                                                         [DO NOT PUBLISH]


             IN THE UNITED STATES COURT OF APPEALS

                    FOR THE ELEVENTH CIRCUIT                      FILED
                      ________________________          U.S. COURT OF APPEALS
                                                          ELEVENTH CIRCUIT
                                                              October 2, 2006
                             No. 06-10957                  THOMAS K. KAHN
                         Non-Argument Calendar                 CLERK
                       ________________________

                  D. C. Docket No. 04-02495-CV-J-NW

EDWIN WILLIAMS,


                                                           Plaintiff-Appellant,

                                  versus

LIMESTONE COUNTY, ALABAMA,
MIKE BLAKELY,
individually,


                                                        Defendants-Appellees,


                       ________________________

                Appeal from the United States District Court
                   for the Northern District of Alabama
                      _________________________

                            (October 2, 2006)

Before ANDERSON, BIRCH and BLACK, Circuit Judges.

PER CURIAM:
       Appellant Edwin Williams appeals the district court’s grant of summary

judgment in favor of Appellees Limestone County, Alabama, and Sheriff Mike

Blakely on Williams’ Eighth and Fourteenth Amendment claims brought pursuant

to 42 U.S.C. § 1983.1 Williams asserts, on appeal, that genuine issues of material

fact remain on his claims, which issues should have precluded the district court

from granting summary judgment. After review, we affirm.

                                   I. BACKGROUND

       As Sheriff of Limestone County, Alabama, Sheriff Mike Blakely is

responsible for promulgating the policies and procedures of the Limestone County

Jail with respect to the medical care of inmates. Generally speaking, official policy

mandates that inmates receive a health screening prior to booking, are monitored if

need be, and can request medical services if desired. At the time of the events

forming the basis for this appeal, Limestone County had a contract with Naphcare,

Inc., under which Naphcare was obligated to provide medical services for inmates

in the Limestone County Jail. In addition to associating a doctor for inmate

treatment, the contract provided that two nurses would be on duty at the jail seven

days a week, and at least one nurse would be on call 24 hours a day, seven days a

week. Thus, when no nurse was physically present at the jail, a nurse would


       1
        Williams’ claims against defendants Naphcare, Inc. and Barbara Longmire were settled
through mediation and, consequently, do not form part of the instant appeal.

                                              2
remain on call for medical emergencies. In the event of such an emergency, jail

personnel were instructed to contact the nurse, who would diagnose the symptoms

and, if needed, arrange for an ambulance to transport the inmate to a hospital.

      From March 11, 2004, until March 17, 2004, Williams was incarcerated in

the Limestone County Jail on a charge of residential building without a permit and

for violating probation on a previous charge of performing construction without a

license. During intake, Williams indicated to the jail nurse that he had previously

experienced chest pain and shortness of breath. Around 2:15 AM on March 15,

2004, Williams experienced chest pain, was short of breath, broke out in a sweat,

and had chills. His cell mates summoned help, at which time jail personnel

escorted Williams out of his cell so they could take his blood pressure. The

deputies, however, declined Williams’ request for medical attention at this time.

Around 3:00 AM, jail personnel called Barbara Longmire, the Naphcare nurse on

call for medical emergencies at the time. Longmire said Williams’ symptoms did

not sound like a heart problem, and advised the jail staff to give him Tylenol.

Deputies called Longmire two more times with Williams’ blood pressure readings.

After the third conversation, Longmire advised the deputies to take Williams to the

hospital, to which the deputies responded that “they didn’t really have enough

people right then to have an escort to take him.” Longmire agreed that Williams’



                                          3
hospital visit could wait until after breakfast. According to Williams, jail

personnel informed him that Longmire had not authorized a hospital stay.

      Later that morning, Nolita Wilson, another nurse with Naphcare, arrived at

the jail for her shift and checked on Williams. She noted, though Williams

disputes it, that Williams claimed his problem might have been acid reflux or

indigestion. Wilson decided to monitor Williams closely, telling him to return to

sick call if he began to feel worse. Williams did not request further treatment,

never went to see Wilson again, and was never taken to the hospital.

      On March 19, 2004, Williams went to Decatur General Hospital, where he

learned he had suffered a heart attack while in the Limestone County Jail.

Williams had emergency heart surgery at Huntsville Hospital, and was informed

that medical treatment at the time his chest pain began may have prevented his

heart attack and damage to the lower third of his heart. Williams has not worked

since his surgery and was awarded Social Security disability benefits with an onset

date of March 19, 2004.

      As a result of these events, Williams filed suit for damages against Sheriff

Blakely, in his individual capacity, and Limestone County pursuant to 42 U.S.C.

§ 1983, alleging violations of the Eighth and Fourteenth Amendments. The district

court granted summary judgment in favor of the defendants, and this appeal



                                           4
followed.

                             II. STANDARD OF REVIEW

       We review de novo the district court’s grant of a motion for summary

judgment, viewing all evidence and factual inferences in the light most favorable to

the nonmoving party. See Turnes v. AmSouth Bank, N.A., 36 F.3d 1057, 1060

(11th Cir. 1994). Summary judgment is proper if the pleadings, depositions, and

affidavits show that there is no genuine issue of material fact and that the moving

party is entitled to judgment as a matter of law. See Celotex Corp. v. Catrett, 106

S. Ct. 2548, 2552 (1986). In order to defeat summary judgment, the non-moving

party “must do more than simply show that there is some metaphysical doubt as to

the material facts.” See Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 106 S.

Ct. 1348, 1356 (1986). The non-moving party must make a sufficient showing on

each essential element of the case for which he bears the burden of proof. See

Celotex, 106 S. Ct. at 2552.

                                    III. DISCUSSION 2


       2
         We only discuss in detail Williams’ Eighth and Fourteenth Amendment claims against
Sheriff Blakely. On appeal, Williams presses the same claims against Limestone County,
arguing “the [C]ounty had the responsibility to set up adequate procedures and to provide
adequate training in basic response[s] to medical emergencies.” We reject Williams’ claims
against Limestone County, as they find no support in the record and are without merit. Under
Alabama law, Limestone County is not responsible for assuring procedures are in place for
inmates to receive medical care. See Marsh v. Butler County, 268 F.3d 1014, 1026 n.6 (11th Cir.
2001). Rather, Alabama law assigns counties a “limited role in building and funding the jails.”
See Turquitt v. Jefferson County, Ala., 137 F.3d 1285, 1289-91 (11th Cir. 1998). Contrary to

                                               5
       It is well-settled that to establish liability under § 1983 for inadequate

medical treatment, a prisoner must show that the failure to provide him medical

care amounted to cruel and unusual punishment under the Eighth Amendment of

the United States Constitution.3 See Estelle v. Gamble, 97 S. Ct. 285, 292 (1976).

That is, a prisoner must show his inadequate care arose from a “deliberate

indifference to [his] serious medical needs.” Id. at 291. This standard

encompasses both objective and subjective components. First, the prisoner must

prove an objectively serious medical need, “one that has been diagnosed by a

physician as mandating treatment or one that is so obvious that even a lay person

would easily recognize the necessity for a doctor’s attention.” Farrow v. West, 320

F.3d 1235, 1243 (11th Cir. 2003) (quotation and citation omitted). Second, the



Williams’ conclusory allegations, nothing in the record suggests (1) Limestone County failed to
provide adequate funding for medical services; or (2) Limestone County voluntarily assumed the
obligation to provide adequate training through its contract with Naphcare. As a result,
Limestone County is not a responsible party for any purported deliberate indifference to
Williams’ medical needs. The district court, therefore, did not err in granting summary
judgment in Limestone County’s favor on these claims.
       3
          It is unclear from the record whether Williams was being held as a convicted prisoner
for violating his probation, in which case the Eighth Amendment applies to him, or as a pretrial
detainee on the charge of residential building without a permit, in which case the Fourteenth
Amendment is applicable. See Bell v. Wolfish, 99 S. Ct. 1861, 1872 (1979); Tittle v. Jefferson
County Comm’n, 10 F.3d 1535, 1539 n.3 (11th Cir. 1994). The district court relied on cases
interpreting the Eighth Amendment’s prohibition against cruel and unusual punishment, and not
the Fourteenth Amendment’s guarantee of due process. This distinction, however, does not alter
our analysis because the standard for violations of the Eighth Amendment apply to pretrial
detainees through the due process clause. See Tittle, 10 F.3d at 1539 (noting “[w]hether the
alleged violation is reviewed under the Eighth or Fourteenth Amendment is immaterial”). With
this in mind, we couch our analysis in Eighth Amendment terms.

                                               6
prisoner must show the prison official acted with deliberate indifference to that

need. To establish the requisite deliberate indifference, “the prisoner must prove

three facts: (1) subjective knowledge of a risk of a serious harm; (2) disregard of

that risk; and (3) by conduct that is more than mere negligence.” Brown v.

Johnson, 387 F.3d 1344, 1351 (11th Cir. 2004). Put generally, deliberate

indifference is medical treatment that is “so grossly incompetent, inadequate, or

excessive as to shock the conscience or to be intolerable to fundamental fairness.”

Rogers v. Evans, 792 F.2d 1052, 1058 (11th Cir. 1986).

      In establishing liability pursuant to § 1983, however, a prisoner cannot rely

on theories of vicarious liability or respondeat superior. See Cook ex rel. Estate of

Tessier v. Sheriff of Monroe County, Fla., 402 F.3d 1092, 1115-16 (11th Cir.

2005). Section 1983 requires proof of an affirmative causal link between the

official’s acts or omissions and the alleged constitutional deprivation. See Zatler v.

Wainwright, 802 F.2d 397, 401 (11th Cir. 1986). The causal connection may be

proven by showing the official (1) was personally involved in the acts or omissions

which resulted in the constitutional deprivation; (2) established a policy or custom

that resulted in the constitutional deprivation; or (3) breached a duty imposed by

state or local law. Id. A failure to adequately train subordinates “constitutes an

actionable policy or custom for § 1983 purposes ‘only where the failure to train



                                          7
amounts to deliberate indifference to the rights of persons with whom the

[subordinates] come into contact.’” Cook, 402 F.3d at 1116 (quoting City of

Canton v. Harris, 109 S. Ct. 1197, 1204 (1989)). “Failure to train can amount to

deliberate indifference when the need for more or different training is obvious,

. . . and when the failure to train is likely to result in the violation of a

constitutional right.” Belcher v. City of Foley, 30 F.3d 1390, 1397-98 (11th Cir.

1994). In general, then, a failure to train satisfies the subjective prong of the

Eighth Amendment calculus, and imposes supervisory liability on a prison official,

where that failure evinces a disregard of the strong likelihood that, absent such

training, prison personnel would subject an inmate to “acts or omissions

sufficiently harmful to evidence deliberate indifference to serious medical needs.”

Estelle, 97 S. Ct. at 292.

       On appeal, the parties do not dispute that Williams’ severe chest pains and

heart attack constituted a serious medical condition. See Mata v. Saiz, 427 F.3d

745, 754 (10th Cir. 2005). Instead, the parties contest whether, under the

subjective prong of the analysis, Sheriff Blakely demonstrated deliberate

indifference to Williams’ serious medical needs. In this regard, Williams’ primary

contention on appeal is that Sheriff Blakely’s failure to adequately train jail

personnel in emergency medical procedures constituted deliberate indifference to



                                              8
his medical needs, which indifference caused his injury. We disagree. Nothing in

the record, or in the facts as Williams asserts them, supports the conclusion that

Sheriff Blakely’s failure to train jail personnel in emergency medical procedures

constituted deliberate indifference to his serious medical needs.

       First, Williams fails to provide any evidence—or even allege—that there

was a history or pattern of jail personnel’s deliberate indifference to inmates’

serious medical needs that would render obvious the need for additional or

different medical training. In fact, Williams cites only the incident involving

himself. On these facts, this is insufficient to establish Sheriff Blakely’s liability

for a failure to train the jail staff.4 See City of Oklahoma City v. Tuttle, 105 S. Ct.

2427, 2436 (1985). Thus, we cannot say, on this record, that “the need for more or

different training [was] obvious,” such that by failing to ensure jail personnel were

trained in emergency medical procedures, Sheriff Blakely disregarded a substantial

risk that the jail staff would be deliberately indifferent to inmates’ medical needs.

Belcher, 30 F.3d at 1397-98.

       Second, there is no indication from the record that Sheriff Blakely had notice


       4
          This is not to say, of course, that under certain circumstances, the risk or likelihood of a
constitutional violation cannot be “so obvious” that a failure to train constitutes deliberate
indifference without prior notice. See City of Canton, 109 S. Ct. at 1205. We only hold that the
facts of this case do not fall within that “narrow range of circumstances [in which] a plaintiff
might succeed without showing a pattern of constitutional violations.” Gold v. City of Miami,
151 F.3d 1346, 1352 (11th Cir. 1998).

                                                  9
his policies, training procedures, or supervision were “likely to result in the

violation of a constitutional right.” Id. The contract between Naphcare and

Limestone County provided for 24-hour care at the jail, and jail personnel were

trained to call Naphcare’s on-call nurse should a medical emergency arise outside

of the nurses’ standard work hours. Williams has neither asserted nor explained

why Sheriff Blakely should have anticipated these procedures were likely to result

in the jail staff’s deliberate indifference to Williams’, or any other inmate’s, serious

medical needs. Indeed, as the district court held, “[Sheriff Blakely] had reason to

expect that if medical attention was needed, it would be provided under the

Naphcare contract, and [Williams] has offered no evidence to the contrary.”

Nothing in the summary judgment record indicates Sheriff Blakely knew, or even

should have known, that the failure to train jail personnel in emergency medical

procedures was likely to result in a callous unresponsiveness to inmates’ medical

conditions. In fact, the record only permits the conclusion that Sheriff Blakely had

every reason to assume medical emergencies would be handled according to the

normal routine. Thus, like the district court, we cannot say that by relying solely

on established procedures and Naphcare’s medical services, Sheriff Blakely

disregarded a substantial risk that jail personnel would be deliberately indifferent

to inmates’ serious medical conditions.



                                           10
       Finally, supervisory officials are entitled to rely on medical judgments made

by medical professionals responsible for prisoner care. See, e.g., Durmer v.

O’Carroll, 991 F.2d 64, 69 (3d Cir. 1993); White v. Farrier, 849 F.2d 322, 327

(8th Cir. 1988). In this case, Sheriff Blakely promulgated general procedures for

dealing with emergency situations, which procedures relied primarily on the

medical expertise Naphcare was obligated by contract to provide. The fact that

alternative procedures, such as providing jail personnel with additional medical

training, might have better addressed Williams’ particular needs does not show that

Sheriff Blakely was deliberately indifferent to Williams’ medical needs.

“[D]eliberate indifference is a stringent standard of fault, requiring proof that [the]

actor disregarded a known or obvious consequence of his action.” Bd. of County

Comm’rs v. Brown, 117 S. Ct. 1382, 1391 (1997). See also Adams v. Poag, 61

F.3d 1537, 1543 (11th Cir. 1995). Williams, as the district court concluded, thus

failed to meet his burden on summary judgment of establishing that Sheriff

Blakely’s failure to train jail personnel amounted to deliberate indifference to

Williams’ serious medical condition. Accordingly, we affirm the district court’s

grant of summary judgment in favor of Sheriff Blakely.5


       5
         Because Williams has failed to establish the deliberate indifference integral to his
Eighth and Fourteenth Amendment claims, we need not address the issue of whether Sheriff
Blakely is entitled to qualified immunity. See Saucier v. Katz, 121 S. Ct. 2151, 2156 (2001)
(noting “[i]f no constitutional right would have been violated . . . there is no necessity for further

                                                  11
                                    IV. CONCLUSION

         For the foregoing reasons, we affirm the well-reasoned order of the district

court.

         AFFIRMED.




inquiries concerning qualified immunity”).

                                             12
