April Myrick v. Fulton County, Georgia

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 1 of 51

[PUBLISH]

In the

United States Court of Appeals

For the Eleventh Circuit

____________________

No. 22-10441

____________________

APRIL M. MYRICK,

as guardian of Za'Kobe K. Rickerson, a minor

as guardian of Jordan I. Rickerson, a minor,

SHEENA PETTIGREW,

Mother and Natural Guardian

of Elijah Pettigrew, a minor,

THE ESTATE OF ANTONIO DEVON MAY,

by and through his Administrator April M. Myrick,

Plaintiffs-Appellants,

versus

FULTON COUNTY, GEORGIA,

SHERIFF THEORDORE JACKSON,

in his individual capacity,

SHERIFF OF FULTON COUNTY, GEORGIA,

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 2 of 51

2 Opinion of the Court 22-10441

in his official capacity,

SERGEANT JOHN DOE,

in his official and individual capacities,

JOHN DOE DEPUTIES, individually,

NAPHCARE, INC., et al.,

Defendants-Appellees.

____________________

Appeal from the United States District Court

for the Northern District of Georgia

D.C. Docket No. 1:19-cv-02440-TWT

____________________

Before NEWSOM, LUCK, and TJOFLAT, Circuit Judges.

TJOFLAT, Circuit Judge:

This appeal arises from the tragic death of Antonio May on

September 11, 2018. April Myrick, Sheena Pettigrew, and the Es-

tate of Antonio May (collectively the “Appellants”) appeal the Dis-

trict Court’s orders dismissing their claims against Sheriff Theo-

dore Jackson and granting summary judgment to the Fulton

County Sheriff’s Department Officers, NaphCare, and NaphCare

employee Travis Williams. After careful review of the record (in-

cluding the portions of the incident captured on video), and with

the benefit of oral argument, we affirm the District Court’s dismis-

sal of the claims against Sheriff Jackson, and its grant of summary

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 3 of 51

22-10441 Opinion of the Court 3

judgment to both the Officers and Williams. Because the District

Court erred in granting NaphCare summary judgment, however,

we vacate the District Court’s summary judgment in favor of

NaphCare and remand the case against NaphCare for further pro-

ceedings.

I.

A.

The Atlanta Police Department (the “APD”) responded to a

criminal trespass call at the American Cancer Society building in

downtown Atlanta very early in the morning on September 11,

2018. A male subject had thrown multiple rocks at the building,

shattering one of the glass windows. Upon their arrival, APD of-

ficers heard a male voice yelling and noticed a male subject laying

on the ground with his arms spread out. APD officers identified

the subject as Antonio May, and building security informed APD

that May threw the rocks at the building. May told the APD offic-

ers that he wanted to go to jail and indicated that he was not feeling

well; the APD officers took May to Grady Hospital to be examined.

Grady Hospital records show that May arrived around

5:30 AM and stated that he felt paranoid and thought someone was

chasing him. He also admitted to smoking methamphetamine that

night but refused lab work. The Grady Hospital records note that

May had a history of meth use and that he was also restless, was

picking at his skin, and had hyper-verbal speech. In addition to us-

ing methamphetamine, May admitted to consuming a large 22-

ounce beer that morning. May told hospital employees that he felt

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 4 of 51

4 Opinion of the Court 22-10441

like he was having a mental breakdown and that he had been trying

to get the police to help him because of his paranoia, but that they

arrested him instead. May further indicated that he had been using

methamphetamine for several years, but claimed his problem was

not methamphetamine, but rather his mental breakdown. Finally,

the records indicate that May denied suicidal ideation, homicidal

ideation, audio or visual hallucinations, and prior psychological

hospitalizations. The hospital, on the recommendation of a psy-

chiatrist, released May to be transported to the Fulton County Jail,

as that structured environment was “likely to be of the most benefit

for him given his current meth intoxication.” They also stated that

May was “safe for discharge from a psychiatric perspective.”

B.

May arrived at the Fulton County Jail around 9:00 AM on

the morning of September 11, 2018. As a brief overview, the Ful-

ton County Jail contracts with NaphCare to provide all medical ser-

vices to the inmates at the jail. When an inmate arrives at the Ful-

ton County Jail, he is initially strip searched. He then goes to triage,

where a nurse or paramedic does a very brief intake screening prior

to taking custody of the inmate. The inmate then goes through the

booking process, after which the medical department performs a

full medical screening, or receiving screening, before the medical

provider at the jail determines where to house the inmate.

If the inmate expresses feelings of suicide or self-harm dur-

ing the intake examination, a mental health professional typically

evaluates him as soon as possible, and makes sure that he is

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 5 of 51

22-10441 Opinion of the Court 5

observed and isolated so that he is not a danger to himself or others.

The medical provider on duty makes the final decisions regarding

detox procedures if an inmate indicates that he is on drugs or the

intake nurse or paramedic suspects that is the case.1 On the day

that May was taken to Fulton County Jail, the provider on duty was

David Didier.

EMT Travis Williams conducted May’s intake screening.2

When Williams asked him if he was suicidal, May indicated that he

was, but that he did not have a plan to harm himself. Williams also

stated that the arresting officer gave him paperwork from Grady

Hospital indicating doctors diagnosed May as having methadone

use disorder. 3 On the intake screening form, Williams noted that

May was actively or suspected to be detoxing and that May had

current suicidal thoughts, but that he had no current plan regarding

those thoughts.

When the intake screening is done, the nurse or paramedic

places the screening form in a dedicated place for the provider to

find, and the inmate moves to the booking process. If the intake

1 The medical provider—an employee of NaphCare and not the Fulton

County Jail—is typically a nurse practitioner or physician’s assistant in charge

of overseeing NaphCare’s provision of medical services.

2 Travis Williams was an employee of NaphCare, as was medical provider

David Didier.

3 The same records also indicate that May was diagnosed with substance-in-

duced psychotic disorder.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 6 of 51

6 Opinion of the Court 22-10441

screening reveals anything abnormal, the intake nurse or para-

medic reviews it with the provider. At his deposition, Williams

stated that after completing the intake screening, he took the form

to let the provider know about May’s suicidal ideations and poten-

tial drug use. On the way, Williams stated that he stopped at the

booking desk and told them that May had thoughts of suicide and

self-harm.4 He then testified that he told the medical provider on

duty, Didier, that May had come in from Grady with methadone

use disorder and substance-induced psychotic disorder, that he

voiced thoughts of suicide, and that he was possibly detoxing. 5

After Williams concluded May’s intake screening, the record

reveals little about what happened to May. The intake screening

took place around 9:00 AM, and then May was sent to booking.

Before booking could be concluded and May could be dressed out

and housed elsewhere in the jail, he needed to have a full medical

screening, also known as a receiving screening. Sergeant Myron

Bush, the intake supervisor from 7 AM–3 PM on September 11, re-

ported that, at some time during the booking process, May dis-

played erratic behavior and signs of mental illness, claiming that

people were watching him. Bush made the decision to place May

in holding cell 172 because it was near medical and medical would

4 Williams did not remember who he spoke with at the booking desk. Re-

gardless, it is undisputed that, whomever he told, that information was never

passed along to the other Fulton County Jail officers working that day.

5 According to Didier’s deposition testimony, he does not recall Williams in-

forming him that May was suicidal and detoxing.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 7 of 51

22-10441 Opinion of the Court 7

be able to observe May. The record shows that May was placed in

the holding cell by noon at the latest. Bush also reported that May

beat on the glass on the door of the holding cell a few times

throughout the day and took several minutes to comply with com-

mands. Bush decided to “fast track” May and get him through

medical screening as quickly as possible. He informed Sergeant Ja-

millah Saadiq, the incoming intake supervisor, that May was to be

fast tracked. Lieutenant Derrick Paige, Direct Action Response

Team (“DART”) commander and unit manager over the intake

area on September 11, 2018, also recalled that prior to May’s alter-

cation with the Officers, he observed May being combative and

banging on the glass on the door to the holding cell. Paige in-

structed May to put his shirt back on, and May complied, but he

continued to yell and curse at everyone and bang on the door as

people walked by.

NaphCare records show that May’s vitals were taken at

10:46 AM, and that someone attempted to take his vitals at

3:29 PM, but that attempt was not successful. Those records also

show that NaphCare ran a drug screening test on May, and that, at

the latest, the results of that test were available by 12:55 PM on

September 11, 2018. 6 The results show that May was positive for

6 The lab report indicates that the results were last updated at 11:55 AM CDT.

This would be 12:55 PM Eastern time, which is the time zone in Atlanta. This

does not indicate when the results were first available, but it does show that

by 1 PM at the latest—hours before the incident at issue here—NaphCare

knew or should have known that May tested positive for drugs.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 8 of 51

8 Opinion of the Court 22-10441

amphetamines, ecstasy, and methamphetamine. The record does

not indicate that May was ever treated for the drugs or that his su-

icidal thoughts were monitored while he was in the holding cell.

The parties do not dispute the point that none of the officers in-

volved were aware that May was suicidal or potentially detoxing.

C.

Sergeant Jamillah Saadiq, the intake supervisor on the after-

noon of September 11, 2018, first encountered May when she

walked through the intake area and saw him naked in the holding

cell. 7 She asked May to put his clothes on and went to get assis-

tance to see if they could get May’s clothes on and get him through

the rest of the intake process.

She requested assistance from DART Officer Aaron Cook.8

Cook, along with Officers Omar Jackson and Jamel Goodwine, ar-

rived and noticed May naked and masturbating in the cell9—in

7 She worked the 3 PM–11 PM shift and took over from Sergeant Myron Bush,

who was the intake supervisor for the previous shift.

8 Direct Action Response Team, or DART, members were solely assigned to

DART and were not stationed at any specific location within the Fulton

County Jail. Instead, they provided facility patrol, removed contraband from

inmates’ cells during shakedowns, assisted with floor operations when needed,

responded to emergencies, and engaged inmates if an inmate became com-

bative. DART members received additional training, such as tactical school,

beyond what a floor officer normally received.

9 Officers Jackson and Goodwine did not recall seeing May masturbating, but

did recall seeing him naked in the cell.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 9 of 51

22-10441 Opinion of the Court 9

violation of both jail policy and state law. Cook instructed May to

get dressed. Cook then asked for the door to cell 172 to be opened

while he continued to give loud verbal commands to May to back

up and then get face down on the ground. May responded by say-

ing something along the lines of “I ain’t doing that shit,” and took

an aggressive stance—clenched fists and separated feet—in front of

the cell door. At this point, Cook removed his county-issued taser

and gave another loud verbal command to get on the ground; May

still did not comply. May, still in an aggressive stance, then stepped

toward Officer Cook.10 All three officers testified that, at that mo-

ment, they believed May represented a threat to them. Cook then

deployed his taser, striking May in the back.11 May fell to the

ground, but almost immediately got back up and charged at the

officers while screaming, kicking, and punching. Cook twice at-

tempted to send another charge through the taser to incapacitate

May but, according to the taser logs, these additional attempts had

no potential for effectiveness.

By now, other officers had joined to help get May under con-

trol. Officer Jackson, assisted by Officers Goodwine and Jason

10 Appellants argue that the Officers’ testimony that May stepped toward

Cook is not credible and that the Officers’ depositions contradict the state-

ments they gave immediately after the incident. We address this argument

infra part III.A.1.

11 The taser log shows that Cook’s taser was deployed at 3:49.22 PM and that

the charge was partially successful for the first two seconds, but then the con-

nection was lost.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 10 of 51

10 Opinion of the Court 22-10441

Roache, attempted to restrain May’s legs, but May continued to

kick. To gain compliance, Officer Jackson stunned May’s left leg

with his taser, which allowed him to cross May’s legs at the an-

kles. 12 Officer William Whitaker observed May kicking at the

other officers and, believing him to be an immediate threat, de-

ployed his taser; the taser had no effect on May. 13 Officer Whita-

ker attempted to drive stun May with his taser three times; these

attempts may have been successful.14 Believing the stuns to be in-

effective, and because May was still being combative, refusing to

get down, and trying to exit the cell, Whitaker pepper-sprayed May

in the face.

After Officer Whitaker deployed the pepper spray, Officer

Roache took May to the ground using a tactical maneuver. With

the help of Officers Cook, Jackson, and Goodwine, Officer Roache

successfully placed leg irons on May.15 May continued to punch at

Officer Roache. Officer Kenesia Strowder, who noticed her team-

mates struggling with May while she conducted crowd control,

stepped in to help and attempted to handcuff May. May continued

12 The taser log shows that Jackson’s taser was used to stun May at

3:50.11 PM.

13 According to the log, Officer Whitaker deployed his taser at 3:50.18 PM.

14 Of the three attempts to stun May, the taser log indicates that the first had

no potential for effectiveness. The second and third attempts to stun May

might have been successful.

15 This was the only time Officer Goodwine made contact with May.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 11 of 51

22-10441 Opinion of the Court 11

to resist and grabbed Strowder’s handcuffs; Strowder gave May

verbal commands to drop the cuffs. When May did not comply,

Strowder struck him with a closed fist four times—once in each of

the face, arm, hand, and back. Officer Jermaine Copeland then ap-

plied handcuffs to May. The handcuffs were transferred to waist

chains as May continued to kick his legs. Officer Guito Delacruz

put a spit mask over May’s face after seeing him spit.

With May restrained, Officers Cook, Jackson, Whitaker, and

Roache placed May in a restraint chair16 and moved him to the

showers for decontamination, as is protocol after using pepper

spray. 17 The Officers placed May in the restraint chair with the

following restraints applied: handcuffs, waist chain, leg restraints,

and the shoulder straps from the chair itself. May continued his

aggressive and combative behavior. The Officers removed May’s

spit mask and decontaminated his face with cool water from a hose.

16 There is much debate in this case as to whether the chair used to transport

May from the holding cell to the shower and then to the property room was a

restraint chair or a transport chair. The difference in the type of chair used is

not relevant for purposes of this appeal. For consistency, we refer to it as a

restraint chair because this case comes to us on a motion for summary judg-

ment, and Appellants classified it as a restraint chair.

17 According to their depositions, Officers Copeland, Goodwine, and Dela-

cruz never touched the restraint chair. Following the incident, Officers Cook,

Jackson, Whitaker, Roache, and Delacruz, as well as Lieutenant Derrick Paige,

were disciplined for improperly applying the restraint chair’s wrist restraints

and failing to remove the waist chain and leg irons in a timely manner; the

Officers testified during the Fulton County Sheriff’s Office of Professional Ser-

vices investigation that they used a transport chair and not a restraint chair.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 12 of 51

12 Opinion of the Court 22-10441

After they removed the leg restraints, the Officers attempted to

dress May, who continued to kick and resist. As they attempted to

dress May, Officers Whitaker and Roache each delivered one

closed-hand strike to May’s legs to gain compliance. Once they

dressed May, the Officers reapplied his restraints, including the spit

mask, and Officer Whitaker wheeled May into the property room

for examination by the medical staff.

Officer Cook left the property room to get Didier, the med-

ical provider, who was required to perform an evaluation after a

use of force incident. Shortly thereafter, Didier arrived in the prop-

erty room. Didier conducted a visual evaluation of May, who was

awake and not in distress. Didier then left the area to gather equip-

ment. As Didier performed his assessment, DART Commander

and Intake Unit Manager Lieutenant Derrick Page arrived. Be-

cause May no longer appeared to be resisting, Lieutenant Paige in-

structed the officers to remove the handcuffs and place May’s

hands in the chair restraints, which they began to do.

At some point the officers realized May had become unre-

sponsive. Approximately fifteen seconds after Didier left, Officer

Whitaker lifted May’s spit mask. May’s legs and head moved at

that time. Approximately ten seconds later, Whitaker rocked the

chair up and down slightly; May did not move. Approximately ten

seconds after that, Whitaker dropped the chair into resting posi-

tion, which jolted May but did not cause any reaction. The officers

began to look at May and touch him, but May did not respond.

Lieutenant Paige directed the officers to get May out of the chair

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 13 of 51

22-10441 Opinion of the Court 13

and start lifesaving measures. The officers began to remove May’s

restraints and move him to the floor, which took about two

minutes. During this time, May remained unresponsive in the

chair.

Officer Roache gave May chest compressions while Officer

Copeland performed rescue breathing. For about the next half

hour, various officers, medical staff, and Atlanta Fire Department

personnel—who arrived on scene approximately 15 minutes after

May became unresponsive—attempted to resuscitate May, who

died on the floor of the property room. According to the medical

examiner’s report, May died of sudden cardiovascular collapse due

to probable excited delirium with physical restraint use and acute

methamphetamine intoxication; the manner of death is listed as

undetermined.

D.

On May 29, 2019, Appellants 18 brought this lawsuit in the

United States District Court for the Northern District of Georgia

alleging the following claims, all stemming from May’s death:

1. Excessive force and deliberate indifference claims under 42

U.S.C. § 1983 against Jason Roache, Derrick Paige, Jamel

Goodwine, William Whitaker, Aaron Cook, Omar Jackson,

18 Appellants are May’s estate; April Myrick, the legal guardian and grand-

mother of two of May’s children, Za’Kobe and Jordan Rickerson; and Sheena

Pettigrew, the mother and natural guardian of Elijah Warren, another of

May’s children.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 14 of 51

14 Opinion of the Court 22-10441

Jermaine Copeland, Kenesia Strowder, and Guito Delacruz

(collectively, the “Officers”);19

2. Supervisory liability under 42 U.S.C. § 1983 against Fulton

County, Georgia and Sheriff Theodore Jackson for unconsti-

tutional policies that led to May’s death; 20

3. Common law and statutory failure to warn claims against

Axon Enterprise; 21

4. Discrimination under the Americans with Disabilities Act

(the “ADA”) and Rehabilitation Act against Sheriff Jackson

in his official capacity and against Fulton County, Georgia;22

19 Jasmine Rowe, Jamillah Saadiq, Mary Stovall, and Jordan Wilcher were

originally listed as defendants on the excessive force and deliberate indiffer-

ence claims, but the parties jointly stipulated to dismiss all claims against those

officers under Federal Rule of Civil Procedure 41(a)(1)(A)(ii). Appellants

moved the District Court to add Myron Bush as a defendant to the excessive

force and deliberate indifference claims, but the District Court denied that re-

quest.

20 Fulton County moved the District Court to dismiss all the claims against it.

The District Court granted that motion. Appellants do not appeal the dismis-

sal of claims as to Fulton County, so that claim is not before this Court on

appeal.

21 The parties stipulated to the dismissal of all claims against Axon Enterprise,

Inc. pursuant to Rule 41(a)(1)(A)(ii).

22 Appellants do not reference their ADA or Rehabilitation Act claims in their

appeal, so this issue is not properly before this Court. See Access Now, Inc. v.

Sw. Airlines Co., 385 F.3d 1324, 1330 (11th Cir. 2004) (“[A] legal claim or

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 15 of 51

22-10441 Opinion of the Court 15

5. Medical negligence under Georgia law against NaphCare,

Inc. and paramedic Travis Williams. 23

Sheriff Jackson moved the District Court to dismiss the

claims against him. The District Court granted that motion. Spe-

cifically, the Court found that, as an arm of the State, Sheriff Jack-

son was not a person within the meaning of § 1983. As such, the

Court held that it lacked jurisdiction to entertain the § 1983 claims

against Sheriff Jackson (in his official capacity) because he was en-

titled to Eleventh Amendment immunity. With respect to Sheriff

Jackson in his individual capacity, the District Court held that he

was entitled to qualified immunity on the § 1983 claims of supervi-

sory liability based on a failure to train and inadequate policies be-

cause Appellants (1) failed to demonstrate that qualified immunity

was not appropriate on the failure to train claims; (2) did not plau-

sibly allege a history of widespread abuse that would have placed

Sheriff Jackson on notice of a need for correction; (3) had not plau-

sibly alleged that a causal connection existed between Sheriff Jack-

son and the alleged constitutional violation; (4) had not plausibly

pleaded that the Sheriff directed the deputies to act unlawfully or

knew that they would do so and failed to stop them; and (5) had

not shown that it was clearly established that the Sheriff had an ob-

ligation to disregard the medical expertise of the contractors he

argument that has not been briefed before this court is deemed abandoned

and its merits will not be addressed.”).

23 Appellants moved the District Court to add David Didier as a defendant to

the medical negligence claim. The Court also denied that request.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 16 of 51

16 Opinion of the Court 22-10441

hired to provide healthcare. The District Court dismissed the ADA

and Rehabilitation Act claims because Appellants did not success-

fully allege that Sheriff Jackson (or any Fulton County Jail em-

ployee) was aware of May’s disability, so he could not have discrim-

inated against him based on that disability.

Following discovery, the Fulton County Officers moved the

District Court for summary judgment on the claims against them.

The District Court granted that motion on qualified immunity

grounds. The Court held that, under the objective reasonableness

standard, the Officers did not subject May to objectively unreason-

able force. May violated both jail policy and state law, refused to

put on his clothes, and ignored instructions. Once May stepped

towards Officer Cook, Cook deployed his taser. This was a reason-

able amount of force in the Court’s view. According to the Court,

“the crucial fact underlying this analysis is May’s step toward the

Officers. . . . This step . . . indicates that a reasonable officer under

the same circumstances could have determined that May repre-

sented a safety or flight risk.” Order, Doc. 240 at 17.

The District Court similarly found all of the following to be

objectively reasonable uses of force, given May’s continued re-

sistance to the Officers and noncompliance with their commands:

the subsequent taser deployments; Officer Whitaker’s use of the

pepper spray; Officer Roache’s takedown of May; Officer

Strowder’s closed-fist strikes; Officer Delacruz’s use of a spit mask;

and the use of a restraint chair with additional restraints by Officers

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 17 of 51

22-10441 Opinion of the Court 17

Paige, Delacruz, Whitaker, Roache, and Jackson.24 The District

Court also found that Appellants had not provided specific case law

that would indicate that the alleged constitutional violations were

clearly established, instead painting the collective use of force by all

Officers as collectively unreasonable. According to the Court, the

actions of the Officers “do not represent such shocking conduct

that their unconstitutionality can be inferred by anything less than

clear precedent.” Order, Doc. 240 at 24. The Officers were thus

entitled to qualified immunity on the excessive force claim.

The District Court also granted the Officers summary judg-

ment on the deliberate indifference claim. Even if Appellants had

successfully met the first element of such a claim—showing a sub-

stantial risk of serious harm—the Court held that they did not show

a genuine issue of material fact as to the second—deliberate indif-

ference to that risk. This was because the video footage “dispels

any notion that the Officer Defendants responded unreasonably to

May’s conditions.” Id. at 26. Because the Officers got May medical

assistance and reacted when he became unconscious, Appellants

failed to show that the Officers were deliberately indifferent.

Like the Officers, NaphCare and Travis Williams jointly

moved the District Court for summary judgment as to the medical

negligence claims against them. As it did with the Officers, the

24 On appeal, Appellants make arguments regarding only three of these al-

leged uses of excessive force: Officer Cook’s use of the taser, Officer

Strowder’s closed-fist strikes, and the use of illegal restraints by Officers Dela-

cruz, Cook, Whitaker, Roache, and Jackson.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 18 of 51

18 Opinion of the Court 22-10441

District Court granted their motion. The District Court focused

the bulk of its order on the third element of a medical malpractice

claim under Georgia law—proximate cause. Importantly, the

Court noted: “Both of the experts concede in their conclusions that

an intervening event—May’s altercation with the Officer Defend-

ants—occurred between the actions of the NaphCare Defendants

and May’s death.” Id. at 30. According to the Court, “too many

actions and choices made by May and the Officers [stood] in be-

tween the decisions of the NaphCare Defendants and May’s death

to deem their failure to sedate May the proximate cause of the

events.” Id.

E.

In their timely appeal, Appellants largely reassert the same

arguments as below. They argue that Sheriff Jackson is not entitled

to Eleventh Amendment immunity in his official capacity, that he

is a person within the meaning of § 1983, that he is not entitled to

qualified immunity in his individual capacity, and that he can be

held liable under a supervisory liability theory in both his official

and individual capacities. They further argue that Williams and

NaphCare are not entitled to summary judgment because they

have shown proximate cause between May’s death and the lack of

medical care he received, as required by Georgia law. Finally, Ap-

pellants argue that the Officers are not entitled to summary judg-

ment on the excessive force and deliberate indifference claims be-

cause (1) the amount of force used on May was not objectively rea-

sonable; (2) the Officers’ depositions are not credible; and (3) none

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 19 of 51

22-10441 Opinion of the Court 19

of the Officers rendered first aid, offered to assist, or took May di-

rectly to receive medical care. We address each of these claims in

turn.

II.

To begin, we address Appellants’ argument that the District

Court erred in granting Sheriff Jackson’s motion to dismiss. We

review a district court’s ruling on a motion to dismiss for lack of

subject matter jurisdiction under Federal Rule of Civil Procedure

12(b)(1) de novo. Smith v. United States, 7 F.4th 963, 973 (11th Cir.

2021). Likewise, we review a district court’s grant of a motion to

dismiss for failure to state a claim under Federal Rule of Civil Pro-

cedure 12(b)(6) de novo. McGroarty v. Swearingen, 977 F.3d 1302,

1306 (11th Cir. 2020). We accept the factual allegations in the com-

plaint as true and construe them in the light most favorable to the

plaintiff. Id. We may dismiss a complaint pursuant to Rule 12(b)(6)

on a dispositive issue of law. Patel v. Specialized Loan Servicing, LLC.,

904 F.3d 1314, 1321 (11th Cir. 2018) (citing Marshall Cnty. Bd. of

Educ. v. Marshall Cnty. Gas Dist., 992 F.3d 1171, 1174 (11th Cir.

1993)).

A.

“An assertion of Eleventh Amendment immunity essentially

challenges a court’s subject matter jurisdiction.” Seaborn v. Fla.

Dep’t of Corrs., 143 F.3d 1405, 1407 (11th Cir. 1998). The Eleventh

Amendment bars suit against a state by its own citizens and by cit-

izens of another state—even if the state is not a named party to the

action. Edelman v. Jordan, 415 U.S. 651, 662–63, 94 S. Ct. 1347, 1355

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 20 of 51

20 Opinion of the Court 22-10441

(1974). The law is “well-settled that Eleventh Amendment immun-

ity bars suits brought in federal court when the State itself is sued

and when an ‘arm of the [s]tate’ is sued.” Manders v. Lee, 338 F.3d

1304, 1308 (11th Cir. 2003) (en banc) (internal citation omitted).

Whether Sheriff Jackson is entitled to Eleventh Amendment im-

munity thus turns on whether he was acting as an arm of the state,

which in turn depends on “the particular function in which [he]

was engaged when taking the actions out of which liability is as-

serted to arise.” Id. Taken together, the Appellants’ allegations

point to Sheriff Jackson engaging in the following “particular func-

tions”: creating and implementing force policy; hiring, training,

and disciplining officers; and providing medical care to detainees.

We consider four factors in determining whether an entity

is an “arm of the state”: (1) how state law defines the entity; (2)

what degree of control the state maintains over the entity; (3)

where the entity derives its funds; and (4) who is responsible for

judgments against the entity. Id. at 1309. Whether Sheriff Jackson

is an “arm of the state” for Eleventh Amendment purposes is a

question of federal law, but that federal question can only be an-

swered by considering provisions of state law. Id.

1.

Our seminal case on whether a defendant is an “arm of the

state” for Eleventh Amendment immunity purposes, Manders v.

Lee, also deals with a county sheriff in Georgia. It also addresses

the sheriff’s “force policy at the jail and the training and disciplining

of his deputies in that regard.” Manders, 338 F.3d at 1307–09. As

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 21 of 51

22-10441 Opinion of the Court 21

such, with respect to the first two “particular functions” Sheriff

Jackson allegedly performed—implementing force policy and

training and disciplining his officers—we need only look to Manders

because it deals with the law of the same state, the same type of

actor, and the same specific functions. Under Manders, Sheriff Jack-

son acted as an arm of the state with respect to his force policy and

training and disciplining his officers, and he is entitled to Eleventh

Amendment immunity. See id. at 1328.

In Manders, we held that because, under state law, “the sher-

iff wears a ‘state hat’ when he creates and implements force policy

in the jail,” the first factor weighed heavily in favor of immunity.

Id. at 1319. We also found that, as to the second factor, “only the

State possesses control over sheriffs’ force policy and that control

is direct and significant in many areas, including training and disci-

pline.” Id. at 1320. The counties, on the other hand, have no au-

thority or control over force policy. Id. at 1322. The third factor—

who funds the entity—also tilted in favor of immunity. Though

the county bore the major burden of funding sheriffs’ offices and

jails, it did so because of a state mandate. Id. at 1323. Ultimately,

“[p]ayment of Sheriff [Jackson’s] budget, when required by the

State, does not establish any control by [Fulton] County over his

force policy at the jail or how he trains and disciplines his [offic-

ers].” Id. at 1324. As far as who is responsible for paying judgments

against the entity, under Georgia law, neither the State nor the

county were required to pay an adverse judgment against the sher-

iff—but the funds of both were implicated by such a judgment. Id.

at 1329. We did not hold that this final factor pointed towards

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 22 of 51

22 Opinion of the Court 22-10441

immunity, saying only that “[a]t a minimum, this final factor does

not defeat [it].” Id.

In sum, Sheriff Jackson acted as an “arm of the state” with

respect to force policy and training and disciplining officers. He is

entitled to Eleventh Amendment immunity.

2.

The other specific function Sheriff Jackson performed was

providing medical care. Manders does not speak directly to

whether Sheriff Jackson acted as an “arm of the state” with respect

to the provision of medical care, but its discussion of the structure

of the sheriff’s office, generally speaking, is still instructive. The

State still controls, trains, and disciplines the sheriff’s office. Our

discussion of the third and fourth Manders factors apply with equal

force here. The third factor tilts in favor of immunity because

some state money goes to the sheriff’s office, and a state mandate

requires the county to fund the sheriff’s budget but prohibits the

county from dictating how the sheriff spends those funds. Id. at

1323. The fourth factor does not point in either direction—coun-

ties are not responsible for adverse judgments against the sheriff in

his official capacity, and no state law requires the state to pay those

judgments either. Id. at 1324–28.

Manders’s discussion of the first and second factors is not di-

rectly applicable to the provision of medical care. We address them

now. With respect to the second factor, control, Georgia courts

have interpreted O.C.G.A. § 42-4-4(a)(2) as “giving sheriffs exclu-

sive control vis-à-vis the county over choosing vendors for medical

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 23 of 51

22-10441 Opinion of the Court 23

care.”25 Lake v. Skelton, 840 F.3d 1334, 1339–40 (11th Cir. 2016).

Specifically, the Georgia Supreme Court held:

A sheriff is an elected, independent constitutional of-

ficer who is not an employee of the [county] board

and is not, therefore, subject to the control of the

board. The sheriff’s duties include a duty to provide

medical care to prisoners placed in his custody. To

fulfill that duty, the sheriff is necessarily vested with

authority to enter into contracts with medical care

providers. The board cannot control the sheriff’s

choice.

Bd. of Comm’rs of Spalding Cnty. v. Stewart, 668 S.E.2d 644, 645 (Ga.

2008) (internal citations omitted). This supports the conclusion

that a sheriff acts as an “arm of the state” when he provides medical

care because the county has no control over the way such care is

provided.

Finally, we consider the first factor—how Georgia state law

defines the entity. Manders clearly stated that in addition to per-

forming common law duties to enforce the law and preserve the

peace on behalf of the State, the sheriff’s office “perform[s] specific

statutory duties, directly assigned by the State.” Manders, 338 F.3d

at 1319 (emphasis added). One such statutory duty assigned by the

25 O.C.G.A. § 42-4-4(a)(2) reads, in pertinent part: “It shall be the duty of the

sheriff . . . [t]o furnish persons confined in the jail with medical aid, heat, and

blankets, to be reimbursed if necessary from the county treasury, for neglect

of which he shall be liable to suffer the penalty prescribed in this Code sec-

tion.”

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 24 of 51

24 Opinion of the Court 22-10441

state is furnishing medical aid. O.C.G.A. § 42-4-4(a)(2) (“It shall be

the duty of the sheriff [t]o furnish persons confined in the jail with

medical aid . . . .” (emphasis added)).

Further, in Lake v. Skelton we discussed O.C.G.A. § 42-5-2,

according to which it is “the responsibility of the governmental

unit, subdivision, or agency having the physical custody of an in-

mate to maintain the inmate, furnishing him food, clothing, and

any needed medical and hospital attention.” 840 F.3d at 1340 (quot-

ing O.C.G.A. § 42-5-2). We stated that Georgia law clearly required

the sheriff to “take . . . custody of the jail and the bodies of such per-

sons as are confined therein.” Id. (quoting O.C.G.A. § 42-4-4(a)(1)).

This meant that the sheriff, not the county, was the governmental

unit with custody of the inmates. Id. Thus “Section 42-5-2 sup-

port[ed the] conclusion that Georgia imposes food-service respon-

sibilities directly on the sheriff as part of his custodial duties.” Id.

If, under § 42-5-2, the sheriff wears a “state hat” with respect to

food-service responsibilities, that same provision must lead to the

conclusion that the sheriff wears a “state hat” with respect to the

provision of medical care as well. Indeed, our holding in Lake that

the sheriff was an arm of the state with respect to providing food

relied at least in part on the idea that, under Georgia law, the sheriff

was an arm of the state with respect to providing medical care. See

id. at 1342.

As in Manders and Lake, the first three factors here weigh in

favor of immunity. The fourth factor does not defeat it. Alto-

gether, we conclude that Sheriff Jackson acted as an “arm of the

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 25 of 51

22-10441 Opinion of the Court 25

state” and is entitled to Eleventh Amendment immunity with re-

spect to the particular function of providing medical care. The Dis-

trict Court correctly dismissed the claims against Sheriff Jackson in

his official capacity.

B.

We next turn to Appellants’ argument that the District

Court improperly dismissed their claims against Sheriff Jackson in

his individual capacity for supervisory liability under 42 U.S.C.

§ 1983. A complaint is subject to dismissal under Rule 12(b)(6)

when its factual allegations, on their face, establish an affirmative

defense that bars recovery. Ingram v. Kubik, 30 F.4th 1241, 1250

(11th Cir. 2022). That means that if a defendant raises the affirma-

tive defense of qualified immunity, the district court must dismiss

any claims that do not allege a violation of clearly established law.

Id.

Qualified immunity “shields a government official from lia-

bility unless he violates ‘clearly established statutory or constitu-

tional rights of which a reasonable person would have known.’”

Piazza v. Jefferson Cnty., 923 F.3d 947, 951 (11th Cir. 2019) (quoting

Foy v. Holston, 94 F.3d 1528, 1532 (11th Cir. 1996)). The defendant

asserting the qualified immunity defense bears the initial burden of

showing that he or she was acting within his or her discretionary

authority.26 Id. at 951. After the defendant makes this showing,

26 In the instant case, the parties do not dispute that Sheriff Jackson was acting

within his discretionary authority.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 26 of 51

26 Opinion of the Court 22-10441

the burden shifts to the plaintiff to show that qualified immunity is

not appropriate. Lee v. Ferraro, 284 F.3d 1188, 1194 (11th Cir. 2002).

The Supreme Court has established a two-part test for eval-

uating a claim of qualified immunity. We must ask (1) whether,

taken in the light most favorable to the injured party, the facts al-

leged show the officer’s conduct violated a constitutional right; and

(2) if the right violated under those alleged facts was clearly estab-

lished at the time of the alleged violation. Ashcroft v. al-Kidd, 563

U.S. 731, 735, 131 S. Ct. 2074, 2080 (2011). Courts have discretion

to consider these two questions in whichever order they find ap-

propriate in light of the particular case. Pearson v. Callahan, 555 U.S.

223, 236, 129 S. Ct. 808, 818 (2009). For a plaintiff to overcome a

claim of qualified immunity, both questions must be answered af-

firmatively. If the answer to one is “no,” the court need not reach

the other.

Turning to Appellants’ supervisory liability claim, we begin

by acknowledging that “the standard by which a supervisor is held

liable in [his or her] individual capacity for the actions of a subordi-

nate is extremely rigorous.” Christmas v. Harris Cnty., 51 F.4th 1348,

1355 (11th Cir. 2022) (quoting Braddy v. Fla. Dep’t of Lab. & Emp’t.

Sec., 133 F.3d 797, 802 (11th Cir. 1998)). It is well established in this

Circuit that “supervisory officials are not liable under § 1983 for the

unconstitutional acts of their subordinates on the basis of re-

spondeat superior or vicarious liability.” Cotton v. Jenne, 326 F.3d

1352, 1360 (11th Cir. 2003) (quoting Hartley v. Parnell, 193 F.3d 1263,

1269 (11th Cir. 1999)). “Instead, supervisory liability under § 1983

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 27 of 51

22-10441 Opinion of the Court 27

occurs either when the supervisor personally participates in the al-

leged unconstitutional conduct or when there is a causal connec-

tion between the actions of a supervising official and the alleged

constitutional deprivation.” Id. at 1360 (citing Gonzalez v. Reno, 325

F.3d 1228, 1234 (11th Cir. 2003)).

Here, Appellants do not allege that Sheriff Jackson person-

ally participated in the alleged unconstitutional conduct, so they

must allege facts that show a causal connection between his actions

and the alleged constitutional deprivation. Appellants can meet

that extremely rigorous challenge in several ways. A causal con-

nection may be established when:

(1) a history of widespread abuse puts the responsible

supervisor on notice of the need to correct the al-

leged deprivation, and he or she fails to do so; (2) a

supervisor’s custom or policy results in deliberate in-

difference to constitutional rights; or (3) facts support

an inference that the supervisor directed subordinates

to act unlawfully or knew that subordinates would act

unlawfully and failed to stop them from doing so.

Mathews v. Crosby, 480 F.3d 1265, 1270 (11th Cir. 2007) (internal quo-

tation marks and citations omitted).

The complaint does not allege that Sheriff Jackson person-

ally directed the Officers to act unlawfully or that he knew they

would do so and failed to stop them. That leaves options one and

two. With respect to the first, “[t]he deprivations that constitute

widespread abuse sufficient to notify the supervising official must

be obvious, flagrant, rampant and of continued duration, rather

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 28 of 51

28 Opinion of the Court 22-10441

than isolated occurrences.” Christmas, 51 F.4th at 1355 (quoting

Keith v. DeKalb Cnty., 749 F.3d 1034, 1048 (11th Cir. 2014)). Any at-

tempt by Appellants to demonstrate a causal connection between

Sheriff Jackson and the alleged constitutional deprivation based on

such a history of widespread abuse must fail. There is simply noth-

ing alleged in the complaint demonstrating that Sheriff Jackson

would have had notice of the alleged widespread abuse.

Three allegations in the complaint address alleged obvious,

flagrant, rampant, and continued abuse. First, according to the

complaint, “Fulton County, GA has paid numerous settlements and

judgments based on the unconstitutional actions of the Fulton

Sheriff and Sheriff deputies.” This does not come close to showing

a widespread history of abuse. There is no indication that the judg-

ments and settlements were for the same types of allegedly uncon-

stitutional actions. There is no indication that these incidents were

of continued duration, as opposed to isolated incidents, with one

occurring every few years. See Clark v. Evans, 840 F.2d 876, 885 (11th

Cir. 1988) (“[I]t is clear that four cases in four years would have been

insufficient to put [the Sheriff] on notice . . . .”).

Second, the complaint alleges that Sheriff Jackson permitted

a custom of excessive force by permitting unwarranted use of

tasers on inmates, “as evidenced by jail staff and inmates hearing

deputies use the term ‘Taser Tuesday’ on the day Mr. May was

TASED at the jail.” But that statement by itself does not indicate

that such a policy or custom existed. There is no indication in the

complaint of even a single other allegedly unwarranted tasing.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 29 of 51

22-10441 Opinion of the Court 29

Finally, the complaint alleges that Sheriff Jackson’s deliberate

indifference through his “failure or failures to train as alleged” are

“failures of policy, widespread practice, and/or custom.” But

again, the complaint does not allege any facts outside of the inci-

dent with May, and an isolated incident does not give sufficient no-

tice of a failure to train. The abuses must be of a continuous na-

ture.

The last remaining avenue for establishing a causal connec-

tion is to show a custom or policy that resulted in deliberate indif-

ference to May’s constitutional rights. Appellants can also allege

“that the absence of a policy led to a violation of constitutional

rights.” Piazza, 923 F.3d at 957 (citing Rivas v. Freeman, 940 F.2d

1491, 1495 (11th Cir. 1991)). A policy is a “decision that is officially

adopted by the [law enforcement agency], or created by an official

of such rank that he or she could be said to be acting on behalf of

the [law enforcement agency].” Christmas, 51 F.4th at 1356 (quot-

ing Sewell v. Town of Lake Hamilton, 117 F.3d 488, 489 (11th Cir.

1997)). “A custom is an unwritten practice that is applied consist-

ently enough to have the same effect as a policy with the force of

law.” Id. (quoting Goebert v. Lee Cnty., 510 F.3d 1312, 1332 (11th

Cir. 2007)). “Demonstrating a policy or custom requires showing

a persistent and wide-spread practice.” Goebert, 510 F.3d at 1332

(quoting Depew v. City of St. Mary’s, 787 F.2d 1496, 1499 (11th Cir.

1986) (alterations adopted)). Importantly, the unconstitutional act

“must have been carried out pursuant to the alleged policy or cus-

tom.” Christmas, 51 F.4th at 1356 (internal quotation marks and

citations omitted).

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 30 of 51

30 Opinion of the Court 22-10441

But proving that a policy (or absence thereof) or custom

caused a constitutional harm would require Appellants to point to

multiple incidents. Piazza, 923 F.3d at 957 (citing Rivas, 940 F.2d at

1495–96); see also Grech v. Clayton Cnty., 335 F.3d 1326, 1330 (11th

Cir. 2003) (en banc) (“Because a county rarely will have an offi-

cially-adopted policy of permitting a particular constitutional vio-

lation, most plaintiffs [ ] must show that the county has a custom

or practice of permitting it and that the [ ] custom or practice is the

moving force behind the constitutional violation.”). “A single inci-

dent of a constitutional violation is insufficient to prove a policy or

custom even when the incident involves several subordinates.” Pi-

azza, 923 F.3d at 957 (alteration adopted) (quoting Craig v. Floyd

Cnty., 643 F.3d 1306, 1312 (11th Cir. 2011)). Under § 1983, proof of

a single incident of unconstitutional activity is only sufficient to im-

pose liability on a governmental entity as part of a policy or custom

if the challenged policy itself is unconstitutional. Ireland v. Prum-

mell, 53 F.4th 1274, 1289 (11th Cir. 2022) (citing City of Oklahoma

City v. Tuttle, 471 U.S. 808, 823–24, 105 S. Ct. 2427, 2436 (1985) (plu-

rality opinion)); see also Craig v. Floyd Cnty., 643 F.3d 1306, 1311

(11th Cir. 2011) (“In the absences of a series of constitutional viola-

tions from which deliberate indifference can be inferred, the plain-

tiff must show that the policy itself is unconstitutional.” (cleaned

up)).

The complaint focuses only on May’s experience at the Ful-

ton County Jail—it does not point to other instances of excessive

force or deliberate indifference aside from noting that Fulton

County has paid judgments and settlements for unknown claims in

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 31 of 51

22-10441 Opinion of the Court 31

the past. Because Appellants’ complaint focuses solely on May’s

experience—a single incident of allegedly unconstitutional activ-

ity—and because none of the policies or customs it alleges are un-

constitutional on their own, the complaint does not, as a matter of

law, state a claim against Sheriff Jackson for supervisory liability.

See Piazza, 923 F.3d at 958.

Because Appellants cannot overcome Sheriff Jackson’s de-

fense of qualified immunity, the District Court correctly granted

his motion to dismiss.

III.

Next, we address Appellant’s argument that the District

Court improperly granted summary judgment to the Officers for

the 42 U.S.C. § 1983 excessive force and deliberate indifference

claims against them. We review a district court’s grant of sum-

mary judgment based on qualified immunity de novo. Stephens v.

DeGiovanni, 852 F.3d 1298, 1313 (11th Cir. 2017). Summary judg-

ment is proper where the evidence “shows that there is no genuine

dispute as to any material fact and the movant is entitled to judg-

ment as a matter of law.” Fed. R. Civ. P. 56(a). At this stage, we

review the evidence, draw all reasonable inferences, and resolve all

doubts in favor of the non-moving party—but only to the extent

supportable by the record. Baxter v. Roberts, 54 F.4th 1241, 1253

(11th Cir. 2022). In cases where a video contradicts the non-

movant’s version of the facts, we accept the video’s depiction in-

stead and view the facts in the light depicted by the video. Id. (quot-

ing Shaw v. City of Selma, 884 F.3d 1093, 1098 (11th Cir. 2018)). “We

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 32 of 51

32 Opinion of the Court 22-10441

may affirm on any ground supported by the record, regardless of

whether that ground was relied upon or even considered below.”

Waldman v. Conway, 871 F.3d 1283, 1289 (11th Cir. 2017) (per cu-

riam).

The Officers raised the affirmative defense of qualified im-

munity. Qualified immunity shields “government officials per-

forming discretionary functions . . . from liability for civil damages

insofar as their conduct does not violate clearly established statu-

tory or constitutional rights of which a reasonable person would

have known.”27 Harlow v. Fitzgerald, 457 U.S. 800, 818, 102 S. Ct.

2727, 2738 (1982). We have said that qualified immunity “protect[s]

from suit all but the plainly incompetent or one who is knowingly

violating the federal law.” Ferraro, 284 F.3d at 1194 (internal quota-

tion marks and citation omitted).

The same two-part test discussed in part II.B, supra, applies

in the summary judgment context as well: to overcome a defense

of qualified immunity, Appellants must show (1) the Officers vio-

lated a constitutional right and (2) that right was clearly established

at the time of the alleged violation. Piazza, 923 F.3d at 951.

“Clearly established” means that “at the time of the officer’s con-

duct, the law was sufficiently clear that every reasonable official

would understand that what he is doing is unlawful.” District of

Columbia v. Wesby, 138 S. Ct. 577, 589 (2018) (internal quotation

marks and citations omitted). That is, “existing law must have

27 It is undisputed that the Officers were acting in their discretionary capacity.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 33 of 51

22-10441 Opinion of the Court 33

placed the constitutionality of the officer’s conduct ‘beyond de-

bate.’” Id. (quoting al-Kidd, 563 U.S. at 741, 131 S. Ct. at 2083).

Plaintiffs can show that a constitutional right was clearly estab-

lished in three ways: (1) citing case law with indistinguishable facts

that clearly establishes the constitutional right; (2) pointing to a

broad statement of principle within the Constitution, statute, or

case law that clearly establishes the constitutional right; or (3) alleg-

ing conduct so egregious that a constitutional right was clearly vi-

olated, even in the total absence of case law. Lewis v. City of W. Palm

Beach, 561 F.3d 1288, 1291–92 (11th Cir. 2009) (citing Mercado v. City

of Orlando, 407 F.3d 1152, 1159 (11th Cir. 2005)).

A.

Claims alleging excessive force by pretrial detainees are gov-

erned by the Fourteenth Amendment’s Due Process Clause.

Crocker v. Beatty, 995 F.3d 1232, 1246 (11th Cir. 2021). A detainee

must show “that the force purposely or knowingly used against

him was objectively unreasonable.” Kingsley v. Hendrickson, 576

U.S. 389, 397, 135 S. Ct. 2466, 2473 (2015). If an officer used objec-

tively unreasonable force, he or she violated a detainee’s Four-

teenth Amendment rights. This would satisfy the first prong of the

qualified immunity analysis.

Objective reasonableness turns on the “facts and circum-

stances of each particular case.” Id. (quoting Graham v. Connor, 490

U.S. 386, 396, 109 S. Ct. 1865, 1872 (1989)). A court “must make

this determination from the perspective of a reasonable officer on

the scene, including what the officer knew at the time, not with the

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 34 of 51

34 Opinion of the Court 22-10441

20/20 vision of hindsight.” Id. The following non-exhaustive list

of factors bears on the reasonableness of the force used:

the relationship between the need for the use of force

and the amount of force used; the extent of the plain-

tiff’s injury; any effort made by the officer to temper

or to limit the amount of force; the severity of the se-

curity problem at issue; the threat reasonably per-

ceived by the officer; and whether the plaintiff was ac-

tively resisting.

Id. A court also needs to consider the “legitimate interests that

stem from the government’s need to manage the facility in which

the individual is detained, appropriately deferring to policies and

practices that in the judgment of jail officials are needed to preserve

internal order and discipline and to maintain institutional security.”

Id. (internal quotation marks and citation omitted) (alteration

adopted).

We may not examine the actions of a group of defendants

collectively. “[E]ach defendant is entitled to an independent quali-

fied-immunity analysis as it relates to his or her actions and omis-

sions. So we must be careful to evaluate a given defendant’s qual-

ified-immunity claim, considering only the actions and omissions

in which that particular defendant engaged.” Alocer v. Mills, 906

F.3d 944, 951 (11th Cir. 2018).

The only allegedly excessive uses of force addressed by Ap-

pellants in this Court are: (1) Officer Cook’s use of his taser; (2)

Officer Strowder’s closed-fist strikes; and (3) Officers Delacruz,

Cook, Whitaker, Roache, and Jackson’s use of additional restraints.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 35 of 51

22-10441 Opinion of the Court 35

As explained below, the District Court did not err in granting sum-

mary judgment with respect to these claims.

1.

Officer Cook’s use of his taser against May was not objec-

tively unreasonable force and did not violate May’s constitutional

rights when viewed under the Kinglsey factors. Officer Cook ap-

proached May’s cell because May was naked and masturbating in

violation of jail policy and state law. May actively resisted Cook’s

directive for May to put his clothes on. Officer Cook’s interaction

with May stemmed from the need to preserve internal order and

discipline and to maintain institutional security. Officer Cook’s use

of the taser came after several attempts to get May to comply. Of-

ficer Cook reasonably perceived May to be a threat because May

was noncompliant and took an aggressive stance. In fact, all three

officers present at that moment perceived May to be a threat. Fur-

ther, after being tased by Officer Cook, May continued to resist and

became even more combative, indicating that his injuries from the

taser were not severe. Under the Kingsley factors, then, Officer

Cook’s use of his taser was reasonable under the circumstances.

This conclusion also conforms to this Court’s precedent. See Draper

v. Reynolds, 369 F.3d 1270, 1277–78 (11th Cir. 2004) (holding that a

single use of a taser to subdue a hostile, belligerent, and uncooper-

ative suspect was not excessive force).

Appellants’ primary argument is that the Officers’ testimony

that May stepped towards Officer Cook is not credible and that

without that fact, Officer Cook’s initial use of the taser was

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 36 of 51

36 Opinion of the Court 22-10441

unreasonable. They argue that if May had stepped toward Officer

Cook, as several officers stated in their depositions, the taser prong

would not have landed on his lower back. The autopsy report

shows a 1/8 x 1/8 inch blackened abrasion with a central puncture

mark on the lateral right side of May’s lower back, just above the

right buttock. Officer Jackson’s after-incident report and deposi-

tion testimony confirm that this was the taser probe fired by Officer

Cook. Appellants also argue that the Officers’ testimony that May

stepped towards Officer Cook—a crucial fact—is unreliable be-

cause it contradicts the written statements made after the incident,

because none of the Officers were wearing body cameras, and be-

cause the Officers were “likely coached by [their] counsel to fit

[their] testimony within the confines of qualified immunity.”

There may be a question as to whether May stepped toward

Officer Cook. Appellants are correct that none of the officers men-

tioned the alleged step in their incident reports. But we need not

address whether May stepped toward Officer Cook. Even assum-

ing that he didn’t, it was reasonable under the circumstances for

Officer Cook to tase May. The undisputed record, when viewed in

the light most favorable to Appellants, shows that (1) May was na-

ked in his cell in violation of jail policy and state law; (2) Officer

Cook repeatedly instructed May to put his clothes on; (3) May re-

fused to comply; (4) May was defiant and took an aggressive stance;

(5) Officer Cook tased May; (6) the taser was only partially effec-

tive; and (7) May jumped back up almost immediately and contin-

ued to resist. These facts, when viewed through the lens of the

Kingsley factors, do not suggest that Officer Cook’s initial use of his

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 37 of 51

22-10441 Opinion of the Court 37

taser on May was objectively unreasonable, so we cannot say that

Officer Cook violated May’s Fourteenth Amendment rights.

We have said that “where a suspect appears hostile, belliger-

ent, and uncooperative, use of a taser might be preferable to a phys-

ical struggle causing serious harm to the suspect or the officer.”

Smith v. LePage, 834 F.3d 1285, 1294 (11th Cir. 2016). That fairly

describes the situation in this case. May was naked in his cell in

violation of jail policy and state law. When Officer Cook told him

to get dressed, he replied “I ain’t doing that shit.” May then as-

sumed an aggressive stance—or, as Officer Cook described it, a

“fighting stance. Closed, clenched fists, separated feet.” Doc. 209-

5 at 24:14–15. May’s conduct reasonably caused Officer Cook to

believe May wanted to harm him.

Under our precedent, and given the situation that he con-

fronted, Officer Cook was within his rights to tase May. We have

declined to find a Fourth Amendment violation in similar circum-

stances. In Draper v. Reynolds, we held that it was reasonable to tase

a suspect who defied lawful orders, “used profanity, moved around

and paced in agitation, and repeatedly yelled” at law enforcement.

369 F.3d at 1278. All that was also true here. If anything, May’s

aggressive stance made the situation here more volatile, in that it

gave the officers reason to believe that a brawl might ensue. So if

it was reasonable to tase the suspect in Draper, it was reasonable to

tase May here. See id. (observing that trying to use force to subdue

the suspect, rather than deploying the taser, could have “escalated

a tense and difficult situation into a serious struggle”). As such, the

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 38 of 51

38 Opinion of the Court 22-10441

District Court properly granted Officer Cook summary judgment

based on qualified immunity.

2.

Nor were the closed-fist strikes delivered by Officer

Strowder objectively unreasonable. Officer Strowder, both in her

deposition and her after-incident statement, said that she saw her

colleagues involved in an altercation with May and stepped in to

help handcuff May, who continued to resist and grabbed her hand-

cuffs. Strowder testified that she gave May verbal commands to

drop the cuffs and that when he did not comply, she struck him

with a closed fist four times—once in each of the face, arm, hand,

and back.

In the first place, Appellants attempt to create a genuine is-

sue of material fact by arguing that Officer Copeland’s deposition

testimony directly contradicts Officer Strowder’s version of events.

According to Appellants, Officer Copeland’s testimony shows that

“May permitted the officers to handcuff him without any issues.”

Officer Copeland did not dispute Officer Strowder’s testimony; he

said he did not recall May grabbing her handcuffs, or her delivering

closed-fist strikes—not that those things did not occur. But even if

he had disputed Officer Strowder’s recollection of events, Officer

Copeland’s testimony was not, as Appellants argue, that May “did

not resist being placed in handcuffs and permitted the officers to

handcuff him without any issues.” Officer Copeland indicated that

there was an ongoing struggle—as did the testimony of every of-

ficer involved.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 39 of 51

22-10441 Opinion of the Court 39

Even under the most favorable version of events, there is

simply no dispute that an active struggle was ensuing in the holding

cell. Under the Kingsley factors, Officer Strowder’s punches were

not objectively unreasonable given the struggle between May and

the Officers—regardless of whether he grabbed her handcuffs.

May actively resisted. Officer Strowder gave May verbal warnings.

Her closed-fist strikes were in response to that resistance and the

safety and security risks May posed. The injury resulting from the

punches was relatively minimal.

Because Officer Strowder’s use of force was not clearly un-

reasonable, she did not violate May’s Fourteenth Amendment

rights. The District Court properly granted her summary judg-

ment as well.

3.

Finally, Appellants argue that Officers Delacruz, Cook,

Whitaker, Roache, and Jackson used excessive force when they

placed additional restraints on May while he was in the restraint

chair. We need not decide if one of May’s constitutional rights was

violated by the additional restraints because, even if it was, that

right was not clearly established. 28

28 It is true that Officers Delacruz, Cook, Whitaker, Roache, and Jackson were

disciplined for violating Fulton County Jail policy with respect to the addi-

tional restraints. But violation of a local policy or procedure does not auto-

matically mean that May’s constitutional rights were violated. See Davis v.

Scherer, 468 U.S. 183, 194, 104 S. Ct. 3012, 3019 (1984) (“Officials sued for con-

stitutional violations do not lose their qualified immunity merely because their

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 40 of 51

40 Opinion of the Court 22-10441

Appellants can show that a constitutional right was clearly

established in three ways: (1) citing case law with indistinguishable

facts; (2) pointing to a broad statement of principle within the Con-

stitution, statute, or case law; or (3) alleging conduct so egregious

that everyone would know it violated the Constitution. Lewis, 561

F.3d at 1291–92. There is simply no case law with indistinguishable

facts that would clearly establish this constitutional right, nor do

Appellants point to any. In fact, most case law in this Circuit would

tend to indicate that the use of restraints was permissible. See, e.g.,

Brown v. City of Hunstville, 608 F.3d 724, 740 (11th Cir. 2010) (“For

even minor offenses, permissible force includes physical restraint,

use of handcuffs, and pushing into walls.”). Similarly, Appellants

do not point to a broad statement of principle within the Constitu-

tion, statute, or case law that would establish the right.

That leaves the third option—conduct so egregious that any

person would know it was unconstitutional. Appellants argue that

the preeminent case using egregious behavior to clearly establish a

constitutional right—Hope v. Pelzer, 536 U.S. 730, 122 S. Ct. 2508

(2002)—applies. In Hope, the defendant was placed in leg irons,

handcuffed to a hitching post, and made to stand in the Alabama

sun in June for seven hours with no shirt, no bathroom breaks, and

only one glass of water. Id. at 734–35, 122 S. Ct. at 2512–13. His

conduct violates some statutory or administrative provision.”). Simply be-

cause something is in violation of a policy, or even illegal, does not make it

unconstitutional.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 41 of 51

22-10441 Opinion of the Court 41

arms were above shoulder height the entire time. Id. at 734, 122 S.

Ct. at 2512. The guards taunted him. Id. at 735, 122 S. Ct. at 2513.

But the situation in Hope is far removed from the type of be-

havior exhibited by the Officers here. Qualified immunity operates

to make sure that “before they are subjected to suit, officers are on

notice their conduct is unlawful,” and serves to give them “fair

warning.” Id. at 739–40, 122 S. Ct. at 2515 (internal quotation

marks and citations omitted). In the absence of case law or a broad

statement or principle that clearly establishes a constitutional right,

the behavior in question must be so obviously unconstitutional

that any reasonable officer would have notice. That is just not the

case here. We cannot say that using additional restraints to

transport May from the holding cell to the shower and from the

shower to the property room was so obviously unconstitutional

that any officer would have fair warning that they were violating a

detainee’s constitutional rights.

Because it was not clearly established that the Officers’ ac-

tions would have violated May’s constitutional rights, we need not

decide whether such a constitutional right existed. The District

Court did not err in granting the Officers summary judgment with

respect to the restraints.

B.

We now turn to Appellants’ allegation that Officers Roache,

Goodwine, Whitaker, Cook, Delacruz, Copeland, Jackson, and

Lieutenant Paige exhibited deliberate indifference to May’s serious

medical need, in violation of the substantive component of the

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 42 of 51

42 Opinion of the Court 22-10441

Fourteenth Amendment’s Due Process Clause, when they “liter-

ally stood by and watched Mr. May struggle and go unconscious

without offering any assistance.” This claim, like the excessive

force claims discussed above, is subject to the same two-step qual-

ified immunity analysis. Deliberate indifference claims made un-

der the Fourteenth Amendment are held to the same standards as

deliberate indifference claims made under the Eighth Amendment.

Goebert, 510 F.3d at 1326.

A claim of deliberate indifference to serious medical needs

includes both an objective and subjective component. Keohane v.

Fla. Dep’t of Corr. Sec’y, 952 F.3d 1257, 1266 (11th Cir. 2020). Appel-

lants must show (1) that May had an objectively serious medical

need; (2) that the Officers acted with subjective deliberate indiffer-

ence to that need; and (3) that the Officers’ deliberate indifference

caused May injury. Patel v. Lanier Cnty., 969 F.3d 1173, 1188 (11th

Cir. 2020).

The District Court assumed that Appellants established that

May had an objectively serious medical need, so we will as well.

But the District Court found—and we agree—that Appellants can-

not establish a genuine issue of material fact as to the second ele-

ment. The “deliberate indifference” element itself has three ele-

ments. A defendant is deliberately indifferent to a serious medical

need when he or she (1) has subjective knowledge of a risk of seri-

ous harm; (2) disregards that risk; and (3) acts with more than gross

negligence. Id. (quoting Harper v. Lawrence Cnty., 592 F.3d 1227,

1234 (11th Cir. 2010)).

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 43 of 51

22-10441 Opinion of the Court 43

Even if we assume that the Officers had subjective

knowledge of the serious risk of medical harm, we cannot say that

they disregarded that risk or that they acted with more than gross

negligence. Taken in the light most favorable to Appellants, the

video of the property room plainly shows that very soon after en-

tering the property room, Didier conducted an initial examination

of May, who was conscious, alert, and not showing any signs of

distress at the time. Didier left to get medical equipment and while

he was gone, May began to exhibit signs of distress. The video

shows clearly that the Officers noticed the change in May and im-

mediately responded. They began to touch him and see if he was

alert. They undid his restraints and got him on the floor. They

began to provide CPR until medical personnel arrived. That the

Officers responded shows that they did not disregard May’s needs,

and the actions they took in responding were not “more than

grossly negligent.” Even if Appellants are correct, and the Officers

should have taken May to Didier’s office as opposed to waiting for

Didier in the property room, that does not meet the high bar of

being “more than grossly negligent.”

Because Appellants cannot show that the Officers were de-

liberately indifferent to May’s serious medical need, they cannot

show his Fourteenth Amendment rights were violated. As such,

the Officers are entitled to qualified immunity and the District

Court did not err in granting them summary judgment.

IV.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 44 of 51

44 Opinion of the Court 22-10441

We turn now to the final set of claims brought by Appel-

lants—the Georgia medical negligence claims against Travis Wil-

liams and NaphCare. The District Court granted summary judg-

ment on these claims in favor of Williams and NaphCare. The

same summary judgment standards discussed earlier thus apply.

In Georgia, “[a] person professing to practice surgery or the

administering of medicine for compensation must bring to the ex-

ercise of his profession a reasonable degree of care and skill. Any

injury resulting from a want of such care and skill shall be a tort for

which a recovery may be had.” O.C.G.A. § 51-1-27. A claim under

this medical malpractice statute essentially has three elements. A

plaintiff must show (1) the duty inherent in the doctor-patient rela-

tionship; (2) the breach of that duty by failing to exercise the requi-

site degree of skill and care; and (3) that this failure was the proxi-

mate cause of the injury sustained. Med. Ctr. of Cent. Ga. v. Landers,

616 S.E.2d 808, 813 (Ga. Ct. App. 2005). 29 Further, O.C.G.A. § 9-

11-9.1 requires plaintiffs to attach to the complaint an affidavit from

an expert setting forth at least one negligent act or omission.30 To

29 The first element of the claim—that a doctor-patient duty exists—is not in

dispute. Fulton County Jail contracted with NaphCare to provide the medical

care needed at the jail.

30 “In any action for damages alleging professional malpractice against: (1) [a]

professional licensed by the State of Georgia . . . the plaintiff shall be required

to file with the complaint an affidavit of an expert competent to testify, which

affidavit shall set forth specifically at least one negligent act or omission

claimed to exist and the factual basis for each such claim.” O.C.G.A. § 9-11-

9.1(a).

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 45 of 51

22-10441 Opinion of the Court 45

satisfy this requirement, Appellants attached an affidavit from Dr.

Joseph Wright.

A.

The second element of a medical malpractice claim is dis-

positive with respect to Travis Williams. Taking the facts in the

light most favorable to Appellants, as we must, the record shows

that May arrived at the Fulton County Jail around 9:00 AM on Sep-

tember 11, 2018. Williams conducted his intake screening. May

told Williams that he was suicidal but that he did not plan to harm

himself. The arresting officer gave Williams paperwork from

Grady showing that May had methadone use disorder. Williams

noted on the screening form that May was actively or suspected to

be detoxing and that he had suicidal thoughts. After completing

the screening, Williams took the form and placed it in the dedicated

place for the provider to find it. Williams also told Didier, the med-

ical provider on duty, that May had come in from Grady with

methadone use disorder and substance-induced psychotic disorder,

that he voiced thoughts of suicide, and that he was possibly detox-

ing.

Dr. Timothy Hughes, who served as Appellants’ standard of

care expert, argued that Williams breached the standard of care in

two ways. First, Williams failed to immediately communicate in-

formation about May’s drug problems and drug-induced psychotic

behavior to the jail medical provider. Second, Williams failed to

communicate May’s claim of suicidal ideation to the appropriate

medical or mental health provider for actionable medical orders.

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 46 of 51

46 Opinion of the Court 22-10441

Dr. Hughes testified that if Williams had communicated his find-

ings to the medical provider, he would have complied with the

standard of care.

But nothing in the record suggests—and therefore no rea-

sonable jury could find—that Williams failed to communicate his

findings. The intake screening form clearly shows that Williams

marked that May was actively or suspected to be detoxing and that

he had current suicidal thoughts. Williams’s deposition testimony

indicated that he took the intake sheet, went to the provider, and

told him that May had methadone use disorder, was possibly de-

toxing, and had thoughts of suicide. The only evidence in the rec-

ord that could even potentially challenge that testimony is Didier’s

testimony that he did not recall Williams informing him about

May. But Didier never refuted that it happened—he simply indi-

cated that he did not remember it.

Because all evidence in the record shows that Williams did

not breach his duty of care to May, the District Court was correct

in granting summary judgment in his favor.

B.

Finally, we address the medical negligence claim against

NaphCare. We agree with Appellants that the District Court was

too quick to grant NaphCare summary judgment. This claim turns

on the third element of a Georgia medical malpractice claim—

proximate cause.

A plaintiff cannot succeed on a medical malpractice claim,

even if there is evidence of negligence, “unless the plaintiff

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 47 of 51

22-10441 Opinion of the Court 47

establishes by a preponderance of the evidence that the negligence

either proximately caused or contributed to cause plaintiff harm.”

Zwiren v. Thompson, 578 S.E.2d 862, 864 (Ga. 2003) (internal quota-

tion marks and citation omitted). To establish proximate cause by

a preponderance of the evidence in a Georgia medical malpractice

claim, the plaintiff must use expert testimony. Id. at 865. “Georgia

case law requires only that an expert state an opinion regarding

proximate causation in terms stronger than that of medical possi-

bility, i.e., reasonable medical probability or reasonable medical

certainty.” Id. at 867. “What amounts to proximate cause is unde-

niably a jury question.” Id. at 865 (quoting Ontario Sewing Mach.

Co. v. Smith, 572, S.E.2d 533, 536 (Ga. 2002)); see also Dowdell v. Wil-

helm, 699 S.E.2d 30, 32 (Ga. Ct. App. 2010) (“Normally, questions

of proximate cause are for the jury, but plain and indisputable

cases . . . may be decided by the court as a matter of law.”). That

question must be “determined on the facts of each case upon mixed

considerations of logic, common sense, justice, policy and prece-

dent.” Zwiren, 578 S.E.2d at 865 (quoting Atlanta Obstetrics & Gy-

necology Grp. v. Coleman, 398 S.E.2d 16, 17 (Ga. 1990)).

In their response to NaphCare’s motion for summary judg-

ment, Appellants relied mainly on the medical report and deposi-

tion of Dr. Timothy Hughes, but also referred to the report and

deposition of Dr. William Anderson, as well as the affidavit from

Dr. Wright that they had attached to their complaint as required

by O.C.G.A. § 9-11-9.1.

As relevant here, Dr. Hughes’s report stated:

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 48 of 51

48 Opinion of the Court 22-10441

It is my expert opinion that had Mr. May been appro-

priately screened and examined with the correct and

prompt follow through by NaphCare medical staff, to

include immediate classification to suicide watch and

to have appropriate sedation ordered for his metham-

phetamine-induced psychotic behavior, the events

that transpired and culminated in an episode of ex-

cited delirium and subsequent sudden cardiac

death—further exacerbated by the use of force sec-

ondary to his untreated psychotic behaviors—would

in all medical probability not [have] occurred. 31

In short, Dr. Hughes’s report concluded the failure of NaphCare

medical staff to properly screen, examine, and treat May was the

proximate cause of his death. This testimony is supported by both

Dr. Anderson32 and Dr. Wright. 33

31 In his deposition, Dr. Hughes twice stated that, had earlier intervention and

observation on the part of NaphCare occurred, it is “more probable than not”

that the confrontation—and May’s death—would not have occurred.

32 Dr. Anderson testified that had May been treated medically, as opposed to

with force, the outcome would have been different.

33 According to Dr. Wright: “Had Mr. May been closely observed in a medical

setting and put on chemical sedation at the Fulton County Jail as opposed to

being placed in a holding cell with no medical treatment, with a reasonable

degree of medical certainty, the confrontation between the deputies and Mr.

May would not have occurred, or Mr. May would have been treated differ-

ently based on his medical and psychological issues, thereby preventing his

death.”

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 49 of 51

22-10441 Opinion of the Court 49

The District Court held that, even if it was admitted, this

testimony “would not provide sufficient support for a medical mal-

practice claim under Georgia law.” Order, Doc. 240, at 29–30. Ac-

cording to the Court, May’s altercation with the Officers occurred

between the actions of the NaphCare defendants and May’s death.

The Court found that “too many actions and choices made by May

and the Officers stand in between the decisions of the Naphcare

defendants and May’s death to deem their failure to sedate May the

proximate cause of the events.” Id. at 30. As such, the District

Court held that the encounter between May and the Officers broke

the natural and continuous sequence of events required for proxi-

mate cause. Id. at 30–31.

We agree with Appellants that, based on Dr. Hughes’s testi-

mony, there is enough of a genuine issue of material fact for

NaphCare’s liability to reach a jury. Dr. Hughes did not solely rest

his argument on NaphCare’s failure to sedate May. It was the fail-

ure of the staff to follow through with May at all that was the prob-

lem. While this included the need for sedation, it also included im-

mediate classification to suicide watch and observation.

This is not a “plain and indisputable” case. Dr. Hughes

clearly stated that, in his medical opinion, May’s death “would in

all medical probability not occurred,” but-for breach of the stand-

ard of care by NaphCare. To be clear, we do not hold that

NaphCare’s employees were the proximate cause of May’s death.

We hold only that, based on Dr. Hughes’s testimony, there is a gen-

uine issue of material fact as to whether NaphCare employees were

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 50 of 51

50 Opinion of the Court 22-10441

the proximate cause of May’s death. A reasonable jury could find

that they were. 34

V.

We affirm the District Court’s dismissal of the claims against

Sheriff Jackson in both his official and individual capacities. We

also affirm the grant of summary judgment to the Officers and

Travis Williams. We vacate, however, the grant of summary judg-

ment to NaphCare, and we remand the matter to the District

Court.35

34 Prior to its motion for summary judgment, NaphCare moved to exclude

portions of Dr. Hughes’s report and subsequent testimony under Daubert v.

Merrell Dow Pharmaceuticals, Inc. 509 U.S. 579, 113 S. Ct. 2786 (1993). Namely,

NaphCare argued that Dr. Hughes’s opinions “amount[ed] to nothing more

than speculation and personal opinions with no identifiable scientific support,

and so they must be excluded.” The District Court denied this motion as moot

in its order granting summary judgment to NaphCare. Our holding also says

nothing as to the admissibility of Dr. Hughes’s opinions.

35 The District Court only had jurisdiction over the state medical negligence

claim because it exercised supplemental, or pendent, jurisdiction over it. See

28 U.S.C. § 1367(a) (“[I]n any civil action of which the district courts shall have

original jurisdiction, the district courts shall have supplemental jurisdiction

over all other claims that are so related to claims in the action within such

original jurisdiction that they form part of the same case or controversy under

Article III of the United States Constitution.”). When, as here, the federal

claims have been disposed of and all that remains is the state law claim, we

have encouraged the dismissal of the remaining state law claim. See Vibe Micro,

Inc. v. Shabanets, 878 F.3d 1291, 1296 (11th Cir. 2018) (“When all federal claims

are dismissed before trial, a district court should typically dismiss the pendent

state claims as well.”). At the very least, the District Court must be mindful of

its obligation to ensure that the factors underlying supplemental jurisdiction—

USCA11 Case: 22-10441 Document: 51-1 Date Filed: 06/07/2023 Page: 51 of 51

22-10441 Opinion of the Court 51

AFFIRMED IN PART, VACATED AND REMANDED IN

PART

judicial economy, convenience, fairness, and comity—continue to weigh in

favor of exercising jurisdiction. See Ameritox, Ltd. v. Millennium Lab’ys, Inc., 803

F.3d 519, 537 (11th Cir. 2015) (“[O]nce a district court possesses discretion to

dismiss the supplemental claims, it must be continuously mindful regarding

whether or not the factors favor dismissal.”).