2 U.S.C. § 1983 imposes liability on “every person who, under color of any statute, ordinance, regulation, custom, or usage, of any State,” violates “any rights, privileges, or immunities secured by the Constitution.” The U.S. Supreme Court has held municipalities and other local governmental bodies are ’persons’ within the meaning of § 1983.
But the text of § 1983 imposes liability on only those who subject a person, or cause that person to be subjected, to a loss of federal rights. It is not enough to hold a county liable merely because its employee violated rights. Section 1983 doesn’t authorize vicarious liability against a municipality. Rather, a municipality can be liable in only three situations: first and second, when execution of a government’s (a) policy or [(b)] custom inflicts the injury the plaintiff suffered, and third, when a municipal official with final policymaking authority in the area of the act or decision makes the challenged act or decision. This is often referred to as the “policy or custom” requirement.
Besides the policy or custom requirement, though, a litigant must show two other things. First, the claimant must establish that the municipality undertook the challenged policy, custom, act, or decision with the requisite degree of culpability. That is, it is required that the county to have acted with deliberate indifference to its known or obvious consequences. And second, the litigant must point to a direct causal link between the municipal action and the
deprivation of federal rights. So the plaintiff must show that through its deliberate conduct, the municipality was the ‘moving force’ behind the injury alleged.
Hence, to establish a claim under a custom or policy theory, the litigant must show (1) that the claimant’s constitutional rights were violated; (2) that the municipality had a custom or policy that constituted deliberate indifference to that constitutional right; and (3) that the policy or custom caused the violation.
For a custom or policy theory to be actionable, the custom or policy must be so well-settled and pervasive that it assumes the force of law; it must be “persistent and widespread,” so the municipality had either actual or constructive knowledge of it. Put simply, the policy must, in fact, be a “policy.” So normally, random acts or isolated incidents are insufficient to establish a custom or policy.
A longstanding and widespread practice is deemed authorized by the policymaking officials because they must have known about it but failed to stop it. The policy-or-custom requirement ensures that a municipality is held liable only for those deprivations resulting from the decisions of its duly constituted legislative body or of those officials whose acts may fairly be said to be those of the municipality. It also prevents the imposition of liability based upon an isolated incident.
As for causation, the courts consider whether there is a direct causal link between a municipal policy or custom and the alleged constitutional deprivation.
In a Section 1983 deliberate indifference case that the United States Court of Appeals for the Eleventh Circuit decided on November 20, 2025, the federal appellate court stated: “Here, Smothers has presented enough evidence for a reasonable jury to conclude that Walker County had a policy of contracting with Preemptive to provide the Jail’s exclusive medical care, even though the county knew Preemptive was incompetent and offered inadequate care. Indeed, Walker County knew that several detainees had died in Preemptive’s care. And it received several credible complaints that they died because Preemptive failed to provide necessary and adequate medical care.”
“These deaths were not isolated incidents or anomalies, either. And the persistent poor quality (and lack) of medical care in the Jail was no secret. In 2018, Nick Smith ran for sheriff on it. He promised that he’d improve the Jail’s medical care. But Walker County refused to allow Sheriff Smith to get rid of Preemptive once he won. And Sheriff Smith didn’t have the contractual authority to end the contract with Preemptive on his own. The county’s deliberate decision to continue and then renew its contract with Preemptive under these circumstances … was an official policy to knowingly provide inadequate medical care to the people in the Jail. Over several years, Walker County refused itself to rectify obvious deficiencies in the quality of care that inmates were receiving. Even worse, it rejected the sheriff’s efforts to improve the medical care in the jails. This pervasive and longstanding course of conduct established a custom or policy.”
“Alabama law assigns the duty to provide “[n]ecessary medicines and medical attention” for jail inmates to the sheriff. See Ala. Code § 14-6-19. But § 14-6-20, Ala. Code, allows a county, if it so desires, to “elect a physician, or as many physicians as in its discretion may be necessary, to attend the inmates of the jails in such counties . . .” This law also empowers counties to remove any such medical providers “at the will of the county commission.” Id. And Walker County entered into and renewed its contracts with Preemptive under this statute. In doing so, a reasonable jury could conclude, the county acted with deliberate indifference to the “known or obvious consequences” of its policy of continuing to contract with Preemptive.”
“We have no trouble concluding that this evidence would allow a reasonable jury to find that the county reserved for itself the authority to change its policy of providing inadequate medical care to inmates. But the county refused to do so, in disregard of the obvious consequences—the deaths and other harms to inmates. This conduct satisfies the deliberate-indifference culpability standard.”
“When Mitchell first arrived at the Walker County Jail, it was obvious to the healthcare staff at the Jail that he needed medical attention. Yet the Jail never provided adequate care. An expert witness testified that Preemptive’s care for Mitchell fell well below the standard of care on a routine and recurring basis, and that lack of adequate care directly contributed to Mitchell’s death. Based on this testimony and other evidence in the record, a reasonable jury could find “a direct causal link” between the county’s policy or custom of continuing its contract with Preemptive “and the alleged constitutional deprivation.””
“In short, Smothers presented enough evidence for a reasonable jury to conclude that the county was deliberately indifferent to Mitchell’s Eighth Amendment rights. At the very least, the evidence is “in dispute, as to whether the [county] voluntarily undertook” a duty to provide medical care to Jail detainees, making “entry of summary judgment improper” … So we vacate the district court’s grant of summary judgment to the county.”
“[W]e conclude that the district court erred in finding that state law bars holding the county liable for the role its policy may have had in Mitchell’s death. In other words, Walker County’s policy of maintaining the contract with Preemptive can confer Monell and Estelle-based liability on the county. The general scope of counties’ duties under Alabama law does not change this answer. And Smothers presented enough evidence for a reasonable jury to find in her favor. So we reverse the district court’s grant of summary judgment for the county and remand for further proceedings.”
Source Smothers v. Childers, No. 24-13131.
If you or a loved one were injured due to the lack of appropriate medical care in jail in the United States, you should promptly seek the legal advice of a local medical malpractice lawyer in your state who handles jail medical malpractice claims and may investigate your claim and represent you or your loved one, if appropriate.
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