                       RECOMMENDED FOR FULL-TEXT PUBLICATION
                            Pursuant to Sixth Circuit Rule 206
                                   File Name: 09a0418p.06

               UNITED STATES COURT OF APPEALS
                                FOR THE SIXTH CIRCUIT
                                  _________________


                                                   X
 Representative of the Estate of CHRISTOPHER -
 EUNICE M. SPEARS, individually and as
                                                    -
 MCCARGO et al.,                                    -
                           Plaintiffs-Appellees, -
                                                         No. 09-5408

                                                    ,
                                                     >
                                                    -
                                                    -
           v.
                                                    -
                                                    -
 MATTHEW RUTH and CITY OF CLEVELAND,
                                                    -
                        Defendants-Appellants. -
 TENNESSEE,

                                                    -
                                                   N
                      Appeal from the United States District Court
                 for the Eastern District of Tennessee of Chattanooga.
                No. 07-00058—Curtis L. Collier, Chief District Judge.
                               Argued: November 18, 2009
                         Decided and Filed: December 10, 2009
                                                                                       *
      Before: MARTIN and SUTTON, Circuit Judges; REEVES, District Judge.

                                   _________________

                                        COUNSEL
ARGUED: Reid A. Spaulding, WATSON, ROACH, BATSON, ROWELL &
LAUDERBACK, P.L.C., Knoxville, Tennessee, for Appellants. Zachary H. Greene,
MILLER & MARTIN PLLC, Chattanooga, Tennessee, for Appellee. ON BRIEF: Reid
A. Spaulding, Robert H. Watson, Jr., WATSON, ROACH, BATSON, ROWELL &
LAUDERBACK, P.L.C., Knoxville, Tennessee, for Appellants. Zachary H. Greene,
Roger W. Dickson, Travis R. McDonough, Kevin D. Hudson, MILLER & MARTIN
PLLC, Chattanooga, Tennessee, for Appellee.




        *
        The Honorable Danny C. Reeves, United States District Judge for the Eastern District of
Kentucky, sitting by designation.


                                              1
No. 09-5408            Spears et al. v. Ruth et al.                                           Page 2


                                      _________________

                                            OPINION
                                      _________________

       BOYCE F. MARTIN, JR., Circuit Judge. Matthew Ruth, a police officer, and
the City of Cleveland, Tennessee, bring this interlocutory appeal of the district court’s
denial of summary judgment on qualified immunity grounds. Eunice M. Spears, mother
of the deceased, responds individually and as representative of the estate of Christopher
McCargo. Christie McCargo, the daughter of the deceased, Clay McCargo and Madeline
McCargo, relatives of the deceased, respond individually. Officer Ruth claims that the
district court erred in denying his request for summary judgment and that he is entitled
to qualified immunity as a matter of law because plaintiffs have not shown that Officer
Ruth was “deliberately indifferent” to Chrisopher McCargo’s serious illness or injury
while McCargo was in Officer Ruth’s care. “Deliberate indifference” is required to
establish a Fourteenth Amendment claim for failure to provide medical assistance.1 The
City of Cleveland claims that the district court erred in denying its request for summary
judgment because plaintiffs have not shown that the city’s “no transport” policy caused
a constitutional violation. This showing is necessary to establish a cause of action
against a municipality under 28 USC § 1983.2 For the reasons set forth below, we
REVERSE the district court’s denial of summary judgment to Officer Ruth and the City
of Cleveland and REMAND for entry of judgment for the defendants.

                                                  I.

       In February 2006, Officer Ruth received a dispatch that a man, later identified
as Christopher McCargo, was running up and down the street, hallucinating and
otherwise behaving bizarrely. When Officer Ruth arrived at the scene, McCargo told
Officer Ruth that he had smoked crack cocaine. Shortly thereafter, the Emergency
Medical Services (EMS) arrived, and, after examining McCargo, decided not to take him

       1
           Weaver v. Shadoan, 340 F.3d 398, 410 (6th Cir. 2003).
       2
           Cash v. Hamilton County Dept. Of Adult Prob., 388 F.3d 539, 542 (6th Cir. 2004).
No. 09-5408           Spears et al. v. Ruth et al.                                            Page 3


to the hospital. A factual dispute exists regarding whether Officer Ruth told the
Emergency Medical Technicians (EMTs) that McCargo had been behaving in a bizarre
manner and that McCargo had admitted smoking crack cocaine. It is unclear whether
McCargo affirmatively refused medical treatment or remained silent when asked if he
needed help.

        Officer Ruth arrested McCargo for public intoxication and transported him to the
Bradley County Justice Center. Witnesses at the scene and Officer Ruth testified that
McCargo kicked violently once placed into the back seat of the car. When Officer Ruth
arrived at the jail, Bradley County jail officers, including a nurse, noticed McCargo
“rocking back and forth stating don’t let the dogs get me.” The nurse performed another
medical exam before checking McCargo into the jail, though Officer Ruth told them that
the “EMTs at the scene had already cleared him.” Testimony differs as to whether
Officer Ruth told the Bradley County jail officers that McCargo admitted smoking crack
cocaine and that the EMTs had noticed something white in McCargo’s mouth.3

        As McCargo continued to hallucinate, jail officers placed him in a restraint chair
“for his own safety,” tasing him to “relax his muscles.” McCargo remained restrained
for approximately three and a half hours, during which time he was calm but continued
to hallucinate. Shortly after the officers released him from the chair, McCargo began to
shake and spit up blood and then became unconscious. EMS personnel took McCargo
to the hospital where he was diagnosed with respiratory and cardiac failure and
multi-organ failure resulting from cocaine use. McCargo lapsed into a coma from which
he never recovered. He died eleven months later.

        At the time that Officer Ruth encountered McCargo, two conflicting police
department policies regarding the transportation of individuals for medical services
existed. One policy instructed police who encountered detainees exhibiting signs of
“excited delirium” to transport them to the hospital for treatment, making no provision



        3
          It is unclear from the record whether Officer Ruth was aware that one of the EMTs had seen a
white substance in McCargo’s mouth. The other EMTs concluded McCargo had nothing in his mouth.
No. 09-5408            Spears et al. v. Ruth et al.                                                Page 4


for officers to engage the services of an EMS vehicle instead.4 However, Police Chief
Wes Snyder’s concurrent written memorandum prohibited his officers from transporting
any individual to the hospital in a police vehicle for medical services. Plaintiffs claim
that this policy caused Officer Ruth not to transport McCargo to the hospital himself,
resulting in his death.

         Plaintiffs filed their original complaint in the Circuit Court of Bradley County,
Tennessee. The Defendants removed the case to the United States District Court for the
Eastern District of Tennessee. The defendants timely filed motions for summary
judgment asserting various defenses including qualified immunity. Summary judgment
was granted for Defendants on all grounds but two: (1) Ruth’s request for summary
judgment on the basis that he was protected by qualified immunity against the charge of
violating McCargo’s Fourteenth Amendment right to adequate medical care; and (2) the
City’s request for summary judgment on plaintiffs’ theory as to Police Chief Synder’s
“no transport” policy. Ruth and the City timely sought interlocutory review of these
rulings.

                                                    II.

         “We review the district court’s grant of summary judgment de novo.” Hiney
Printing Co. v. Brantner, 243 F.3d 956, 959 (6th Cir. 2001). “Summary judgment is
appropriate where ‘the pleadings, depositions, answers to interrogatories, and admissions
on file, together with the affidavits, if any, show that there is no genuine issue as to any
material fact and that the moving party is entitled to judgment as a matter of law.’”
Cummings v. City of Akron, 418 F.3d 676, 682 (6th Cir. 2005) (citing FED.R.CIV.P.
56(c)). “We ‘must view all the facts and the inferences drawn therefrom in the light most
favorable to the nonmoving party,’” id. (quoting Birch v. Cuyahoga County Probate
Court, 392 F.3d 151, 157 (6th Cir. 2004)), and we will “uphold a grant of summary
judgment ‘[w]here the record as a whole could not lead a rational trier of fact to find for


         4
            This policy instructed officers on how to recognize symptoms of cocaine psychosis and
instructed officers to transport individuals exhibiting such symptoms, including “paranoia, bizarre behavior
. . . hallucinations . . . and aggressive, violent behavior” to the hospital. It is unclear whether Ruth had
been trained on this policy at the time of McCargo’s death.
No. 09-5408        Spears et al. v. Ruth et al.                                     Page 5


the non-moving party,’” Id. (quoting Matsushita Elec. Indus. Co. v. Zenith Radio Corp.,
475 U.S. 574, 587 (1986)).

                                            III.

       Government officials are immune from civil liability unless, in the course of
performing their discretionary functions, they violate the plaintiff’s clearly established
constitutional rights. See Hills v. Kentucky, 457 F.3d 583, 587 (6th Cir. 2006) (citing
Saucier v. Katz, 533 U.S. 194, 201 (2001)).

       “Pretrial detainees have a right under the Fourteenth Amendment to adequate
medical treatment, a right that is analogous to the right of prisoners under the Eighth
Amendment.” Estate of Carter v. City of Detroit, 408 F.3d 305, 311 (6th Cir. 2005)
(citing Watkins v. City of Battle Creek, 273 F.3d 682, 685-86 (6th Cir. 2001)). “A cause
of action under §1983 for failure to provide adequate medical treatment requires a
showing that the defendants acted with deliberate indifference to the serious medical
needs of the pretrial detainee.”      Id. (internal citations and quotations omitted).
Deliberate indifference requires that the defendants “knew of and disregarded a
substantial risk of serious harm to [the plaintiff’s] health and safety.” Watkins, 273 F.3d
at 686 (citing Farmer v. Brennan, 511 U.S. 825, 835-37 (1994)).

       “There are two parts to the claim, one objective, one subjective. For the
objective component, the detainee must demonstrate the existence of a sufficiently
serious medical need.” Estate of Carter, 408 F.3d at 311 (internal citations and
quotations omitted). “For the subjective component, the detainee must demonstrate that
the defendant possessed a sufficiently culpable state of mind in denying medical care.”
Id. (internal citations and quotations omitted).

       A.      Officer Ruth

       In this case, plaintiffs allege that, because Officer Ruth failed to inform the EMTs
on the scene and at the jail that McCargo had admitted he smoked crack cocaine, Officer
Ruth violated McCargo’s constitutional right to receive medical care.
No. 09-5408            Spears et al. v. Ruth et al.                                             Page 6


                  1.       Existence of a Sufficiently Serious Medical Need

         “[W]here a plaintiff’s claims arise from an injury or illness so obvious that even
a layperson would easily recognize the necessity for a doctor’s attention . . . it is
sufficient to show that [the plaintiff] actually experienced the need for medical treatment,
and that the need was not addressed within a reasonable time frame.” Blackmore v.
Kalamazoo County, 390 F.3d 890, 899-900 (6th Cir. 2004) (internal citations and
quotations omitted).

         In Blackmore, we previously denied prison officials’ request for summary
judgment, finding that the seriousness of the detainee’s underlying medical condition,
appendicitis, could be discerned by the average layperson without medical proof because
the detainee complained of sharp stomach pain over two days and vomited, which were
“classic signs of appendicitis.” Id. at 900.5 Similarly, we have found that a detainee
lying face down, unresponsive and exhibiting symptoms of delirium tremens showed
medical need sufficient for lay people to recognize he needed medical attention. Bertl
v. City of Westland, No. 07-2547, slip op. at 5, (6th Cir. Feb. 2, 2009).

         Several factual disputes exist regarding how obvious McCargo’s symptoms
actually were to Officer Ruth, the EMTs, and jail officers. Officer Ruth does not contest
that: (1) McCargo told Officer Ruth that he had smoked crack cocaine; (2) McCargo
told Officer Ruth that he had been running away from dogs; and (3) the dispatcher told
Officer Ruth that McCargo was “running up and down the street” and “acting like he had
bugs crawling on him and in his pockets and thinks they are coming to get him.”
However, it is unclear from the record whether Officer Ruth told the EMTs or the jail
officers that McCargo admitted he had smoked crack cocaine and about McCargo’s
bizarre behavior. The record also does not reflect whether Officer Ruth knew about the
white substance one of the EMTs believed that he saw in McCargo’s mouth.




         5
          We additionally held that verifying medical evidence was needed only in cases involving “minor
maladies or non-obvious complaints of a serious need for medical care.” Id. at 898.
No. 09-5408         Spears et al. v. Ruth et al.                                    Page 7


       However, the EMTs and a jail nurse, who presumably had a greater facility than
the average layperson to recognize an individual’s medical need, observed McCargo’s
behavior and administered tests based on those observations. Both the EMTs and jail
officers concluded that McCargo did not need to be transported to the hospital.
Therefore, plaintiffs have not established that McCargo’s condition and need for medical
attention, which was not obvious to trained medical personnel, would have been obvious
to a layperson or to Officer Ruth—who was less able than EMTs to determine
McCargo’s medical needs. We thus find that the plaintiffs have not established the
obvious existence of a sufficiently serious medical need.

               2.       Sufficiently Culpable State of Mind

       Plaintiffs must show that the “‘official [was] aware of facts from which the
inference could be drawn that a substantial risk of serious harm exists, and he must also
draw the inference.’” Watkins, 273 F.3d at 686 (quoting Farmer, 511 U.S. at 837). The
official must then disregard that risk. Comstock v. McCrary, 273 F.3d 693, 703 (6th Cir.
2001) (citing Farmer, 511 U.S. at 837). A plaintiff can demonstrate this “in the usual
ways, including inference from circumstantial evidence . . . and a factfinder may
conclude that a prison official knew of a substantial risk from the very fact that the risk
was obvious.” Terrance v. Northville Reg’l Psychiatric Hosp., 286 F.3d 834, 843 (6th
Cir. 2002) (internal citations and quotations omitted).

       In a case that is factually similar to the current case, we held that officers were
not deliberately indifferent when a detainee, who swallowed cocaine during a police
chase, became sick, vomited, lost consciousness, and then died. Weaver, 340 F.3d 398.
When EMS personnel arrived on the scene, the officers, who had not actually seen the
detainee ingest any drugs, still requested that the EMTs examine the detainee for a
possible drug overdose. Despite numerous offers of help by the EMTs, the detainee
refused treatment and, when asked if he wanted to go to the hospital, replied, “No, I want
to go to jail, and I haven’t taken nothing. Leave me alone.” Id. at 403. Similarly, in
Watkins v. City of Battle Creek we found that officers were not deliberately indifferent
to the medical needs of a detainee who denied swallowing drugs even after being assured
No. 09-5408        Spears et al. v. Ruth et al.                                    Page 8


that he would not face additional charges for admitting to doing so. 273 F.3d 682, 686
(6th Cir. 2001). He continued to deny taking drugs and refused medical treatment. He
later died in police custody. Id. at 685.

       Similarly, here there is no evidence that Officer Ruth was aware of facts from
which the inference could be drawn that a substantial risk of serious harm existed, that
he drew that inference and chose to disregard the risk. Although Officer Ruth admits
that McCargo told him that he had smoked crack cocaine, Officer Ruth was entitled to
rely on the EMTs’ and the jail nurse’s medical assessments that McCargo did not need
to be transported to the hospital. Further, Officer Ruth’s disputed failure to tell the
EMTs and jail officers that McCargo admitted to smoking crack cocaine was at worst
negligent, and does not rise to the level of a constitutional violation. Therefore,
plaintiffs have not shown that Officer Ruth was deliberately indifferent. Because Officer
Ruth committed no constitutional violation against McCargo, we need not address the
question of whether McCargo had a clearly established right to medical care in these
circumstances. Based on the reasons set forth above, we find that, because no
constitutional violation occurred, Ruth is entitled to qualified immunity. Hills, 457 F.3d
at 587 (citing Katz, 533 U.S. at 201).

       B.      The City of Cleveland

       The City of Cleveland also requests summary judgment, arguing that plaintiffs
have failed to show that (1) a constitutional violation occurred; and (2) that the
constitutional violation was caused by a particular policy or custom. See Cash, 388 F.3d
at 542-43.

       To establish municipal liability under section 1983, the plaintiff must establish
that: (1) the plaintiff’s harm was caused by a constitutional violation; and (2) the city
was responsible for that violation. Id. Municipalities are liable for harms resulting from
a constitutional violation only when the injury resulted from an “implementation of [the
municipality’s] official policies or established customs.” Monell v. Dep’t of Soc. Servs.,
436 U.S. 658, 708 (1978) (Powell, J., concurring). “There are at least four avenues a
plaintiff may take to prove the existence of a municipality's illegal policy or custom.
No. 09-5408           Spears et al. v. Ruth et al.                                           Page 9


The plaintiff can look to (1) the municipality’s legislative enactments or official agency
policies; (2) actions taken by officials with final decision-making authority; (3) a policy
of inadequate training or supervision; or (4) a custom of tolerance or acquiescence of
federal rights violations.” Thomas v. City of Chattanooga, 398 F.3d 426, 429 (6th Cir.
2005) (internal citations omitted).

        “‘Official policy’ often refers to formal rules or understandings—often but not
always committed to writing—that are intended to, and do, establish fixed plans of
action to be followed under similar circumstances consistently and over time.” Pembaur
v. City of Cincinnati, 475 U.S. 469, 480-81 (1986). A municipality can be shown to
have a “custom” causing constitutional violations, even if that custom was not formally
sanctioned, provided that the plaintiff offers proof of policymaking officials’ knowledge
and acquiescence to the established practice. Monell, 436 U.S. at 690-691; Memphis,
Tenn. Area Local, Am. Postal Workers Union v. City of Memphis, 361 F.3d 898, 902 (6th
Cir. 2004).

        The plaintiff must also demonstrate “‘a direct causal link’ between the policy and
the alleged constitutional violation” in order to show that the municipality’s “‘deliberate
conduct’ can be deemed the ‘moving force’ behind the violation.” Graham ex. rel.
Estate of Graham v. County of Washtenew, 358 F.3d 377, 383 (6th Cir. 2004) (quoting
Waters v. City of Morristown, 242 F.3d 353, 362 (6th Cir. 2001).6

         As demonstrated above, plaintiffs have not shown facts sufficient to find that a
constitutional violation occurred. Even had a violation occurred, plaintiffs have failed
to show that Police Chief Snyder’s policy prohibiting his officers from transporting
individuals to the hospital in a police vehicle for medical services caused McCargo’s
injuries. At most, the evidence shows that Officer Ruth was reluctant to transport
McCargo to the hospital. However, this reluctance could have sprung from any number




        6
         A municipality cannot be held liable in section1983 actions on a respondeat superior theory.
Monell, 436 U.S. at 691.
No. 09-5408            Spears et al. v. Ruth et al.                                               Page 10


of motivations, including the possibility that Officer Ruth, relying on the EMTs’
assessment, did not believe that McCargo needed to go to the hospital for treatment.7

                                                   IV.

         Because the record as a whole does not support the inference that a reasonable
trier-of-fact could find a causal connection between either Officer Ruth’s actions or
Police Chief Synder’s no-transport policy and McCargo’s injuries, we REVERSE the
district court’s denial of summary judgment to Officer Ruth and the City of Cleveland
and REMAND for entry of judgment for the defendants.




         7
           Arguably, the individuals in the best position to have detected McCargo’s condition and called
for assistance were officers at the jail who observed McCargo’s hallucinations and other bizarre behavior
during the three and a half hours that he was in custody. However, as those officers are not parties in this
suit, we may not address their potential liability.
