                     United States Court of Appeals
                             FOR THE EIGHTH CIRCUIT
                                   ___________

                                   No. 07-2921
                                   ___________
 Susan Vaughn,                         *
                                       *
              Appellee,                *
                                       *       Appeal from the United States
 v.                                    *       District Court for the
                                       *       Eastern District of Arkansas.
 Christopher Gray, et al.,             *
                                       *
              Appellants.              *
                                       *
                                   ___________

                              Submitted: December 12, 2008
                                 Filed: March 6, 2009
                                  ___________

Before LOKEN, Chief Judge, BEAM, Circuit Judge, and KYLE,1 District Judge.
                              ___________

KYLE, District Judge.

       Appellee, Susan Vaughn, commenced this action under 42 U.S.C. § 1983,
contending that Appellants were deliberately indifferent to the serious medical
needs of her brother, Phil Blount, which resulted in his death. Appellants, several
officers and employees of the Greene County, Arkansas Sheriff’s Department,




      1
        The Honorable Richard H. Kyle, United States District Judge for the
District of Minnesota, sitting by designation.
moved for summary judgment based on qualified immunity, which was denied by
the district court.2 Appellants appeal and we affirm.

I.    BACKGROUND

       Vaughn first brought an action against Greene County and Sheriff Dan
Langston in his individual capacity. The district court denied summary judgment
on the ground of qualified immunity for Sheriff Langston, but we reversed, finding
he was entitled to qualified immunity. Vaughn v. Greene County, 438 F.3d 845
(8th Cir. 2006). While the first action was on appeal, Vaughn filed a second
action, asserting the same Section 1983 claims against four additional officers and
employees of the Greene County Sheriff’s Department in their individual and
official capacities: Christopher L. Gray, David Wanner, Michael Johnson, and
Chris Hall The two actions were consolidated, and thereafter the four new
defendants moved for summary judgment on the ground of qualified immunity.
The motion was granted with respect to Chris Hall, but denied for the remaining
defendants. Vaughn v. Greene County, Nos. 2:03CV00070, 2:04CV00213, 2007
WL 2409581, at *3-5 (E.D. Ark. Aug. 10, 2007).

       In determining that the remaining defendants (hereinafter the “Appellants”)
were not entitled to qualified immunity, the district court relied upon the following
facts as first described by this Court:

      On December 23, 2001, Blount, a 46-year-old moderately obese man,
      was arrested and taken to the Greene County Jail (Jail), where he was
      incarcerated on a charge of first-degree sexual assault. During the
      Jail's intake procedure, Blount completed a medical intake form,
      indicating he had a history of mental illness, headaches,
      epilepsy/seizures, ulcers, and kidney/bladder problems, but indicating
      he did not have a history of heart problems or high or low blood

      2
       The Honorable James M. Moody, United States District Judge for the
Eastern District of Arkansas.
                                         -2-
pressure. Although Blount had no medications with him upon his
arrival at the Jail, Blount's mother, Carolyn Barber (Barber), later
brought Blount's medications, including an anti-depressant. Inmate
medication logs from the Jail, as well as written jailer statements,
indicate Blount received his anti-depressant medication from
December 24, 2001, until January 2, 2002, when the Jail ran out of the
medication for Blount's last two dosages on that day. According to
these records, Blount's new prescription did not arrive until January 4,
2002, but would not be administered until the next day's shift starting
at 6:00 a.m.

On January 4, 2002, jailer Chris Hall (Hall) spoke with Blount's
cellmate, who said Blount had been ingesting shampoo and engaging
in other odd behavior. Hall repeated this information to Jail Sergeant
Mark Harmon, who in turn informed the other jailers. Around 3:00
p.m., Blount was moved to an isolation cell to be monitored. At
approximately 10:30 or 11:00 p.m., jailer Chris Gray (Gray) observed
Blount vomiting in the isolation cell. Blount asked Gray for a nurse
because his stomach was bothering him. Gray asked Blount if he was
vomiting because of the shampoo he had ingested, but Blount did not
respond. Blount was not given the opportunity to see a nurse
following his request. During the night and early morning hours,
Blount and the other inmates were checked by Jail personnel about
once every hour.

On January 5, 2002, at about 5:15 a.m., jailer Michael Johnson
(Johnson) observed Blount pacing in his cell and repeatedly drinking
water and throwing up. Approximately thirty minutes later, at 5:50
a.m., Johnson went to Blount's cell to give him his medications and
observed Blount lying naked on the floor of his cell. Johnson and the
shift supervisor entered Blount's cell, found him unresponsive,
initiated CPR, and called for an ambulance. Blount was transported to
the hospital, where he was pronounced dead. An autopsy led to the
determination Blount died of natural causes: arteriosclerotic
cardiovascular disease, causing a heart attack that resulted in Blount's
death. Detectable amounts of Blount's anti-depressant medication
were found in Blount's system during his autopsy.


                                  -3-
      According to Barber, Blount called her numerous times on January 3
      and 4, 2002, and stated he was nauseated and vomiting. Barber
      attempted to contact Sheriff Langston to ask for someone to take
      Blount to a doctor, but Barber was unable to reach the sheriff. Barber
      later went to the Jail twice on January 4, told a Jail staff member
      Blount was sick, and was told Blount was receiving his medications.
      Additionally, Vaughn, Blount's sister, called the Jail before Blount's
      death to tell the Jail staff he was sick. Vaughn also wrote and faxed a
      letter to Sheriff Langston, informing him Blount had mental problems
      and needed to be placed in a different facility.

Id. at *1-2 (quoting Vaughn, 438 F.3d at 847-48).

      While Appellants do not deny their knowledge of Blount’s repeated
vomiting over a seven-hour period and his request for medical assistance, they
contend that there is no evidence in the record of their deliberate indifference to
Blount’s medical needs, and therefore, they are entitled to qualified immunity.

II.   ANALYSIS

       We review de novo the denial of a motion for summary judgment based on
qualified immunity. Vaughn v. Ruoff, 253 F.3d 1124, 1127 (8th Cir. 2001).3 Such
review “is limited to issues of law, and we will not review the merits of the case or
the sufficiency of the evidence.” Id. “However, the nonmoving party is still given
the benefit of all relevant inferences at the summary judgment stage, and if a
genuine dispute exists concerning predicate facts material to the qualified
immunity issue, the defendant is not entitled to summary judgment.” Plemmons v.
Roberts, 439 F.3d 818, 822 (8th Cir. 2006) (internal quotations and citations
omitted).
      3
        Vaughn argues that the Court lacks jurisdiction over this interlocutory appeal.
However, it is well settled that “[a] denial of summary judgment on the grounds of
qualified immunity . . . may be reviewed on interlocutory appeal.” Pace v. City of Des
Moines, 201 F.3d 1050, 1052 (8th Cir. 2000) (citing Mitchell v. Forsyth, 472 U.S.
511, 528 n.9 (1985)).

                                         -4-
       In deciding whether an official is entitled to qualified immunity, the Court
asks two questions: “(1) whether . . . there was a deprivation of a constitutional
right; and, if so, (2) whether the right was clearly established at the time of the
deprivation such that a reasonable official would understand his conduct was
unlawful.” Vaughn, 438 F.3d at 850. In this case, Appellants argue only that
Vaughn has not established the deprivation of a constitutional right, and therefore,
we need not address whether that right was “clearly established.”

       “Deliberate indifference” to a prisoner’s serious illness or injury constitutes
cruel and unusual punishment under the Eighth Amendment. Estelle v. Gamble,
429 U.S. 97, 104 (1976); Gregoire v. Class, 236 F.3d 413, 417 (8th Cir. 2000) (“It
is well established that the Eighth Amendment prohibition on cruel and unusual
punishment extends to protect prisoners from deliberate indifference to serious
medical needs.”).4 “Deliberate indifference has both an objective and a subjective
component.” Butler v. Fletcher, 465 F.3d 340, 345 (8th Cir. 2006). The objective
component requires a plaintiff to demonstrate an objectively serious medical need.
Grayson v. Ross, 454 F.3d 802, 808-09 (8th Cir. 2006); Moore v. Jackson, 123
F.3d 1082, 1086 (8th Cir. 1997). The subjective component requires a plaintiff to
show that the defendant actually knew of, but deliberately disregarded, such need.
Grayson, 454 F.3d at 808-09; Moore, 123 F.3d at 1086. Appellants do not contest
the district court’s finding of an “objectively serious medical need,” and thus we
only address the subjective component of whether Appellants “deliberately
disregarded” such need.

      4
        The conditions of confinement for pre-trial detainees, such as Blount, are
analyzed under the Due Process Clause of the Fifth and Fourteenth Amendments, not
the Eighth Amendment. Johnson-El v. Schoemehl, 878 F.2d 1043, 1048 (8th Cir.
1989) (citing Bell v. Wolfish, 441 U.S. 520, 535 (1979)). Nevertheless, we have held
that courts should “apply the identical deliberate-indifference standard” for pre-trial
detainees and convicted criminals. Crow v. Montgomery, 403 F.3d 598, 601 (8th Cir.
2005).
                                         -5-
       In order to demonstrate that a defendant actually knew of, but deliberately
disregarded, a serious medical need, the plaintiff must establish a “mental state
akin to criminal recklessness: disregarding a known risk to the inmate’s health.”
Gordon v. Frank, 454 F.3d 858, 862 (8th Cir. 2006). However, while a deliberate-
indifference claim requires the establishment of a defendant’s actual, subjective
knowledge, such knowledge can be demonstrated with circumstantial evidence.
See Farmer v. Brennan, 511 U.S. 825, 842 (1994) (“Whether a prison official had
the requisite knowledge . . . is a question of fact subject to demonstration in the
usual ways, including inference from circumstantial evidence.”). Indeed, a
factfinder may determine that a defendant was actually aware of a serious medical
need, but deliberately disregarded it, “from the very fact that the [medical need]
was obvious.” Id. Moreover, this Court has noted that the “[i]ntentional delay in
providing medical treatment shows deliberate disregard if a reasonable person
would know that the inmate requires medical attention.” Gordon, 454 F.3d at 862.5

      No Appellant claims that he was unaware of the physical symptoms
displayed by Blount in the hours before his death. In fact, Appellants were aware
that Blount was vomiting throughout the night and requesting medical attention.
Rather, Appellants claim that they did not deliberately disregard Blount’s serious
medical need because they believed that his vomiting was caused by the ingestion
of shampoo, and thus, they did not actually “draw the inference” that Blount’s
vomiting constituted a serious medical need. See Farmer, 511 U.S. at 837.

      5
         A prison official cannot be held liable for deliberately disregarding the serious
medical needs of an inmate without proof of his actual knowledge of that serious
medical need. Grayson, 454 F.3d at 808-09; Moore, 123 F.3d at 1086. However, the
Supreme Court has held that knowledge may be inferred when a risk is so obvious
that a reasonable person would recognize it. Farmer, 511 U.S. at 842. The fact that
this inference can be drawn using a “reasonable person” framework is not a new legal
standard and does not misstate the law of deliberate indifference, as Appellants
contend.
                                           -6-
       It is true that “an official’s failure to alleviate a significant risk that he
should have perceived but did not, while no cause for commendation, cannot . . . be
condemned.” Id. at 838. Indeed, defendants “do not violate the Eighth
Amendment when, in the exercise of their professional judgment, they refuse to
implement a prisoner’s requested course of treatment.” Long v. Nix, 86 F.3d 761,
765 (8th Cir. 1996). Nevertheless, based on their knowledge of Blount’s medical
symptoms, coupled with his request for medical assistance, a reasonable jury could
determine that Appellants were actually aware that Blount needed medical
attention, but simply chose to do nothing about it. Appellants’ self-serving
contention that they did not have the requisite knowledge does not provide an
automatic bar to liability in light of the objective evidence to the contrary.

       Appellants were aware that Blount was a 46-year-old, mentally ill,
moderately obese man with several medical conditions. Blount was behaving
strangely and vomiting throughout the night, and Appellants do not deny their
knowledge of Blount’s continual vomiting over a seven-hour period. Moreover,
there was a significant period of time between the alleged ingestion of shampoo
and the beginning of Blount’s vomiting. Blount allegedly ingested shampoo
during the day on January 4, and at 3:00 p.m., he was placed in isolation. It wasn’t
until 10:30 p.m. that night that Blount was first discovered to be vomiting. Thus, a
jury may reasonably infer from these facts that, despite Appellants’ contention,
they did not actually believe Blount’s vomiting to be insignificant or caused by the
ingestion of shampoo.

       In addition, Blount requested medical attention. The record indicates that
Appellants did nothing to address Blount’s request for care. No Appellant
informed a superior officer of Blount’s condition or did anything to assist Blount.
A reasonable jury could conclude that Appellants’ knowledge of Blount’s
symptoms and his request for medical assistance, coupled with Appellants’ failure
to take any responsive action, is sufficient to establish deliberate indifference. See


                                         -7-
Hartsfield v. Colburn, 491 F.3d 394, 401 (8th Cir. 2007) (noting that an inference
of deliberate indifference is strengthened when “an inmate communicates his
distress directly . . . and prison officials fail to respond”).

       This Court has affirmed the denial of summary judgment based on qualified
immunity when confronted with facts similar to those at issue here. In Plemmons,
an inmate told prison staff that he felt he was having a heart attack when he was
experiencing arm and chest pain, nausea, profuse sweating, and had experienced
heart attacks in the past. 439 F.3d at 824. The inmate was in fact having a heart
attack, but a jailhouse official did not immediately call for medical assistance,
believing the inmate to be having a panic attack. Id. The inmate made further
complaints, but was then forced to wait for an undue period of time before an
ambulance was called. Id. We held that these facts created a genuine issue as to
whether the defendants deliberately disregarded the serious medical condition of
the inmate. Id.

       Appellants rely on Pagels v. Morrison, 335 F.3d 736 (8th Cir. 2003), and
Jackson v. Everett, 140 F.3d 1149 (8th Cir. 1998), to support reversal. In both
cases, prison officials received notes from inmates warning of a threat of inmate
violence that later materialized, resulting in inmate injury. However, the officials
were found not to be deliberately indifferent to a serious risk of harm to the
inmates because they had conducted investigations into the notes and determined
them to be unfounded and unreliable. Pagels, 335 F.3d at 740-42; Jackson, 140
F.3d at 1151-53. In contrast, Appellants here took no action to investigate, or
otherwise respond to, the objective medical symptoms of Blount or his request for
medical care throughout the seven-hour period that he was vomiting. A reasonable
jury might well conclude that such inaction by Appellants constituted deliberate
indifference.6

      6
         Appellants also argue that Vaughn’s claims should be dismissed because
“[t]his court has . . . routinely rejected prisoners’ claims where there is no cure or
                                         -8-
      Finally, because the individual Appellants are not entitled to dismissal based
on qualified immunity, the claims against Greene County also may stand.

III.   CONCLUSION

    For all the foregoing reasons, we affirm the district court’s denial of
summary judgment for Appellants based on qualified immunity.
                       _____________________________




treatment for the alleged serious medical need.” While the record indicates that
Blount suffered from a heart condition, this does not mean that if given prompt
medical attention, such care could not have saved or prolonged his life.
                                        -9-
