendant “kn[ew] of and disregard[ed] an excessive
risk to inmate health or safety; the official must both be aware of facts from which the inference
 No. 22-5407                    Helphenstine v. Lewis County, et al.                       Page 8

could be drawn that a substantial risk of serious harm exists, and he must also draw the
inference.” Farmer, 550 U.S. at 837.

       But in Brawner, we considered whether the Supreme Court’s decision in Kingsley v.
Hendrickson, 576 U.S. 389 (2015), required “modification of the subjective prong of the
deliberate-indifference test for pretrial detainees,” like Helphenstine.     14 F.4th at 596.    In
Kingsley, the Court addressed the standard for excessive force claims brought by both pretrial
detainees and convicted prisoners. 576 U.S. at 400–02. The Court concluded that a pretrial
detainee need demonstrate “only that the force purposely or knowingly used against him was
objectively unreasonable,” rather than both objectively and subjectively unreasonable, like a
prisoner must. Id. at 396–97, 400–02. It based its decision largely on the difference between the
Due Process Clause of the Fourteenth Amendment (from which a pretrial detainee’s claim arises)
and the Cruel and Unusual Punishments Clause of the Eighth Amendment (from which a
prisoner’s claim arises). Id. at 398–402. The Court did not, however, address whether an
objective-only standard applies to other pretrial-detainee claims, such as deliberate indifference.
See Brawner, 14 F.4th at 592.

       Brawner answered the question left open by Kingsley, holding that Kingsley required
modification of the subjective component of a pretrial detainee’s deliberate indifference claim:
“Given Kingsley’s clear delineation between claims brought by convicted prisoners under the
Eighth Amendment and claims brought by pretrial detainees under the Fourteenth Amendment,
applying the same analysis to these constitutionally distinct groups is no longer tenable.” Id. at
596. We modified the subjective prong as follows: “A pretrial detainee must prove more than
negligence but less than subjective intent—something akin to reckless disregard.” Id. (internal
quotation marks omitted).     In other words, a plaintiff must prove that a defendant “acted
deliberately (not accidentally), [and] also recklessly ‘in the face of an unjustifiably high risk of
harm that is either known or so obvious that it should be known.’” Id. (quoting Farmer, 511 U.S.
at 836).

       Recently, however, a panel of this court called this reading of Brawner into question.
See Trozzi v. Lake Cnty., 29 F.4th 745 (6th Cir. 2022). In Trozzi, the panel agreed that Brawner
modified the subjective element. Id. at 753–54. But based on the Brawner opinion itself,
 No. 22-5407                     Helphenstine v. Lewis County, et al.                        Page 9

“post-Brawner decisions, and background principles,” id. at 754, it concluded that the subjective
inquiry “still requires consideration of an official’s actual knowledge of the relevant
circumstances.” Id. at 755. It then framed the test this way: “Reading Farmer, Kingsley,
Brawner, and Greene [v. Crawford Cnty., 22 F.4th 593 (6th Cir. 2022)] together, a plaintiff must
satisfy three elements for an inadequate-medical-care claim under the Fourteenth Amendment:
(1) the plaintiff had an objectively serious medical need; (2) a reasonable officer at the scene
(knowing what the particular jail official knew at the time of the incident) would have
understood that the detainee’s medical needs subjected the detainee to an excessive risk of harm;
and (3) the prison official knew that his failure to respond would pose a serious risk to the pretrial
detainee and ignored that risk.” Id. at 757–58 (emphasis added).

       We hold that this framing of the elements is irreconcilable with Brawner. We appreciate
that our sister circuits are all over the map on this issue. As an initial matter, four circuits have
rejected the extension of Kingsley to deliberate indifference claims. See Cope v. Cogdill, 3 F.4th
198, 207 n.7 (5th Cir. 2021); Whitney v. City of St. Louis, 887 F.3d 857, 860 n.4 (8th Cir. 2018);
Strain v. Regalado, 977 F.3d 984, 989–93 (10th Cir. 2020); Dang by & through Dang v. Sheriff,
Seminole Cnty., 871 F.3d 1272, 1279 n.2 (11th Cir. 2017). Three more circuits continue applying
the pre-Kingsley framework, though without ruling out a future switch. See Miranda-Rivera v.
Toledo-Davila, 813 F.3d 64, 74 (1st Cir. 2016); Moore v. Luffley, 767 F. App’x 335, 340 n.2 (3d
Cir. 2019); Mays v. Sprinkle, 992 F.3d 295, 300–01 (4th Cir. 2021). As to the circuits that extend
Kingsley’s objective inquiry to deliberate indifference, they disagree on the question to ask. One
circuit asks what “a reasonable official in the [defendant’s] circumstances would have
appreciated” about the risks facing a detainee. Gordon v. Cnty. of Orange, 888 F.3d 1118, 1125
(9th Cir. 2018). One circuit asks what the defendant himself knew or should have known about
the risks. Darnell v. Pinerio, 849 F.3d 17, 34–35 (2d Cir. 2017). And a third circuit asks if the
defendant displayed “purposeful, knowing, or reckless disregard of the consequences.” Miranda
v. Cnty. of Lake, 900 F.3d 335, 354 (7th Cir. 2018); Pittman by & through Hamilton v. Cnty. of
Madison, 970 F.3d 823, 827 (7th Cir. 2020) (same).

       Whatever the merits of these approaches to Kingsley, we do not think that Brawner leaves
the question open. Simply put, Brawner held that Kingsley required us to lower the subjective
 No. 22-5407                     Helphenstine v. Lewis County, et al.                      Page 10

component from actual knowledge to recklessness. Indeed, several panels of our court have
interpreted Brawner in this way. See Greene, 22 F.4th at 610 (“A jury could find that Greene’s
need for immediate medical attention was ‘known or so obvious that it should [have been] known
to [defendant.]’” (first alteration in original)); Britt v. Hamilton Cnty., No. 21-3424, 2022
WL 405847, at *2 (6th Cir. Feb. 10, 2022) (“The key question in this case goes to deliberate
indifference: Did the officers act ‘recklessly in the face of an unjustifiably high risk’ that is
either ‘known or so obvious that it should be known’?” (quoting Brawner, 14 F.4th at 596–97)).

       Because Brawner was decided before Trozzi, Brawner controls. Stewart v. Trierweiler,
867 F.3d 633, 638 (6th Cir. 2017); Salmi v. Sec’y of Health & Hum. Servs., 774 F.2d 685, 689
(6th Cir. 1985). Accordingly, plaintiff must show (1) that Helphenstine had a sufficiently serious
medical need and (2) that each defendant “acted deliberately (not accidentally), [and] also
recklessly ‘in the face of an unjustifiably high risk of harm that is either known or so obvious that
it should be known.’” Brawner, 14 F.4th at 596 (quoting Farmer, 511 U.S. at 836).

                                                 2.

       Defendants do not challenge the district court’s finding that Helphenstine suffered an
objectively serious medical need. Thus, our focus rests exclusively on the subjective prong.

       Greene v. Crawford County is instructive for the subjective analysis. There, Dwayne
Greene was booked into the county jail. 22 F.4th at 601. He was drunk, and the booking staff
suspected he would experience alcohol withdrawal. Id. But by the time Greene was booked, the
jail nurse had left and would not return to the jail for four days. Id. Greene was detained without
incident for a few days until jailers observed him hallucinating. Id. at 601–02. A jailer requested
a mental health evaluation for Greene, so a mental health counselor evaluated Greene and
determined he was experiencing delirium tremens (a severe form of alcohol withdrawal). Id. at
602–03. The counselor did not encourage jail staff to seek medical treatment. Id. at 603. By the
end of that day, “Greene had been in the jail for three days and had not received any basic
medical care. He had not seen a medical professional, had not received any medication, had not
had his blood pressure, temperature, or any vitals checked, had not received an IV, and had not
 No. 22-5407                    Helphenstine v. Lewis County, et al.                    Page 11

been offered any fluids beyond water.” Id. Greene was found unresponsive in his cell at 7:38
a.m. the next morning and taken to the hospital, where he later died. Id. at 603–04.

       Greene’s estate brought deliberate indifference claims against several jailers. Id. at 604.
The district court granted summary judgment in favor of some and denied as to others. Id. at
607–08. On appeal, we held that “a jury could find that Greene was in ‘obvious’ need of some
medical attention in the hours following [the] evaluation.” Id. at 608–09 (quoting Brawner,
14 F.4th at 597). Despite Greene’s hallucinations and the fact that he “had not slept in over
24 hours prior to his incapacitation[,]” the “County Defendants nonetheless failed to seek any
basic medical assistance.” Id. at 609. “At a certain point, [that] bare minimum observation
ceases to be constitutionally adequate.” Id. We left the question of when that point occurred “for
the jury to determine.” Id. We then applied these principles to each defendant and held that a
jury could find that several defendants recklessly failed to act reasonably by not seeking medical
assistance for Greene. Id. at 609–13.

                                                 3.

       With this framing in mind, we review each defendant’s actions individually. Id. at 607.

       Mark Riley. Riley moved Helphenstine from general population to the detox cell on
April 16, knew that Helphenstine was “dope sick,” and knew that he vomited at least once. Riley
admitted that “somebody needed to call Dr. [v]on Luhrte” at that time. Because he neither
placed that call nor asked another defendant to call Dr. von Luhrte on April 16, a reasonable jury
could find that Riley acted with deliberate indifference.

       Riley resists, arguing that during his shift, no reasonable officer would understand that
Helphenstine was experiencing an objectively serious medical need. “A sufficiently serious
medical need is one that has been diagnosed by a physician as mandating treatment or one that is
so obvious that even a lay person would easily recognize the necessity for a doctor’s attention.”
Griffith, 975 F.3d at 567 (internal quotation marks removed). Vomiting is “a clear manifestation
of internal physical disorder.” Blackmore v. Kalamazoo Cnty., 390 F.3d 890, 899 (6th Cir.
2004). Further, that jailers “deem[] [a detainee]’s condition sufficiently serious to place him in
an observation cell” tends to show a sufficiently serious medical need. Id.
 No. 22-5407                    Helphenstine v. Lewis County, et al.                     Page 12

       When Helphenstine began to fall ill on April 16, Riley knew he needed medical attention:
Riley knew he had vomited, moved him to an observation cell, and testified that someone needed
to call a doctor. Thus, a reasonable jury could conclude that Helphenstine’s medical need was, at
this point, so obvious that a lay person like Riley should—and did—recognize the need for
medical attention. See id.

       Because Riley, a lay person, recognized that Helphenstine’s condition was serious
enough that he needed medical attention, a jury could also reasonably conclude that Riley
recklessly disregarded that known risk to Helphenstine’s health via his inaction. Accordingly,
we reverse the district court’s grant of summary judgment in favor of Riley.

       Amanda McGinnis. Defendant McGinnis had, comparatively, a large amount of contact
with Helphenstine. Late in the evening on April 17, she knew he was going through withdrawal,
and she sent the initial fax to Dr. von Luhrte early on April 18, noting that Helphenstine was
vomiting and soiling himself, refusing to eat or drink, and had not gotten out of bed for 24 hours.
She knew that other deputies cleaned Helphenstine’s cell of vomit and feces while he showered
that morning and that he was not feeling well at that point. In the early morning hours of April
19, another jailer had to help McGinnis hold Helphenstine’s head up for him to drink. McGinnis
even admitted that she consciously treated Helphenstine’s medical needs differently on account
of his being detained:

       Q: If—and I understand that you were constrained by your employment and the
       things—the way things worked at the jail but if you’d come home one night and
       seen a family member or a loved one in Mr. Helphenstine’s condition that you
       saw the night of the 17th when you sent the medical request form to Dr. [von
       Luhrte], would you have taken them to the hospital?
       A: Yes.

A reasonable jury could find that McGinnis acted with deliberate indifference.

       Despite McGinnis’s admission that she would have taken “a family member or a loved
one” in Helphenstine’s condition to the hospital, she took no action to help him beyond faxing
Dr. von Luhrte—which she knew would not result in a response for at least several hours. The
district court concluded that McGinnis had done enough, relying on the general principle that it
is often sufficient for a jailer to contact a medical professional when they perceive a medical
 No. 22-5407                      Helphenstine v. Lewis County, et al.                    Page 13

issue with an inmate or detainee. See Winkler v. Madison Cnty., 893 F.3d 877, 903 (6th Cir.
2018).    But that general rule applies when a jailer contemporaneously contacts a medical
professional who can provide near-immediate treatment. Indeed, we have found that as little as a
one-hour delay in treatment could be enough for a jury to conclude that a jailer was indifferent to
an inmate’s medical needs. See Terrance v. Northville Reg’l Psychiatric Hosp., 286 F.3d 834,
845 (6th Cir. 2002) (holding that “although she knew about the decedent’s serious medical
condition, [the defendant] chose to wait [almost an hour] for Dr. Said instead of immediately
contacting another physician or the emergency team,” from which a jury could impose liability).
The same is true here: A jury could conclude that McGinnis’s choice to send a fax in the middle
of the night, when no one would be present at Dr. von Luhrte’s office and no one would respond
for several hours, was deliberately indifferent to Helphenstine’s medical needs.

         Moreover, McGinnis was with Helphenstine shortly before his death and observed that he
was effectively unresponsive. Around 3 a.m. on April 19, Helphenstine could not even lift his
head to drink. McGinnis knew that Helphenstine had not received any medical attention or care
beyond two doses of antiemetics. Despite this personal observation and knowledge, she did not
seek medical attention for him.

         We have held that similar facts were enough to establish a constitutional violation under
the pre-Brawner standard, so they are certainly enough to defeat summary judgment now. See
Smith v. Cnty. of Lenawee, 505 F. App’x 526 (6th Cir. 2012). In Smith, a defendant shift
commander was only present at the jail for a detainee’s final hours of life before the detainee
died of delirium tremens. Id. at 534–35. The commander knew that the detainee was medicated,
and that she was “resting more quietly . . . than she had during the previous day.” Id. at 535.
However, when he went into the detainee’s cell, he did not check the detainee’s vitals, and she
was largely unresponsive. Id. at 534–35. We found that the commander “was on notice that [the
detainee] was very ill and yet did nothing to make sure that [the detainee] had not taken a turn
for the worse.” Id. at 535.

         We cited Smith approvingly in Greene: “[A defendant] did not observe Greene in a near-
lifeless state like [the] officer in Smith observed. However, worse than the officer in Smith, [that
defendant] knew on December 8 that Greene had not received any medication—or any basic
 No. 22-5407                    Helphenstine v. Lewis County, et al.                    Page 14

medical assistance—in four days.” 22 F.4th at 611. Given this information, which the defendant
actually knew, a jury could infer that the defendant was on notice of Greene’s serious illness and
yet did nothing—enough to satisfy Brawner and defeat summary judgment. Id.

       The same is true here: McGinnis observed Helphenstine in a near-lifeless state, knowing
that Helphenstine had not received even basic medical observation or assistance. A jury could
reasonably conclude that she recklessly failed to act reasonably by not seeking medical
assistance for Helphenstine. The district court erred in concluding otherwise.

       Anthony Ruark and Sandy Bloomfield. The Smith/Greene analysis is equally applicable
to Ruark and Bloomfield, and a reasonable jury could conclude that they acted with deliberate
indifference.

       Ruark knew that Helphenstine was in withdrawal and observed him vomiting at least
twice in the early morning hours of April 17.       Ruark testified that he could not recall if
Helphenstine could “hold[] anything down” at the time. And a jury could conclude that around
3 a.m. on April 19, Ruark saw Helphenstine lying face down, barely moving, and had to
physically lift his head for McGinnis to help him to drink. But Ruark did not seek medical
attention for Helphenstine.

       Similarly, Bloomfield knew Helphenstine was in the observation cell because he was
“dope sick,” and she knew he was going through withdrawal. Bloomfield was aware that he had
diarrhea and had been vomiting and sweating. She saw Helphenstine lie face-down on his mat
via the jail cameras on the morning of April 19. And she watched McGinnis and the other
officer try to get Helphenstine to drink some liquid, but instead observed him lying down without
moving. Yet Bloomfield did not seek medical attention for Helphenstine.

       As in Smith and Greene, these defendants observed Helphenstine in a near-lifeless state
after days of illness.   A jury could reasonably conclude that they recklessly failed to act
reasonably by not seeking medical assistance for Helphenstine.

       To avoid this conclusion, Bloomfield argues that she believed Helphenstine was, at
various times, “coherent,” responsive, and improving. Thus, she argues, she did not know of any
 No. 22-5407                        Helphenstine v. Lewis County, et al.                             Page 15

risk, so she could not disregard that risk and she is not liable. But these observations are of no
moment when we apply Brawner. Although Bloomfield observed Helphenstine’s condition
fluctuate, the record demonstrates that she should have known that he was urgently in need of
medical care—at the very least, when she observed Helphenstine unmoving and unable to lift his
own head to drink, she should have recognized a serious need for medical care. Reckless
inaction in the face of that obvious need is enough to proceed to a jury under Brawner. The
district court erred in concluding otherwise.

        Jeff Lykins.     Lykins is Lewis County’s elected Jailer.             Plaintiff brings a deliberate
indifference claim against Lykins both in his individual and supervisory capacities, which we
address in turn.

        Lykins first learned of Helphenstine’s condition on April 17, when he reviewed Riley’s
report (dated April 16) that Helphenstine had vomited and was moved to an observation cell. He
interacted with Helphenstine on April 18 around the time of the scheduled arraignment, when he
thought Helphenstine “looked okay.” And Lykins agreed that at that time, there was no one at
the jail “who could determine whether Mr. Helphenstine’s condition was a medical emergency,
other than Dr. [v]on Luhrte.”

        Further, Dr. von Luhrte testified that he called the jail on the afternoon of April 18 and
spoke with someone who identified himself only as “the jailer,” whom Dr. von Luhrte believed
to be Lykins. The doctor testified that he instructed the jailer to take Helphenstine to the hospital
twice, which Helphenstine refused. But Lykins testified that he did not speak to Dr. von Luhrte
that day (as did all other Lewis County defendants). And no defendant ever heard Helphenstine
refuse treatment. This leaves a material dispute of fact, from which a jury could conclude that
Dr. von Luhrte told Lykins to take Helphenstine to the hospital, but Lykins did not act on that
advice. If the jury believed Dr. von Luhrte, it could also reasonably conclude that Lykins knew
Helphenstine’s condition needed hospital care. Under such circumstances, a trier of fact could
reasonably conclude that Lykins acted at least recklessly by disregarding that advice.4

        4
         True, Lykins would have been entitled to rely on Dr. von Luhrte’s medical advice. See Winkler, 893 F.3d
at 895. However, he is not entitled to ignore or reject Dr. von Luhrte’s advice.
 No. 22-5407                    Helphenstine v. Lewis County, et al.                     Page 16

Accordingly, the district court erred when it granted summary judgment in favor of Lykins in his
individual capacity.

       However, for plaintiff’s supervisory-liability claim to succeed, she must show that Lykins
was actively involved in offensive conduct, and that his conduct caused Helphenstine’s injuries.
Crawford v. Tilley, 15 F.4th 752, 761–62 (6th Cir. 2021). She has not done so.

       We begin and end with active involvement. “To succeed on a supervisory liability claim,
a plaintiff must show that a supervisory official at least implicitly authorized, approved or
knowingly acquiesced in the unconstitutional conduct of the offending subordinate.” Id. at 761
(brackets and quotation marks omitted). This requires active unconstitutional conduct by the
supervisor because supervisory liability will not attach for a failure to act. Id. But plaintiff’s
claim rests entirely on Lykins’s purported failure to act: she argues that Lykins “failed to effect
[Dr. v]on Luhrte’s order that Helphenstine be taken to the hospital”; “did not check on
Helphenstine”; and “conducted no investigation at all into what had happened to Helphenstine,
or the performance of his staff or [Dr. v]on Luhrte.” There is no evidence that he directed any
subordinate to act in a way that violated Helphenstine’s rights, nor is there evidence that he
authorized or acquiesced in any unconstitutional conduct. Thus, the district court properly
granted summary judgment in Lykins’s favor on the supervisory-liability claim against him.

       John Byard and Andy Lucas. The two remaining individual Lewis County defendants
had no reason to know that Helphenstine was suffering a serious medical need. Accordingly, the
district court properly granted summary judgment in their favor.

       Byard merely walked Helphenstine from the jail to the courthouse on April 18; informed
the judge that Helphenstine was “acting like he’s just clear out of it,” had “[s]tuff coming out of
his mouth,” and was “really not coherent”; and walked Helphenstine back to the jail.

       Lucas had only two brief contacts with Helphenstine. Around 9:00 p.m. on April 18, he
saw Helphenstine in the isolation cell, when Helphenstine told Lucas he “was not going to drink
anymore whiskey again.” Around 11:30 p.m., he brought Helphenstine a Mountain Dew to
drink. There is no evidence that Lucas was aware of Helphenstine’s medical condition over the
 No. 22-5407                      Helphenstine v. Lewis County, et al.                    Page 17

previous days, particularly since Lucas spent most of his shift physically separated from the part
of the jail where Helphenstine was housed.

          Neither Byard nor Lucas observed vomiting, diarrhea, shaking, sweating, or any other
manifestation of illness. Neither had any “reason to appreciate the seriousness of [Helpenstine’s]
condition.” Speers v. Cnty. of Berrien, 196 F. App’x 390, 396 (6th Cir. 2006). Although both
Byard and Lucas knew that Helphenstine was going through withdrawal, that knowledge alone
did not require either of them to seek medical care for Helphenstine, particularly since
withdrawal “typically may be managed in a prison setting and indeed frequently is managed
there.” Id. at 395. While it may have been prudent for Byard and Lucas to seek some medical
care for Helphenstine, no reasonable jury could conclude that they were aware of a serious
medical need, nor that they recklessly disregarded a known or obvious risk to Helphenstine’s
health.

          In response, plaintiff highlights Lucas’s admission that if he knew the jail’s policy that
classified withdrawal as a medical emergency, he would have called an ambulance for
Helphenstine on April 18. Unlike McGinnis’s similar admission, though, this question was not
premised on Lucas’s personal knowledge of Helphenstine’s condition. It was based only on the
jail’s policy, which Lucas failed to follow. Alone, the failure to follow an internal policy does
not give rise to a deliberate indifference claim. Griffith, 975 F.3d at 578.

          For these reasons, we affirm the district court’s grant of summary judgment in favor of
Byard and Lucas.

          Dr. von Luhrte. Because Dr. von Luhrte is a physician, the subjective component of
plaintiff’s claim against him is slightly different than that of the other defendants. Generally, “a
patient’s disagreement with his physicians over the proper course of treatment alleges, at most, a
medical-malpractice claim, which is not cognizable under § 1983.” Darrah v. Krisher, 865 F.3d
361, 372 (6th Cir. 2017). But “a doctor’s provision of ‘grossly inadequate medical care’ to an
involuntary detainee may amount to deliberate indifference.” Miller v. Calhoun Cnty., 408 F.3d
803, 819 (6th Cir. 2005) (quoting Terrance, 286 F.3d at 844). “Grossly inadequate medical care
is medical care that is ‘so grossly incompetent, inadequate, or excessive as to shock the
 No. 22-5407                    Helphenstine v. Lewis County, et al.                      Page 18

conscience or to be intolerable to fundamental fairness.’” Id. (quoting Terrance, 286 F.3d at
844). And when the medical need is obvious, “medical care which is so cursory as to amount to
no treatment at all may amount to deliberate indifference.” Terrance, 286 F.3d at 843 (citation
omitted).

       Dr. von Luhrte was never physically present at the jail, but he received a fax explaining
that Helphenstine was in withdrawal, “soiling himself and vomiting [and] refusing to eat and
drink due to upset stomach.” This led him to believe that Helphenstine “might be getting
dehydrated.” But in response, Dr. von Luhrte merely faxed two prescriptions to the jail and
encouraged Helphenstine to rest, sip liquids, and eat bland food.         He testified that by the
afternoon of April 18, Helphenstine’s condition may have been a medical emergency and he
required treatment that only a hospital could provide. Nonetheless, Dr. von Luhrte neither
visited the jail, nor provided medical care or direction for Helphenstine’s treatment.

       To be sure, Dr. von Luhrte maintains that he called the jail twice and advised that
Helphenstine must be taken to the hospital immediately. However, the jail does not have record
of either telephone call and no Lewis County defendant recalls ever speaking to Dr. von Luhrte.
Thus, there is a genuine issue of material fact as to whether the phone calls occurred.

       On this record, a reasonable jury could conclude that Dr. von Luhrte acted with deliberate
indifference. Dr. von Luhrte knew that Helphenstine was in distress and knew that he needed
treatment that only a hospital could provide. With this knowledge, a reasonable jury could
conclude that he did not direct the jail staff to transport Helphenstine to the hospital, and thus
find that this inaction in the face of Helphenstine’s serious medical need was deliberately
indifferent. See Gibson v. Muskowitz, 523 F.3d 657, 662–63 (6th Cir. 2008).

       Moreover, a jury could conclude that the treatment Dr. von Luhrte did provide was “so
cursory as to amount to no treatment at all[.]” Terrance, 286 F.3d at 843 (citation omitted).
Despite acknowledging that Helphenstine needed IV fluid replacement and hospital-grade care,
he only prescribed antiemetics and advised the jailers to help Helphenstine orally rehydrate.
A reasonable jury could conclude that Dr. von Luhrte knew that treatment plan would be
inadequate.    See id.; cf. Rouster v. Cnty. of Saginaw, 749 F.3d 437, 448 (6th Cir. 2014)
 No. 22-5407                    Helphenstine v. Lewis County, et al.                      Page 19

(“Had [the defendant] been subjectively aware of the seriousness of [the inmate’s] medical
condition, her decision to treat him only with over-the-counter medication might have been so
cursory as to amount to a conscious disregard of his needs.”). Thus, the question of “whether
that course of treatment constituted deliberate indifference is a question best suited for a jury.”
Darrah, 865 F.3d at 370. The district court erred when it granted summary judgment in Dr. von
Luhrte’s favor.

       Lewis County.     Plaintiff also seeks to impose municipal liability on Lewis County.
“A municipality is a ‘person’ under 42 U.S.C. § 1983, and so can be held liable for constitutional
injuries for which it is responsible.” Morgan v. Fairfield Cnty., 903 F.3d 553, 565 (6th Cir. 2018)
(citing Monell v. Dep’t of Soc. Servs. of City of New York, 436 U.S. 658, 690 (1978)).
A municipality cannot be liable under a theory of respondeat superior; it can only be held liable
for “its own wrongdoing.” Id. This requires plaintiff to demonstrate that the alleged federal
violation occurred because of a municipal “policy or custom.”          Monell, 436 U.S. at 694.
A municipality may be held liable under one of four recognized theories: “(1) the existence of
an illegal official policy or legislative enactment; (2) that an official with final decision making
authority ratified illegal actions; (3) the existence of a policy of inadequate training or
supervision; or (4) the existence of a custom of tolerance or acquiescence of federal rights
violations.” Burgess v. Fischer, 735 F.3d 462, 478 (6th Cir. 2013). Plaintiff argues that Lewis
County failed to adequately train and supervise its jailers regarding medical emergencies.
We agree.

       “A municipality’s culpability for a deprivation of rights is at its most tenuous where a
claim turns on a failure to train.” Connick v. Thompson, 563 U.S. 51, 61 (2011). There are two
ways to support a claim that a failure to train or supervise is the result of a municipality’s
deliberate indifference. Plaintiff may prove (1) a “pattern of similar constitutional violations by
untrained employees” or (2) “a single violation of federal rights, accompanied by a showing that
[the municipality] has failed to train its employees to handle recurring situations presenting an
obvious potential for a constitutional violation.” Shadrick v. Hopkins Cnty., 805 F.3d 724, 738–
39 (6th Cir. 2015) (internal quotation marks omitted). Plaintiff has not identified any other
constitutional violations, so she must demonstrate that the single violation (Helphenstine’s death)
 No. 22-5407                      Helphenstine v. Lewis County, et al.                         Page 20

was accompanied by Lewis County’s failure to train the jailers to handle this potentially
recurring situation. This sort of claim is available only “in a narrow range of circumstances,”
where a federal rights violation “may be a highly predictable consequence of a failure to equip
[employees] with specific tools to handle recurring situations.” Board of Cnty. Comm’rs of
Bryan Cnty. v. Brown, 520 U.S. 397, 409 (1997).

        The question here is whether the County’s failure to train its employees amounted to
deliberate indifference, on behalf of the County, to the rights of detainees. See City of Canton v.
Harris, 489 U.S. 378, 388 (1989). Such a claim has three elements. Plaintiff must show (1) that
the County’s “training or supervision was inadequate for the tasks performed; (2) the inadequacy
was the result of the municipality’s deliberate indifference; and (3) the inadequacy was closely
related to or actually caused the injury.” Winkler, 893 F.3d at 902 (citation omitted). Here, a
reasonable jury could conclude that she has met her burden.

        First, the adequacy of the training program. Drug and alcohol withdrawal was common
among people housed at the jail. The jail’s written policies stated that “[d]rug or alcohol
withdrawal” constituted an emergency. But the written policies contained no instructions or
guidelines for how staff should care for an inmate in withdrawal beyond contacting the “Jail
Medical Coordinator and the Facility Physician[.]”5

        The record is mixed on whether the jailers ever received any training or instruction
regarding withdrawal or medical emergencies. McGinnis testified that she had received training
on   what    constituted    an    alcohol-withdrawal-related      medical    emergency,      identifying
uncontrollable vomiting, diarrhea, or unresponsiveness. Most jailers agreed that an inmate
experiencing a medical emergency should be sent to the hospital, but the deputy jailers also
testified that they had not received any training regarding withdrawal or how to identify medical
emergencies. Indeed, Lykins agreed that no one at the jail had specific “training to determine
whether someone going through alcohol or drug withdrawal was experiencing signs or symptoms
that indicated that their withdrawal was about to be fatal.” And several Lewis County defendants

        5
          The medical coordinator is not a medically trained position. Rather, the medical coordinator is
responsible for corresponding with Dr. von Luhrte, making appointments, and medical billing.
 No. 22-5407                     Helphenstine v. Lewis County, et al.                        Page 21

professed ignorance when asked if they knew that a jail policy identified drug or alcohol
withdrawal as a medical emergency—some had never even seen the policy.

        The Lewis County defendants argue (and the district court held) that they received
sufficient training because some defendants testified that they knew what to look for to identify a
medical emergency. We find this argument unpersuasive for two reasons. First, defendants
testified that they did not receive training on how to identify a withdrawal-related medical
emergency. The fact that they could identify some symptoms of medical emergencies likely
came from some other source (perhaps experience or common sense). It did not come, on this
record, from a training provided by the jail. And second, even if they were able to identify signs
of a medical emergency in the abstract, they were unable to do so when one presented itself. For
example, McGinnis and Ruark testified that severe vomiting could be an emergency. But these
defendants observed Helphenstine vomiting—Ruark even testified that he was not sure that
Helphenstine could hold anything down—and did not seek medical intervention. Given this, a
reasonable jury could conclude that their training, to the extent they were trained, was
insufficient.

        Finally, the district court held that the fact that the jailers received only CPR and first aid
training cannot create a question of fact on a failure-to-train claim in this circuit. That statement
of the law is inaccurate. True, we have held that jailers trained in CPR and first aid received
adequate training to respond to medical emergencies. See Winkler, 893 F.3d at 903; Berry v.
Delaware Cnty. Sheriff’s Off., 796 F. App’x 857, 864 (6th Cir. 2019). But in Winkler, the jail
had trained medical staff on site forty hours per week, and medical staff was “available to jail
personnel, either in person or by phone, for consultation about an inmate 24 hours a day, 7 days a
week.” 893 F.3d at 885, 903. And in Berry, the jail had “nursing coverage 24 hours a day, seven
days a week,” so the jailers’ training was sufficient. 796 F. App’x at 864. Those jailers could
immediately contact medically trained staff, so first aid and CPR training was sufficient to bridge
the short gap between contacting a medical professional and medical treatment. Not so here,
where a detainee was almost wholly reliant on the jailers for medical care.
 No. 22-5407                    Helphenstine v. Lewis County, et al.                      Page 22

       At bottom, it appears that defendants were not trained on how to identify or address a
medical emergency. A jury could easily conclude that this training program, to the extent that it
existed, was insufficient.

       Second, Lewis County’s deliberate indifference. “Deliberate indifference is a stringent
standard of fault, requiring proof that a municipal actor disregarded a known or obvious
consequence of his action.” Connick, 563 U.S. at 61 (brackets and quotation marks omitted). If
the “unconstitutional consequences of failing to train” employees are “patently obvious,” the
county “could be liable under § 1983 without proof of a pre-existing pattern of violations.” Id. at
64. Asking employees to use professional judgment that lies outside their area of expertise may
demonstrate deliberate indifference. See Canton, 489 U.S. at 390 & n.10. For example, absent
specific training on the use of deadly force, armed police officers would not be “equipped with
the tools” necessary to make the relevant legal determination. Connick, 563 U.S. at 70.

       The inadequacy of the training and supervision at the jail demonstrates that it results from
the County’s deliberate indifference to the rights of its inmates because the possible
unconstitutional consequences are patently obvious. This is particularly palpable when viewing
Lewis County’s woeful training policy against the backdrop of Dr. von Luhrte’s performance
and the County’s lack of supervision.

       Begin with the written policies: The County hired Dr. von Luhrte to provide medical
care to inmates, but required him to visit the jail only once a week. This violates Kentucky’s
administrative regulations, which mandate that a jail conduct at least two sick calls per week.
501 Ky. Admin. Regs. 3:090(10)(a), 3:170. And the County had a policy that the elected jailer,
Lykins, was to publish a quarterly report on the jail’s medical services. But Lykins did not do
so. Indeed, Lykins had never actually seen Dr. von Luhrte visit the jail, and explicitly testified
that the County did not supervise Dr. von Luhrte’s performance in any way.

       Further, Dr. von Luhrte was unaware of the policies and regulations that did exist,
including the ones regarding the standard of care he owed to the inmates. He agreed that he had
no knowledge of the specific “medical services that are supposed to be provided to inmates in
Kentucky jails.” Dr. von Luhrte testified that he often treated minor ailments over the phone
 No. 22-5407                    Helphenstine v. Lewis County, et al.                     Page 23

without examining the patient. And he admitted that he did not have the experience to treat an
inmate in withdrawal.

       The jail doctor was unable to deal with common medical conditions at the jail, and he
was rarely present at the jail. The deputy jailers did not have any medical training or medical
knowledge, so often, no one at the jail could recognize or treat a medical emergency. But with
no medical professionals on site, the County effectively asked the jailers to make determinations
about what constituted a medical emergency—a requirement well outside their area of expertise.
And the County did not supervise the jailers or Dr. von Luhrte at all. A reasonable jury could
easily conclude that these policies were the result of the County’s deliberate indifference to
inmate health and safety. See Shadrick, 805 F.3d at 742 (“Because it is so highly predictable that
a poorly trained [County employee] working in the jail setting ‘utterly lacks an ability to cope
with constitutional situations,’ a jury reasonably could find that [the County]’s failure to train
reflects ‘deliberate indifference to the highly predictable consequence, namely, violations of
constitutional rights.’” (quoting Connick, 563 U.S. at 64, 67 (brackets omitted))).

       Third, relation to Helphenstine’s death.      There is a dispute of material fact as to
Helphenstine’s cause of death. It is not clear whether he died from fentanyl intoxication (as set
forth on the death certificate), alcohol withdrawal (as asserted by one of plaintiff’s experts), or
severe dehydration due to alcohol withdrawal (as identified by another of plaintiff’s experts). On
this record, a jury could conclude that he died from withdrawal (or related complications), which
was mismanaged and ignored by defendants.

       In sum, a jury could conclude that Helphenstine’s death was the result of the County’s
deliberate indifference. Helphenstine fell ill on April 16 and received no medical attention or
care until his death three days later. No Lewis County defendant tried to effect Dr. von Luhrte’s
advice that Helphenstine be provided with rehydrating food or drink. County employees gave
him two doses of antiemetics, but no County employee ever checked his vitals; provided him
with rehydration beyond sips of Mountain Dew, water, Ensure, or juice; or sought hospital-level
care. The County offered little more to Helphenstine than observation, and “[a]t a certain point,
bare minimum observation ceases to be constitutionally adequate.” Greene, 22 F.4th at 609.
Plaintiff has demonstrated that a reasonable jury could conclude that the County’s training and
 No. 22-5407                     Helphenstine v. Lewis County, et al.                       Page 24

supervision was inadequate, that the inadequacy was caused by Lewis County’s indifference, and
that the inadequacy caused Helphenstine’s death. The district court improperly granted summary
judgment in favor of Lewis County.

                                                 B.

       The Lewis County Defendants also argue that they are entitled to qualified immunity on
plaintiff’s claims. Qualified immunity shields public officials from personal liability under
§ 1983 unless they “violate clearly established statutory or constitutional rights of which a
reasonable person would have known.” Harlow v. Fitzgerald, 457 U.S. 800, 818 (1982). To
determine whether defendants are entitled to qualified immunity, we must ask two questions:
(1) “whether the facts that a plaintiff has . . . shown . . . make out a violation of a constitutional
right,” and (2) “whether the right at issue was ‘clearly established’ at the time of [the]
defendant’s alleged misconduct.” Pearson v. Callahan, 555 U.S. 223, 232 (2009) (citation
omitted).

       The inquiry is simple for defendants Byard and Lucas. Having concluded above that
their conduct did not rise to the level of deliberate indifference, they are entitled to qualified
immunity because they did not violate Helphenstine’s constitutional rights.             But for the
remaining defendants, who may have violated a constitutional right, we must consider whether
the right they allegedly violated was clearly established. See, e.g., Burwell v. City of Lansing,
7 F.4th 456, 476 (6th Cir. 2021).

       “For a right to be clearly established, the contours of the right must be sufficiently clear
that a reasonable official would understand that what he is doing violates that right.”            Id.
(brackets and internal quotation marks omitted). “The unlawfulness must be apparent in the light
of pre-existing law, but we need not find a case in which the very action in question has
previously been held unlawful.” Id. at 476–77 (brackets, ellipses, and citation omitted). In this
case, we look to see how clearly the right to be free from deliberate indifference was established
at the time Helphenstine died in 2017. See Brosseau v. Haugen, 543 U.S. 194, 198 (2004) (per
curiam).
 No. 22-5407                    Helphenstine v. Lewis County, et al.                     Page 25

       It has been true since 1972 that “where the circumstances are clearly sufficient to indicate
the need of medical attention for injury or illness, the denial of such aid constitutes the
deprivation of constitutional due process.” Greene, 22 F.4th at 615 (citation omitted); see also
Fitzke v. Shappell, 468 F.2d 1072, 1076 (6th Cir. 1972). “Furthermore, we reiterated in 2013
that it is clearly established that a prisoner has a right not to have his known, serious medical
needs disregarded by a medical provider or an officer.” Greene, 22 F.4th at 615 (brackets,
ellipses, and citation omitted). For example, over a decade ago, we “denied qualified immunity
to an officer who failed to seek medical assistance for an individual suffering from [severe
alcohol withdrawal] in a situation of obvious illness even when the officer knew that the detainee
was on withdrawal medication and being observed.” Id. (citing Smith, 505 F. App’x at 535).

       Just like in Greene, Helphenstine experienced a dangerous medical condition for at least
a day before his death. The Lewis County defendants did not provide any medical assistance
during that time beyond two doses of antiemetics. Helphenstine’s right not to have his serious
medical needs disregarded by the Lewis County defendants was clearly established in this
scenario. Id. Accordingly, none of the remaining Lewis County defendants are entitled to
qualified immunity.

                                                C.

       The district court declined to exercise supplemental jurisdiction over plaintiff’s state-law
negligence claim once it granted summary judgment in favor of defendants on plaintiff’s § 1983
claim. Because we reverse the district court’s grant of summary judgment as to the § 1983 claim
in part, we also reverse the district court’s dismissal of the state-law claim in part: on remand,
the district court should reconsider whether it should now exercise supplemental jurisdiction over
the negligence claim against the remaining defendants. See, e.g., Bishop v. Children’s Ctr. for
Developmental Enrichment, 618 F.3d 533, 538–39 (6th Cir. 2010).
 No. 22-5407                    Helphenstine v. Lewis County, et al.                      Page 26

                                               III.

       For these reasons, we reverse the district court’s grant of summary judgment in favor of
Riley, McGinnis, Ruark, Bloomfield, Lykins (in his individual capacity), Dr. von Luhrte, and
Lewis County. We affirm the district court’s judgment as to Byard, Lucas, and Lykins (in his
supervisory capacity), and remand for further proceedings consistent with this opinion.