Intoxication-Like Symptoms Are Not an “Obvious” Medical Risk: Tenth Circuit Affirms DUI Probable Cause and Rejects Deliberate-Indifference and Monell Claims in Waters v. City of Altus

Introduction

In Waters v. City of Altus, Oklahoma (No. 24-6264, Oct. 3, 2025), the United States Court of Appeals for the Tenth Circuit affirmed the dismissal of a civil rights action brought under 42 U.S.C. § 1983 by the personal representatives of Brent Waters, who died in custody two hours after a traffic stop. The plaintiffs alleged unlawful arrest, deliberate indifference to medical needs, and municipal liability against the City of Altus and two police officers, Thomas Hobbs and Jacob Parsons. The district court dismissed at the pleading stage under Federal Rule of Civil Procedure 12(b)(6) on qualified immunity grounds. The Tenth Circuit affirmed.

The decision is notable for three reasons. First, it underscores that probable cause for a DUI arrest can exist based on observed erratic driving, field impairment, and a suspect’s admission that he is “not good to drive,” even if later toxicology disproves intoxication. Second, it clarifies that intoxication-like symptoms (confusion, dilated pupils, imbalance, fatigue) and non-specific shoulder pain do not, without more, create an “obvious” medical risk sufficient to allege deliberate indifference to serious medical needs. Third, it confirms that district courts have discretion at the Rule 12(b)(6) stage to decline consideration of body-camera footage even when referenced in the complaint and central to claims.

Although issued as an unpublished order and judgment, the opinion may be cited for its persuasive value (Fed. R. App. P. 32.1; 10th Cir. R. 32.1), and it consolidates existing Tenth Circuit doctrine on probable cause, deliberate indifference, and Monell liability in the context of police encounters that present potentially overlapping criminal and medical explanations for a suspect’s behavior.

Summary of the Opinion

Unlawful arrest claim: Affirmed dismissal. The court held the officers had probable cause to arrest for DUI based on erratic driving (curb strike; near collision), physical and cognitive impairment (confusion, disorientation, dilated pupils, difficulty walking/balancing), failure of a field sobriety test, and the driver’s statement that he was “not good to drive.” Later toxicology showing no drugs or alcohol does not negate earlier probable cause.
Deliberate-indifference claim (medical care): Affirmed dismissal. While Mr. Waters’s death satisfies the objective “serious medical need” prong, plaintiffs did not plausibly allege the subjective prong—actual knowledge and disregard of a substantial risk—because the observed signs were consistent with intoxication (a condition that does not present an “obvious” risk by itself), “shoulder pain” is not the sort of unmistakable marker of a medical emergency that would make the risk obvious, and after the detainee collapsed the officers took reasonable measures (chest compressions; calling EMS).
Municipal liability (Monell): Affirmed dismissal. Absent a plausible underlying constitutional violation by individual officers, there can be no municipal liability.
Procedural point (videos at Rule 12(b)(6)): The district court did not abuse its discretion by declining to review body-camera footage submitted with the motion to dismiss because the amended complaint already contained extensive, video-based factual allegations.

Case Background

Around 8:00 a.m. on September 13, 2019, Officer Hobbs stopped Brent Waters after observing veering, a curb strike, and a near collision. Mr. Waters attributed his driving to sleep deprivation and a foggy windshield. Officer Parsons arrived, noted that Mr. Waters seemed “off” and had dilated pupils, and inquired about medical conditions and marijuana use. Mr. Waters repeatedly declined EMS, stated he “just need[ed] to sleep,” and conceded he was “not good to drive.” He struggled to exit the vehicle, appeared disoriented, failed the “walk-and-turn” test, and twice complained that his left shoulder hurt. The officers arrested him for DUI.

Officer Parsons transported Mr. Waters to a hospital for a blood draw; before results came back, Mr. Waters was taken to jail and placed in an interrogation room with a drug recognition expert (DRE) at 9:15 a.m. He collapsed a minute later. The DRE performed chest compressions; EMS soon arrived and transported him to a hospital. Mr. Waters was pronounced dead at 10:05 a.m. Toxicology was negative; an autopsy attributed death to atherosclerosis of the left main coronary artery, with hyperglycemia as another significant cause.

Plaintiffs (pro se) sued the officers and the City under § 1983. The district court granted a Rule 12(b)(6) motion to dismiss based on qualified immunity, finding no plausible constitutional violation. The Tenth Circuit affirmed de novo.

Detailed Analysis

Procedural posture and standard of review

The appeal arises from a Rule 12(b)(6) dismissal premised on qualified immunity. On such a motion, courts accept well-pleaded facts as true and assess plausibility (Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009); Brokers’ Choice of America, Inc. v. NBC Universal, Inc., 861 F.3d 1081, 1105 (10th Cir. 2017)). Qualified immunity creates a presumption that officials are immune unless the plaintiff plausibly alleges both a constitutional violation and that the right was clearly established at the time (Truman v. Orem City, 1 F.4th 1227, 1235 (10th Cir. 2021)). The panel resolved the case on the first prong: no plausible constitutional violation.

Importantly, the Tenth Circuit rejected the plaintiffs’ argument that the district court erred by not reviewing body-camera footage submitted with the motion to dismiss. Relying on Prager v. LaFaver (180 F.3d 1185, 1189 (10th Cir. 1999)), the court reiterated that a district court has discretion, not an obligation, to consider such materials even if referenced in the complaint and central to the claims—especially where, as here, the complaint already contains extensive allegations derived from the footage.

Precedents cited and their influence

Hall v. Bellmon, 935 F.2d 1106, 1110 (10th Cir. 1991): Courts liberally construe pro se filings but do not assume facts not alleged. This ensured the plaintiffs received the benefit of liberal construction, but still needed plausible facts.
Prager v. LaFaver, 180 F.3d 1185, 1189 (10th Cir. 1999): Confirms judicial discretion at the motion-to-dismiss stage to consider—or decline to consider—extrinsic documents (including video) referenced in the complaint.
Truman v. Orem City, 1 F.4th 1227, 1235 (10th Cir. 2021): Articulates the qualified immunity framework and presumption; plaintiffs must plausibly allege both a constitutional violation and clearly established law.
Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009): Establishes the plausibility standard for pleadings.
Donahue v. Wihongi, 948 F.3d 1177, 1189 (10th Cir. 2020): States the probable cause standard—facts within officers’ knowledge sufficient to warrant a prudent belief that an offense has been or is being committed.
J.H. ex rel. J.P. v. Bernalillo County, 806 F.3d 1255, 1260 (10th Cir. 2015): Probable cause precludes recovery for unlawful arrest under the Constitution.
Lance v. Morris, 985 F.3d 787, 793 (10th Cir. 2021): Pretrial detainees’ medical care claims are assessed under the same deliberate-indifference standard as Eighth Amendment claims for convicted prisoners.
Strain v. Regalado, 977 F.3d 984, 989 (10th Cir. 2020): Deliberate indifference requires objective (serious medical need) and subjective (actual knowledge and disregard) components.
Estate of Beauford v. Mesa County, 35 F.4th 1248, 1262 (10th Cir. 2022): Defines “sufficiently serious” medical need—diagnosed as mandating treatment or so obvious a lay person would recognize the need for a doctor.
Quintana v. Santa Fe County Board of Commissioners, 973 F.3d 1022, 1029 (10th Cir. 2020): Knowledge can be inferred for obvious risks; “unconsciousness” is an obvious risk, while symptoms common to intoxication are not.
Prince v. Sheriff of Carter County, 28 F.4th 1033, 1045 (10th Cir. 2022) and Burke v. Regalado, 935 F.3d 960, 994 (10th Cir. 2019): A detainee’s death is sufficiently serious for the objective prong.
Crowson v. Washington County, 983 F.3d 1166, 1184, 1191 (10th Cir. 2020): Monell requires a policy or custom causing a constitutional violation and municipal deliberate indifference; ordinarily there is no municipal liability without an underlying constitutional violation by an officer.

Legal reasoning

Fourth Amendment: Probable cause to arrest for DUI

The court held that the officers had probable cause based on the totality of circumstances known at the time: erratic driving (curb impact and near collision), pronounced impairment (confusion, disorientation, dilated pupils, difficulty walking and balancing), failure of the walk-and-turn test, and Mr. Waters’s admission that he was “not good to drive.” The subsequent toxicology and autopsy do not retroactively negate probable cause; the assessment is ex ante and based on reasonably trustworthy information (Donahue, 948 F.3d at 1189).

This component of the opinion reinforces a familiar principle: where observable conduct and standardized field sobriety results indicate impairment, officers may reasonably conclude a DUI offense is underway. That a medical condition later emerged as the cause does not render the initial arrest unconstitutional.

Fourteenth Amendment: Deliberate indifference to serious medical needs

The panel accepted that the objective prong was met because the “ultimate harm of death” is sufficiently serious (Prince; Burke). The dispositive question was the subjective prong—whether the officers actually knew of and disregarded a substantial risk of serious harm (Strain; Quintana).

Two interlocking conclusions led to affirmance:

The signs observed before the collapse—confusion, disorientation, dilated pupils, imbalance, fatigue—are “common to many intoxicated individuals” and therefore do not themselves present an “obvious risk” that would allow the court to infer knowledge of a substantial risk (Quintana, 973 F.3d at 1029). Plaintiffs alleged that the officers attributed the symptoms to marijuana; even though that proved wrong, the officers’ contemporaneous understanding did not evince deliberate indifference.
Mr. Waters twice complained of left shoulder pain and repeatedly declined EMS, stating he “just needed to sleep.” The court held that non-specific shoulder pain—without more—does not present the kind of unmistakable medical emergency that would make the risk obvious to a layperson. Nor did plaintiffs plausibly allege that either officer knew Mr. Waters was unconscious before he collapsed; by contrast, unconsciousness is an example of an obvious risk (Quintana).

Finally, after Mr. Waters collapsed in the interrogation room, the DRE promptly performed chest compressions and EMS was called. These actions are inconsistent with deliberate indifference and instead suggest reasonable, immediate response to a medical emergency. Taken together, the complaint did not plausibly allege the officers knew of and disregarded a substantial risk before the collapse, or that they failed to take reasonable measures after it.

Municipal liability (Monell)

The Monell claim was premised on alleged failures to train and supervise. The court affirmed dismissal because plaintiffs failed to plausibly allege any underlying constitutional violation by the individual officers. Under Tenth Circuit doctrine, without a constitutional violation, there is no municipal liability (Crowson, 983 F.3d at 1184, 1191). The court did not reach secondary questions about policy/custom or municipal deliberate indifference because the predicate constitutional tort was not plausibly alleged.

Treatment of body-camera video at the pleading stage

Addressing a procedural objection, the panel held there was no abuse of discretion in the district court’s choice to decide the motion to dismiss without reviewing the body-camera footage submitted by defendants. Relying on Prager v. LaFaver, the court emphasized that while a district court may consider documents referenced in the complaint and central to the claims, it is not required to do so; here, the amended complaint already contained “extensive” factual allegations based on the footage. This clarification is a practical reminder for litigants: incorporation-by-reference is permissive, not mandatory, in the Tenth Circuit at Rule 12(b)(6).

Impact and implications

For police practices and detention medical screening

The opinion reinforces that observations supporting impairment, together with field sobriety failures and a suspect’s admission of unfitness to drive, will generally suffice for DUI probable cause—even where a later, alternative medical explanation emerges. Officers should continue to document such observations carefully.
On medical care, the panel’s application of Quintana confirms a high bar for pleading deliberate indifference when signs can reasonably be understood as intoxication. Unless the risk is obvious (e.g., unconsciousness, severe respiratory distress, seizures), or the detainee communicates clear red-flag symptoms, a plaintiff must allege facts showing officers actually knew of a substantial risk and disregarded it. Repeated offers of EMS, a detainee’s explicit refusals, and a prompt response once a medical crisis materializes will undermine deliberate-indifference claims.

For § 1983 litigation strategy

Pleading deliberate indifference: Plaintiffs must allege what the officers actually perceived that would make the risk obvious to a layperson, such as loss of consciousness, reports of crushing chest pain radiating to jaw/arm with shortness of breath, or classic diabetic crisis indicia (e.g., fruity breath, confusion plus known diabetes and extreme thirst/vomiting) that were communicated to or apparent to the officers.
Videos at Rule 12(b)(6): In the Tenth Circuit, defendants cannot force video review at the motion-to-dismiss stage. Plaintiffs who reference video should ensure their complaint contains the critical factual narrative because courts may limit themselves to the pleadings. Conversely, defendants seeking early dismissal should identify contradictions between the complaint’s characterization and the video, but must recognize the court retains discretion whether to consider the video at that stage.
Monell claims: This decision reiterates that Monell liability commonly rises or falls with the existence of an underlying constitutional violation. Where officers are exonerated on the “no violation” ground, Monell claims typically fail. (By contrast, when officers prevail solely on “not clearly established,” some courts allow Monell claims to proceed; this case did not present that scenario.)

Doctrinal continuity on the Fourteenth Amendment standard

The Tenth Circuit continues to apply a subjective deliberate-indifference standard for pretrial detainees’ medical care claims (Lance; Strain), requiring actual knowledge and disregard of a substantial risk. The panel’s reliance on Quintana’s “obvious risk” framework (unconsciousness versus intoxication-like symptoms) reinforces that the Tenth Circuit has not shifted to a purely objective standard for medical-care claims by pretrial detainees. This clarity will shape how district courts in the circuit assess the sufficiency of allegations at the pleading stage.

Persuasive value despite nonprecedential status

Although the order is nonprecedential, it may be cited for persuasive value. Given its concise synthesis of probable cause, deliberate indifference, and Monell doctrines in a common fact pattern (impaired driving with a latent medical crisis), it is likely to influence district courts within the Tenth Circuit addressing similar allegations.

Complex concepts simplified

Probable cause: A practical, common-sense judgment based on facts known to officers at the time, sufficient to believe a crime has been or is being committed. It does not require certainty and is not undone by later information.
Qualified immunity: A doctrine that shields government officials from suit unless plaintiffs plausibly allege both a constitutional violation and that the right was clearly established. Courts may resolve either prong first.
Deliberate indifference (medical care): Requires two showings:
- Objective: A serious medical need—either diagnosed as requiring treatment or so obvious that a layperson would recognize medical attention is necessary.
- Subjective: The official actually knew of a substantial risk of serious harm and disregarded it by failing to take reasonable measures.
Obvious risks (e.g., unconsciousness) can permit an inference of knowledge; intoxication-like symptoms typically do not.
“Obvious risk”: A situation so apparent that a reasonable person would recognize the urgent need for medical attention. Examples include unconsciousness or seizure; ordinary signs of intoxication, without more, are not obvious risks.
Monell liability: Municipal liability under § 1983 for constitutional violations caused by a municipal policy or custom, coupled with municipal deliberate indifference. Ordinarily, there must be an underlying constitutional violation by an officer.
Incorporation by reference at Rule 12(b)(6): In the Tenth Circuit, courts may—but need not—consider documents or videos referenced in the complaint and central to the claims. Refusal to review such materials is not error if the pleadings otherwise suffice.
Drug Recognition Expert (DRE): A trained officer who evaluates a suspect for impairment. Here, the DRE’s immediate chest compressions after collapse underscored the reasonableness of the response to the emergent medical crisis.

Conclusion

Waters v. City of Altus provides a clear, practical application of settled Tenth Circuit principles to a tragic set of facts. The panel reaffirmed that:

Probable cause for DUI may rest on observed dangerous driving, field impairment, and the driver’s own admission of unfitness, regardless of later negative toxicology.
For deliberate-indifference claims, death satisfies the objective seriousness prong, but plaintiffs must plausibly allege that officers actually knew of a substantial risk. Intoxication-like symptoms and isolated shoulder pain, coupled with repeated refusals of EMS and a prompt response upon collapse, do not meet the subjective standard.
Monell claims fail in the absence of a plausible underlying constitutional violation.
District courts retain discretion to forgo reviewing body-camera footage at the motion-to-dismiss stage when the complaint already details the pertinent facts.

The opinion’s central takeaway is succinct: intoxication-like signs are not, without more, an “obvious” medical emergency that permits inferring deliberate indifference. By tightly cabining the subjective knowledge requirement and reaffirming basic probable cause doctrine, the Tenth Circuit provides a roadmap for both law enforcement practices and § 1983 pleading in cases where possible intoxication and latent medical conditions intersect.