Margaret Starks v. St. Louis County

United States Court of Appeals
For the Eighth Circuit
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No. 24-2540
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Margaret Starks
Plaintiff - Appellant
v.
St. Louis County
Defendant - Appellee
Faisal Khan, in his individual capacity; Delores J. Gunn, in her individual capacity;
Melissa Susman, in her individual capacity; William Trachsel, in his individual
capacity
Defendants
Cedric Ivy, in his individual capacity
Defendant - Appellee
Connie Heitman, in her individual capacity
Defendant
Reginald Tinoco, in his individual capacity; Debra Tucker, in her individual
capacity; Rita Hendrix, in her individual capacity; Faye Crancer, in her individual
capacity
Defendants - Appellees
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Appeal from United States District Court
for the Eastern District of Missouri - St. Louis
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Submitted: September 16, 2025
Filed: November 18, 2025
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Before BENTON, GRASZ, and KOBES, Circuit Judges.
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KOBES, Circuit Judge.
Drexel Starks experienced heroin withdrawal while jailed at the St. Louis
County Justice Center. He later died at the hospital. His mother, Margaret Starks,
sued under 42 U.S.C. § 1983, alleging that jail nurses Reginald Tinoco and Debra
Tucker and correctional officer Cedric Ivy were deliberately indifferent to his
serious medical need. She also sued nurse supervisors Rita Hendrix and Faye
Crancer and St. Louis County for failure to train or supervise and the County for an
unlawful policy, practice, or custom of denying detainees medical care.1 The district
court2 granted the defendants’ motion for summary judgment, holding that Margaret
failed to establish a violation of Drexel’s constitutional rights. Reviewing de novo,
we affirm. Jackson v. Buckman, 756 F.3d 1060, 1065 (8th Cir. 2014) (standard of
review).
Drexel was arrested for possession of a controlled substance while on parole
and taken to jail on August 4, 2015. He told the jail nurse that he was “dope sick”
and had used heroin the day before. She noted he was well-hydrated but had
symptoms of Acute Withdrawal Syndrome (AWS), so she put him on withdrawal
protocol, which included “comfort” medication and twice daily nurse assessments.
1 Claims against defendants Khan, Gunn, Susman, Heitman, and Trachsel were
voluntarily dismissed below.
2 The Honorable Ronnie White, United States District Judge for the Eastern
District of Missouri, now retired.

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Nurses assessed Drexel three times during the first 24 hours. He had AWS
symptoms of dry mouth and unsteady gait but showed signs of improvement on the
morning of August 5, with a nurse noting a moist mouth and steady gait.
There is no evidence of another assessment. Nurses Tinoco and Tucker were
working in Drexel’s unit during the following shifts, but testified that they never
interacted with him, despite the withdrawal protocol requiring nurses to “call
inmate[s] out to assess.” The protocol was explicit: “NO CALL, NO SHOW not
accepted. Officer MUST get inmate.”
Around 2:00 p.m. on August 6, a correctional officer reported that Drexel was
suffering from withdrawal. Drexel was on the floor with a small pool of saliva by
his face. A nurse asked what was wrong and he replied, “I’m okay.” Although he
responded to several more questions, she could not find a pulse or blood pressure
reading. She called a nurse practitioner, and Drexel was transferred to the infirmary
about forty minutes later. He was then moved to the hospital and pronounced dead
at 3:51 p.m. The medical examiner determined that the cause of death was
“unexpected death in patient withdrawing from heroin and cocaine with dehydration
and cardiac dysrhythmia.”
Margaret alleges that jail staff were deliberately indifferent to Drexel’s serious
medical need in violation of the Fourteenth Amendment. See Jackson, 756 F.3d at
1065 (applying the Eighth Amendment’s deliberate indifference standard to
Fourteenth Amendment claims by pretrial detainees). To prevail, she must show
that Drexel had an objectively serious medical need and that defendants “actually
knew of, but deliberately disregarded, such need.” Cannon v. Dehner, 112 F.4th
580, 586 (8th Cir. 2024) (citation omitted). An objectively serious medical need is
“either obvious to the layperson or supported by medical evidence, like a physician’s
diagnosis.” Id. (citation omitted). “A medical condition is not per se obvious to a
layperson because it later results in death.” Jones v. Minn. Dep’t of Corr., 512 F.3d
478, 483 (8th Cir. 2008). Deliberate indifference is “akin to criminal recklessness.”
Cannon, 112 F.4th at 587.

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No reasonable jury could find an objectively serious medical need here based
on medical evidence. There was no physician’s diagnosis, and the nurse’s intake
assessment is not enough. See id. at 586 (nurse treatment prior to a doctor’s initial
diagnosis did not establish a serious medical need unless the need was obvious to a
layperson); see also Jones, 512 F.3d at 482 (where prisoner had been examined by
a nurse, she “was not diagnosed by a physician as requiring treatment”).
That means Drexel’s “condition must have been so obvious that a layperson
would easily recognize the need for treatment.” Jones, 512 F.3d at 482. We don’t
think the evidence, viewed in the light most favorable to Margaret, meets this
standard. AWS was common among detainees. When asked whether AWS was
serious, Margaret’s expert witness testified: “Well, it’s not very comfortable . . . I
can’t ever remember seeing a patient die from it.” Margaret points to evidence that
Drexel vomited on August 4 and complained of dehydration on August 6, but Nurse
Hendrix testified that all inmates suffering from AWS experience vomiting, often
causing dehydration.
The nurse assessments showed Drexel’s AWS symptoms were improving.
There is nothing in the record indicating that Drexel’s condition was worse than an
average AWS case before 2:00 p.m. on August 6.3 See Jones, 512 F.3d at 482–83
(no objectively serious medical need where an inmate “was unable to stand or walk
under her own power, was ‘google-eyed’ and unresponsive, was rolling on the
ground while grunting and groaning, was bleeding from the mouth, smelled as if she
had urinated on herself, and was breathing at a very rapid rate”); see also Grayson
v. Ross, 454 F.3d 802, 810 (8th Cir. 2006) (no objectively serious need where
inmate’s methamphetamine use resulted in death but inmate’s behavior did not make
it obvious to a layperson that inmate required immediate medical attention). And,
given that Drexel’s condition did not appear worse than the average case of AWS,
“the prison officials had no background knowledge that made it obvious that these
3 The nurse who responded to Drexel’s cell at 2:00 p.m. on August 6 is not a
defendant, and there is no allegation that she was deliberately indifferent to Drexel’s
medical needs.

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symptoms required medical attention” and “a reasonable jury could not find that
[Drexel] had a medical need so obvious that a layperson would easily recognize the
need for a doctor’s immediate attention.” Jones, 512 F.3d at 483.
Margaret also points to Hendrix’s estimate that twenty inmates with AWS
died in the past seven years. But that estimate was given during a series of questions
asking Hendrix to speculate about inmates who died at hospitals after receiving
proper assessments, without specifying the causes of death. See Fed. R. Civ. P.
56(c)(1)(B). And county records contradict her claim. Besides Drexel, 11 inmates
died between 2008 and 2015; no cause of death was AWS or drug withdrawal.4
There is evidence that the nurses negligently violated the “no call, no show”
policy, but negligence is not “akin to criminal recklessness.” Cannon, 112 F.4th at
587. We have found withholding medication to be deliberate indifference, but those
cases involved actual knowledge of the inmate’s serious medical need and needed
medication was intentionally withheld. See, e.g., Dadd v. Anoka Cnty., 827 F.3d
749 (8th Cir. 2016) (plaintiff arrested after serious dental surgery and officers
ignored his request for his doctor-prescribed pain medication despite knowing his
need for it); Presson v. Reed, 65 F.4th 357 (8th Cir. 2023) (deliberate indifference
where defendants knew about plaintiff’s need for prescription medications but
refused care saying, “you will get them tomorrow but tomorrow never comes”).
Here, Tinoco and Tucker testified that they never interacted with Drexel. At most
they knew that Drexel was on the AWS protocol and that his symptoms had been
improving. See Hott v. Hennepin Cnty., 260 F.3d 901, 907–08 (8th Cir. 2001)
(evidence was insufficient to show suicide presented so great a risk that failure to
conduct checks according to jail policy amounted to deliberate indifference); see
also Cannon, 112 F.4th at 587 (“Grossly incompetent or inadequate care can
constitute deliberate indifference but the care provided must be so inappropriate as
to evidence intentional maltreatment or a refusal to provide essential care.” (citation
omitted)).
4 Two of the inmates died from unknown causes.

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Margaret similarly argues Officer Ivy was deliberately indifferent by denying
or interfering with Drexel’s medical treatment and not taking him to see the nurse.
It’s true that the record indicates Officer Ivy knew Drexel refused to cooperate with
medical, refused a legal visit, said he would not get up, and refused to eat his lunch.
But this evidence is insufficient for a reasonable jury to find that Officer Ivy knew
about Drexel’s medical condition, let alone that he “disregarded an excessive risk to
[Drexel’s] health or safety.” Liebe v. Norton, 157 F.3d 574, 577 (8th Cir. 1998)
(cleaned up).
Because there is no constitutional violation, Margaret’s claims against
Hendrix, Crancer, and the County fail as a matter of law. Corwin v. City of
Independence, 829 F.3d 695, 700 (8th Cir. 2016) (“This circuit has consistently
recognized as a general rule that, in order for municipal liability to attach, individual
liability first must be found on an underlying substantive claim.” (citation omitted)).
Margaret suggests that “a municipality may be held liable for its unconstitutional
policy or custom even when no official has been found personally liable,” Webb v.
City of Maplewood, 889 F.3d 483, 486 (8th Cir. 2018) (where the individual officers
had immunity, the question of whether their acts were unlawful remained open); see
also Speer v. City of Wynne, 276 F.3d 980, 986 (8th Cir. 2002) (“[S]ituations may
arise where the combined actions of multiple officials or employees may give rise
to a constitutional violation, supporting municipal liability, but where no one
individual’s actions are sufficient to establish personal liability for the violation.”),
but those cases “do not suggest that municipal liability may be sustained where there
has been no violation of [Drexel’s] constitutional rights as a result of action by the
municipality’s officials or employees,” Speer, 276 F.3d at 986.
Affirmed.
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