                            In the
 United States Court of Appeals
              For the Seventh Circuit
                         ____________

No. 03-3036
NORMAN CALHOUN,
                                              Plaintiff-Appellant,
                                v.

KENNETH RAMSEY, Sheriff of
Kane County, and CORRECTIONAL
MEDICAL SERVICES, INC.,
                                           Defendants-Appellees.

                         ____________
         Appeal from the United States District Court for
        the Northern District of Illinois, Eastern Division.
          No. 00 C 3307—Ronald A. Guzmán, Judge.
                         ____________
   ARGUED SEPTEMBER 23, 2004—DECIDED MAY 17, 2005
                   ____________



  Before EASTERBROOK, WOOD, and EVANS, Circuit Judges.
  WOOD, Circuit Judge. Norman Calhoun brought this ac-
tion under 42 U.S.C. § 1983 against Kenneth Ramsey, the
Sheriff of Kane County, and Correctional Medical Services,
Inc. (CMS), a private company that contracted with the
County to provide medical care to inmates incarcerated in
the county jail, complaining about injuries he sustained at
the jail. He claimed that his injuries resulted from the fact
that the jail’s medical policy made no provision for advance
2                                                 No. 03-3036

verification of a detainee’s medications. This omission, he
argued, amounted to deliberate indifference to his medical
needs in violation of the Eighth Amendment.
  A jury found in favor of the defendants, and Calhoun now
appeals. He complains about both the jury instructions on
municipal liability and the introduction of certain evidence.
We see no error with respect to either of these points, and
we therefore affirm.


                               I
  In 1999, Calhoun was sentenced to serve evenings and
weekends at the Kane County Jail to satisfy a 120-day
sentence for a motor vehicle violation. His sentence was to
begin at 7:30 p.m. on June 1, 1999. In the days leading up
to that time, Calhoun called the jail twice, in an effort to ob-
tain pre-incarceration approval of his medication. He was
doing so because he knew that detainees were not free
simply to retain their own medications and take them as
directed. Instead, consistent with the Illinois County Jail
Standards, 20 Ill. Admin. Code § 701.40(j), the Kane County
Jail’s medical policy requires that medication prescribed to
inmates prior to incarceration must be verified and approved
by the jail’s medical director before it can be administered
to the inmate. CMS Policy 30.05. Moreover, “[a]ny medica-
tion in the possession of a detainee at admission shall be
withheld until verification of its proper use is obtained and
documented. This verification shall be made as soon as pos-
sible, but within the time interval specified for administra-
tion of the medication on the prescription container.” 20 Ill.
Admin. Code § 701.40(j). Calhoun was hoping to complete
these administrative steps before he actually reported to the
jail.
  Each time, his efforts were rebuffed. The jail personnel
told him that pre-approval was not important, and that he
should just make arrangements at the time he checked
No. 03-3036                                                3

in. On the evening of June 1, therefore, Calhoun arrived
at the jail thirty minutes before the designated time. He
reported to the booking area of the jail, where Officer Peter
O’Connor took his intake information. Calhoun handed
Officer O’Connor a bag containing eight prescription medi-
cations that he was taking and told the officer that he had
to take some of the medication that night. The prescription
labels on the bottles for two of the medications, Diazepam
and Trazodone, stated that they had to be administered at
“QHS,” a medical term referring to “hour of sleep.” The other
medication did not have to be taken until the next morning.
O’Connor placed Calhoun in a holding cell within the
booking area. About fifteen minutes after his arrival at the
jail, Lynn Kimmel, a nurse employed by CMS assigned to
the jail, came to speak with him about his medications. As
required by the jail’s policy, Kimmel took Calhoun’s pre-
scription medicines with her when she left his cell, so that
she could obtain authorization to administer them.
  At around 8:30 p.m, Kimmel paged the jail physician and
psychiatrist to obtain authorization to administer Calhoun’s
medications. Half an hour later, the psychiatrist authorized
Trazodone, to be administered at “QHS,” which at the jail
meant between 10 p.m. and 10:30 p.m. At around 9:15 p.m.,
jail officials notified Kimmel that Calhoun needed medical
attention. She promptly returned to his cell, arriving around
9:20 p.m., where she found him lying on the floor complain-
ing of pain. Kimmel was not authorized to administer medi-
cation without a doctor’s order, but she checked Calhoun’s
vital signs, which showed elevated blood pressure. She then
directed the jail staff to call for an ambulance. The ambu-
lance arrived at 9:45 p.m. and transported Calhoun to the
hospital, where he was treated in the emergency room. The
hospital discharged Calhoun in good condition at 11:30
p.m., a little more than one hour after his arrival at the
hospital and four hours after his report time. He did not
return to the jail that night or subsequently because he was
4                                                No. 03-3036

released from the Sheriff’s custody at that time and was not
required to serve the rest of his sentence at the jail.
  Believing that the events of June 1 demonstrated delib-
erate indifference to his medical needs in violation of the
Eighth Amendment, Calhoun filed suit against Sheriff
Ramsey, CMS, Officer O’Connor and Nurse Kimmel under
42 U.S.C. § 1983. Calhoun alleged that he had been injured
as a result of the jail’s failure to administer his medication
in a timely fashion. The jail’s failure, he asserted, was the
result of a constitutionally inadequate policy: specifically,
a policy that made no provision for advance verification of
medication and indeed prohibited this approach, as illustrated
by the refusal of the jail personnel to respond positively to
Calhoun’s efforts to obtain approval for his medications
before he reported to serve his sentence. The district court
granted summary judgment in favor of defendants O’Connor
and Kimmel and partial summary judgment in favor of CMS
and Ramsey on some claims. Calhoun does not appeal from
these rulings.
  The only claim presented to the jury was the one against
the Sheriff and CMS in which Calhoun alleged that the
absence of a pre-verification procedure in the jail’s policy
and the jail’s refusal to verify his medication in advance
amounted to deliberate indifference to his medical needs.
After a trial, the jury found in favor of CMS and Ramsey.
  Calhoun appeals the jury verdict on two grounds. First,
he alleges that the jury instructions misstated the law by
requiring “evidence that the circumstances he endured were
not an isolated incident,” but had been caused by a “wide-
spread policy or practice that was so permanent and well
settled as to constitute a custom or usage with the force of
law.” Second, he argues that the court improperly permitted
the defendants to introduce extrinsic evidence to impeach
him on a collateral matter.
No. 03-3036                                                    5

                               II
  Calhoun objects that the jury instructions misstated the
law on municipal liability, at least for a claim like his that
postulated liability under § 1983 through an express policy.
He argues that evidence of only one violation is sufficient
for finding liability under this theory. On that assumption,
he continues, the following portions of the jury instructions
were erroneous:
    In order to prove that the defendants had a deliberately
    indifferent policy or practice, the plaintiff must estab-
    lish that there existed a wide-spread policy or practice
    that was so permanent and well-settled as to constitute
    a custom or usage with the force of law.
    For purposes of proving a widespread practice that is so
    permanent and well-settled as to constitute a custom or
    usage with the force of law, the plaintiff is required to
    present evidence that the circumstances that he en-
    dured was not an isolated incident. (Emphasis added.)
  We review jury instructions de novo to determine whether
they provide fair and accurate summaries of the law. United
States v. Tingle, 183 F.3d 719, 729 (7th Cir. 1999). We give
the district court substantial discretion with respect to the
precise wording of jury instructions so long as the final
result, read as a whole, completely and correctly states the
law. See id. Even if the instruction contains an error or
misguides the jury, we reverse a jury verdict only if the
error prejudiced a litigant. See Molnar v. Booth, 229 F.3d
593, 602 (7th Cir. 2000).
  We must first address the defendants’ assertion that
Calhoun waived this argument by objecting at trial only to
the first paragraph reproduced above but not to the second.
It is true that a litigant’s failure to raise an objection before
the trial court that would alert the court to the basis of a
perceived defect precludes appellate review. See Haley v.
6                                                No. 03-3036

Gross, 86 F.3d 630, 644 (7th Cir. 1996). As the first instruc-
tion requires a showing of more than one incident, however,
we think that Calhoun sufficiently alerted the court to the
argument he now advances, namely, that he is not required
to present evidence of other incidents of violations resulting
from a municipality’s express policy under § 1983. There-
fore, we can reach the merits of this claim.
  In Monell v. N.Y. City Dept. of Social Servs., 436 U.S. 658
(1978), the Supreme Court established both the fact that
“municipalities and other local government units [were]
included among those persons to whom § 1983 applies,” id.
at 690, and the limits of such actions. Most importantly,
Monell held that “a municipality cannot be held liable
under § 1983 on a respondeat superior theory.” Id. at 691.
Instead, municipal liability exists only “when execution of
a government’s policy or custom, whether made by its law-
makers or by those whose edicts or acts may fairly be said
to represent official policy, inflicts the injury.” Id. at 694.
We have identified three different ways in which a muni-
cipality or other local governmental unit might violate
§ 1983: (1) through an express policy that, when enforced,
causes a constitutional deprivation; (2) through a “wide-
spread practice” that although not authorized by written
law and express policy, is so permanent and well-settled as
to constitute a “custom or usage” with the force of law; or (3)
through an allegation that the constitutional injury
was caused by a person with “final decision policymaking
authority.” McTigue v. City of Chi., 60 F.3d 381, 382 (7th
Cir. 1995).
  The express policy theory applies, as the name suggests,
where a policy explicitly violates a constitutional right when
enforced. See Monell, 436 U.S. at 658. So, for example, if the
Kane County Jail had a policy that directed the sheriff’s
personnel to throw away all prescription medications brought
in by detainees or prisoners without even reading the label
and without making alternative provisions for the affected
No. 03-3036                                                    7

individuals, the County would be liable assuming that such
a policy would, on its face, violate the Eighth Amendment
(or the Due Process clause, for pre-trial detainees). Under
this type of claim, one application of the offensive policy re-
sulting in a constitutional violation is sufficient to establish
municipal liability. City of Okla. v. Tuttle, 471 U.S. 808, 822
(1985).
   A second way of complaining about an express policy is to
object to omissions in the policy. This, as we understand the
argument, is what Calhoun is doing. In fact, we think that
it is more confusing than useful to distinguish between
claims about express policies that fail to address certain
issues, and claims about widespread practices that are not
tethered to a particular written policy. In both of these
situations, the claim requires more evidence than a single
incident to establish liability. See Tuttle, 471 U.S. at 822-23
(challenging the city’s police officer training policy as
inadequate). This is because it is necessary to understand
what the omission means. No government has, or could
have, policies about virtually everything that might happen.
The absence of a policy might thus mean only that the
government sees no need to address the point at all, or that
it believes that case-by-case decisions are best, or that it
wants to accumulate some experience before selecting a
regular course of action. At times, the absence of a policy
might reflect a decision to act unconstitutionally, but the
Supreme Court has repeatedly told us to be cautious about
drawing that inference. See, e.g., Bd. of the County Comm’rs
of Bryan County v. Brown, 520 U.S. 397, 409 (1997) (reject-
ing Monell claim based on absence of more thorough
screening of candidates for sheriff’s deputy); City of Canton
v. Harris, 489 U.S. 378, 388 (1989) (rejecting a failure-to-train
claim).
  Both in the “widespread practice” implicit policy cases
and in the cases attacking gaps in express policies, what is
8                                                 No. 03-3036

needed is evidence that there is a true municipal policy at
issue, not a random event. If the same problem has arisen
many times and the municipality has acquiesced in the
outcome, it is possible (though not necessary) to infer that
there is a policy at work, not the kind of isolated incident
that Brown held cannot support municipal liability. So, for
example, in addressing whether a city’s failure adequately
to train its police officers amounted to a policy for Monell
purposes, the Supreme Court had the following to say:
    [T]he word “policy” generally implies a course of action
    consciously chosen from among various alternatives; it
    is therefore difficult in one sense even to accept the sub-
    mission that someone pursues a “policy” of “inadequate
    training,” unless evidence be adduced which proves that
    the inadequacies resulted from conscious choice—that
    is, proof that the policymakers deliberately chose a train-
    ing program which would prove inadequate.
Tuttle, 471 U.S. at 823 (footnote omitted); see also Harris,
489 U.S. at 388 (finding liability should be imposed only
when the degree of fault rises to the level of “deliberate in-
difference” to rights, that is, where the municipality’s “choice
to follow a course of action is made from among various al-
ternatives by . . . policymakers.”) (quoting Pembaur v.
Cincinnati, 475 U.S. 469, 483-84 (1986) (Brennan, J.,
plurality)).
  Accordingly, the Court has held that “where the policy
relied upon is not itself unconstitutional, considerably more
proof than the single incident will be necessary in every
case to establish both the requisite fault on the part of the
municipality and the causal connection between the [omis-
sion in the policy] and the constitutional deprivation.”
Tuttle, 471 U.S. at 824 (footnote omitted). Even though the
Court in Harris did not absolutely foreclose the possibility
that a plaintiff might succeed in proving a failure-to-train
claim without showing a pattern of constitutional violations,
No. 03-3036                                                 9

see 489 U.S. at 390 & n.10, it later clarified that it was
“simply hypothesiz[ing] that, in a narrow range of circum-
stances, a violation of federal rights may be a highly pre-
dictable consequence of a failure to equip law enforcement
officers with specific tools to handle recurring situations.”
Brown, 520 U.S. at 409. Although the Court has therefore
left room for this “narrow range of circumstances,” it is
telling that no court has directly addressed such a case. Cf.
Woodward v. Correctional Medical Services, 368 F.3d 917,
929 (7th Cir. 2004) (commenting that evidence of a single
violation may be enough where a jail takes no precautions
against the possibility of inmate suicide but imposing
liability based on the jail’s repeated failures to ensure one
inmate’s safety and condoning violations of its own suicide-
watch policy).
  Against this backdrop, we have no trouble concluding that
there was nothing wrong with the jury instructions to which
Calhoun has objected. Whether we look at this case as one
in which Calhoun was complaining about the failure of the
County’s express policy to make provision for advance
verification of medications, or if we look at it as one in
which Calhoun is arguing that the County has an implicit
policy reflected in an alleged widespread practice of imped-
ing detainee access to medication (a distinction Calhoun has
discussed at length), the result is the same. Because he
cannot point to any language in the jail’s policy that is
constitutionally suspect, he must provide enough evidence
of custom and practice to permit an inference that the County
has chosen an impermissible way of operating. Calhoun did
not even try to show that Kane County’s affirmative
decision to require that medication must be verified “within
the time interval specified for administration of the medi-
cation on the prescription container,” see 20 Ill. Admin. Code
§ 701.40(j), was so inadequate as to amount to an Eighth
Amendment violation. This strategic decision was a wise
one. First, the County’s policy uses a time interval between
10                                               No. 03-3036

doses that even the prescribing physician apparently
believes is appropriate for the particular patient. Second,
this court has upheld another jail’s policy, identical to the
one in Kane County, which is also based on the Illinois
County Jail Standards, 20 Ill. Admin. Code § 701.40(j). See
Garvin v. Armstrong, 236 F.3d 896 (7th Cir. 2001).
  Having argued that the jail had a “practice of refusing” to
pre-verify medication, Calhoun cannot now turn around and
argue that the district court erred by instructing the jury on
a custom or usage theory. Indeed, the instructions were
consistent with Calhoun’s proposed instructions and
provided an alternative theory for his claim. His effort to
hold Kane County liable on the basis of this single incident
is inconsistent with Brown, and the district court was cor-
rect to reject instructions that would have misstated the law.


                             III
  Calhoun’s other argument on appeal relates to a decision
by the district court to admit certain impeachment evi-
dence. At trial, Calhoun testified that he had been working
in June 1999 when he reported to the jail to begin his work-
release sentence. On cross-examination, the defendants con-
fronted him with sworn statements he had made to the
Social Security Administration in an application for disa-
bility benefits. In the application, Calhoun stated that he
had become unable to work in November 1998. Calhoun now
argues that these statements related to a collateral matter
and were therefore inadmissible.
  We have held that “a witness may not be impeached by
contradiction as to collateral or irrelevant matters elicited
on cross-examination. A matter is collateral if the impeach-
ing fact could not have been introduced into evidence for
any purpose other than the contradiction.” Taylor v. Nat’l
R.R. Passenger Corp., 920 F.2d 1372, 1375 (7th Cir. 1990)
(internal citation and quotation marks omitted). In other
No. 03-3036                                               11

words, a party may not “contradict for the sake of contradic-
tion.” United States v. Bitterman, 320 F.3d 723, 727 (7th
Cir. 2003) (quotation marks omitted).
  In permitting the defendants to introduce the statements
in Calhoun’s disability application, the court held that they
were not about a collateral matter because they related to
one of the essential issues of the case: Calhoun’s physical
condition both before and after the events at the jail. The
court noted that this issue was material to the question of
damages and that it was Calhoun’s contention that his
condition after June 1, 1999, was much worse than it had
been before. The statements in the application reveal that
Calhoun was unable to work prior to the jail incident. Thus,
whatever their effect may have been on his credibility, those
statements were relevant to the question of the extent, if
any, of the effect the incident had on his overall condition.
  We agree with the district court that Calhoun’s state-
ments to the Social Security Administration did not relate
to a collateral matter. They threw light on a material issue
in the case—his condition before the events at the jail— and
therefore they were admissible. The district did not abuse
its discretion in admitting this evidence.


                            IV
  For these reasons, we AFFIRM the judgment.
12                                        No. 03-3036

A true Copy:
      Teste:

                    ________________________________
                    Clerk of the United States Court of
                      Appeals for the Seventh Circuit




               USCA-02-C-0072—5-17-05
