                     United States Court of Appeals
                           FOR THE EIGHTH CIRCUIT
                                    ___________

                                    No. 06-3900
                                    ___________

Jela D. Jones, as Trustee for the heirs    *
of Brenda Diane Jones, deceased,           *
                                           *
               Plaintiff – Appellant,      *
                                           * Appeal from the United States
       v.                                  * District Court for the District
                                           * of Minnesota.
Minnesota Department of Corrections, *
Rick Hillengass, Heidi Gillies, Laura      *
Westphal, Kathy Duklet, Troy Hedtke, *
Dave Knutson, Kevin Fors, Schahara         *
Schutte, Marla Prescott, Katie Ziegler, *
Dave Hergott, Darryl Galloway, and         *
Pamela Smith, each individually and in *
their official capacities,                 *
                                           *
               Defendants – Appellees.     *
                                      ___________

                              Submitted: October 19, 2007
                                 Filed: January 9, 2008
                                  ___________

Before LOKEN, Chief Judge, GRUENDER, and BENTON, Circuit Judges.
                              ___________

BENTON, Circuit Judge.

      Jela D. Jones sued the Minnesota Department of Corrections and individual
prison officials for allegedly violating his mother’s Eighth Amendment rights, by
deliberate indifference to her serious need of medical care, causing her death. The
district court1 granted summary judgment to the defendants. Jones appeals. Having
jurisdiction under 28 U.S.C. § 1291, this court affirms.

                                          I.

       On November 4, 2003, Brenda Diane Jones was sentenced to 33 months in
prison for aiding and abetting a controlled substance crime. She was then held at the
Blue Earth county jail for three days awaiting transfer to the Minnesota Department
of Corrections facility in Shakopee. Blue Earth officers told Shakopee officers that
Jones had been “fine” until told of the transfer, at which point she became “violently
sick” and “uncooperative.” As suggested by Blue Earth, Shakopee had extra officers
to assist Jones from the vehicle. Jones arrived at Shakopee at 9:45 a.m., during the
second watch shift. Officers directed her to exit the vehicle. She did not respond,
mumbling and exhibiting a blank stare. As two officers tried to help Jones out of the
vehicle, she swung her legs to the side as if attempting to exit.2 One officer pushed
Jones from behind, another pulled from the front, in order to remove her from the
vehicle. Jones had an unpleasant odor, like urine or body odor, which was noted by
various officers throughout the intake process.

       Once outside the vehicle, she sat down on the floor of the intake garage. Jones,
mumbling, did not comply with instructions to stand up. One officer applied a
pressure-point technique to make Jones comply, which produced no response.
Officers called for more assistance. One officer described Jones as grunting and
rolling around on the floor. Many officers described Jones’s breathing as “heavy,”
“labored,” and “fast paced.” No officer thought Jones was having trouble catching her


      1
       The Honorable Richard H. Kyle, United States District Court for the District
of Minnesota.
      2
         The autopsy reported that Jones was morbidly obese, weighing 285 pounds
at 5'1" tall.

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breath. Most officers stated that her breathing was rapid as if she had been exerting
herself. One officer said that her breathing sounded like his breathing used to sound
when he was overweight. One officer thought Jones might be over-medicated.
Another officer would have called for an A-team response and medical, but did not
because the A-team and watch commander were already there. The officers lifted
Jones into a wheelchair, transporting her to the Mead Unit for the intake process.

       By policy, inmates must be screened for medical, dental, and mental health
within 24 hours of arrival at Shakopee. Lt. Westphal – concerned that, due to her size,
Jones could not walk or stand during intake – started the screening immediately.
Nurse Pamela Smith began the evaluation, but did not complete it because Jones did
not answer her questions. Nurse Smith did take Jones’s pulse (which was normal) and
respiration (which was three times faster than normal). Nurse Smith stated that
Jones’s respiration returned to normal by the end of the examination, but her records
do not indicate a second respiration rate. Jones drank two glasses of water after Nurse
Smith offered her a drink. Nurse Smith noted that Jones appeared “uncomfortable,”
grunting, with dried blood on her mouth and lips. Lt. Westphal also noticed severe
chapping and cracking of her lips. Nurse Smith’s records indicate that Blue Earth had
not noted any heart problems, and that she planned to re-examine Jones in “a day or
so” when she might be more cooperative. Nurse Smith told officers that Jones was
able to proceed with intake.

       By policy, inmates must submit to an unclothed body search as part of intake.
Told of the search, Jones replied “you want me to do what?” Asked to remove her
clothing, Jones took one arm out of her jail uniform, but did not respond to further
requests. Officers stated that Jones seemed unwilling or unable to get out of the
wheelchair, commenting that her feet hurt and she wanted to remove her socks. One
officer helped remove her socks, looked at her feet and legs, but did not think they
appeared swollen. Because Jones would not cooperate with the unclothed body
search, four female officers performed a staff-assisted unclothed body search. She

                                         -3-
moaned and grunted throughout the search, saying her neck and arm hurt when the
officers held them. When one officer inquired whether Jones was “ok,” she grunted
in response.

      A medical examination is required after a staff-assisted unclothed body search.
Sgt. Hedtke asked Nurse Smith to perform the examination. Nurse Smith claims she
performed the examination, finding no signs of injury. Two officers and another
inmate stated, however, that Nurse Smith was in the cell with Jones for only 15
seconds, telling her, “this is what happens when people don’t listen to officers,”
without asking Jones any medical questions.

       Shortly after the body search, the second watch officers left due to a shift
change. Lt. Westphal briefed the watch commander for the third shift on the
occurrences of the day. During the third shift, inmates reported that Jones was
moaning in her cell. Officer Eskelson – noticing Jones’s eyes appeared strange and
were darting back and forth – asked Nurse Smith if she was planning to look in on
Jones during her rounds (although not required by policy since Jones was not on
medication). Nurse Smith responded that she had seen Jones earlier in the day and
nothing was wrong with her. As part of her rounds, Officer Eskelson checked on
Jones every half hour; each time it appeared Jones was resting. Later, Officer
Eskelson sent an email stating, “This new one on the bed naked – no one cares.”
Eskelson found Jones unresponsive in her cell at 9:03 p.m. Emergency medical staff
performed CPR. Jones was pronounced dead at 9:35 p.m, about 12 hours after
arriving at Shakopee. Autopsy revealed she died of a pulmonary edema. During her
12 hours at Shakopee, Jones never told anyone that she needed medical attention; only
complaining that her feet hurt, and that her neck and arm hurt during the search.

      Jela Jones, as trustee for his mother’s heirs, sued the Minnesota Department of
Corrections, individual officers, and Nurse Smith. In addition to the Eighth
Amendment claims, Jones also brought state-law claims for excessive force and

                                         -4-
wrongful death. The district court dismissed the claims against the Department and
the individual defendants in their official capacity, based on the Eleventh Amendment.
The court granted summary judgment to the individual defendants in their personal
capacities, finding that Jones did not suffer from an objectively serious medical need,
the defendants were not subjectively aware of a serious medical need, and the
defendants did not deliberately disregard a serious medical need. The court declined
supplemental jurisdiction over the state law claims, dismissing them without
prejudice. Jones appeals the grant of summary judgment to the individual defendants
in their personal capacities.

                                           II.

             This court reviews de novo a grant of summary judgment. See RSBI
Aerospace, Inc. v. Affiliated FM Ins. Co., 49 F.3d 399, 401 (8th Cir. 1995).
Summary judgment is appropriate if, taking the facts in the light most favorable to the
non-moving party, there are no genuine issues of material fact and the moving party
is entitled to judgment as a matter of law. See Fed. R. Civ. P. 56(c); Celotex Corp.
v. Catrett, 477 U.S. 317, 323 (1986). A genuine issue of material facts exists if there
is a dispute about a fact material to the outcome of the case, and the dispute is genuine
in that a reasonable jury could return a verdict for either party. See RSBI, 49 F.3d at
401.

      “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.” Gregoire v. Class, 236 F.3d 413, 417 (8th Cir. 2000). In a
deprivation of medical care case, the inmate must show (1) an objectively serious
medical need; and (2) the defendants actually knew of the medical need but were
deliberately indifferent to it. See Grayson v. Ross, 454 F.3d 802, 808-09 (8th Cir.
2006).



                                          -5-
       An objectively serious medical need is one that either has been diagnosed by
a physician as requiring treatment, or is so obvious that even a “layperson would
easily recognize the necessity for a doctor’s attention.” See Coleman v. Rahija, 114
F.3d 778, 784 (8th Cir. 1997), quoting Camberos v. Branstad, 73 F.3d 174, 176 (8th
Cir. 1995). “ ‘To establish a constitutional violation, it is not enough that a reasonable
official should have known of the risk.’ Rather, a plaintiff must demonstrate the
official actually knew of the risk and deliberately disregarded it.” Vaughn v. Greene
County, Ark., 438 F.3d 845, 850 (8th Cir. 2006), quoting Farmer v. Brennan, 511
U.S. 825, 837 (1994). The determination that prison officials had actual knowledge
of a serious medical need may be inferred from circumstantial evidence or from the
very fact that the risk was obvious. See Farmer, 511 U.S. at 842. If prison officials
have actual knowledge of a serious medical need, and fail to take reasonable measures
to address it, they may held liable for deliberate indifference. See id. at 847.
“However, ‘[a] showing of deliberate indifference is greater than gross negligence and
requires more than mere disagreement with treatment decisions.” Pietrafeso v.
Lawrence County, S.D., 452 F.3d 978, 983 (8th Cir. 2006), quoting Gibson v. Weber,
433 F.3d 642, 646 (8th Cir. 2006).


                                           A.


       The determination that a medical need is objectively serious is a factual finding.
See Rahija, 114 F.3d at 784. If there is a dispute, and a reasonable jury could return
a verdict for either party, then summary judgment is not appropriate. Here, Jones was
not diagnosed by a physician as requiring treatment. Therefore, Jones’s condition
must have been so obvious that a layperson would easily recognize the need for
treatment. On the undisputed facts of this case, no reasonable jury could find that
Jones suffered from an objectively serious medical need.




                                           -6-
       This court has found a serious medical need that was obvious to a layperson
where an inmate: was pregnant, bleeding, and passing blood clots, see Pool v.
Sebastian County, Ark., 418 F.3d 934, 945 (8th Cir. 2005); had swollen and bleeding
gums and complained of extreme tooth pain, see Hartsfield v. Colburn, 371 F.3d 454,
457 (8th Cir. 2004); experienced excessive urination, diarrhea, sweating, weight loss,
and dehydration related to known diabetes, see Roberson v. Bradshaw, 198 F.3d 645,
647-48 (8th Cir. 1999); or exhibited signs of early labor and her medical records
clearly documented a history of rapid labor and delivery, see Rahija, 114 F.3d at 785.


       The determination whether a medical need is sufficiently obvious cannot be
analyzed in a vacuum. The prison officials’ background knowledge is part of the
analysis. See Roberson, 198 F.3d at 647-48 (describing the deputy’s knowledge of
inmate’s diabetes and complaints in determining whether inmate suffered from
medical condition obvious to a layperson); Rahija, 114 F.3d at 784-85 (discussing
inmate’s medical records which indicated previous rapid delivery in finding it would
have been obvious to a layperson that inmate required medical attention for pre-term
labor). In each of the cases cited, the inmate exhibited physical symptoms related to
known medical issues or to complaints of pain.


       Jones claims that his mother “was unable to stand or walk under her own
power, was ‘google-eyed’ and unresponsive, was rolling on the ground while grunting
and groaning, was bleeding from the mouth,[3] smelled as if she had urinated on
herself, and was breathing at a very rapid rate” which made it obvious to a layperson
that his mother needed medical attention. Jones’s symptoms are not a sufficiently
obvious medical issue. Unlike passing blood clots while pregnant; bleeding gums
with complaints of extreme tooth pain; excessive urination, dehydration, sweating, and
weight loss; and signs of early labor – which all obviously indicate a medical issue –

      3
       The record does not support the assertion that Jones was “bleeding from the
mouth.” The record does show that she had dried blood and cuts on her lips.

                                         -7-
Jones’s symptoms are not easily recognizable medical issues. See Grayson, 454 F.3d
at 809-10 (not obvious to a layperson that pre-trial detainee needed medical treatment
where detainee was found in a creek, soaking wet; was combative; gave nonsense
answers to questions; began screaming while in the holding cell; and officers were
aware that detainee had taken meth). Importantly, in this case the prison officials had
no background knowledge that made it obvious that these symptoms required medical
attention. True, Blue Earth staff checked the “medical problems” box on the form sent
to Shakopee, but they also checked all the other boxes: behavioral problems,
psychological problems, and incompatibility with other inmates. The form also
indicated that Jones was a “difficult inmate” and that Blue Earth staff would “send
all applicable incident reports.” There was no elaboration on any medical problems.
Blue Earth staff told Shakopee officers that Jones had become violently sick and
uncooperative, but only upon learning of her transfer to Shakopee. Blue Earth also
informed Shakopee that Jones was able to move around and partake in day-to-day
activities before hearing of the transfer. Taking Jones’s symptoms in context, and
given that Jones never expressed a need for medical attention, a reasonable jury could
not find that Jones had a medical need so obvious that a layperson would easily
recognize the need for a doctor’s immediate attention.


       Jones relies on Johnson v. Hamilton, 452 F.3d 967, 973 (8th Cir. 2006), where
this court found that a fractured finger was an objectively serious medical need. In
Johnson, however, there was a tentative diagnosis that the finger was fractured, so that
case did not address the “so obvious a layperson would easily recognize it” prong.
Similarly, in Bryan v. Endell, 141 F.3d 1290, 1291 (8th Cir. 1998), an inmate’s broken
hand had been treated, and therefore there was no discussion of whether a broken hand
is sufficiently obvious.


      Jones also argues that “certain medical conditions are per se serious, such as
conditions resulting in death.” No doubt, a diagnosis of pulmonary edema would

                                          -8-
constitute a serious medical condition. See Robinson v. Hager, 292 F.2d 560, 564
(8th Cir. 2002) (assuming that a stroke is a “serious medical harm, the risk of which
was substantial in plaintiff’s case” due to known hypertension). The question here,
however, is not, in hindsight, whether Jones had a serious medical condition, but
rather, whether the condition was so obvious that a layperson would have easily
recognized the need for medical treatment. While some medical conditions that result
in death are obvious to a layperson, not all are. See Grayson, 454 F.3d at 809-10 (no
objectively serious medical need because it would not have been obvious to a
layperson that an inmate required immediate medical attention even though
intoxication resulted in death). A medical condition is not per se obvious to a
layperson because it later results in death.


                                           B.


       There is no genuine dispute that any of the defendants were deliberately
indifferent to Jones’s known medical need. Jones claims that the defendants had
actual knowledge of a serious medical need, but on this record no reasonable jury
could find that they did.


       No circumstantial evidence supports the inference that any defendant believed
Jones had a serious medical issue. Jones points to Lt. Westphal’s suspicions that there
were “medical issues.” Describing Jones’s behavior in the intake garage, Lt. Westphal
stated that she “couldn’t tell [] if it was a withdrawal thing or whether it was a medical
issue.” Lt. Westphal described Jones’s grunting as “sighing, oh poor me[,] I am here
and I don’t want to be.” She also stated that “when I addressed [Jones] and gave her
her options, it instantaneously stopped.” When Lt. Westphal spoke with the nurses
about performing the medical screening immediately, she stated, “I can’t imagine that
there is not something medical because of her weight.” Lt. Westphal told the nurses
that she needed to know “can this person walk, can she not walk, can she do the intake

                                           -9-
process by herself or do I need to figure out a different way of doing this.” Taken as
a whole, Lt. Westphal’s statements do not show that she believed Jones had an
objectively serious medical need. The most generous inference from this evidence is
that Lt. Westphal thought Jones may have long-term medical issues due to her weight.
The evidence does not support the inference that Lt. Westphal believed Jones required
immediate medical attention.


       Since Jones’s medical issues were not obvious, actual knowledge cannot be
inferred from the obviousness of the need. “[A]n official’s failure to alleviate a
significant risk that he should have perceived but did not, while no cause for
commendation, cannot under our cases be condemned as the infliction of
punishment.” Farmer, 511 U.S. at 838. At most, the Shakopee staff was negligent
in not recognizing a medical need, which does not rise to the level of deliberate
indifference. See James ex rel. James v. Friend, 458 F.3d 726, 730 (8th Cir. 2006)
(“A review of appellees’ conduct in this case, however arguably negligent it may now
appear in the clear light of hindsight, does not reveal the existence of deliberate
indifference.”).


                                          C.


       Jones asserts that the defendants are not entitled to qualified immunity.
Government officials are entitled to qualified immunity for discretionary decisions
unless they violate a clearly established constitutional right. See Gordon ex rel.
Gordon v. Frank, 545 F.3d 858, 862 (8th Cir. 2006). “Officials are not liable for bad
guesses in gray areas; they are liable for transgressing bright lines.” See Vaughn, 438
F.3d at 852. Because (as determined above) the defendants did not violate Jones’s
Eighth Amendment rights, they are entitled to qualified immunity. See Grayson, 454
F.3d at 808 (“If the answer [to whether a constitutional right was violated] is no, we
grant qualified immunity.”).

                                         -10-
       Jones contends that Nurse Smith is not entitled to qualified immunity because
her duty to examine his mother was ministerial, not discretionary. Qualified immunity
is defeated, however, only where the violation of the ministerial duty gives rise to the
cause of action. See Sellers ex rel. Sellers v. Baer, 28 F.3d 895, 902 (8th Cir. 1994)
(“[P]laintiffs make no claim that they are entitled to damages simply because the
regulations they cite were violated. Instead, they seek damages based on their claims
that the Fifth and Fourteenth Amendments were violated. Thus, the issue before us
is whether the officers’ conduct violated any clearly established constitutional rights,
not whether the officers may have violated departmental regulations.”). Jones’s claim
is based on a violation of his mother’s Eighth Amendment rights, not violations of
Department directives and guidelines on medical screenings. Therefore, even if Nurse
Smith violated one of her ministerial duties to examine Jones (which this court need
not decide), she is entitled to qualified immunity.


                                          III.


      The judgment of the district court is affirmed.


                       ______________________________




                                         -11-
