                       NOT RECOMMENDED FOR PUBLICATION
                               File Name: 18a0559n.06

                                           No. 17-3964


                          UNITED STATES COURT OF APPEALS                               FILED
                               FOR THE SIXTH CIRCUIT                             Nov 05, 2018
                                                                             DEBORAH S. HUNT, Clerk
 CAMERON NORTH,                        )
                                       )
      Plaintiff-Appellant,             )
                                       )
                                                                ON APPEAL FROM THE
 v.                                    )
                                                                UNITED STATES DISTRICT
                                       )
                                                                COURT     FOR      THE
 CUYAHOGA COUNTY; CATHERINE CLACK; )
                                                                NORTHERN DISTRICT OF
 FATHER MIROLOVICH, A.P.N.; JOHN DOE; )
                                                                OHIO
 UNKNOWN        CORRECTIONAL OFFICERS; )
 UNKNOWN DOCTORS; UNKNOWN NURSES,      )
                                                                            OPINION
                                       )
      Defendants-Appellees.            )


       BEFORE:        CLAY, STRANCH, and LARSEN, Circuit Judges.

       JANE B. STRANCH, Circuit Judge. Twenty-year-old Cameron North suffered a stroke

caused by untreated endocarditis—an infection in his heart—while incarcerated at the Cuyahoga

County Correctional Center. North survived but lost partial use of his left side and suffers from

depression. He filed suit against medical and correctional staff at the jail and against Cuyahoga

County pursuant to 42 U.S.C. § 1983 and Monell v. Department of Social Services, 436 U.S. 658

(1978), alleging deliberate indifference to his serious medical needs in violation of the Eighth

Amendment. Finding no constitutional violation, the district court granted summary judgment and

dismissed the claims against the individual defendants and the County. On appeal, North

challenges only the dismissal of his Monell claim against the County, arguing that the County’s

policies, customs, and failure to train its employees deprived him of his right to constitutionally
No. 17-3964, North v. Cuyahoga County


adequate medical care. For the reasons that follow, we AFFIRM the judgment of the district

court.

                                                I.    BACKGROUND

           Cameron North entered the Cuyahoga County Correctional Center (a county jail) in

February 2013 to begin an eight-month sentence for a probation violation. He had an initial health

screening the next day and underwent a physical examination approximately one week later.

Shortly after arriving at the jail, North began working as a trustee in the kitchen. Trustee status

carries various privileges, including better food and living conditions; inmates must be medically

cleared before becoming trustees and can have their status discontinued if they develop certain

medical issues.

           At some point during his incarceration, North began experiencing health problems, starting

with withdrawal-related body aches and pains. On March 27, North was taken to the medical unit

after complaining to a correctional officer (CO) about a possible pulled muscle in his arm. Afraid

that he would lose his trustee status, North told Nurse Catherine Clack that his “arm hurt earlier

[but was] better now” and signed a refusal of medical treatment form. On March 29, North

reported to his grandmother that his hand was swollen and painful, that he could barely move his

thumb, and that he had woken up the last two nights sweating badly. North concealed this injury

from his COs and did not seek medical attention; about one week later, the swelling and pain had

improved significantly.

           In early May, North began experiencing pain in his neck, shoulders, and abdomen that

worsened when he lay down or breathed deeply. North believes he completed a “kite” form to

request medical care at some point in early May.1 On May 8, he called off work and told his COs



1
    North’s memory of his time in the jail is significantly impaired due to his stroke.

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No. 17-3964, North v. Cuyahoga County


that he wanted to go to the medical unit. North’s mother, Elizabeth North, called the jail that same

day and a “warden’s medical concern” was noted. North was seen by Nurse Practitioner Father

Mirolovich that evening. His blood pressure was 151/56, his pulse was 101, and his temperature

was 99.2 degrees. Mirolovich documented North’s complaints of neck, shoulder, and abdominal

pain, that the pain was associated with taking deep breaths, and that it had begun two days earlier.

Mirolovich examined North but did not review North’s medical records during that visit.

Mirolovich noted that North’s abdomen was tender when palpated, which he believed required

further evaluation. Finding no point of tenderness on North’s shoulder, Mirolovich suspected that

North could be experiencing referred pain, possibly caused by inflammation of the gallbladder.

Mirolovich found no other abnormalities during the physical examination. He ordered urinalysis,

which he marked as “done,” ordered lab work (blood tests) for the next morning, and gave North

a packet of ibuprofen. Nurse Clack then “noted” the order form, which indicates that she filled

out a lab requisition form and brought it to the lab. Neither a lab requisition form nor urinalysis

test results appear in the record.

        Despite Mirolovich’s orders, North’s blood was not drawn the following morning; in fact,

it was never drawn. The parties dispute why the blood test did not happen. North testified at his

deposition that he did not refuse the blood test and that he remembers asking his COs about the

blood tests after May 8. Jail phone call recordings from May 8 and 9 indicate that North expected

his blood to be drawn on May 9 and that the results would be in the following day. North’s mother

called the jail again on May 9 and submitted another warden’s medical concern. At some point on

May 9 or 10, North became sufficiently concerned about losing his trustee status and being

transferred to a more dangerous housing pod that he tried to get out of having the blood test by

telling a nurse that his pain had gone away.



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No. 17-3964, North v. Cuyahoga County


       On May 10, North’s trustee status was discontinued. The discontinuation order was signed

by Mirolovich but did not contain any information about North’s medical condition. Mirolovich

did not inquire into North’s condition or check to see if North’s labs had come back. Despite

having his trustee status discontinued, North was temporarily permitted to stay in his housing pod

but was not allowed to work.

       On May 10, North told his mother that he still had not had his blood drawn, that he planned

to tell medical that he felt fine, and that he was going to take the blood test. North’s mother again

called the jail and submitted a third warden’s medical concern. No one came to get him that day,

and North hoped the blood test would happen over the weekend or on Monday. On Saturday, May

11, North’s blood still had not been drawn. North reported to his family that he was feeling better;

his shoulder pain was still present, but his abdominal pain had mostly ceased, leading him to

believe that he had simply pulled a muscle in his back. On May 13, North told his mother that his

blood test still had not happened; he stated that he did not want to do the test but would in order to

hopefully go back to work. When his mother suggested that he submit a kite, North responded

that he would not.

       While talking on the phone that evening, North collapsed. A medical emergency was

called at approximately 9:20 p.m. and North was transported to the medical unit, where he was

observed for approximately one hour. At 10:15 p.m., North was examined by a nurse practitioner

and EMS was called; North was transported to the hospital at 10:45 p.m. It was subsequently

determined that North had suffered a stroke caused by endocarditis, an infection in his heart. North

underwent heart surgery and significant physical therapy and has lost partial use of his left side.




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No. 17-3964, North v. Cuyahoga County


                                                 II.    ANALYSIS

         A.       Standard of Review

         This court reviews a grant of summary judgment de novo. See Quigley v. Thai, 707 F.3d

675, 679 (6th Cir. 2013). Summary judgment is appropriate if, viewing the evidence in the light

most favorable to the nonmoving party and drawing all reasonable inferences in that party’s favor,

there is no genuine issue of material fact and the moving party is entitled to judgment as a matter

of law. Id. We turn directly to the merits for complete resolution of this case.

         B.       Constitutional Violation

         “To prevail on a cause of action under § 1983, a plaintiff must prove ‘(1) the deprivation

of a right secured by the Constitution or laws of the United States (2) caused by a person acting

under the color of state law.’” Shadrick v. Hopkins County, 805 F.3d 724, 736 (6th Cir. 2015)

(quoting Jones v. Muskegon County, 625 F.3d 935, 941 (6th Cir. 2010)). The constitutional right

at issue in this appeal is the Eighth Amendment’s protection against cruel and unusual punishment.

The governing standard for an Eighth Amendment violation is deliberate indifference to an

inmate’s serious medical need.2 See Farmer v. Brennan, 511 U.S. 825, 834–35 (1994). An inmate

can bring suit under § 1983 for an Eighth Amendment violation “whether the indifference is

manifested by prison doctors in their response to the prisoner’s needs or by prison guards in

intentionally denying or delaying access to medical care or intentionally interfering with the

treatment once prescribed.” Estelle v. Gamble, 429 U.S. 97, 104–05 (1976) (footnotes omitted).



2
  The phrase “deliberate indifference” is also used in analyzing a specific category of Monell claims (namely those
brought under a failure-to-train, failure-to-supervise, or failure-to-screen theory of liability). See Garner v. Memphis
Police Dep’t, 8 F.3d 358, 365–66 (6th Cir. 1993) (noting that the deliberate indifference test is used to analyze failure-
to-train claims but not affirmative policy or custom claims); see also Arrington-Bey v. City of Bedford Heights, 858
F.3d 988, 995 (6th Cir. 2017). In the failure-to-train municipal liability context, the plaintiff must show that the
municipality acted with deliberate indifference to the risk of constitutional violations. See Garner, 8 F.3d at 365. The
standard governing whether there is an underlying Eighth Amendment constitutional violation, in contrast, requires
deliberate indifference to an inmate’s serious medical needs. See Farmer v. Brennan, 511 U.S. 825, 834–35 (1994).

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No. 17-3964, North v. Cuyahoga County


Deliberate indifference requires proof that the inmate had a sufficiently serious medical need and

that a municipal actor knew of and disregarded an excessive risk to the inmate’s health or safety.

See Winkler v. Madison County, 893 F.3d 877, 890–91 (6th Cir. 2018). The deliberate indifference

standard, thus, has both objective and subjective components. Id.

       The objective component “requires that the inmate have a sufficiently serious medical need

such that she is incarcerated under conditions posing a substantial risk of serious harm.” Ford v.

County of Grand Traverse, 535 F.3d 483, 495 (6th Cir. 2008) (citation and internal quotation marks

omitted). A medical need is sufficiently serious if it “has been diagnosed by a physician as

mandating treatment or . . . is so obvious that even a lay person would easily recognize the

necessity for a doctor’s attention.” Jones, 625 F.3d at 941 (quoting Harrison v. Ash, 539 F.3d 510,

518 (6th Cir. 2008)).

       To satisfy the subjective component, a plaintiff must show that officials had a “sufficiently

culpable state of mind,” namely “deliberate indifference to inmate health or safety.” Farmer, 511

U.S. at 834 (citations and internal quotation marks omitted). Deliberate indifference is greater

than negligence but does not require proof that the officials intended to cause harm. See Shadrick,

805 F.3d at 737. “Acting or failing to act ‘with deliberate indifference to a substantial risk of

serious harm to a prisoner is the equivalent of recklessly disregarding that risk.’” Id. at 737–38

(quoting Farmer, 511 U.S. at 836). The plaintiff must “allege facts which, if true, would show

that the official being sued subjectively perceived facts from which to infer substantial risk to the

prisoner, that he did in fact draw the inference, and that he then disregarded that risk.” Phillips v.

Roane County, 534 F.3d 531, 540 (6th Cir. 2008) (quoting Comstock v. McCrary, 273 F.3d 693,

703 (6th Cir. 2001)).




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No. 17-3964, North v. Cuyahoga County


       Recognizing that officials “do not readily admit this subjective component,” courts may

“infer from circumstantial evidence that a prison official had the requisite knowledge.” Id.

(citation omitted). The “very fact that the risk was obvious” may permit a factfinder to conclude

that an official was aware of it, Farmer, 511 U.S. at 842, and a defendant’s denial of knowledge

is not dispositive, see Estate of Carter v. City of Detroit, 408 F.3d 305, 313 (6th Cir. 2005).

Plaintiffs are not required to prove that the defendant was aware of the exact nature or

consequences of the defendant’s action or failure to act; demonstrating that the defendant was

aware of the plaintiff’s condition and knew that “serious risks accompany” it is sufficient.

Dominguez v. Corr. Med. Servs., 555 F.3d 543, 550 (6th Cir. 2009). An official’s failure to follow

applicable policies and protocols can be persuasive evidence of deliberate indifference in the

Eighth Amendment context. See Phillips, 534 F.3d at 541. We turn next to the claim on appeal,

whether Cuyahoga County is liable for North’s alleged Eighth Amendment violation.

       C.      Municipal Liability

       Municipalities are not subject to respondeat superior liability in § 1983 actions; rather, they

are responsible only for injuries caused by those acts that may fairly be said to represent official

policy or by their policies or customs. See Ford, 535 F.3d at 495. In addition to demonstrating an

underlying constitutional violation, “[a] plaintiff bringing a § 1983 claim against a municipality

must . . . identify the policy or custom that caused her injury.” Id. In the absence of a formally

approved policy, a “custom” can give rise to municipal liability when the “practice is so

widespread as to have the force of law.” Bd. of Cty. Comm’rs v. Brown, 520 U.S. 397, 404 (1997).

In addition to identifying “conduct properly attributable to the municipality,” id., a plaintiff must

show that the municipality was a “moving force” behind the alleged violation, Monell, 436 U.S.

at 694. In other words, “a plaintiff must identify the policy, connect the policy to the [municipality]

itself and show that the particular injury was incurred because of the execution of that policy.”
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No. 17-3964, North v. Cuyahoga County


Garner v. Memphis Police Dep’t, 8 F.3d 358, 364 (6th Cir. 1993) (citation and internal quotation

marks omitted); see also Alkire v. Irving, 330 F.3d 802, 815 (6th Cir. 2003). This type of municipal

liability is sometimes referred to as an affirmative policy or custom theory.

       An additional theory of municipal liability is based on a municipality’s failure to

adequately train or supervise its employees. This can give rise to liability when the training and

supervision “were inadequate for the tasks the [employees] were required to perform, the

inadequacy resulted from [the municipality’s] deliberate indifference, and the inadequacy actually

caused, or is closely related to, [the plaintiff’s] injury.” Shadrick, 805 F.3d at 738. A plaintiff can

make this deliberate indifference showing in one of two ways:

       [He] can show a pattern of similar constitutional violations by untrained employees
       and [the municipality’s] continued adherence to an approach that it knows or should
       know has failed to prevent tortious conduct by employees . . . . Alternatively, [the
       plaintiff] can establish 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. This
       second mode of proof is available 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.

Id. at 738–39 (brackets, citations, and internal quotation marks omitted).           “Single-incident

liability” is available in cases alleging inadequate training of nurses in a correctional setting. See

id. at 742 (“Because it is so highly predictable that a poorly trained [licensed practical] nurse

working in the jail setting utterly lacks an ability to cope with constitutional situations, a jury

reasonably could find that [the defendant’s] failure to train reflects deliberate indifference to the

highly predictable consequence, namely, violations of constitutional rights.” (brackets, citations,

and internal quotation marks omitted)).

       D.      Application

       North pursues both affirmative policy or custom and failure-to-train theories of liability in

his suit against Cuyahoga County. We first ask whether North has shown that medical or
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No. 17-3964, North v. Cuyahoga County


nonmedical jail personnel violated his Eighth Amendment right to adequate medical treatment—

in other words, whether anyone at the jail acted with deliberate indifference to North’s serious

medical needs.

                 1.    Eighth Amendment Violation by Jail Personnel

       We begin with the objective prong of the Eighth Amendment deliberate indifference test.

North argues that endocarditis, an infection in the heart, is an objectively serious medical

condition. According to Dr. Lawrence Mendel, North’s expert witness, endocarditis “is a serious

and potentially fatal medical issue.” The County does not dispute that North has satisfied the

objective prong. See Kosloski v. Dunlap, 347 F. App’x 177, 179 (6th Cir. 2009).

       Turning next to the subjective prong, North alleges that several named and unnamed jail

personnel were deliberately indifferent to his serious medical needs.            We analyze each

individually.

                       a.      Nurse Practitioner Mirolovich

       North first argues that Nurse Practitioner Mirolovich was deliberately indifferent by

providing a deficient examination on May 8; failing, in the days that followed, to ensure that the

ordered lab work was completed; and signing off on the May 10 order discontinuing North’s

trustee status without providing any follow-up care. North cites to this court’s decision in Phillips

v. Roane County in support. In Phillips, a jail doctor conducted a perfunctory evaluation of a

detainee, during which he ran no tests and “failed to even touch her.” 534 F.3d at 544. A few

days later, after the detainee submitted a second medical request complaining of a possible kidney

infection, the doctor ordered a urinalysis but “failed to follow up or confirm that the test had been

done.” Id. We concluded that these facts were “sufficient to establish that [the doctor] had

knowledge of [the detainee’s] serious need for medical attention and disregarded that need.” Id.



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No. 17-3964, North v. Cuyahoga County


       Mirolovich’s evaluation of North was less cursory than the evaluation performed by the

doctor in Phillips. Mirolovich asked North about his symptoms and conducted a physical

examination based on those symptoms, which included looking at North’s eyes, listening to his

lungs and heart, and palpating his abdomen, neck, and shoulder. Although Mirolovich knew about

North’s neck, shoulder, and abdominal pain, there is no indication that he was aware of any chest

pain. Having examined North, Mirolovich ordered additional testing, including urine and blood

work. Mirolovich did not follow up to verify that those tests were performed; instead, he relied

on the medical staff to ensure that they were completed. The trustee discontinuation form that

Mirolovich signed two days after examining North contained no information about North’s

medical condition, and Mirolovich testified that he relied on the medical staff to follow protocols

in deciding whether to discontinue a trustee’s status. Mirolovich’s practices may well have been

negligent—in that he should have taken a more active role in ensuring that North received the

testing and treatment he needed—but they do not support an inference that Mirolovich disregarded

a known or obvious risk of serious harm.

                       b.      Nurse Clack

       Next, North argues that Nurse Clack acted with deliberate indifference when she failed to

properly complete the lab requisition form pertaining to North’s blood and urine tests. On May 8,

Clack “noted” Mirolovich’s form ordering lab work and urinalysis for North. She has no memory

of this particular incident but testified that when she “notes” an order, it means that she has filled

out a lab requisition form and put it in the lab. Clack understood Mirolovich’s note that the

urinalysis was “done” to mean that the test had already been completed and reviewed by

Mirolovich. Neither urinalysis test results nor a lab requisition form appears in the record.

Viewing the evidence in the light most favorable to North, the record supports an inference that

Clack either failed to properly complete the lab requisition form or failed to take it to the lab. And
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No. 17-3964, North v. Cuyahoga County


in any event, Clack failed to take steps to verify that the lab work was completed, instead relying

on other members of the medical staff once she did her part. On this record, Clack’s conduct was,

at most, negligent.

                       c.      Other Medical and Non-Medical Personnel

       North also argues that other medical and non-medical personnel at the jail were deliberately

indifferent to his serious medical needs between May 8 and 13. Specifically: (1) COs failed to

ensure that North received his blood test despite North’s repeated complaints and requests; (2) the

warden’s assistant failed to document at least some calls from North’s mother; and (3) Nursing

Director Patricia Ruzicka Regan directed North’s mother to call the warden, rather than taking any

steps to ensure that North received medical care.

       These claims all falter on the subjective awareness prong. Even assuming the COs were

aware that North was supposed to go to the medical unit, the record contains insufficient evidence

that any of them were subjectively aware of a serious risk to North’s health. The COs also may

not have disregarded the risks they were aware of:         there is some evidence in the record

demonstrating that COs contacted the medical unit when North complained about his arm in March

and again in the days following North’s May 8 appointment with Mirolovich. Likewise, while the

warden’s assistant was supposed to document medical concerns from family members, her failure

to do so does not rise to the level of deliberate indifference as there is insufficient evidence that

she was subjectively aware of the severity of North’s condition.

       The claim as to Nursing Director Ruzicka Regan suffers from the same infirmity. When

Sgt. Philip Christopher received Ms. North’s call on May 9, he called Ruzicka Regan, advised her

of Ms. North’s concerns and that she had submitted a medical concern to the warden’s office the

previous day, and asked if Ruzicka Regan would speak with Ms. North. Ruzicka Regan advised

Christopher to have Ms. North submit another medical concern with the warden’s office.
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No. 17-3964, North v. Cuyahoga County


Christopher did not remember what he conveyed to Ruzicka Regan but speculated that it may have

been either that North complained of pain under his rib or that he had not yet been seen by the

medical unit. Ruzicka Regan did not recall this conversation with Christopher but testified that

when she receives a complaint from a family member, she would ordinarily place the inmate on

the sick call list and speak with the family member. Her failure to do so in this case was likely

negligent; however, the record does not show that she was aware of, and disregarded, a substantial

risk of harm.

       In sum, North is unable to show that any jail employee acted with deliberate indifference

to his serious medical needs.

                2.     County Liability in the Absence of a Violation by Jail Personnel

       Even if no individual violated North’s Eighth Amendment rights, North argues that the

County can still be held liable for his injury because its policies and customs caused North to be

denied constitutionally adequate medical care.

       There must be a constitutional violation for a § 1983 claim against a municipality to

succeed—if the plaintiff has suffered no constitutional injury, his Monell claim fails. See City of

Los Angeles v. Heller, 475 U.S. 796, 799 (1986) (per curiam). A court’s finding that an individual

defendant is not liable because of qualified immunity, however, does not necessarily foreclose

municipal liability. See Garner, 8 F.3d at 365; see also Richko v. Wayne County, 819 F.3d 907,

920 (6th Cir. 2016) (rejecting the argument that a county cannot be held liable because the

individual defendants are not liable as “unsound”). Whether and under what circumstances a

municipality can be liable when the plaintiff suffered a constitutional violation but cannot attribute

it to any individual defendant’s unconstitutional conduct is a more complicated question—one that

this court recently noted in Winkler, 893 F.3d at 899–900.



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No. 17-3964, North v. Cuyahoga County


       Winkler acknowledged the broad statement in Watkins v. City of Battle Creek, 273 F.3d

682, 687 (6th Cir. 2001), that, without a constitutional violation by an individual defendant,

municipal defendants cannot be held liable. 893 F.3d at 899–900. We also noted, however, that

       other cases from this circuit have indicated that [this] principle might have a
       narrower application. Judge Cole, in a concurring opinion in Epps v. Lauderdale
       County, 45 F. App’x 332 (6th Cir. 2002), explained:

               When no constitutional harm has been inflicted upon a victim,
               damages may not be awarded against a municipality. But a finding
               that the individual government actor has not committed a
               constitutional violation does not require a finding that no
               constitutional harm has been inflicted upon the victim, nor that the
               municipality is not responsible for that constitutional harm. . . . A
               given constitutional violation may be attributable to a municipality’s
               acts alone and not to those of its employees—as when a government
               actor in good faith follows a faulty municipal policy. A municipality
               also may be liable even when the individual government actor is
               exonerated, including where municipal liability is based on the
               actions of individual government actors other than those who are
               named as parties. Moreover, it is possible that no one individual
               government actor may violate a victim’s constitutional rights, but
               that the combined acts or omissions of several employees acting
               under a governmental policy or custom may violate an individual’s
               constitutional rights.

Id. at 900 (quoting Epps, 45 F. App’x at 334–35 (Cole, J., concurring)). There is “no indication

that Watkins considered any of the situations discussed in Epps,” id., and the Supreme Court case

it relies on, Heller, 475 U.S. 796, “is not nearly so sweeping regarding the scope of Monell

liability,” Winkler, 893 F.3d at 900.

       Several other circuits have interpreted Heller to permit municipal liability in certain

circumstances where no individual liability is shown. See id. at 900–01; Fairley v. Luman, 281

F.3d 913, 917 (9th Cir. 2002) (“If a plaintiff establishes he suffered a constitutional injury by the

City, the fact that individual officers are exonerated is immaterial to [municipal] liability under

§ 1983.”); Speer v. City of Wynne, 276 F.3d 980, 985–86 (8th Cir. 2002) (“Our court has previously



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No. 17-3964, North v. Cuyahoga County


rejected the argument that Heller establishes a rule that there must be a finding that a municipal

employee is liable in his individual capacity as a predicate to municipal liability. . . . The

appropriate question under Heller is whether a verdict or decision exonerating the individual

governmental actors can be harmonized with a concomitant verdict or decision imposing liability

on the municipal entity. The outcome of the inquiry depends on the nature of the constitutional

violation alleged, the theory of municipal liability asserted by the plaintiff, and the defenses set

forth by the individual actors.”); Curley v. Village of Suffern, 268 F.3d 65, 71 (2d Cir. 2001)

(“Heller should not, of course, be applied indiscriminately. For example, where alleged injuries

are not solely attributable to the actions of named individual defendants, municipal liability may

still be found.” (citing Barrett v. Orange Cty. Human Rights Comm’n, 194 F.3d 341, 350 (2d Cir.

1999))); Fagan v. City of Vineland, 22 F.3d 1283, 1292 (3d Cir. 1994) (holding that, in certain

circumstances, “an underlying constitutional tort can still exist even if no individual police officer

violated the Constitution”); see also Daniel v. Cook County, 833 F.3d 728, 734 (7th Cir. 2016)

(permitting the plaintiff to pursue a Monell claim where widespread, systemic, gross deficiencies

in the jail’s medical recordkeeping and scheduling systems resulted in the denial of medical care,

even though no individual medical provider could be held responsible); Anderson v. City of

Atlanta, 778 F.2d 678, 686 (11th Cir. 1985) (explaining, the year before Heller was decided, that

Monell and its progeny “do not require that a jury must first find an individual defendant liable

before imposing liability on local government” in part because “if the jury were to find, as it did,

that the deprivation of [the plaintiff’s] constitutional rights was a result of understaffing, then it

would logically find no fault on the part of the individual arresting officers”); Garcia v. Salt Lake

County, 768 F.2d 303, 310 (10th Cir. 1985) (holding, the year before Heller was decided, that

“[a]lthough the acts or omissions of no one employee may violate an individual’s constitutional



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No. 17-3964, North v. Cuyahoga County


rights, the combined acts or omissions of several employees acting under a governmental policy

or custom may violate an individual’s constitutional rights”).

       In many cases, a finding that no individual defendant violated the plaintiff’s constitutional

rights will also mean that the plaintiff has suffered no constitutional violation. In a subset of § 1983

cases, however, the fact that no individual defendant committed a constitutional violation—e.g.,

acted with deliberate indifference to an inmate’s serious medical need—might not necessarily

“require a finding that no constitutional harm has been inflicted upon the victim, nor that the

municipality is not responsible for that constitutional harm.” Epps, 45 F. App’x at 334 (Cole, J.,

concurring).

       The type of claim North advances—one premised on failure to act rather than affirmative

wrongdoing—might fit within this analysis. Assuming that our caselaw allows for such an

approach, we consider his affirmative policy or custom and failure-to-train claims in turn.

                        a.      Affirmative Policy or Custom

       As discussed above, in addition to demonstrating a constitutional violation, a plaintiff

pursuing an affirmative policy or custom claim against a municipal entity must (1) show the

existence of a policy, (2) connect that policy to the municipality, and (3) demonstrate that his injury

was caused by the execution of that policy. See Garner, 8 F.3d at 364. This does not require a

showing that the municipality acted with deliberate indifference to the risk of constitutional

violations. See id. at 365–66 (the deliberate indifference test is used to analyze failure-to-train

claims but not affirmative policy or custom claims); see also Arrington-Bey v. City of Bedford

Heights, 858 F.3d 988, 995 (6th Cir. 2017). Here, however, because North has not demonstrated

that any individual jail employee violated his Eighth Amendment right to adequate medical care

by acting with deliberate indifference, he must show that the municipality itself, through its acts,

policies, or customs, violated his Eighth Amendment rights by manifesting deliberate indifference
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No. 17-3964, North v. Cuyahoga County


to his serious medical needs. See Ford, 535 F.3d at 495 (explaining that, in the absence of a

constitutional violation by an individual officer, the Eighth Amendment deliberate indifference

standard “is relevant to the ultimate determination of whether a municipality can be held liable”

for an Eighth Amendment violation). In other words, deliberate indifference is relevant to North’s

policy-based Monell claim because it is necessary to our determination of whether North suffered

an Eighth Amendment injury.

       North argues that the jail had a custom of denying and delaying inmates access to medical

care. Specifically: (1) inmates were unable to access medical care because COs, who were not

medically trained, had discretion in deciding whether to report inmate medical requests and

complaints to the medical unit, and some failed to do so, and inmates who submitted medical kites

were often subject to long delays; (2) the jail had a practice of arbitrarily revoking trustee status,

creating a coercive environment in which trustees like North avoided medical care even when they

needed it; and (3) the medical records system did not function properly and there were no systems

in place to ensure that ordered lab work or other needed follow-up care actually happened.

       We first consider the arguments related to medical requests and kites. According to jail

policy, kites are the primary mechanism through which inmates request non-emergency medical

care. Nurses generally review and respond to kites within 24 hours, though response time depends

on the severity of the medical need, and kites were occasionally lost or inadvertently not responded

to. In addition to submitting kites, inmates can ask their COs to contact the medical unit for them.

Upon receiving such a request, COs are expected to contact their supervisor or the medical unit

directly, but they can exercise some discretion in deciding how to respond and may instruct an

inmate to submit a kite for a minor issue. Some COs had a practice of passing along every

legitimate request to the medical unit or their supervisor, and some contacted medical even if the



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No. 17-3964, North v. Cuyahoga County


inmate did not request treatment. Inmates sometimes complained that COs were not contacting

the medical unit when they so requested or were not doing so as quickly as desired. North has not

presented evidence showing a widespread custom of COs failing to properly forward medical

concerns and requests. In light of the alternate means of requesting medical care available to

inmates, any custom of minimal CO discretion does not rise to the level of deliberate indifference

to serious medical needs in violation of the Eighth Amendment.

       North also argues that the jail arbitrarily revoked inmates’ trustee status when they sought

medical care, creating a coercive environment in which trustees would avoid needed medical

treatment. Medical personnel were responsible for evaluating whether to discontinue an inmate’s

trustee status for a medical reason, and inmates were aware that they might lose their status if they

had medical issues. Although North’s fear of losing his status and housing caused him to conceal

or minimize his medical needs, it is not unreasonable for the County to have a policy that prohibits

inmates with certain medical problems from working, especially in the kitchen, where there is risk

both to the inmate and to others. The apparent lack of clear protocols could create a risk of arbitrary

enforcement but, under these circumstances, does not rise to the level of deliberate indifference to

serious medical needs in violation of the Eighth Amendment.

       Finally, North argues that the jail’s recordkeeping system was deficient and that there was

no system in place to ensure that ordered medical tests and treatment were actually performed. At

the time of North’s incarceration, the jail still used a paper records system. Inmate charts were

kept, but nurses and providers did not always have them, especially when an inmate came to the

medical unit unexpectedly and was not on the sick call list. The jail had some recordkeeping

policies, such as a requirement that “[i]nmates will be given a professional clinical judgment




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No. 17-3964, North v. Cuyahoga County


regarding their health condition and will receive care that is ordered.” However, certain documents

that should have been in North’s chart—assuming they existed—apparently were not there.

       While imperfect, the apparent problems with the recordkeeping system seem to consist of

“one or two missteps” rather than the kind of widespread, gross deficiencies that would support a

finding of deliberate indifference. Daniel, 833 F.3d at 734–35 (quoting Dixon v. County of Cook,

819 F.3d 343, 348 (7th Cir. 2016)). Providers, nurses, medical technicians and, to a lesser extent,

COs, each played a role in ensuring that inmates received medical care. There was apparently no

backup system in place to ensure that mistakes were caught and corrected. As discussed above,

however, inmates could follow up by submitting a kite and/or talking to their CO, thereby

minimizing the likelihood that an error would go undetected. North has shown only one other

concrete example of a patient who experienced a delay in lab testing. Meanwhile, jail personnel

repeatedly affirmed that they had not witnessed instances when inmates’ medical needs were not

met in a timely fashion. Nurse Clack agreed that it was “possible” that she had seen “a delayed

provision of medical care that result[ed] in some kind of medical problem for an inmate,” but she

explained those delays were caused not by failures within the medical unit, but by patients who

did not go to the medical unit in a timely fashion. Another nurse at the jail similarly could not

think of “any specific instance” when ordered lab work was not completed in a timely fashion or

a delay in care otherwise resulted in medical problems for an inmate. When Christopher was asked

the same questions, the only example he could think of was North’s case.

       On this record, North has not demonstrated systemic County deficiencies that rise to the

level of deliberate indifference to serious medical needs in violation of the Eighth Amendment.

                      b.      Failure to Train

       Lastly, North argues that the County failed to adequately train its medical and non-medical

personnel. North must demonstrate that the training was “inadequate for the tasks the [employees]
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No. 17-3964, North v. Cuyahoga County


were required to perform, the inadequacy resulted from [the County’s] deliberate indifference, and

the inadequacy actually caused, or is closely related to, [his] injury.” Shadrick, 805 F.3d at 738.

       We begin with the training provided to non-medical (correctional) personnel. Although

COs exercised some discretion, they typically passed inmate medical requests along to the medical

unit and did not attempt to assess the inmate’s medical needs on their own. Furthermore, inmates

were able to request medical care through the kite system and did not have to rely on COs to access

care. Failing to provide COs with additional medical training, therefore, does not constitute

deliberate indifference in this case.

       This court’s decision in Shadrick is instructive with respect to the medical personnel

training. In Shadrick, the jail contracted with a company to provide medical care; the company,

in turn, employed licensed practical nurses (LPNs) to provide medical care to the inmates. 805

F.3d at 728. The LPNs came into the job with some medical training but lacked the authority to

diagnose conditions and received no substantive training once employed. Id. at 740. Although

written policies and procedures existed, LPNs were unable to discuss or identify the requirements

of these policies and protocols, failed to follow them, and were permitted to use them at their

discretion; LPNs were also allowed to define the scope of their own practice. Id. at 740–41.

Furthermore, despite a written policy to the contrary, the LPNs followed an unwritten custom of

providing medical assistance only if an inmate requested it or if there was an emergency. Id. at

734, 740–41. Taken together, this evidence was sufficient to permit a jury to find that the training

program was inadequate and that the company was “deliberately indifferent to the need to train

and supervise its LPN nurses to provide adequate medical care to inmates, especially in view of

the obvious risk that the Constitution could be violated without such training and supervision.” Id.

at 741. These facts, combined with evidence that the company’s president and other top officials



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No. 17-3964, North v. Cuyahoga County


failed to train the LPNs, enforce existing policies, or adequately investigate or respond to the

inmate’s death, also supported a finding that the inadequate training resulted from the company’s

“own deliberate indifference to the rights of inmates with whom the nurses came into contact,” id.

at 742–43, and that the “inadequate training and supervision actually caused, or was closely related

to, [the inmate’s] injury and death,” id. at 743.

       Although some of the factors relevant in Shadrick are present here, there are also some

important differences. In addition to LPNs, the jail employed nurses and medical providers with

more advanced training and certifications (e.g., registered nurses (RNs), nurse practitioners (NPs),

and physicians) to treat inmates. NPs, like Mirolovich, have Master’s degrees in nursing, may

assess and treat patients, and practice under a “collaborative agreement” with a physician.

Mirolovich did not recall receiving or reviewing jail policies, but he did receive some training on

providing care in the correctional setting during staff meetings. Nurses typically went through a

two-week orientation training program when they began working at the jail and received and

signed off on having reviewed a copy of the jail policies; policy updates were provided and

discussed at staff meetings. There is no evidence that nurses were permitted to use the policies at

their discretion or to define the scope of their practice and no indication that nurses or providers

refused to provide care unless an inmate requested it. In sum, the County’s training program is

not so inadequate that failing to provide additional training constitutes deliberate indifference to

an obvious risk of injury. See id. at 741.

                                       III. CONCLUSION

       For the reasons explained above, we AFFIRM the judgment of the district court.




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