VERTULIE LAPRE , Administrator of the Estate of Okoi Ofem v. City of Chicago

In the
United States Court of Appeals
For the Seventh Circuit
No. 17-3024
VERTULIE LAPRE , Administrator of the
Estate of Okoi Ofem,
Plaintiff-Appellant,
v.
C ITY OF C HICAGO ,
Defendant-Appellee.
Appeal from the United States District Court for the
Northern District of Illinois, Eastern Division.
No. 1:15-cv-03199 — Virginia M. Kendall, Judge.
A RGUED SEPTEMBER 12, 2018 — D ECIDED D ECEMBER 17, 2018
Before EASTERBROOK, R OVNER , and HAMILTON, Circuit
Judges.
R OVNER , Circuit Judge. Okoi Ofem committed suicide in a
jail cell at a City of Chicago lockup. His mother, Vertulie Lapre,
sued the City under 42 U.S.C. § 1983, for failing to prevent her
son’s death. Because Lapre lacks evidence that the City was

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2 No. 17-3024
deliberately indifferent to the risk of suicide for detainees held
in City lockups and also cannot show that the City’s policies
and practices were the cause of Ofem’s death, we affirm the
district court’s grant of summary judgment in favor of the City.
I.
Chicago police officers arrested eighteen-year-old Okoi
Ofem on a misdemeanor assault charge on September 12, 2013,
and took him to the City’s 4th District Police Station. After
processing, Ofem arrived at the 4th District Lockup (“Lockup”)
at approximately 3:30 p.m., roughly two hours after his arrest.
A Chicago police officer and two detention aides were on duty
at the Lockup. Pursuant to City policy, detention aide William
Zaremba conducted a visual inspection of Ofem and asked him
a series of screening questions, marking his responses on a
processing report. From the visual inspection, Zaremba noted
on the report that Ofem displayed no signs of pain, injury, or
infection; he did not appear to be under the influence of drugs
or alcohol or showing signs of withdrawal; he did not seem to
be despondent or irrational, and was not carrying medication.
Zaremba recorded a “No” in response to every screening
question, including whether Ofem was taking any medication,
whether this was his first arrest, whether he had ever at-
tempted suicide or serious harm, whether he had serious
medical or mental problems, whether he was receiving any
treatment, and whether he was “transgender/intersex/gender
non-conforming.” Ofem refused to list an emergency contact,
and appeared to be “miffed” or angry about the charge, but
did not appear depressed. Zaremba took Ofem’s shoelaces, belt
and keys and placed him in a one-person cell. Ofem declined
all offers of food that day.

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No. 17-3024 3
The next morning, one of the assigned detention aides for
the Lockup did not show up to work. At 6 a.m., Officer James
Carrillo was assigned to take the place of the missing aide.
Carrillo’s regular assignment was that of paper review officer.
He had received no specific training as a lockup keeper but he
occasionally filled in when the need arose. Another assigned
aide, Dennis Graham, began the shift but left at approximately
8 a.m. to attend a meeting. Early that morning, Ofem was taken
to the criminal court. Ofem arrived back at the Lockup at 10
a.m., an unexpected and unusually early return. During the
ride back to the Lockup, Ofem did not inform the transport
officers that he was suicidal or contemplating self-harm.
Carrillo received Ofem back into the Lockup, and was the only
person on duty at that time. Ofem appeared surprised and
confused about what had happened at court, and asked
Carrillo what was happening. Carrillo replied that Ofem had
likely been sent to the wrong court—one that handled felony
charges—and that he would have to go instead to another
court that handled misdemeanor charges. Carrillo thought that
Ofem appeared tired and Ofem again declined all offers of
food. Ofem did not inform Carrillo or any other officer that he
was contemplating suicide or self-harm. He was again placed
in a one-person cell, and there were no other detainees in the
Lockup at that time.
Between his 10:00 a.m. return and 1:00 p.m., someone at the
jail visually inspected Ofem every fifteen minutes, sometimes
in person and sometimes via a poor-quality video monitor. The
District Station Supervisor also conducted a walk-through at
11:30 a.m. At 12:45 p.m., Carrillo and detention aide Graham
(who had apparently returned from his meeting) checked on

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4 No. 17-3024
Ofem in person. At 1:00 p.m., Carrillo checked on Ofem
through the video monitor and did not notice anything amiss.
At 1:10 p.m., Carrillo glanced at the video monitor and saw
Ofem hanging from a horizontal bar in his cell. Carrillo and
Graham immediately went to the cell, which was approxi-
mately fifteen feet away on the other side of a door, and saw
that Ofem had used his jeans to hang himself. He had tied the
jeans to the cell in such a way that the officers had difficulty
opening the cell door. Graham used a pocket knife to cut
through the jeans and Carrillo forced the door open. At the
same time, Officer James Mangan ran to call for medical
assistance. Once they removed the pants from Ofem’s neck, he
let out a groan. Carrillo attempted to rouse Ofem by calling to
him, slapping him and shaking him. When Ofem did not
respond, Carrillo administered chest compressions. Paramed-
ics arrived and took over from Carrillo. Ofem was transported
to a hospital where he died the following day.
At the time of Ofem’s incarceration and death, City lockup
facilities operated under “Special Order S06-01-02,” a directive
from the Superintendent of Police outlining the responsibilities
of lockup personnel “to ensure arrestees are properly pro-
cessed, booked, and safeguarded.” R. 120–25 (hereafter
“Special Order”). The Special Order specified, in relevant part,
that lockup personnel will:
7. prior to accepting any arrestee, conduct an initial
inspection of the subject following the Guidelines

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No. 17-3024 5
for Arrestee Screening and Monitoring chart (CPD-
11.523).1
8. if screening process indicates that the arrestee is
perceived to be mentally/chemically impaired or
suicidal, the station supervisor will be notified
immediately.
9. not accept any arrestee into the lockup who has
injuries or illnesses that may require hospitalization
or the immediate attention of a healthcare profes-
sional.
1 The Guidelines for Arrestee Screening and Monitoring is a color chart
that, under City policy, is to be posted in the arrestee processing area of
each facility, among other places. It contains four columns for evaluating
arrestees: “SICK/INJURED/EMOTIONAL RISK;” “INTOXICATED/
IMPAIRED/PREGNANT;” “INFECTION/COMMUNICABLE DISEASES;”
and “NO SIGNS OF DISTRESS.” Under the first column, a section titled, “Is
arrestee suicidal?” lists warning signs: “Express Desire or Intent to Harm
Self or Others;” “Actual Self Harm/Suicide Attempt;” “Hyper-
active/Extremely Agitated;” and “Intense Guilt/Remorse.” Another section
of the same column advises officers to assess whether the arrestee is
irrational or delusional, cannot follow simple commands, is disoriented or
hallucinating, or is unaware of his or her surroundings. For all parts of the
first column, affirmative answers require notifying the District Station
Supervisor and sending the arrestee to the nearest approved hospital or
mental health intake facility. Although there are multiple references to this
chart in the record, the chart itself does not appear to be part of the record,
and so we provide this information for background purposes only. A
version last revised in May 2013 can be accessed through https://home.
chicagopolice.org/inside-the-cpd/department-directives-system/ (last visited
December 4, 2018).

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6 No. 17-3024
13. complete the intake screening questions process
following the Guidelines for Arrestee Screening and
Monitoring chart.
15. in those instances in which an arrestee responds
“yes” to the arrestee questions of “attempted
suicide/serious harm,” check the corresponding box
in the Additional Lockup Demographics/Cautionary
Descriptors field.
16. in those instances during the visual check of the
arrestee they determine/categorize the arrestee to be
despondent, check the corresponding box in the
Additional Lockup Demographic/Cautionary
Descriptors field.
18. in those instances in which the subject arrestee
has been identified as a present or prior danger to
themselves (i.e. attempt suicide, caused harm to self,
despondent), place the subject in a cell closest to the
lockup keeper and will place another arrestee in the
cell with the subject arrestee.
23. complete a visual check of each arrestee every 15
minutes following the Guidelines for Arrestee
Screening and Monitoring chart and record the time
of each inspection, a concise statement of conditions
found, notable occurrences, actions take[n], if any,
and the initials and employee identification number
on the Inspection Log.
R.120–25 (emphasis in original). The Special Order also
requires the Station Supervisor to inspect the lockup and the

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No. 17-3024 7
arrestees at the start of his or her tour, and, at a minimum,
conduct at least four thorough inspections of the lockup and
the arrestees per tour. Station Supervisors are also charged
with immediately evaluating any arrestees who exhibit signs
of being mentally or chemically impaired or suicidal, and
taking appropriate action. R. 120–25. The State of Illinois also
enacted jail and lockup standards (“Illinois Lockup Stan-
dards”) that were in effect at the time of Ofem’s death, includ-
ing requirements to personally inspect detainees at least every
thirty minutes.
Vertulie Lapre, Ofem’s mother and the administrator of his
estate, sued the City and several individual officers and
detention aides pursuant to 42 U.S.C. § 1983, alleging that the
City and these individuals were responsible for Ofem’s death
in custody. The claims against the individuals were dismissed
with prejudice and the City sought summary judgment on the
only claim remaining, Count III of the First Amended Com-
plaint. That count alleged that the City was liable for Ofem’s
death under Monell v. Dep’t of Social Servs. of City of New York,
436 U.S. 658 (1978), because the City’s policies, practices and
customs led to Ofem’s death.
Lapre originally asserted twelve policies (we will use
“policies” as shorthand for “policies, practices and customs”)
or gaps in policies as leading to Ofem’s death, but at the
summary judgment stage, the parties and the district court
focused on five specific policies or gaps. The district court
granted summary judgment in favor of the City, largely
because Lapre failed to present evidence of constitutionally
inadequate City-wide policies and because she could not

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8 No. 17-3024
demonstrate that the City’s policies caused a deprivation of
Ofem’s federal rights. Lapre appeals.
II.
On appeal, Lapre contends that the City’s policies regard-
ing detainees were deliberately indifferent to the risk of suicide
and were the “moving force” behind Ofem’s suicide. She faults
the City for not implementing policy changes that the City
knew would prevent suicides, and would have prevented
Ofem’s suicide. She contends that the district court improperly
ignored disputed facts and inappropriately resolved certain
fact disputes in favor of the defendants, viewing the evidence
in a light most favorable to the City. We review the district
court’s grant of summary judgment de novo, examining the
record in the light most favorable to Lapre and construing all
reasonable inferences from the evidence in her favor. Anderson
v. Liberty Lobby, Inc., 477 U.S. 242, 255 (1986); Yahnke v. Kane
County, Ill., 823 F.3d 1066, 1070 (7th Cir. 2016). Summary
judgment is appropriate when there are no genuine disputes
of material fact and the movant is entitled to judgment as a
matter of law. Fed.R.Civ.P. 56(a); Anderson, 477 U.S. at 256;
Yahnke, 823 F.3d at 1070. We may affirm summary judgment on
any basis we find in the record. Nature Conservancy v. Wilder
Corp. of Delaware, 656 F.3d 646, 653 (7th Cir. 2011).
A plaintiff seeking to impose liability on a municipality
under section 1983 must identify a municipal policy or custom
that caused the plaintiff’s injury. Board of Cty. Comm’rs of Bryan
Cty., Okla. v. Brown, 520 U.S. 397, 403 (1997).
Locating a “policy” ensures that a municipality
is held liable only for those deprivations result-

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No. 17-3024 9
ing from the decisions of its duly constituted
legislative body or of those officials whose acts
may fairly be said to be those of the municipal-
ity. Similarly, an act performed pursuant to a
“custom” that has not been formally approved
by an appropriate decisionmaker may fairly
subject a municipality to liability on the theory
that the relevant practice is so widespread as to
have the force of law.
Brown, 520 U.S. at 403–04 (citations omitted). The plaintiff must
not only identify conduct properly attributable to the munici-
pality but must also demonstrate that, “through its deliberate
conduct, the municipality was the ‘moving force’ behind the
injury alleged. That is, a plaintiff must show that the municipal
action was taken with the requisite degree of culpability and
must demonstrate a direct causal link between the municipal
action and the deprivation of federal rights.” Brown, 520 U.S.
at 404. See also Estate of Novack ex rel. Turbin v. County of Wood,
226 F.3d 525, 531 (7th Cir. 2000) (where the municipal policy is
itself unconstitutional, the constitutional injury can be said to
have been directly caused by the municipality; indirect liability
may be proved by demonstrating a series of bad acts that allow
an inference that the policymaking level of government was
aware of the problem and, by failing to do anything to remedy
it, adopted the misconduct of subordinates). Finally:
a plaintiff seeking to establish municipal liability
on the theory that a facially lawful municipal
action has led an employee to violate a plaintiff's
rights must demonstrate that the municipal
action was taken with “deliberate indifference”

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10 No. 17-3024
as to its known or obvious consequences. A
showing of simple or even heightened negli-
gence will not suffice.
Brown, 520 U.S. at 407 (citation omitted).
In certain circumstances, municipal liability may also be
established by a policy gap, by a city’s failure to have proce-
dures in place for addressing a known risk of serious harm.
Suicide is a known risk in the custody setting, and occurs at
higher rates than in non-custodial settings. Boncher ex rel.
Boncher v. Brown Cty., 272 F.3d 484, 486 (7th Cir. 2001). For that
reason, we have remarked that “[j]ail managers who decided
to take no precautions against the possibility of inmate
suicide—to have no policy, for example no suicide-watch
option—would be guilty of deliberate indifference in the
relevant sense; they would be ignoring a known and serious
risk of death of persons under their control for whose safety
they are responsible.” Boncher, 272 F.3d at 486 (citations
omitted). But when a policy is in place, the standards detailed
above apply.
On appeal, Lapre identifies five municipal policies that she
asserts evidenced the City’s deliberate indifference towards the
risks of suicide and that were the moving force behind Ofem’s
death: “1) the policy decision to not remove horizontal bars
from the 4th District; 2) the practice of not providing first aid
to hanging victims by not training lockup personnel and not
installing suicide kits; 3) the policy of not reassessing returnees;
4) the policy and custom of not personally inspecting detainees
and leaving them isolated; and 5) the failure to properly train
personnel on detecting mental health issues and potential

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No. 17-3024 11
suicide subjects.” Plaintiff-Appellant’s Brief, at 18. For each of
these policies, she argues that the district court improperly
construed the facts in favor of the defendant or ignored
evidence that she presented. Because our review is de novo, we
need not address whether the district court erred on eviden-
tiary matters. We will independently review the record
evidence on which Lapre relies.
A.
We begin with the presence of horizontal bars at the 4th
District Lockup. The City is, in fact, aware of the risk posed by
horizontal bars in lockup cells, and this very issue has been
litigated previously. See Frake v. City of Chicago, 210 F.3d 779,
781–82 (7th Cir. 2000). Like Ofem, Frake hanged himself from
the horizontal bars of his City lockup cell using an item of
clothing that he had been allowed to keep. Frake’s father sued
the City under section 1983 for deliberate indifference to the
risk of suicide posed by the horizontal bars. At the time of
Frake’s death, City policies were similar to those in place under
the Special Order that controlled at the time of Ofem’s death.
Lockup personnel were required to visually assess arriving
detainees for signs of pain, injury, drug or alcohol intoxication,
despondency and the need for medication. They also ques-
tioned detainees about medical and mental health issues and
whether the detainee had ever attempted suicide. As is
currently required, lockup personnel also confiscated belts,
shoelaces, ties and other items that a person could use for self-
harm. At the time of Frake’s death, the jailers checked the cells
every fifteen minutes and the watch commander and desk
sergeant were required to inspect the lockup twice per tour of

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12 No. 17-3024
duty. Training was provided to officers for suicide awareness.
210 F.3d at 781.
We noted in Frake that a finding of deliberate indifference
required a showing that officials were aware of a substantial
risk of serious injury to detainees but nevertheless failed to
take appropriate steps to protect detainees from that known
danger. 210 F.3d at 782. Jailers are not required to guarantee
the safety of detainees, and the “existence or possibility of
other better policies which might have been used does not
necessarily mean that the defendant was being deliberately
indifferent.” Id. We rejected the plaintiff’s contention that the
number of suicides and attempts alone could demonstrate
deliberate indifference but we also declined to endorse the
City’s argument that the relatively low rate of suicides com-
pared to the number of arrests proved it could not be held
liable. We declined to consider the risks of the horizontal bars
in isolation, instead weighing the additional precautions taken
to reduce the risk of suicide. In light of the City’s other safe-
guards, we found that continued use of cells with horizontal
bars did not meet the standard for deliberate indifference. 210
F.3d at 782.
Lapre cites Frake as evidence that the City has been well
aware of the risks posed by horizontal bars for twenty years.
She contends that, since Frake, the City does not use horizontal
bars when building new lockup facilities. She notes anecdotal
evidence from personnel at the 4th District regarding the
prevalence of continued attempted and completed suicides.
She also cites statistical evidence of the rates of suicides per
detainee, asserting that the rate has actually increased substan-
tially since Frake. All of this, she asserts, demonstrates that the

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No. 17-3024 13
continued presence of horizontal bars exhibits deliberate
indifference.
Lapre’s proposed statistical evidence suffers serious flaws.
She co-mingles suicides and suicide attempts and appears to
have no reliable information supporting her contention that the
rate of suicides has increased in the last twenty years. Nor does
she provide the metric that we have held is the most relevant
when assessing government responsibility for suicide risk:
It is not the number of suicides that is a meaning-
ful index of suicide risk and therefore of govern-
mental responsibility, … but the suicide rate; …
and it is not even the rate by itself, but rather the
rate relative to the “background” suicide rate in
the relevant free population (the population of
the area from which the jail draws its inmates)
and to the rate in other jails.
Boncher, 272 F.3d at 486–87. There is no basis on this record to
conclude that there are more suicides in City lockups now than
there were at the time of Frake, or that these are disproportion-
ate to the suicide rate in the relevant free population. See also
Pittman v. County of Madison, Ill., 746 F.3d 766, 780 (7th Cir.
2014) (the bare fact that other inmates attempted or committed
suicide does not demonstrate that a jail’s policies were inade-
quate, that officials were aware of any suicide risk posed by the
policies or that officials failed to take appropriate steps to
protect the inmate). She also provides no evidence regarding
the rate of suicides in lockups that still have horizontal bars
versus the rate in the new lockups that are constructed without
horizontal bars.

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14 No. 17-3024
Nor does Lapre acknowledge the other precautionary
measures that the City took to prevent the known risk of
suicide in its facilities. As we noted above, at the time of
Ofem’s death, the City had in place policies that exceeded
those in effect at the time of Frake’s death. In addition, the
City’s efforts to replace old lockup facilities with new ones that
do not employ horizontal bars is not evidence of deliberate
indifference but of deliberate efforts to remedy the situation.
That the City might have proceeded more quickly does not
mean that it was deliberately indifferent to the risk. Pittman,
746 F.3d at 780 (possibility of better policies does not necessar-
ily mean the defendant was deliberately indifferent); Frake, 210
F.3d at 782 (same). Finally we note that Lapre’s anecdotal
evidence of events in the 4th District is insufficient to demon-
strate a City-wide “practice [that] is so widespread as to have
the force of law.” Brown, 520 U.S. at 403–04. Taken as a whole,
the measures in place and the changes being made by the City
do not demonstrate deliberate indifference under Frake for the
City’s continued use of cells with horizontal bars. See also Estate
of Novack, 226 F.3d at 531 (finding no liability for an inmate
suicide where the plaintiff failed to show a pattern of suicide
at the jail from which the finder of fact could draw an inference
that the county was aware that its policies for treating mentally
ill inmates at risk for suicide were inadequate and chose to do
nothing in the face of this knowledge).
B.
We turn to Lapre’s assertion that the City has a practice of
not providing first aid to hanging victims by not training
lockup personnel and not installing “suicide kits.” She con-
tends that a jury must decide whether the failure to provide

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No. 17-3024 15
proper first aid in the first few minutes after discovering Ofem
in distress was a proximate cause of his death. Although Lapre
does not specify the contents of the suicide kits, it is apparent
from her argument that such kits would at least include a
device for cutting down a person who is hanging, and a device
to enable lockup personnel to engage in mouth-to-mouth
resuscitation. Lapre asserts that the absence of a suicide kit
caused a delay in cutting Ofem down from the bar, and that
the aid delivered thereafter was disjointed and ineffective.
The City did not provide first aid training to lockup
personnel prior to 2012, and the officers present on the day of
Ofem’s death were arguably not trained regarding when and
how to perform CPR. Graham testified that he cut Ofem down
in a matter of seconds using a pocket knife that he carries with
him. Carrillo called out to Ofem, slapped and shook him, and
then delivered chest compressions when Ofem did not
respond. At the same time, another officer called for emer-
gency responders, who arrived and took over the chest
compressions from Carrillo. We need not decide whether
Lapre has presented sufficient evidence to demonstrate that
this care was inadequate or inappropriate because she has
presented no evidence that the absence of a suicide kit or a lack
of training for lockup personnel proximately caused Ofem’s
death. 2
2 The American Heart Association provides science-based CPR guidelines.
For healthcare providers and trained persons, the AHA recommends
conventional CPR, which consists of repeated cycles of thirty chest
compressions and two mouth-to-mouth breaths. For the general public or
bystanders, the AHA recommends hands-only CPR, which consists of chest
(continued...)

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16 No. 17-3024
On appeal, Lapre concedes that she did not present
evidence related to causation on this claim, but asserts that the
City did not mention causation when it moved for summary
judgment. Because she was not on notice that causation would
be an issue, she argues that she did not have an opportunity to
present facts from the medical examiner and from her expert
regarding causation. But the City did in fact argue in its
opening brief on summary judgment that Lapre provided no
evidence that any of the alleged City policies caused a constitu-
tional deprivation. R. 119, at 13–14. The City repeated the point
in its reply brief. R. 131, at 9–10. Lapre was therefore on notice
that causation was at issue.
Moreover, to recover from a municipality under section
1983, a plaintiff must demonstrate that, “through its deliberate
2 (...continued)
compressions only. See https://cpr.heart.org/AHAECC/CPRAnd
ECC/AboutCPRECC/WhatIsCPR/UCM_499896_What-is-CPR.jsp (last
visited Nov. 30, 2018). The Mayo Clinic additionally recommends that
before beginning CPR, if the person appears unconscious, the person
rendering aid should tap or shake his or her shoulder and ask loudly, “Are
you OK?” If the person does not respond, the person rendering aid should
call for emergency services and then begin chest compressions only. See
https://www.mayoclinic.org/first-aid/first-aid-cpr/basics/art-20056600 (last
visited Nov. 30, 2018). Neither site mentions the use of a device to aid
mouth-to-mouth respiration. The American Red Cross sells such devices in
order to protect the person rendering aid from disease transmission. See
https://www.redcross.org/store/cpr-keychain-with-face-shield-and-glove
s/ARC-CPR-03.html?#start=2&cgid=cpr-keychains&viewratings=true (last
visited Nov. 30, 2018). Although it is not necessary for us to decide the issue
of whether the care provided to Ofem was appropriate, it appears to have
conformed largely to guidelines provided by reputable organizations.

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No. 17-3024 17
conduct, the municipality was the ‘moving force’ behind the
injury alleged,” showing “a direct causal link between the
municipal action and the deprivation of federal rights.” Brown,
520 U.S. at 404. A plaintiff opposing summary judgment must
identify “admissible evidence that would permit the trier of
fact to make a finding in the non-movant's favor as to any issue
as to which it bears the burden of proof.” Packer v. Trustees of
Ind. Univ. Sch. of Medicine, 800 F.3d 843, 847 (7th Cir. 2015).
Because Lapre admittedly presented no evidence on causation,
the district court correctly rejected this claim.
C.
Lapre next contends that the City had a policy of not
reassessing detainees who were returning to the Lockup after
an absence. According to Lapre, the Special Order does not
require lockup personnel to reassess detainees via the mental
health questionnaire, Ofem was not reassessed when he
returned from court, Carrillo was not trained to reassess
detainees, and none of the deposed City personnel were aware
that reassessment was required. She argues that, if Carrillo had
reassessed Ofem, it is likely that the assessment would have
provided information that prompted further inquiry into
Ofem’s state of mind. As such, she asserts that the failure to
reassess was a cause in fact of Ofem’s death.
The Special Order is arguably ambiguous on the issue of
whether a detainee will be reassessed via the intake screening
questions on return to the lockup following an absence.
Construing the Special Order in Lapre’s favor, we will assume
that the Special Order requires personnel to employ the intake
questions only when a detainee first arrives at a lockup. The

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18 No. 17-3024
Special Order does, however, require some assessment of a
detainee’s mental health every fifteen minutes during the
visual check. At that time, lockup personnel are directed to
follow the Guidelines for Arrestee Screening and Monitoring
chart. The warning signs listed on the chart include whether
the detainee expresses a desire to harm himself, engages in
actual self-harm, is hyperactive or extremely agitated, or is
feeling intense guilt or remorse. That said, it seems highly
unlikely that a visual check through a grainy video feed would
reveal whether an arrestee is suicidal under the standards
provided in the chart.
But even if we assume that the City had a policy of assess-
ing detainees only on initial entry to the lockup, Lapre’s
evidence falls short of demonstrating that the City’s facially
lawful policy was deliberately indifferent to a known or
obvious consequence of the policy. Brown, 520 U.S. at 407.
Lapre has presented no evidence that the policy itself led to
additional suicides or that suicides would have been prevented
by a different policy. Nor has she shown that the City was
aware that this policy was leading to an increase in detainee
suicides, for example, and yet persisted in continuing the
practice. See Brown, 520 U.S. at 406–07. See also Connick v.
Thompson, 563 U.S. 51, 61–62 (2011) (deliberate indifference is
a stringent standard of fault, requiring proof that a municipal
actor disregarded a known or obvious consequence of his
action). In Connick, the Court held that “when City
policymakers are on actual or constructive notice that a
particular omission in their training program causes City
employees to violate citizens’ constitutional rights, the City
may be deemed deliberately indifferent if the policymakers

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No. 17-3024 19
choose to retain that program.” 563 U.S. at 61–62. Because
Lapre has presented no evidence that the City was on actual or
constructive notice that its policy to fully assess mental health
only on first admission to the lockup was leading to constitu-
tional deprivations, we cannot say that the City acted with the
requisite level of fault for a finding of deliberate indifference.
Moreover, Lapre has presented little more than speculation in
support of causation on this claim, asserting without evidence
that a full reassessment would have led to further inquiry
which would have presumably led to an intervention that
saved Ofem.
D.
Lapre next asserts that the City was deliberately indifferent
to the risk of detainee suicide through its policy of not person-
ally inspecting detainees and leaving them isolated. Instead,
the City conducted at least some of the visual inspections
through a grainy video feed even though the Illinois Lockup
Standards require in-person checks at least every half hour.
Lapre asserts that failing to follow the Illinois standards is
evidence of deliberate indifference. She also contends that a
reasonable inference may be drawn from the record that Ofem
was left completely alone and isolated from his return to the
jail at 10 a.m. until his suicide a little more than three hours
later. Such isolation was the moving force behind Ofem’s
suicide, she argues.
We begin with the only evidence in the record regarding in-
person inspections and interactions. When Ofem returned
unexpectedly from court, he was the only person in the
Lockup. He spoke with Carrillo on his return at 10 a.m.

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20 No. 17-3024
regarding the court mixup. Carrillo also asked Ofem if he
wanted something to eat, and Ofem declined. Ofem accepted
Carrillo’s offer of a phone call, and the call lasted a few
minutes. Although Ofem was placed in the cell closest to
Carrillo’s work station, only fifteen or twenty feet away, there
was a closed steel door separating them. Carrillo testified that
either he, an unnamed fellow officer, or the Station Supervisor
personally checked on Ofem every fifteen minutes from 10 a.m.
to 12:45 p.m. On two or three occasions, Carrillo asked Ofem
if he wanted something to eat, and Ofem declined each time.
On one occasion when the other officer checked on Ofem, that
officer asked Carrillo to come in to discuss the court mixup
again. At 11:30, the Station Supervisor checked the Lockup in
person. At 12:45, Carrillo and Graham jointly conducted an in-
person check on Ofem. Carrillo noticed nothing unusual at any
of these inspections. When Carrillo was getting ready to check
Ofem at 1:00 p.m., he was busy responding to a request from
another officer, and so Carrillo checked on Ofem through the
video monitor instead of conducting an in-person check. At
1:10 p.m., Carrillo and Graham discovered Ofem hanging from
the bars of his cell, less than a half hour after the final in-person
check.
Lapre faults the district court for crediting Carrillo’s
testimony that someone inspected Ofem in person every fifteen
minutes (except at 1:00 p.m., when Carrillo testified that he
viewed Ofem via the video feed), arguing that a jury could
disbelieve Carrillo’s testimony. But Lapre herself concedes,
consistent with Carrillo’s testimony, that Carrillo offered food
to Ofem multiple times between 10 a.m. and the time of his
death, and that Ofem refused to eat each time. So Lapre admits

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No. 17-3024 21
that Carrillo made at least several in-person visits to Ofem’s
cell. Moreover, although the “movant has the burden of
showing that there is no genuine issue of fact, … the plaintiff
is not thereby relieved of his own burden of producing in turn
evidence that would support a jury verdict.” Anderson, 477 U.S.
at 256. Lapre’s assertions that a jury could disbelieve Carrillo
are not sufficient to establish that Ofem was left alone for the
three hours preceding his death. “When the testimony of a
witness is not believed, the trier of fact may simply disregard
it. Normally the discredited testimony is not considered a
sufficient basis for drawing a contrary conclusion.” Bose Corp.
v. Consumers Union of U.S., Inc., 466 U.S. 485, 512 (1984). If we
disregard Carrillo’s testimony, the record still shows that
Carrillo spoke to Ofem approximately three times after he
returned from court and before his death less than three hours
later. No fair inference may be drawn that Ofem was com-
pletely isolated because Lapre concedes that Carrillo offered
Ofem food multiple times. We are left then with the City’s
policy of visually inspecting detainees every fifteen minutes,
a policy which does not expressly require an in-person check.
The City’s policy additionally requires the Station Supervisor
to conduct thorough inspections of the Lockup and the
detainees at the start of each tour and at least four times per
tour. And there is some evidence that Carrillo personally
checked Ofem several times during the last three hours of his
life.
Lapre has offered no evidence of any particular wide-
spread practice regarding the visual inspections, and so we do
not know whether detainees in general were left isolated for
extended periods of time, whether they were inspected in

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22 No. 17-3024
person every fifteen minutes or whether there was a combina-
tion of in-person and video checks. Moreover, Lapre presents
no evidence that the City, as a matter of wide-spread custom
or practice, failed to follow the Illinois Lockup Standard of
conducting an in-person inspection every half hour. In any
case, a violation of a state law would not necessarily demon-
strate a denial of due process, and compliance with state law
is not an automatic defense because state law might not
comport with constitutional standards. Boncher, 272 F.3d at 487.
See also Estate of Novack, 226 F.3d at 532–33 (section 1983
provides no remedy for failure to meet state law require-
ments). We have only anecdotal evidence regarding what
happened in the 4th District on the day of Ofem’s death. That
evidence does not support Lapre’s contention that Ofem was
isolated or that the City’s general practice was to isolate
detainees.
Lapre also failed to offer evidence that in-person inspec-
tions of any particular frequency would affect the suicide risk
for detainees or that the City was aware that more frequent in-
person visits would make a difference. Her evidence that the
City had contemplated installing computer card readers at the
back of each lockup so that the visits could be recorded
electronically adds nothing to the analysis because there is no
evidence regarding why the City was considering adopting
this procedure. Without evidence of either a wide-spread
practice, knowledge of a risk created by a practice, or causa-
tion, the claim was properly rejected.

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No. 17-3024 23
E.
Lapre’s final claim regards the failure to properly train
personnel on detecting mental health issues and identifying
persons who are suicidal. Under City of Canton, Ohio v. Harris,
“the inadequacy of police training may serve as the basis for
§ 1983 liability only where the failure to train amounts to
deliberate indifference to the rights of persons with whom the
police come into contact.” 489 U.S. 378, 388 (1989).
In resolving the issue of a city's liability, the
focus must be on adequacy of the training pro-
gram in relation to the tasks the particular offi-
cers must perform. That a particular officer may
be unsatisfactorily trained will not alone suffice
to fasten liability on the City, for the officer's
shortcomings may have resulted from factors
other than a faulty training program. It may be,
for example, that an otherwise sound program
has occasionally been negligently administered.
Neither will it suffice to prove that an injury or
accident could have been avoided if an officer
had had better or more training, sufficient to
equip him to avoid the particular injury-causing
conduct. Such a claim could be made about
almost any encounter resulting in injury, yet not
condemn the adequacy of the program to enable
officers to respond properly to the usual and
recurring situations with which they must deal.
And plainly, adequately trained officers occa-
sionally make mistakes; the fact that they do says

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24 No. 17-3024
little about the training program or the legal
basis for holding the City liable.
Moreover, for liability to attach in this circum-
stance the identified deficiency in a city's train-
ing program must be closely related to the ulti-
mate injury. Thus in the case at hand, respondent
must still prove that the deficiency in training
actually caused the police officers' indifference to
her medical needs. Would the injury have been
avoided had the employee been trained under a
program that was not deficient in the identified
respect?
Harris, 489 U.S. at 390–91 (citations and footnote omitted).
As we noted above, the City’s Special Order and the
Guidelines for Arrestee Screening and Monitoring both
provided standards for determining whether a person is
suffering from mental illness or heightened suicide risk. The
City also provided extensive training records for each person
who interacted with Ofem on the day of his death, indicating
course titles and whether the employee passed or failed the
course. Lapre’s only evidence regarding City training policies
is anecdotal evidence of the training provided to the 4th
District personnel who monitored Ofem during his time in the
Lockup. Those officers did not recall specific training programs
or the dates of any training that they were given on identifying
mental health issues or suicide risk. Although Lapre asserts
both that the City failed entirely to train its officers and that the
training provided was inadequate, Lapre has presented no
evidence regarding City-wide policies or practices regarding

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No. 17-3024 25
training. She does not point, for example, to evidence that the
City has no training program or that the program the City
employs has faults. Even if we disregard the City’s evidence,
Lapre has produced no evidence regarding the City’s training
practices from which we may infer deliberate indifference.
That there may have been lapses in training in the 4th District
is not sufficient to allow an inference of deliberate indifference
by the City as a matter of policy or wide-spread practice.
Finally, Lapre also fails to show causation on her training
claim. She has provided no evidence that the City’s training
program led to Ofem’s death, or that the City’s program
ignored a recurring problem. She has provided nothing more
than speculation regarding whether better trained officers
would have responded differently, or that a different outcome
was possible based on better training. In the absence of this key
evidence, summary judgment in favor of the City was appro-
priate.
III.
The suicide of a teenager in a City lockup is an unmitigated
tragedy. The question is whether that death occurred as a
result of deliberate indifference by the City through its policies,
practices or customs. Lapre focused her discovery on the
narrow circumstances of Ofem’s death rather than on the
City’s official policies or unofficial but wide-spread practices
or customs. As a result, she was unable to provide evidence
that the City failed to adequately address the known conse-
quences of its official or unofficial practices in the lockups. Nor
did she provide evidence that any policy or policy gap was the

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26 No. 17-3024
moving force in Ofem’s death. The judgment in favor of the
City is therefore
AFFIRMED.

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