Excessive Force in Medical Emergencies and Post‑Hoc Ratification: Commentary on Miles Guptill v. City of Chattanooga

I. Introduction

The Sixth Circuit’s published decision in Miles Guptill v. City of Chattanooga, Tennessee; Officer Joel Gunn (No. 24‑5688, Nov. 26, 2025) makes two important contributions to federal civil-rights law:

It squarely holds that an officer’s single punch to the head of a non-combative, mentally ill hospital patient can constitute excessive force under the Fourth Amendment, while nevertheless granting the officer qualified immunity because the right was not “clearly established” as of January 2021.
It clarifies that a police chief’s later decision in an internal affairs investigation to mark a use-of-force charge as “not sustained” does not amount to municipal “ratification” sufficient to impose Monell liability on the city.

The case arises from a confrontation in a Tennessee hospital, where plaintiff Miles Guptill voluntarily sought treatment for a mental health crisis. While hospital staff attempted to administer an antipsychotic injection (Geodon) over his objections, off‑duty Chattanooga Police Officer Joel Gunn—working security in full police uniform—intervened. After lightly restraining Guptill’s arm, Gunn twisted his arm behind his back and then struck him, driving Guptill’s head into a cinderblock wall. Guptill sustained head trauma.

Guptill sued under 42 U.S.C. § 1983 for excessive force and brought related state-law claims. The district court granted Officer Gunn qualified immunity on the federal claim and dismissed all federal claims against the City of Chattanooga, but allowed a state-law assault-and-battery claim against Gunn to proceed. On appeal, the Sixth Circuit (Judge Davis for the court, joined by Judge Stranch; Judge Thapar concurring in part and in the judgment) affirmed in full.

The opinion is significant on three fronts:

It refines Fourth Amendment excessive-force analysis in “medical emergency” or mental-health contexts, building on Estate of Hill v. Miracle.
It applies the qualified immunity “clearly established law” requirement in a nuanced way, highlighting the “hazy border” between acceptable and excessive force.
It tightens the requirements for Monell “single-act” liability based on post‑incident ratification by a police chief, emphasizing the “moving force” requirement and the difference between discretionary internal discipline decisions and municipal policy-setting.

II. Summary of the Opinion

A. Factual Background

On January 11, 2021, at about 10:00 a.m., 57‑year‑old Miles Guptill checked himself into Erlanger Hospital in Chattanooga seeking mental health treatment. He had been diagnosed with schizophrenia, chronic depression, bipolar disorder, and PTSD, and he reported delusions and “doing crazy things” such as chasing his wife, whom he believed was unfaithful. He described himself as “very manic” but denied suicidal or homicidal ideation.

Hospital staff placed him in a room designated for patients under emergency detention for serious mental illness and informed him that he could not leave. A physician, Dr. Brian Reuhland, ordered an intramuscular injection of Geodon and completed a Tennessee “Certificate of Need” (CON)—a statutory form that, once executed, authorizes emergency detention of a mentally ill person posing an imminent substantial likelihood of serious harm. Although the CON language reflected acute psychosis and risk of harm, the doctor did not sign it until 2:59 p.m., after the use-of-force incident.

Around 1:00 p.m., nurses attempted to administer the Geodon shot. According to the record (including bodycam footage), Guptill:

Persistently but politely asked why he needed the medication.
Pleaded not to be injected, saying “I don’t want no shot.”
Did not raise his voice or threaten staff.

As staff became more insistent, two male nurses started to restrain his arm. Officer Gunn, in full CPD uniform, was working off‑duty as hospital security and watching from the doorway with another security officer. As tensions rose, two nurses, the other guard, and Gunn came into the small room; all were substantially larger than Guptill (5'6", 145 lbs., in a hospital gown).

When nurses lightly restrained his arm, Gunn entered more actively, placed his hand on Guptill’s arm, and sharply twisted it behind his back. When Guptill stepped over the bed and pulled away to relieve shoulder pain, Gunn responded with a single, forceful punch to the side of Guptill’s head and face, causing his head to strike the adjacent cinderblock wall. Guptill then said he would “stop.”

A nurse immediately intervened, telling Gunn: “Don’t do that. Hey, step out.” After Gunn left and returned with a notepad, the nurse admonished him, stating:

“You’re only supposed to strike when you’re in fear of your life, and we were not, and there were four guys bigger than him in there.”
He now had to treat “head trauma” because “his head hit a brick wall.”
“We were in control. We still had him restrained. And you hit a restrained person. When I was holding him, you hit him.”

Gunn disagreed, asserting that the nurse had lost control and that Guptill “got out of your restraint.”

A field supervisor for the City initiated an inquiry. The Internal Affairs investigation led the CPD commander of professional standards and the deputy chief to recommend that the allegations of improper use of force could be sustained. The Police Advisory Review Committee split 4–4 on whether the force was within policy. After a disciplinary hearing, Interim Chief Eric Tucker, acting as final CPD decisionmaker on discipline, concluded there was not a preponderance of evidence that Gunn violated any CPD policy, and marked the charge “not sustained.”

B. Procedural History

On January 11, 2022, exactly one year after the incident, Guptill filed a civil action in federal court asserting six counts:

§ 1983 claim against Gunn for excessive force (Fourth Amendment).
§ 1983 failure to train claim against the City.
§ 1983 failure to supervise claim against the City.
§ 1983 claim against the City based on policies, procedures, and customs causing the alleged constitutional violation.
State-law malicious-harassment claims against both Gunn and the City.
State-law common-law assault and battery claim against Gunn.

The district court granted Gunn’s motion for summary judgment in part, holding that he was entitled to qualified immunity on the federal excessive-force claim but denying summary judgment on the assault-and-battery claim because a reasonable jury could find excessive force under state tort standards. In a separate order, the court granted the City’s motion for summary judgment on all federal claims and declined supplemental jurisdiction over the City’s remaining state malicious-harassment claim, dismissing it without prejudice. A motion to alter or amend was denied, and Guptill appealed the adverse federal rulings.

C. Holdings

The Sixth Circuit affirmed on all issues raised:

Excessive force / qualified immunity (Gunn):
- Viewing the record (including bodycam footage) in the light most favorable to Guptill, a reasonable jury could find that Gunn’s punch to the head, driving Guptill into a cinderblock wall, was more force than reasonably necessary in the circumstances and thus violated the Fourth Amendment.
- However, as of January 2021, there was no clearly established law—from the Supreme Court or the Sixth Circuit—that would have put every reasonable officer on notice that using a single punch under these specific medical-emergency circumstances was unconstitutional. Gunn therefore was entitled to qualified immunity, and the § 1983 claim was properly dismissed.
Monell liability (City of Chattanooga):
- Guptill’s only live Monell theory on appeal was that the City ratified Gunn’s unconstitutional force when Interim Chief Tucker marked the internal-affairs charge as “not sustained.”
- The court held:
  - Tucker’s role in resolving an internal disciplinary complaint, though involving discretion, did not make him a “final policymaker” for the City under Pembaur/Praprotnik and Sixth Circuit precedents.
  - Even if Tucker had final disciplinary authority, his post‑incident, after‑the‑fact decision to decline discipline eight months later could not be the moving force behind the harm that had already occurred.
  - To treat such post hoc review as ratification would collapse Monell’s prohibition on respondeat superior municipal liability.
- Accordingly, the City was not liable under § 1983, and summary judgment in its favor was affirmed.
Concurrence (Judge Thapar): Judge Thapar joined the opinion but added an observation regarding the unresolved Supreme Court question of which courts’ precedents count as “controlling authority” for qualified immunity purposes. He warned against expecting officers to parse decisions from multiple circuits and suggested prior Sixth Circuit suggestions to that effect are incorrect, though the majority here did not depend on out-of-circuit authority.

III. Detailed Analysis

A. Excessive Force in the Medical-Emergency / Mental-Health Context

1. From Graham to Estate of Hill

The court begins its excessive-force analysis with settled Fourth Amendment doctrine: claims of excessive force during a “seizure” are governed by an “objective reasonableness” standard, looking at the totality of the circumstances from the perspective of a reasonable officer on the scene. The classic Graham v. Connor triad looks to:

The severity of the crime at issue,
Whether the suspect poses an immediate threat to officers or others, and
Whether the suspect is actively resisting arrest or attempting to flee.

But the court acknowledges that Graham is an “imperfect fit” here: Guptill had committed no crime, was not being “arrested,” and was not fleeing. He was a hospital patient in a mental-health crisis, resisting medical treatment rather than criminal arrest. In such circumstances, the Sixth Circuit has developed a modified analytical framework, building on Estate of Hill v. Miracle, 853 F.3d 306 (6th Cir. 2017).

Estate of Hill involved a diabetic emergency where the plaintiff violently resisted paramedics and posed a risk of serious medical harm or death if untreated. In that case, the Sixth Circuit articulated a three-part set of factors tailored to medical or mental-health crises:

Was there a medical emergency that rendered the person incapable of making a rational decision under circumstances that posed an immediate threat of serious harm to self or others?
Was some degree of force reasonably necessary to ameliorate that immediate threat?
Was the force used more than reasonably necessary in the circumstances?

These factors are non-exhaustive and serve as a guide within the broader totality-of-the-circumstances analysis.

2. Application to Guptill

a. Existence of a “Medical Emergency”

Guptill argued that he was not experiencing an emergency of the sort contemplated in Estate of Hill: the CON form had not been signed, he voluntarily came to the hospital, drove himself, and was calm and polite in the video. He distinguished his conduct from Hill (who was combative, bleeding, and at risk of seizure or death) and from the suicidal, intoxicated plaintiff in Caie v. West Bloomfield Township, who stood chest-deep in a lake.

The court acknowledged that the record was mixed. On the one hand:

Guptill did not yell, threaten, or attack anyone.
He was focused on refusing an injection and asking questions about it.

On the other hand:

He had been actively experiencing delusions and self-described “crazy” behavior, including fixating on his wife’s supposed infidelity.
He had a long history of serious mental illness diagnoses.
Medical staff placed him in a room used for emergency detention and told him he could not leave.
Dr. Reuhland completed a CON describing acute psychosis and a substantial risk of harm, even though the form remained unsigned at the moment of the encounter.

Given these facts, the court held it was not objectively unreasonable for Gunn, observing that Guptill was in a CON-type room and that staff were proceeding as if formal emergency detention was warranted, to perceive a medical emergency requiring prompt intervention to prevent potential harm to Guptill or others. The key is not whether a medical emergency actually existed in hindsight, but whether a reasonable officer in Gunn’s position could so perceive it at the time.

b. Necessity of Some Force

The second prong asks whether some level of force was reasonably necessary to address the threat.

Here, the court found that:

Guptill was persistently resisting the injection, both verbally and physically.
When nurses gripped his arm, he pulled away and stepped over the bed to relieve pain from Gunn’s arm-twist, which constituted physical struggle with an officer and staff.
Under Sixth Circuit precedent, “active resistance” includes physically struggling, threatening, or disobeying officers’ instructions.

The court concluded that while Guptill’s resistance was not violent (unlike Hill’s flailing and blood-spraying), he was actively resisting attempts to restrain and medicate him. Considering the perceived emergency, a reasonable officer could have believed that:

Medical staff were having difficulty gaining control, and
Some degree of force from security was needed to help staff safely restrain Guptill and administer medication intended to stabilize his mental state.

Thus, it was objectively reasonable for Gunn to believe that some force was necessary to aid staff in this medical emergency context.

c. Degree of Force: Excessive or Reasonable?

The critical question is whether punching Guptill’s head into a cinderblock wall was more force than reasonably necessary. The court answers that question in the plaintiff’s favor—at least at the summary judgment stage.

Key points in the court’s reasoning include:

Relative threat level. While Guptill was delusional and resisting, he:
- Was unarmed, physically smaller, and in a vulnerable hospital gown.
- Was surrounded by multiple larger staffers and a second security officer.
- Was not swinging, striking, or making threats.
- Was using polite and respectful language (“please,” “sir”) despite distress.
The court characterizes the threat as, at most, “modest.”
Existence of less violent alternatives.
- At least two staffers had “a firm grip” on Guptill when Gunn intervened.
- The room was small; Guptill’s movement was restricted.
- Gunn could have used lower levels of force—maintaining or adjusting holds, repositioning, or assisting staff without a head strike.
- The court expressly contrasts this with Estate of Hill, where four paramedics could not restrain the plaintiff and the use of a taser was upheld.
Perceptions of other trained professionals on scene.
- No nurse asked Gunn to intervene; he “assumed” he was needed.
- A nurse immediately demanded he stop and leave after the punch, indicating that staff did not perceive such force as necessary.
- The same nurse later told Gunn: “We were still in control. We still had him restrained. And you hit a restrained person.”
These contemporaneous reactions by staff are strong evidence that less force would have sufficed.
Use of a head strike in a mental-health context.
- Gunn struck a mentally unstable, unarmed patient in the side of the head, causing impact with a hard surface.
- Sixth Circuit precedent emphasizes the duty to “de-escalate” and adjust force downward when dealing with emotionally disturbed individuals (Champion, Martin).
CPD policy and internal reactions.
- CPD policy states that force cannot be greater than necessary to achieve lawful objectives.
- Senior internal reviewers and half of the Police Advisory Review Committee believed the force could be excessive under policy.
- While violation of policy is not dispositive of a constitutional violation, it is “certainly relevant” to reasonableness.

Taken together, these facts create a triable issue on whether Gunn’s punch was excessive. The court explicitly holds that a reasonable juror could find a Fourth Amendment violation—thus satisfying the first prong of the qualified immunity test.

B. Qualified Immunity: Clearly Established Law

1. The “Clearly Established” Standard

Under Harlow v. Fitzgerald and its progeny, once a defendant invokes qualified immunity, the plaintiff must show:

A violation of a federal right, and
That the right was “clearly established” at the time of the challenged conduct.

A right is “clearly established” only if every reasonable official would understand that what he is doing violates that right. The precedent must put the unlawfulness of the conduct “beyond debate,” although a case need not be factually identical. In practice:

Supreme Court cases are the primary source.
Controlling circuit precedent may also clearly establish the law.
Out-of-circuit cases count only in “extraordinary” situations where they unmistakably foreshadow an outcome under existing authority.
When an officer’s conduct lies in a “hazy border” between acceptable and excessive force, the law is not clearly established.

2. The Specific Right at Issue

The plaintiff framed the right as a hospital patient’s right to be free from an “unjustified punch to the head” when officers have no reason to perceive him as a threat. The court refines this to the narrower, more context-specific question:

Whether a person who is experiencing a mental health emergency and physically resisting treatment in a non-threatening manner has the clearly established right not to be punched by a law enforcement officer.

This tight framing is crucial. Courts repeatedly warn against defining rights at a high level of generality (e.g., “freedom from excessive force”) because such abstract formulations would always be clearly established and would defeat qualified immunity in nearly every case.

3. Prior Cases Considered

The court surveys several precedents:

Meadows v. City of Walker, 46 F.4th 416 (6th Cir. 2022).
- Recognized a clearly established right of people who pose no safety risk to be free from “gratuitous violence” during arrest.
- However, Meadows involved an arrestee context, not a perceived medical emergency during mental-health treatment; the application is not straightforward here, where some risk and some resistance existed.
Martin v. City of Broadview Heights, 712 F.3d 951 (6th Cir. 2013).
- Held that using body weight, head and body strikes, and restraints on an unarmed, mentally unstable, minimally dangerous individual who merely struggled to avoid being handcuffed violated clearly established law.
- But that case involved a prolonged beating with multiple techniques, not a single punch in an emergent medical setting where officers were assisting medical staff, so it did not map cleanly onto this scenario.
Dugan v. Brooks, 818 F.2d 513 (6th Cir. 1987).
- Found excessive force where an officer struck someone from behind in the head with a nightstick “without cause and without warning,” causing serious injury.
- Dugan involves essentially a gratuitous attack without any ongoing struggle or perceived emergency; again, distinguishable from a dynamic restraint situation in a hospital.
Estate of Hill and Caie (medical-emergency cases).
- These provide the framework for evaluating reasonableness in medical emergencies but do not specifically address head strikes in hospital settings when a patient is partially restrained and mildly resisting.
Jones v. Ceinski, 136 F.4th 1057 (11th Cir. 2025).
- An Eleventh Circuit case holding that even a “single punch” may constitute excessive force when used against someone who no longer poses a danger.
- Nonbinding; and in any event post-dates the events here. It cannot contribute to the “clearly established” law as of January 2021.

The common thread is that while prior cases condemn gratuitous, unprovoked, or extended violence against compliant or minimally dangerous persons, none squarely address an officer’s use of a single punch to gain compliance with medical directives in a perceived emergency, where the patient is physically resisting but not overtly threatening.

4. The Court’s Conclusion on Clearly Established Law

The court therefore concludes:

As of January 2021, no Supreme Court or Sixth Circuit case squarely governed this fact pattern.
Existing precedents, taken collectively, did not place the unconstitutionality of Gunn’s specific conduct “beyond debate.”
The conduct falls within the “hazy border” between acceptable and excessive force, where qualified immunity protects the officer even if a jury might ultimately find the force excessive.

Accordingly, Gunn is entitled to qualified immunity. Importantly, however, by now holding that this conduct can violate the Fourth Amendment, the court has clarified the law going forward in the Sixth Circuit. Future officers facing similar circumstances after this published decision may find it more difficult to claim that the law is not clearly established.

C. Monell Liability and Post‑Incident Ratification

1. The Monell Framework

Under Monell v. Department of Social Services, municipalities cannot be held vicariously liable merely because they employ a tortfeasor. Instead, liability attaches only when the municipality, through its own policy or custom, is the “moving force” behind the constitutional violation.

The Sixth Circuit recognizes four primary avenues for establishing municipal liability:

Existence of an unconstitutional official policy or legislative enactment.
Decision of an official with final policymaking authority that ratifies illegal action.
Policy of inadequate training or supervision amounting to deliberate indifference.
Custom of tolerance or acquiescence in federal-rights violations.

Guptill relied solely on the second route: ratification by a final policymaker, arguing that Interim Chief Tucker’s “not sustained” decision ratified Gunn’s unconstitutional force.

2. Final Policymaker Requirement

The Supreme Court in Pembaur and Praprotnik held that a single decision by an official can constitute municipal policy only if that official has final authority to establish municipal policy with respect to the action in question, as a matter of state law. Two key principles follow:

Mere discretion to make decisions or exercise judgment is not enough.
The decisionmaker must have authority that is final and unreviewable, and not constrained by the policies of superior officials.

The Sixth Circuit has applied these principles to reject Monell claims based on internal disciplinary decisions:

Feliciano v. City of Cleveland: Authority to resolve an internal complaint does not make one a final policymaker for the city.
Burgess v. Fischer: On a “single-act” theory, the plaintiff must show a deliberate choice among alternatives by the official responsible for establishing final policy on that subject, and that choice must be the moving force behind the harm.

Applying this framework, the court notes that:

At most, Guptill established that Tucker’s authority was discretionary with respect to internal discipline.
Nothing in the record suggests that Tucker’s disciplinary decisions were “final and unreviewable” for the City as a whole or that he set city-wide policy on police use of force.

Therefore, Tucker does not qualify as the City’s final policymaker on the relevant subject, at least based on the record and arguments presented.

3. The “Moving Force” Requirement and Post Hoc Decisions

Even assuming Tucker were a final policymaker, the court emphasizes another fatal flaw: causation.

Monell demands that the municipal act—here, the alleged ratification—be the moving force behind the plaintiff’s injury. But Tucker’s “not sustained” decision occurred about eight months after the incident. It did not:

Authorize Gunn’s use of force in advance, or
Cause or influence Gunn’s behavior in the hospital.

Rather, it was an after-the-fact evaluative decision about whether Gunn had violated department policy. As the court explains:

“Single-act” scenarios that point to a policymaker’s “post hoc” actions following an act of alleged malfeasance are not typically enough to show that the policymaker was the moving force behind a plaintiff’s injury.

Were it otherwise, every internal decision not to discipline an officer—or every “not sustained” IA finding—could be recharacterized as municipal ratification, effectively resurrecting respondeat superior liability under the guise of Monell.

Because Tucker’s internal decision neither preceded nor caused the use of force, it cannot serve as the necessary Monell “moving force.” Summary judgment for the City on the ratification theory was therefore proper.

D. Judge Thapar’s Concurrence: Scope of Controlling Authority for QI

Judge Thapar’s brief concurrence highlights a developing tension in qualified immunity doctrine: Which precedents count as “controlling authority” sufficient to clearly establish a right?

He notes that the Supreme Court has repeatedly reserved this question. In particular, the Court has not definitively decided whether circuit-court decisions (as opposed to only Supreme Court decisions) qualify as controlling authority for qualified immunity purposes.

Thapar expresses concern that:

It is unrealistic and unfair to require line officers, in “an uncertain and dangerous world,” to master complex and sometimes conflicting circuit-precedent across the country.
Any suggestion that officers must track not only Supreme Court and home-circuit decisions but also the law of all eleven sister circuits is unsound.

Although the majority opinion flags the limited role of out-of-circuit cases (consistent with existing Sixth Circuit law), it does not rely on them. Thapar therefore concurs in the judgment and in the opinion, but signals his discomfort with broader judicial expectations of officers’ legal knowledge.

The concurrence does not change the operative rule in the Sixth Circuit—circuit precedent remains a primary source of clearly established law—but it serves as a cautionary note that future Supreme Court decisions could further constrain the sources of law relevant to the “clearly established” inquiry.

IV. Complex Concepts Simplified

A. Qualified Immunity

Qualified immunity is a doctrine that shields government officials (including police officers) from personal liability for money damages under § 1983 unless:

They violate a constitutional or statutory right, and
That right was clearly established at the time of the violation.

Key features:

It is not a defense to whether the Constitution was violated but to whether the officer may be sued personally.
Courts may decide either prong first (violation or clearly established) and may dismiss on the “clearly established” prong without deciding the constitutional question.
Here, the court decided both: there was a potential violation, but it was not clearly established in 2021.

B. “Clearly Established” Law

A right is “clearly established” when:

Existing precedent (primarily Supreme Court and controlling circuit decisions) has already addressed similar circumstances,
Such that every reasonable officer would know that the conduct is unlawful.

General propositions (e.g., “no excessive force”) are not enough. The legal rule must be particularized to the facts at hand, without requiring a case on “all fours.”

C. Excessive Force in Medical / Mental-Health Settings

Traditional excessive-force analysis focuses on crime severity, immediate threat, and resistance. In medical or mental-health contexts, courts instead examine:

Whether the person is suffering a medical emergency and lacks capacity to make a rational decision about treatment.
Whether an immediate threat of serious harm to self or others exists if treatment is not provided.
Whether some force is reasonably necessary to secure treatment and prevent harm.
Whether the degree of force used is proportional and as limited as reasonably possible in context.

Officers are expected to account for diminished capacity and, where possible, to de-escalate and tailor force downward.

D. Monell Liability and Ratification

Under Monell:

A city is not automatically liable for an officer’s unconstitutional act (no pure vicarious liability).
The plaintiff must show that the city’s own policy or custom caused the constitutional violation.

“Ratification” is one way to show a municipal policy or custom. It requires:

A decision by an official who is a final policymaker for that type of action (not just someone with discretionary authority in one area, like internal investigations).
A “deliberate choice” among alternatives.
That this choice was the moving force behind the plaintiff’s harm—in other words, it caused or authorized the conduct that injured the plaintiff.

A later internal decision not to discipline an officer usually does not satisfy these elements, especially when made months after the incident.

E. “Final Policymaker”

A “final policymaker” is an official whose decisions:

Set official policy for the municipality on a particular subject,
Are not subject to review by higher authorities within the municipal structure, and
Are not constrained by established policies of supervisors.

For example, a city council or, in some circumstances, a city’s top official may be final policymakers on specific issues. A police chief may or may not be a final policymaker depending on local law and the scope of his authority.

V. Impact and Implications

A. For Excessive-Force Litigation in Medical Settings

The opinion solidifies several principles in the Sixth Circuit:

Medical-emergency framework is here to stay.
- Estate of Hill’s tailored factors will be applied when officers intervene in medical or mental-health crises, especially in hospitals or similar settings.
- Traditional Graham factors still guide the inquiry but are supplemented or adjusted to reflect the medical context.
Some force may be reasonable even when the patient is not violent.
- Active physical resistance to treatment—even if not aggressive—can justify some level of force, particularly when staff perceive an emergency and the patient is under or about to be under lawful detention.
Head strikes in mental-health detentions are inherently suspect.
- This decision warns officers that punching an unarmed, mentally ill patient in the head, driving him into a hard surface, may be found excessive—especially when multiple staffers already have control.
- Future plaintiffs may cite this case as clearly establishing that such force is disproportionate in similar circumstances.
Policy violations are relevant but not dispositive.
- Internal determinations that force “could be sustained” under policy, or splits within advisory committees, can bolster a plaintiff’s excessive-force claim.
- But they do not automatically translate into constitutional violations.

B. For Qualified Immunity Doctrine

On qualified immunity, the decision:

Illustrates the “two-step” approach: courts may find a constitutional violation yet still grant immunity because the law was not clearly established at the time.
Demonstrates the court’s commitment to narrow, context-specific formulations of rights under the clearly established prong.
By deciding the first prong (violation), contributes to the development of law that may eliminate immunity for similar conduct in future cases.
Reflects ongoing tension (picked up in the concurrence) about the extent of legal knowledge reasonably expected of officers and the role of circuit versus Supreme Court precedent.

C. For Municipal Liability and Internal Affairs Processes

The Monell holding has practical consequences for plaintiffs and municipalities:

Internal discipline decisions rarely suffice for Monell ratification.
- A plaintiff cannot generally rely on a police chief’s later “not sustained” finding as an automatic ratification of unconstitutional force.
- Courts will scrutinize whether the official is a true final policymaker and whether the decision caused the violation, rather than merely responding to it.
Respondeat superior remains off the table.
- The decision reinforces Monell’s core limitation: cities are not insurers of all police misconduct.
- Plaintiffs must develop robust evidence of prior similar incidents, patterns of non-discipline, or explicit policies endorsing problematic practices to succeed on custom or failure-to-train theories.
Municipalities retain substantial insulation from single-incident liability.
- Absent a clear directive from a high-level policymaker that authorizes specific unconstitutional conduct, one-off incidents—followed by contested internal reviews—will seldom meet Monell’s strict causation standard.

D. For Policy and Training

From a policy perspective, the decision underscores:

The need for specialized training for police officers working in hospitals or with mentally ill individuals on:
- Recognizing and responding appropriately to psychiatric crises.
- De-escalation tactics tailored to treatment settings.
- Avoiding high-risk techniques like head strikes, especially near hard surfaces.
The importance of clear hospital–police protocols:
- When hospital staff want security to intervene, how and under whose direction.
- What threshold of risk or resistance warrants physical intervention by armed officers versus medical restraint options.

VI. Conclusion

Guptill v. City of Chattanooga is a consequential Sixth Circuit decision at the intersection of mental-health care, policing, and constitutional tort law. It does four notable things:

It confirms that an officer’s single punch to the head of a non-violent, mentally ill patient in a hospital can constitute excessive force under the Fourth Amendment, especially where multiple staffers already have control and less violent alternatives are available.
It nonetheless grants the officer qualified immunity, finding that, as of January 2021, no binding precedent clearly prohibited this precise use of force in a perceived medical emergency, placing the conduct in a “hazy border” of reasonableness.
It narrows the use of Monell ratification theories based on internal affairs outcomes, holding that a later “not sustained” decision by a police chief in an internal investigation does not, without more, constitute municipal policy or the moving force behind an earlier injury.
Through Judge Thapar’s concurrence, it highlights ongoing doctrinal uncertainty about what counts as “controlling authority” for clearly established law and how much legal nuance can realistically be imputed to officers in the field.

Going forward, this published opinion itself becomes a key precedent in the Sixth Circuit. Officers and municipalities now have clearer notice that using a head strike in a hospital mental-health context, under circumstances like those here, risks violating the Fourth Amendment. At the same time, plaintiffs are reminded that overcoming qualified immunity and establishing municipal liability remain distinct and demanding hurdles, especially when relying on single incidents and internal disciplinary records alone.